research on substance use disorders during the covid 19 pandemic

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COVID-19 and Substance Use

• The drug overdose and addiction crisis collided with the COVID-19 pandemic, with the potential to worsen the negative impacts of each for individuals. People who use drugs are more vulnerable to acquiring the virus that can cause COVID-19 and more likely to have worse health outcomes .
• However, the pandemic also led to opportunities for health care providers, substance use disorder recovery support systems, and other services to reach more people. For example, the U.S. government allowed flexibility for remote prescribing of buprenorphine and take-home dosing of methadone, medications used to treat opioid use disorder.
• NIDA conducts and supports research on the impacts of the COVID-19 pandemic on substance use and related health outcomes, and how the pandemic impacted adolescent health and brain development, including mental health and substance use. The institute is also researching sustainable, evidence-based strategies to overcome structural barriers to care .

Are people who have substance use disorders at greater risk for COVID-19?

Research shows that substance use, substance use disorders, and non-fatal overdoses are associated with an increased risk for developing COVID-19 and for related negative health outcomes. This association is particularly strong among people with opioid or tobacco use disorder. 1

An analysis of electronic health records from more than 73 million patients at 360 U.S. hospitals in June 2020 found that while people with substance use disorders made up only 10.3% of the study sample, they accounted for 15.6% of patients diagnosed with COVID-19. Overall, people with a previous diagnosis of a substance use disorder were 1.5 times more likely to have COVID-19 than those without a diagnosis. The study also found people with such a diagnosis were more likely to experience severe outcomes of COVID-19 than those without, including hospitalization (41% versus 30%) and death (9.6% versus 6.6%). 

How might drug use and addiction contribute to worse health outcomes from a COVID-19 infection?

Drug misuse and addiction can affect the body in ways that can increase the likelihood of worse health outcomes from COVID-19. For example, both COVID-19 and substance use can affect heart and lung function, amplifying the negative health effects of each.

• Smoking or vaping drugs—including tobacco/nicotine, marijuana, heroin, or crack cocaine—has been shown to worsen lung conditions like chronic obstructive pulmonary disease (COPD) and asthma. Chronic lung diseases can make a person more likely to get severely ill from COVID-19.
• High doses of opioids can slow breathing and lead to low levels of oxygen in the blood, which can also lead to heart, brain, and lung complications. Because COVID-19 affects the lungs, people who use opioids at high doses may have more severe illness when infected.
• Stimulants such as methamphetamine, cocaine, and amphetamine constrict the blood vessels and may increase the risk for stroke, heart attacks, abnormal heart rhythm, seizures, and other conditions that may lead to more severe heart or lung damage in someone with COVID-19.

Did drug use increase during the COVID-19 pandemic?

Limited data indicate there were significant increases in many kinds of drug use in the United States since the national emergency was declared in March 2020. 2  Researchers found the number of positive drug screens for fentanyl, cocaine, heroin, and methamphetamine increased from previous years. 3  Based on one online survey, adults who used cannabis prior to the pandemic monthly or less than weekly showed greater odds of increased non-medical use during the pandemic. 4

Studies also suggest many people increased their use of alcohol and other substances in the early stages of the pandemic, especially people with clinical anxiety and depression and those experiencing COVID-19-related stress. 5

However, according to the Monitoring the Future survey, which measures drug and alcohol use among adolescents and young adults, the percentage of adolescents reporting substance use decreased significantly in 2021. The findings represent the largest one-year decrease in overall illicit drug use reported since the survey began in 1975. These numbers generally held steady through 2022.

NIDA continues to study the effects of the COVID-19 pandemic on substance use. Read more about current research .

Did the COVID-19 pandemic affect the frequency of drug overdose?

Drug overdoses increased during the COVID-19 pandemic. However, other factors beyond the pandemic itself, such as proliferation of illicit, potent fentanyl in the drug supply, also occurred during the pandemic years, making it difficult to determine the exact cause of the increase.

More than 110,000 people died from drug overdose in the U.S. in 2022 according to the Centers for Disease Control and Prevention, the most in any year to that point. This increase follows a steady rise in overdose deaths in the United States that has been occurring since at least the 1980s. Fentanyl and other synthetic opioids have been the main drivers of overdose deaths since 2016.

Factors related to the pandemic may have exacerbated these trends. These include social isolation, stress, people using drugs alone and an increase in rates of drug use. People also faced decreased access to substance use treatment, harm reduction services, and emergency services. Along with partners at the National Institutes of Health (NIH), NIDA researchers are assessing the impact of COVID-19 policies on mental health, suicide, substance use, and drug overdoses in adults. 

What’s the relationship between health disparities, drug use, and COVID-19 outcomes?

The COVID-19 pandemic highlighted issues underlying health inequities that contribute to drug use and related poor health outcomes. In many cases, the pandemic worsened these disparities, potentially increasing people’s vulnerability to developing substance use disorders. These disparities also played a role in health outcomes related to COVID-19.

Racial inequities. The COVID-19 pandemic has highlighted the large racial and other health equity disparities in the United States that play a role in addiction. Systemic issues like poverty and residential segregation affected access to testing, insurance, and medical care. 6  Black, Latino/a, and American Indian people have been hospitalized and died at a higher rate than White people throughout the pandemic. 7  Further, children from communities of color have had the greatest burden of caregiver loss to COVID-19-related deaths.

Economic and environmental disadvantages. Issues that have been related to substance use disorders and poor health outcomes became even more pressing during the pandemic.

• Among frontline workers (those who generally can’t work from home), Black, Latino, and American Indian/Alaska Native people are more likely than White people to occupy low-income positions with a higher risk of exposure to the virus that causes COVID-19 and lower level of protection. 8
• Limited employment and transportation opportunities and a lack of healthcare resources, particularly in rural areas, became even more pressing during the COVID-19 pandemic, worsening mental health and increasing the risk of overdose. 9
• A high percentage of individuals with substance use disorders experience homelessness or housing instability, which puts them at increased risk for COVID-19 among other infectious diseases, because of higher rates of underlying health conditions and community spread in homeless shelters. 10

How did the COVID-19 pandemic impact substance use treatment and recovery services?

Physical distancing and other public health measures at the onset of the pandemic disrupted access to medication and other support services for many people. For example, many treatment centers and syringe service programs faced challenges providing in-person services in response to COVID-19 social distancing policies.

However, the pandemic also led to opportunities for health care providers, recovery support systems and other services to reach more people. For example, the U.S. government allowed flexibility for remote prescribing of buprenorphine and take-home dosing of methadone, medications used to treat opioid use disorder. Studies found that the flexibilities were effective in engaging and retaining patients and were not associated with harms .

In fact, one study found that expanded availability of opioid use disorder-related telehealth services and medications during the COVID-19 pandemic was associated with a reduced likelihood of fatal drug overdose among Medicare beneficiaries.

To help expand evidence-based treatment interventions, NIDA’s small business innovation research (SBIR) and small business technology transfer (STTR) programs are supporting the development of digital and telehealth tools. These include apps that help providers find treatment for patients and monitor their medications, and that help people in recovery connect with peers and coaches.   

How did NIDA support research on the intersection of substance use disorders and COVID-19?

Along with other NIH partners, NIDA supported research on the intersection of COVID-19 and substance use disorders. Studies, some of which are ongoing, have included:

Children and Adolescents. The HEALthy Brain and Child Development (HBCD) study is looking at the impact of COVID-19 on maternal health and substance use, and infant development. The Adolescent Brain Cognitive Development SM (ABCD) study is investigating the impact of the COVID-19 pandemic on adolescent health and brain development, including mental health and substance use. Read about findings related to COVID-19 .

Epidemiology. Under an NIH-wide program, NIDA has led research to detect SARS-CoV-2 in wastewater , a project that takes advantage of expertise NIDA developed to detect the presence of drugs in wastewater. Studies have shown that concentrations in wastewater correlated with new diagnoses of COVID-19.  The Population Assessment of Tobacco and Health (PATH) study is collecting additional data on the relationship between COVID-related stressors, mental health, and substance use.

Mental Health. Research is assessing the impact of COVID-19 outcomes and policies on mental health, suicide, substance use, and drug overdoses in adults. This includes examining the effects of the pandemic on substance use, mental health, and treatment access in both caregiving adults and their young adult children.

Treatment Policy. Clinical trials characterize the impact of COVID-19 related policy changes on drug use, drug supply, and access to medicines for opioid use disorder (MOUD) in rural primary and American Indian/Alaskan Native communities, and on access to buprenorphine across the entire U.S. For example, researchers assessed how MOUD providers are using telemedicine, COVID-19-related changes in how they treat opioid use disorder, and the impact of telemedicine on MOUD care.

Health Inequities. Researchers leveraged the Justice Community Opioid Innovation Network (JCOIN) infrastructure to implement and evaluate a COVID-19 testing approach in justice settings, for non-incarcerated individuals with previous involvement in the legal system, and low-income Latino/a people.

HIV-related Health. Researchers examined COVID-19 related changes in substance use, SUD treatment, and HIV prevention and care among those at high risk for HIV. 

Latest from NIDA

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Find more resources on covid-19 and substance use disorders.

• Find a COVID-19 vaccine near you at Vaccines.gov .
• Read more information on COVID-19 risk and severity among people who use substances from the Centers for Disease Control and Prevention (CDC) .
• See more COVID-19 research at the National Institutes of Health .
• Researchers: Find coronavirus COVID-19 information for NIH applicants and recipients of NIH funding .
• Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States [published correction appears in Mol Psychiatry. 2020 Sep 30;:]. Mol Psychiatry. 2021;26(1):30-39. doi:10.1038/s41380-020-00880-7
• Vo AT, Patton T, Peacock A, Larney S, Borquez A. Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times . Int J Environ Res Public Health. 2022;19(14):8883. Published 2022 Jul 21. doi:10.3390/ijerph19148883
• Wainwright JJ, Mikre M, Whitley P, et al. Analysis of Drug Test Results Before and After the US Declaration of a National Emergency Concerning the COVID-19 Outbreak . JAMA. 2020;324(16):1674-1677. doi:10.1001/jama.2020.17694
• Assaf RD, Gorbach PM, Cooper ZD. Changes in medical and non-medical cannabis use among United States adults before and during the COVID-19 pandemic . Am J Drug Alcohol Abuse. 2022;48(3):321-327. doi:10.1080/00952990.2021.2007257
• Roberts A, Rogers J, Mason R, et al. Alcohol and other substance use during the COVID-19 pandemic: A systematic review . Drug Alcohol Depend. 2021;229(Pt A):109150. doi:10.1016/j.drugalcdep.2021.109150
• Vasquez Reyes M. The Disproportional Impact of COVID-19 on African Americans . Health Hum Rights. 2020;22(2):299-307.
• Tai DBG, Sia IG, Doubeni CA, Wieland ML. Disproportionate Impact of COVID-19 on Racial and Ethnic Minority Groups in the United States: a 2021 Update . J Racial Ethn Health Disparities. 2022;9(6):2334-2339. doi:10.1007/s40615-021-01170-w
• Goldman N, Pebley AR, Lee K, Andrasfay T, Pratt B. Racial and ethnic differentials in COVID-19-related job exposures by occupational standing in the US . Preprint. medRxiv. 2021;2020.11.13.20231431. Published 2021 Apr 6. doi:10.1101/2020.11.13.20231431
• Walters SM, Bolinski RS, Almirol E, et al. Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis . Addict Sci Clin Pract. 2022;17(1):24. Published 2022 Apr 25. doi:10.1186/s13722-022-00303-8
• Tsai J, Wilson M. COVID-19: a potential public health problem for homeless populations . Lancet Public Health. 2020;5(4):e186-e187. doi:10.1016/S2468-2667(20)30053-0

Substance use during the pandemic

Opioid and stimulant use is on the rise—how can psychologists and other clinicians help a greater number of patients struggling with drug use?

Vol. 52 No. 2 Print version: page 22

• Substance Use, Abuse, and Addiction

The ongoing stress and uncertainty of COVID-19 have led to increased demand for mental health services from psychologists in the United States —but conditions like anxiety and depression aren’t the only mental health issues people are facing. Experts say misuse of opioids and stimulants is also on the rise—and psychologists are in a good position to help.

On top of the other risks arising with substance misuse, those with substance use disorders (SUD) are both more likely to develop COVID-19 and experience worse COVID-19 outcomes, including higher risk of hospitalization and mortality (Wang, Q., et al., Molecular Psychiatry , 2020).

According to the Centers for Disease Control and Prevention , as of June 2020, 13% of Americans reported starting or increasing substance use as a way of coping with stress or emotions related to COVID-19. Overdoses have also spiked since the onset of the pandemic. A reporting system called ODMAP shows that the early months of the pandemic brought an 18% increase nationwide in overdoses compared with those same months in 2019. The trend has continued throughout 2020, according to the American Medical Association , which reported in December that more than 40 U.S. states have seen increases in opioid-related mortality along with ongoing concerns for those with substance use disorders.

Mandy Owens , PhD, a clinical psychologist and researcher at the University of Washington Alcohol and Drug Abuse Institute, says she’s observed a spike in substance use that includes an increase in both quantity and frequency of drug use during the pandemic. Some people who use substances may have also started new drugs if their usual substances became more difficult to access. For example, Owens says Washington state has seen an uptick in the use of fentanyl, a synthetic opioid that’s increasingly produced illicitly, due to a shift in drug supply availability . But precise data on use and drug type are hard to come by, according to Wilson Compton , MD, MPE, deputy director of the National Institute on Drug Abuse.

Health care records are the primary source of data on substance use, and it can take months for medical providers to provide toxicology reports for overdose incidents to the CDC, says Sharon Walsh , PhD, a professor of behavioral science, pharmacology, pharmaceutical sciences, and psychiatry at the University of Kentucky (UK) and director of the UK Center on Drug and Alcohol Research. Tracking substance use accurately also heavily depends on the ability to do door-to-door household or school-based surveys, which have been more difficult to conduct during the pandemic.

However, Walsh says state-level data are a bit clearer. According to her research, Kentucky has seen increased emergency room visits for overdose-related incidents during the pandemic. By contrast, the state experienced a decline in emergency medical service runs for non-opioid related emergencies. “It really magnifies the opioid problem when you look at it against a decline in presentation at the hospital for other conditions,” she says.

The relationship between the pandemic and drug use

Compton cautions against conflating all increased drug use directly with COVID-19. For example, shifts in drug availability may also be to blame for increased illicit opioid use deaths; if heroin isn’t easy to access, someone might take fentanyl, which is much stronger. But experts agree based on research and clinical observation that pandemic-related strains, from economic stress and loneliness to general anxiety about the virus, are a major driver for the increase. “There’s sort of a perfect storm of factors that we know increase drug use,” says William Stoops , PhD, a professor of behavioral science, psychiatry and psychology at the University of Kentucky. “People are more stressed and isolated, so they make unhealthy decisions, including drinking more and taking drugs.” (See January Monitor for more on drinking habits during COVID-19 .)

As their stress increases, people may have fewer ways to manage it, which Owens says probably contributes to the uptick in substance misuse. For example, resilience-promoting activities, like physical activity and social interactions, haven’t been as safe to engage in or easy to access, which can lead some people to start using drugs or use them more often or in greater amounts.

There are also practical pandemic-related reasons for the rise in overdoses. Compton says people are more likely to die when they are using drugs alone, because there’s no one there to call 911 or administer naloxone, an opioid-reversal agent. For those living alone during the pandemic, this isolation presents an obvious risk. And in the early part of the pandemic, it was more difficult for people to seek the medical care they needed for recovery from opioid use because some clinics and community-based organizations decreased their services.

Walsh says that in March and April, Kentucky methadone clinics saw an increase in patients ending treatment and a decrease in new patients starting treatment. “Physicians have been concentrating largely on COVID-19, and medical systems are overwhelmed, so people can’t always access the care they need,” says Stoops. “There’s also a stigma around substance use disorder that keeps people away from treatment, and even more so during a pandemic.”

A shift toward telemedicine

Fortunately, it’s become easier throughout the pandemic for people to access care for substance use disorders, thanks to the increased availability of telemedicine for behavioral health concerns. While the pandemic initially caused many clinics and community-based organizations to close their doors, telehealth options for physical and mental health problems have become increasingly available as insurance providers and organizations have recognized the need. In addition, it’s becoming more common for community-based groups like Narcotics Anonymous and Alcoholics Anonymous to meet virtually. And most insurers, including Medicaid, have lifted previous telehealth restrictions on treatment for behavioral health, including substance use disorder.

