Addictive behaviors in the COVID-19 era

Nedelciuc, Gheorghe1, Peste, Irina2, Tcaciuc, Anca Maria3, Olaru, Adriana4, Harabula, Bogdan5

Since the emergence of this public health challenge, radical measures have been adopted with
the intention of alleviating the dissemination of infections. Although these initiatives have been deemed
successful, the collateral damage has to be addressed and properly managed.
There are some key areas afflicted by the pandemic, with all its ramifications.
The financial security of many households has taken a toll, due to numerous job losses and
salary reductions. As of May 2020, more than 40 million workers have been furloughed in Europe’s
biggest economies: Germany, UK, France, Italy, Spain and Netherlands 1. In Romania, almost 200.000
individuals lost their job in just a couple of months, following the implementation of restrictions 2.
Household job loss during the pandemic has led to a sizeable elevation in reported symptoms of anxiety
and depression. 53% of adults who experienced household job loss reported such symptoms, in contrast
to 32% of adults not facing household job loss, in a survey conducted by CDC, in 2020 3.
The quarantine and social distancing that prone to social isolation and all the uncertainty
surrounding this situation have instilled a significant amount of psychological distress in individuals,
culminating in symptoms of anxiety, depression and suicidal ideation 4,5. CEVA DESPRE EFECTELE IZOLARII
SOCIALE Moreover, the diminished opportunity for engaging in pleasurable activities, due to all of the
restrictions, and the constant flow of alarming updates on the evolution of the pandemic have
facilitated an increase in maladaptive coping mechanisms. Boredom and loneliness have also been
experienced6. Surveys conducted by CDC during June 24-30, 2020, among a number of 5.412 adults
revealed that a staggering 41% of respondents reported at least one mental health or behavioral
condition. Symptoms of depression and anxiety were the most prominent, with one in three persons
affected, followed by symptoms of a trauma- and stressor-related disorder related to the pandemic,
with one in four persons affected. By comparison, in the second quarter of 2019, just 10% of adults
reported symptoms of anxiety or depression, in a survey conducted by NCHS (National Center for Health
Statistics) . 13,3 % of respondents disclosed having started or increased substance use to cope with
stress or emotions related to COVID-19. 10,7% of respondents expressed having seriously considered
suicide, in the last 30 days before completing the survey 5.
Healthcare systems have been under tremendous pressure since the start of the pandemic,
facing numerous shortcomings: overcrowded hospitals, lack of protective equipment, especially at the
onset of the pandemic and workforce shortage. Resources were redistributed, the main focus being the
treatment of patients with COVID-19. It is thus unsurprising to notice that individuals with substance use
disorders have faced more obstacles in accessing the much needed healthcare. The closure of treatment
centers, the demoted position of preventive care, the discontinuation of medications and follow-up
interventions and probably, the increased stigma towards persons with substance use disorders, in this
context, have made it difficult for individuals engaging in additive behaviors to seek out and take part in
a proper treatment strategy7.
All these factors converge in enhancing the risk of engaging in addictive behaviors, be it the use
of substances like alcohol, nicotine or cannabis or behavioral addictions, such as indulging in excessive
internet use, video games, gambling or porn. The magnitude of this problem drew a lot of attention
with the crisis of substance use disorders being synthetized in the following words “epidemic in the
midst of a pandemic”8.
With regards to SUD, alcohol, nicotine and opioids have been particularly troublesome. There
has been noted an increase in relapse rates and a rise in terms of quantity of substance usage. An online
survey conducted in China, gathering 6.416 valid questionnaires, in June 2020, revealed that for alcohol,
the relapse to abuse from abstinence affected one in five individuals, whereas one in four tobacco
smokers relapsed to abuse from abstinence. 32% of regular alcohol drinkers and 20% of regular tobacco
smokers increased the usage of these substances 9. Also, it is reported that sales of alcoholic beverages
were up 22% in the USA, in March 2020, when compared to March 2019 10. In addition, online purchasing
of alcoholic beverages registered an outstanding 243% increase 11. There has also been noticed an
increase in deaths by overdose, the main culprits being synthetic opioids and combinations involving
opioids. CDC reports a 38.4% rise in overdose deaths due to synthetic opioids, from the 12-month
