For the first time in decades, American life expectancy is decreasing. This is in part due to what Princeton economists Anne Case and Angus Deaton called "deaths of despair," or deaths related to bleak economic or social circumstances, and those largely driven by suicide, drug and alcohol overdoses, and alcoholic liver disease. As we face COVID-19 with little end in sight, we have to wonder how the pandemic will influence rates of substance use in our country, and in turn, deaths of despair.
Lloyd I. Sederer, MD
Sadly, unless somehow mitigated, the numbers are likely to increase. We may be in for a perfect storm of factors driving substance abuse rates higher than we have seen before—the "triple trouble" of a pandemic, unemployment, and diminished personal and community supports.
In conducting their research, Case and Deaton found a robust correlation between unemployment/economic insufficiency and rising death rates among people ages 25-55, especially men. The numbers are especially dramatic in white, high school–educated working men and women from middle America. Many in this population spend their lives doing manual labor and end up financially insecure due to unemployment. They, and their children, often have few future work prospects. They don't have health insurance or other benefits, and intoxicants like opioids, alcohol, and crystal meth are readily available—an easy-access form of self-medication.
COVID-19 is expected to leave well over 30 million Americans jobless and many more without health or other safety-net benefits. Compound this with what we know from post-disaster studies (eg, 9/11, hurricanes, floods, and tornadoes), that use of substances generally increases following major traumatic events, especially use of alcohol, which is easier to measure and thus report. Rates rise especially high among those who had substance use and abuse problems before a disaster.
In the wake of the coronavirus pandemic, communities already affected by rising deaths of despair—the Midwest, South, and Northeast—will probably be further razed by the economic and psychological consequences of COVID. Moreover, through isolation and social distancing, they will be deprived of people in their lives who provide support, which is essential to resilience. Their access to affordable healthcare may also be limited and insufficient to restore their health, and, in the severest cases, to keep them alive.
Even if we weren't already facing massive unemployment, we would probably still see more substance use problems among those affected by our current disaster. We don't yet have studies on the COVID pandemic, but I believe that the research that we do have on substance use illuminates what's ahead for our country and elsewhere.
The authors of another study reported on the association of adverse mental health effects with repeated exposure to disasters. They studied 547 people exposed to multiple disasters, including floods, tornadoes, dioxin contamination, and/or radioactive well water. The condition they found most common was alcohol use disorder, which typically predated the disaster, just as much substance abuse predates COVID in already economically stagnated communities of this country.
Other research has also shown what might be expected: that the highly prevalent psychological distress following disasters fosters self-medication with both legal and illegal psychoactive substances, and does so more among those already vulnerable to mitigating distress with drugs and alcohol. Many survivors of 2008's Hurricane Ike were found to turn to alcohol. After Hurricane Katrina , substance abuse disorders in New Orleans soared—with alcohol and drug consumption associated with a greater risk for post-traumatic stress disorder—while the events of 9/11 led to an increase in binge drinking and substance use and abuse in those touched by the tragedy.
The aftermath of 2012's Hurricane Sandy takes us closer to the opioid epidemic. The authors of a 2015 study demonstrated that the ongoing provision of buprenorphine was associated with no sustained increases in opioid, cocaine, or benzodiazepine use—a glimmer of hope in postdisaster addiction treatment. Yet, shorter time in treatment, disruptions in buprenorphine supply, and a past history of repeat positive opioid urine tests were predictive of addiction relapse after the storm.
These reports are telling if we're to stem substance abuse and the opioid epidemic in the wake of the coronavirus pandemic. Deaths of despair may come to have even greater meaning, calling upon those of us in healthcare to do all we can to mitigate the losses and suffering.
How can mental health professionals help? We can better standardize screening for substance use in mental health and help our primary care colleagues do the same. We can be more diligent about detecting problems early, and ensure access to buprenorphine and naltrexone at our clinics and programs. We can increase contact and outreach to our patients already at known risk for substance use and abuse disorders, and urge patients and families to access substance use 12-step programs, as well as those that combine psychosocial interventions with medications ("comprehensive treatment").
Those of us working in hospitals can better identify patients presenting to the emergency department with substance-related trauma or evidence of violent interactions or abuse, and engage them in that moment. We can employ motivational enhancement techniques to move patients along the continuum from denial to acceptance to readiness to change.
However the coronavirus pandemic plays out, helping curtail a rise in substance abuse will be a challenge. But as President Abraham Lincoln remarked a long time ago, "The best way to predict the future is to create it."
Dr Sederer is the former chief medical officer for the New York State Office of Mental Health and an adjunct professor in the Department of Epidemiology at the Columbia University School of Public Health. His latest book is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs.
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Cite this: What Past Disasters Tell Us About COVID-19 and Substance Abuse - Medscape - May 18, 2020.
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