Substance Use Disorders and COVID-19: Multi-Faceted Problems Which Require Multi-Pronged Solutions

COVID-19-Related Financial Hardship Is Associated With Depression and Anxiety in Substance Use Treatment Across Gender and Racial Groups

ABSTRACT

Many individuals lost their employment during the COVID-19 pandemic and experienced financial hardship. These experiences may increase risk for co-occurring conditions, including substance use disorders (SUDs) and related symptoms of depression and anxiety. This study aimed to examine the associations between COVID-19-related financial hardship and/or job loss and co-occurring symptoms, across gender and racial groups. Respondents (N = 3493) included individuals entering SUD treatment in the United States in March-October of 2020. Results demonstrated that COVID-19-related financial hardship and unemployment in the household was associated with greater depression and anxiety severity among people in SUD treatment (p's < 0.05). Our findings highlight financial hardship and loss of employment as risk factors for co-occurring depression and anxiety. However, additive effects between marginalized identity status and COVID-19 economic hardship on co-occurring symptoms were not observed.

High levels of all-cause mortality among people who inject drugs from 2018 to 2022

BACKGROUND

Mortality among people who inject drugs (PWID) is high, with overdose and HIV infection being the main causes of death. In Greece, there have been no data on mortality, and two HIV outbreaks have been recorded in this population in the past decade. In this study, we aim to estimate the all-cause crude mortality rate and the standardised mortality ratio in this population during 2018-2022.

METHODS

PWID recruited from two community-based programs in Athens and Thessaloniki during 2018-2021 were interviewed and tested for HIV/HCV. Data on vital status (deceased/alive) and date of death were obtained from death registries through December 31, 2022. All-cause crude mortality rates (CMR) and standardised mortality ratios (SMR) were estimated. Determinants of mortality were assessed using Cox proportional-hazards model.

RESULTS

Of 2,530 participants, 301 died over 8,543 person-years (PYs) of follow-up. The CMR (95 % CI) was 3.52 (3.15-3.94) deaths per 100 PYs; 3.10 per 100 PYs (2.68-3.58) in Athens and 4.48 per 100 PYs (3.74-5.37) in Thessaloniki. An increasing trend in CMR was identified over 2018-2022 in Athens (from 2.90 to 4.11 per 100 PYs, 41.5 % increase, p = 0.018). The pooled SMR (95 % CI) was 15.86 (14.17-17.76) for both cities and was particularly increased in younger individuals, females, those injecting daily, not enrolled to opioid agonist treatment and HIV-infected individuals. Older age, living in Thessaloniki, Greek origin, homelessness, history of injection in the past 12 months, and HIV infection were independently associated with higher risk of death.

CONCLUSION

Mortality among PWID in the two largest cities (Athens and Thessaloniki) in Greece in 2018-2022 was high, with the population in Thessaloniki being particularly affected. The increasing trend in mortality in Athens may reflect the long-term impact of the COVID-19 pandemic. Preventive programs such as take-home naloxone, screening and treatment for HIV, are urgently needed.

Perspectives of Canadian Healthcare and Harm Reduction Workers on Mobile Overdose Response Services: A Qualitative Study

BACKGROUND

Supervised consumption sites (SCS) are an evidence-based intervention proven effective for preventing drug overdose deaths. Obstacles to accessing SCS include stigma, limited hours of operation, concerns about policing, and limited geographic availability. Mobile overdose response services (MORS) are novel technologies that provide virtual supervised consumption to help reduce the risk of fatal overdoses, especially for those who use alone. MORS can take various forms, such as phone-based hotlines and mobile apps. The aim of this article is to assess the perceptions of MORS among healthcare and harm reduction staff to determine if they would be comfortable educating clients about these services.

METHODS

Twenty-two healthcare and harm reduction staff were recruited from Canada using convenience, snowball, and purposive sampling techniques to complete semistructured interviews. Inductive thematic analysis informed by grounded theory was used to identify main themes and subthemes.

RESULTS

Four themes were identified: (1) increasing MORS awareness among healthcare providers was seen as useful; (2) MORS might lessen the burden of drug overdoses on the healthcare system but could also increase ambulance callouts; (3) MORS would benefit from certain improvements such as providing harm reduction resources and other supports; and (4) MORS are viewed as supplements for harm reduction, but SCS were preferred.

CONCLUSIONS

This research provides valuable perspectives from healthcare and harm reduction workers to understand their perception of MORS and identifies key areas of potential improvement. Practical initiatives to improve MORS implementation outcomes exist.

Use of Behavioral Health Treatment Among Parenting Women With Opioid Use Disorder in the United States

OBJECTIVE

To examine use of mental health treatment, substance use disorder treatment, and perceived barriers to treatment by whether a major depressive episode occurred during the past year among parenting women with opioid use disorder.

DESIGN

Secondary analysis of survey data from the National Survey on Drug Use and Health, 2015-2019.

SETTING

United States.

PARTICIPANTS

Women aged 18 to 44 years with opioid use disorder and at least one child in the household.

METHODS

We computed descriptive statistics for demographic characteristics, treatment by major depressive episode status, and barriers to treatment by major depressive episode status. We conducted multinomial logistic regression to examine associations among demographic characteristics, major depressive episode status, and type of treatment.

RESULTS

Of the 36% of respondents in our weighted sample (N ≈ 254,300) who experienced major depressive episode, 35% received substance use disorder and mental health treatment, and 27% did not receive any form of treatment. We found that identification as a person of color was significantly associated with a lower relative risk of receiving any type of treatment. Frequently reported barriers to treatment included affordability, access, and stigma.

CONCLUSION

Respondents with opioid use disorder and co-occurring major depressive episode did not obtain necessary treatment. Barriers to treatment, including affordability, access to treatment, and stigma, need to be addressed, particularly among women of color.

Effect of modified income assistance payment schedules on substance use service access: Evidence from an experimental study

BACKGROUND

Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization.

METHODS

This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services.

RESULTS

Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants.

CONCLUSION

Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access.

Adoption of Electronic Health Record Among Substance Use Disorder Treatment Programs: Nationwide Cross-Sectional Survey Study

BACKGROUND

Electronic health record (EHR) systems have been shown to be associated with improvements in care processes, quality of care, and patient outcomes. EHR also has a crucial role in the delivery of substance use disorder (SUD) treatment and is considered important for addressing SUD crises, including the opioid epidemic. However, little is known about the adoption of EHR in SUD treatment programs or the organizational-level factors associated with the adoption of EHR in SUD treatment.

OBJECTIVE

We examined the adoption of EHR in SUD programs, with a focus on changes in adoption from 2014 to 2017, and identified organizational-level factors associated with EHR adoption.

METHODS

We used data from the 2014 and 2017 National Drug Abuse Treatment System Surveys. Our analysis included 1027 SUD programs (531 in 2014 and 496 in 2017). We used chi-square and Mann-Whitney U tests for categorical and continuous variables, respectively, to assess changes in EHR adoption, technology use, program, and client characteristics. We also investigated differences in characteristics and barriers to adoption by EHR adoption status (adopted EHR vs had not adopted or were planning to adopt EHR). We then conducted multivariate logistic regressions to examine internal and external factors associated with EHR adoption.

RESULTS

The adoption of EHR increased significantly from 57.6% (306/531) in 2014 to 69.2% (343/496) in 2017 (P<.001), showing that nearly one-third (153/496, 30.8%) of SUD programs had not yet adopted an EHR system by 2017. We identified a significant increase in technology use and ownership by a parent company (P=.01 and P<.001) and a decrease in the percentage of uninsured patients in 2017 (P<.001), compared to 2014. Our analysis further showed significant differences by adoption status for three major barriers to adoption: (1) start-up costs, (2) ongoing financial costs, and (3) privacy or security concerns (P<.001). Programs that used computerized scheduling (adjusted odds ratio [AOR] 3.02, 95% CI 2.23-4.09) and billing systems (AOR 2.29, 95% CI 1.62-3.25) were more likely to adopt EHR. Similarly, ownership type, such as private nonprofit (AOR 1.86, 95% CI 1.31-2.65) and public (AOR 2.14, 95% CI 1.27-3.67), or interest in participating in a patient-centered medical home (AOR 1.93, 95% CI 1.29-2.92), were associated with an increased likelihood to adopt EHR. Overall, SUD programs were more likely to adopt an EHR system in 2017 compared to 2014 (AOR 1.44, 95% CI 1.07-1.94).

