The social and economic impacts of the coronavirus pandemic are driving more people to substance abuse while also limiting access to prevention, treatment, support and rehabilitation - services already in short supply. Without immediate actions, the consequences will be felt for years to come.

The isolation and anxiety prompted by the coronavirus pandemic and associated social and economic fallouts have led to an increase in substance abuse[1]even by people who have not previously had problems.

Policymakers and health care services are alert to the mental health ramificationsof the pandemic and, to a lesser extent, the increase inalcohol consumption.There are manycommon risk factorsthat contribute to both mental illness and substance use and addiction, but despite the high prevalence ofcomorbiditybetween these two disorders, the issues of increased substance abuse and decreased access to treatment and rehabilitation have not been adequately acknowledged or addressed.

The pandemic means that many people in treatment or rehabilitation for substance abuse arenot able to access these servicesbecause facilities are overloaded, because of isolation measures or because of financial difficulties.

The lockdowns and social isolation requirements will causesubstantial shiftsin illicit drug markets, drug use patterns and related harms.If people with addictions areunable to accesstheir illegal drugs of choice or the prescription medicines needed to control their addiction, this can lead to drug substitution and contamination and increased alcohol consumption.

Social distancing also increases thelikelihood of overdosesif there are no observers to administer naloxone to reverse the overdose. Disruption of care and access to medications such as methadone, which usually requires observation of its ingestion, can lead torelapses. In the United States the coronavirus pandemic has been labelled"a national relapse trigger".

The pandemic also means that new population cohorts are developing drug and alcohol problems, often unseen and unrecognised. The lack of access to usual medical care can drive patients with conditions such as trauma, depression and chronic pain to resort toself-medicationwith alcohol and drugs, both legal and illegal. There isgrowing evidencethat many people are drinking more during pandemic lockdowns. There are fears that opioid misuse, already aserious public health issue, will increase.

The pandemic poses additional health, social and economic risks for people with substance abuse disorders who aremore likelyto be homeless, in prison, and to face discrimination and stigma when accessing healthcare and other social services. Many live under circumstances where the risk of infection is high andsocial isolation is difficult, if not impossible.

Many of the people with substance abuse disorders are older.There has been anincreasein the number of older Australians who are using illicit drugs and thenon-prescribed use of pharmaceutical productsis relatively common among this population.Older people are the most likely todrink alcohol daily, with the highest rates seen among people aged over 70.

The virus itself is amajor threatfor this population which hasa high prevalence of chronic medical conditions. Because the virus attacks the respiratory system, anyone who smokes or vapes tobacco, marijuana, crack cocaine or methamphetamines is at increased risk.Patients who use opioids are particularly vulnerable to the virus from this physiological standpoint because opioids act to slow breathing, thus increasing the risk of low blood oxygen levels.

Australian data on the impact of the pandemic on drug use and abuse is scarce. Oneearly studyfound that lockdown restrictions have had limited impacts on drug purchase and use but users are smoking and drinking more. Apaper published in Maypredicted changes in both illegal drug market activity, including supply chain disruptions, and drug use behaviours. In theabsence of an illegal drug of choice, people may turn to alternatives, including pharmaceutical medicines, alcohol or tobacco.

Self-reported levels of alcohol consumption are up with28 percent of adults reporting they areusing alcoholto cope with anxiety and stress.A nationalYouGov Galaxy pollconducted at the beginning of Aprilfound 20 percent of respondents were drinking more during home isolation.There has been anincrease in the involvement of alcoholin family violence situations which have dramatically escalated since the COVID-19 restrictions were introduced.

As early as April there werereportsof alcohol and drug treatment andrehabilitation centres closing or refusing to take new admissions as the sector prepared for a worsening of the coronavirus pandemic.

Even before the pandemicmental healthandsubstance abuseservices and workforce have been insufficient to meet the demand and in many cases are unaffordable for those with the greatest need. The pandemic has furtherhighlighted thehuge unmet needfor these services.

Substance abuse services havetraditionally been delivered separatelyfrom mental health and general healthcare services. In Australia this artificial divide is aggravated by thedivision of responsibilities and fundingbetween the federal and state and territory governments and between the public and private sectors.

While bothfederalandstategovernments have made additional commitments to support the mental health and wellbeing of Australians during the coronavirus pandemic, there has been virtually nothing provided to support substance abuse treatment.

An announcement in April from the federal Health Minister is the only mention of, and funding for, substance abuse: an additionalS$6 millionfor online and phone support services for people experiencing drug and alcohol problems.

The Victorian governmenthas issuednew guidelinesfor dispensing methadone and buprenorphine during the coronavirus lockdown. These replacement medicines for opioid addiction usually require daily pharmacy visits but the new guidelines enable takeaway doses.

It is notable that theNational Mental Health and Wellbeing Pandemic Response Planapproved by National Cabinet in May mentions increased substance abuse in the Executive Summary and cites the National Household Drug Survey as a source of information but does not otherwise address the issue. Similarly, thefederal government’sCoronavirus (COVID-19) National Health Planfor mental health support does not mention this issue.

Thereis a number of obvious actions that must be taken to address the needs of people who are experiencing substance abuse problems as a consequence of the coronavirus pandemic.

1. More data

There arecallsfor more data and research in this area.It is particularly important to identify the population cohorts affected for several reasons these may not be those expected (substance abuse is not confined to marginalised populations) and to enable targeted and culturally appropriate information and services.

2. Improved access to services and increased service capacity

Rehabilitation and treatment services are seeing anincrease in demandat the same time as their capacity is severely restricted.For many, support lines and telehealth services are inadequate replacements. Successful remote consultations are reliant on pre-existing relationships with patients and developing newtherapeutic relationships from scratch over the phone or video ishard to achieve.Those who need support groups such as Alcoholics Anonymous or Narcotics Anonymous may not have computer or internet access to attend online meetings.

3. Special attention to the needs of youth and young adults

The effects of the coronavirus outbreaks are felt most keenly by young adults ages 18 to 24 years and there areconcernsabout what this means for their experimentation with drugs and alcohol.

4. Special attention to the needs of health care workers

Health care workers already have high rates of substance abuse. It is estimated the lifetime prevalence of substance abuse inAustralian doctorsis approximately 8 percent.This rate will only be boosted by thestress and anxietycaused by working on the frontlines of the pandemic.

5. Protective social policies

Effective social protection systems are crucial for everyone when a crisis hits, and especially for safeguarding the poor and vulnerable. The impacts of unemployment and loss of income will last for some time and affect peoples’ mental health and wellbeing, widen socioeconomic disparities, and magnify the marginalisation of individuals with substance abuse disorders. While some jurisdictions have acted to findaccommodation for the homeless, many of whom have mental health and substance abuse problems, these have not always been permanent solutions.

6. Mobilisation of community social capital

Mobilization of community social capital is an important resource in disaster management and in pandemic times.Social inclusionis a key support for individuals with substance use and mental health disorders.

7. Integrated primary care, addiction and mental health care services

This must be a long-term goal of efforts to address substance abuse, with a vision that extends well beyond simply coping with the impact of the coronavirus pandemic.

Integrated and coordinated models that operate across primary health, mental health and specialist alcohol and drug services together with appropriate financing mechanisms must be developed, implemented and evaluated. Such modelsreduce access barriersby simplifying referral pathways between services, improve organisational efficiencies and, importantly, improve patient outcomes.The physical co-location of these services is a key factor in ensuring continued patient engagement.

This article is an adaption of a larger piece looking at the impact of the coronavirus pandemic on substance abuse in both the United States and Australia that is available on theUS Studies Centre website.