Priorities for Alcohol Use Disorder Treatment and Prevention During COVID-19’s Second Wave

Comical memes have circulated referencing the US population emerging as “alcoholics” from COVID-19 quarantine. Although these are amusing, the intersection between substance use disorders and global pandemic conditions is far more menacing. By the end of 2020, deaths from COVID-19 surpassed 300 000, and more than 19 million cases were reported in the United States. Although the pandemic affects everyone, the risk is especially severe for the millions of vulnerable Americans with alcohol use disorder (AUD) and, alternately, for those at risk for developing this condition as a result of pandemic-related factors.

Consensus is emerging among disaster researchers that the severity and incidence of substance use disorders increase as a result of disaster-related psychological changes. Disaster exposures involve behavior changes and readjustment related to unanticipated problems, such as job loss, housing insecurity, and loss of a loved one.¹ Research shows that coping with such trauma-related stressors as well as posttraumatic stress symptoms may manifest in increased alcohol consumption.² Moreover, substantial research has shown that the tensions of having children at home, financial instability, lack of mobility, and other pandemic stressors may exacerbate domestic violence against partners or children. These associations are further augmented by alcohol consumption.³

The pandemic’s stressors and alcohol consumption are reciprocal. It is well-recognized that alcohol abuse is associated with a range of communicable and noncommunicable conditions such as HIV/AIDS, cardiovascular disease, and liver disease. Furthermore, persons with AUD have increased susceptibility to respiratory pathogens and lung injury, including a two to four times greater risk of acute respiratory distress syndrome, which is a key cause of death in COVID-19.⁴ Thus, the World Health Organization (WHO) and the Centers for Disease Control and Prevention have issued statements about the short- and long-term physical and mental impacts of alcohol abuse during the pandemic. Serious implications for access to services for patients with alcohol-related issues have also been noted.

The confluence of fear, routine disruption, financial distress, and isolation experienced throughout the world during a global pandemic can certainly affect mental health and substance use at a population level. For example, research on the psychological sequelae of SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) showed substantial increases in posttraumatic stress symptoms, which were correlated with substantial increases in alcohol use up to three years after the SARS epidemic.⁵ Moreover, evidence from previous mass traumas, such as the 9/11 attacks and Hurricane Katrina, suggests that the stress of these events and anxiety about the future can increase alcohol consumption and exacerbate AUD.⁶ Similarly, COVID-19 has resulted in an overall increase in fear, anxiety, and depressive symptoms among the general population. In a recent cross-sectional survey, about one fourth of respondents indicated experiencing a trauma or stress-related disorder, and at least 10% reported an increase or initiation of alcohol use specifically related to COVID-19.⁷

Although an overall decrease in alcohol-related sales at bars and restaurants has been observed as a result of COVID-19 closures, other forms of alcohol distribution have reported record-level activity. Such findings may be cause for concern, as research shows that a greater overall alcohol intake is associated with an increased risk of developing AUD. Off-premise sales of alcoholic beverages rose by 55% during May 2020 compared with May 2019.⁸ Online sales went up 477% since the start of quarantine, and ready-to-drink cocktails rose by 106% compared with last year.⁹ Alcohol home delivery and cocktail carryout services have taken the place of bars during quarantine, and in most states, liquor stores remain open for business; although the service industry is slowly reopening, home delivery could become the new normal. With these changes in alcohol consumption and distribution, it is important to activate a multidimensional range of approaches to mitigate the more serious alcohol-related harms arising from this pandemic.

Routine access to drug treatment is vital to avoid relapse and to treat AUD-related comorbidities. However, not only is COVID-19 making access to in-person treatments nearly impossible, but it is limiting the amount of services available. One avenue to alleviate the lack of access for in-person consultation is to increase access to telebehavioral health services. In addition, we need to support longitudinal research to further understand the impact of COVID-19 on substance use. Finally, we need to review current alcohol policies and suggest changes that may be warranted.

TELEMEDICINE

Although this is a highly isolative time for most, many AUD recovery programs rely on peer support, behavioral therapies, and in-person treatments that help patients avoid relapse or escalation in alcohol use. However, in-person visits might prove difficult during the pandemic: traditional in-person therapies or support groups have been cancelled or moved online, COVID-19 has affected staff availability for work, and some patients may require home isolation. A study of substance use disorder service utilization after Hurricane Katrina observed a downward trend in admissions over time because of systemic interruptions in access. However, it may be possible to circumvent such interruptions related to COVID-19, engaging and retaining patients in treatment. Nora Volkow, director of the National Institute on Drug Abuse, reported that COVID-19 has resulted in increased availability of telephone- and Web-based peer support channels to aid individuals’ recovery.¹⁰ For example, Alcoholics Anonymous meetings, an effective method for drug and alcohol abstinence when used in conjunction with other treatment options, is now widely available via common online meeting platforms.¹¹

