Abstract
Background:
The unprecedented first wave of the COVID-19 pandemic severely impacted mental health services globally. However, the negative impact of such disruptions on people with substance use disorders (SUD) seeking treatment remains unclear. We aim to explore the behaviors adopted by these individuals to overcome the service disruptions.
Materials and Methods:
We explored the changes related to substance use behavior (quit attempts, withdrawal experienced, treatment-seeking, and risky behaviors), and behavioral changes in response to COVID-19 lockdown. A cross-sectional survey was conducted among 404 people with SUD seeking treatment from seven centers across India. They were assessed by a specially designed structured questionnaire during the first wave (June–September) of the pandemic.
Results:
An overwhelming majority experienced withdrawal symptoms, with close to half making quit attempts and seeking treatment during the lockdown. Three-fourth of the sample reported difficulty in accessing treatment services and medications. Patients with opioid use were significantly more likely to think about quitting (χ2 = 20.408, P = 0.000), make attempts (χ2 = 12.436, P = 0.000), seek treatment (χ2 = 7.536, P = 0.006), and self-medicate for withdrawal symptoms (χ2 = 5.885, P = 0.015). In turn, those with alcohol use were more likely to use telepsychiatry services (χ2 = 35.143, P = 0.000) and experience stigma by family members (χ2 = 29.951, P = 0.000) and neighbors (χ2 = 17.725, P = 0.000). Among COVID-19 safety precautions, majority practised wearing masks and social distancing but not others.
Conclusion:
COVID-19 lockdown led a significant proportion of substance users, especially opioid users, to make quit attempts and seek help. However, these could not be sustained due to difficulty in accessing treatment services. Further, significant proportion failed to adhere to COVID-19 safety precautions.
Keywords: COVID-19, substance use disorders, treatment, withdrawal symptoms
INTRODUCTION
The COVID-19 pandemic has caused significant morbidity and mortality throughout the world.[1] While a number of effective vaccines have been approved, their rollout is neither inclusive nor adequately planned.[2] In fact, many countries are currently facing a second wave of pandemic.[3] As the number of infected people rises, there is a likelihood that the strict measures initiated during the first wave may be put in place again. Measures such as lockdown or quarantine, while being useful in controlling the spread of the infection, have challenges of their own.[4] Such interventions are likely to impact the availability and accessibility to general medical health care including mental health and de-addiction services.[5,6]
Subjective experiences during the first wave of the pandemic suggest a significant negative impact on de-addiction services.[7,8,9] According to an international survey of addiction professionals, disruptions were seen in harm reduction, outreach, and routine clinical services.[10] Due to quarantine measures, the availability and accessibility to addiction services have been reported to be very limited; the problem is more pronounced in developing countries.[11,12] Therefore, patients with substance use disorders (SUD) in developing countries are more vulnerable to experience negative treatment outcomes. Sudden abstinence from substances in those with severe disorders can lead to withdrawal effects, which can be life-threatening in the absence of adequate treatment.[13] Further, available data from the USA suggest that the COVID-19 period was associated with increased death due to drug overdoses.[14]
Substance use is often accompanied by several communal practices, which in turn can be a risk factor for coronavirus spread.[15] As people who use substances usually sit in close proximity, often indulging in substance sharing, their chances of violating universal safety precautions (USP) remain high. While there are indications that some substance users and drug sellers might be adapting to USPs, flouting precautionary behaviors against COVID-19 is not uncommon.[16] Such violations are likely to be higher in people with severe SUD; however, this vulnerable population has not been studied well over this period.
Therefore, our aim was to explore the experiences of the substance users with regard to their substance use behavior, treatment availability, accessibility, and adherence to USP during the COVID-19 lockdown period in India.
METHODS
Study procedure
The Government of India announced a complete lockdown on March 25, 2020, after an overnight notice to contain the spread of COVID-19. The complete lockdown period extended till May 3, during which all nonessential activities including shops, work, and travel were suspended and people were asked to stay in their home except for emergencies.[4] In accordance with the government orders, all psychiatry outpatient departments were shut down and treatment was available only through emergency or telemedicine services.