leading up to June 2019 compared with the 12-month period leading up to May 2020 12. Social isolation
decreases the chance of naloxone being administered in useful time. Also, overdose deaths involving
psychostimulants, such as methamphetamine, rose by 34.7% percent 12. Another worrisome fact relies in
the fact that due to the limited availability of the usual drugs of abuse, in the context of restricted
travelling, some individuals have tried different substances.
In the realm of behavioral addictions, some key aspects have been observed. In the context of
online classes and transition to telework, the usage of social media to remain connected in times of
physical distancing and the limited options for making use of spare time, internet has played an
important role in people’s lives during this pandemic. An online survey conducted in China, gathering
6.416 valid questionnaires, conveyed that 46.8% respondents increased dependence on internet use
and 16.6% spent longer hours on the internet, as compared to preCOVID times. The rate for severe
dependence went up from 3.5% to 4.3% 9. Another study, conducted on subjects older than 60 revealed
a 41.7% rise in using the internet for daily errands 13. Visits to pornographic sites have also increased
during the pandemic, in part due to boredom, spending more time on the internet and the accessibility,
affordability and anonymity that these sites have provided 13. In circumstances of stress and financial
insecurity, online gambling has been appealing for certain individuals. Data from UK showed a marginal
increase in the number of bets and active accounts on online gambling platforms, in November 2020 14.
The most noteworthy aspects to consider are the facts that individuals with substance-use
disorders have an increased risk of infection with SARS-CoV2 and also, worse outcomes, in terms of
mortality and hospitalization. An electronic health records (EHRs) evaluation of 73,099,850 unique
patients (of whom 12,030 had a diagnosis of Covid-19) from US, conveyed the increased risk for Covid-
19 for those individuals with a recent diagnosis of SUD (AOR 8.669). Patients with SUD also had higher
prevalence of CKD, liver, lung, CVD, T2D, obesity and cancer. When compared to general COVID-19
patients, there could be seen a sizeable difference in terms of death 9,6% for individuals with SUD
versus 6,6% and hospitalization, 41% for individuals with SUD versus 30,1% 15.
The same electronic health records showed that the highest risk for infection was among opioid
users, at 2.4, versus general population. Individuals with cocaine use disorder were 1.6 times more likely
to have a COVID-19 diagnosis, followed by alcohol use disorder (1.4 times) and tobacco use disorder (1.3
times) 15. Individuals with SUD go to great lengths to acquire and consume drugs. This has been
particularly troublesome during this pandemic, as they have been exposing themselves to a heightened
risk of infection. They interacted with dealers and shared drugs. Even for legal substances, the effect is
evident. Alcohol and nicotine addiction weaken immune responses and decision making abilities,
exposing individuals to an elevated risk of infection 9.
In the light of a new study, which included 236 379 patients diagnosed with COVID-19, it seems
that patients who suffered from COVID-19 are at increased risk of psychiatric sequelae in the first 6
months after infection. The highest estimated incidence was for anxiety disorder, at 17.39%. This could
contribute to heightened prevalence of substance use disorders 16.
The management of cases involving addictive behaviors poses the need for a complex strategy,
at various levels of society. Public health strategies should seek to promote incorporating internet
activities as just a part of a daily routine involving other occupations, such as exercising. Awareness
campaigns and education programs may reach marginalized communities. Community-level intervention
and prevention efforts could strengthen economic supports to reduce financial stress. Narcotics
Anonymous and Alcoholics Anonymous are already having online meetings 17.
Telehealth has been proving to be a valuable gain during this pandemic, enabling treatment for
various mental health conditions: depression, anxiety, substance use disorders. In the USA, physicians
can start patients on buprenorphine for opioid recovery, something they could not do before 18. Also,
Opioid Treatment Program providers prescribe take-home methadone for maintenance, for longer
periods of time19. Psychologists can provide CBT for anxiety, depression, cocaine and methamphetamine
addiction and help patients adhere to medication and deal with stressors 20. It remains to be seen if
telehealth will become a regular part of medical practice following the denouement of the pandemic.

