COVID-related stressors and increasing instances of substance abuse

Throughout 2020, the United States has been playing catchup against the coronavirus. As several well-researched articles have noted, lack of appropriate and timely response has been at the forefront and can be attributed to numerous factors including the highly contagious nature of the virus and, simultaneously, a delay in formulating an adequate medical management and containment strategy. Unfortunately, this catchup game has led to one of the greatest losses of human life during a pandemic in recent years. While there are few, if any, silver linings with respect to eradicating this pandemic, the same does not have to be true when we look back years from now and examine how we began mobilizing to stem what is likely to become an increasingly serious public health crisis: psychological/emotional stress and skyrocketing rates of substance abuse.

Though data remains preliminary, 2020 has seen a rise in the number of opioid-related overdoses, with more than 35 states reporting increases in opioid-related mortalities. The aggravating circumstances behind this disturbing trend are still unknown. It could be due to a rise in the number of people in recovery who had fallen into despair due to the COVID crisis. It could also be because individuals who were already struggling with substance abuse disorders were forced to resort to stronger and often deadlier forms of opioids (i.e., fentanyl) because of financial issues or an inability to procure drugs with which they had greater familiarity.

Opioid-related abuse may not be the only form of substance abuse on the rise. Since states began locking down in March, there have been record sales of alcohol and cannabis (in states where usage is allowed). Given that the increase in use is occurring in conjunction with social isolation, prolonged confinement, and the additional environmental stressors of living through the pandemic, it is reasonable to assume that abuse of these substances will become common.

Though alcohol use is normalized in our culture, heavy drinking is estimated to have resulted in the premature deaths of 93,296 Americans between 2011 and 2015. The average amount of time that was shaved off an individual’s life due to excessive alcohol use: 29 years.

Acute stress disorder and post-traumatic stress disorder

Without question, COVID-19 will inflict lasting trauma on many people in the U.S. This is especially true of those who are on the frontlines of the pandemic, those who have suddenly lost a loved one, or those who have had to undergo lifesaving but invasive medical procedures like intubation.

Depending on the nature of the traumatic experience and a host of other factors that can influence resilience, between 5 and 20 percent of those who experience such trauma may develop acute stress disorder (ASD). ASD is characterized by five symptom categories, including: intrusive symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms. ASD is diagnosed when nine or more symptoms from these categories persist for one month or less starting three days after the traumatic event. If the symptoms persist for longer, the diagnosis will likely become post-traumatic stress disorder (PTSD), which affects as many as half of those who initially suffer from ASD. If treated, the average time for PTSD to remit is approximately three years. If untreated, it may persist for up to 64 months, if not longer.

Self-medicating with drugs and alcohol is extremely common among patients with PTSD, with an estimated 46% of such patients developing a concomitant drug or alcohol use disorder. Conversely, research has shown that early intervention and support directly following the traumatic event can substantially improve prognosis.

Allosteric overload

A more insidious element of the pandemic has less to do with trauma and more to do with lower levels of stress that do not reach the threshold of ASD or PTSD, but can, over time, do serious damage. While there will certainly be thousands of patients who will develop PTSD during or following the COVID pandemic, a far larger number of people are experiencing a steady diet of daily stressors: troubling headlines, worries about infection, the inability to travel freely, and the threat of financial ruin. These individuals may be experiencing what Bruce McEwen described as allosteric overload.

Briefly put, McEwen’s research revealed that there is a body-wide network that is hardwired not simply to maintain homeostasis, but to constantly respond and adapt to environmental factors. McEwen called this allostasis. Additionally, he wrote that, “Allostasis also clarifies the inherent ambiguity in the term ‘homeostasis’ by distinguishing between the systems that are essential for life (homeostasis) and those that maintain these systems in balance (allostasis).”

When these systems become overly stressed, this can result in allosteric overload. Most germane to this post, allosteric overload pertains to protracted physiological changes that occur following the activation of the hypothalamic-pituitary-adrenal (HPA) axis—the hormonal/neurological cascade that springs into action when we feel threatened—which is characterized by the release of stress hormones, the most well-known of which is cortisol (appropriately known as “the stress hormone”). If allosteric overload is chronic and the systems designed to maintain balance cannot correct themselves, this can lead to allosteric states like hypertension and a host of other inflammatory diseases. More importantly, these allosteric states often lead to symptoms like sleep disturbances, anxiety, and mood disorders. These are the kinds of conditions for which people around the world self-medicate.

Steps forward

While the rise in substance use disorders during COVID will become more apparent as the pandemic eventually ebbs, the silver lining is that this is not a novel problem. We understand substance use disorders far better than we understand COVID-19, and we also know that one of the largest obstacles to treatment is the shame associated with admitting that one has a problem. Furthermore, we also possess lifesaving drugs (such as Naloxone) that can prevent those with opioid use disorder from dying of an overdose.

Moving forward, we in the mental health community should encourage efforts to eliminate stigmas associated with addiction. More concretely, policymakers should be ready for the increase in opioid-related overdoses and ensure first responders have access to drugs like Naloxone. Secondly, COVID-19 patients and family members should receive easier access to mental health care to improve resiliency and potentially reduce instances of substance abuse disorders that begin as PTSD-related self-medication.