For example, Compton says physicians can now start patients on buprenorphine, a drug used for opioid recovery, through telehealth without conducting an in-person exam. Opioid Treatment Program providers (at so-called “methadone clinics”) have also been offering patients take-home methadone for maintenance more frequently during the pandemic. “Normally you have to be extraordinarily stable to take as many as 30 doses at a time home, but they’ve relaxed some of those [requirements] so patients don’t have to show up every day to an opioid treatment program,” Compton says.

Better access to telehealth means people with substance use issues can also seek remote mental health care. While Owens says accessing treatment can be difficult for people without reliable internet or phone service, according to Compton, clinicians are largely reporting more patients showing up for psychotherapy appointments thanks to the increasing use of telehealth. “One clear benefit of changes in treatment infrastructure throughout the pandemic is that the availability of telehealth may have helped some folks that were on the precipice of seeking help go seek that help,” says Justin Strickland, PhD, a postdoctoral fellow in behavioral pharmacology at the Johns Hopkins University School of Medicine.

What psychologists can do to help

Psychologists are well positioned to support patients struggling with substance use disorders. But how they help their patients depends on the type of drug. For opioid use disorder, medications like buprenorphine are a key component of treatment. Owens says encouraging patients to seek medical treatment is the first step to preventing long-term impact of opioid use, including overdose. Concurrent psychological treatment can help people adhere to the medication schedule, identify and respond in more healthy ways to stressors that have led them to opioid use, and address related conditions such as pain, post-traumatic stress, anxiety, and depression.

According to Paul Christo , MD, an associate professor in the Division of Pain Medicine at the Johns Hopkins University School of Medicine, it’s also important for psychologists to advocate for expanded availability of naloxone, which, in certain states, anyone can request from a pharmacy to have on hand to treat narcotic overdose in emergencies. “We need greater awareness around the country that this is something that can prevent someone from dying,” Christo says.

There’s no FDA-approved medication physicians can use to help patients recover from use of stimulants, such as cocaine and methamphetamine, but Stoops says there are a number of behavior-based interventions, such as cognitive behavioral therapy (CBT), that psychologists can use to help. Some clinicians couple CBT with an approach called contingency management, which promotes abstinence by providing alternative reinforcers like gift cards or vouchers when patients show they have not used drugs.

Psychologists should also make a habit of asking all their patients about any substance use. Owens encourages clinicians not to assume patients without a SUD diagnosis aren’t misusing substances or at risk for misuse in the future. “As stressors have continued and effective coping skills have been cut off, it’s more likely for people to turn to substances,” she says.

If a patient says they have been using, Owens encourages clinicians to extend compassion, with the goal of helping patients understand how compounding stressors may be influencing their substance use and identify better ways to cope. “Instead of assuming people want to quit using, psychologists should help patients do a functional analysis of the substance’s role in their lives,” she says.

It’s also important, Owens says, to recognize that weekly outpatient appointments might not be enough for every patient, especially those with more free time on their hands during the pandemic. Psychologists should coordinate care with other providers as needed, focusing on adding as much structure and support to their patients’ routine as possible. For example, Owens treats a patient with a SUD in an outpatient setting once weekly, but the patient also participates in intensive outpatient care through another local provider. Psychologists should also consider encouraging patients to participate in virtual community support groups, adds Owens. There’s no black-and-white approach to helping patients struggling with substance use, she says. “It’s really about tailoring to what each patient needs.” 

Collision of SUD and COVID-19: A NIDA update NAADAC, the Association for Addiction Professionals, 2020

Mental health and substance use disorders in the era of COVID-19: With a special focus on the impact of the pandemic on communities of color: A workshop National Academies of Sciences, Engineering, and Medicine, 2020

Special report: New solutions for the opioid crisis Monitor , June 2019

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Substance Use Among Youth During the COVID-19 Pandemic: a Systematic Review

• Child and Family Disaster Psychiatry (B Pfefferbaum,Section Editor)
• Open access
• Published: 27 April 2022
• Volume 24 , pages 307–324, ( 2022 )

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• Hannah M. Layman   ORCID: orcid.org/0000-0003-0993-6115 1 ,
• Ingibjorg Eva Thorisdottir   ORCID: orcid.org/0000-0003-2249-0410 2 , 3 ,
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Purpose of Review

To review the literature on the trends in substance use among youth during the coronavirus SARS-CoV-2 (COVID-19) pandemic.

Recent Findings

The pandemic has given rise to concerns about the mental health and social well-being of youth, including its potential to increase or exacerbate substance use behaviors. This systematic review identified and included 49 studies of use across alcohol, cannabis, tobacco, e-cigarettes/vaping, and other drugs, and unspecified substances. The majority of studies across all categories of youth substance use reported reductions in prevalence, except in the case of other drugs and unspecified drug and substance use, which included three studies that reported an increase in use and three studies that reported decrease in use.

Overall, the results of this review suggest that the prevalence of youth substance use has largely declined during the pandemic. Youth substance use in the post-pandemic years will require monitoring and continued surveillance.

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The Impact of the COVID-19 Pandemic on Adolescent Substance Use

Adolescent Substance Abuse

Epidemiology and Historical Drug Use Patterns

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Introduction

The adolescent years represent an important developmental stage during which the foundation for future patterns in substance use is often established [ 1 ]. Both the quantity and frequency of use during this period are strongly associated with risks for heavy use and misuse of substances in adulthood [ 2 , 3 ]. As an example of the staggering economic and societal costs, substance use in the USA alone has been estimated at over $400 billion annually by the US Surgeon General [ 4 ]. In addition to the direct economic impact, the societal harm caused by substance use in the USA has been estimated at over $800 billion annually due to premature death or quality-of-life adjustments [ 5 ]. Youth alcohol, tobacco, and other drug use impairs psychological and neurocognitive development and increases risk for academic failure, chronic disease, and mental illness [ 6 , 7 ]. Thus, the prevention of youth substance use remains an important priority for public health globally.

Various domains of established risk and protective factors play an important role in preventing the development of youth substance use. These include access to care and support provided by parents, family, and friends; structure, supervision, and support from school faculty and staff; and access to and participation in pro-social leisure time activities [ 8 , 9 ]. Studies that take an ecologic view of substance use have further assessed the impact of environmental factors known as “context effects,” which independently contribute to the odds of alcohol, tobacco, and other drug use among youth. Generally, such studies have found that youth who live under challenging home situations or in resource-limited areas, or both, are more likely than other youth to be negatively affected by sudden environmental changes and thus may turn to substance use as a coping mechanism [ 10 , 11 , 12 ].

The COVID-19 Pandemic

The novel coronavirus SARS-CoV-2 (COVID-19) was officially declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [ 13 ]. Over 400 million confirmed cases and close to 6 million deaths worldwide have been attributed to the virus [ 14 ]. Thus, virtually no human on earth has been unaffected by the virus. During this time, entire countries, regions, states, cities, and towns have enacted various laws, rules, and guidelines in their efforts to curb the spread of the virus and its impact on human health. Some of the more drastic mitigation measures have included closing of borders, lockdowns and curfews, or both, in cities and towns; severe limits on social gatherings and assembly (e.g., religious services); restricted access to worksites and entertainment venues and services (e.g., restaurants, theaters, and sports events); and mandates for physical (or social) distancing and wearing face masks. In most places, these efforts have included closing of schools and restriction of services for youth, such as sport clubs and extracurricular programs, and the prohibition of social gatherings [ 15 , 16 ]. Such extreme measures at the societal level are unprecedented in modern times and have not been seen since the influenza pandemic of 1918 [ 17 ].

In addition to the social restrictions, the mitigation efforts to curb the spread of the virus have resulted in unintended consequences that have been harmful in the lives of youth [ 18 ]. These include disruption of parental (or caregiver) income and associated financial consequences and stunted academic progress due to school closings, remote instruction, and recurring changes in instructional formats. The pandemic has also increased feelings of loneliness among young people because of long-term social isolation and limited opportunities to interact with peers [ 12 ]. During this period, inconsistent and poorly planned institutional responses have been reported [ 19 ], including a decline in access to harm-reduction services and treatment of substance use [ 20 ]. In a recent review, Pfefferbaum highlighted the negative psychological effects of the pandemic on children and youth, including the significant increase in the prevalence of clinical depression, suicidal ideation, and anxiety, all of which have the potential to contribute to an increase in substance use behaviors [ 21 ].

The Current Study

Given the human and societal costs associated with youth substance use, we sought to critically assess the impact that the COVID-19 pandemic has had on youth substance use. Some recent studies have shown an increase of substance use among youth, particularly vulnerable youth, such as those living in resource-poor areas or under challenging family circumstances [ 22 ], while others have found a reduction in substance use despite an overall worsening of mental health status [ 23 ••]. However, despite the significance of the pandemic, a wholistic review of research on youth substance use during the era of the COVID-19 pandemic has not been conducted to date. Consequently, the objective of this systematic review was to provide an overview of the most recent research into youth substance use during the period of the COVID-19 pandemic.

This systematic review sought to examine the prevalence of substance use among adolescents during the COVID-19 pandemic. Following the identification and selection of peer-reviewed papers, we examined each relevant paper by country, sample characteristics (type, age, sample size, period of study enrollment), study design, substance use behavior or outcome (type, measurement), and covariates included in the analyses. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was used to guide the design, execution, and reporting of findings for this systematic review. The research question, inclusion criteria, and search terms were defined using the PICO approach (Population, Intervention [or Exposure], Comparator, and Outcome). We identified and used previously published research articles and reviews on substance use during the COVID-19 pandemic to guide the creation of the search terms. The protocol for this systematic review was registered at PROSPERO (CRD42022311679).

Inclusion and Exclusion Criteria

Studies were selected based on the following criteria: (1) examined the substance use among youth during the COVID-19 pandemic; (2) study participants were 24 years old or younger; and (3) the study was published in the English language. Cross-sectional and longitudinal studies were included. When two manuscripts presented findings from non-independent datasets, the manuscript with the larger number of study participants was included. Articles were excluded if either COVID-19 (or a related term: COVID pandemic, Coronavirus, etc.) or substance use (or related terms: substance abuse, addiction, alcohol, nicotine, smoking, vaping, tobacco, licit drug/s, illicit drug/s, drug/s, etc.) was not identified in the paper’s title or abstract.

Identification of Studies

All databases within Web of Science were used in conducting the search. The search was limited to studies published on, or subsequent to, the date the COVID-19 pandemic began (December 1, 2019) to studies published up to February 15, 2022. Thus, the last search for this review was conducted on February 15, 2022. Titles, abstracts, and articles were reviewed to identify potentially relevant manuscripts. The search terms included combinations of COVID, adolescent*, child*, youth, substance use, substance abuse, drug, substance drug, smoking, tobacco use (Table 1 ). Reference lists of included research studies and published reviews of substance use among youth during the COVID-19 pandemic were also searched.

Data Extraction

The initial search based on the inclusion and exclusion criteria was performed by one investigator (HL) and then repeated by a second investigator (IET) to ensure that all relevant articles were included. The investigators conducting the search were located across two different countries (the USA and Iceland) with access to different research databases. As such, the second investigator’s search yielded an additional 17 studies that were not included in the first search. These discrepancies in the search findings from the two investigators who performed the search were discussed and a consensus was reached by the two investigators. Key elements of relevance for this review were extracted from each paper, summarized, and entered into an Excel spreadsheet, which was used to inform the broader discussion of the current state of the literature among the collaborating authors.

The initial search yielded 423 articles of potential interest. Of those, 49 articles met full eligibility criteria (see Fig.  1 for PRISMA flow chart). Five articles were published in 2020, 38 in 2021, and 6 in 2022. Forty-six articles from 23 countries reported on studies conducted with single-country samples and three articles reported on studies from multiple countries. Most of the studies were conducted in North America ( n  = 22) or Europe ( n  = 19). Twenty-nine articles reported studies that were based on cross-sectional designs and 20 on longitudinal designs. Forty-four articles reported on participant samples of between 10 and 25 years of age, and five articles also included older individuals. Regarding outcomes, 14 articles reported studies with a single substance use outcome, 29 articles included multiple substance use outcomes, five articles reported on general substance use without specifying type of substance, and one article focused solely on substance abuse disorder. Below, we have organized the summaries of our findings from the review of the 49 articles by substance use outcome (Table 2 ). Articles reporting on multiple substance use outcomes are included in multiple summaries based on the respective outcome.

PRISMA flow diagram of the bibliographic search. The 15 Web of Science databases included: Arts & Humanities Citation Index, Book Citation Index, Emerging Sources Citation Index, BIOSIS Citation Index, BIOSIS Previews, Conference Proceedings Citation Index, Data Citation Index, Derwent Innovations Index, KCI-Korean Journal Database, MEDLINE®, Russian Science Citation Index, Science Citation Index Expanded, Social Sciences Citation Index, SciELO Citation Index, Zoological Record, Zoological Record (1864-present). Reasons for excluding reports included the following: reason 1, accidentally included/wrong topic; reason 2, not a research article; and reason 3, date of publications prior to the COVID-19 outbreak

Alcohol Use

A total of 32 studies included measures on alcohol use; 27 of those also included measures on one or more other types of substance use [ 22 , 23 ••, 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 •, 33 , 34 ••, 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ], with five focusing exclusively on alcohol use as the outcome [ 49 , 50 , 51 , 52 , 53 ]. Fourteen studies employed a cross-sectional design [ 22 , 25 , 26 , 33 , 37 , 38 , 39 , 40 , 41 , 44 , 45 , 46 , 48 , 49 ] and 18 used longitudinal designs [ 23 ••, 24 , 27 , 28 , 29 , 30 , 31 , 32 •, 34 ••, 35 , 36 , 42 , 43 , 47 , 50 , 51 , 52 , 53 ]. Twenty-four studies used a non-random selection of participants, including convenience, purposive, or volunteer samples [ 22 , 24 , 25 , 26 , 28 , 29 , 31 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 49 , 50 , 51 , 52 , 53 ].

Five studies reported increase in alcohol use [ 22 , 26 , 30 , 36 , 45 ], 12 studies reported decrease in alcohol use [ 23 ••, 32 •, 34 ••, 35 , 38 , 39 , 47 , 48 , 50 , 51 , 52 , 53 ], and four studies reported no change [ 24 , 28 , 31 , 43 ], as noted above, mainly because of cross-sectional design where alcohol was employed as a covariate or group divider. Eleven studies reported neither an increase nor a decrease in alcohol use [ 25 , 27 , 29 , 33 , 37 , 40 , 41 , 42 , 44 , 46 , 49 ]. Ten studies included a mention of gender [ 23 ••, 25 , 28 , 33 , 41 , 42 , 43 , 45 , 46 , 51 ], and five in relation to alcohol use [ 23 ••, 28 , 33 , 45 , 51 ]. One concluded that boys [ 33 ] used more alcohol than girls during the pandemic, while two studies reported on greater increase in use among girls [ 28 , 45 ]. No gender difference was reported in two of the studies [ 23 ••, 51 ].

Cannabis Use

A total of 20 studies included measures on use of cannabis, including marijuana, hashish, and edibles. Seventeen of these also included measures into one or more other type of substance use [ 24 , 25 , 26 , 27 , 28 , 31 , 32 •, 33 , 34 ••, 35 , 36 , 39 , 42 , 44 , 46 , 47 , 54 ], three of which focused exclusively on cannabis use as the outcome [ 55 •, 56 , 57 ]. Nine studies employed a cross-sectional design [ 25 , 26 , 33 , 39 , 44 , 46 , 54 , 56 , 57 ] and 11 used a longitudinal design [ 24 , 27 , 28 , 31 , 32 •, 34 ••, 35 , 36 , 42 , 47 , 55 •]. Fifteen studies used a non-random selection of participants, including convenience, purposive, or volunteer samples [ 24 , 25 , 26 , 28 , 31 , 35 , 36 , 39 , 42 , 44 , 46 , 54 , 55 •, 56 , 57 ].

Four studies reported an increase in the prevalence or frequency of cannabis use during the pandemic [ 26 , 36 , 55 •, 57 ], five studies reported a decrease in cannabis use [ 28 , 32 •, 35 , 39 , 47 ], and three studies reported no change [ 24 , 31 , 34 ••]. Eight studies did not report an increase or decrease in cannabis use for similar reasons as mentioned above [ 25 , 27 , 33 , 42 , 44 , 46 , 54 , 56 ]. Three studies included a mention of gender and two in relation to cannabis use [ 25 , 28 , 33 ]. One concluded that cannabis use among boys had increased more than use among girls during the pandemic [ 33 ], and one study reported that use among girls had increased more than for boys [ 28 ]. One study included an assessment of gender without relevance to cannabis use outcome [ 25 ].