CONCLUSIONS

Our findings highlighted that SUD programs may be on track to achieve widespread EHR adoption. However, there is a need for focused strategies, resources, and policies explicitly designed to systematically address barriers and tackle obstacles to expanding the adoption of EHR systems. These efforts must be holistic and address factors at multiple organizational levels.

Assessing the risk of COVID-19 reinfection and severe outcomes among individuals with substance use disorders: a retrospective study using real-world electronic health records

OBJECTIVE

Despite advancement in vaccines and treatments for COVID-19 over the past 2 years, many concerns remain about reinfection and waning immunity against COVID-19 and its variants, especially among people with substance use disorder (SUD). The study assessed the risk of COVID-19 reinfection and severe illness among adults with SUD and their vaccination status to inform management in this vulnerable population as the pandemic continues.

DESIGN

Retrospective cohort study.

SETTING

Nationwide electronic health records (TriNetX database) in the USA among adults with COVID-19 infection from January 2020 to June 2022.

PARTICIPANTS

Adults (age ≥18 years) who were infected by COVID-19, excluding those who had cancer or lived in nursing homes or palliative care facilities.

OUTCOME MEASURES

COVID-19 reinfection was defined as a new diagnosis after 45 days of the initial infection. Logistic regression was applied to assess the OR of COVID-19 reinfection and severe outcomes within 30 day of reinfection for adults with alcohol (AUD), opioid (OUD), cocaine (CUD), stimulant (STUD), cannabis (CAUD) and other use disorders, controlled for demographic and comorbid conditions.

RESULTS

The SUD cohort was 13%-29% more likely to be reinfected by COVID-19 and had significantly higher 30-day mortality. Adults with AUD, STUD and OUD were at greater risks (adjusted ORs, AORs=1.69-1.86) of emergency department, hospital and intensive care admissions after 30 days of reinfection. Individuals with SUD and multiple vaccines doses were associated with decreased risks of worse COVID-19 outcomes. Lower COVID-19 reinfection rates (AORs=0.67-0.84) were only found among individuals with AUD, CUD or CAUD who had COVID-19 vaccination.

CONCLUSIONS

Individuals with SUD had greater risks of COVID-19 reinfection and poor outcomes, especially those with OUD, STUD and AUD. Multiple vaccinations are recommended to reduce severe illness after COVID-19 reinfection in the SUD population.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia

BACKGROUND

People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia.

METHODS

In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists.

RESULTS

We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens.

CONCLUSION

Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

Overall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy Changes

Importance

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization.

Objective

To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status.

Design, Setting, and Participants

This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023.

Exposure

The expansion of telehealth services during COVID-19 onset.

Main Outcomes and Measures

Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined.

Results

Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days).

Conclusions

In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

Interrupted Time Series Analysis: Patient Characteristics and Rates of Opioid-Use-Disorder-Related Emergency Department Visits in the Los Angeles County Public Hospital System during COVID-19

The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82–6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations.

Impact of COVID-19 on alcohol use disorder recovery: A qualitative study

In March 2020, restrictions on in-person gatherings were introduced due to the coronavirus disease (COVID-19) pandemic, requiring alcohol use disorder (AUD) recovery resources to migrate to virtual platforms. This study investigated how these restrictions impacted recovery attempts and explored participant experiences with virtual resources using a qualitative approach. Participants attempting recovery from AUD (N = 62; Mage = 48.2; F = 53.2%; 71% White) completed virtual semistructured interviews from July 2020 to August 2020 on their experience during the COVID-19 lockdown, impacts on recovery, and experiences with online resources. Interviews were recorded, transcribed, and analyzed using a thematic coding process. Three overarching themes were identified: Effect on Recovery, Virtual Recovery Resources, and Effect on General Life. Within each overarching theme, lower order parent themes and subthemes reflected varied participant experiences. Specifically, one group of participants cited negative impacts due to COVID-19, a second group reported positive impacts, and a third group reported experiencing both positive and negative impacts. Participants reported both positive and negative experiences with virtual resources, identifying suggestions for improvement and other resources. Findings suggest that while individuals in AUD recovery experienced significant hardships, a proportion experienced positive impacts as well, and the positive and negative consequences were not mutually exclusive. Additionally, the results highlight the limitations of existing virtual resources. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association between smartphone overdependence and generalized anxiety disorder among Korean adolescents

BACKGROUND

This study aimed to investigate the association between smartphone overdependence and generalized anxiety disorder among South Korean adolescents.

METHODS

Participants were selected from the Korean Youth Health Behavior Survey 2020. The primary dependent variable was the generalized anxiety disorder that was measured based on seven item instrument (GAD-7). The main exposure of interest was the smartphone overdependence using the integrated scale developed by the National Information Society Agency in Korea. Weighted chi-square test and multiple logistic regression were used to assess the association between smartphone overdependence and generalized anxiety disorder.

RESULTS

The final participants comprised of 54,948 middle and high school students. 13,775 students (25.1 %) were classified as the smartphone overdependence group. Of those who reported overly dependent on smartphones, 2803 students (20.3 %) had generalized anxiety disorder. The risk for generalized anxiety disorder were 2.15 folds (95 % CI 2.01-2.30) higher among the overdependence group in compared to their counterparts. Specifically, the risk for generalized anxiety disorder increased when smartphone has negatively affected relationships with friends and colleagues (OR: 2.35, 95 % CI 2.08-2.64). The sensitivity of smartphone overdependence scale was verified and the risk for generalized anxiety disorder increased in magnitude with the severity of smartphone overdependence.

CONCLUSION

The findings of the study showed significant association between smartphone overdependence and generalized anxiety disorder among South Korean adolescents. The negative changes in social relationships due to excessive smartphone use and the severity of overdependence accounted for the risk for generalized anxiety disorder.

Treatment Court Family Nights: An Accessible and Adaptable Support for Families Engaging in Recovery

Introduction

While public health measures including physical distancing and stay-at-home orders have clear benefits in COVID-19 mitigation and prevention, they have provided unique challenges for individuals with substance use disorder (SUD), including Treatment Court (TC) participants.

Methods

This study involved a qualitative evaluation of TC Family Nights; one series of Family Nights was conducted before the COVID-19 pandemic and the second series was adapted and held remotely due to COVID-19 distancing requirements.

Results

Several important themes emerged, including general positive experiences, accessible session logistics, naloxone training, attention to stigma, building recovery capital, group engagement, social interaction, and community action. These themes will help inform future SUD recovery education.

Conclusion

Online recovery support events provide a new model for courts and recovery organizations that seek multiple ways to provide connection and support for their participants and families during times when accessibility is prioritized, in-person activities are discouraged, and in resource-sparse and geographically isolated communities.

