Opinion

Why we should care about substance use amid a pandemic


Shani Macaulay


9/04/2020 10:34:54 AM

Dr Shani Macaulay reflects on how the ongoing coronavirus outbreak may affect people who experience issues with alcohol and other drugs.

Man drinking alone
Trauma leads to an increase in problematic AOD use, and a worsening of severity in those with an established substance use disorder.

At first I am transfixed by my mobile screen, reading every latest update.
 
The climbing rate of infections and deaths – first in China and later Italy, Spain and the US – seems relentless. We go out shopping and buy an extra can of baked beans, bemused by the lack of toilet paper.
 
Other friends and family continue to frequent public places and carry on as though it’s business as usual. Until the city starts shutting down.
 
Our accountant has become a coronavirus expert because he wants to be prepared for what is coming. Who can blame him? My neighbours are terrified.
 
However, on the one walk a day my family and I allow ourselves, we can still see people carrying on as though everything is normal. It is not.
 
This dangerous coronavirus has a reproduction number (R0) of between 2 and 3, and identified cases are rising exponentially.
 
Our international borders close, Australia starts to get more serious. Then come the news reports of cruise ships allowing sick passengers to disembark … across Australia. Cases pop up in the remote WA town of Broome, where Aboriginal and Torres Strait Islander people make up 30% of the population. I worry about the risk of complications from COVID-19 due to higher rates of comorbidity and pray it does not reach more isolated communities.
 
As a two-doctor family, my partner and I talk and hope that our efforts as a community will start to flatten the curve. We are virtually on quarantine as a family, aware we are potential vectors.
 
We have asked our elders to start ‘shielding’. No conversation with colleagues or community is without a discussion on the latest COVID-19 update, especially so as we are doctors. Our community is looking to us to try to make sense of this chaos. It is coming like a tsunami as we scramble to find limited and vital resources such as personal protective equipment (PPE).
 
We are rapidly adjusting how we practice and some of us are feeling quite unprepared.
 
But we are preparing. Planning is underway and many changes have been made already in the way society and our health system operates. GPs have performed an incredible feat to change the way they operate.  
 
Although there is still a way to go in terms of appropriate resourcing to protect GPs, telehealth is increasingly giving us more power to hold our consultations in a safe and effective way. The Government has committed more funding for mental health and domestic violence services.
 
While frontline doctors brace coronavirus cases, we also need to consider the huge impact this will have on society more broadly.
 
The sudden rise in unemployment, new restrictions on freedom to travel, even intrastate, the enforced isolation of families and restrictions on social connectedness will all impact wellbeing.
 
This will have a significant and ongoing impact on Australians’ social determinants of health.
 
Alcohol and other drugs
One of my specific interests is helping patients address their alcohol and other drug (AOD) use. As we know, there is significant overlap between people who use AODs, marginalised and vulnerable populations and poor social determinants of health.
 
Mental health and domestic violence services have already experienced a significant increase in demand due to the COVID-19 pandemic, and AOD use is likely contributing to these presentations.
 
When we look at Australia’s burden of disease, we know substance use disorders (SUDs) and mental health disorders are a leading cause of non-fatal burden of disease.   
 
In the cohort accessing AOD treatment services, mental health disorders co-occur in as many as 76% of patients. Vulnerable populations are finding themselves isolated from their usual support networks and isolated within dysfunctional family situations. Internet searches for domestic violence support have increased by a staggering 75% during this current crisis.
 
We will almost certainly see escalating AOD use due to trauma. Mental health worsens during and after a disaster, as does problematic AOD use. Trauma leads to an increase in problematic AOD use and a worsening of severity in those with an established SUD. We also know trauma is seemingly ubiquitous in those with an SUD, with rates of post-traumatic stress disorder (PTSD) in this population as high as 62%.
 
The self-medication hypothesis is used to explain the nature of increased AOD use as a coping strategy to relieve suffering, including emotional pain, flashbacks, anxiety, insomnia and so on.
 