Tobacco Use

A total of 27 studies included measures on tobacco use, with all but two including measures on one or more other types of substance use [ 22 , 23 ••, 25 , 26 , 27 , 29 , 30 , 33 , 34 ••, 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 54 , 58 ]. One study exclusively assessed nicotine dependence [ 59 ], and one study solely employed a general measure of smoking [ 9 ]. Seventeen studies employed a cross-sectional design [ 22 , 25 , 26 , 33 , 37 , 38 , 39 , 40 , 41 , 44 , 45 , 46 , 48 , 54 , 58 , 59 , 60 ] and 10 studies used longitudinal designs [ 23 ••, 27 , 29 , 30 , 34 ••, 35 , 36 , 42 , 43 , 47 ]. Twenty studies used a non-random selection of participants, again including convenience, purposive, or volunteer samples [ 22 , 25 , 26 , 29 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 54 , 58 , 59 , 60 ].

Of all studies included for tobacco use, only two studies reported an increase in smoking behavior during the pandemic [ 26 , 34 ••], six studies reported a decrease in smoking behavior [ 22 , 23 ••, 35 , 36 , 39 , 61 ], and one study reported no change in smoking behavior [ 47 ]. Eighteen studies did not report an increase or decrease in smoking behavior, again, mainly because of cross-sectional design and where smoking was employed as a covariate or group divider, or both [ 25 , 27 , 29 , 30 , 33 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 54 , 58 , 59 ]; most of these studies focused on mental health. Nine studies reported on some form of gender difference [ 23 ••, 24 , 33 , 40 , 41 , 43 , 47 , 48 , 59 ] but only two of them reported such difference in smoking, with one reporting increased use among boys [ 33 ] and one increased use for girls [ 48 ].

E-cigarette Use/Vaping

A total of 16 studies included measures on e-cigarettes or vaping. Twelve of those also included measures into one or more other type of substance use [ 23 ••, 24 , 25 , 26 , 27 , 28 , 29 , 32 •, 34 ••, 36 , 54 , 58 ] but four were exclusively about e-cigarette use/vaping [ 62 , 63 , 64 , 65 ]. Nine of the studies employed a cross-sectional design [ 25 , 26 , 58 , 59 , 62 , 63 , 64 , 65 ] and eight used longitudinal designs [ 23 ••, 24 , 27 , 28 , 29 , 32 •, 34 ••, 36 ]. Thirteen of the studies used a non-random selection of participants such as convenience, purposive, or volunteer samples [ 24 , 25 , 26 , 28 , 29 , 36 , 54 , 58 , 62 , 63 , 64 , 65 ].

One study reported an increase in e-cigarette use/vaping [ 26 ], eights studies reported a decrease in e-cigarette use/vaping [ 23 ••, 28 , 36 , 62 , 63 , 64 , 65 ], and two studies reported no change [ 24 , 34 ••]. Six studies reported neither an increase nor a decrease in e-cigarette use/vaping [ 25 , 27 , 29 , 32 •, 54 , 58 ]. Three studies included a mention of gender [ 23 ••, 25 , 28 ] but only one in relation to e-cigarette use/vaping which reported non-significant gender differences in such use [ 23 ••].

Use of Other Drugs and Unspecified Substance Use

A total of 19 studies included measures on other drugs or substance use without specification. Twelve of these studies employed a general measure of substance use or drug use [ 22 , 25 , 30 , 40 , 43 , 45 , 46 , 66 , 67 , 68 , 69 , 70 ] without specification of substance but the remaining seven studies included measures on substances such as opioids/prescription drugs, heroin, cocaine, methamphetamine, and inhalants [ 27 , 31 , 33 , 34 ••, 39 , 42 , 44 ]. Twelve studies employed a cross-sectional design [ 22 , 25 , 33 , 39 , 40 , 44 , 45 , 46 , 67 , 68 , 69 , 70 ] and seven used longitudinal designs [ 27 , 30 , 31 , 34 ••, 42 , 43 , 67 ]. Fifteen studies used a non-random selection of participants such as via convenience, purposive, or volunteer samples [ 22 , 25 , 31 , 39 , 40 , 42 , 43 , 44 , 45 , 46 , 66 , 67 , 68 , 69 , 70 ].

Three studies reported increase in substance use [ 22 , 27 , 34 ••], three studies reported a decrease in use [ 39 , 67 , 67 ], and one study reported no change during the pandemic [ 31 ]. Twelve studies did not report an increase or decrease in substance use where such measures were primarily employed as covariates or group dividers [ 25 , 30 , 33 , 40 , 42 , 43 , 44 , 45 , 46 , 68 , 69 , 70 ]. Four studies included a mention of gender [ 25 , 33 , 43 , 70 ] but none of them in relation to differences in substance use.

The COVID-19 pandemic and associated social restrictions implemented to contain the spread of the virus have led to concerns from parents, educators, and healthcare professionals and researchers about what effects the pandemic may have had on the mental health and social well-being of youth. To partially address this concern, the objective of this systematic review was to examine the prevalence of youth substance use during the COVID-19 pandemic. Based on 49 studies published to date and captured in our search, the overall results of our review suggest that the prevalence of youth alcohol, cannabis, tobacco, and e-cigarette/vaping use has declined during the pandemic.

This finding of an overall decline in the prevalence of substance use during the pandemic is certainly positive, but it begs the question: To what can the decrease be attributed? Youth substance use most often takes place outside the home environment and usually within the context of the peer group. Moreover, youth substance use is highly dependent on availability and access to drugs and other substances. The public health restrictions that were necessary during the COVID-19 pandemic limited the time most adolescents spent in-person with their peers, and it follows that availability and access to alcohol, tobacco, and other substances was effectively limited during community lockdowns. In short, young people confined to their homes with parents had fewer opportunities for accessing and using substances. Thus, limited peer-group gatherings, decreased availability and access to substances, and increased time spent in the home with parents—all well-established factors shown to be effective in prevention efforts aimed at decreasing substance use [ 71 ]—are likely to have conferred important protection against substance use during COVID-19 as observed in the decline in prevalence reported across the bulk of studies we reviewed.

These promising and positive findings of an overall decrease in substance use, however, need to be viewed with some caution. First, some groups of youth may have had more pre-pandemic vulnerability to substance use during the pandemic for several reasons. For instance, there is evidence that mental health problems have been on the rise among many adolescents prior to and during the pandemic. In addition, for older adolescents and young adults experiencing increased stress and mental health problems, there is evidence that alcohol, drugs, and other substances may have offered a coping mechanism during the pandemic [ 12 ]. Youth that used substances by themselves, moreover, had increased symptoms of depression [ 28 ].

Spending more time in the household is not always a consistent protective factor. One study found that youth were drinking and using other substances with their parents shortly after social distancing measures were imposed, suggesting that permissive parental attitudes and behaviors could encourage and facilitate youth alcohol consumption and other substance use [ 72 ]. These permissive attitudes and modelling of health compromising behavior can influence the perceived norms towards substance use, resulting in increased use after the pandemic. Moreover, adolescents living with family conflict or dysfunction are more likely to engage in substance use [ 73 ]. One systematic review of 32 reports [ 74 ] found evidence that domestic violence has increased during the pandemic, indicating that the at-risk group of youth living with family conflict and dysfunction increased during this time. Finally, in addition, youth living under the stress of parental substance use, family dysfunction, and domestic violence could predispose the later onset of substance use and violent behavior. Youth who missed out on “normal teenage years” or important rites of passage that were interrupted by the pandemic may also have difficulties with substance use later in life when restrictions are removed, and social gatherings allowed. What this means for the prevalence of substance use in the post-pandemic years will require monitoring and further surveillance. Thus, the long-term effects of the pandemic and its potential dormant or latent effects on responsible adult substance use are unknown at this time and not likely to be fully understood until years later.

Implications for Prevention and Treatment

Although the findings of our review suggest that the various mitigation strategies to contain the spread of COVID-19—masking, physical distancing, and community lockdowns that imposed restrictions on social gatherings—may have had detrimental impact on the mental health and social well-being of youth [ 21 ], such measures did not necessarily lead or contribute to an increase in youth substance use. Notwithstanding, there are several implications for prevention and treatment that should be considered in the aftermath of this pandemic. First, focusing on improving adolescent mental health should be a priority. Poor mental health is a well-known risk factor for substance use and misuse and the majority of young people with substance use problems suffer from co-occurring mental health issues that are often difficult to treat [ 75 , 76 ]. Second, although remote learning enabled young people to maintain some connection to schooling, studies have pointed to the negative impact of virtual learning on the academic and social development of many young people and thus may have set the stage for a “lost generation” of youth who could be at even greater risk for substance use in the future [ 19 ]. Post-pandemic efforts undoubtedly will need to address the gaps in academic and social development of this cohort of young people—especially those for whom there have been significant disparities in access to educational opportunities. This suggests that community-wide surveillance and prevention of substance use needs to become a greater community priority than prior to the pandemic. Third, COVID-19 has demonstrated both the value of e-health and telemedicine to address the health needs of people during the pandemic [ 77 ]. However, the limited availability and access to mental health counseling and other forms of virtual treatment during the early phases of the COVID-19 pandemic may have contributed to placing young people at greater risk for substance use. As such, greater investment in e-health treatment for mental health problems and referral should be a greater priority in the future.

Limitations

The findings of this review should be viewed with some caution because of design and other methodological limitations of the studies we reviewed. First, most of the published studies we reviewed utilized cross-sectional designs and focused largely on prevalence of use; few studies utilized longitudinal designs, outcome measures varied, and any follow-up was of limited time duration. Second, many studies used non-probability sampling methods to identify and obtain participants, including convenience, purposive, or volunteer samples, all of which limit the external validity of their findings. Third, few studies reported analyses that examined differences by gender. This remains an important question for future research because of the gender differences that have been observed in substance use and mental health outcomes during the COVID-19 pandemic [ 23 ••]. Finally, most of the studies reviewed included investigations of substance use of a single category, rather than across multiple categories of substance use, thus precluding analysis of any synergistic or gateway effects of multiple drug use for which the pandemic may have been responsible.

Recommendations for Future Research

Our review suggests several directions for future investigation. First, numerous studies have now documented the impact of COVID-19 on the lives and well-being of adolescents in the immediate aftermath of the pandemic; however, more longitudinal studies are needed to assess the latent and long-term effect of the pandemic on substance use behaviors among youth. Although the pandemic may not have fostered increased substance use among most young people, further investigation is needed to understand differential risk across high-risk adolescents and differences by gender during the pandemic. In addition, more attention should be given to the role of key covariates in understanding youth substance use. For example, covariates such as socioeconomic status and social determinants of mental health should be addressed in research that seeks to understand the relationship of substance use to youth mental health and social well-being. Finally, as more studies are published, meta-analyses of youth substance use during and following the pandemic will be possible and are needed to better understand how and to what extent the pandemic influenced substance use and any underlying causal mechanisms.

Conclusions

This systematic review of youth substance use during the COVID-19 pandemic assessed studies across several categories of substances, including alcohol, cannabis, tobacco, e-cigarette/vaping, and use of other drugs and unspecified substances. Regardless of the type of substance use, we found little evidence across the 49 studies we reviewed that the prevalence of use increased in response to the potential social and emotional deprivations associated with the pandemic. In fact, apart from some increase in the use of unspecified drugs or other substances, the majority of studies reported reductions in use across alcohol, cannabis, and tobacco and related products. Thus, we conclude that the bulk of the available evidence suggests that the prevalence of youth substance use largely declined during the first 2 years of the pandemic.

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This research was funded in part by the Centers for Disease Control and Prevention (#U48DP006391), and the Icelandic Research Fund (#217612).

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ALK, TH, JPA, IDS, and IET conceived the study. HML and IET conducted the initial search and review of included studies. HML created the PRISMA diagram and tables. ALK drafted the Introduction and Results sections. TH drafted the Methods section and registered the study on PROSPERO. JPA drafted the Abstract and contributed to writing and editing multiple versions of the manuscript. All authors reviewed and approved the final version of the manuscript.

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Alfgeir Kristjansson, Inga Dora Sigfusdottir, and Inga Eva Thorisdottir disclose that they are affiliated with Planet Youth, a youth substance use prevention service organization that is distributed globally through sale of the Planet Youth Guidance Program, which is based on the Icelandic Prevention Model, from which they receive salary or consulting fees; all other authors disclose no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.

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Layman, H.M., Thorisdottir, I.E., Halldorsdottir, T. et al. Substance Use Among Youth During the COVID-19 Pandemic: a Systematic Review. Curr Psychiatry Rep 24 , 307–324 (2022). https://doi.org/10.1007/s11920-022-01338-z

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PERSPECTIVE article

Substance use disorders and covid-19: multi-faceted problems which require multi-pronged solutions.

• 1 Department of Social Work, Umeå University, Umeå, Sweden
• 2 Centre for Demography and Ageing Research (CEDAR), Umeå University, Umeå, Sweden
• 3 The Swedish National Graduate School for Competitive Science on Ageing and Health (SWEAH), Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
• 4 Department of Epidemiology and Global Health, Faculty of Medicine, Umeå University, Umeå, Sweden
• 5 Research Centre for Generational Health and Ageing, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia
• 6 School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
• 7 MD/PhD Program, School of Medicine, Oregon Health & Science University, Portland, OR, United States
• 8 Psychiatry Unit, Department of Clinical Science, Umeå University, Umeå, Sweden
• 9 Oregon Health & Science University- Portland State University, School of Public Health, Portland, OR, United States
• 10 Cross-National Behavioral Health Laboratory, Graduate School of Social Work, University of Denver, Denver, CO, United States

COVID-19 shocked health and economic systems leaving millions of people without employment and safety nets. The pandemic disproportionately affects people with substance use disorders (SUDs) due to the collision between SUDs and COVID-19. Comorbidities and risk environments for SUDs are likely risk factors for COVID-19. The pandemic, in turn, diminishes resources that people with SUD need for their recovery and well-being. This article presents an interdisciplinary and international perspective on how COVID-19 and the related systemic shock impact on individuals with SUDs directly and indirectly. We highlight a need to understand SUDs as biopsychosocial disorders and use evidence-based policies to destigmatize SUDs. We recommend a suite of multi-sectorial actions and strategies to strengthen, modernize and complement addiction care systems which will become resilient and responsive to future systemic shocks similar to the COVID-19 pandemic.

Introduction

Persistent use of psychoactive substances increases risk of substance use disorders (SUDs) – biopsychosocial disorders with multiple risk factors interacting at individual and contextual levels resulting in co-morbid health conditions and affecting people from all social and economic backgrounds ( 1 , 2 ). The health consequences of SUDs (e.g., cardiovascular diseases, respiratory diseases, type-2 diabetes, immune and central nervous system depression, and psychiatric disorders) and the associated environmental challenges (e.g., housing instability, unemployment, and criminal justice involvement) increase risk for COVID-19 ( 3 – 7 ). COVID-19 adds to the complexity of SUD as it affects the lives of individuals with SUD.

The Intersection of Substance Use Disorder and COVID-19

SUDs and COVID-19 intersect on five dimensions. First, drug and alcohol use are often communal (e.g., sharing blunts, smoking pipes, or syringes) and may contribute to the spread of COVID-19 ( 8 ). Second, many individuals with SUD have limited financial resources, unstable housing and limited access to clean water and soap increasing their risk of infection ( 8 , 9 ). Third, co-morbidities prevalent among people with SUD are associated with more severe COVID-19 symptoms, complications and fatalities and increase vulnerability to COVID-19 ( 3 – 7 ). Fourth, COVID-19 public health mitigation measures (i.e., physical distancing, quarantine and isolation) may exacerbate loneliness, mental health symptoms, withdrawal symptoms and psychological trauma ( 10 – 13 ). Fifth, COVID-19 mitigation measures are likely to inhibit access to SUD treatment services ( 8 ). For many patients, the face-to-face interaction with practitioners is a key therapeutic ingredient for their recovery. These collisions between COVID-19 and SUD lead to more severe outcomes, especially among older adults with SUD who already have limited individual and social resources ( 3 ).

Finally, because COVID-19 burdens health care and social services, resources may be diverted from addiction services at a time when people with SUD need additional interventions. Lived experience of stigma and discrimination may also deter people with SUD from seeking healthcare during the pandemic ( 14 ). It is important that addiction care and social service providers are made aware regarding the vulnerability of the different sub-populations to COVID-19. This will enable providers to treat people with SUD in a non-stigmatizing and nondiscriminatory manner and provide appropriate services ( 15 – 17 ).

The COVID-19 pandemic has serious implications for individuals with SUD including long-term socioeconomic and public health effects. Drawing on evidence from previous economic and health disasters, we examine the potential economic, public health and social implications of COVID-19 and SUDs, and provide a short description of efforts to ensure continuity of addiction services during the pandemic. The article closes with recommended policy approaches and solutions for tackling SUD within both the context of COVID-19 and the resulting shock to health and economic systems.