We reached out to 12 publicly funded psychiatry centers across India; 11 agreed to participate in the study. We chose the centers with the intention to capture data from different regions in India. Therefore, multiple sites from across the country added to the generalizability of our study. Each center got the study protocol approved by their respective institutional ethical committees. The study period was between June 15 and September 15, 2020, and varied for each center in accordance with restarting of outpatient services. Among the 11 centers, three continued to have their psychiatry services closed as the existing services were diverted to the care of patients with COVID-19, while another one dropped out of the study. Hence, final data were collected from seven centers from different regions of India: North (Chandigarh, Rohtak, and Rishikesh), West (Jodhpur), Central (Raipur), and East (Bhubaneswar and Patna).
Participants
We conducted a face-to-face or telephonic interview with patients attending de-addiction services following the withdrawal of the nationwide lockdown. We used a cross-sectional study design with convenience sampling. Patients meeting the following inclusion criteria were included: (i) first registration to the outpatient services for SUD, or patients already registered in the clinic, (ii) patients ≥18 years of age, and (iii) patients providing informed consent for participation in the study. We excluded subjects presenting with (i) severe and complicated withdrawal requiring urgent medical attention and (ii) acute comorbid physical or severe mental illness.
Questionnaire used
We used a pretested structured questionnaire exploring multiple aspects of substance-related behaviors during the lockdown. The questionnaire was drafted by the first author and circulated among others. Subsequent to a number of suggestions, a consensus was reached among all the investigators. The questionnaire was administered by the investigators in Hindi. The participants were evaluated on the following domains: (a) sociodemographic, (b) current substance use and related characteristics, (c) substance availability, quality and cost-related, (d) quit attempts during the lockdown, (e) treatment-seeking, (f) behavioral changes due to COVID-19, and (g) stigma experienced.
For this particular paper, we describe the findings related to substance use-related behavior, i.e., quit attempts and related behavior, treatment-seeking, and behavioral changes conforming with the prescribed standards during COVID-19 – broadly be considered as drug demand and harm reduction. Details of supply-related domains have been discussed in another paper.
For the substance use profile, we identified the current use, and the substance for which treatment was sought or considered most problematic by the patient was considered as the primary substance. We explored different domains of substance use experience during the lockdown (March 25–May 3, 2020) such as changes in the frequency and amount of substance use, compensatory strategies, experience related to withdrawals and quitting, help-seeking and treatment availability, changes in behaviors due to pandemics, and adherence to USP. The patients were asked to recall and rate the maximum severity of withdrawal symptoms experienced during the lockdown period (March 25–May 3, 2020) on a 4-point Likert scale, mild to very severe. Additionally, complicated alcohol withdrawal was defined by alcohol withdrawal seizure and delirium. Stigma experienced was evaluated by exploring if our study participants were being discriminated (e.g., forced social isolation, blaming, and shaming) by family members and, or neighbors because of their substance use during the lockdown.
Statistical analysis
There was no missing data for the sociodemographic and clinical variables. Some responses (<1%) were missing for supply-related variables for two phases of the lockdown, and those cases were excluded. Descriptive statistics were used for the analysis. We used Chi-square tests to compare patients using alcohol and opioid on different categorical variables including quitting, help sought, withdrawals experienced, and stigma.
RESULTS
Sociodemographic and substance use profile
A total of 404 patients from 7 centers were evaluated. The center-wise distribution of the sample was Chandigarh (n = 100, 24.8%), Bhubaneshwar (n = 79, 19.6%), Rohtak (n = 67, 16.6%), Jodhpur (n = 51, 12.6%), Patna (n = 41, 10.1%), Raipur (n = 38, 9.4%), and Rishikesh (n = 28, 6.9%). Majority of them were male (97%), married (69%), educated (94%), and were from urban backgrounds [Table 1].
Table 1.