[ During a pandemic, In case of prescribing a drug treatament, healthcare providers should

respect standards relating to individual prescriptions. To order a prescription, especially for a patient
that the provider does not know, the provider must ensure that the medication is still required, that it is
well-tolerated, and that the dosage is appropriate for the patient’s condition. The prescriptions are to
be sent by the following methods: verbal transmission from doctor or authorized healthcare provider to
pharmacist, fax transmission, transmission by electronic means.

By telemedicine, the healthcare provider may prescribe benzodiazepines or psychostimulants to

a previously known patient, as long the provider ensures appropriate and timely follow-up, either in-
person or by telemedicine. In the case of a new patient provider is permitted to prescribe
benzodiazepines or psychostimulants by telemedicine, if they judge and document in the medical file
that it is medically indicated, and that delay in initiating treatment will entail a risk to the patient. For all
patients, the prescribed quantity must be safe and take into account the patient`s condition and the
associated risks. Prescribers should document safety concerns and measures to address them when
prescribing any psychoactive substance.

Bruneau, J., Rehm, J., Wild, T.C., Wood, E., Sako, A., Swansburg, J., & Lam, A. Telemedicine Support for
Addiction Services: National Rapid Guidance Document. Montreal, Quebec: Canadian Research Initiative
in Substance Misuse; May 15th, 2020. 47 p. Version 1. ]
[ The social isolation associated with the quarantine can lead to mental healt problems even in people
who didn`t show any signs of mental issues before. These can include acute stress disorders, irritability,
insomnia, emotional distress and mood disorders, including depressive symptoms, fear and panic,
anxiety and stress because of financial concerns, frustrations and boredom, loneliness, lack of supplies
and poor communication. As long as the quarantine period is extended, the poorer the mental health
outcomes, specifically, symptoms of post‐traumatic stress disorder, avoidance behaviour and anger,
may be seen. Longer times in quarantine are particularly associated with increasing symptoms of post-
traumatic stress disorder, which may indicate that quarantine itself can be perceived and experienced as
a traumatic event.

For people with an existing mental health condition, isolation presents more severe problems and can
exacerbate feelings of anxiety and anger. People in treatment for a range of conditions such as
alcoholism and other similar issues may also be vulnerable to set backs and additional complications
arising from enforced social isolation. Many people in these vulnerable groups rely on supports and
programs that may be lost or interrupted due to restrictions associated with COVID‐19.

Life in the pandemic: Social isolation and mental health. https://doi.org/10.1111/jocn.15290. Published:
April 6, 2020 ]

[ Some people on illegal drugs also suffer from chronic conditions. This people have an
increase risk of developing severe breathing problems if infected with COVID-19. Chronic
obtructive pulmonary disease (COPD) and Asthma are higher among drug user undergoing
already treatment. Also, smoking heroin and cocaine can incrase the risk. Individuals that
inject themselves with drugs and those that use cocaine have an increase risk of
cardiovascular disease. HIV, viral hepatitis and cancer determine weak immune system
which is quite high among people who inject drugs. Metamfetaminas can lead in blocking
the blood vessels and also can apper pulmonary lesions. Smoking and nicotine dependince
are very frequent among some drug consumers and can increase some risk and more
negatively effect.

Implicaţiile COVID-19 asupra persoanelor care consumă droguri şi asupra furnizorilor de

servicii de asistenţă. https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-
people-who-use-drugs. Published: March 25, 2020 ]
 Once the pandemic starts, humans were asked to be patient, to respect social distancing and
limiting drastically any human contact. It is clear that any addictions, even behavioral food addiction
would dramatically increase during this period. Many people finds comfort and consolation through
food consumption, leading to substantial weight gain and worsening of eating disorders such as bulimia
or binge eating. The worsening sedentary lifestyle that resulted from the restrictions imposed during the
pandemic along with risk-seeking behavior led to a significant increase in obesity. The main problem is
that obese patients have been associated with a higher risk of morbidity and mortality in case of COVID-
19 infection. In addition to this, there are some metabolic obesity-related comorbidities, like type 2
diabetes or hypertension that have been shown to be associated with increased disease severity and
mortality

Faredj Cherikh, Sébastien Frey, Corali Bel, Giuseppe Attanasi, Marco Alifano and Antonio Iannelli
Behavioral Food Addiction During Lockdown: Time for Awareness, Time to Prepare the Aftermath Obes
Surg. 2020 May 13 : 1–3

Many studies have been made to show how the alcohol dependence is affected by covid
pandemic. One of the studies show how alcohol consumption was affected using a test called Alcohol
Use Disorders Identification Test (AUDIT). This test is a brief 10-item questionnaire, a simple and
effective method of screening for harmful alcohol use developed by the World Health Organization that
focuses on hazardous alcohol consumption. The questions used in this test assess the frequency and
quantity of alcohol consumed, behaviors associated with dependence, and harm resulting from alcohol
use. A total of 5,931 individuals completed the test between April and September 2020. In that period,
harmful alcohol use and likely dependence increased month-by-month for those under lockdowns
compared to those not under restrictions. It seems that the job loss is one of the main reason people
start consuming alcohol, another cause is the increased stress determined by the struggling with the
managing work-from-home responsibilities.

