Stefania Chiappini
Amira Guirguis
Ann John2
John Martin Corkery
Fabrizio Schifano- 1Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
- 2Swansea University Medical School, Swansea University, Swansea, United Kingdom
Introduction
There is concern the Coronavirus Disease (COVID)-19 pandemic is having a negative impact on the mental health of the general population through a range of suggested mechanisms: fear, uncertainty, and anxiety; social distancing/isolation; loneliness; and economic repercussions (1–3). Previous disasters such as the Severe Acute Respiratory Syndrome (SARS) in 2003 (4–6) contributed to increased anxiety, mood, and thought disorders, adjustment disorders, and post-traumatic stress disorders (PTSD) (1, 7–15), resulting, in extreme cases, in suicidal behaviours (e.g., suicidal ideation, suicide attempts, and actual suicide) (10, 16), especially in cases of concomitant Substance Use Disorder (SUD) (17, 18). According to a recent study from the Well Being Trust (18) the high levels of stress, isolation and unemployment due to the COVID-19 pandemic could cause up to 75,000 “deaths of despair” related to deaths to drug, alcohol, and suicide (18). High risk of mental illness was previously identified in individuals with existing or history of mental illnesses (1, 9, 12, 14, 19), but also vulnerable categories might be considered the elderly (>80 years old), children/adolescents, individuals from deprived areas, peri-natal women and BAME (Black, Asian and minority ethnicities) (1, 12, 14, 19). Finally, healthcare workers have been experiencing emotional overload due to several reasons, including both organizational issues relating to the shortage of suitable personal protective equipment, reduction in human resources and relentless work shifts (20–23), but also the burden developed by the fear of becoming infected and infecting relatives, high mortality rates, grieving the loss of patients and colleagues, separation from families (22–24). Specifically, according to Huang et al. (25), among the first-line medical staff of a Tertiary Infectious Disease Hospital for COVID-19 in China, the incidence of anxiety and post traumatic symptoms in female medical staff was higher than that in male, and in nurses more represented than that in doctors (25).
Discussion
Often overlooked in this scenario are those with SUD (26, 27), who may experience: (a) changes in levels of drug use—an increase is often seen as a reactive behaviour to negative impact of disasters; (b) a shift to other substances if access to those previously used become limited; (c) a relapse, if they had already recovered from alcohol/drug addiction. Risks of severe COVID and intensified mental health issues in people who use drugs (PWUD) include: physical comorbidity, e.g., lung or cardiovascular disease, HIV, viral hepatitis infections; psychological comorbidity, e.g., general distress, sleep disorders, anxiety/mood disorders, psychotic symptoms; and homelessness, incarceration, economic difficulties, and socioeconomic issues deriving from drug addiction (8, 11, 27, 28). Overdose risk for addicted people who are home-isolating, and hence with typically no one to inject them with naloxone, should be considered in a time of overloaded emergency services and healthcare systems in general (27, 29). The COVID-19 pandemic is already impacting drug markets, including shortages of numerous types of drugs at the street level, price increases for consumers on the black market and reductions in purity. Synthetic drugs’ availability, such as methamphetamine, is drastically reduced due to air travel restrictions and flight cancellations, while cocaine, mostly trafficked by sea, continues to be detected in European ports during the pandemic (30). Heroin and opioids seem to be pushed toward being trafficked along maritime routes. Finally, cannabis appears to be less available, due to restrictions on movement across regions and borders under coronavirus lockdown. These disruptions are likely to grow and further increase risks for people who use drugs, for example by increasing variability in drug purity, the likelihood of adulteration, and contamination of heroin supply with synthetic opioids, such as fentanyl. These issues can also encourage shifts to more at-risk drug using behaviours such as use of drugs such as street benzodiazepines, and synthetic cannabinoids (31). Additionally, the COVID-19 crisis is likely to increase the need to access drug treatment and services, e.g., extra demand for opioid substitution therapy and other medication. Access to drug services is being disrupted by self-quarantine, social distancing and other public health measures adopted for dealing with COVID-19 (27, 29, 31). Similarly, community pharmacies are challenged by staff shortages, service disorganisation, and self-isolation (27, 29, 32).
