Discussing Substance Use with Clients during the COVID-19 Pandemic: A Motivational Interviewing Approach

The COVID-19 pandemic is accompanied by many stressors, including disruption of routines, social isolation, unemployment, and hypervigilance regarding health and safety from the virus. Risk for potentially traumatic events is heightened for first responders, medical professionals, and individuals whose loved ones become ill with the virus. Risk for victimization may also be heightened for individuals sheltering at home with an abusive partner (Bradbury-Jones & Isham, 2020). During this time of potential increases in stress and trauma, some people may turn to substances to cope. The use of alcohol and other substances is common among trauma-exposed individuals (Stewart, 1996), especially when accompanied by posttraumatic stress (Debell et al., 2014). Thus, trauma-exposed individuals may have heightened risk for substance use during the pandemic. As suggested by the self-medication hypothesis (Khantzian, 1997), using substances to cope can be negatively reinforcing, and over time may contribute to problematic patterns of substance use.

During this pandemic, many people are drinking more frequently and in greater quantities than typical (CCSA, 2020). Pandemic-related stress may contribute to increased use. In China, hazardous and harmful drinking was higher in the epicenter for the COVID-19 outbreak than in other regions, and higher than in previous epidemiological surveys (Ahmed et al., 2020). Heightened alcohol use is reflected in sales, which have increased over 50% in the US (Micallef, 2020) despite widespread closure of bars and restaurants. Cannabis industry analysists also reported sharp increases in revenue as social distancing began in the US (Wells, 2020). Simultaneously, media images and messages have normalized, if not glamorized, substance use as an acceptable and effective method for coping with pandemic-related stressors (e.g., virtual happy hours, signature drinks such as “quarantinis”). The classification of liquor stores and cannabis dispensaries as essential businesses may also contribute to normalization. In the presence of added stressors, normalized use, and limited options for out-of-home recreational activities, individuals are at risk for problematic consumption of alcohol and cannabis (Clay & Parker, 2020; Knopf, 2020a). Those who are in recovery may also find it more difficult to stay sober as support groups change and move to virtual platforms (Knopf, 2020b).

Any increase in problematic substance use is worrisome, as misuse is linked to a variety of physical and psychological risks. Alcohol is linked to weakened immune functioning (Sarkar et al., 2015) and cardiovascular conditions that can increase the severity and mortality of COVID-19 (Jordan et al., 2020; Klatsky, 2015). Smoking or vaping cannabis or tobacco can also compromise the respiratory system, potentially increasing susceptibility to COVID-19 and worsening respiratory symptoms for individuals infected (Liu et al., 2020; Volkow, 2020). Substance use can also exacerbate mental health problems and interfere with recovery from traumatic events (Boden & Fergusson, 2011; Kaysen et al., 2011).

It is a critical time to engage in conversations with clients regarding their substance use, and Motivational Interviewing (MI) offers an ideal framework to do so. Conceived in the addictions field, MI is a client-centered, evidence-based method of communication designed to address ambivalence and promote behavior change (Miller & Rollnick, 2013). The tenets of MI are well-suited for the assessment and discussion of substance use during uncertain and stressful times. The approach is non-judgmental, empathic, strength-based, individualized, and emphasizes the client’s autonomy. Thus, conversations can connect substance use/misuse with current stressors, trauma history, and personal values that are meaningful to the client in order to provide context and motivation to strive for healthy use and when indicated, facilitate a discussion of goals for changing use. MI can be used with existing clients, new clients, or individuals not yet seeking behavioral treatment (e.g., in primary care). Many providers are switching to telehealth during the pandemic, and MI has been implemented successfully via telephone to intervene with substance misuse (Walker et al., 2017) and other high-risk behaviors (Mbilinyi et al., 2011; Picciano et al., 2007). MI has also been used successfully to reduce substance use among individuals with trauma histories and PTSD (Tucker et al., 2017; Walker et al., 2017), suggesting it is likely to be effective in the current high-stress context.

For providers less familiar with MI, it may be difficult to think about how to incorporate MI into an ongoing practice in the midst of the pandemic. To begin, we encourage reflective listening when asking how substance use has changed with the pandemic. This provides a way to assess current and changed use, while fostering discussion about how and why clients are using. MI can also be used to uncover and affirm healthful coping. For example, if a client reports, “I have one drink on Wednesdays over a Zoom call with friends and it feels like a treat,” responding with, “You’re careful and specific about how you drink right now – you want to maintain control” can help the individual identify positive coping strategies. The client-centered communication can also help people identify and address worrisome patterns. For instance, after a client discloses increased use, a provider may reflect, “You’re having a difficult time managing stress and your solution right now has been alcohol. What concerns do you have about that long-term?”

MI can also facilitate problem solving by identifying the needs being addressed through substance use and what skills might be helpful. For a client who reports drinking because of loneliness, a provider may reflect, “Loneliness is uncomfortable and you want to find alternatives.” An MI approach invites clients to take an honest look at their use and recognizes the responsibility for decisions inherently rests in the client. Offering feedback is done with explicit permission or the message, “what you do with this is up to you.”

In these ways, MI can allow open exploration of substance use change during unprecedented times. These strategies are well-suited for telemedicine and appropriate for trauma-exposed individuals, who may be vulnerable to using substances to cope during the pandemic. Thus, we encourage MI-based assessment and early intervention to address potential escalations in substance use and mitigate harms of the pandemic, along with further research into its efficacy in this specific context.