Possible substance use disorders among first responders during the COVID-19 era: a quasi-experimental study of personal and residential vulnerability

Background: During the COVID-19 pandemic possible substance use disorders (SUD) were exacerbated from increased stress and isolation. Experiences of symptomology differ widely by occupations.Objectives: The objectives were to determine if there is a temporal relationship between COVID-19 vulnerability and possible SUDs among first responders, and to examine the association with neighborhood vulnerability.Methods: We conducted an analysis with two distinct cohorts dependent on time of entry: 1) First responders that began counseling prior to COVID-19 and 2) First responders that began counseling after the start of COVID-19. Data were collected at intake from first responders seeking mental health services between 2017 and 2021 at an organization in Dallas/Fort Worth, Texas. The study sample included 195 mostly male (75%) first responders (51% law enforcement officers; 49% emergency medical technicians/firefighters). Bivariate models tested unadjusted relationships between covariates and possible SUD. Adjusted models consisted of a two-level multivariable logistic regression models.Results: Nearly 40% (n = 77) screened positive for a possible SUD. Those beginning counseling after COVID-19 did not have higher odds of SUDs. For every unit increase in neighborhood Severe COVID-19 Health Risk Index at a first responder's residential location there was an increase in the odds of a possible SUD (AOR = 3.14, 95% CI: 1.47, 6.75).Conclusions: Our study highlights the degree to which personal and residential vulnerability to COVID-19 impacted first responders. The increased occupational stress of this population, and an established pattern of maladaptive coping, elucidates the need for preventative and clinical approaches to strengthen the resilience of this population.

Trends in Substance Use and Abuse During COVID-19 Among the General Population

BACKGROUND

COVID-19 pandemic has brought many public health issues, including substance use and abuse. Individuals abusing substances are vulnerable to severe infections caused by SARS-CoV-2 virus as well as impairment of the immune system, mental health, and physical health. Despite considerable efforts to minimize and prevent substance use, the use of tobacco, alcohol, and illicit substances is ever increasing resulting in morbidity and mortality which significantly leads to socio-economic costs.

METHODS

A quantitative review of the literature searched in PubMed and Google Scholar databases yielded a total of 1416 studies among which 27 cross-sectional studies, conducted on the general population of 15 and above years of age, were selected based on the eligibility criteria.

FINDINGS

A sample of 1,021,118 individuals were investigated in this study. The most commonly used substances were marijuana (100%), methadone (69.86%), and large cigar (60%). A total of 26 substances were reported to have been used during pandemic, 13 of which showed trends in usage (increased/decreased/no change). Of the total sample, 45.89% were males, 54.14% females, and 1.28% others.

CONCLUSION

Everyone and anyone is susceptible to alcohol, tobacco, and other substance use and abuse at different stages of their lives. Therefore, the need for effective preventive strategies is critical in community efforts to combat substance abuse. Combined efforts from local and global stakeholders will lead to curbing the issue of substance use and abuse worldwide.

Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers

The United States is experiencing a syndemic of homelessness, substance use disorder, and mental health conditions, which has been further exacerbated by the COVID-19 pandemic. Although it is expected that mitigation strategies will curb community transmission of COVID-19, the unintended consequences of social isolation on mental health and substance use are a growing public health concern. Awareness of changing mental health and substance use treatment needs due to the pandemic is critical to understanding what additional services and support are needed during and post-pandemic, particularly among people experiencing homelessness who have pre-existing serious mental illness or substance use disorder. To evaluate these effects and support our understanding of mental health and substance use outcomes of the COVID-19 pandemic, we conducted a qualitative study where behavioral health providers serving people experiencing homelessness described the impact of COVID-19 among their clients throughout the United States. Behavioral health providers shared that experiencing social isolation worsened mental health conditions and caused some people to return to substance use and fatally overdose. However, some changes initiated during the pandemic resulted in positive outcomes, such as increased client willingness to discuss mental health topics. Our findings provide additional evidence that the social isolation experienced during the pandemic has been detrimental to mental health and substance use outcomes, especially for people experiencing homelessness.

Supporting syringe services programs in the initiation and scale-up of vaccine administration: findings from in-depth interviews

Background

Vaccine-hesitant persons who inject drugs are at increased risk for several vaccine-preventable diseases. However, vaccination rates among this population remain low. While syringe services programs (SSPs) are places where persons who inject drugs feel comfortable accessing services, few offer vaccination services. This study describes facilitators and barriers to vaccination at SSPs.

Methods

We used convenience sampling to conduct semi-structured, qualitative in-depth interviews with 21 SSPs in the USA from June to August 2021. Interview questions asked SSPs about their perceptions, priorities, barriers, facilitators, and the effects of partnerships and policies on vaccine administration. We used deductive thematic analysis to identify the main themes.

Results

Eight (n = 8) SSPs offered vaccinations, and thirteen (n = 13) did not offer vaccinations. Most SSPs believed offering vaccination services was important, although addressing SSP participants’ immediate needs often took precedence. Staffing, physical space, and logistical issues were the most common barriers to vaccine administration reported by SSPs, followed by SSP participant-related barriers. Facilitators of vaccine administration included access to a tracking system, partnering with agencies or other organizations providing vaccines, and having a licensed vaccination provider on-site. Partnerships provided SSPs opportunities to expand capacity but could also restrict how SSPs operate. Recommended policy changes to facilitate vaccine administration included subsidizing the cost of vaccinations and addressing restrictions around who could administer vaccinations.

Conclusions

Increasing the availability of vaccination services at SSPs requires addressing the varying capacity needs of SSPs, such as tracking systems, licensed vaccinators, and free or low-cost vaccination supplies. While these needs can be met through partnerships and supportive policies, both must consider and reflect cultural competence around the lived experiences of persons who inject drugs.

Substance use and common contributors to morbidity: A genetics perspective

Excessive substance use and substance use disorders (SUDs) are common, serious and relapsing medical conditions. They frequently co-occur with other diseases that are leading contributors to disability worldwide. While heavy substance use may potentiate the course of some of these illnesses, there is accumulating evidence suggesting common genetic architectures. In this narrative review, we focus on four heritable medical conditions - cardiometabolic disease, chronic pain, depression and COVID-19, which are commonly overlapping with, but not necessarily a direct consequence of, SUDs. We find persuasive evidence of underlying genetic liability that predisposes to both SUDs and chronic pain, depression, and COVID-19. For cardiometabolic disease, there is greater support for a potential causal influence of problematic substance use. Our review encourages de-stigmatization of SUDs and the assessment of substance use in clinical settings. We assert that identifying shared pathways of risk has high translational potential, allowing tailoring of treatments for multiple medical conditions.

Funding

SSR acknowledges T29KT0526, T32IR5226 and DP1DA054394; RLK acknowledges AA028292; AA acknowledges DA054869 & K02DA032573. The funders had no role in the conceptualization or writing of the paper.

Mobile phone ownership, digital technology use and acceptability of digital interventions among individuals on opioid use disorder treatment in Kenya

Background

There is limited research on the use of digital interventions among individuals with opioid use disorders (OUD) in low-and-middle income countries. This study aimed to assess mobile phone ownership, digital technology use and acceptability of digital interventions for treatment among individuals on treatment for OUD in Nairobi, Kenya.

Methods

A cross-sectional study was conducted among individuals with OUD. Structured questionnaires were used to collect data on socio-demographic and clinical characteristics, use of mobile phones and other digital technology and acceptability of digital interventions for treatment.

Results

One hundred and eighty participants were enrolled comprising 83.3% males with mean age of 31.5 years (SD 8.6). Mobile phone ownership was reported by 77.2% of participants of which 59.7% used smartphones. One hundred and sixty-six (92.2%) used phones to call, 82.8 and 77.2% used phones to send and receive text messages respectively; 30% used the internet; 57.2% had replaced the phone in past year and 51.1% of participants reported use of at least one social media platform, of these 44.4% had searched social media for information on drug use. Acceptability to receive treatment by phone was 95% and computer 49.4% with majority (88.1%) preferring a text message-based intervention. The preferred approach of delivery of a text message-based intervention were: one text message per day once a week, message to be personalized and individuals allowed to choose time and day to receive the message. Factors associated with acceptability of digital interventions were education level, being single, smartphone ownership and employment.

Conclusion

Majority of individuals on treatment for OUD had access to mobile phones but with high device turnover and limited access to computers and internet. There was high acceptability of digital interventions to provide treatment for OUDs, mostly through phones. These findings highlight factors to consider in the design of a digital intervention for this population.

