In early 2020, the COVID-19 outbreak complicated the diagnosis, treatment and rehabilitation
of patients with substance use disorders and increased the risks of substance abuse
and addictive behaviours, such as online gaming disorders, in the general public.
Substance use disorder is a chronic recurrent brain disease characterised by strong
cravings, high recurrence rates, and a high proportion of comorbidity of mental and
physical disorders.1 Therefore, regular long-term therapeutic interventions are critical
to preventing drug relapses while maintaining withdrawal.
COVID-19 severely affects normal medical diagnoses, treatments and managements of
patients with substance use disorder coupled with addiction-related behaviour. It
also adversely impacts the mental state of the general public in several ways and
leads to broader symptoms, including anxiety, tension and insomnia, that may increase
the risk of alcohol abuse, sedative and hypnotic drug abuse, and other addictive behaviours.
The State Council’s Comprehensive Team for Joint Prevention and Control of COVID-19
released a series of documents to address the importance of focusing on the prevention
and control of both imported cases and internal transmission in particularly vulnerable
places, such as supervision sites, pension facilities, welfare homes and mental health
institutions.2 3 It is also of utmost importance to ensure the continuous, regular
and effective treatment of existing patients with addiction problems, reduce the risk
of drug relapse and prevent new cases of addiction during the pandemic.
To this end, the Chinese Association of Drug Abuse Prevention and Treatment, the Academic
Group of Drug Dependence of the Chinese Society of Psychiatry, the Academic Group
of Addiction of the Chinese Society of Psychosomatic Medicine, and the Specialty Committee
of Addiction Medicine of the Chinese Psychiatrist Association jointly published an
expert consensus to inform the public with proper guidance to prevent addiction and
provide professional diagnoses, treatment and management of these addictions. Since
these issues are faced by various groups of people, we addressed these problems based
on different populations.
Practical difficulties faced by the general population and patients with addiction
problems during the pandemic
COVID-19 has caused a serious and comprehensive impact on the public. The dual stress
fomented by ‘confronting a pandemic’ and ‘isolation at home’ negatively impacts mental
health to various degrees. Those affected often manifest symptoms such as tension,
worry, fear, depression and distress. If not properly vented, these emotional problems
can increase the risk of substance abuse and gaming disorders.4 Studies have shown
that when stressed, abstinent patients with substance use disorder are more likely
to have negative emotions and are preconditioned to return to previous behavioural
patterns as a coping mechanism. For example, they relieve anxiety, depression or insomnia
through excessive use of tobacco, alcohol or even drugs, all of which lead to relapses
or exacerbations of existing conditions.5–7
For current patients with addiction problems, the amount and frequency of substance
use are amplified when they encounter stressful situations. Therefore, the occurrence,
development, addiction relapse and the state of stress may mutually influence and
aggravate each other during the pandemic. This in turn increases the aggregated risk.
In addition to mutual influences, daily medical treatments for patients with addiction
problems are also affected to varying degrees based on restrictive isolation policies
and delivery inconveniences during a pandemic. For instance, patients who require
methadone maintenance therapy may not be able to receive methadone in a timely manner,
and this may increase the risk of psychobehavioural problems and potential relapse.
Addiction problems and prevention advice that the general public should focus on during
the pandemic
The COVID-19 pandemic is a serious public crisis that has interactive susceptibility
with addictive behaviours. Stressful circumstances can increase the risk of addictive
behaviour; therefore, it is important to prevent the occurrence of substance use and
other addictive behaviours during difficult situations, such as this pandemic.
Addiction problems
As mentioned, during the pandemic—especially during long periods of isolation—several
kinds of stress may lead to negative emotions and related maladaptive coping styles.
Among the types of addictive substances and behaviours that warrant special attention
are abuse of alcohol or sedative hypnotics and compulsive internet gaming.
Alcohol abuse
As a central nervous system depressant, alcohol is widely used by the general public.
