31 August 2020
The isolation and anxiety prompted by the coronavirus pandemic and the associated social and economic fallouts have led to an increase in substance abuse[^1] even by people who have not previously had problems. But the pandemic also means that access to needed healthcare, support and social services for substance abuse problems, already in short supply, is increasingly difficult.
Policymakers and healthcare services are alert to the mental health ramifications of the pandemic and, to a lesser extent, the increase in alcohol consumption seen during lockdowns and social isolation. But despite the high prevalence of comorbidity between substance abuse and mental health disorders, the issues of increased substance abuse and decreased access to treatment and rehabilitation have not been adequately acknowledged or addressed in either the United States and Australia.
This paper looks at the impact of the coronavirus pandemic on substance abuse in both the United States and Australia and analyses their governments’ responses to this growing challenge.
The coronavirus pandemic is driving a dramatic increase in mental health problems internationally in large part due to increased levels of anxiety and stress. Surveys in both the United States and Australia highlight the surge in mental health disorders in these countries. There are many common risk factors that contribute to both mental illness and substance use and addiction, including anxiety and stress. The pandemic has, unsurprisingly then, also seen an increase in the use and abuse of alcohol, illegal drugs and pharmaceutical products. But to date, little has been done by governments and policymakers to specifically address substance abuse issues, which remain largely unmentioned, unaddressed, and unmonitored.
As a result of the pandemic, access to substance abuse treatment services has been limited. The pandemic may also mean people with addictions are unable to access their illegal drugs of choice. Many in treatment or rehabilitation for substance abuse are unable to access these services because facilities are overloaded, because of isolation measures or even because of financial difficulties. It may result in people with addictions being unable to access their illegal drugs of choice or the prescription medicines needed to control their addiction, increasing the risk of drug substitution, contamination and increased alcohol consumption.
The pandemic has also resulted in new population cohorts developing drug and alcohol problems, often unseen and unrecognised. The lack of access to usual medical care has driven patients with conditions such as trauma, depression and chronic pain to resort to self-medication with alcohol and a range of drugs, both legal and illegal. There is growing evidence that many people are drinking more during pandemic lockdowns. At the same time, the already existing opioid epidemic in the United States is seen as escalating; in Australia, opioid misuse is a serious public health problem but there is currently no evidence to date that use of these drugs has increased as a consequence of the pandemic.
These are issues that cause both health and societal problems and may well underpin the shocking increase in domestic violence seen as a result of the pandemic. The United Nations has described a worldwide increase in domestic abuse as a "shadow pandemic" alongside coronavirus.
People who use illicit drugs may be particularly vulnerable to contracting COVID-19 as a consequence of underlying health issues, stigma, social marginalisation and higher economic and social vulnerabilities, including access to safe housing and healthcare. The risk of coronavirus transmission may be particularly elevated due to the behaviours and contexts associated with drug use, such as individuals gathering to share drugs and drug use equipment.
Effective management of substance abuse and mental health disorders is challenging. Dual diagnosis ( a term used to describe when a person is experiencing both mental health and substance abuse disorders) is now seen as “the expectation not the exception”, adding complexity to assessment, diagnosis, treatment and recovery while increasing non-compliance and the frequency of relapses. This is why interventions are best provided through integrated programs that address both mental health and substance abuse and that have a “no wrong door” approach to access – meaning people can get help regardless of which service or agency they connect with – though such programs remain uncommon.
Services for the prevention and treatment of substance abuse have traditionally been delivered separately from other mental health and general healthcare services, largely because substance abuse has traditionally been seen as a social or criminal problem.
The United States has one major advantage over Australia in this area. The healthcare reforms resulting from the 1996 Mental Health Parity and Addiction Equity Act and the Affordable Care Act (ACA, Obamacare) required parity for health insurance cover (including exclusions, co-payments and deductibles) for physical and mental health and substance abuse services and made them more affordable. Mental health and substance abuse services are usually referred to together as “behavioural health” services; this language and the legislative mandates reinforce recognition of the inter-relationships between physical and mental health and substance abuse – and the corollary that these services must be integrated. Too often this exists more in the abstract than reality, but it does provide a basis for holistic patient care, as supported by scientific evidence.