Possibilities and constraints of rapid online ethnography: Lessons from a rapid assessment of COVID-19 policy for people who use drugs

During the COVID-19 Pandemic, health care provision changed rapidly and funding became available to assess pandemic-related policy change. Research activities, however, were limited to contactless, online delivery. It was clear early on that some elements of online rapid ethnography were feasible and effective, while others would not approach traditional ethnographic depth. We conducted an online Rapid Assessment, Response, and Evaluation (RARE) project from August 2020 to September 2021 to understand how COVID-19 policy impacted people who use drugs. Our interdisciplinary research team conducted online ethnographic interviews and focus groups with 45 providers and community stakeholders, and 19 clients from rural and urban areas throughout Arizona. In addition, 26 webinars, online trainings, and virtual conferences focused on opioid policy and medication for opioid use disorders (MOUD) were opportunities to observe conversations among providers and program representatives about how best to implement policy changes, how to reach people in recovery, and what aspects of the changes should carry forward into better all-around opioid services in the future. Our RARE project was successful in collecting a range of providers' perspectives on both rural and urban implementation of take-home MOUDs as well as a wide view of national conversations, but client perspectives were limited to those who were not impacted by the policies and continued to attend in-person daily clinic visits. We describe challenges to online rapid ethnography and how online research may have allowed for an in-depth, but incomplete picture of how policy changes during COVID-19 policy affected people with opioid use disorders.

The influence of technostress, work–family conflict, and perceived organisational support on workplace flourishing amidst COVID-19

The remote working environment is characterised by excessive use of new technology and work activities that extend to personal time. It is expected of each employee to balance multiple roles whilst maintaining maximum performance and individual wellbeing; however, without adequate support from an organisation, employees languish instead of flourish. The current study applied a model to investigate the combined effect of technostress, work–family conflict, and perceived organisational support on workplace flourishing for higher education employees. The study followed a cross-sectional quantitative research framework. Data were collected from a sample of 227 academic and support staff employees from a selected residential University in South Africa. The results indicated that technostress through perceived organisational support and through work–family conflict influences workplace flourishing. No direct significant effect was reported between technostress and workplace flourishing. Technostress, work–family conflict, and perceived organisational support combined explained 47% variance in workplace flourishing. Perceived organisational support displayed the strongest direct effect on workplace flourishing, and technostress is a strong determinant of work–family conflict, which then mediates the relationship between technostress and workplace flourishing. The study concluded that providing organisational support and creating policies favourable to work–life balance assist employees in managing techno-overload, techno-invasion, and techno-complexity (technostress) better and enhance workplace flourishing. Although employees struggle in the remote working context with demands imposed by techno-overload, techno-invasion, and techno-complexity, the results indicate that perceived organisational support and balanced work life act as job resources that enhance emotional, psychological, and subjective wellbeing (workplace flourishing).

Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times

We carried out a scoping review to characterize the primary quantitative evidence addressing changes in key individual/structural determinants of substance use risks and health outcomes over the first two waves of the COVID-19 pandemic in the United States (US). We systematically queried the LitCovid database for US-only studies without date restrictions (up to 6 August 2021). We extracted quantitative data from articles addressing changes in: (a) illicit substance use frequency/contexts/behaviors, (b) illicit drug market dynamics, (c) access to treatment and harm reduction services, and (d) illicit substance use-related health outcomes/harms. The majority of 37 selected articles were conducted within metropolitan locations and leveraged historical timeseries medical records data. Limited available evidence supported changes in frequency/behaviors/contexts of substance use. Few studies point to increases in fentanyl and reductions in heroin availability. Policy-driven interventions to lower drug use treatment thresholds conferred increased access within localized settings but did not seem to significantly prevent broader disruptions nationwide. Substance use-related emergency medical services’ presentations and fatal overdose data showed a worsening situation. Improved study designs/data sources, backed by enhanced routine monitoring of illicit substance use trends, are needed to characterize substance use-related risks and inform effective responses during public health emergencies.

Mixed methods prospective findings of the initial effects of the U.S. COVID-19 pandemic on individuals in recovery from substance use disorder

The beginning of the U.S. COVID-19 pandemic interrupted integral services and supports for those in recovery from substance use disorders. The current study used qualitative and quantitative data to identify 1) pandemic-related barriers/stressors, 2) coping strategies employed, and 3) how the stressors and strategies predicted subsequent substance use frequency. Participants were 48 adults (40.5% female; 90.2% White) between 26 and 60 years old (M = 42.66, SD = 8.44) who were part of a larger, multi-year longitudinal study of individuals in recovery from substance use disorders. Individuals completed two interviews, one during the six weeks of initial stay-at-home orders in the state in which data were collected and the second within six to twelve months of their initial interview. Common barriers to recovery included cancelled support meetings, changes in job format (i.e., being fired or furloughed), and lack of social support. Common coping strategies included self-care, leisure activities/hobbies, taking caution against exposure, and strengthening personal relationships. The relationship between cravings at baseline and substance use at follow up was stronger for those who experienced worsening of their mental health (B = 21.80, p < .01) than for those who did not (B = 5.45, p = 0.09), and for those who were taking caution against exposure (B = 24.57, p < .01) than for those who were not (B = 1.87, p = 0.53). Those who engaged in self-care (B = 0.00, p>.99) had lower rates of substance use at follow-up than those who did not employ self-care as a coping mechanism (B = 16.10, p < .01). These findings inform research priorities regarding prospective effects of the pandemic on treatment endeavors, particularly emphasizing treating mental health and encouraging self-care strategies.

The influence of race, sexual orientation and gender identity on mental health, substance use, and academic persistence during the COVID-19 pandemic: A cross-sectional study from a national sample of college students in the healthy minds study

Purpose

This study seeks to characterize substance use, mental health, and academic persistence in college students during the COVID-19 pandemic, emphasizing variations by race, sexual orientation, and gender identity.

Methods

National samples (n = 146,810) of undergraduate students from the Healthy Minds Study were compared in two time periods: Fall 2017-Winter 2020 (pre-COVID) and March-December 2020. Descriptive statistics were conducted including t-tests/chi square tests comparing differences between time periods. Logistic regressions were estimated for main outcomes: substance use (licit, illicit, none), anxiety and/or depression symptoms, and academic persistence (student confidence that they will finish their degree). Marginal effects of race, sexual orientation, and gender identity were reported for all logistic regressions.

Results

In March-December 2020, students had 1.70 higher odds of screening positive for anxiety and/or depression compared to pre-COVID semesters. Latinx, Black, and "other" race/ethnicity had significantly higher probabilities of screening positive, as did transgender and gender non-conforming (TGNC) and lesbian, gay, bisexual, and queer (LGBQ) students.;Students had 0.43 times lower odds of reporting substance use in March-December 2020. Asian, Black, and Latinx students had significantly lower probabilities of reporting substance use, as did TGNC and LGBQ students.; During the pandemic, most students (86.7%) report at least 1 day of academic impairment (emotional/mental difficulties that hurt academic performance) in the last month due to mental health (up from 79.9% pre-pandemic).

Conclusions

Using the most comprehensive mental health data in college student populations, this is the first study to describe the impact of the pandemic on undergraduate students' substance use, mental health, and academic persistence/impairment.

Sleep quality and patterns of young West Balkan adults during the third wave of COVID-19 pandemic: a cross-sectional study

OBJECTIVES

To evaluate the sleep patterns among young West Balkan adults during the third wave of the COVID-19 pandemic.

DESIGN AND SETTING

Cross-sectional study conducted using an anonymous online questionnaire based on established sleep questionnaires Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) (February-August 2021).

PARTICIPANTS

Young adults of Bosnia and Herzegovina, Croatia and Serbia.