In addition to social drinking, many individuals imbibe as a form of self-treatment,
such as relief for anxiety or depression, or to help them sleep. However, long-term
excessive drinking often leads to alcohol abuse or dependence and can cause a series
of physical and mental health problems. During any pandemic, there is an increased
risk of fomenting disturbing feelings or aggravating existing negative emotions in
patients with addiction problems as well as in the general public. Some will attempt
to confront their problems by drinking. This in turn increases the risk of alcohol
abuse or eventual addiction. In addition, if alcohol-dependent patients suddenly stop
drinking, they may experience severe withdrawal symptoms which could be life-threatening,
such as delirium tremens, epileptic seizures and electrolyte imbalance. Therefore,
at-risk persons should avoid drinking as a means to cope with emotional problems or
insomnia, and patients with alcohol dependence must be encouraged to remain abstinent
when isolated at home.
Sedative hypnotic abuse
There are many types of sedative and hypnotic drugs, most of which include antianxiety
remedies that can mitigate negative emotions caused by tension, anxiety and fear.
Sedative hypnotics offer mild and generally positive sedative effects when taken in
small dosages. Larger dosages tend to induce sleep. As a pandemic spreads, the number
of individuals with anxiety and insomnia likewise increases gradually, as do the risks
and potential addictions. Some also use sedatives and hypnotic drugs combined with
alcohol to accentuate the effects, and this often results in more serious negative
consequences. Therefore, the preferred recommendations for relieving anxiety and insomnia
are non-pharmaceutical therapies such as relaxation practices, t’ai chi and yoga.
If pharmacotherapy is necessary for acute cases, sedative and hypnotic drugs should
only be used under the guidance of professional doctors rather than self-administration.
Overuse of games and the internet
Gaming disorder is primarily found in adolescents, while excessive internet use is
seen in all ages.8 9 With the popularity of the internet and smartphones, there are
increased risks of addiction to internet games, short videos, online graphic novels
and comics, and even internet gambling, online pornography and other disruptive content.
For teenagers, the influencing factors generally include changes to their daily routines
and home studies during the pandemic period. Some of the most prevalent characteristics
of adolescents are impulsiveness and curiosity. For young and middle-aged adults,
the main factors are disruptive changes to their living and working spaces, as well
as interruptions to their daily social activities. The elderly are adversely affected
by changes to their daily rhythm. Interventions to prevent internet and gaming addictions
should be tailored to the specific characteristics of each age group, including regular
rest and alternative forms of enriching one’s daily life by developing healthy interests
and hobbies.
Prevention and suggestions
During the COVID-19 pandemic, related work can be conducted in accordance with the
different risk levels.
General population
The general public should plan their lives, maintain healthy lifestyles and conform
to proper daily routines during isolation periods. Regular sleeping and eating combined
with moderate exercise provide individuals with sufficient energy to manage the daily
requirements of work and life. Maintain communication with friends and distant family
members through email, telephone and social apps such as WeChat.10 Those who are physically
and mentally capable should make full use of available resources to learn simple,
practical and evidence-based self-adjustment methods (eg, muscle relaxation training,
mindfulness, negative emotion recognition and coping mechanisms). Harmful coping strategies
should be avoided, such as reliance on tobacco, alcohol or other addictive substances.
Parents can also use digital management software to restrict their children’s phone
usage to reduce the potential risks of communicating with anonymous or aggressive
persons.
Expanding public knowledge on addiction is an important way to prevent addictive behaviours.
Professionals should make use of various media, including published articles, animation,
audio and broadcasts, to enhance the accessibility of informative content for different
groups.
Key population
Groups with higher risks of addiction include persons with sleep disorders, smokers,
drinkers, adolescents, individuals who are particularly susceptible to stress or have
specific personality characteristics (eg, impulsiveness, curiosity), people who to
date have abstained from addictive behaviours, patients with mental diseases and so
on.11 12 According to the changes to addictive behaviours after previous public health
or other major stress events, training related to adaptive coping skills should be
available for high-risk groups. This includes maintaining healthy lifestyles, stress
management, coping to a reasonable degree with negative emotions and seeking psychological
assistance, all of which can serve to identify additional risk factors as early as
possible and prevent addiction through further intervention.
Psychological intervention hotlines and outpatient services that screen for addictive
behaviours should be widely available to improve early detection and intervention.
In addition to the aforementioned high-risk groups, visitors should also be asked
about the following problematic characteristics that may manifest during a pandemic:
whether their dosages and frequency of substance use have increased compared with
previous events; whether they have been able to quit again; whether they now rely
on any addictive substances to relieve negative emotions; and whether they experienced
withdrawal symptoms after reducing or quitting substance use. Patients who are known
to have elevated risk or have the aforementioned characteristics should accept brief
interventions or agree to further professional evaluations. Those who are diagnosed
with substance use disorder should be transferred to specialised treatment institutions
that provide addiction medicine to receive timely treatment.