COVID-19 Induced Economic, Public Health, and Social Challenges

Unemployment, substance use, and mental health comorbidity.

The COVID-19 pandemic impacted the global economy leaving millions of people unemployed, without a social safety net and limited access to healthcare and social services ( 18 , 19 ). The associations of involuntary or unexpected unemployment with SUD and mental health, and the positive effect of reemployment are well established. When individuals with SUD lose the structure of employment and sense of purpose, substance use and SUD symptom severity may increase ( 9 , 17 , 20 – 30 ). Home foreclosure in the United States (US) was associated with a delayed onset of depression and anxiety after controlling for pre-existing depression and anxiety ( 31 ). As pandemic-related unemployment soars, and home foreclosures and housing eviction rises, there may be increases in mental health and SUD problems.

Studies of economic crises, similar to the pandemic-induced recession, suggest that SUD-related mortality and suicide will increase. Unemployment in Sweden during the severe recession in the 1990s was associated with alcohol-attributable hospitalization and mortality ( 32 ) and suicide during a 12-year follow-up ( 33 ). An analysis of economic changes in 26 European Union (EU) countries over three decades showed that increases in unemployment were associated with a 28% increase in mortality from SUD and a 4.5% increase in suicide ( 34 ). During the 2008–2010 financial crisis socioeconomic vulnerability among millennials (compared to older generations) was associated with increased alcohol and drug use disorders in the US ( 35 ).

Cuts in Public Expenditures on Healthcare and Social Care: “Where Recession Hurts, Austerity Kills”

Cuts in healthcare and social care expenditures, measures taken in response to the economic impact of COVID-19, may exacerbate the public health effects of acute economic change ( 20 , 36 – 39 ). These changes, compounded with unemployment and loss of income in the post-COVID-19 period, may affect resource allocation and priority setting, widen socioeconomic disparities, and magnify the marginalization of individuals with SUDs ( 40 , 41 ).

When an economic crisis worsens and austerity measures are implemented, public health infrastructure can be stressed and the “risk environments” for SUD may expand ( 42 ). Poverty drives people to rely on informal economies (e.g., sex work, drug dealing) associated with illicit drug use. Compounded by weakened public health infrastructure, this can lead to a rise in preventable infectious diseases. The rapid increase in the HIV infection rate among persons who inject drugs (PWIDs) after the collapse of the Soviet Union and the formation of newly independent states in Eastern Europe, reflected the dismantling of public health infrastructures and increased unemployment ( 43 ). Similarly, the 2008–2010 financial crisis in Greece resulted in ongoing economic depression. Severe austerity measures led to a 40% reduction in hospital budgets by 2013 ( 44 ). However, the austerity measures also resulted in a 30% increase in the utilization of public healthcare services ( 44 ). Further, one-month prevalence of major depression increased from about 3% in 2008 to 8% in 2011 ( 45 ) and suicide mortality increased 56% between 2007 and 2011 ( 46 , 47 ). The austerity also led to budget cuts for harm reduction and opioid treatment programs. Between 2008 and 2010 the number of people who used drugs increased 12% and was much higher for adults between 35 and 64 years (88%) most likely due to relapse ( 48 ). Finally, the number of HIV infected people among PWIDs in Greece increased 16-fold between 2010 (n = 15 cases) and 2011 (n = 260 cases) ( 49 ).

The ongoing pandemic is straining healthcare systems across the globe. Data from the Swedish Perioperative Register (SPOR) reflect a 74% decline in elective surgeries in April 2020 compared to April 2019 due to acute reorganization of healthcare to respond to COVID-19 ( 50 ). If governments react to the economic crisis through reductions in spending for healthcare and social care, the stress on healthcare may be exacerbated and lead to a resource triage and decline in healthcare quality ( 51 ).

People with SUD may be further affected as the COVID-19 impact worsens. This group already faces stigma and discrimination from the general public ( 52 ), policy makers ( 53 , 54 ) and healthcare workers ( 14 , 55 – 58 ). Resource allocation and clinical practice with embedded stigma and discrimination has a prohibitive effect on healthcare utilization by individuals with SUD ( 14 ). Therefore, a reasonable, open and transparent, inclusive, accountable, and responsive process is necessary in priority setting and resource allocation during and after COVID-19.

Changes in Drug Use Patterns During the COVID-19 Induced Systemic Shock

Confinement rules, unemployment and fiscal austerity measures during and following the pandemic period can affect the illicit drug market and drug use patterns. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol analyses and data from the Global Drug Survey (GDS) suggest that there has been a shift in drug market and drug use patterns during the pandemic ( 59 , 60 ). While the use of several psychoactive substances increased, use of recreational synthetic drugs, such as MDMA, diminished likely due to closure of clubs and festival avenues in several European countries.

Economic crises in the United States between 1959 and 2003 were associated with increased adolescent cannabis and illicit drug use, and elevated involvement in illicit drug markets ( 61 ). As people who use drugs lose income and can no longer afford their primary drug of use, suppliers may adulterate drugs or introduce novel psychoactive substances with unknown risks for overdosing and infectious disease transmission. A Hungarian study reported a shift from heroin and amphetamine injection to synthetic cathinone (bath salt) and reduced availability of heroin after the 2008–2010 financial crisis ( 62 ). Synthetic cannabinoids (spice), similarly, became a primary drug of use among the homeless population following a ban on novel psychoactive substances in the United Kingdom ( 63 ). Finally, a wastewater analysis from Northern Italy in 2009 noted a reduction in metabolites from expensive drugs (e.g., cocaine and heroin) and increased metabolites from less expensive drugs (e.g., methamphetamine and cannabis) ( 64 ).

Bereavement and Loneliness: Lasting Effects of the COVID-19 Pandemic

In addition to the economic peril in the post-COVID-19 period, the pandemic is traumatizing people. Shrinking social networks and deaths from COVID-19 leaves many without coping resources ( 65 ). Social isolation, loneliness, death of loved ones, complicated grief, and prolonged bereavement are associated with problematic substance use and relapse both in younger and older adults, and can adversely affect mental health ( 17 , 66 – 75 ).

Older adults who are living alone are more likely to have SUD when compared to married older adults ( 5 ). Living alone is also associated with depression in older adults ( 76 ). The current pandemic potentially adds to the already high percentages of older adults living alone ( 77 ). For some older adults with depression, the pandemic-related bereavement might also affect their remission ( 78 ). Unless socially protective measures are taken, the post-pandemic period will likely exacerbate these risk factors for substance use and mental health disorders.

Current Addiction Care Practice During the COVID-19 Pandemic

Countries differ in legal and regulatory frameworks and the organization of addiction care systems; addiction treatment, however, is recognized internationally as an essential service that should be maintained even in a disaster or pandemic ( 79 ). Many countries have national policies guiding the implementation and application of interventions linked to health and social care systems. During the pandemic, psychiatric and addiction care services are making efforts to ensure continuity of care while mitigating the risk for spreading COVID-19 infections ( 80 , 81 ). In Sweden, the National Board of Health and Welfare posted informational materials on how to prevent the risk of COVID-19 transmission in opioid treatment programs (OTPs); in the United States, the Substance Abuse and Mental Health Services Administration released guidance to allow safer administration of methadone during the pandemic. Most of the measures focus on reducing the number of outpatient treatment visits, increasing the use of telehealth and expanding take-home medication for OTPs ( 82 ). While these current actions mitigate the negative impact of COVID-19 on individuals with SUD, there remains a need to adopt proactive policies which support individuals with SUD and strengthen addiction care services.

Policies and Strategies to Prevent and Treat SUD in the COVID-19 Context

SUD is a biopsychosocial disorder with multiple individual risk factors and consequences. SUD and mental health disorders also have distal determinants. Hence, interventions must be multipronged with community involvement and empowerment. It is important to adopt coordinated multi-sector strategies and innovative holistic approaches to benefit individuals with SUD.

Protective Social Policies Can Improve Living Conditions and Access for Addiction Care Services

Social policies impact health, directly and indirectly, through proximal and distal social determinants such as income, housing, employment, education, place of residence and social capital. Outcomes measured at the population level, mask effects on vulnerable groups and individuals with substance use disorders ( 83 ). Program evaluations do not always account for unintended consequences although realist evaluation methods take a different approach in seeking to answer what works, for whom, in what respects, to what extent, in what contexts and how.

Strong financial assistance systems can alleviate the negative impact of economic peril on mental health, during COVID-19 pandemic induced recession ( 22 , 41 , 84 ). A study of 26 European countries, with cause-specific mortalities as the outcomes (1970–2007) found that countries with stronger social protection (employment support and welfare systems) fared better compared to their counterparts ( 34 ). In a Norwegian study, reemployed individuals were 65% less likely to become harmful alcohol users compared with those who stayed unemployed ( 85 ). These studies suggest that public expenditures for labor market programs supporting gainful employment or earning capacity were associated with reductions in alcohol-related mortality and suicide.

Strong public safety nets for health, unemployment and social care insurances, support vulnerable groups such as people with mental health disorders and SUD, and ensure that they have access to treatment despite loss of income or employment related health insurance ( 63 , 86 ). The number of individuals receiving care for opioid use disorder, for example, increased nearly twofold after Oregon’s Medicaid expansion in 2014 ( 87 ). Given the acute reorganization of healthcare during the pandemic and decrease in healthcare utilization, healthcare plans and resources can be redirected to making structural changes to reduce health disparities and promote health in vulnerable populations ( 88 ).

Develop and Expand Integrated Primary Care, Addiction, and Mental Health Care Systems

National and local policymakers need to accept that substance use disorders, as any other biopsychosocial disorder (e.g., diabetes), often require several intervention components and multiple treatment episodes. These include services for alcohol and drug, mental health and medical problems plus linkages to unemployment services, housing services, and family support services. In many societies, there is little understanding of the complexities of SUD. Many countries have regressive and punitive national policies which are based on prohibitive and moralistic views rather than evidence-based policies promoting the integration of biopsychosocial services and care for individuals with SUD. The lack of willingness to give up on the legacy of separate health, addiction and mental health care systems, true for many countries, further reduces the likelihood that clients with SUD (who as a result of COVID may have developed a number of co-occurring disorders) will receive integrated care, especially in limited resource settings. Parallel treatment between several care providers means that the patient is responsible for the coordination of treatment between different agencies. An integrated care system, however, reduces this burden and can address coexisting conditions simultaneously ( 89 ). Compared to fragmented care, integrated care can increase access to healthcare for individuals with SUD, and may reduce infectious diseases such as COVID-19.

Implement Professional Education About SUD and Co-Occurring Disorders

Health professionals face challenges while using empirically supported screening, assessment, referral treatment, and follow-up for SUD and co-occurring disorders because they lack training about causes and consequences of substance use (including the biomedical aspects), and have limited training with evidence based practices ( 90 , 91 ). In the United States, medical, nursing, and social work programs are beginning to add SUD curricula to their training ( 92 ). Given the likely effects of COVID-19 and other diseases on SUD populations, it is even more critical that physician, nursing, psychology, and social work education programs include addiction and SUD content in their core-curriculum. Rapid training of addiction care professionals, in an emergency situation, (e.g., the current COVID-19 crisis) can help to control rapid outbreaks and provide safe addiction care.

Integrate IT Solutions to Strengthen and Modernize the Addiction Care System

As the current pandemic and the economic crisis threatens health and social care expenditures, information and communication technologies can play vital roles in improving healthcare and social services. New technology solutions that can modernize and strengthen the health and social care systems should be studied, and evaluated for cost-effectiveness.

The Internet of Things has shown effectiveness in monitoring elderly health and medication adherence ( 93 – 96 ). OTPs and other medical treatments for individuals with SUD may benefit from similar technology. Individuals with SUD can learn to manage their substance use and self-monitor symptoms. This can lead to reduced outpatient treatment visits and hospitalizations.

Telehealth has been used in some settings during the COVID-19 pandemic to maintain access to treatment ( 97 ). A systematic review and meta-analysis reported that telehealth, especially live video interaction with therapists, had significant positive effects on patient mental health ( 98 , 99 ). A non-randomized trial found that telehealth-delivered treatment for opioid use disorder was associated with better one-year retention compared to in-person delivered treatment ( 100 ). Studies have showed that older adults can benefit from telehealth services through reduced visits to emergency departments, increased knowledge of infectious diseases prevention, and improved social functioning and mental health ( 101 , 102 ). Future studies should investigate how the telehealth services provided during COVID-19, impacted SUD treatment outcomes and stigma.

Concerns related to telehealth services, in addition to scarcity of evidence on their effectiveness, focus on their accessibility ( 103 ). Limited access to smartphones and internet services leaves millions of people without access to those services ( 104 ). People with SUD may not afford such devices and might not have access to telehealth. One possible solution for this disparity can be mobile health (m-health) technologies. These are less costly and are effective for SUD treatment ( 105 ); they might also be utilized for pandemic surveillance in vulnerable groups ( 106 , 107 ). Social policies focusing on equitable resource allocation and social support (such as health insurance and income insurance) can also address this disparity.

Artificial intelligence (AI), another promising technology that could be used during emergency situations, could support trained clinicians to make treatment decisions. Currently, the research on the potential use and benefits of AI in addiction care and mental health services is in early development and needs to address important scientific, legal and ethical issues ( 108 , 109 ). Current AI research is focused on assisting addiction care practitioners with treatment for alcohol use disorder ( 110 ), identifying and preventing relapse ( 111 ), and identifying risk factors ( 112 , 113 ). Practitioners should, however, be aware that algorithms can be subject to biases (due to misclassification and measurement error, missing data, and small sample size) ( 108 ). The implication of such biases can be severe as they might create disparities in addiction care ( 108 , 109 ). Involving addiction care specialists and patient advocacy groups from the beginning in the development of AI can facilitate innovative, ethical, acceptable, and effective solutions.

Finally, when the technology around unmanned aerial vehicles (drones) improves and becomes cost-effective and ethical and legal issues are addressed, harm reduction kits, and medications could be delivered to individuals with SUD ( 114 – 116 ). Drones can deliver medications (e.g., naloxone) and save lives especially in highly congested cities and rural areas. They can also be used as an alternative for take-home medication for OTPs. Drones are already used for medical delivery services in emergency situations ( 115 ). However, current policies and views on harm reduction and addiction vary from country to country, and this might influence the acceptability of drones as kit-delivery vehicles.

Mobilization of Community Social Capital

During the COVID-19 pandemic voluntary efforts from community members and non-governmental organizations seek to help vulnerable groups. Mental health hotlines opened so that older adults can talk to professionals if they feel lonely or worried. Mobile apps and chat groups are now available for digital support. Community level coalitions and inclusion will be needed to support individuals with substance use and mental health disorders.

Mobilization of community social capital is an important resource in disaster management ( 117 ). A socially cohesive community with strong networks of civic engagement and norms of reciprocity and trust ( 118 ) may be better able to prepare for, manage, and recover from systemic shocks such as the COVID-19 pandemic ( 119 ). Resources (such as social support) from strong community networks, however, often require adhering to the dominant norms in a particular community. Thus, the same mechanisms that provide support based on reciprocity norms, might lead to increased social exclusion of outsiders who do not conform to the dominant norms ( 120 , 121 ). For this reason, the focus should be on policies which promote parity for the treatment of substance use disorder to that of other biopsychosocial health conditions, support the development and implementation of community initiatives that complement addiction and mental health care services and can be leveraged during disaster ( 14 , 54 ).

Strengthening of Cross-National Collaboration

Many illicit substances and their precursors are manufactured and transported through multiple countries, before reaching users. Collaboration between countries can counteract the interplay between SUD and economic crises. After the 2010–2011 HIV outbreak among PWID in Greece, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the European Centre for Disease Prevention and Control (ECDC) were instrumental in setting priorities for responding to and controlling the rapid HIV infection rate ( 122 ). EMCDDA also provides EU countries with early warning systems for novel psychoactive substances and new drug patterns which can emerge during economic crises.

The World Health Organization and the United Nations Office on Drugs and Crime are international organizations guiding efforts to develop and expand effective, evidence-based and ethical treatment for substance use disorders ( 79 ). Hence, national governments should continue funding these organizations, especially during COVID-19 and similar disease outbreaks. Strengthening community treatment capacity is essential during disaster and public health emergencies.

As globalization continues, COVID-19 is unlikely to be the last pandemic, and there will undoubtedly be subsequent global economic crises. These crises, compounded by austerity measures, will disproportionately burden people with SUD due to accumulated social, economic, and health inequities.

Ad hoc measures taken to ensure continuity of care might alleviate some of the challenges these groups face in emergency situations. Evidence-based, collective, and proactive policies and actions are necessary to strengthen and modernize addiction and mental health services.