RESULTS

Of 1058 subjects, mean age was 28.19±9.29 years; majority were women (81.4%) and students (61.9%). Compared with before the pandemic, 528 subjects (49.9%) reported a change in sleeping patterns during the pandemic, with 47.3% subjects reporting sleeping less. Mean sleeping duration during the COVID-19 pandemic was 7.71±2.14 hours with median sleep latency of 20 (10.0-30.0) min. Only 91 (8.6%) subjects reported consuming sleeping medications. Of all, 574 (54.2%) subjects had ISI score >7, with majority (71.2%) having subthreshold insomnia, and 618 (58.4%) PSQI score ≥5, thus indicating poor sleep quality. Of 656 (62.0%) tested subjects, 464 (43.9%) were COVID-19 positive (both symptomatic and asymptomatic) who were 48.8%, next to women (70%), more likely to have insomnia symptoms; and 66.9% were more likely to have poor sleep quality. Subjects using sleep medication were 44 times, and subjects being positive to ISI 15.36 times more likely to have poor sleep quality. In contrast, being a student was a negative independent predictor for both insomnia symptoms and poor sleep quality, and mental labour and not working were negative independent predictors for insomnia symptoms.

CONCLUSIONS

During the third wave of the pandemic, sleep patterns were impaired in about half of young West Balkan adults, with COVID-19-positive subjects and being women as positive independent predictors and being a student as negative independent predictor of impaired sleep pattern. Due to its importance in long-term health outcomes, sleep quality in young adults, especially COVID-19-positive ones, should be thoroughly assessed.

Economic Challenges and Behavioral and Mental Health Risks for Overdose during the COVID-19 Pandemic among People Who Inject Drugs

People who inject drugs (PWID) are a population that disproportionately struggles with economic and mental health challenges. However, despite numerous reports of people globally experiencing new or exacerbated economic and/or mental health challenges during the COVID-19 pandemic, the literature on the effect of the pandemic on PWID and their risk for harm (e.g., overdose) remains sparse. The present study will describe reported changes during the pandemic in risk factors for drug overdose (including changes in mental health symptoms and care access) among PWID in Chicago, and it will examine associations between such risk factor changes and the experience of economic challenges during the pandemic. Participants from an ongoing longitudinal study of young PWID from the Chicago suburbs and their injection risk network members (N = 138; mean age = 28.7 years) were interviewed about changes in their experiences, substance use behavior, and mental health since the start of the COVID-19 pandemic. Bivariate cross tabulations were computed of each "overdose risk factor" with experiences of economic challenges during the pandemic. Fisher's Exact Tests were used to assess statistical significance. Adjusted logistic regression models were also conducted that controlled for sociodemographic characteristics, for time elapsed since the start of the pandemic, and for pre-pandemic income, homelessness, and injection frequency. Over half of our sample reported using alone more than usual during the pandemic, and over 40% reported using more than usual and/or buying drugs that were of a decreased purity or quality. Additionally, a large proportion of our sample (52.5% of those asked) reported more difficulty than usual accessing mental health care. Experiencing loss of a source of income during the pandemic was associated with using more drugs, using alone more, using a larger amount of drugs while using alone, wanting to stop using but being unable, and difficulty accessing mental health care. The preliminary associations found by the present study suggest that economic challenges or disruptions experienced during the pandemic are likely to increase risk for overdose among PWID experiencing such challenges, via changes in the above behaviors and/or conditions that are associated with risk for overdose. Intervention efforts should therefore be focused not only directly on overdose prevention, but also on assisting PWID with their economic challenges and helping them regain economic stability and access to services that may have been impeded by financial difficulty.

The Impact of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Substance Use in the United States

The SARS-CoV-2 pandemic has been associated with dramatic increases in substance use, as marked by increased alcohol, nicotine, and cannabis sales. Lethal opioid overdoses also increased dramatically, especially during the initial phases of the epidemic when lockdowns and social isolation combined with increasing fentanyl contamination of the illicit drug supply resulted in more overdoses and fewer opportunities for rescue. Substance use, and especially inhalational drug use, increases the likelihood of both transmission and severe infection. Youth are especially vulnerable to substance use and have increased risk of long-term problems. These outcomes highlight the need for greater access to substance use treatment. Virtual treatment, which emerged as a promising format during the pandemic, may reduce access barriers. This article reviews trends in substance use during the pandemic, explores root causes of increased use and overdose, and examines the potential to increase treatment through virtual care, especially during future periods of disruption.

The Acute Impact of the Early Stages of COVID-19 Pandemic in People with Pre-Existing Psychiatric Disorders: A Systematic Review

People with pre-pandemic health conditions are more vulnerable and more likely to suffer greater psychosocial impact due to the current COVID-19 pandemic and the lockdown measures. Thus, the objective of this work was to systematically review the impact of the early stages COVID-19 pandemic on people with pre-existing psychiatric disorders. The search was performed between 23 January and 2 September 2021 in PubMed, PsycINFO, and EMBASE. A total of 4167 published results were identified; however, only 49 were included in this review. Results show that there was considerable heterogeneity among studies, which resulted in a low consensus. However, it seems that the impact of the first stage of the COVID-19 pandemic on psychiatric disorders was two-fold: (1) an overall effect, in which people suffering from psychiatric disorders in general experienced more psychological distress and anxiety when compared to people who had no psychiatric diagnosis, and (2) a condition-specific effect, namely in people suffering from eating disorders and obsessive compulsive disorders. Moreover, the current work highlights that there were also some external factors that were related to worsening symptoms. For instance, unemployment or experiencing work and financial difficulties can be a trigger for greater distress during the pandemic for people with mood disorders, and being alone and in social isolation during the COVID-19 pandemic may actually increase substance use and relapse rates. Further studies are needed to prospectively investigate the long-term effects of the current COVID-19 pandemic on people with (pre)-existing psychiatric conditions and on the onset or deterioration of psychiatric-related symptoms in a larger number of participants, as well as exploring the long-term effects of the current pandemic on mental health.

Responding to Covid-19: an analysis of position statements of gerontological societies worldwide

The Covid-19 pandemic, with its adverse implications for older adults, has generated unprecedented public interest in issues around age and ageing globally. We systematically investigated the responses of national gerontological and geriatric societies (NGGS) to emerging challenges during the first wave of the pandemic. Framed within traditional research topics in gerontology, the aim was to identify the spectrum of focal points and positions directed towards governments, policy makers, researchers and society. A comprehensive, two-phased data collection strategy generated N = 22 position statements of NGGS affiliated to the International Association of Gerontology and Geriatrics. Using Ayalon et al. (J Gerontol Ser B, 2020. https://doi.org/10.1093/geronb/gbaa066 ) thematic categorisation of gerontological research, we applied quantitative and qualitative content analysis to analyse "calls for action" within the statements. The content of NGGS' position statements show a high level of agreement on the salient topics during the first wave of the pandemic and reveal shared values such as equality, diversity and inclusion of older adults and the discipline of gerontology to be an applied one with relevance to policy and practice. The results can support future interdisciplinary research in gerontology post Covid-19 based on a vision to contribute to a society of all ages.

Is Methadone Safe for Patients With Opioid Use Disorder and Coronavirus Disease 2019 Infection?

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to not only increase in substance misuse, substance use disorder, and risk of overdose but also lack of access to treatment services. Due to lack of knowledge of the course and impact of COVID-19 and outcomes of it's interactions with existing treatments, the Substance Misuse Service Team initiated a safety improvement project to review the safety of opioid substitution treatment, particularly the safety of methadone. This preliminary retrospective cross-sectional audit of safety improvement intiative underscores the importance of providing treatment services to those with opioid use disorders and that methadone is safe among this population with a high burden of comorbidity, most of which leads to negative outcomes from COVID-19. The outcomes show that patients who have COVID-19 should continue with opioid substitution treatment with methadone. Although treatment with methadone is safe, symptomatic patients should be monitored. In addition, patients who take methadone at home should be educated on the risk of overdose due to, and adverse outcomes from, COVID-19 infection. Patients should monitor themselves using pulse oximeter for any signs of hypoxia.