Advice for patients with addiction problems and their families or guardians
Family support plays an important role in preventing relapses of patients with addiction
problems. Family members can reduce patient cravings and prevent regression by stabilising
family relationships while helping them reduce negative emotions and cope with high-risk
factors. Patients with addiction problems and their families should pay special attention
to all of the followings:
Understand and pay close attention to emotions
Patients and their families can learn to understand their emotional states using appropriate
psychometric assessment tools. Furthermore, they can also receive training to adjust
and relieve negative emotions through mindfulness, meditation, relaxation training
and other methods. Patients and their families should realise that mild tension and
anxiety during stressful situations are considered normal reactions that in turn can
help them remain alert and mitigate their nervousness. Once uncontrolled negative
emotions begin to have a significant impact on daily life and work, patients should
request an online consultation or visit a professional institution for appropriate
treatment.
Build one’s own social support system
Talking with others can effectively help individuals relieve tension and anxiety.
Therefore, the family members of patients with addiction problems can establish their
own social support systems. Family members and close friends should communicate more
frequently and adopt methods of ‘healing in groups’ to help each other solve problems
encountered during a pandemic. If this method does not effectively solve the problem
and bouts of severe insomnia, depression or anxiety continue to occur, the best advice
is to request a phone consultation with a mental health institution. If necessary
in severe cases, the person should visit a psychiatric emergency department to receive
appropriate treatment.
Proper management of addictive substances: strengthening observation and support for
patients
During a pandemic, negative emotions may increase substance abuse. Family members
should carefully monitor all addictive substances at home, including alcohol and sedative
hypnotics. For patients with drug addiction, family members should control all finances
to ensure that the patient is unable to acquire drugs. After using addictive substances,
patients with addiction problems often change their diets, sleep patterns and daily
routines. Therefore, these often serve as indirect indicators that the patient has
suffered a relapse simply by observing changes in their daily life.
Proper responses to withdrawal symptoms and relapses
Patients who are currently using addictive substances, those who have been using alcohol
and sedative hypnotics for a long time, or patients who are receiving drug maintenance
therapy may experience withdrawal symptoms as a result of the pandemic’s impact. When
this occurs, they should seek immediate help from professional institutions. When
a patient relapses for the first time, family members should stabilise their emotions
and avoid casting excessive blame on the patient. At the appropriate time, they can
analyse the causes and discuss countermeasures together with the patient to avoid
further recurrences. If the patient has had repeated relapses, they should be observed
closely, advised patiently and escorted to a medical institution for treatment as
soon as possible once the pandemic is under control or when the conditions are considered
safe enough to visit public facilities. If the relapse has resulted in a physical
or psychiatric emergency, the patient should be taken to a professional medical institution
for emergency treatment.
Actively acquire knowledge related to COVID-19 and strengthen self-protection
Patients and families can acquire scientific knowledge, learn the protective measures
for COVID-19 from official media sources, and control the quality of information to
avoid negative effects caused by false or excessive information. At the same time,
social resources, including community portals, media outlets and hotlines, can be
used to alleviate negative emotions and concerns.
Suggestions for rehabilitation treatment centres
At present, China’s intervention institutions for drug use and addiction include primarily
compulsory isolation drug rehabilitation institutions, voluntary rehabilitation facilities,
methadone maintenance treatment clinics and community treatment centres. During a
pandemic, these institutions should take preventive measures against COVID-19 while
ensuring the continuity of treatment and rehabilitation to the greatest possible extent.
In response to practical difficulties, the various types of institutions should offer
corresponding solutions whenever possible.
Drug treatment and rehabilitation institutions
Isolation and detoxification agencies of the public security and judicial systems
are all stringently managed. Limitations to rehabilitation activities, family visits,
communication and related problems may cause patients to experience emotional stress
with corresponding physical symptoms during a pandemic. In severe cases, negative
effects, self-injury or even psychotic symptoms may occur. At the same time, appropriate
site management and services may be hindered. Possible actions to address these circumstances
include the following:
Patients can be sent outdoors (playground) or to a rehabilitation treatment room in
groups, subject to safety regulations
Through reasonable planning and organisation, participant activity spaces can be amplified
based on the premise that closed isolation may have been a root cause of their negative
behaviour. In these spaces, appropriate recreation can be offered, such as yoga, mindfulness
exercises, aerobics, t’ai chi, baduanjin and other sports that have been found to
reduce anxiety, irritability and stress. For these rehabilitation activities, individuals
should maintain social distancing of more than 1 metre, wear masks and pay attention
to disinfection and ventilation in the activity areas.