The acknowledgement of SUD as a biopsychosocial condition and its destigmatization by policy makers and practitioners are essential components for comprehensive multi-sectorial strategies which will protect and address the needs of people with SUD.

COVID-19 presents opportunities to: adopt social protective policies; shift from fragmented health and addiction care systems to integrated care systems; mobilize community social capital; train healthcare and social care professionals on SUD and mental health disorder, and identify and integrate evidence-based information technology and digital tools into addiction care systems. Only then, will it be possible to provide equitable health and social care to people with SUDs and to have addiction care services which are resilient in the face of future systemic shocks.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.

Ethics Statement

Ethical approval was not needed for this article as no animal nor human studies are presented, and there are no potentially identifiable human images or data.

Author Contributions

Writing—original draft: WJ, ME, MP, KP, DM, LL, Writing—Review and editing: WJ, JS, ME, A-SG, NN, MB, MP, KP, MS, FS, DM, LL. Conceptualization: WJ, JS, NN, DM, LL. Investigation: WJ. Formal Analysis: WJ. Funding acquisition: LL. All authors contributed to the article and approved the submitted version.

Grants from The Swedish Research Council for Health, Working Life and Welfare (FORTE) Grant no. 2016-07213 and Grant No. 2019-01453 have supported this study. An award from the National Institute on Drug Abuse ( F30 DA044700 ) supported KP’s participation in the development of the manuscript. The funding organizations were not involved in the design of the study, data collection, data analysis, the interpretation of data, or writing of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: substance use disorder (SUD), COVID-19, addiction care, integrated care, social capital, pandemic, evidence-based policies and practices, risk environment

Citation: Jemberie WB, Stewart Williams J, Eriksson M, Grönlund A-S, Ng N, Blom Nilsson M, Padyab M, Priest KC, Sandlund M, Snellman F, McCarty D and Lundgren LM (2020) Substance Use Disorders and COVID-19: Multi-Faceted Problems Which Require Multi-Pronged Solutions. Front. Psychiatry 11:714. doi: 10.3389/fpsyt.2020.00714

Received: 19 May 2020; Accepted: 07 July 2020; Published: 21 July 2020.

Reviewed by:

Copyright © 2020 Jemberie, Stewart Williams, Eriksson, Grönlund, Ng, Blom Nilsson, Padyab, Priest, Sandlund, Snellman, McCarty and Lundgren. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Wossenseged Birhane Jemberie, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

The Impact of COVID-19 on Drug Use—and How It Contributes to Overdose Risk

In rural communities, structural and community factors during the pandemic have increased anxiety, depression, and loneliness and altered drug use behaviors

The COVID-19 pandemic has disrupted the lives of people who use drugs in ways that hurt their mental health and changed drug use behaviors, increasing their risk for overdose, according to surveys and interviews with individuals in rural Illinois captured in a new study in Addiction Science and Clinical Practice .

Drug overdoses have soared during the COVID-19 pandemic, with U.S. overdose deaths topping 100,000 during the 12-month period ending in April 2021 . Researchers are beginning to untangle how the pandemic and strategies for preventing the spread of the virus, such as stay-at-home orders, may have contributed to this increase in deaths, from interruptions to harm reduction programs to isolation and worsening mental health.

People who use drugs and live in rural areas may be disproportionately impacted by changes brought on during the pandemic, given that many rural areas have higher rates of opioid and methamphetamine use and already have limited drug treatment and harm reduction services. People who use drugs in rural areas may also experience higher levels of stigma about their drug use, which may contribute to a greater likelihood of using drugs alone and a reluctance to seek medical care.

In a series of surveys and interviews with people who use drugs in rural southern Illinois, the researchers sought to understand their experiences during the COVID-19 pandemic and how disruptions at the structural and community level could affect individuals’ overdose risk. Between August 2020 and May 2021, the researchers conducted surveys with 50 individuals who use opioids (without a prescription) or inject drugs, and did in-depth interviews with a subset of 17 participants.

“We know that there has been a tragic increase in overdose deaths during the pandemic. Our study provides insight into why and how there have been more overdose deaths,” said Suzan Walters , research assistant professor at NYU School of Global Public Health and a researcher with NYU’s Center for Drug Use and HIV/HCV Research (CDUHR).

Not unlike the general population, people who use drugs reported worsened economic conditions—in a region already afflicted by widespread poverty—and mental health during the pandemic. Only 38 percent of participants felt confident that they could maintain a stable income during the pandemic, thanks to layoffs, disruptions to their work in service industries, and fewer available jobs. Moreover, participants reported that the pandemic exacerbated housing and food insecurity.  

A significant proportion of participants reported that their mental well-being had suffered: three-quarters of the survey respondents felt more anxious or on edge during the pandemic, more than half felt more depressed, and nearly half felt lonelier. Anxiety and depression are associated with increased substance use, which in turn can increase the risk for overdose.  

Participants also described how the pandemic changed their everyday drug use behaviors. Two-thirds of survey respondents said the process of getting drugs was more difficult during the pandemic, and over half worried that in the near future they would end up with a bad batch of drugs that would be dangerous. Notably, half of the survey respondents said they were currently more likely to use drugs alone than prior to the pandemic, which can increase overdose risk.

The interviews unearthed an emerging trend of consuming fentanyl “beans” or “buttons ,” which were described as little capsules full of fentanyl. Participants said that fentanyl was cheaper and more readily available than heroin, which became more difficult to obtain during the pandemic.

“Our findings suggest that structural and community issues during the pandemic increased anxiety, depression, and loneliness on the individual level. Drug use patterns also changed, with many talking about fear of fentanyl and increased access to it. All of these factors are likely to increase overdose risk,” said Walters, who is also an affiliated faculty at NYU Langone’s Center for Opioid Epidemiology and Policy (COEP).

To prevent overdoses, the researchers recommend not only ensuring access to resources and services at the individual level, but also addressing larger systemic and community issues, including greater access to economic opportunities and reducing stigma related to drug use.  

Additional study authors include Rebecca Bolinski, Stacy Grundy, and Wiley Jenkins of Southern Illinois University; Ellen Almirol, John Schneider, and Mai Pho of the University of Chicago; Scott Felsher of the Community Action Place, Inc.; Samuel Friedman of CDUHR and NYU Grossman School of Medicine; Lawrence Ouellet of the University of Illinois Chicago; and Danielle Ompad of CDUHR and NYU School of Global Public Health. The work was funded by the NIH Clinical and Translational Science Awards Program (UL1TR001445) and National Institute on Drug Abuse (K01DA053159, P30DA01104, T32 DA007233-31, R25DA026401, 4UH3DA044829-03).

About the NYU School of Global Public Health At the NYU School of Global Public Health (NYU GPH), we are preparing the next generation of public health pioneers with the critical thinking skills, acumen, and entrepreneurial approaches necessary to reinvent the public health paradigm. Devoted to employing a nontraditional, interdisciplinary model, NYU GPH aims to improve health worldwide through a unique blend of global public health studies, research, and practice. The School is located in the heart of New York City and extends to NYU's global network on six continents. Innovation is at the core of our ambitious approach, thinking and teaching. For more, visit: publichealth.nyu.edu/

About CDUHR The mission of the Center for Drug Use and HIV/HCV Research (CDUHR) is to end the HIV and HCV epidemics in drug using populations and their communities by conducting transdisciplinary research and disseminating its findings to inform programmatic, policy, and grass roots initiatives at the local, state, national, and global levels. CDUHR is a Core Center of Excellence funded by the National Institute on Drug Abuse (Grant #P30 DA011041).  It is the first center for the socio-behavioral study of substance use and HIV in the United States and is located at the NYU School of Global Public Health. For more information, visit www.cduhr.org .

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The Implications of COVID-19 for Mental Health and Substance Use

Nirmita Panchal , Heather Saunders , Robin Rudowitz , and Cynthia Cox Published: Mar 20, 2023

Note: This brief was updated on March 20, 2023 to incorporate the latest available data. Concerns about mental health and substance use remain elevated three years after the onset of the COVID-19 pandemic, with 90% of U.S. adults believing that the country is facing a mental health crisis, according to a recent KFF/CNN survey. The pandemic has affected the public’s mental health and well-being in a variety of ways, including through isolation and loneliness, job loss and financial instability, and illness and grief.

Over the course of the pandemic, many adults reported symptoms consistent with anxiety and depression, with approximately four in ten adults reporting these symptoms by early 2021, before declining to approximately three in ten adults as the pandemic continued (Figure 1). Additionally, drug overdose deaths have sharply increased – largely due to fentanyl – and after a brief period of decline, suicide deaths are once again on the rise. These negative mental health and substance use outcomes have disproportionately affected some populations, particularly communities of color and youth. As the end of the declaration of the public health emergency nears – on May 11, 2023 – many people continue to grapple with worsened mental health and well-being and face barriers to care.

This brief explores mental health and substance use during, and prior to, the COVID-19 pandemic. We highlight populations that were more likely to experience worse mental health and substance use outcomes during the pandemic and discuss some innovations in the delivery of services. We analyze and present findings using the most recent data available at the time of this publication – including the Household Pulse Survey and the CDC WONDER database . Key takeaways include:

• Symptoms of anxiety and depression increased during the pandemic and are more pronounced among individuals experiencing household job loss, young adults, and women. Adolescent females have also experienced increased feelings of hopelessness and sadness compared to their male peers.
• Deaths due to drug overdose increased sharply across the total population coinciding with the pandemic – and more than doubled among adolescents. Drug overdose death rates are highest among American Indian and Alaska Native people and Black people.
• Alcohol-induced death rates increased substantially during the pandemic, with rates increasing the fastest among people of color and people living in rural areas.
• After briefly decreasing, suicide deaths are on the rise again as of 2021. From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. Additionally, self-harm and suicidal ideation has increased faster among adolescent females compared to their male peers.
• Several changes have been implemented in the delivery of mental health and substance use services since the onset of the pandemic, including the utilization of telehealth, steps to improve access to treatment for opioid use disorders, expansion of school-based mental health care, and the rollout of the 988 crisis line. As the public health emergency declaration comes to an end, it is possible that some of these changes will be interrupted.

Prevalence of Mental Illness and Substance Use During the Pandemic

Anxiety and depression.

The pandemic was associated with a high prevalence of anxiety and depression symptoms in adults. Research suggests that these symptoms increased during the pandemic, but the extent of this increase is unclear . 1 Throughout the pandemic, symptoms of anxiety and depression have been more pronounced among several populations.

For example, individuals experiencing household job loss were more likely than their counterparts to report symptoms of anxiety and/or depression (53% vs. 30%) in February 2023 (Figure 2). Job loss and unemployment – which have long been associated with adverse mental health outcomes – increased substantially early on in the pandemic .

Fifty percent of young adults (ages 18-24) reported anxiety and depression symptoms in 2023, making them more likely than older adults to experience mental health symptoms (Figure 2). Young adults have experienced a number of pandemic-related consequences – such as closures of universities, transitioning to remote work, and loss of income or employment – that may contribute to poor mental health. Additionally, young adults in college settings may encounter increased difficulty accessing treatment .

Symptoms of anxiety and/or depression were also elevated among women (36%) compared to men (28%) in February 2023 (Figure 2). Even before the pandemic, women were  more likely  than men to report mental health disorders, including serious mental illness.

Concerns about youth mental health further increased with the onset of the pandemic and the recent uptick in gun violence . In a recent KFF/CNN survey , roughly half of parents (47%) said the pandemic had a negative impact on their child’s mental health, including 17% who said it had a “major negative impact”. Poor mental health has been more pronounced among adolescent females in particular. As shown in Figure 3, the gap in the share of adolescent females and males reporting feelings of hopelessness and sadness – symptoms indicative of depressive disorder – widened from 2019 (47% vs. 27%, respectively) to 2021 (57% vs. 29%, respectively). Many female adolescents also reported adverse experiences in 2021, which can negatively impact mental health.

Substance use and deaths

The pandemic has coincided with an increase in substance use and increased death rates due to substances. In 2021, there were over  106,600 deaths  due to drug overdose in the U.S. – the highest on record. This spike in deaths has primarily been driven by substances laced with synthetic opioids, including illicitly manufactured fentanyl .

Further, the overall drug overdose death rate rose by 50% during the pandemic (Figure 4), but varied across states . While drug overdose death rates increased across all racial and ethnic groups, the increases were larger for people of color compared to White people. White people continue to account for the largest share of deaths due to drug overdose per year, but  people of color  are accounting for a growing share of these deaths over time. In 2021, the highest drug overdose death rates were among American Indian Alaska Native (AIAN) people (56.6 per 100,000), Black people (44.2 per 100,000), and White people (36.8 per 100,000) (Figure 4). Differences in drug overdose deaths by sex were also exacerbated during the pandemic. As shown in Figure 4, the gap in the drug overdose death rates between males and females increased from 2019 (29.6 vs. 13.7 per 100,000, respectively) to 2021 (45.1 vs. 19.6 per 100,000, respectively).

Research suggests that substance use among adolescents has declined, yet drug overdose deaths have sharply increased among this population, primarily due to fentanyl-laced substances . Among adolescents, drug overdose deaths have more than doubled from 2019 (282 deaths) to 2021 (637 deaths) following a period of relative stability. 2 Male, Black, and Hispanic youth have experienced the highest increases in deaths due to drug overdose.

During the pandemic, excessive drinking increased along with alcohol-induced deaths. Alcohol-induced death rates increased by 38% during the pandemic, with rates the highest and increasing the fastest among AIAN people. AIAN people died of alcohol-induced causes at a rate of 91.7 per 100,000 in 2021, six times more than the next highest group – Hispanic people at a rate of 13.6. Black people also experienced significant increases in alcohol-induced deaths during COVID, with rates increasing more than 45% (Figure 5). Both rural and metropolitan areas experienced an increase in alcohol-induced deaths during the pandemic, but rural areas saw the largest increase (46% increase compared to 36%).

Suicidal ideation and deaths

Concerns about suicidal ideation and suicide deaths have also grown during the pandemic. Notably, self-harm and suicidal ideation has increased among adolescent females. Thirty percent of adolescent females seriously considered attempting suicide in 2021 compared to 14% of their male peers (Figure 6). Other analyses found that as the pandemic progressed, emergency department visits for  suicide attempts  increased among adolescents, primarily driven by females.

Suicide deaths in the U.S. began to increase in 2021 after briefly slowing in 2019 and 2020 , although some research suggests that some  suicides  may be misclassified as drug overdose deaths since it can be difficult to determine whether drug overdoses are  intentional . From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. 3 In 2021, suicide deaths by firearm accounted for more than half ( 55% ) of all suicides in the U.S., but varied greatly across states .

The pandemic has also raised concerns about mental illness, suicide, and substance use among other populations. Essential workers and people with chronic health conditions may have experienced worsened mental health due to increased risk of contracting or becoming severely ill from COVID-19. Many of these individuals, particularly those with chronic conditions , were already at-risk of experiencing poor mental health outcomes prior to the pandemic. LBGT+ people have historically faced mental health problems at higher rates than their non-LGBT+ peers. The pandemic has continued to negatively impact LBGT+ people’s mental health in disproportionate ways. In addition, people experiencing prolonged COVID-19 symptoms, or long COVID , may be more likely to develop new mental health conditions or to experience worsening of existing ones.

Changes in the Delivery of Mental Health and Substance Use Disorder Services

Leading up to the pandemic, many people faced barriers accessing mental health and substance use disorder services for reasons including costs, not knowing where to obtain care, limited provider options, and low rates of insurance acceptance. Young adults, Black adults, men, and uninsured people were less likely to receive services compared to their peers.

In recent years, access to care barriers may have worsened due to pandemic disruptions and closures, workforce shortages, and increased demand for services. In response to growing need, some policies and strategies were implemented to address access challenges, such as growth of telehealth, improved access to opioid use disorder treatment, the expansion of school-based mental health services, and the rollout of 988; however, challenges remain.

The delivery of mental health and substance use disorder services via telehealth grew sharply during the pandemic. By 2021, nearly 40% of all mental health and substance use disorder outpatient visits were delivered through telehealth. These behavioral health services via telehealth have also been more utilized in rural areas than urban areas during the pandemic. This underscores the role telehealth can play in improving access to behavioral health services in rural areas, which often face additional provider and resource shortages . Further, community health centers – which serve low-income and medically underserved communities, including communities of color and those in rural areas – experienced a large increase in behavioral health visits in 2021, largely driven by telehealth. During the pandemic, many state Medicaid programs expanded coverage of behavioral health telehealth services. This includes broadening the range of behavioral health services offered virtually and allowing for more provider types to be reimbursed for telehealth services. Many  state  Medicaid programs reported that telehealth has helped maintain and expand access to behavioral services during the pandemic. Some private payers have also  improved  coverage for mental health and substance use services by removing pre-pandemic telehealth coverage restrictions. Although telehealth can broaden access to care, in-person care may be necessary or preferred for some or for those experiencing challenges with technology and digital literacy.

