Initiating Substance Use during COVID-19: Predictors and Clinical Implications
Andrew H. Rogers, MA1, Lorra Garey, PhD1, & Michael J. Zvolensky1, 2,3
1Department of Psychology, University of Houston
2 Department of Behavioral Sciences, University of Texas M.D. Anderson Cancer Center
3HEALTH Institute, University of Houston
The COVID-19 pandemic has turned the world upside down with almost no notice. People are facing an unknown stress along with being unemployed, confined to their homes, and told to distance themselves from other people, including loved ones. Not only has COVID-19 been associated with medical morbidity and mortality, but emerging research highlights that mental health concerns are on the rise as a consequence of the pandemic, and more specifically, there has been an increase in substance use and disorders. Given the coping-based function of substance use, it is likely that the limited access to adaptive coping opportunities, such as those facilitated through social interactions, workplace relations, and exercising at a gym, has contributed to people turning to substances as a way to manage the stress associated with of COVID-19. To investigate this phenomenon, we conducted a study between April and May 2020 to understand patterns of substance use during the pandemic. We found that COVID-19-specific worry and fear were highest among those who initiated (for the first time) substance use following COVID-19. What’s more, COVID-19 worry was specifically associated with using substances to cope with increased stress. While these results certainly speak to potential clinical implications, here we give more specific attention to how these findings may be integrated into clinical practice, particularly given the ongoing nature of the pandemic.
Given the saliency of worry and fear constructs in COVID-19 related substance use initiation, Cognitive Behavior Therapy (CBT) is likely an effective treatment for substance use problems related to COVID-19. First, psychoeducation regarding not only the increased availability of substances during this time (i.e. alcohol at home), but also the increase in stress and the process of negative reinforcement is critical. Additionally, given that worry is associated with catastrophic interpretations of events and situations, cognitive modification and thought records may prove useful. However, as the future of the ongoing pandemic and the totality of its impact and consequences on society are not fully known, allowing room for some amount of worry is justified and may be clinically important. Working with clients to tolerate the worry and fear (as an exposure) rather than immediately turning to substances to quell their distress may be effective in reducing substance use problems during COVID-19. Finally, helping clients to identify adaptive coping behaviors, other than substance use, is going to be critical. We suggest clinicians start thinking about creative ways of coping, given the continually increasing restrictions (until the virus is contained).
While CBT-based therapies are certainly promising and likely will be helpful in reducing substance use problems in related to COVID-19, access to these treatments may be limited. Subsequently, greater thought and consideration to alternative approaches for treatment delivery is warranted. First, although many clinics and providers have adapted to tele-health delivery systems for psychotherapy, continuing to increase the number of clinicians who use this approach, and similarly the number of clients that can access tele-health, is critical. Despite the vaccine rollout beginning, the devastation stemming from COVID-19 will likely be experienced for years to come. As tele-health offers an increased opportunity to reach underserved and rural communities, using the time now to develop and normalize tele-health interventions as a standard of care, particularly for substance use interventions, can have a major impact on behavioral health outcomes now and for years to come.
Integrated care models in point of service settings may also be important to consider for substance use treatment during and following COVID-19. Often times, people will go directly to their primary care doctors for both physical and mental health complaints, and given the dearth of mental health services available, primary care doctors are often tasked with treating the mental health complaints as well as medical ailments. Therefore, continuing to work towards service settings that have access to an on-call mental health provider that can see clients during their scheduled visit to their other doctor increases the likelihood they will be retained in care, and decreases client burden of having to schedule a separate appointment for mental health and substance use treatment. There are a number of medical centers around the country already implementing these approaches, but we highlight how this may be particularly important for COVID-19 related mental health and substance use concerns as the true scale of the impact is currently unknown.
Finally, there is emerging research on brief, app-based and/or computerized interventions for substance use that can be adapted and implemented for COVID-19-related substance use concerns. The benefit of app-based interventions is that they are highly accessible to a large proportion of the population, require less time than traditional psychotherapy, and can be completed on the client’s own time. Additionally, given the findings from our study, using app-based interventions that target substance use and/or mental health complaints may be useful during this difficult time characterized by increased stress and reduced access to adaptive coping skills. There have been a number of apps developed and tested that teach mindfulness skills that have been shown to reduce mental health concerns, and may also be applicable in terms of COVID-19-related substance use. Piloting and exploring these apps as first-line interventions for COVID-19-related substance use is warranted. Finally, computerized interventions, such as personalized feedback interventions (PFI), have substantial research showing efficacy and effectiveness for reducing substance use problems, and are typically administered in a brief, 20-30 minute format on a computer. More recent research has shown that it is possible (and effective) to include elements from CBT into PFI interventions, including exposure, that have improved efficacy. Currently, there is research aimed at increased accessibility and generalizability of these interventions, but it is likely they will be helpful, specifically for hard-to-reach population, in reducing COVID-19-related substance use.
While this list is certainly not exhaustive, it provides a preliminary framework to begin thinking about the deleterious mental health and substance use effects that are likely to stem from COVID-19. It is important that we, are providers of mental health services, pay particular attention to the unique effects of COVID-19 on our clients, and recognize that the impact and consequences from this pandemic are likely to persist long after the virus is controlled. Mental health providers do and will continue to serve a critical role in helping our clients through this devastating pandemic.
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