The impact of COVID-19 on access to harm reduction, substance use treatment and recovery services in Scotland: a qualitative study

INTRODUCTION

People who use drugs (PWUD) are considered vulnerable to COVID-19 exposure and the sequelae of infection due to their social circumstances, health conditions, drug purchasing, and substance use. They can depend on access to services that provide harm reduction, substance use treatment, recovery and support, and general healthcare. Social distancing measures and service restrictions posed significant challenges to the health and wellbeing of PWUD.

METHODS

Ethical approvals were secured. PWUD were recruited from voluntary sector homeless and housing, harm reduction, and recovery organisations across central Scotland. Data was collected via semi-structured interviews and analysed using the Framework Method.

RESULTS

Twenty nine PWUD participated and reported mixed experiences of the impacts of COVID-19 lockdown. Several benefitted from policy and practice developments designed to sustain or increase access to harm reduction services. Some PWUD reported improved access to substitute prescribing and/or appreciated being trusted to manage multiple take-home doses. Others noted the loss of regular in-person contact with treatment providers and dispensers. Access to recovery support was challenging for many, especially those unable to access or uncomfortable with online provision who experienced greater isolation. Lack of access to general healthcare services was common, and especially problematic for PWUD with chronic physical and mental health conditions.

CONCLUSIONS

This qualitative research describes the impacts of COVID-19 social and service restrictions on PWUD in Scotland. These impacts were anticipated by policy makers and service providers. Effective and acceptable developments were shown to maintain and even increase service provision for PWUD. Developments were geographically dependent and significant challenges remained for many people. The learning generated can inform responses to increase service access and uptake in post-pandemic times.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

Using Qualitative, Community-Based Input to Steer Post-COVID-19 Pharmacy Practice in Substance Use

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a disproportionately negative impact on individuals with a substance use disorder (SUD). A rapidly changing public health and treatment environment has resulted in increased needs for pharmacist engagement in SUD-focused patient care.

Objectives

This study used semistructured interviews of SUD professionals to evaluate where they believe pharmacy practice could better support people at risk of or having SUD in light of challenges posed by the COVID-19 pandemic.

Methods

Professionals dedicated to the care of individuals with SUD were recruited from a large community substance use coalition to participate in a qualitative study examining how pharmacists could take a more active role in SUD prevention, intervention, recovery, and harm reduction (HR). A consensual qualitative research approach was used in data analysis.

Results

Domains identified in analysis included pharmacists as educators of patients and communities, pharmacists as educators of health care providers, pharmacists as advocates for individuals with SUD, the need for increased pharmacist engagement owing to COVID-19 challenges for individuals with SUD, the need for expanded pharmacy practice interventions, and the need for pharmacist self-development.

Conclusion

Increased medication counseling, HR practices, addressing stigma, and community-level education focused on SUD were among the most commonly reported areas for pharmacy practice development. In addition, the urgent need to adjust pharmacy practice in response to the COVID-19 pandemic was also identified by interviewees.

The Impact of the COVID-19 Pandemic on the Practice of Forensic Medicine: An Overview

During the COVID-19 pandemic, forensic sciences, on the one hand, contributed to gaining knowledge about different aspects of the pandemic, while on the other hand, forensic professionals were called on to quickly adapt their activities to respond adequately to the changes imposed by the pandemic. This review aims to clarify the state of the art in forensic medicine at the time of COVID-19, discussing the following: the influence of external factors on forensic activities, the impact of autopsy practice on COVID-19 and vice-versa, the persistence of SARS-CoV-2 RNA in post-mortem samples, forensic personnel activities during the SARS-CoV-2 pandemic, the global vaccination program and forensic sciences, forensic undergraduate education during and after the imposed COVID-19 lockdown, and the medico-legal implications in medical malpractice claims during the COVID-19 pandemic. The COVID-19 pandemic has greatly influenced different aspects of human life, and, accordingly, the practical activities of forensic sciences that are defined as multidisciplinary, involving different expertise. Indeed, the activities are very different, including crime scene investigation (CSI), external examination, autopsy, and genetic and toxicological examinations of tissues and/or biological fluids. At the same time, forensic professionals may have direct contact with subjects in life, such as in the case of abuse victims (in some cases involving children), collecting biological samples from suspects, or visiting subjects in the case of physical examinations. In this scenario, forensic professionals are called on to implement methods to prevent the SARS-CoV-2 infection risk, wearing adequate PPE, and working in environments with a reduced risk of infection. Consequently, in the pandemic era, the costs involved for forensic sciences were substantially increased.

The Bronze Age of drug checking: barriers and facilitators to implementing advanced drug checking amidst police violence and COVID-19

OBJECTIVES

Unpredictable fluctuations in the illicit drug market increase overdose risk. Drug checking, or the use of technology to provide insight into the contents of illicit drug products, is an overdose prevention strategy with an emerging evidence base. The use of portable spectrometry devices to provide point-of-service analysis of the contents of illicit drugs been adopted by harm reduction organizations internationally but is only emerging in the United States. This study aimed to identify barriers and facilitators of implementing drug checking services with spectrometry devices in an urban harm reduction organization and syringe service program serving economically marginalized people who use drugs in Boston, Massachusetts (USA).

METHODS

In-vivo observations and semi-structured interviews with harm reduction staff and participants were conducted between March 2019 and December 2020. We used the consolidated framework for implementation research to identify implementation barriers and facilitators.

RESULTS

This implementation effort was facilitated by the organization's shared culture of harm reduction-which fostered shared implementation goals and beliefs about the intervention among staff persons-its horizontal organizational structure, strong identification with the organization among staff, and strong relationships with external funders. Barriers to implementation included the technological complexity of the advanced spectroscopy devices utilized for drug checking. Program staff indicated that commercially available spectroscopy devices are powerful but not always well-suited for drug checking efforts, describing their technological capacities as "the Bronze Age of Drug Checking." Other significant barriers include the legal ambiguity of drug checking services, disruptive and oppositional police activity, and the responses and programmatic changes demanded by the COVID-19 pandemic.

CONCLUSIONS

For harm reduction organizations to be successful in efforts to implement and scale drug checking services, these critical barriers-especially regressive policing policies and prohibitive costs-need to be addressed. Future research on the impact of policy changes to reduce the criminalization of substance use or to provide explicit legal frameworks for the provision of this and other harm reduction services may be merited.

How has the COVID-19 epidemic affected the risk behaviors of people who inject drugs in a city with high harm reduction service coverage in Vietnam? A qualitative investigation

Introduction

The COVID-19 outbreak disproportionally affects vulnerable populations including people who inject drugs (PWID). Social distancing and stay-at-home orders might result in a lack of access to medical and social services, poorer mental health, and financial precariousness, and thus, increases in HIV and HCV risk behaviors. This article explores how the HIV/HCV risk behaviors of PWID in Haiphong, a city with high harm reduction service coverage in Vietnam, changed during the early phase of the COVID-19 pandemic, and what shaped such changes, using the risk environment framework.

Method

We conducted three focus group discussions with peer outreach workers in May 2020 at the very end of the first lockdown, and 30 in-depth interviews with PWID between September and October 2020, after the second wave of infection in Vietnam. Discussions and interviews centered on the impact of the COVID-19 pandemic on their lives, and how their drug use and sexual behaviors changed as a result of the pandemic.

Results

The national shutdown of nonessential businesses due to the COVID-19 epidemic caused substantial economic challenges to participants, who mostly were in a precarious financial situation before the start of the epidemic. Unsafe injection is no longer an issue among our sample of PWID in Haiphong thanks to a combination of different factors, including high awareness of injection-related HIV/HCV risk and the availability of methadone treatment. However, group methamphetamine use as a means to cope with the boredom and stress related to COVID-19 was common during the lockdown. Sharing of smoking equipment was a standard practice. Female sex workers, especially those who were active heroin users, suffered most from COVID-related financial pressure and may have engaged in unsafe sex.

