The epidemic within the pandemic: Behavioral health and substance use in the face of COVID-19

Abstract

The coronavirus pandemic has changed life as we knew it. The emergence of a virulent pathogen that we didn't initially understand forced us to quickly reduce our daily interactions, and we were therefore asked to stay home as much as possible and go out only when necessary. Young people were introduced to remote learning, and many of our workplaces immediately transitioned to virtual meetings. Health care facilities were required to reduce capacity and eliminate “nonessential” services while treating large numbers of patients with COVID-19. ICUs filled up quickly with those who had severe disease. At times, we were forced to ration health care when beds were not available. As vaccination rates have increased and rates of severe disease have finally decreased, we are seeing signs that life is beginning its return to its prepandemic state, though some may debate whether that is actually possible. Regardless, a great deal of damage has already been done. Researchers are predicting that it will take years to fully elucidate the effects that COVID-19 has had on life as we knew it. Even though we are just beginning to emerge from this dark time in our history, many of us have witnessed firsthand the negative effects on behavioral health and substance use. We have lost patients. We have observed families who have lost loved ones even in the face of doing everything that CDC recommended. They came to us for answers, and in many cases we didn't have them. In addition, many of us have been impacted directly, as we ourselves and/or our families have struggled throughout the pandemic. However, all of these personal experiences are anecdotal and are thus limited in their perspective. This CPE will discuss scholarship that can be used to see the large-scale impact these events can have on mental and behavioral health, including substance use disorder (SUD). In early 2020, states began the process of issuing mandatory stay-at-home orders. From March 1 to May 31, 2020, a total of 42 states and territories issued mandatory stay-at-home orders, affecting 2,355 of 3,233 (73%) U.S. counties.1Moreland A Herlihy C Tynan MA et al.Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement—United States. CDC: Centers for Disease Control and Prevention, March 1–May 31, 2020www.cdc.gov/mmwr/volumes/69/wr/mm6935a2.htmGoogle Scholar Parents were forced to balance working from home with their children's remote learning activities. While many adults were excited about the opportunity to work from home (WFH), in addition to being with their children throughout the day, no one could have predicted how long we would be subject to these factors or how detrimental they would be to behavioral health and substance use. A country that was already facing a tremendous shortage of behavioral health and addiction clinicians was about to be subjected to further strain. Unfortunately, we did not learn from the past, as we have had multiple events that have demonstrated most of the negative effects our current structures are having on mental health. One of the quickest concerns to emerge from the coronavirus pandemic was centered on financial security. The unemployment rate was 3.8% in February 2020, and by the end of May it had shot up to 13%.2Kochhar R Unemployment rose higher in three months of COVID-19 than it did in two years of the Great Recession. Pew Research Center.www.pewresearch.org/fact-tank/2020/06/11/unemployment-rose-higher-in-three-months-of-covid-19-than-it-did-in-two-years-of-the-great-recession/Google Scholar The transition to WFH, business closures or reduced hours, and reductions in services all compounded the issue rather quickly. Learning objectivesAt the conclusion of this knowledge-based activity, pharmacists will be able to▪Compare and contrast the behavioral and substance use disorder–related issues observed during the COVID-19 pandemic to previous similar historical events.▪List the physiologic effects that may result from prolonged isolation.▪Summarize trends observed in substance use and barriers to treatment over the course of the COVID-19 pandemic.