Enhance health education in rehabilitation institutes
Posters, missionary videos and health education lectures can be used to educate patients
about COVID-19 in a venue. This can help improve patients’ ability to identify diseases,
understand prevention and control techniques, and reduce the risk of negative emotions
caused by inadequate knowledge or misunderstanding.
Strengthen communication with family members by allowing family calls
If possible, the venue should provide family telephones to allow patients to communicate
via telephone or video so they are kept abreast of their situation and receive care
and encouragement from family members, thereby alleviating potential negative emotions.
Receive help from specialist agencies when necessary
Most psychological problems suffered by patients can be resolved by using online consultation
services provided by various medical institutions or other social services. However,
for patients with more severe emotional disorders or persistent hallucinations, impulsive
violence or other detrimental behaviours, appropriate medical treatment should be
sought based on the evaluation of a professional physician. Commonly used medications
include benzodiazepines, antidepressants, mood stabilisers or antipsychotics.
Methadone maintenance treatment facilities
For patients receiving methadone maintenance treatment, the dual effects of opioid
addiction and pandemic stress may leave patients more prone to mental and psychological
distress. In addition, certain circumstances will make treatment of such patients
difficult, including isolation management, fear of being infected when going out to
take medication, conscious avoidance of treatment and complications of the medication
process under pandemic conditions. Open management and treatment in the community
may also increase the risk of relapse. Possible actions to address these issues include
the followings:
Provide a safer medical environment and alleviate patient concerns about infection
during daily medication
Methadone maintenance treatment sites should manage the environment of the entire
facility, maintain clean and ventilated spaces, disinfect regularly, and ensure that
all medical personnel adhere to personal protective measures. Patients should be assisted
when taking medicine in groups at clinics, and long line-ups should be avoided. Patients
receiving medication should be required to wear a mask and cooperate during body temperature
measurements. They should be questioned about any related clinical symptoms and their
epidemiological history, such as cough, shortness of breath, fatigue, diarrhoea and
so on. Those with any abnormalities should be reported to the appropriate departments
for further treatment.
Pay more attention to the education and prevention of COVID-19 and screening evaluations
To reduce the risk of cross-infection, remote networks and psychological interventions
by telephone can be implemented. If a patient’s mental and behavioural problems have
affected regular daily life and social functioning, the patient should be referred
to a mental health institution for further diagnosis and treatment in a timely manner
subject to local safety measures.
Maintain the stability of the treatment plan and prevent additional substance addiction
During a pandemic, care should be taken before avoiding or adjusting any methadone
dose to prevent withdrawal symptoms or fluctuating conditions that increase the difficulty
of treatment. Combined with local methadone maintenance treatment policies and outpatient
management regulations, to ensure safety, patients in stable condition with good compliance
records can be considered for methadone take-home services or provided with alternative
treatments such as Suboxone to minimise risks of cross-infection.
Voluntary drug treatment agencies
Voluntary detoxification is an important part of our drug rehabilitation system. At
present, the domestic voluntary drug treatment institutions encompass primarily the
addiction specialty departments of psychiatric hospitals and independent drug treatment
hospitals. In addition to providing diagnoses and treatment services for drug dependence
and related disorders, they also conduct outpatient and inpatient treatment of issues
related to substance addiction, including alcohol and sedative hypnotics and behavioural
addiction. During this COVID-19 pandemic, the normal diagnoses and treatment of patients
with substance and behavioural dependence throughout the community are inevitably
affected.
Strengthen departmental coordination and optimise the treatment model
The goal should be to establish sound coordination mechanisms with public security
agencies, comprehensive medical institutions, community drug treatment and rehabilitation
agencies, drug maintenance and treatment agencies, and other addiction-related units.