As opioid-related overdose deaths have sharply increased, measures to improve access to treatment have been implemented. Following the onset of the pandemic , the federal government allowed for new  flexibilities  in opioid use disorder (OUD) treatment to ease access barriers, for example allowing for take-home methadone doses and covering telehealth treatment, and the Biden administration has  proposed  making these flexibilities permanent. Further, the 2023  Consolidated Appropriations Act   eliminated  the X-waiver requirement for prescribing buprenorphine, which substantially increases the number of providers who are authorized to prescribe buprenorphine to treat OUD. Voluntary guidelines for providers have also been issued to help reduce opioid overprescribing and misuse. At the same time, the Drug Enforcement Agency recently proposed returning to previous rules that required in-person visits before prescribing controlled substances to patients via telehealth, though there are some exceptions.

In response to growing mental health concerns among youth, integration of mental health services in school-based settings became a priority. Recent legislation aims to expand mental health care in schools – a setting that is easily accessible by children and adolescents. Specifically, legislation provides funding to expand and train mental health providers in schools; implement suicide, drug, and violence prevention programs; and provide trauma support services, among others. Further, recognizing Medicaid’s importance  in covering and financing behavioral health care for  children , CMS is now required to provide updated guidance on how to support and expand school-based behavioral health services. The recently passed Consolidated Appropriations Act (CAA) continues to build on prior pandemic-era legislation that promotes access to behavioral health care for children. For example, to ensure more stable coverage for low-income children the CAA requires states to provide 12 months of continuous eligibility for children in Medicaid and CHIP.

An easy-to-remember number for the suicide and behavioral health crisis hotline, 988, was launched in 2022 . On July 16, 2022, the  federally mandated   crisis number ,  988 , became available to all  landline and cell phone users , providing a single three-digit number to access a network of over 200 local and state funded crisis centers where those in need may receive crisis counseling, resources and referrals. After 988 implementation, national answer rates increased alongside increases in call volume. Long-term sustainable funding of local 988 crisis call centers remains uncertain in many states. In addition to 988, some states are developing behavioral health crisis response systems, such as mobile crisis or crisis stabilization units, which will enable a specialized behavioral health response for behavioral health crises that require intervention. The  CAA included provisions aimed at strengthening and evaluating 988 and the developing behavioral health crisis continuum.

Despite steps taken to improve the delivery of mental health and substance use services, challenges remain. Provider workforce challenges are widespread, with nearly half of the U.S. population ( 47% ) living in a mental health workforce shortage area . Shortages may contribute to access challenges and contribute to increases in psychiatric boarding in emergency rooms. Additionally, provider network directories are often outdated, further contributing to access challenges. While recent legislation has taken steps in response – including funding for at least 100 new psychiatry residency positions, grants for mental health peer support providers, and improvements to provider directories through the CAA – these are relatively small measures in the face of big access challenges. The lack of a diverse mental health care workforce may contribute to limited mental health treatment among people of color. Separately, even with insurance coverage, individuals with mental health needs face challenges accessing care. While Medicaid enrollees have limited out-of-pocket costs there is variation in who is eligible and the range of services covered across states . Additionally, the end of Medicaid’s continuous enrollment provision – on March 31, 2023 – could result in millions of disenrollments over the next year which could disrupt access to behavioral health services. Among private insurance enrollees, enrollees, with mental illness face high out-of-pocket costs; and these costs vary substantially across states . While most adults with mental illness have private insurance, rates of mental illness and substance use disorders are most prevalent among nonelderly adults with Medicaid.

Looking Ahead

Although steps have been taken to address negative mental health impacts stemming from the pandemic, mental health and substance use concerns remain elevated. Heightened racism and increasing gun violence may also contribute to poor mental health outcomes. Further, negative mental health impacts have been more pronounced among several populations, including communities of color, young adults and children – populations which have historically experienced increased barriers to care. Additionally, despite renewed discussions and new federal grants for state parity enforcement under the CAA, challenges with mental health parity persist – including lack of clarity on specific protections, low compliance rates, and slow federal enforcement. Finally, the COVID-19 public health emergency will end in May 2023, which may at least partially unravel steps taken toward delivering mental health services via telehealth and improving access to substance use disorder services.

History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today’s elevated mental health needs will continue well beyond the coronavirus outbreak itself. As we emerge from the COVID-19 pandemic and the federal public health emergency draws to an end, it will be important to consider how the increased need for mental health and substance use services may persist long term, even as new cases and deaths due to COVID-19 hopefully subside.

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

The Household Pulse Survey (HPS) is a rapid response survey that has provided real-time data during the pandemic and includes a 4-item Patient Health Questionnaire (PHQ-4) anxiety and depression screening scale. In order to understand how the prevalence of anxiety and depression may have shifted in the adult population during the onset of the pandemic, mental health estimates from HPS were compared against pre-pandemic data from the National Health Interview Survey, which also includes the 4-item PHQ scale. However, recent research finds that these comparisons may not be reliable given lower response rates and over estimation in HPS; and are no longer included in this brief.

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KFF analysis of Centers for Disease Control and Prevention, Wide-ranging Online Data for Epidemiologic Research (WONDER). Accessed at: https://wonder.cdc.gov/mcd-icd10-expanded.html

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• Medicaid Coverage of Behavioral Health Services in 2022: Findings from a Survey of State Medicaid Programs
• Mental Health and Substance Use State Fact Sheets
• Mental Health and Substance Use Considerations Among Children During the COVID-19 Pandemic
• Mental Health Impact of the COVID-19 Pandemic: An Update
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The impact of the covid-19 pandemic on substance use disorders risk among people living with hiv enrolled in hiv care in the united states: an interrupted time series analysis.

Jennifer P. Jain, PhD and Megan J. Heise, PhD Equal contribution to this work

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Jennifer P Jain, Megan J Heise, Nadra E Lisha, Carlos H Moreira, David V Glidden, Greer A Burkholder, Heidi M Crane, Jeffrey M Jacobson, Edward R Cachay, Kenneth H Mayer, Sonia Napravnik, Richard D Moore, Carol Dawson-Rose, Mallory O Johnson, Katerina A Christopoulos, Monica Gandhi, Matthew A Spinelli, The Impact of the COVID-19 Pandemic on Substance Use Disorders Risk among People Living with HIV Enrolled in HIV Care in the United States: an Interrupted Time Series Analysis, Open Forum Infectious Diseases , 2024;, ofae491, https://doi.org/10.1093/ofid/ofae491

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With rising overdose deaths globally and the social isolation of the COVID-19 pandemic, people with HIV (PWH) with substance use disorders (SUD) may have been disproportionately impacted. We examined whether there was a change in SUD risk among PWH before and after the COVID-19 shelter-in-place (SIP) mandate.

Data were collected between 2018-2022 among PWH enrolled across 8 U.S. sites in the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) cohort. We evaluated changes in reported moderate/high SUD risk after SIP using interrupted time series analyses fit with a mixed-effects logistic regression model.

There were 7,126 participants, including 21,741 SUD assessments. The median age was 51 (IQR=39-58); 12% identified as Hispanic or Latino/a; 46% identified as Black/African American, and 46% White. Moderate/high SUD risk increased continuously after the pandemic’s onset, with 43% (95%CI=40-46%) endorsing moderate/high SUD risk post-SIP, compared to 24% (95%CI=22-26%) pre-SIP ( p <.001). There were statistically significant increases in the use of heroin, methamphetamine, and fentanyl, and decreases in prescription opioids and sedatives post-SIP. Further, there was a significant decrease in reported substance use treatment post-SIP compared to pre-SIP, ( p =.025).

The rising prevalence of SUD through late 2022 could be related to an increase in isolation, depression, and reduced access to substance use and HIV treatment caused by disruptions due to the pandemic. A renewed investment in integrated substance use treatment is vital to address the combined epidemics of substance use and HIV following the COVID pandemic and to support resilience in the face of future disruptions.

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The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment

Felipe ornell.

a Center for Drug and Alcohol Research and Collaborating Center on Alcohol and Drugs, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

b Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

c Faculdade IBGEN, IBGEN Buzines School - Grupo Uniftec, Centro Universitário e Faculdades, Porto Alegre, RS, Brazil

Helena Ferreira Moura

Juliana nichterwitz scherer.

d Universidade do Vale do Rio dos Sinos, São Leopoldo, RS, Brasil

Flavio Pechansky

Felix henrique paim kessler, lisia von diemen.

e Department of Psychiatry, Kingston General Hospital, Queen’s University, Kingston, ON, Canada

Associated Data

The COVID-19 pandemic has brought major challenges to healthcare systems and public health policies globally, as it requires novel treatment and prevention strategies to adapt for the impact of the pandemic. Individuals with substance user disorders (SUD) are at risk population for contamination due to multiple factors—attributable to their clinical, psychological and psychosocial conditions. Moreover, social and economic changes caused by the pandemic, along with the traditional difficulties regarding treatment access and adherence—will certainly worsen during this period, therefore aggravate their condition. In addition, this population are potential vectors of transmission. In that sense, specific strategies for prevention and treatment must be discussed. health care professionals dealing with SUD must be aware of the risks and challenges they will meet during and after the COVID-19 outbreak. Addiction care must be reinforced, instead of postponed, in order to avoid complications of both SUD and COVID-19 and to prevent the transmission of coronavirus.

The COVID-19 pandemic has brought major challenges to healthcare systems and public health policies globally, as it requires novel treatment and prevention strategies to adapt for the impact of the pandemic ( Stratton, 2020 ). Individuals with substance user disorders (SUD) are at risk population for contamination due to multiple factors—attributable to their clinical, psychological and psychosocial conditions ( Lagisetty et al., 2017 ; Peacock et al., 2018 ). Moreover, social and economic changes caused by the pandemic, along with the traditional difficulties regarding treatment access and adherence—will certainly worsen during this period, therefore aggravate their condition. In that sense, specific strategies for prevention and treatment must be discussed ( Bojdani et al., 2020 ; Lagisetty et al., 2017 ).

It is known that the state and the severity of SUD are associated with - and can impact on clinical and psychological conditions ( Lagisetty et al., 2017 ; Schulte and Hser, 2014 ). Therefore, in order to measure the impact of COVID-19 on drug users and to suggest specific strategies, it is important to consider peculiarities of these subgroups, such as: a) persons with mild SUD versus moderate to severe SUD; b) those currently in abstinence versus active substance use; c) those with comorbid psychiatric disorders (including consumption of multiple substances).

Severity of COVID-19 has been associated with some clinical and demographic characteristics, such as chronic respiratory diseases, diabetes, hypertension and immunosuppression—which knowingly increase the lethality risk for COVID-19 ( Cascella et al., 2020 ). In this sense, subjects with moderate to severe SUD—who are already an important risk group, could suffer major impacts, since they have been previously associated with all these conditions ( Lagisetty et al., 2017 ). Furthermore, previous studies have reported that tobacco and alcohol consumption can facilitate and aggravate the flu ( Godoy et al., 2018 ; Meyerholz et al., 2008 ; Sureshchandra et al., 2019 ). The fact that drug users frequently abuse these substances in combination with other drugs can cause additional risk. Elderly patients are also in the main risk group, and it is important to note that the prevalence of SUD in this population is higher than ever in the world, including both licit and illicit drugs ( Kuerbis et al., 2014 ). Therefore, substance use could increase the risk to this already vulnerable age group when associated with these clinical comorbidities.

In addition to the aforementioned facts, coronavirus could make addicts more vulnerable to complications of substance use. Chronic respiratory diseases have already been associated with increased overdose mortality due to opioids, a substance that can depress breathing ( Hulin et al., 2019 ). Therefore, could even mild symptoms of COVID-19 threat this population? Similar questions can be addressed for patients with chronic use of cigars, crack-cocaine ( Dolapsakis and Katsandri, 2019 ), and perhaps even vaporizers, that are kwon to cause pulmonary complications and diseases ( Chand et al., 2019 ; Cherian et al., 2020 ). Although no studies have been conducted yet about the implications of COVID-19 in respiratory complications of drug users, it is probable that the infection will severely be manifested in subjects with SUD involving these specific means of drug use.

While drug use can increase the risks associated with a coronavirus infection, the social and psychological risks of the pandemic can favor and intensify drug abuse, in a potentially catastrophic cycle. Social distance, isolation or quarantine are essential measures to help prevent coronavirus transmission - however, these strategies, and the pandemic outbreak itself, have been associated with negative emotions, such as irritability, anxiety, fear, sadness, anger or boredom ( Ornell et al., 2020 ). These conditions are known to trigger relapse, even in those long-term abstainers, or intensify drug consumption ( Serafini et al., 2016 ; Sinha et al., 2009 ). Withdrawal symptoms elicited during lockdown could also jeopardize these preventive strategies, as it could drive individuals to go outside for drugs. In addition, medical assistance for these symptoms will be limited, since the major medical efforts are geared towards the COVID-19 pandemic. Even in the case of hospitalization, it may be difficult to maintain voluntary stay, generating more stress to healthcare workers, already overburdened because of the pandemic. Homelessness can also compromise preventive strategies, as individuals tend to wander during the day and sleep in crowded places during the night, making them potential vectors of transmission. Social distancing is also challenged during incarceration, permanence in therapeutic communities or other addiction treatment facilities, many of which philanthropic institutions without complying to health security standards. These are conditions highly prevalent among substance users, and may require specific strategies that encompass the individual's needs for prevention of COVID-19, SUD treatment and the protection of healthcare workers ( Volkow, 2020 ). In all these scenarios, drug seeking behaviors could increase exposure to infection for addicts, their families and healthcare professionals.

With regard to world economy—assuming a gigantic financial crisis - would this exacerbate SUD prevalence? Past crises have particularly impacted on more vulnerable populations, increasing substance use ( de Goeij et al., 2015 ; Dom et al., 2016 ). It is therefore expected that vulnerable and at-risk individuals will develop SUD—as well as subjects with mild SUD could progress to more severe forms of the disorder.

With regard to treatment, the need for personal protective equipment (PPE) by health care professionals may limit some strategies, such as street level harm reduction, especially as PPEs become less available. These strategies could be crucial to help curtail and/or adequately treat COVID-19 in this population. On the other hand, professionals dealing with COVID-19 may need special training to deal with substance users, assuming that treatment demand among these patients may increase ( Volkow, 2020 ).

In conclusion, health care professionals dealing with SUD must be aware of the risks and challenges they will meet during and after the COVID-19 outbreak. Addiction care must be reinforced, instead of postponed, in order to avoid complications of both SUD and COVID-19 and to prevent the transmission of coronavirus. Professionals dealing with COVID-19, on the other hand, should consider complications of SUD during treatment. For substance use, strategies must take into consideration clinical, demographic and socioeconomic factors. Telemedicine should be considered for mild cases of SUD and PPEs must be available for those working in the street level. Addiction treatment facilities must adhere to preventive measures, such as quarantine for recently admitted patients and minimal distance between beds, and, for this purpose, special guidance by public health officials should be available. These efforts could help not only individuals with SUD, but also in the control of the pandemic and so, the society as a whole.

Declaration of Competing Interest

The authors declare no conflicts of interest.

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2020.113096 .

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Internalizing personality traits and coping motivations for gaming during the COVID-19 pandemic: A cross-lagged panel mediation analysis

Vol.18, no.3 (2024).

https://doi.org/10.5817/CP2024-3-5

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Anxiety sensitivity and hopelessness are two traits that have been previously linked to increased gaming problems. Research in the early stages of the COVID-19 pandemic showed that emotionally vulnerable individuals were turning to video games as a means of coping with their distress. However, more research is needed on the long-term and enduring pathways from internalizing traits to time spent gaming during COVID-19, after the lockdowns and preventative measures had been lifted. As such, the current study employs a multi-wave longitudinal study that predicted that those participants who experience high levels of anxiety sensitivity or hopelessness would use gaming as a means to cope with their emotional discomfort, resulting in increased gaming behaviours. A sample of 1,001 American gamers ( M age = 38.43, SD = 12.11, 53.2% female) completed three surveys through Mechanical Turk, with the first occurring in July 2021, and subsequent surveys spaced three months apart. This study measured participants’ baseline anxiety sensitivity and hopelessness using the Substance Use Risk Profile. At each time point, participants were asked to recall their average time spent gaming over the past month using a Timeline Follow-Back method, and answer questions related to their coping motivations for gaming using the Motives for Online Gaming Questionnaire. Coping motives consistently predicted time spent gaming at the next timepoint. Furthermore, we found evidence that high levels of anxiety sensitivity at baseline predicted greater future time spent gaming at Time 3, through greater coping motives at Time 2. Hopelessness was correlated with coping motives and time spent gaming at baseline, but did not relate to these variables across time. Anxious individuals who were gaming to cope during the COVID-19 pandemic may be at higher risk for excessive gaming. This may be particularly true for individuals who are higher in anxiety sensitivity. Future research should aim to understand how the relationships between anxiety sensitivity, coping motivations, and time spend gaming exist in the context of symptoms of gaming disorder and functional impairments that exist due to excessive gaming.