Conclusion

While unsafe drug injection might no longer be an issue, group methamphetamine use and unsafe sex were the two most worrisome HIV/HCV risk behaviors of PWID in Haiphong during the social distancing and lockdown periods. These elevated risks could continue beyond the enforced lockdown periods, given PWID in general, and PWID who are also sex workers in particular, have been disproportionately affected during the global crisis.

Effects of E-Government Policy on the Management of Healthcare Systems

E-government began by addressing the challenges of new technologies by delivering e-services to its citizens and has since evolved to include a growing number of areas, such as citizen communication, macroeconomic projections, budget management, and e-healthcare services. E-government is known as the use of information technology to provide administrative services, communication transactions, information exchange, integration of various electronic systems, and autonomous services between the government and citizens, the government and business environment, and the government and government. This paper discusses the role of E-government policy in healthcare crises during COVID 19. Data collected from 435 employees in the tourism industry of Iraq was used to verify the abovementioned relationships via SPSS macro. The results indicate that E-government policy has a significant effect on healthcare crises; job insecurity negatively predicted healthcare crises. The results revealed that social support moderated the relationship between E-government policy and job insecurity. Results of the study contributed to the theory within this study by demonstrating that employees who enjoy a high level of social support show less job insecurity than those with a low level of social support.

OUP accepted manuscript

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has currently affected >220 million individuals worldwide. The complex interplay of immune dysfunction, active malignancy, the effect of cancer treatment on the immune system and additional comorbidities associated with cancer and COVID-19 all affect the outcomes of COVID-19 in patients with cancer. We have discussed the published findings (through the end of September 2021) on the effects of cancer on the morbidity and mortality of COVID-19, common factors between cancer and COVID-19, the interaction of cancer and COVID-19 treatments, the impact of COVID-19 on cancer clinical services, immune test findings in cancer patients with COVID-19 and the long-term effects of COVID-19 on cancer survivors.

Changes in Substance Use Among People Seeking Alcohol and Other Drug Treatment During the COVID-19 Pandemic: Evaluating Mental Health Outcomes and Resilience

Background:

Alcohol and other drug (AOD) use patterns have altered as a result of the coronavirus (COVID-19) pandemic restrictions. This study aimed to: (i) determine the impact of the pandemic on patterns of AOD use among individuals seeking treatment, (ii) identify which mental health and resilience factors were associated with changes in patterns of AOD use and (iii) evaluate changes in the contextual factors (eg, motivations) associated with use.

Methods:

Cross-sectional surveys were completed by clients (n = 325) who had sought AOD treatment from January 2020 onwards. We measured quantity and frequency of AOD use now compared to before the pandemic, mental health (depression, anxiety, trauma exposure), resilience and contextual factors related to AOD use.

Results:

Quantity of tobacco and cannabis use increased post-pandemic, while methamphetamine and alcohol did not change. Depression was associated with more frequent alcohol use now compared to before the pandemic, while anxiety and lower resilience were associated with less frequent cannabis use now. Lower resilience was associated changes in methamphetamine use. Depression was associated with using more frequently for enjoyment and to alleviate loneliness following the pandemic, and anxiety was associated with using earlier in the day and to alleviate boredom.

Conclusions:

The pandemic has led to increased frequency of AOD use for a subset of individuals seeking treatment. Depression, anxiety and resilience are important factors associated with altered AOD use, and changes in the motivations and control surrounding use. Special consideration of this should be considered during AOD treatment through the pandemic.

The impact of COVID-19 on people who inject drugs in New York City: increased risk and decreased access to services

Background

While people who inject drugs (PWID) are vulnerable to the adverse outcomes of events like COVID-19, little is known regarding the impact of the current pandemic on PWID. We examine how COVID-19 has affected PWID in New York City across four domains: substance use, risk behaviors, mental health, and service utilization.

Methods

As part of a randomized trial to improve access to HCV treatment for PWID, we recruited 165 participants. Eligibility criteria included detectable HCV RNA and recent drug injection. The present cross-sectional analysis is based on a subsample of 106 participants. We compared responses between two separate samples: 60 participants interviewed prior to the pandemic (pre-COVID-19 sample) and 46 participants interviewed during the pandemic (COVID-19 sample). We also assessed differences by study group [accessible care (AC) and usual care (UC)].

Results

Compared to the pre-COVID-19 sample, those interviewed during COVID-19 reported higher levels of mental health issues, syringe reuse, and alcohol consumption and greater reductions in syringe-service programs and buprenorphine utilization. In the analysis conducted by study group, the UC group reported significantly higher injection risk behaviors and lower access to buprenorphine treatment during COVID-19, while during the same period, the AC group reported lower levels of substance use and injection risk behaviors.

Conclusion

The current study provides insight on how COVID-19 has negatively affected PWID. Placing dispensing machines of harm-reduction supplies in communities where PWID live and increasing secondary exchange, mobile services, and mail delivery of supplies may help maintain access to lifesaving supplies during big events, such as COVID-19.

Trial registration ClinicalTrials.gov NCT03214679. Registered July 11 2017. https://clinicaltrials.gov/ct2/show/NCT03214679.

Delirium and Cognitive Impairment as Predisposing Factors of COVID-19 Infection in Neuropsychiatric Patients: A Narrative Review

SARS-CoV-2 neuroinvasive and neurotropic abilities may underlie delirium onset and neuropsychiatric outcomes. Only a limited number of studies have addressed the potential effect of SARS-CoV-2 infection on mental health so far. Most studies mainly reported the acute onset of mixed neuropsychiatric conditions in patients infected with SARS-CoV-2, characterized by agitated behavior, altered level of consciousness, and disorganized thinking, regardless of psychological or socioeconomic triggering factors. The present narrative review aims to analyze and discuss the mechanisms underlying the neuroinvasive/neurotropic properties of SARS-CoV-2 and the subsequent mental complications. Delirium appeared as a clinical manifestation of SARS-CoV-2 brain infection in some patients, without systemic or multiple organ failure symptoms. A small number of studies demonstrated that neuropsychiatric symptoms associated with COVID-19, initially presenting as a confused state, may subsequently evolve in a way that is consistent with the patients' neuropsychiatric history. A literature analysis on this topic prevalently showed case reports and case series of patients presenting delirium or delirium-like symptoms as the main outburst of COVID-19, plus a cognitive impairment, from mild to severe, which pre-existed or was demonstrated during the acute phase or after infection. Dementia appeared as one of the most frequent predisposing factors to SARS-CoV-2 infection complicated with delirium. Instead, contrasting data emerged on the potential link between COVID-19 and delirium in patients with cognitive impairment and without a neuropsychiatric history. Therefore, clinicians should contemplate the possibility that COVID-19 appears as delirium followed by a psychiatric exacerbation, even without other systemic symptoms. In addition, cognitive impairment might act as a predisposing factor for COVID-19 in patients with delirium.

Client perspectives on the accessibility and quality of substance use treatment during the COVID-19 pandemic

BACKGROUND

People who use drugs have been particularly vulnerable during the COVID-19 pandemic because of their unique social, harm reduction, and treatment needs. These unique needs and challenges have significant influence on the severity of their substance use, mental health symptomatology, willingness to engage in treatment, and adherence to treatment options. This has included immense challenges related to the dissemination of COVID-19 messaging and the need for harm reduction and treatment service entities to adopt new formats to continue operation.

METHODS

In-depth interview data were collected people who use drugs (N=24) residing in Oklahoma from November 2020 through February 2021 to assess perspectives on (1) their access to harm reduction, substance use prevention, and treatment programs during the COVID-19 pandemic, (2) the perceived quality of such services and programs during this time, and (3) the perceived availability of tailored COVID-19 information.