In response to the long-lasting and wide-ranging challenging effects of the pandemic (5, 12, 19, 27, 29), some harm-avoiding interventions have been adopted, including: more flexible take-home-medication treatment programmes for opioid addicted patients (33, 34); guidance for facilitating controlled substance prescribing (26, 29, 35); tele-health for monitoring drug-dependent patients; and access to virtual support groups through online meetings (15, 26, 32). Conversely, both peer-support groups and rehabilitation facilities have suspended programmes and limited new admissions (27, 32). Hollander & Carr (36) compared and contrasted the acceptability and impact of telemedicine versus in-person consultations. During the COVID pandemic, telehealth has demonstrated to enable continuity of services, while protecting service providers from infection. However, in-person consultations are still needed for certain groups of patients where maintenance in treatment is at risk.
In this context, due to the disruption of drug markets, reduced supply and access to illicit drugs, internet drug-seeking activities may be on the increase. In line with this, rogue/illicit pharmaceutical products, such as benzodiazepines, has also reportedly doubled their prices in some areas (24). Alternative drugs or medications might be considered by users including quetiapine, gabapentinoids, Z-drugs (e.g., zolpidem) (37–39) and some Over-The-Counter (OTC) medications (37, 38), such as codeine; ephedrine and pseudoephedrine; and the antidiarrhoeal loperamide (“poor man’s methadone”).
Implications in Practice
Interventions addressing the health, psychological, and social effects of the pandemic are required. Healthcare professionals have an important role in educating patients about the common psychological effects of a pandemic. COVID-19, together with general environmental factors, such as stress or trauma, may contribute to both a mental illness and a SUD developing. A proactive approach to upscale our mental health care, emergency preparedness and response for people with SUDs is urgently needed; mental health services should develop and evaluate: clear remote assessment; care pathways for people at risk; psycho-education strategies, regarding self-harm/suicide, overdoses, and domestic violence; and staff training to support new ways of working (1, 7, 12). Healthcare providers, including pharmacists, and public health policies are challenged to: develop strategies to implement prevention measures against transmission of COVID-19 in drug users settings, such as preventing overcrowding or sharing drug-using equipment; and ensure continuity of care for drug-users and people with SUDs. Specifically, access to community maintenance, e.g., expand methadone delivery via mobile teams for quarantined patients should be facilitated (40, 41). Monitoring psychosocial needs and delivering psychosocial support to vulnerable patients as well as healthcare workers should be provided (2, 3, 8, 42, 43). It is crucial to strengthen telemedicine and support it with appropriate governance and funding in order to be able to monitor the mental health situation post-pandemic. Supporting healthcare workers with appropriate equipment, training on telehealth and caring for their safety with respect to protection against infection and spread of infection, preventing violence and burglary in drug treatment services, pharmacies would enable robust support against a possible mental health wave post-pandemic. Prescribers and pharmacists should be warned about: possible requests to prescribe more drugs than needed to take home; excessive sales of prescription/OTC products which might be diverted and abused; and aggression toward staff. Developing multidisciplinary support platforms could be helpful in reducing the mental distress due to misinformation and teaching problem-solving strategies to cope with the pandemic (13).
Author Contributions
The opinion was developed by all authors. SC drafted the first version of the manuscript with input from all authors. All authors contributed to the article and approved the submitted version.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry (2020) 7(6):468–71. doi: 10.1016/S2215-0366(20)30171-1
2. Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry (2020) 7(6):547–60. doi: 10.1016/S2215-0366(20)30168-1
3. Smith K, Ostinelli E, Cipriani A. Covid-19 and mental health: a transformational opportunity to apply an evidence-based approach to clinical practice and research. Evid Based Ment Health (2020) 23(2):45–6. doi: 10.1136/ebmental-2020-300155
4. Chan SM, Chiu FK, Lam CW, Leung PY, Conwell Y. Elderly suicide and the 2003 SARS epidemic in Hong Kong. Int J Geriatr Psychiatry (2006) 21(2):113–8. doi: 10.1002/gps.1432
5. Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, et al. Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review. Encephale (2020) 46(3S):S3–S13. doi: 10.1016/j.encep.2020.04.005
6. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Disaster Technical Assistance Center. Supplemental Research Bulletin. Issue 5: Traumatic Stress and Suicide After Disasters (2015). https://www.samhsa.gov/sites/default/files/dtac/srb_sept2015.pdf (Accessed May19, 2020).