Also important is the fortification of contacts and liaisons with consultants. Given
the actual situation in any local area, it is necessary to refine the work content
and procedures to further ensure that persons with substance abuse and behavioural
problems can receive prompt medical treatment, timely referrals and hospitalisation
when necessary.
Strengthen publicity and expand the coverage of treatment and prevention of addictive
diseases
Voluntary detoxification agencies should not only ensure routine diagnoses and treatment
but also assume the responsibility of preventing addictive behaviours caused by serious
public health events. Measures like science popularisation and professional training
to assist the general population’s ability to improve self-screening for substance
abuse and behavioural problems also benefit the community medical institutions and
non-addiction-related professional medical personnel in their attempts to identify
addiction-related disorders and to expand the coverage of prevention and treatment
services. The screening of addictive substance use, prevention and education for clinic
patients, as well as the timely identification, diagnosis and treatment of related
mental and behavioural problems may all occur under stressful conditions. Follow-up
sessions can be conducted through appropriate communication channels (eg, phone, email,
WeChat and so on).
Strengthen internal management to ensure treatment effectiveness
It is necessary to improve the management of facilities and all hospitalised patients,
to adopt appropriate measures to isolate and prevent infection from spreading among
both the hospital staff and patients, and to eliminate the introduction of possible
sources of out-of-hospital external infections. Also important is the dissemination
of related medical knowledge and the provision of pharmaceutical and/or psychological
interventions to treat mental and psychological problems such as stress, negative
feelings and insomnia. Also, the optimisation of outpatient appointment schedules
would enable patients to visit doctors in an orderly manner and prevent infection
risks caused by too many persons gathering in confined spaces. Telemedicine services
can also be provided to discharged patients by telephone, online consultation and
other methods to enhance continuous service quality.
Management of comorbid COVID-19 and/or other diseases in patients with addiction problems
Patients with addiction problems often suffer from several physical and mental illnesses.
This substantially increases the difficulty of treatment once a patient contracts
COVID-19. The treatment of comorbid physical and mental illnesses often requires the
deployment of alternative addiction treatments.
Suspected or actual COVID-19 infection in patients with addiction problems
Patients with addiction problems who are either suspected of being infected or are
infected with COVID-19 should be isolated immediately for a predetermined period.
Isolation, treatment and recovery management should be provided in accordance with
the stipulated requirements for suspected or infected patients. Special attention
should be paid when asking patients about previous and current substance abuse, withdrawal
symptoms previously experienced, and other physical diseases. Addiction professionals
should be invited to join treatment groups, thereby allowing general physicians and
these specialists to jointly formulate the most appropriate treatment plans. When
controlling physical diseases, medical teams should treat the symptoms generated by
withdrawal from addictive substances. Patients suffering from the dual effects of
COVID-19 and withdrawal may complicate the disease and increase the difficulty of
treatment. Therefore, the patient’s vital signs should be closely monitored and variances
should be treated promptly. Psychosocial interventions should also be provided during
treatment.
Other comorbid physical or mental diseases in patients with addiction problems
Often that patients with addiction problems have other comorbid physical or mental
diseases. Reports show that about 50%–70% of patients with addiction problems suffer
from other mental illnesses, and 20%–50% of patients with other mental illnesses also
suffer from substance use disorders. Also, long-term use of psychoactive substances
may lead to malnutrition, low immune function and a higher risk of contracting other
physical diseases.13 Practical difficulties during this pandemic have inconvenienced
patients from receiving timely medical treatment, and this in turn may lead to increased
risk of addictive substance use. Therefore, more attention should be paid to the physical
and mental conditions of patients with comorbid conditions. If treatments not involving
drugs are ineffective in coping with negative emotions and/or exacerbations of physical
illnesses, patients should be instructed to seek professional treatment as soon as
possible.
In sum, according to the theory of stress-facilitated addictive behaviours when coupled
with environmental and other restrictions, the prevalence of patients with addiction-related
disorders may increase during a pandemic, while existing patients may exacerbate their
poor condition or even relapse,14 thus posing greater challenges for the healthcare
personnel. This article provides a summary of the common addictive behaviour problems
that may occur or worsen among the general population and patients with addiction
problems during a pandemic and proposes possible intervention methods. We hope to
use this research as a foundation to further explore a set of effective prevention
and treatment methods for addiction that are bound to be necessary during future major
public health crises in order to prepare and benefit the general population.