Rebecca Lewinson

York university, faculty of health, department of psychology, toronto, canada.

Rebecca E. Lewinson is a PhD candidate in Clinical Psychology at York University. Her research interests focus on health psychology, including pain inferences, numerical anchoring, and problematic gaming.

Jeffrey D. Wardell

York university, faculty of health, department of psychology, toronto, canada; institute for mental health policy research, centre for addition and mental health, toronto, canada; department of psychiatry, university of toronto, toronto, canada.

Jeffrey D. Wardell is an Assistant Professor of Psychology at York University and a registered Clinical Psychologist with expertise in the assessment and treatment of addictive behaviour. His research seeks to elucidate causes of addictive behaviour, with a particular focus on young adults, people living with HIV, and people who use cannabis for therapeutic purposes.

Joel Katz is a Distinguished Research Professor of Psychology and Tier 1 Canada Research Chair in Health Psychology at York University. He is the Research Director of the Pain Research Unit and Lead Researcher of the Transitional Pain Service both in the Department of Anesthesia and Pain Management at the Toronto General Hospital in addition to serving as a Professor in the Department of Anesthesiology & Pain Medicine at the University of Toronto. Dr. Katz’s research is aimed, broadly, at understanding the psychological, emotional, and biomedical factors involved in acute and chronic pain.

Matthew T. Keough

Matthew T. Keough is an Associate Professor in the Department of Psychology. He is a registered clinical psychologist and former Chair of the Addiction Psychology section of the Canadian Psychological Association. He was previously an Assistant Professor in the Department of Psychology at the University of Manitoba (2017 – 2019). Dr. Keough’s research focuses on improving understanding of the etiology and treatment of addictive behaviour, including both substance use and behavioural addictions (e.g., problem gambling). Dr. Keough’s work is mechanism-focused and is rooted in motivational models of personality and cognitive theory.

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Authors’ Contribution

Rebecca E. Lewinson: writing—original draft; writing—review & editing; methodology; data curation; conceptualization; formal analysis. Jeffrey D. Wardell: conceptualization; methodology; writing—review & editing. Joel Katz: supervision; writing—review & editing. Matthew T. Keough: supervision; writing—review & editing; formal analysis; conceptualization; methodology.

Editorial Record

First submission received: January 24, 2023

Revisions received: December 6, 2023 February 15, 2024

Accepted for publication: April 12, 2024

Editor in charge: David Smahel

Introduction

The COVID-19 pandemic has been shown to have continued negative impacts on symptoms of depression, anxiety, and overall feelings of loneliness worldwide (Kotwal et al., 2022; Rosenberg et al., 2021; Shattuck et al., 2022; Sommerlad et al., 2021). As a result of the changes imposed by the COVID-19 pandemic and ongoing stressors that persisted well beyond the initial lockdown, many sought new ways to cope with their isolation and negative emotions. One such method is the use of video games. A recent systematic review looked at articles published since December 2019 (Pallavicini et al., 2022). The researchers found that many people turned to video gaming during the pandemic to mitigate their stress, anxiety, depression, and loneliness; however, for those individuals who were at-risk for addictive behaviour, particularly male youths or those with maladaptive or avoidant coping styles, excessive gaming was found to have long-term increases in symptoms of anxiety, depression, and overall stress, but short-term relaxing effects to the player (Pallavicini et al., 2022). This may indicate that these at-risk populations experience greater distress or risk for developing gaming problems as a means of coping with their distress (Pallavicini et al., 2022). This discovery is reinforced by earlier research conducted by Melodia and colleagues (2022) prior to the pandemic. In their systematic review, they examined 26 articles published between 2010 and 2020 that explored avoidance and escape coping strategies for gaming. Their analysis revealed a significant connection between escape or avoidance coping motives and the prevalence of excessive gaming behaviours (Melodia et al., 2022). However, while these studies give information regarding gaming activity and its potential negative effects both prior to and during the pandemic, much still remains unknown regarding the longitudinal pathways of risk for gaming problems in this context, and the mechanisms that would explain that risk.

Gaming Activity During COVID-19

The USA has seen significant growth in the number of self-reported video gamers since the beginning of the COVID-19 pandemic, from 164 million in 2019 to 215 million in 2022. (Entertainment Software Association, 2019, 2022). Not only are more Americans playing video games, but the amount of time spent gaming is steadily rising, from an average of 8.3 hours per week in 2019, to 13 hours per week in 2022, representing a nearly 57% increase in time spent gaming. (Entertainment Software Association, 2019, 2022). Moreover, Verizon reported a 75% increase in online gaming activity, corresponding with stay-at-home directives (Shanley, 2020).

Gaming, in itself, is not inherently problematic; in fact, previous research has shown that gaming can be associated with numerous benefits with regard to social (Wiederhold, 2021), emotional, and physical development (Merino-Campos & del Castillo Fernndez, 2016), particularly with moderate game play (Granic et al., 2014). However, it is important to note that there are passionate gamers who do not encounter gaming-related problems or functional impairment. The specific genre or nature of the video games that are played may influence the positive outcomes associated with gaming. For example, cooperative or team-based video games (e.g., World of Warcraft) have been linked to increased prosocial behaviours and social skills in some studies (Gentile et al., 2009; Lenhart et al., 2008). On the other hand, casual or puzzle video games (e.g., Bejeweled, Angry Birds) have found to have mood-boosting and relaxing effects (Russoniello et al., 2009).

Despite these benefits, there are also times when gaming can lead to functional impairment, distress, or other problems. Though there are some differences throughout the literature in the constructs used to measure problematic gaming (King et al., 2013; Kuss, 2013), most literature agrees that the term “excessive gaming” encompasses problematic gaming habits that also cause gaming-related problems or functional issues (King et al., 2013). As such, excessive gaming is essentially a term used to conceptualize addiction to gaming, without a formal diagnosis being attached to the definition (Sanders et al., 2017). Excessive gaming has been associated with a number of mental health concerns including anxiety (Wang et al., 2017), depression (Liu et al., 2018), and substance use (Na et al., 2017). A systematic review of 24 articles conducted by González-Bueso et al. (2018) examined the relations between gaming problems, anxiety, and depression. The authors concluded that there were significant positive correlations between gaming problems and emotional disorders, namely anxiety and depression. However, the authors note that the lack of longitudinal studies that examine the directional relations between gaming problems, anxiety, and depression is a significant limitation (González-Bueso et al., 2018).

A further meta-analysis included data collected from 210, 557 participants, aiming to determine risk and protective factors to the development of Gaming Disorder (Ropovik et al., 2023). The researchers included studies published from 2013 onwards. Relevant to the current study, they found that anxiety, stress, gaming time, and escape motives all were risk factors for the development of Gaming Disorder (Ropovik et al., 2023). Collectively, these studies demonstrate an established relationship between anxiety and depression with excessive gaming; however, in the context of the global pandemic where emotional issues have peaked, there is a need for research that is focused on how vulnerable individuals are coping, and if they are gaming more in order to cope.

Anxiety Sensitivity and Hopelessness

Internalizing personality traits, such as anxiety sensitivity and hopelessness, are risk factors that can help us to better understand gaming risk by providing insights into how individuals with these traits may use gaming as a coping mechanism for anxiety or hopelessness. Anxiety sensitivity is defined as the fear that physiological or emotional symptoms of anxiety will have harmful consequences (Mantar et al., 2011). For example, an individual high in anxiety sensitivity may fear an impending heart attack if they notice an increase in their heart rate. The literature identifies anxiety sensitivity as an enduring personality trait that contributes to higher risk for virtually all anxiety disorders (Mantar et al., 2011; Olatunji & Wolitzky-Taylor, 2009; Schmidt et al., 2010; Taylor et al., 1992). Hopelessness is conceptualized as a stable trait of depression-proneness. Individuals who are high in hopelessness tend to have frequent negative thoughts about themselves, others, and about the future. Consequently, high levels of trait hopelessness have been associated with increased risk for recurrent major depressive episodes (Mac Giollabhui et al., 2018; Soloff et al., 2000; Szanto et al., 1998). Overall, the literature on personality indicates that both anxiety sensitivity and hopelessness are more than simply experiencing situational or state-level negative emotions. They are enduring traits that give risk to emotional vulnerability.

Within the context of the COVID-19 pandemic, previous research has shown that higher anxiety sensitivity can contribute experiencing high levels of fear related to COVID-19 (Warren et al., 2021), elevated symptoms of anxiety and depression (Rogers et al., 2021; Warren et al., 2021), or post-traumatic stress disorder (Li et al., 2020; Zhao et al., 2022) and significant functional impairment in their daily life (Manning et al., 2021). Studies have also found that individuals who experience higher levels of anxiety sensitivity are also more likely to experience problematic gaming behaviours during the pandemic (Kahraman & Yertutanol, 2021), and are also more likely to report coping motivations for gaming (Biolcati et al., 2021). This is consistent with pre-pandemic literature that found associations between anxiety sensitivity, problematic and excessive internet use (Taş, 2019), gambling and risk-taking behaviours (Broman-Fulks et al., 2014), and video game use (Kahraman & Yertutanol, 2021). Moreover, anxiety symptoms more generally have been positively associated with problematic or excessive gaming behaviours both before (Mannikko et al., 2015; Wang et al., 2017) and during the COVID-19 pandemic (Fazeli et al., 2020; Teng et al., 2021). Given that individuals higher in anxiety sensitivity seem to have experienced an exacerbated level of emotional distress caused by the COVID-19 pandemic, those same individuals may have gamed excessively in order to manage these symptoms.

Comparatively, there is significantly less research surrounding the association between hopelessness and excessive gaming during the COVID-19 pandemic. Despite this, the available research does suggest a positive association between hopelessness and COVID-19 related depression and loneliness (Akova et al., 2022; Padmanabhanunni & Pretorius, 2021). Teng et al. (2021) conducted a two timepoint study (October/November 2019 and April/May 2020) with 1,178 children and adolescents to characterize changes before- and during- the COVID-19 pandemic with regards to excessive video game use, and symptoms of gaming problems, depression, and anxiety. The researchers found that higher symptoms of anxiety and depression at Time 1 each independently positively predicted symptoms of gaming problems and excessive video game use at Time 2 (Teng et al., 2021). It is important to note that this study did not measure trait hopelessness; however, as mentioned, there is a strong association between trait hopelessness and symptoms of depression (Akova et al., 2022; Padmanabhanunni & Pretorius, 2021).

Given that the rates of depression in North America skyrocketed during the COVID-19 pandemic, with moderate to severe depression rates in the USA increasing from 8.5% in 2018 to 27.8% in the first few months of the pandemic (March and April 2020; Ettman et al., 2020), it stands to reason that these increases in depressive symptoms during the pandemic may be a contributing factor to increased time spent gaming. Other studies conducted during the pandemic have also found a positive association between levels of depression or hopelessness and gaming problems (Chen et al., 2021; Cudo et al., 2022). Biolcati et al. (2021) recruited 627 self-reported video game players and asked them to complete the Substance Use Risk Profile Scale along with the Internet Gaming Disorder Scale—Short Form and the Motives for Online Gaming Questionnaire during the COVID-19 pandemic. The researchers found that hopelessness was a distinguishing trait between those who met criteria for Gaming Disorder and those who did not, where higher levels of hopelessness were associated with more symptoms of Gaming Disorder. However, while the relationship between anxiety sensitivity or hopelessness and excessive gaming has been previously defined, the motivations for gaming in this relationship are not yet well understood. Biolcati et al. (2021) did find that there was a positive association between anxiety sensitivity and coping motives for gaming; however, more research is needed to better understand this association.

Coping Motives

Motivational theory identifies reasons for engaging in addictive behaviours as proximal factors related to risk for problem alcohol and other substance use (Cooper et al., 1995; Cox & Klinger, 1988; Miller et al., 2000), as well as for behavioural addictions, such as gambling (Chantal & Vallerand, 1996; Rodriguez et al., 2015) and gaming (Przybylski & Weinstein, 2019; Weinstein et al., 2017). Coping motives in particular have been found in various forms of addiction. For example, Cooper (1994) introduced a four-factor model of motivations for alcohol use, consisting of social motives, coping motives, enhancement motives, and conformity motives, while Myrseth et al. (2017) suggested a four-dimensional model of motivation for online gaming consisting of social motives, coping motives, enhancement motives, and self-gratification motives. Coping motives have also been found in other addictive behaviours including gambling (Schlagintweit et al., 2017; Stewart & Zack, 2008) and substance use (Hogarth et al., 2019; Votaw & Witkiewitz, 2021). According to these motivational models of addiction, people who are emotionally vulnerable are at risk for excessive gaming and related harms due to their strong coping motives for playing (Balhara et al., 2018). These people may have been the ones who increased their gaming in efforts to cope with the enduring pandemic situation.

Myrseth et al. (2017) identified four key motives for gaming, namely: enhancement motives (internal, positive reinforcement; gaming for the pleasurable experience of gaming itself), coping motives (internal, negative reinforcement; reduction of negative emotions), social motives (external, positive reinforcement motives; increasing social interaction), and self-gratification motives (gaming to satisfy one’s own personal desires). Coping motives seem to be the most central to problematic gaming, particularly among those with emotional vulnerabilities, as they have been found to predict increased risk for gaming harms (Myrseth et al., 2017). Furthermore, coping motives independently predict a loss of control of gaming behaviours as well as the development of gaming problems (Myrseth et al., 2017).

A longitudinal study conducted by Lewinson et al. (2022) examined the relations between emotional vulnerability (i.e., state depression and anxiety symptoms) and video game usage in the first six months of the COVID-19 pandemic. A sample of 332 Canadian gamers were recruited through Prolific to participate in a longitudinal study with three time points spaced three months apart beginning in April 2020 (approximately six weeks after the declared state-of-emergency in several parts of the United States). At each time point, participants were asked to complete surveys assessing their levels of anxiety and depression (collectively called “emotional vulnerability”), time spent gaming, gaming problems, and motivations for gaming. The researchers found that higher initial levels of emotional vulnerability predicted future excessive time spent gaming and gaming problems six months into the pandemic. Moreover, the researchers found that individuals who were higher in emotional vulnerability at the outset of the pandemic were more likely to use video gaming as a coping method, which in turn related to increased gaming harms. However, it is important to note that the measures of emotional vulnerability in this study were state-like emotions, and captured initial reactions to the pandemic situation; as such, the relationship between video game usage and coping is currently unclear in individuals who are higher in trait hopelessness or trait anxiety sensitivity. Furthermore, the aforementioned study occurred during the first year of the pandemic; since that time, much has changed societally with the alleviation of lockdown procedures and mandatory masking, and increased availability of vaccines. As such, it is important to understand this association over time, during a different period of the COVID-19 pandemic.

While previous research acknowledges that gaming has increased during the pandemic, the longitudinal pathways and mechanisms that underlie the relationship between excessive gaming and internalizing traits such as anxiety sensitivity and hopelessness remain unclear. This study will provide insights into how individuals with these internalizing traits may use gaming as a coping mechanism, and how this may be attributed to more time spent gaming.

It is important to note that while the present study was conducted during a specific period of the COVID-19 pandemic, the identified psychological pathways and coping strategies extend beyond the immediate context of the study. By elucidating the relationships between internalizing traits, coping motives, and excessive gaming, this research contributes to a broader understanding of the enduring impact of psychological distress on gaming behaviors. As we explore these pathways, we acknowledge the necessity of considering the study’s timeframe and contextualizing the findings within the evolving landscape of the COVID-19 pandemic and its aftermath.