Sociodemographic characteristics
| Variable | n (%) |
|---|---|
| Male | 393 (97.3) |
| Marital status | |
| Never married | 116 (28.7) |
| Married | 279 (69.1) |
| Education status | |
| Illiterate | 15 (3.7) |
| Literate | 9 (2.2) |
| Primary | 35 (8.7) |
| Middle | 73 (18.1) |
| Higher secondary | 161 (39.85) |
| Graduation | 82 (20.30) |
| PG | 29 (7.18) |
| Employment | |
| Never employed | 28 (6.9) |
| Presently unemployed | 122 (30.2) |
| Presently employed | 90 (22.3) |
| Part time | 24 (5.9) |
| Self-employed | 120 (29.7) |
| Student | 17 (4.2) |
| Any other | 3 (0.7) |
| Living | |
| Joint family | 174 (43.1) |
| Nuclear family | 222 (55.0) |
| Background | |
| Rural | 159 (39.4) |
| Urban | 213 (52.7) |
| Religion | |
| Hinduism | 347 (85.9) |
| Islam | 14 (3.5) |
| Sikhism | 41 (10.1) |
| Distance (km) | |
| <10 | 125 (30.9) |
| 10-24 | 76 (18.8) |
| 25-49 | 61 (15.1) |
| 50-99 | 44 (10.9) |
| >99 | 98 (24.3) |
| Interest in telepsychiatry services | 373/404 |
| Yes | 223 (59.7) |
Among the participants, 52% were currently using alcohol, while 45%, 63%, and 19% were using opioids, tobacco, and cannabis, respectively [Table 2].
Table 2.
Clinical profile of the sample
| Substance | Primary substance, n (%) | Current use, n (%) |
|---|---|---|
| Alcohol | 166 (41.1) | 210 (52) |
| Opioids | 157 (38.9) | |
| Heroin | 74 (18.3) | 80 (19.8) |
| Natural | 57 (13.4) | 63 (15.6) |
| Pharmaceuticals | 27 (6.7) | 39 (9.7) |
| Cannabis | 21 (5.2) | 76 (18.8) |
| Tobacco | 53 (13.1) | 256 (63.4) |
| Others | 7 (1.7) | 10 (2.5) |
Substance use behavior during the lockdown
The majority (97%, 391) reported using any substance multiple times a week, with 3/4th (n = 310) using it on a daily basis. About 28% each reported increasing the frequency (n = 112) and amount (n = 113) of substance intake, while 36% (143) and 39% (157) reported decreasing their frequency and amount, respectively, during the lockdown period [Table 3]. A total of 221 (54.7%) reported using compensatory behaviors to overcome the shortage of drug supply, with stocking as the most common strategy. About 13% (52) reported shifting to other substances, mainly cannabis (n = 17), multiple (n = 15), alcohol (n = 12), and opioids (n = 8).
Table 3.
Substance use behavior during lockdown
| Substance use behavior | N (%) |
|---|---|
| Frequency of substance use during lockdown | |
| Many times a day | 210 (51.9) |
| Daily | 100 (24.7) |
| Many times a week | 81 (20.0) |
| Once a week | 8 (1.9) |
| Less than once a week | 5 (1.2) |
| Frequency compared to before lockdown | |
| Higher than usual (>50% increase) | 41 (10.1) |
| Slightly higher than usual (up to 50% increase) | 71 (17.6) |
| Normal to previous use | 148 (36.6) |
| Slightly less use (up to 50% reduction) | 108 (26.7) |
| Markedly reduced (>50% reduction) | 35 (8.6) |
| Amount compared to before lockdown | |
| Significantly more than previous (>50% increase) | 44 (10.9) |
| Slightly more (up to 50% increase) | 69 (17.1) |
| Similar | 134 (33.2) |
| Slightly less (up to 50% reduction) | 123 (30.4) |
| Significantly reduced (>50% reduction) | 34 (8.4) |
| Compensatory behavior | |
| No compensatory | 183 (45.3) |
| Stocking | 178 (44.1) |
| Increased intake | 60 (14.9) |
| Shifting to other substance | 52 (12.9) |
| Alcohol | 12 |
| Opioids | 8 |
| Others | 17 |
| Multiple | 15 |
Quit attempt and related behaviors
Over 2/3rd (n = 270) of the respondents considered quitting the substance, while over half of them made attempts (n = 215) and sought treatment (n = 203) during the lockdown period. Around 90% (n = 357) reported experiencing withdrawal symptoms, 63% (n = 224) of whom reported moderate-to-severe symptoms, with 3.9% (n = 14) reporting complicated withdrawals. Forty-five percent (n = 162) reported using different strategies to manage withdrawal symptoms including the use of medications previously prescribed (15.5%), over-the-counter medications (17.9%), and reaching out to health services using telephonic services (22.4%) or emergency services (15%) [Table 4]. Patients with opioid use in comparison to alcohol use were significantly more likely to think about quitting (χ2 = 20.408, P = 0.000), make quit attempts (χ2 = 12.436, P = 0.000), as well as seek treatment (χ2 = 7.536, P = 0.006). In turn, those with alcohol use were more likely to experience stigma by family members (χ2 = 29.951, P = 0.000) and neighbors (χ2 = 17.725, P = 0.000) [Table 5].
