It’s a Risky Time for People with Substance Use Issues

If your consumption of mind-altering substances has been increasing in tandem with the COVID-19 infection curve, you’re not alone.

In the last two weeks of March, sales at BC Liquor Stores were up 40 per cent compared to the same period the previous year. BC Cannabis Stores have also experienced an increase in sales. And research shows that stress, depression, anxiety, trauma, social isolation, boredom and popular culture references that encourage substance use — all things that have been increasing during the pandemic — make people more vulnerable to substance use disorder and relapse. Substance use disorder, which affects about one in five Canadians in their lifetime, occurs when a person’s substance use harms them or other people.

“People are struggling with stress, fear and anxiety, and they’re traumatized,” said Katie Branter, a naturopathic doctor in Victoria and founder of Spirited Sobriety, a coaching service to help women get sober. “They’re exhausted and they’re not doing the things they love. People don’t know what to do with their energy and their emotions, so they self-medicate. It’s a hugely risky time and people need support.”

Meanwhile, services for people with substance use disorder, such as Alcoholics Anonymous meetings, are being suspended or moving online, making them inaccessible to many. With governments closing borders and restricting people’s movements, the supply and distribution of drugs is being disrupted, potentially exposing people to a more toxic supply. And people who are homeless and use substances can’t physically isolate, putting them at increased risk of infection and negative health consequences.

The short and long-term effects of the pandemic on people with substance use disorder worry experts. Adding to their concerns is the fact that British Columbia is in the midst of two overlapping public health emergencies: the COVID-19 pandemic and the opioid overdose crisis.

How the pandemic can influence substance use

Many of us have lost our jobs. Our finances are strained. The kids are out of school. We’re confined to our homes. We can’t do many of the things we enjoy. We’re scared that we or someone we love might catch COVID-19. Life as we know it has drastically changed, and we have no idea when it’s going back to normal. In fact, according to an April 6 poll by Angus Reid, 87 per cent of Canadians say the worst is yet to come financially, mirroring what health officials are telling us about infections and deaths.

All of this stress and trauma can trigger mental illnesses, such as depression and anxiety, and lead people to use substances to cope. A February 2020 review article published in The Lancet found that the psychological impacts of being quarantined include depression, anger, insomnia and post-traumatic stress symptoms. Research also shows that stress increases the risk of starting to use substances, transitioning to regular or excessive use and ultimately developing substance use disorder. It’s too soon, however, to say for sure how the pandemic will affect substance use.

“Substance use will reflect these difficult times in all sorts of dramatic and probably unpredictable ways,” said Tim Stockwell, director of the Canadian Institute for Substance Use Research at the University of Victoria. “It’ll fall out differently for different people.”

Stockwell pointed out that finances will be an important mitigating factor. Some people will have less money to purchase drugs and alcohol because they lost their jobs. At the same time, it’s cheaper to buy booze in stores compared to bars and restaurants, so that may encourage some people to drink more.

While on the surface the spike in alcohol sales suggests people are drinking more, many may simply be stocking up to minimize trips to the store or out of fear there may be a shortage or the stores might close. In fact, the biggest jumps in sales at BC Liquor Stores were for high-volume items — such as boxed wine, which increased 144 per cent — and sales have now levelled off to seasonal norms.

A 2016 systemic review of studies on the effects of the 2008 economic crisis on substance use patterns in the European Union found that consumption of illicit drugs increased during the economic crisis and that people transitioned from expensive drugs, such as cocaine, to cheaper ones like amphetamines. The review also found that while consumption of alcohol declined overall due to economic constraints, it increased among vulnerable subgroups, leading to serious negative effects. For instance, people who lost their jobs, faced long-term unemployment, or had a history of mental illness were more likely to binge drink and end up in hospital or die due to alcohol-related reasons.