In Australia, the artificial divide between mental health and substance abuse services continues. Like the health care system as a whole, this is aggravated by the division of responsibilities and funding between the federal and state and territory governments and between the public and private sectors.
The biggest issue facing both countries is that the workforce tasked with servicing those facing mental health and substance abuse challenges cannot meet the demand. In many cases, such services are unaffordable for those with the greatest need (see United States data for behavioural health services here, Australian data for substance abuse services here, and Australian data for mental health services here).
Statistics from the Addiction Center show the extent of the substance abuse problem that existed in the United States before the arrival of the pandemic:
The data trends compiled by the US National Institute for Drug Abuse (data collected prior to the pandemic) indicate that substance abuse is declining somewhat among younger Americans and is a growing problem in older age groups.
The National Drug Strategy Household Survey 2019 (NDSHS) shows the extent of the problems in Australia before the pandemic:
Again, many of the people with substance abuse disorders are older. Older people are the most likely to drink alcohol daily, with the highest rates seen among people aged over 70. The NDSHS shows there has been an increase in the number of older Australians who are using illicit drugs and the use of non-prescribed use of pharmaceutical products is relatively common among older Australians.
The available data highlight how substance abuse problems are growing in both the United States and Australia as a consequence of the epidemic.
Recent research survey results from the US Centers for Disease Control and Prevention (CDC) show Americans reporting signs of eroding mental health in reaction to the toll of coronavirus and the life-altering restrictions imposed by lockdowns; 13.3 per cent of those surveyed reported having started or increased substance use to cope with stress or emotions related to the coronavirus pandemic.
With respect to opioid misuse and abuse, American experts are increasingly talking about an epidemic within a pandemic. More than 40 states have reported increases in opioid-related mortality, particularly from illicitly manufactured fentanyl and fentanyl analogues. Suspected opioid overdoses increased by 42 per cent in May 2020 compared with the same month in 2019.
In Australia, self-reported levels of alcohol consumption are up, with 28 per cent of adults in May 2020 reporting they use alcohol to cope with anxiety and stress. A national YouGov Galaxy poll conducted at the beginning of April found 20 per cent of respondents had purchased more alcohol since the lockdown began and were drinking more in home isolation. There has been an increase in the involvement of alcohol in family violence situations which have dramatically escalated since the COVID-19 restrictions were introduced.
Australian data on the impact of the pandemic on drug use and abuse is scarce. One early study of people who inject or use drugs found that lockdown restrictions have had limited impacts on drug purchase and use but that users are smoking tobacco and drinking more. A paper published in May predicted changes in both illegal drug market activity, including supply chain disruptions, and drug use behaviours. In the absence of a drug of choice, people may turn to alternatives as substitutes or complements, including pharmaceutical medicines, alcohol or tobacco.
As early as April, there were reports of alcohol and drug treatment and rehabilitation centres closing or refusing to take new admissions as the sector prepared for a worsening of the coronavirus pandemic.
In both countries, the pandemic poses additional health, social and economic risks for people with substance abuse disorders who are already more likely to be homeless, in prison, and to face discrimination and stigma when accessing healthcare and other social services. Many live under circumstances where the risk of infection is high and social isolation is difficult, if not impossible.
The lockdowns and social isolation requirements are expected to cause substantial shifts in the availability of illicit drugs and the way they are sold, drug use patterns and related harms. Social distancing also increases the likelihood of overdoses if there are no observers to administer naloxone, a drug to reverse the overdose. At the same time, there are substantial challenges for the delivery of harm reduction and drug treatment services. Disruption of care and access to medications such as methadone, which usually requires observation of its ingestion, can lead to relapses. In the United States, the coronavirus pandemic has been labelled “a national relapse trigger”.