Table 4.
Quitting related factors related with lockdown
| Reasons for quitting | N (%) |
|---|---|
| Current reason for seeking help | 382 |
| Unavailability | 67 (17.5) |
| Unaffordability | 64 (16.7) |
| Craving | 158 (41.4) |
| Improved motivation | 72 (18.9) |
| Other factors | 21 (5.5) |
| Thought of quitting substance during the lockdown | 270 (67.0) |
| Made quit attempts during the lockdown | 215 (53.3) |
| Sought treatment | 203 (50.4) |
| Withdrawal severity | 357 (88.6) |
| Mild | 133 (37.2) |
| Moderate | 177 (49.6) |
| Severe | 40 (11.2) |
| Very severe | 7 (1.9) |
| Complicated withdrawal | 14 (3.9) |
| Withdrawal management | 357 |
| Self-limited | 195 (54.6) |
| OTC medication | 64 (17.9) |
| Took available medications | 55 (15.4) |
| Contacted health services through phone | 80 (22.4) |
| Contacted emergency services | 54 (15.1) |
| Took other substance | 67 (18.8) |
OTC – Over-the-counter
Table 5.
Comparison of quitting and related behaviors among alcohol and opioid users
| Alcohol (n=166) | Opioid (n=156) | χ2 (P) | |
|---|---|---|---|
| Thought of quitting | |||
| Yes | 102 | 131 | 20.408 (0.000) |
| No | 64 | 25 | |
| Made quit attempt | |||
| Yes | 84 | 109 | 12.436 (0.000) |
| No | 82 | 47 | |
| Sought treatment | |||
| Yes | 79 | 98 | 7.536 (0.006) |
| No | 87 | 58 | |
| Withdrawal management OTC | |||
| Yes | 22 | 37 | 5.885 (0.015) |
| No | 144 | 119 | |
| Sought treatment through phone calls | |||
| Yes | 43 | 4 | 35.143 (<0.0001) |
| No | 123 | 152 | |
| Sought treatment through emergency services | |||
| Yes | 24 | 22 | 0.008 |
| No | 142 | 134 | |
| Stigma faced from family members | |||
| Yes | 44 | 27 | 29.951 (<0.0001) |
| No | 89 | 130 | |
| Stigma faced from neighbors | |||
| Yes | 19 | 4 | 17.725 (0.000) |
| No | 137 | 152 |
OTC – Over-the-counter
Access to treatment services
Three-fourth of the sample reported access to treatment and medications as difficult during the lockdown period. Among those with opioid use, 4/5th of the individuals reported difficulty in accessing opioid substitution therapy services [Figure 1]. Patients with opioid use disorders were significantly more likely to self-medicate their withdrawal symptoms (χ2 = 5.885, P = 0.015), while those with alcohol use disorders used telepsychiatry services for their withdrawal conditions (χ2 = 35.143, P = 0.000).
Figure 1.
Access to treatment, medication and opioid agonist therapy services (n for treatment and medication access = 344, n for opioid agonist therapy access = 167)
Prophylactic measures
A significant majority of the patients reported using masks (96%) or practicing social distancing (72.5%). Over 80% reported some change in their substance-related behavior, with the majority using masks (77.7%). Other precautionary behaviors followed by patients included taking substance alone (34.7%), maintaining physical distancing while collecting substance (17%), and washing bottles or the packages (13.9%). Further changes in dealers’ behavior were also reported with wearing masks (43.6%), physical distancing (22%), and use of gloves (17.7%). The majority reported being engaged in different risky behaviors during the lockdown [Table 6].