Another potentially mitigating factor is the fact that substance use is social for many people. If we can’t gather at pubs or parties, will we consume as much? Many people have started having virtual cocktail hours, but Stockwell said such situations make it easy to abstain and avoid the pressure to drink. For instance, no one can offer you a shot and you can put grape juice in your wine glass. Stockwell pointed out that young people already spend more time socializing online and use less substances. “It may be that virtual connections break the link between socializing and substance use,” he said, adding that people may feel more comfortable or less stressed connecting online than in real life, reducing their reliance on substances.

However, some people with extra time on their hands and reduced responsibilities may start consuming more substances, especially if their incomes are not affected by the crisis.

“Substances affect the reward centres of our brains,” Stockwell said. “We like them, they make us feel good, and for a lot of us, the reason we don’t do it all the time is because we either can’t afford it or they interfere with our performance or the ability to do other things. So if we no longer have to go to work, if we no longer have to show our faces and put on a good show in front of other people, then perhaps people say, ‘What the heck? I’m stressed, I’m anxious, I’m just going to use more.’”

It doesn’t help that joke after joke after joke on social media suggest people are turning to their vices to cope with the stress, uncertainty, and boredom brought on by the pandemic, giving people social license to use more than normal.

People may also turn to substances to cope with feelings of boredom and loneliness. While social distancing doesn’t have to mean social isolation, the reality is it does for many people. (Politicians and health officials have started using the term “physical distancing” rather than “social distancing” to stress that people don’t have to socially disconnect from each other.) People who live alone and don’t have access to online social networks are particularly vulnerable.

“We’re social beings. We’re going to suffer from not being able to have lots of social contact,” Stockwell said. “Community connections are a protective factor against a whole range of issues, including substance use problems, so this will put more of us at risk.”

The dangers of substance use during the pandemic

Substance use is associated with a range of negative health effects, some of which make people more vulnerable to COVID-19. Excessive alcohol consumption can weaken the immune system and make people more susceptible to pneumonia and acute respiratory distress syndromes, deadly conditions associated with COVID-19. Smoking cannabis can also compromise lung function, and long-term opioid use can lead to respiratory and heart problems.

“People who use drugs might have concurrent health issues, including compromised immune systems, that might make them more vulnerable to infection and more likely to experience severe symptoms and negative outcomes because of infection,” said Lindsey Richardson, an associate professor of sociology at the University of British Columbia and a research scientist at the British Columbia Centre on Substance Use.

Richardson is concerned that physical distancing and self-isolation requirements will force more people to use drugs alone, which increases their risk of overdosing. In fact, according to a 2018 BC Coroners Service investigation, the majority of people who died of drug overdoses between 2016 and 2017 had been using alone. She’s also worried that the disruption in the drug supply might force people to pay higher prices and rely on new dealers and an unknown, and potentially more toxic, supply. “We’re dealing with an unregulated market, so potency and purity might be fluctuating, which affects people’s risk of overdose,” Richardson said. “It’s very challenging to know at this stage how the drug market will adapt over time.”

Richardson’s fears are already coming true. From March 23 to 29, Vancouver police attended eight suspected overdose deaths, the most in a single week since August 2019. A city news release pointed out that this is in stark contrast to the decline in the number of overdose deaths in Vancouver over the past year.

While some people questioned why the provincial government deemed liquor stores and cannabis shops essential services and allowed them to stay open during the pandemic, Bernie Pauly, a professor of nursing at the University of Victoria and a scientist at the Canadian Institute for Substance Use Research, said it’s important to help ensure a safe, continuous supply. “Closing liquor stores could cause unintended harms, especially for those with very heavy or chronic daily use of alcohol and at risk of withdrawal,” said Pauly, adding that severe withdrawal can lead to seizures and death. “You want to avoid going into severe withdrawal because then you will need to call 911 and go to the hospital.”

However, substance use, especially at excessive levels, can make people more aggressive and violent toward their partners and children. This is compounded by the fact that stress, financial pressures and social isolation also increase the risk of family violence.