▪Highlight methods that have been utilized to facilitate the delivery of treatment during the COVID-19 pandemic.Preassessment questionsBefore participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment.1.Which of the following parameters are NOT typically affected by social isolation? a.Cortisolb.Blood pressurec.White blood cell countd.Cognitive performance2.Which of the following statements is TRUE for the period of June 2019 through January of 2020? a.The incidence of suicidal ideation more than doubled.b.A greater than fivefold increase in the prevalence of anxiety and depression was observed in adults.c.Essential employees and nonessential employees were equally affected by depression and anxiety.d.Essential employees were more than 4 times as likely to initiate substance use versus nonessential employees.3.Which of the following was NOT cited as a potential explanation for patients with SUDs being more susceptible to severe COVID-19? a.Difficulty adhering to social isolation measuresb.Impaired immune response due to chronic opioid usec.Lung function impairment due to smoking, vaping, or inhalingd.Individuals with SUDs refusing to wear personal protective equipment At the conclusion of this knowledge-based activity, pharmacists will be able to ▪Compare and contrast the behavioral and substance use disorder–related issues observed during the COVID-19 pandemic to previous similar historical events.▪List the physiologic effects that may result from prolonged isolation.▪Summarize trends observed in substance use and barriers to treatment over the course of the COVID-19 pandemic.▪Highlight methods that have been utilized to facilitate the delivery of treatment during the COVID-19 pandemic. Before participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment. 1.Which of the following parameters are NOT typically affected by social isolation? a.Cortisolb.Blood pressurec.White blood cell countd.Cognitive performance2.Which of the following statements is TRUE for the period of June 2019 through January of 2020? a.The incidence of suicidal ideation more than doubled.b.A greater than fivefold increase in the prevalence of anxiety and depression was observed in adults.c.Essential employees and nonessential employees were equally affected by depression and anxiety.d.Essential employees were more than 4 times as likely to initiate substance use versus nonessential employees.3.Which of the following was NOT cited as a potential explanation for patients with SUDs being more susceptible to severe COVID-19? a.Difficulty adhering to social isolation measuresb.Impaired immune response due to chronic opioid usec.Lung function impairment due to smoking, vaping, or inhalingd.Individuals with SUDs refusing to wear personal protective equipment The most recent example that we can compare to was the Great Recession of 2008, when the decline in economic activity dropped us into the deepest recession this country has seen since World War II.3Weinberg J The Great Recession and its aftermath: 2007–. Federal Reserve History.www.federalreservehistory.org/essays/great-recession-and-its-aftermathGoogle Scholar By looking at the data surrounding this and other crises, we can gain some insight into the impact of the COVID-19 pandemic on mental health. It is widely accepted that during times of stress, individuals may turn to substances to “self-medicate.” It may also be surmised that people increase use of those substances that are easily accessible, such as those that are legal. One study evaluated the use of alcohol during the 2008 recession by interviewing over 2,000,000 individuals between 2006 and 2010.4Bor J Basu S Coutts A et al.Alcohol use during the Great Recession of 2008–2009.Alcohol Alcohol. 2013; 48: 343-348Google Scholar The investigators examined multiple factors including participation, frequency, intensity, total alcohol consumption, and frequency of binge drinking.4Bor J Basu S Coutts A et al.Alcohol use during the Great Recession of 2008–2009.Alcohol Alcohol. 2013; 48: 343-348Google Scholar In what may be a surprise to many, it was found that all had decreased with the exception of binge drinking.4Bor J Basu S Coutts A et al.Alcohol use during the Great Recession of 2008–2009.Alcohol Alcohol. 2013; 48: 343-348Google Scholar Episodes of frequent binging increased from 4.8% in 2006–2007 to 5.1% in 2008–2009, corresponding to approximately 770,000 more individuals who were frequent bingers.4Bor J Basu S Coutts A et al.Alcohol use during the Great Recession of 2008–2009.Alcohol Alcohol. 