RESULTS

Several factors emerged related to accessing and quality of substance use services during COVID-19, including poor accessibility (e.g., internet access), diminished quality (i.e., lack of social support), and lack of tailored COVID-19 prevention and treatment messaging.

CONCLUSIONS

Upticks in COVID-19 cases and deaths are expected to continue as new SARS-CoV-2 variants are introduced. The present findings highlight the need for tailored COVID-19 messaging (e.g., minimizing the sharing of substance use supplies that can spread COVID-19, mask wearing, COVID-19 vaccination), which is responsive to unique needs of substance using populations. Similarly, as prevention and treatment programs are delivered online, efforts are necessary to ensure equitable access and enhanced quality of services.

Substance and Internet use during the COVID-19 pandemic in China

The coronavirus disease 2019 (COVID-19) has adversely influenced human physical and mental health, including emotional disorders and addictions. This study examined substance and Internet use behavior and their associations with anxiety and depression during the COVID-19 pandemic. An online self-report questionnaire was administered to 2196 Chinese adults between February 17 and 29, 2020. The questionnaire contained the seven-item Generalized Anxiety Disorder Scale (GAD-7) and Patient Health Questionnaire (PHQ-9), questions on demographic information, and items about substance and Internet use characteristics. Our results revealed that males consumed less alcohol (p < 0.001) and areca-nut (p = 0.012) during the pandemic than before the pandemic. Age, gender, education status, and occupation significantly differed among increased substance users, regular substance users, and nonsubstance users. Time spent on the Internet was significantly longer during the pandemic (p < 0.001) and 72% of participants reported increased dependence on the Internet. Compared to regular Internet users, increased users were more likely to be younger and female. Multiple logistic regression analysis revealed that age <33 years (OR = 2.034, p < 0.001), increased substance use (OR = 3.439, p < 0.001), and increased Internet use (OR = 1.914, p < 0.001) were significantly associated with depression. Moreover, anxiety was significantly related to female gender (OR = 2.065, p < 0.001), "unmarried" status (OR = 1.480, p = 0.017), nonstudents (OR = 1.946-3.030, p = 0.001), and increased substance use (OR = 4.291, p < 0.001). Although there was a significant decrease in social substance use during the pandemic, more attention should be paid to increased Internet use. Increased Internet use was significantly associated with both anxiety and depression, and increased substance use was related to depression. Professional support should be provided to vulnerable individuals to prevent addiction.

Treating an Epidemic During a Pandemic: Experience Treating Opioid Use Disorder at the Baltimore Convention Center Field Hospital

During the COVID-19 pandemic, access to addiction treatment has plummeted. At the same time, patients with opioid use disorder are at higher risk of COVID-19 infection and experience worse outcomes. The Baltimore Convention Center Field Hospital (BCCFH), a state-run COVID-19 disaster hospital operated by Johns Hopkins Medicine and the University of Maryland Medical System, continues to operate 14 months into the pandemic to serve as an overflow unit for the state’s hospitals. BCCFH staff observed the demand for opioid use disorder care and developed admission criteria, a pharmacy formulary, and case management procedures to meet this need. This article describes generalized lessons from the BCCFH experience treating substance use disorder during a pandemic.

BDZs, designer BDZs, and Z-drugs: pharmacology and misuse insights

Benzodiazepines (BZDs) are a widely prescribed class of sedative-hypnotics compounds for the treatment of a broad range of conditions as anxiety and obsessive-compulsive disorders, phobias, sleep related problems associated with insomnia and for the management of alcohol and GHB withdrawal. Zolpidem, zopiclone and zaleplon, commonly known as Z-drugs are non-benzodiazepine hypnotic drug with pharmacology similar to BDZs. Despite their usefulness, BDZs and Z-drugs present a potential for abuse and dependence. Moreover, the non-medical use of BDZs is a well-known phenomenon and represents an increasingly widespread public health problem since is associated with an elevated risk of serious health consequences or fatal overdose, especially among specific group of users. The spectrum of BDZs and Z-drugs misuse is extended by new synthetic BDZs, which may pose high risks to users, since the majority have never undergone clinical trials or tests and consequently their pharmacology and toxicology is largely unknown.

Psychoactive Substance Use and Its Relationship to Stress, Emotional State, Depressive Symptomatology, and Perceived Threat During the COVID-19 Pandemic in Mexico

People can increase their use of psychoactive substances in response to stressful situations as a maladaptive mechanism for reducing negative affective states. It is therefore necessary to examine changes in the use of such substances and their relationship to mental health in light of the COVID-19 pandemic.

Objective: Evaluate the relationship between psychoactive substances and stress, emotional state, and symptomatology during the COVID-19 lockdown in Mexico.

Method: A national survey was conducted, using the free Google Forms platform, of residents of Mexico aged 18 and older. The survey was disseminated through social media.

Results: The sample comprised 4,122 individuals, mostly women (71.8%), with an age range of 18–81 years (M = 37.08, SD = 12.689), of which 46.8% were single, and 42.9% married. In general, there was a reduction in substance use during the first 2 months of the quarantine; the most commonly used substances were alcohol, tobacco, and tranquilizers. Respondents who described having greater use than before the pandemic presented greater stress, depressive symptomatology, and perceived threat than those who did not use substances.

Conclusions: Respondents who did not use substances reported lower levels of stress, depressive symptomatology, impact of the coronavirus pandemic, and perception of its threat. Women reported greater stress, depressive symptomatology, and emotional intensity than men.

Substance use, depression, and loneliness among American veterans during the COVID-19 pandemic

BACKGROUND AND OBJECTIVES

Behavioral health issues, such as substance use, depression, and social isolation, are of grave concern during COVID-19, especially for vulnerable populations. One such population is US veterans, who have high rates of pre-existing behavioral health conditions and may thus be at-risk for poorer outcomes. The current study aimed to investigate substance use among US veterans during COVID-19 as a function of pre-existing depression, loneliness, and social support.

METHODS

We investigated the relationship between pre-pandemic depression and substance use during COVID-19 using linear (alcohol) and logistic (cannabis) regression among a large sample of US veterans (N = 1230). We then tested if loneliness and social support moderated these effects.

RESULTS

Though there was a decrease in alcohol and cannabis use among the overall sample, veterans who screened for depression prior to the pandemic exhibited higher levels of substance use after the pandemic's onset. Loneliness compounded the effects of depression on rates of alcohol use. Social support was not protective for the effects of depression on either alcohol or cannabis use.

DISCUSSION AND CONCLUSIONS

Veterans with pre-existing depression may be in need of attention for substance use behaviors. Interventions aimed at alleviating loneliness among veterans may be useful in mitigating alcohol use, but not cannabis use, amid COVID-19.

SCIENTIFIC SIGNIFICANCE

Our findings are among the first to report tangible behavioral health outcomes experienced by US veterans as a result of COVID-19. Results can help inform treatment efforts for veterans who are struggling with substance use during and post-pandemic.

Treatment and help services for gambling during COVID-19: Experiences of gamblers and their concerned significant others

Aims:

During the COVID-19 pandemic, many treatment or help services for gambling were closed or moved online. At the same time, closures of gambling opportunities impacted gambling availability and practices. This study investigates gamblers’ and their concerned significant others’ (CSOs) experiences and views on treatment and help services during this exceptional time and perceptions on how to develop services further after the pandemic.

Design:

Three online questionnaires to elicit gambler and CSO experiences were conducted during the spring 2020 in Finland. In total, 847 respondents answered and shared experiences on how the situation had impacted their gambling behaviour and service needs, how service closures or the moving of services online had impacted them, and how they thought the prevention and treatment of gambling harms should be organised during and after COVID-19.

Results:

Changed gambling practices reduced overall service needs. Service closures had negative impacts, but online services were considered positively, as these provided a low-threshold option. Respondents also shared insights into how the service provision for gamblers should further be developed during and after COVID-19.