We also need to be mindful of the potential for trauma (direct or vicarious), as well as increasing AOD use, in healthcare workers and ourselves as GPs. Doctors are renowned for prioritising patient care above their own needs – they need to ensure they are prioritising their self-care now more than ever.
 
Mental health
GPs will need increased vigilance to screen for suicidal thoughts and perform a risk assessment. AOD use is a recognised main risk factor for suicide.
 
There is a cluster of risk factors for suicide named the ‘lethal combination’:
 
An at-risk person + life event + sense of hopelessness + mental health disorder + alcohol + impulsivity.
 
These are all increasingly likely to occur during and after this pandemic.
 
Psychopathology in children will likely be increased during and after the pandemic, with worsening mental health, domestic violence and enforced isolation within dysfunctional family dynamics.
 
The Adverse Childhood Events (ACE) Study determined that the likelihood of poor health outcomes increased with each adverse childhood event.
 
In addition to traumatic events, ACE include a sense of threat to the safety and stability of a child’s household and immediate environment. This threat to safety and stability can include living around people with problematic AOD use and poor mental health.
 
The influential study found that four or more ACE led to poor health outcomes, including an increased rate of mental health problems such as anxiety and depression, and physical health issues such as heart disease and cancer. Supportive care, education and appropriate referrals have been shown to improve outcomes in children aged 0–5.
 
People with SUDs also have a higher rate of medical comorbidity.
 
For example, there are increased rates of lung disease such as chronic obstructive pulmonary disease (COPD) and impaired immune function in those with SUDs. Acquiring COVID-19 may cause increased rates of mortality and morbidity in this population.
 
There may be increasing difficulties for those on treatment such as opioid substitution therapy being able to obtain their medications. These individuals will be at further risk of exposure to COVID-19, as they have to attend a pharmacy regularly.
 
Those that are choosing to inject drugs may have difficulty finding sterile injecting equipment. Those in peer support groups like Alcoholics Anonymous will be at a loss now that Australians can only meet in groups of two.
 
The Federal Government has closed pubs and restaurants, and introduced new limits on volumes of take-away alcohol in recognition of the burden-related harms place on the health system. As people’s finances become strained and this situation develops, we may see more cases of complicated unplanned alcohol withdrawal.
 
GPs can and will continue to manage these seemingly intractable problems, just as we do in general practice every day.
 
We can learn from past disasters and international communities who are also experiencing the fallout from COVID-19. We can prepare and plan for the anticipated worsening of substance use and mental health issues.
 
I am hopeful that we can undergo transformation as a profession and come away from this with more flexible and innovative ways of consulting. Primary care will continue to be the bedrock of Australians’ health and wellbeing during and after this crisis.
 
GPs display adaptability and resilience every day in their practice. This time may feel disorienting and sometimes overwhelming, and that is okay.
 
Our world is changing – and we are changing with it.
 
For support in managing problematic AOD use, GPs can register to participate in the RACGP’s AOD GP Education Program.
 
The program’s Essential Skills Education is designed to assists GPs seeking to improve their AOD consultations; the Treatment Skills Pathway focuses on treating AOD issues and provides GPs with direct access to AOD specialists; and the Advanced Skills Training provides an opportunity for more experienced GPs to support treatment of AOD use in their community.



alcohol and other drugs coronavirus COVID-19 pandemic



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Dr Christopher Charles Davis   10/04/2020 8:44:06 AM

Really good article thank you. For a lot of people, now is actually a good time for GP supervised alcohol withdrawal as a lot of people have their support person at home with them and there are less social triggers. Daily F2F review for the first 3 days is usually enough and then phone follow up. Injectable Buprenorphine is now invaluable and worth considering switching our opioid dependent patients onto.


Dr Shani Macaulay   15/04/2020 8:10:53 AM

Dear Dr Davis,
Two excellent points.
Thank you.