2013; 48: 343-348Google Scholar From a behavioral health perspective, we also observed a large increase in “deaths of despair” among working age Americans.5Case A Deaton A Deaths of Despair and the Future of Capitalism. Princeton University Press, 2021Google Scholar Suicide and substance use–related mortality were responsible for most of these deaths, with loss of hope due to the lack of employment and rising inequality were cited as primary factors.5Case A Deaton A Deaths of Despair and the Future of Capitalism. Princeton University Press, 2021Google Scholar Our country had another experience that was just as relevant and that occurred long before the 2008 Great Recession; that is, the Great Depression, which began in 1929. (There is some debate as to whether the Great Depression ended in 1933, 1939, or 1941, depending on the criteria used.) The Great Depression crippled the U.S. economically.6Tapia Granados JA Diez Roux AV Life and death during the Great Depression.Proc Natl Acad Sci U S A. 2009; 106: 17290-17295Google Scholar During that time, urban legends about mass suicides were common, especially among Wall Street employees. Although that claim has never been validated, suicide rates did increase in that time.6Tapia Granados JA Diez Roux AV Life and death during the Great Depression.Proc Natl Acad Sci U S A. 2009; 106: 17290-17295Google Scholar Over that decade, suicide rates rose from 13.9 to 17.4 per 100,000 people.7Lake J A mental health pandemic: The second wave of COVID-19.Psychiatric Times. June 14, 2020; www.psychiatrictimes.com/view/a-mental-health-pandemic-the-second-wave-of-covid-19Google Scholar However, it's interesting to note that most other statistics related to morbidity and mortality improved.7Lake J A mental health pandemic: The second wave of COVID-19.Psychiatric Times. June 14, 2020; www.psychiatrictimes.com/view/a-mental-health-pandemic-the-second-wave-of-covid-19Google Scholar Unfortunately, data are not available related to substance use for that period, as medicine was in the early stages of accepting the concept of addiction as a “disease.” For many people, SUDs and behavioral health issues are intertwined; therefore, one may have a dramatic effect on the other. Improvements in behavioral health management regularly lead to reduced severity of SUDs and vice versa. On the other hand, worsening of one can increase the magnitude of the other. From my personal observations thus far, reactions to the COVID-19 pandemic seem to support this effect. The resultant effects on SUDs and behavioral health due to the pandemic stem from multiple factors. Most would start by pointing at social isolation as the primary culprit. A 2019 University of Michigan study on healthy aging found that 34% of adults aged 50 to 80 years reported feeling lonely.7Lake J A mental health pandemic: The second wave of COVID-19.Psychiatric Times. June 14, 2020; www.psychiatrictimes.com/view/a-mental-health-pandemic-the-second-wave-of-covid-19Google Scholar Among the number of households of adults living alone, 60% reported feeling a lack of companionship and 41% reported feeling isolated.8Malani P Kullgren J Piette J et al.National poll on healthy aging. University of Michigan.deepblue.lib.umich.edu/bitstream/handle/2027.42/148147/NPHA_Loneliness-Report_FINAL-030419.pdfGoogle Scholar It's also important to note that 28% of the people who reported feeling lonely also ranked their health as either fair or poor.8Malani P Kullgren J Piette J et al.National poll on healthy aging. University of Michigan.deepblue.lib.umich.edu/bitstream/handle/2027.42/148147/NPHA_Loneliness-Report_FINAL-030419.pdfGoogle Scholar In individuals who felt rarely socially isolated, the rate was significantly less at 13%.8Malani P Kullgren J Piette J et al.National poll on healthy aging. University of Michigan.deepblue.lib.umich.edu/bitstream/handle/2027.42/148147/NPHA_Loneliness-Report_FINAL-030419.pdfGoogle Scholar Isolation in and of itself has been correlated with many adverse health effects, including elevated blood pressure, morning spikes in cortisol levels, disrupted sleep, declines in cognitive performance, and increases in functional impairment.9Cacioppo JT Hawkley LC Norman GJ et al.Social isolation.Ann N Y Acad Sci. 2011; 1231: 17-22Google Scholar Perceived social isolation or loneliness is also a better predictor of mortality after heart attack than other cardiovascular risk factors.10Seeman TE Health promoting effects of friends and family on health outcomes in older adults.Am J Health Promot. 