William D.S.Killgore , Sara A, Cloonan, Emily C., Taylor, Daniel A., Lucas, Natalie S., Dailey. Alcohol
dependence during COVID-19 lockdowns Psychiatry Research Volume 296, February 2021, 113676

1. The Covid-19 pandemic means that pacients are suffering from more stress and anxiety as a result of the
change and uncertainty the virus is causing. Higher levels of psychological distress are causing many
problems, consumption of pornography habits is one of them. Social isolation and loneliness that came out
of the covid-19 pandemic has led to excessive use of pornography, pacients use porn for temporary relief
from the negative feelings. Another thing the pandemic took from us is the freedom to do and go
wherever we want, so boredom may occur. Studies show a link between boredom and increased online
 sexual activity. Other people use pornography as a surviving mechanism for coping with their loneliness,
depressive symptoms and even fear of death.

Fabio Zattoni, Murat Gül, Matteo Soligo, Alessandro Morlacco, Giovanni Motterle, Jeanlou Collavino,
Andrea Celeste Barneschi, Marco Moschini, Fabrizio Dal Moro. The impact of COVID-19 pandemic on
pornography habits: a global analysis of Google Trends. Int J Impot Res (2020).

2. As we write this opinion paper, the social and economic restrictions due to
the coronavirus pandemic have already seriously impacted health and social
fields. COVID-19 outbreak has led to the implementation of social distancing
to contain the spread of the disease, changing people’s lifestyle. People have
been going through a moment of anxiety and fear for their health and their
jobs, and they are forced to live an unfamiliar lifestyle, deprived of
relationships. Furthermore, the condition of people with psychological
troubles may have worsened during the pandemic as a result of the
unconsciously mirroring of others feelings (1). This peculiar situation may
have pushed more people toward a deviant behavior linked to licit or illicit
substance use, and it may have been a good opportunity for drug dealers to
attract new customers. However, global issues have not favored the usual
trade business. Indeed, social distancing has substantially reduced drug
trafficking on the streets, pushing consumers toward illegal markets on the
dark web or through messaging applications (2. Furthermore, the paucity of
classic drugs, together with the impossibility to go out to look for those, might
have induced addicts to misuse psychoactive prescription drugs such as
benzodiazepines (3–5). In this concern, although there is limited scientific
evidence, the impact of the COVID-19 pandemic could lead to substantial
modifications in substance use patterns, and an increased risk of substitution,
adulteration, contamination, and dilution with a potentially harmful
substance. As such, reports from forensic science and toxicology laboratories
are crucial for the early detection and response to such events (6, 7).
Moreover, in this period of home confinement, users might no longer be
looking for “socializing” substances to be used in recreational settings, but for
psychotropic drugs to be consumed in solitude.
Even short periods of isolation and loneliness can have negative consequences
on physical and mental well-being. The feeling of isolation can lead to
anxiety and anger, and even sleep disorders, depression, and post-traumatic
stress disorders, which may be underestimated due to the lack of specific
screening tools (8, 9). Moreover, psychiatric assistance from health
professionals is not assured due to the temporary monopolization of
psychiatric facilities for COVID-19 treatment (10). In addition to drug
addicts using prescription sedatives available at home, some may have
shifted to narcotics such as new synthetic opioids or designer
benzodiazepines, available online. Indeed, these two classes of new
psychoactive substances showed the highest consumption increase in 2019. –
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Millennium Health, a national drug testing laboratory in America, also

found worrisome trends when comparing the period this year before the
national emergency was declared on March 13, to the period from then to
the end of May. It found an increase of 32% for nonprescribed fentanyl,
20% for methamphetamine, 12.5% for heroin and 10% for cocaine,
accompanied by an 18% increase in suspected drug overdoses.
(https://www.ehstoday.com/covid19/article/21139889/drug-abuse-on-
the-rise-because-of-the-coronavirus - Drug Abuse on the Rise Because of
COVID-19 David Sparkman, EHS TODAY AUG 24, 2020)