7. Courtet P, Olié E, Debien C, Vaiva G. Keep socially (but not physically) connected and carry on: preventing suicide in the age of COVID-19. J Clin Psychiatry (2020) 81(3):20com13370. doi: 10.4088/JCP.20com13370
8. GOV.UK. COVID-19 mental health campaign launches (2020). https://www.gov.uk/government/news/covid-19-mental-health-campaign-launches (Accessed May 19, 2020).
9. Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun (2020) 87:100–6. doi: 10.1016/j.bbi.2020.04.069
10. Mamun MA, Griffiths MD. First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. Asian J Psychiatr (2020) 51:102073. doi: 10.1016/j.ajp.2020.102073
11. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. N Eng J Med (2020). doi: 10.1056/NEJMp2008017
12. Reger MA, Stanley IH, Joiner TE. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? JAMA Psychiatry (2020). doi: 10.1001/jamapsychiatry.2020.1060
13. Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr (2020) 52:102066. doi: 10.1016/j.ajp.2020.102066
14. Thakur V, Jain A. COVID 2019-Suicides: A global psychological pandemic. Brain Behav Immun (2020) 0889–1591(20):30643–7. doi: 10.1016/j.bbi.2020.04.062
15. WHO. Mental health and psychosocial considerations during COVID-19 outbreak (2020). https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf (Accessed May 24, 2020).
16. Griffiths MD, Mamun MA. COVID-19 suicidal behavior among couples and suicide pacts: Case study evidence from press reports. Psychiatry Res (2020) 289:113105. doi: 10.1016/j.psychres.2020.113105
17. Dsouza DD, Quadros S, Hyderabadwala ZJ, Mamun MA. Aggregated COVID-19 suicide incidences in India: Fear of COVID-19 infection is the prominent causative factor. Psychiatry Res (2020) 28:113145. doi: 10.1016/j.psychres.2020.113145
18. Petterson S, Westfall J, Miller BF. Projected Deaths of Despair During the Coronavirus Recession. Well Being Trust (2020) 8:2020. WellBeingTrust.org.
19. Wand APF, Zhong B-L, Chiu HFK, Draper B, De Leo D. Covid-19: The implications for suicide in older adults. Int Psychogeriatr (2020), 16. doi: 10.1017/S1041610220000770
20. CDC, 2020; Centers for Disease Control and Prevention (CDC). Healthcare Personnel and First Responders: How to Cope with Stress and Build Resilience During the COVID-19 Pandemic (2020). https://www.cdc.gov/coronavirus/2019-ncov/hcp/mental-health-healthcare.html (Accessed July 7, 2020).
21. Epidemiology for public health. Istituto Superiore di Sanità. COVID-19: stress management among healthcare workers (2020). https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-stress-management-healthcare-workers (Accessed July 7, 2020).
22. Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care (2020) 9(3):241–7. doi: 10.1177/2048872620922795
23. Wu K, Wei X. Analysis of Psychological and Sleep Status and Exercise Rehabilitation of Front-Line Clinical Staff in the Fight Against COVID-19 in China. Med Sci Monit Basic Res (2020) 26:e924085. doi: 10.12659/MSMBR.924085
24. Zhuo K, Gao C, Wang X, Zhang C, Wang Z. Stress and sleep: a survey based on wearable sleep trackers among medical and nursing staff in Wuhan during the COVID-19 pandemic. Gen Psychiatr (2020) 33(3):e100260. doi: 10.1136/gpsych-2020-100260
25. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of medical staff in a tertiary infectious disease hospital for COVID-19. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi (2020) 38(3):192–5. doi: 10.3760/cma.j.cn121094-20200219-00063
26. Drug Enforcement Administration (DEA). COVID-19 information page (2020). www.deadiversion.usdoj.gov/coronavirus.html. (Accessed May 21, 2020)
27. European Monitoring Centre for Drug and Drug Addiction (EMCDDA). The implications of COVID-19 for people who use drugs (PWUD) and drug service providers (March 2020). http://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en (Accessed May 19, 2020).