2000; 14: 362-370Google Scholar However, while social isolation certainly is a contributor—and a major one at that—it is far from the only one. Even though it is feasible to conclude that social isolation is the primary factor behind the worsening behavioral and substance use outcomes, there are also operational issues to consider. As mentioned previously, when facilities began to close or reduce their hours, their capacity for treatment was diminished. Some facilities were forced to prematurely discharge large volumes of patients. The ability to transfer patients between programs was significantly reduced, and the flexibility to intensify or step-down care was lost. If an individual attempted to access care, they may have faced significant barriers. For those who were allowed to remain in facilities, visits from family and friends were prohibited.11Malapani C COVID-19 and the need for action on mental health. Columbia: Columbia University of Department of Psychiatry.www.columbiapsychiatry.org/news/covid-19-and-need-action-mental-healthGoogle Scholar Out of this combination of factors, we quickly started to see some trends emerge. When comparing mental health reports from January through June 2019 to those from January 2021, there was a greater-than-threefold increase in the prevalence of anxiety and depression in adults.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar Over 41% of adults reported symptoms in 2021 versus 11% in 2019.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar Additionally, the incidence of suicidal ideation more than doubled.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar The effects on essential employees, including health care workers, was even more pronounced, with symptoms of anxiety and/or depression found at 42% for these workers versus 30% in nonessential workers.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar Approximately 25% of essential workers initiated or increased substance use to cope with stress or emotions related to COVID-19, compared to 11% for nonessential workers.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar There were also significant differences seen in suicidal ideation between the two groups (22% vs. 8%, respectively). A comprehensive review of physical and mental health impacts of COVID-19 on health care workers shed additional light on this topic.13Shaukat N Ali DM Razzak J Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review.Int J Emerg Med. 2020; 13: 40Google Scholar Rates of behavioral health issues in health care workers during COVID-19 are reported in the Table. TableRates of behavioral health issues in health care workers during COVID-19 pandemicSource: Adapted from 13Shaukat N Ali DM Razzak J Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review.Int J Emerg Med. 2020; 13: 40Google Scholar.Behavorial health issuePercentage experiencedGeneral anxiety23.00–44.00%Mild anxiety16.09%Moderate anxiety4.78%Severe anxiety2.17%Stress27.40–71.00%Depression50.40%Insomnia34.00% Open table in a new tab In addition, the authors also found that health care workers were 1.52 times more likely to experience depression, 1.57 times more likely to feel anxiety, 2.97 times more likely to have insomnia, and 1.6 times more likely to experience general distress than others.13Shaukat N Ali DM Razzak J Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review.Int J Emerg Med. 2020; 13: 40Google Scholar The effects of the pandemic on substance use and overdose rates have been dramatic. Although the numbers are yet to be finalized for 2021, 2020 was the worst year to date for overdose deaths with approximately 28.3 per 100,000 people, up 31% from 2019.14Hedegaard H Miniño AM Spencer MR et al.Drug overdose deaths in the United States. CDC: Centers for Disease Control, 1999–2020www.cdc.gov/nchs/products/databriefs/db428.htmGoogle Scholar To witness this was beyond disheartening. Before the pandemic, it seemed as if we were finally making some strong strides in slowing the rate of overdoses in this country, but COVID-19 and the increasing presence of fentanyl halted that almost immediately. To begin with, we already had a fractured and siloed treatment system for SUDs, and then we had a massive shortage of clinicians to treat both behavioral health and substance use issues. This drastic increase in substance use and overdoses overloaded a system that was already beyond its limits. Chelsi Cheatom, a leader in the realm of harm reduction, expected to see demand drop during the pandemic because of public transportation cuts and calls for people to shelter in place.15Bauman V Lopez I The opioid crisis, fueled by Covid, is worse than ever.Bloomberg Businessweek. February 20, 2021; www.bloomberg.com/news/articles/2021-02-20/covid-pandemic-has-only-made-the-opioid-crisis-worseGoogle Scholar However, the reality was the opposite. According to Cheatom, “We have a line outside of our door.”15Bauman