The virus itself is a major threat for this population. This is particularly true for those who inject drugs because they are also likely to have a high prevalence of chronic medical conditions. The virus attacks the respiratory system so anyone who smokes or vapes tobacco, marijuana, crack cocaine or methamphetamines is at increased risk. Patients who use opioids are particularly vulnerable to the virus from this physiological standpoint because opioids act to slow breathing, thus increasing the risk of low blood oxygen levels, known as hypoxemia.
In both the United States and Australia, the dramatic increases in mental health and substance abuse issues have highlighted the huge unmet need for services.
In the United States
Additional funding of US$425 million for community-based behavioural services and suicide prevention was provided in the 2020 Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Most of this funding goes to states and community providers.
In April, the Substance Abuse and Mental Health Services Administration (SAMHSA) – an agency of the Department of Health and Human Services - announced grants for the financial year 2020 for Certified Community Behavioral Health Clinics of US$200 million from appropriated funding and US$250 million from emergency COVID-19 funding. A survey of behavioural health providers serving high-needs or high-risk coronavirus populations taken around this time revealed inadequate resources to serve their populations; there is no evidence that this additional funding has been sufficient to address the needs.
There is an important role here for Medicaid, the public health insurance program that provides healthcare coverage to low-income families or individuals. Nearly 12 per cent of Medicaid beneficiaries over the age of 18 have a substance abuse disorder and Medicaid accounts for more than 20 per cent of American spending on treatment costs. The government’s own Medicaid website acknowledges that the Obamacare Medicaid expansion provisions created a “paradigm shift” in terms of eligibility, benefits and provider capacity for substance abuse treatment. One study has even linked Medicaid expansion to a 6 per cent reduction in opioid overdose deaths.
There is also funding available specifically to address the opioid crisis, although this has not been increased to address the impact of the pandemic. In September 2019, the Trump Administration announced US$1.8 billion in funding to states with US$932 million provided through SAMHSA and US$300 million over each of the next three years provided through the CDC. It remains unclear, however, how much of this has been distributed to individual states.
Offsetting this are the Trump Administration’s ongoing efforts to cap Medicaid spending and repeal the Affordable Care Act (ACA_, known as Obamacare. It is estimated that the repeal of the ACA would see around 2.8 million people with substance abuse disorders lose access to treatment.
As a result of the pandemic, several federal emergency waivers and authorities have been granted to facilitate access to behavioural healthcare services. These include increasing reimbursement rates and the number of eligible providers for telehealth services as well as allowing remote treatment initiation for medication-assisted treatment. However, it is unclear if these new arrangements will continue into the future and how they have affected the delivery and effectiveness of substance abuse services. Permanent changes in data privacy have been instituted to promote integration across substance use disorder treatment and other parts of the healthcare system.
While both federal and state governments have made additional commitments to support the mental health and wellbeing of Australians during the coronavirus pandemic, there has been virtually nothing provided to support substance abuse treatment.
An announcement in April from the federal Minister for Health is the only mention of, and funding for, substance abuse: an additional A$6 million, to be provided by June 2020, for online and phone support services for people experiencing drug and alcohol problems.
The Victorian government has issued new guidelines for dispensing methadone and buprenorphine during the coronavirus lockdown. These replacement medicines for opioid addiction usually require daily pharmacy visits but the new guidelines enable takeaway doses.
It is notable that the National Mental Health and Wellbeing Pandemic Response Plan approved by the National Cabinet in May mentions increased substance abuse in the executive summary and cites the National Household Drug Survey as a source of information but does not otherwise address the issue. Similarly, the federal government’s Coronavirus (COVID-19) National Health Plan for mental health support does not mention this issue.
There is a number of obvious actions that must be taken to address the needs of people who are experiencing substance abuse problems, including the exacerbation of existing problems, as a consequence of the coronavirus pandemic. These are applicable and relevant in both the United States and Australia.
1. More data
There are calls in both countries for more data and research in this area (see for example the United States here and Australia here). It is particularly important to identify the population cohorts affected for several reasons: Firstly, these may not be those expected – alcohol abuse and illegal drug use is not confined to marginalised populations – and secondly, they would enable appropriately targeted and culturally appropriate information and services.