Overburdened women’s shelters in Greater Vancouver are bracing for an influx of women and children fleeing violence, while struggling to implement measures to ensure social distancing and reduce the risk of a COVID-19 outbreak. Provincial health officer Bonnie Henry told The Tyee British Columbia is looking at additional spaces that shelters could expand into to allow for proper physical distancing.

How to find help with substance use

Just days after British Columbia declared a state of emergency, Katie Branter, the naturopathic doctor, held her first free online support group. It's one of many cropping up across the country, including hundreds of Alcoholics Anonymous and Narcotics Anonymous groups. (Entry to Branter’s group is now closed, but people can reach out to the Alcohol and Drug Information Referral Service for advice on how to access supports.)

Branter meets daily with seven other women on Zoom. Some of the women are trying to stay sober while others are just looking for support during these trying times. “We’re connecting,” said Branter, who got sober after her addiction to alcohol intensified following the tragic death of her teenage son. “With any addiction, when you don’t have that connection, it’s a trigger. This group is creating a container for healing for all of us and it’s been incredibly powerful.”

Unfortunately, online groups aren’t accessible to everyone. Participation requires hardware such as a phone or tablet, an internet connection and technological literacy.

In an open letter to the B.C. Ministry of Health, B.C. Ministry of Mental Health and Addictions, B.C. Ministry of Social Development and Poverty Reduction, and BC Housing, nurses, researchers, and homeless advocates asked for vulnerable people to be provided with phones and internet access to increase opportunities for virtual contact and peer-to-peer support.

In anticipation of drug supply issues, British Columbia is moving forward with a program that will provide vulnerable substance users with a safe supply. “These guidelines are to enable us to provide a safe supply for people and to ensure that they’re able to comply with our public health advice around isolation or quarantine should that be required,” Henry said at her March 26 news conference, adding that the program is particularly to support people in places like the Downtown Eastside.

How to stay safe while using substances

Experts recommend people plan and keep track of their substance use and follow safety recommendations. People in the general population can follow “Canada’s Low-Risk Alcohol Drinking Guidelines,” which advise women to have no more than 10 drinks a week and no more than two drinks a day most days, and men to have no more than 15 drinks a week and no more than three drinks a day most days.

For those with alcohol use disorder, Pauly, who prepared a list of safer drinking tips during COVID-19, advises them to slow down, pace their drinking, and have “spacers” — non-alcoholic drinks between alcoholic ones. She also urged people to familiarize themselves with the early symptoms of withdrawal — shakes, sweating, increased anxiety and nausea — and slowly sip alcohol if they start to experience them.

For people who use illicit drugs, the Harm Reduction Coalition has released a list of harm reduction tips, including minimizing the need to share supplies. The coalition points out that emergency services might be stretched due to COVID-19 and slow to respond to 911 calls, so people should plan and prepare for overdose by having naloxone, fentanyl testing strips and a breathing mask on hand. It also advises people who are using alone to try using less to lower their risk of overdose. “We really need to focus on harm reduction strategies and respect people’s choices around substance use,” Pauly said.

Branter advised people who are trying to stay sober to be present in their cravings and recognize what they actually are. “Is that craving actually anxiety? Is it fear? Is it a feeling of needing to connect with others?” she said, adding that writing it down might help.

Experts also recommend coming up with a routine that involves activities that get you moving, help you relax and allow you to connect with people. There’s a wide variety of activities that you can participate in online. Some of them, like mindfulness, have even been shown to help prevent relapse. Finding meaning in your life by joining efforts to help your community can also help you stay positive and sober.

“We need some rhythm and routine in our lives so that we’re not lost and feeling meaningless,” Stockwell said. “We all need meaning in our lives and we can get that from each other. And it’s more important than perhaps it’s ever been.”

Perhaps in finding connection and meaning, we can help flatten the COVID-19 and the substance use curve.