V Lopez I The opioid crisis, fueled by Covid, is worse than ever.Bloomberg Businessweek. February 20, 2021; www.bloomberg.com/news/articles/2021-02-20/covid-pandemic-has-only-made-the-opioid-crisis-worseGoogle Scholar As we pushed deeper into the pandemic, many of the hypothesized effects began to materialize. From August 2019 to July 2020, a 31% increase in overdoses was observed.14Hedegaard H Miniño AM Spencer MR et al.Drug overdose deaths in the United States. CDC: Centers for Disease Control, 1999–2020www.cdc.gov/nchs/products/databriefs/db428.htmGoogle Scholar Millennium Health, one of the largest laboratory testing organizations in the country, saw dramatic increases in testing positive for substances. Samples testing positive for fentanyl were up by 32%, while heroin, methamphetamine, and cocaine rose by 12%, 20%, and 10%, respectively.16Firth S Interplay of COVID-19, substance use and mental health. MedPage Today.www.medpagetoday.com/infectiousdisease/covid19/89876Google Scholar Emergency Medical Service runs for suspected opioid overdose also significantly increased.17Khare A Sidana A Mohemmed A et al.Acceleration of opioid-related EMS runs in the spring of 2020: The National Emergency Medical Services Information System data for 2018-2020.Drug Alcohol Depend. 2022; 232109271 Google Scholar Beyond the previously cited issues that likely contributed to this trend, there were other factors that were more specific to SUDs. Many of us who work directly in the field observed these issues. For example, some states launched harm reduction initiatives that encouraged people who use substances to make sure someone is with them while they are using. That way, if they happened to overdose the other individual could administer naloxone and call 911. For many, fear of viral transmission prevented this from occurring. We also observed a large exodus of individuals out of recovery housing. Loss of jobs resulted in the inability to continue to pay rent and health insurance, and this meant most individuals could not afford to pay for care out-of-pocket. Opioid Treatment Programs (OTPs) that provide treatment with methadone (and sometimes also buprenorphine) were also adversely affected. Most OTPs observed increases in patients concluding their treatment and decreases in new patients initiating treatment.18Abramson A Substance use during the pandemic.Monitor on Psychology. 2021; 52: 22Google Scholar In an attempt to combat these problems, some federal regulations were relaxed. For example, during a public health emergency, the Secretary of HHS has the power to temporarily suspend regulations that may impede the delivery of care. In this case, states were permitted to request blanket exceptions for all stable patients in an OTP to receive 28 days of take-home doses of methadone. Alternatively, they could also request up to 14 days of take-home medication for those patients who are less stable, but whom the OTP believes can safely handle this level of take-home medication. Practitioners working in OTPs were allowed to continue treating existing patients with methadone and/or buprenorphine via phone only or audio/visual telehealth. New patients receiving methadone were still required to have an in-person evaluation first; new patients receiving buprenorphine were exempt.19American Society of Addiction Medicine COVID-19 resources.www.asam.org/quality-care/clinical-guidelines/covidGoogle Scholar On the outpatient side, regulations that had traditionally impeded the ability to provide rapid access to the lifesaving medication were also suspended. As a schedule III–controlled substance, prescribers were required to conduct an in-person evaluation before commencing treatment. This was the result of the Ryan Haight Online Pharmacy Consumer Protection Act, initially passed in 2008, which prevented the prescribing of controlled substances unless an initial in-person examination was completed.20Baney L Brady J Stevenson S-L The future of telehealth and the Ryan Haight Act post-pandemic. NABP: National Association of Boards of Pharmacy.nabp.pharmacy/news/blog/the-future-of-telehealth-and-the-ryan-haight-act-post-pandemic/Google Scholar Despite this act, some felt that buprenorphine should have been excluded from this regulation because the ability to engage a patient efficiently and rapidly with SUDs is essential in getting them on the road to recovery. Even before the pandemic, it was very difficult to find a buprenorphine clinician in many areas throughout the country. However, the requirement for in-person