2. Improved access to services and increased service capacity
Rehabilitation centres and addiction treatment services are seeing an increase in demand at the same time as their capacity is severely restricted by the virus. In many cases, support lines and telehealth services are inadequate replacements. Success in remote consulting is very reliant on pre-existing relationships with patients and while developing new therapeutic relationships from scratch over the phone or video is possible, it is harder to achieve than with face-to-face encounters. Those who are involved in support groups such as Alcoholics Anonymous or Narcotics Anonymous, for example, may not have computer or internet access to attend online meetings.
3. Special attention to the needs of youth and young adults
The mental health effects of the coronavirus outbreaks are felt most keenly by young adults ages 18 to 24 years. One survey found nearly 63 per cent had symptoms of anxiety or depression that they attributed to the pandemic and nearly a quarter had started or increased their abuse of substances, including alcohol, marijuana and prescription drugs, to cope with their emotions.
4. Special attention to the needs of healthcare workers
Healthcare workers already have high rates of substance abuse. It is estimated the lifetime prevalence of substance abuse in Australian doctors is approximately 8 per cent. The rate is even higher in the United States, where an estimated 10 to 15 per cent of medical professionals will misuse alcohol or drugs at some point in their career as current estimates suggest that at least 100,000 medical professionals struggle with a substance abuse disorder. This rates will only be boosted by the stress and anxiety caused by working on the frontlines of the pandemic.
5. Protective social policies
Effective social protection systems are crucial for everyone when a crisis hits, and especially for safeguarding the poor and vulnerable. The impacts of unemployment and loss of income are likely to last for some time and will affect peoples’ mental health and wellbeing, widen socioeconomic disparities, and magnify the marginalisation of individuals with substance abuse disorders. While some jurisdictions in both countries have acted to find accommodation for the homeless, many of whom have mental health and substance abuse problems, these have not always been permanent solutions.
6. Mobilisation of community social capital
Mobilisation of community social capital is an important resource in disaster management – and in pandemic times. Community-level coalitions and inclusion are needed to support individuals with substance use and mental health disorders. Social distancing is a factor that is known to worsen the abuse of drugs. It has been postulated that building emotional resilience and facilitating human connection are factors that can prevent opioid dependency.
7. Develop and expand integrated primary care, addiction and mental healthcare services
This must be a long-term goal of efforts to prevent, treat and rehabilitate substance abuse, with a vision that extends well beyond simply coping with the impact of the coronavirus pandemic.
Integrated and coordinated models that operate across primary health, mental health services and specialist alcohol and drug services – together with appropriate financing mechanisms – must be developed, implemented and evaluated. Such models reduce access barriers by simplifying referral pathways between services, improve organisational efficiencies and, most importantly, improve patient outcomes. The physical co-location of these services is also a key factor in ensuring continued patient engagement.
In Australia, a number of proposals have been put forward, including a 2020-21 budget submission to the Australian Government from 14 organisations involved in delivering healthcare and substance abuse treatment services which make the case for increased coordination across all levels of government to improve the integration and delivery of treatment services for alcohol and other drugs. In the United States, an evidence report prepared for the Agency for Healthcare Research and Quality makes the case for the integration of mental health and substance abuse into primary care. A published report of pilot innovations in integrated primary care as delivered across the US Air Force highlights the improved outcomes that are possible.
The coronavirus pandemic has served to highlight the inadequacies, inequalities and built-in biases of every aspect of healthcare and social services. Nowhere is that more the case than for substance abuse. The social and economic impacts of the pandemic are driving more people to substance abuse while also limiting access to prevention, treatment, support and rehabilitation. The consequences will be felt into the future, arguably well after the virus itself has been controlled. Immediate actions are needed to mitigate the long-term effects.
The United States Studies Centre at the University of Sydney (USSC) is pleased to announce the appointment of Duncan Ivison and Chelsey Martin to its board.
Chairman of the USSC Board, Mark Baillie...