Table 6.
Prophylactic measures taken by patients
| Prophylactic measures | N (%) |
|---|---|
| General precautions | |
| Mask | 397 (96) |
| Social distancing | 292 (72.5) |
| Handwashing | 224 (55.6) |
| Staying inside | 115 (28.5) |
| Changes in substance-related behavior | |
| No changes | 66 (16.4) |
| Taking substance alone rather than in company | 140 (34.7) |
| Wearing a mask when going out to get substance | 313 (77.7) |
| Using gloves to collect substance | 46 (11.4) |
| Washing the bottle/foil after collecting it from the dealer | 56 (13.9) |
| Practising physical distancing/avoiding face-to-face delivery | 69 (17.1) |
| Not sharing cigarette/bidi/hookah | 45 (11.2) |
| Changes in dealers behavior | |
| No changes | 182 (45.2) |
| Wearing a mask | 214 (53.1) |
| Using gloves to collect substance | 71 (17.7) |
| Practising physical distancing or avoiding face to face delivery | 89 (22.1) |
| Any risk-taking behavior | 248 (61.4) |
| Traveling during lockdown | 176 (43.6) |
| Sitting in groups | 52 (12.9) |
| Wandering in groups | 66 (16.3) |
| Altercation with police | 23 (5.7) |
| Others | 23 (5.7) |
DISCUSSION
Over 60% of the patients either increased or maintained their usual substance intake pattern, with half of them adopting various compensatory strategies to ensure availability. Over 2/3rd considered quitting the substance, with over 50% making quit attempts during the lockdown period. Patients with opioid use disorders were significantly more likely to consider and attempt quitting as well as seek treatment. However, the overwhelming majority reported poor access to treatment and medications. Further, with the exception of wearing the mask and observing social distancing, other USP were ignored. The majority of patients reported being engaged in different high-risk behaviors during the lockdown.
The lockdown implemented in India was one of the strictest in the world. As a result, complete prohibitions were imposed on the sale of alcohol and tobacco products. In addition, travel-related restrictions would have potentially disrupted the drug supply chain. These factors should have contributed to limited substance intake, and our study reports that one-third reduced their usual substance intake. However, the majority of patients continued to use substances regularly during the lockdown period. It is likely that local supply chains may have been less affected or figured out loopholes to overcome the restrictions. As for one in four patients who increased their frequency and amount of the substance, such an increase could be a maladaptive strategy to cope with the uncertainty and stress related to the pandemic. Due to the unprecedented nature of the COVID-19 pandemic, it remains difficult to predict the overall impact on drug and alcohol use.[17] Surveys based on the general population provide conflicting findings, with some suggesting decrease in alcohol[18,19,20] and drug use,[21] while others suggesting increased alcohol, cannabis, and tobacco use.[22,23,24,25,26] Limited evidence suggests that the COVID-19 pandemic may contribute toward increased drinking in heavy drinkers[27] or relapse in previously abstinent individuals with alcohol use disorder.[28] Further, our findings suggest that in order to overcome the accessibility and availability barriers, compensatory behaviors such as stocking were adopted by the majority and others resorted to shifting to other substances such as cannabis and benzodiazepines which were available.
Sudden lockdown due to COVID-19 was considered by many as an opportunity to reduce their substance.[29] Limited availability and accessibility as well as strict COVID-19 restrictions on social gatherings may discourage individuals from using substances.[30,31] Few studies seem to suggest that COVID-19 can lead to increased motivation and quit attempts among smokers and high-risk drinkers.[32,33] Two-third of our sample considered quitting and over 50% made active quit attempts during the lockdown. While it is likely that COVID-19-related lockdown would have forced the majority to quit substance, it is unclear if such abstinence lasted beyond the lockdown period. Further, there are indications that such forced quit attempts could lead to a surge in the presentation of complicated withdrawals.[13,34] A significant majority in our study also reported experiencing withdrawal effects during the lockdown, with 2/3rd of these experiencing moderate-to-severe symptoms.