consultations has now been loosened.20Baney L Brady J Stevenson S-L The future of telehealth and the Ryan Haight Act post-pandemic. NABP: National Association of Boards of Pharmacy.nabp.pharmacy/news/blog/the-future-of-telehealth-and-the-ryan-haight-act-post-pandemic/Google Scholar Additionally, DEA agreed to exempt prescribers from having to obtain additional licenses for each state in which they are prescribing, a previous prepandemic requirement.21More than 80 organizations call on DEA to finalize special registration for telemedicine. PursueCue.www.pursuecare.com/more-than-80-organizations-call-on-dea-to-finalize-special-registration-for-telemedicine/Google Scholar DEA has also been promulgated by law to develop a nationwide telemedicine registration program, but has yet to do so.21More than 80 organizations call on DEA to finalize special registration for telemedicine. PursueCue.www.pursuecare.com/more-than-80-organizations-call-on-dea-to-finalize-special-registration-for-telemedicine/Google Scholar As a result of the suspension of the Ryan Haight Online Pharmacy Consumer Protection Act and other regulations, multiple new companies popped up to offer buprenorphine treatment via telemedicine. Some of these have been quite successful in engaging patients and contracting with health plans to provide services to their network. Digital SUD platform vendors such as Pear Therapeutics, Dynamicare Health, and Chess Health also gained some traction as states and health plans were seeking additional ways to engage patients. These apps vary in their offerings, but some include counseling modules, peer support, and contingency management that rewards patients for positive behaviors related to recovery. Pear Therapeutics’ reSET® and reSET-O® are currently the only FDA-cleared digital therapeutics available to aid in the management of SUDs, while Dynamicare Health has also recently applied for FDA clearance and has been granted “breakthrough” status. Some within the field predict that the use of digital platforms to manage SUDs will continue to expand, but it will be challenging to reach the degree of acceptance that behavioral health apps currently have. Multiple published studies have described the effects that the COVID-19 pandemic has had on substance use. As during the Great Recession of 2008, the frequency of binge drinking increased significantly for both men and women during the early months of the pandemic.22Tucker JS Rodriguez A Green Jr., HD et al.Trajectories of alcohol use and problems during the COVID-19 pandemic: The role of social stressors and drinking motives for men and women.Drug Alcohol Depend. 2022; 232109285 Google Scholar There was also a significant decrease in alcohol use in men but use in women remained somewhat constant.22Tucker JS Rodriguez A Green Jr., HD et al.Trajectories of alcohol use and problems during the COVID-19 pandemic: The role of social stressors and drinking motives for men and women.Drug Alcohol Depend. 2022; 232109285 Google Scholar According to the study, both men and women averaged the same number of drinks per day.22Tucker JS Rodriguez A Green Jr., HD et al.Trajectories of alcohol use and problems during the COVID-19 pandemic: The role of social stressors and drinking motives for men and women.Drug Alcohol Depend. 2022; 232109285 Google Scholar This study also examined some other aspects of alcohol use that previous studies had not; for example, it was found that both groups reported an increase in negative consequences due to their drinking as the pandemic continued.22Tucker JS Rodriguez A Green Jr., HD et al.Trajectories of alcohol use and problems during the COVID-19 pandemic: The role of social stressors and drinking motives for men and women.Drug Alcohol Depend. 2022; 232109285 Google Scholar Other studies have found that moderate percentages of individuals reported increased alcohol use. One survey of over 1,500 individuals found that the frequency of alcohol consumption had increased by 14%.23Pollard MS Tucker JS Green Jr., HD Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US.JAMA Netw Open. 2020; 3e2022942 Google Scholar In a smaller survey of 170 adults, 30.1% reported that their alcohol use had increased during the pandemic.24Peterson ZD Vaughan EL Carver DN Sexual identity and psychological reactions to COVID-19.Traumatology. 2021; 27: 6-13Google Scholar In almost all of these studies, women had higher drinking frequencies than men.22Tucker JS Rodriguez A Green Jr., HD et al.Trajectories of alcohol use and problems during the COVID-19 pandemic: The role of social stressors and drinking motives for men and women.Drug Alcohol Depend. 