28. Zhu S, Wu Y, Zhu CY, Hong WC, Yu ZX, Chen ZK, et al. The immediate mental health impacts of the COVID-19 pandemic among people with or without quarantine managements. Brain Behav Immun (2020) 87:56–8. doi: 10.1016/j.bbi.2020.04.045
29. Volkow ND. Collision of the COVID-19 and Addiction Epidemics. Ann Intern Med (2020a) 173(1):61–2. doi: 10.7326/M20-1212
30. United Nations (UN). COVID-19 causes some illegal drug prices to surge, as supplies are disrupted worldwide (2020). https://news.un.org/en/story/2020/05/1063512 (Accessed May 25, 2020).
31. Volkow ND. Coping with the Collision of Public Health Crises: COVID-19 and Substance Use Disorders (2020b). NIH Director’s Blog with Dr. Volkow. https://directorsblog.nih.gov/2020/04/21/coping-with-the-collision-of-public-health-crises-covid-19-and-substance-use-disorders/ (Accessed May 19, 2020).
32. Green TC, Bratberg J, Finnell DS. Opioid use disorder and the COVID 19 pandemic: A call to sustain regulatory easements and further expand access to treatment. Subst Abus (2020) 41(2):147–9. doi: 10.1080/08897077.2020.1752351
33. Advisory Council on the Misuse of Drugs (ACMD). COVID-19: ACMD advice on proposed legislative changes to enable supply of controlled drugs during a pandemic (April 2020). https://www.gov.uk/government/publications/acmd-advice-on-covid-19-emergency-legislation-to-enable-supply-of-controlled-drugs (Accessed May 21, 2020).
34. Substance Abuse and Mental Health Services Administration (SAMHSA). FAQs: Provision of methadone and buprenorphine for the treatment of opioid use disorder in the COVID-19 emergency (2020). https://www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf (Accessed May19, 2020).
35. Levander XA, Wakeman SE. Covid-19 will worsen the opioid overdose crisis is we don"t prepare now (2020). STAT. https://www.statnews.com/2020/03/17/covid-19-will-worsen-the-opioid-overdose-crisis-if-we-dont-prepare-now/ (Accessed May 25, 2020).
36. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. New Engl J Med (2020) 382(18):1679–81. doi: 10.1056/NEJMp2003539
37. Levine DA. “Pharming”: the abuse of prescription and over-the-counter drugs in teens. Curr Opin Pediatr (2007) 19(3):270–4. doi: 10.1097/MOP.0b013e32814b09cf
38. Reeves RR, Ladner ME, Perry CL, Burke RS, Laizer JT. Abuse of medications that theoretically are without abuse potential. South Med J (2015) 108(3):151–7. doi: 10.14423/smj.0000000000000256
39. Schifano F. Recent Changes in Drug Abuse Scenarios: The New/Novel Psychoactive Substances (NPS) Phenomenon. Brain Sci (2018) 8(12):221. doi: 10.3390/brainsci8120221
40. Becker WC, Fiellin DA. When Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis. Ann Intern Med (2020) 173(1):59–60. doi: 10.7326/M20-1210
41. Simeone R. Doctor Shopping Behavior and the Diversion of Prescription Opioids. Subst Abuse (2017) 11:1178221817696077. doi: 10.1177/1178221817696077
42. Kawohl W, Nordt C. COVID-19, unemployment, and suicide. Lancet Psychiatry (2020) 7(5):389–90. doi: 10.1016/S2215-0366(20)30141-3
Keywords: COVID-19, addiction, mental health, drug abuse, prescription drug misuse
Citation: Chiappini S, Guirguis A, John A, Corkery JM and Schifano F (2020) COVID-19: The Hidden Impact on Mental Health and Drug Addiction. Front. Psychiatry 11:767. doi: 10.3389/fpsyt.2020.00767
Received: 13 June 2020; Accepted: 20 July 2020;
Published: 29 July 2020.
Edited by:
Fernando Barbosa, University of Porto, PortugalReviewed by:
Domenico De Berardis, Azienda Usl Teramo, ItalyMercedes Lovrecic, National Institute for Public Health, Slovenia
Copyright © 2020 Chiappini, Guirguis, John, Corkery and Schifano. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Stefania Chiappini, c3RlZmFuaWFjaGlhcHBpbmk5QGdtYWlsLmNvbQ==; Amira Guirguis, YW1pcmEuZ3Vpcmd1aXNAc3dhbnNlYS5hYy51aw==