To make matters worse, those who suffered from distressing withdrawal symptoms had limited access to health services, with only a minority able to contact emergency or telehealth services. In fact, 3/4th reported difficulty in accessing treatment or medications during the lockdown period. Similar challenges were faced in accessing opioid-assisted therapy. Further, opioid users were more likely to contemplate and attempt quitting, and show help-seeking behavior than dependent alcohol users. Unaffordability of substance and withdrawal symptoms seemed to be a major driver for help-seeking in subjects with opioid dependence. However, difficult treatment access was a major barrier in the help-seeking of opioid-dependent subjects. Since the lockdown was initiated, fears of SUD treatment availability and accessibility have been raised[8] and reported.[34,35] Evidence suggest that stigma and discrimination contribute to limited treatment access among substance users.[36] In our study as well, large proportion reported experiencing stigma from family members and neighbors due to their substance use; those using alcohol reported more perceived stigma than opioid users. High level of stigma might influence their treatment retention and outcome.
Reports from different countries suggest that SUD services were significantly impacted.[10] Although there are incidences where adaptations were made in Indian settings,[37,38,39,40] it is evident that those were far and few and inadequate to help the majority affected by the lockdown. There is an urgent need for addiction services to adapt and innovate using telehealth platforms so as to reach out to clients like being done in other parts of the world.[41] Only a fraction (11%) of patients in our study expressed some unwillingness in using the telehealth services for their treatment, suggesting significant acceptability of such services. Telehealth services functioning during the lockdown also suggest that such services are feasible and accepted by clinicians as well as service users.[42,43] Compared to those with opioid use, a higher proportion of those with alcohol misuse sought treatment by teleservices. This possibly could be explained by a higher concern for privacy and confidentiality for those using opioids than those with alcohol misuse because the former is a controlled substance under the Narcotic Drugs and Psychotropic Prevention Act (1985).
Among USP, an overwhelming majority reported using masks for their safety, while 3/4th practiced social distancing and half washed hands frequently. However, only a minority reported staying inside their houses during the lockdown. General population survey indicates much higher knowledge and adherence to USP in comparison to our sample.[44,45,46,47,48,49] According to the Health belief model hypothesis, changes in health-related behaviors are dependent on the perceived threat (perceived vulnerability and severity) and cost–benefit analysis (perceived benefit and perceived barriers).[50,51] For people using substances, this would mean staying inside and limiting their activities. However, withdrawal state and craving are likely to act as a strong perceived barrier and hence offset any perceived benefits. Further, while being under the influence of the substance, people might downplay the perceived threat and fail to adhere to USP. In fact in our study, despite the majority wearing masks, 3/5th reported being involved in COVID-19-related risky behaviors. The most common risky behavior being traveling outdoors, sitting, or wandering in groups. Similar communal risky behaviors among substance users have been reported in studies conducted during the early stages of pandemic.[52,53]
Ours is the first multicentric study from India which has explored the experiences of the substance users during the lockdown. There are several limitations to our findings. Firstly, since the data were collected after the lockdown was over, it is difficult to rule out recall bias. Secondly, since this is a hospital-based study, it fails to capture the experience of the population which would have remained abstinent even after the lockdown was lifted. Moreover, our study captured the high frequency and heavy substance-using population, and therefore, our results should not be extrapolated to the low frequency, occasional users thirdly, data collected from different centers vary in number, and hence the generalizability can be questioned. Despite these limitations, our study adds significantly to the growing evidence on the impact of COVID-19 among substance users.
CONCLUSION
The COVID-19 pandemic had mixed effects on the frequency and amount of substance used during the lockdown. The prevailing situation due to complete closure and suspension of nonessential activities motivated a significant proportion of substance users to make quit attempts. However, the majority faced hurdles in accessing treatment services. Further, most of the patients did not adhere to COVID-19 precautionary guidelines, exposing themselves to several situations which could increase the risk of contracting the infection. Since multiple waves of the pandemic are expected in the near future, lessons need to be learned from the experience of the first lockdown. Further, patients with SUD need to have directed interventions to ensure awareness regarding the USP.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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