2022; 232109285 Google Scholar, 23Pollard MS Tucker JS Green Jr., HD Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US.JAMA Netw Open. 2020; 3e2022942 Google Scholar, 24Peterson ZD Vaughan EL Carver DN Sexual identity and psychological reactions to COVID-19.Traumatology. 2021; 27: 6-13Google Scholar There has also been a small study published evaluating cannabis consumption in the early pandemic period.25Merrill JE Stevens AK Jackson KM et al.Changes in cannabis consumption among college students during COVID-19.J Stud Alcohol Drugs. 2022; 83: 55-63Google Scholar In this study, a group of college students who were regular users of cannabis reported decreased use during this period.25Merrill JE Stevens AK Jackson KM et al.Changes in cannabis consumption among college students during COVID-19.J Stud Alcohol Drugs. 2022; 83: 55-63Google Scholar It was concluded by the authors that this reduction was likely due to schools closing and students being required to return home and live with their parents.25Merrill JE Stevens AK Jackson KM et al.Changes in cannabis consumption among college students during COVID-19.J Stud Alcohol Drugs. 2022; 83: 55-63Google Scholar One of the more surprising research findings relative to the pandemic is that patients with SUDs were significantly more susceptible to COVID-19, and if positive were more likely to have severe cases.26Board AR Kim S Park J et al.Risk factors for COVID-19 among persons with substance use disorder (PWSUDs) with hospital visits–United States, April 2020–December 2020.Drug Alcohol Depend. 2022; 232109297 Google Scholar There were many hypothesized reasons for this, including drug-seeking behavior that may lead to difficulty adhering to social distancing measures, using with others, exposure through congregate settings, impaired immune response from chronic opioid use, and higher likelihood of being positive for certain infectious diseases that may ultimately affect the lungs.26Board AR Kim S Park J et al.Risk factors for COVID-19 among persons with substance use disorder (PWSUDs) with hospital visits–United States, April 2020–December 2020.Drug Alcohol Depend. 2022; 232109297 Google Scholar In addition, substance users who vaped, smoked, or inhaled may have also been at an increased risk of complications due to impairment of pulmonary function.27Baillargeon J Polychronopoulou E Kuo Y-F et al.The impact of substance use disorder on COVID-19 outcomes.Psychiatr Serv. 2020; 72: 578-581Google Scholar Although currently published research is scarce, one study concluded that individuals with SUDs were more likely to test positive for COVID-19 than those without SUDs.28Wang L Wang Q Davis PB et al.Increased risk for COVID-19 breakthrough infection in fully vaccinated patients with substance use disorders in the United States between December 2020 and August 2021.World Psychiatry. 2021; 21: 124-132Google Scholar Risks also vary depending on the type of SUD.28Wang L Wang Q Davis PB et al.Increased risk for COVID-19 breakthrough infection in fully vaccinated patients with substance use disorders in the United States between December 2020 and August 2021.World Psychiatry. 2021; 21: 124-132Google Scholar Individuals with cannabis use disorder were found to be 5.3 times more likely to test positive, versus 10.2 times in those with opioid use disorder, when compared to those without disorders.29Wang QQ Kaelber DC Xu R et al.COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States.Mol Psychiatry. 2021; 26: 30-39Google Scholar Outcomes were also found to be significantly worse in those with SUDs, as studies have demonstrated significant increases in the risk of hospitalization and mortality.27Baillargeon J Polychronopoulou E Kuo Y-F et al.The impact of substance use disorder on COVID-19 outcomes.Psychiatr Serv. 2020; 72: 578-581Google Scholar, 28Wang L Wang Q Davis PB et al.Increased risk for COVID-19 breakthrough infection in fully vaccinated patients with substance use disorders in the United States between December 2020 and August 2021.World Psychiatry. 2021; 21: 124-132Google Scholar, 30Allen B El Shahawy O Rogers ES et al.Association of substance use disorders and drug overdose with adverse COVID-19 outcomes in New York City: January–October 2020.J Public Health (Oxf). 