Online support may present challenge: access to a computer or the Internet may be limited, messaging can be easily misinterpreted, and communication challenges can arise from the lack of visual and aural cues typically relied on in face-to-face communication. It is critical to provide alternative options to virtual groups. A recent study in London, United Kingdom, demonstrated that virtual clinical contact with an alcohol nurse specialist during lockdown was positively correlated with avoiding relapse and even developing new abstinence behaviors during isolation.¹² Because of a decrease in accessible in-person treatment options, aggressive outreach programs should be put in place to retain existing patients in care and encourage new patients to seek treatment; research shows that patient outreach interventions result in increased treatment attendance and continuity of care.⁹

Policy changes have also been enacted to support rapid adoption of telebehavioral health services to ensure continuity of care for people with AUDs, and many states are expanding Medicaid and reopening insurance exchanges under the Affordable Care Act. The Substance Abuse and Mental Health Services Administration (SAMHSA) has relaxed regulations governing telehealth, broadening access to recovery services.¹³ Although these are steps in the right direction, we must continue to expand and improve existing telebehavioral health services to prepare for a coming mental health and substance use disorder crisis—a “second wave” as described by the mental health community—and support from the government will be required to reinforce the behavioral health system.

LONGITUDINAL RESEARCH

It is important that longitudinal research be conducted on the potential psychological effects and comorbid AUDs anticipated from this unprecedented health crisis. Drawing from past observation, we can predict that we are likely to witness a long-term increase in AUD cases stemming from both an increase in current consumption and psychological distress related to COVID-19. Research from China found that alcohol use increased substantially up to three years after the SARS epidemic.⁵ It is important to note that the SARS epidemic did not require mass, long-term isolation as we have experienced with COVID-19. Research shows that longer durations of quarantine are associated with poorer mental health and posttraumatic stress symptoms, thus psychological consequences from the current pandemic may be more severe.¹⁴

Post-9/11 research showed that alcohol use increased as a result of posttraumatic stress symptoms and that the intensity of exposure predicted a greater likelihood of binge drinking.¹⁵ With recent studies showing that the COVID-19 pandemic is having similar psychological effects and that alcohol is being used as a coping mechanism, an increase in alcohol use and a subsequent increase in the amount of AUD cases is to be expected. Health registries such as the World Trade Center Registry and similar longitudinal analyses will help us better understand and respond to the complex relationship between pandemic-related trauma, AUD, and other psychological comorbidities.

POLICY ANALYSIS

The vast majority of states have allowed alcohol takeout and delivery, and at least 40 states deemed liquor stores essential businesses during shelter-in-place orders. However, relaxed sales policies that may serve to protect restaurants and bars contribute to major long-term costs from alcohol harm. The relaxation of licensing restrictions is allowing establishments such as restaurants and bars, which are not usually authorized to sell alcohol to go, to sell alcohol for at-home consumption. In addition, home delivery services such as contactless delivery may result in alcohol being left unattended without verifying the condition or even the age of the customer, contributing to possible alcohol abuse.¹⁶ A WHO alcohol policy review describes the importance of restricting physical access to alcohol, and literature reviews have shown that regulating the hours, days, and density of alcohol availability are effective strategies for reducing alcohol-related harms, including alcohol-related violence.^17,18

Undoubtedly, ease of alcohol access is warranted as an approach to harm reduction: restriction of access to alcohol could result in dangerous withdrawal symptoms among people with severe AUD, and there is a risk that people will stockpile alcohol to manage anxiety. However, it is important to ensure that these loosened restrictions are examined and possibly reversed as bars and restaurants reopen and more so when the epidemic recedes. Relaxed alcohol access policies should serve only to maintain population health, not to benefit alcohol-related industries.

Finally, it should be noted that federal- and, in some cases, state-level operations policies were already in place before COVID-19 to guide behavioral health services during large-scale crises. In 2013, SAMHSA published Disaster Planning Handbook for Behavioral Health Treatment Programs, which has specific guidance for organizations to modify services in times of a flu pandemic.¹⁹ The publication deals with planning for telebehavioral care, hygiene, staffing, communication, and vulnerable patients, as well as steps for implementing emergency plans. An evaluation of substance use disorder treatment services related to 9/11-related trauma reported the need for agencies and administrators to develop, communicate, and practice emergency operations, emphatically stating, “States, counties, cities, and programs must have a disaster plan!”^20(p30) Many municipalities likely have response plans that may or may not encompass disasters such as pandemics. Where such plans are in place, it is essential that stakeholders conduct thorough examinations of the degree to which their plans were executed, the effectiveness of the plans, and elements of the plans that require revision in light of COVID-19. SAMHSA’s disaster planning handbook provides helpful guidance for programs to develop, enhance, and evaluate their emergency preparedness plans.

CONCLUSIONS

COVID-19 poses a major threat not only to the general public but to the AUD population especially. The physical effects of the virus, along with related stressors, may lead to a growing AUD population. It is our contention that alcohol-related harms may be managed and even prevented through the activation of various channels; in particular, we focus on telebehavioral health to treat AUD and the future reversal of relaxed alcohol access policies in states. Further, by engaging in extensive longitudinal research from here forward, we can better understand the interplay between substance abuse and traumatic events, prepare for and possibly avoid a second wave of COVID-related AUD, and improve AUD care in pandemic and other future crisis situations.