2020; 43: 462-465Google Scholar So far, we have discussed the effects of the pandemic in those with pre-existing SUDs. However, it is logical to also wonder if more individuals have initiated substance use during this period. Published reports are currently lacking, but one survey conducted in over 5,400 American adults found that about 13% had initiated or increased substance use during this period to cope with stress or emotions related to COVID-19.31Czeisler MÉ Lane RI Petrosky E et al.Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States. CDC: Centers for Disease Control, June 24–30, 2020www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htmGoogle Scholar The authors further stratified this data and found some additional serious outcomes. According to their study, approximately one in four respondents ages 18 to 24 years stated that they had started or increased their substance use to cope with stress or emotions linked to the pandemic.31Czeisler MÉ Lane RI Petrosky E et al.Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States. CDC: Centers for Disease Control, June 24–30, 2020www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htmGoogle Scholar This was the largest percentage across respondents in any age group.31Czeisler MÉ Lane RI Petrosky E et al.Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States. CDC: Centers for Disease Control, June 24–30, 2020www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htmGoogle Scholar Approximately 11% of adults had seriously contemplated suicide in the preceding 30 days, and that percentage was more than double for the 18- to 24-year age group.29Wang QQ Kaelber DC Xu R et al.COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States.Mol Psychiatry. 2021; 26: 30-39Google Scholar The Addiction Policy Forum in Boston conducted a survey of 1,079 individuals with SUDs and SUD-impacted individuals.32Hulsey J Mellis A Kelly B COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorders.www.addictionpolicy.org/covid19-reportDate: 2020Google Scholar The study examined the impact of COVID-19 on individuals with SUDs and found that 74% of respondents had noticed changes in their emotions since the pandemic began.32Hulsey J Mellis A Kelly B COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorders.www.addictionpolicy.org/covid19-reportDate: 2020Google Scholar Twenty percent of respondents reported an increase in substance use, and 1% reported being impacted by experiencing a fatal overdose since the onset of the pandemic.32Hulsey J Mellis A Kelly B COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorders.www.addictionpolicy.org/covid19-reportDate: 2020Google Scholar Overall, approximately 4% of respondents reported an overdose.32Hulsey J Mellis A Kelly B COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorders.www.addictionpolicy.org/covid19-reportDate: 2020Google Scholar Respondents also identified a clear impact on treatment services and difficulties accessing specific services like naloxone and syringe exchange programs.32Hulsey J Mellis A Kelly B COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorders.www.addictionpolicy.org/covid19-reportDate: 2020Google Scholar The COVID-19 pandemic has negatively impacted substance use and behavioral health. We are still in the pandemic, and it will be some time before we are able to adequately examine its comprehensive effects. However, we do know for a fact that more individuals were lost to overdose in 2020 than any other year on record.14Hedegaard H Miniño AM Spencer MR et al.Drug overdose deaths in the United States. CDC: Centers for Disease Control, 1999–2020www.cdc.gov/nchs/products/databriefs/db428.htmGoogle Scholar Therefore, it will be no surprise to anyone if overdose deaths in 2021 surpass that number. Even once the pandemic is over, people will not stop using substances, and the effects that COVID-19 has already had will be long-lasting. Some researchers are estimating that this period will exert its negative effects for at least a decade after it has ceased.12Panchal N Kamal R Cox C et al.The implications of COVID-19 for mental health and substance use. KFF.www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Google Scholar This country was not prepared to quickly scale up services for behavioral health and addiction, and as a result many lives have been lost. There is, however, at least one positive aspect of the pandemic that has emerged, and that is the expansion of telemedicine-delivered care and the use of digital therapeutics. We need to continue to find innovative technological approaches to engage those who use substances and ensure that we are offering services that are optimal to facilitate long-term recovery.