Aims and Hypothesis

Psychological distress during the COVID-19 pandemic has been proposed to lead to longer-term or enduring impacts on maladaptive substance use for coping purposes (Rehm et al., 2020). With regards to gaming behaviours, it is possible that we might see similar enduring distress-related pathways. We examined these pathways later in the pandemic, focusing on trait-level internalizing factors and longer-term excessive gaming. Using a three-timepoint longitudinal survey design beginning in July 2021 (with subsequent timepoints spaced three months apart), we examined how anxiety sensitivity and hopelessness were prospectively positively related to time spent gaming across time. We expect that individuals that are high in hopelessness and anxiety sensitivity will game more frequently due to their coping motivations for gaming. In addition, we tested the mediational role of coping motives as a secondary aim. Invariance tests were also conducted for biological sex (male versus female). Prior research has found variations between sexes in their gaming behaviours, including their gaming preferences and confidence levels in gaming; however, as this information has not been found during the COVID-19 pandemic, this invariance analysis was exploratory in nature (Lange & Schwab, 2018; Lucas & Sherry, 2004; Terlecki et al., 2011). Furthermore, gaming disorders are more prevalent in males (Marraudino et al., 2022), and previous research has shown that male youths in particular are more at-risk for experiencing detrimental effects such as increased anxiety, depression, and loneliness, due to excessive gaming (Pallavicini et al., 2022). As such, it is imperative to assess whether the proposed pathways remain consistent across sex to ensure the validity of our results’ interpretation within our sample.

Participants and Procedure

This research was reviewed and approved by the York University Research Ethics Board (Human Participants Review Committee certificate #e2021-238). Participants residing in the United States were recruited through CloudResearch, a research platform that integrates with Mechanical Turk to allow researchers to more easily conduct longitudinal academic or social research (Litman et al., 2017). Mechanical Turk is a crowdsourcing platform that allows workers to complete “Human Intelligence Tasks” in exchange for money (Buhrmester et al., 2011; Litman et al., 2015). Eligibility to participate was determined using pre-existing screening data available on CloudResearch, with participants being eligible if they were older than 18 years of age, live in the United States of America, and self-report that they regularly play video games (more than one hour per day of gaming). Only n  = 2 participants endorsed 0 hours of daily gaming at baseline; these participants were included in the analysis as they are individuals who are self-reported gamers, who therefore have motives for their gaming behaviour, and including them allowed us to avoid bias and allow us the full spectrum of gaming in our sample. The conscientious responders scale (Marjanovic et al., 2014), as well as an additional attention-check item created by the researchers ( when asked what your favorite color is, please respond with “coffee” ), were included to ensure that the participants were attending to the surveys and responding conscientiously (Marjanovic et al., 2014). Participants were excluded from analysis if they failed more than two attention-check items (six participants at each Time 1 and 2, three participants from Time 3). During data collection at Time 3, a technical error caused nine participant’s data to be unable to be connected to their previous responses at Time 1 and Time 2. This data was also excluded from analysis. Data collection took place as follows: July 2021 (Time 1), October 2021 (Time 2), and January 2022 (Time 3). Although many lockdown measures were listed, life at these time points had not fully returned to normal, with remote or hybrid work and travel, and other restrictions still being in place in a number of locations across the United States. Participants were compensated $1 USD for their participation in Time 1, $2 USD for their participation in Time 2, and $3 USD for their participation in Time 3.

Table 1 outlines the timeline of the study as well as which measures were used at each time point. Measures were completed online, and hosted through Qualtrics (Qualtrics, 2014). The order of measure presentation was non-randomized.

Table 1 . Synopsis of Measures Used at Time 1, Time 2, and Time 3.

Electronic Gaming Motives Questionnaire (EGMQ)

The EGMQ is a self-report measure of video gaming motives (Myrseth et al., 2017). In the current study, only the coping motives subscale was used. The coping motives subscale consists of four items (e.g., to forget your worries) , with participants responding to the items on a 1 ( almost never/never ) to 4 ( almost always ) scale. (Myrseth et al., 2017). In previous studies, the EGMQ has been shown to have good criterion validity (based on measures of gaming behaviours including categories of games played, the typical number of hours played per week, feelings of loss of control over gaming, and symptoms of gaming problems measured by the Gaming Addiction Scale), and good internal consistency (Myrseth et al., 2017). The coping motives subscale of the EGMQ in the present study had internal consistencies of Ω = .816, Ω = .810, and Ω = .844 at Time 1, Time 2, and Time 3, respectively.

The Substance Use Risk Profile Scale (SURPS)

The SURPS (Woicik et al., 2009) measures personality risk for substance abuse on four dimensions; however, only the two internalizing subscales were used in this study: hopelessness (e.g., seven items; I am content ), and anxiety sensitivity (e.g., five items; It frightens me when I feel my heart beat change ). Each item is rated on a 1 ( strongly disagree ) to 4 ( strongly agree ) Likert-type scale (Woicik et al., 2009). The SURPS was collected only at baseline (Time 1) for the current study. This scale was chosen as it efficiently and reliably assesses hopelessness and anxiety sensitivity, minimizing participant burden by capturing both variables in a single instrument. Additionally, the SURPS is commonly employed in gaming research to deliniate personality variables associated with substance use risk, potentially providing valuable insights for future studies in this field. In previous studies, the SURPS has shown strong discriminant and convergent validity, good concurrent, incremental, and construct validity, and good internal consistency (Woicik et al., 2009). In the current study, the SURPS had an internal consistency of Ω = .789 and Ω = .906 for the anxiety sensitivity and hopelessness subscales, respectively.

Time Spent Gaming

At each time point, participants were asked to indicate how much time on average (in hours) they had spent gaming each day over the past month. This number was multiplied by 30 to determine the participants’ total time spent gaming over the previous month at each time point. This procedure was based on the Timeline Follow-Back method which has been used in previous studies to measure gambling-related behaviours (Weinstock et al., 2004), substance use (Agrawal et al., 2008), and video gaming (Peter et al., 2020).

Data Analysis Overview

The data set for this manuscript is available online. We conducted preliminary analyses prior to hypothesis testing with a cross-lagged panel model (CLPM). CLPM is often used in longitudinal research to examine the reciprocal relationships between two or more variables measured at multiple timepoints. Namely, it is designed to explore the direction and strength of relationships between variables over time by analyzing how changes in one variable at an earlier timepoint predicts changes in another variable at a later timepoint (Muthén & Muthén, 2017). It is a widely used framework to test mediation with longitudinal data, such as the data presented in the current study.

In the case of the current study, hopelessness and anxiety sensitivity (Time 1) were treated as predictors of coping motives and time spent gaming (Time 2 and Time 3), while also being considered as concurrent correlates of coping motives and time spent gaming at Time 1. Given the temporal nature of the data, reciprocal pathways were also included to examine the presence of mediation as a secondary aim.

The preliminary analysis involved data screening (i.e., winsorizing extreme values to + 3.29 standard deviations from the mean and verifying multiple regression assumptions), and conducting a missing data analysis. For the missing data, we used a series of t -tests to examine potential baseline differences between participants with complete data versus those with incomplete data (Enders, 2010). In this analysis, we utilized full information maximum likelihood (FIML) as the specific estimation technique within the CLPM to handle missing data. FIML is commonly used to handle missing data and provides unbiased estimates when data is missing at random. This enhances the robustness of our statistical model.

Next, we used a cross-lagged mediation model in MPlus v8.4 to test the hypothesized pathways from internalizing traits to gaming via coping motives across the three timepoints (Muthén & Muthén, 2017). In this model, anxiety sensitivity and hopelessness were specified as predictors of the mediator (coping motives) and outcome variable (time spent gaming) at Time 2 and Time 3. Anxiety sensitivity and hopelessness were specified as correlates of the mediator and outcome variable at Time 1, as these variables were measured concurrently. The autoregressive effects and cross-lagged effects were specified among coping motives and time spent gaming across the three time points.

Fit of the hypothesized model was evaluated using several indices. For comparative fit index (CFI), > .95 was considered excellent, while between .90 and .95 is adequate. A root mean square error of approximation (RMSEA) of .06 or below is considered excellent, while a score between .06 and .10 is considered adequate. A score above .10 is considered poor fit. A standardized root mean square residual (SRMR) below .05 is considered excellent, while a score between .05 and .08 represents adequate fit (Fabrigar et al., 1999; Hu & Bentler, 1999; Kyndt & Onghena, 2014). In addition, the presence and magnitude of direct and indirect paths were evaluated using a bootstrapped bias-corrected 95% Confidence Interval (CI) approach (Fritz & MacKinnon, 2007). If the 95% CI for a given direct or indirect path coefficient does not include zero, the effect is considered to be supported (Fritz & Mackinnon, 2007; Hu & Bentler, 1999; Kline, 2013). The fit of our model is based on the comprehensive set of indices described above.

Following the evaluation of the CLPM in the full sample, the invariance of our model was tested across biological sex (i.e., men vs. women) to ensure that the interpretations of our results are consistent across our sample. In order to proceed with the path invariance testing, the proposed model was first tested in each sex group individually to ensure good fit (Cheung & Rensvold, 2002). A configural model was then tested, one that allows the paths to vary freely between groups. Assuming that good model fit was established in these first two steps, a path invariance model was estimated that constrains the direct effects to be equal effects across sex groups. If there were no significant differences in model fit between the configural and invariant models, then it was inferred that the overall model applies equally across sex (i.e., to both males and females) groups (Cheung & Rensvold, 2002). Differences in fit between path invariant and configural models were evaluated using the Δχ 2 test and the change in CFI value. A significant difference between models is supported if the p -value for the Δχ 2 test is below .05 and/or the ΔCFI is ≥.01 (Cheung & Rensvold, 2002).

Preliminary Analyses

1,001 participants (532 females; 469 males) completed the study at Time 1. At Time 2, n  = 699 (69.8%) of participants participated in the study. At Time 3, n  = 747 (74.6%) of participants participated in the study. “Completers” ( N  = 435) are those who completed all three time points, while “non completers” ( N  = 566) completed less than three time points. Our variables did not show any substantial skew or kurtosis, based on Kline (2011) who indicates that a skew of < 3 and kurtosis of < 10 is acceptable for normality. Table 3 outlines the skew and kurtosis of our variables.

There were no significant differences between completers and non-completers with regards to amount of time spent gaming, t (999) = .965, p  = .335, d  = .062 hopelessness, t (999) = −.579, p = .563, d = −.037, or coping motivations, t (999) = .525, p = .60, d = .033. Effect sizes represent Cohen’s d for missingness. There were also no significant differences between completers and non-completers in their sociodemographic factors (see Table 2). However, there was a significant difference between completers ( M = 7.66, SD = 3.039) and non-completers ( M  = 8.26, SD  = 3.063) in anxiety sensitivity, t (999) = 3.075, p = .002, d =.196. This indicates that individuals who were lower in anxiety sensitivity were more likely to complete all three time points of this study.

Sociodemographic Variables

Table 2 shows the sociodemographic variables, comparing completers and non-completers.

Table 2. Sociodemographic Variables .

Descriptive Statistics

Table 3 shows the descriptive data for the observed variables. The values for time spent gaming represent the average number of hours that participants spent gaming over the previous month. Our participants therefore spent an average of 3.02 hours per day gaming at Time 1, 2.83 hours per day gaming at Time 2, and 2.79 hours per day gaming at Time 3. In our sample, we observed a wide range of hopelessness, anxiety sensitivity, coping motives, and time spent gaming.

Table 3. Descriptive Statistics for the Observed Variables .

Mediation Model

Model results.

Our model supports an adequate-to-excellent fit based on the fit indices described above: χ 2 = 38.807, df  = 4, p  = < .001, χ 2 / df = 9.70; CFI = .971, RMSEA = .093, 95% CI [.068, .121], SRMR = .022. It should be noted that although the χ 2 / df ratio is high, this ratio is also sensitive to larger sample sizes (Alavi et al., 2020). Furthermore, it is important to acknowledge that a number of df’s in our model are quite low, which is problematic pertaining to RMSEA as low df’s will often result in inflated RMSEA (Fabrigar et al., 1999; Hu & Bentler, 1999; Kyndt & Onghena, 2014). Given this, the final model was selected based on the comprehensive results across fit indices, given the detrimental impact of low df on RMSEA estimates. The coefficients and 95% CIs for the cross-lagged panel model are shown in Figure 1.

Cross-Lagged Effects

Results showed that Time 1 time spent gaming predicted Time 2 coping motives, β = .063, 95% CI [.007, .125], but this prospective association was not supported from Time 2 time spent gaming to Time 3 coping motives, β = .041, 95% CI [−.058, .126]. In contrast, we did find consistent cross-lagged effects from coping motives to time spent gaming across Time 1 to Time 2, and across Time 2to Time 3. Overall, this suggests that coping motives were a driver of future excessive gaming.

Figure 1. Cross-Lagged Panel Model of Hopelessness and Anxiety Sensitivity to Time Spent Gaming and Coping Motives .

Note. Grey arrows represent non-significant pathways, while black arrows denote significant pathways. Standardized estimates are shown with their corresponding 95% bias-corrected bootstrapped confidence intervals. 95% confidence intervals are reported between squared brackets.

There were no significant direct effects from Time 1 anxiety sensitivity to Time 3 coping motives or Time 3 time spent gaming. As hypothesized, we observed a mediational effect from Time 1 anxiety sensitivity to Time 3 time spent gaming, via Time 2 coping motives, β = .007, 95% CI [.001, .021]. We did not find support that hopelessness was associated with concurrent or future coping motives or time spent gaming.

Invariance Testing

The invariance of the proposed model was tested across sex (male vs. female; see Table 4). The model fit the data well for males and for females.

Table 4. Invariance Testing by Sex: Model Fit Information .

This study is the first to longitudinally examine how anxiety sensitivity and hopelessness are prospectively related to time spent gaming during the COVID-19 pandemic, and the coping motivations that underlie that relationship. Overall, we found evidence for the hypothesis that coping motivations for gaming were a predictor of future excessive gaming for those with relatively higher anxiety sensitivity in our sample. Hopelessness was correlated with time spent gaming and coping motivations at baseline, but no longitudinal associations were supported in the data.

These findings are consistent with previous research, showing that those who report higher levels of anxiety sensitivity also tend to demonstrate elevated gaming behaviours (Kahraman & Yertutanol, 2021; Taş, 2019). Furthermore, these findings are consistent with previous literature showing that individuals who are higher in anxiety sensitivity are more likely to report coping motivations for gaming (Biolcati et al., 2021). Previous research has shown that individuals who experience higher levels of anxiety sensitivity are particularly at-risk for experiencing symptoms of anxiety and were disproportionately affected by the COVID-19 pandemic (Panteli et al., 2022). The current study’s findings help to explain this association by providing a directional aspect to the relationship, showing that that higher levels of anxiety sensitivity seem to prompt gamers to use video games as a coping mechanism for their emotional discomfort during the COVID-19 pandemic.

While coping motives were identified as a predictor of future excessive gaming in individuals with elevated anxiety sensitivity, this relationship did not hold longitudinally for the personality trait of hopelessness. Hopelessness has been shown in previous studies to be associated with gaming-related problems (Biolcati et al., 2021; Chen et al., 2021; Yu et al., 2023); however, in the current study, gaming was measured only through time spent gaming. It is possible that this measurement of time spent gaming was not specific enough to capture this relationship. In contrast, those with higher anxiety sensitivity were likely excessively anxious, and therefore may have engaged in more time gaming during the pandemic, whereas those higher in hopelessness may have engaged in gaming more episodically. Unfortunately, as gaming problems were not specifically measured, it is not possible to disentangle this possibility; however, this is an area for future research.

It is also possible that for those higher in hopelessness, gaming was used as a means of escape, rather than a means of coping. A study by Biolcati et al. (2021) examined personality traits, including anxiety sensitivity and hopelessness, in relation to gaming motives and Gaming Disorder. The research included 627 Italian gamers and employed some similar questionnaires (SUDS, IGDS-SF9), along with a different gaming motives questionnaire, the Motives for Online Gaming Questionnaire (MOGQ). The results revealed that hopelessness predicted escape, recreation, and fantasy motives but not coping motives, whereas anxiety sensitivity predicted coping, escape, and fantasy motives. These results parallel the findings of the current study, where only anxiety sensitivity was linked to coping motives.

It is worth noting that Biolcati et al. (2021) employed the MOGQ, which distinguishes coping and escape motives as separate categories, potentially providing more detailed insights into gaming motives. The lack of significance in predicting coping motives related to hopelessness could be related to the possibility that individuals higher in hopelessness may use gaming as an avoidant coping strategy (escape), rather than actively addressing their negative emotions (coping). It may be that the gaming motive questionnaire used in the current study was not able to capture this important differentiation. Furthermore, given that there was an initial relationship found between hopelessness and time spent gaming at baseline, it may be that individuals higher in hopelessness turned to gaming as a means to cope with their emotional distress in the short term, but may have been motivated to game for other reasons, such as escape, fantasy, or recreation in the long term that our questionnaire was unable to capture (Fazeli et al., 2020; Liu et al., 2018) Future research should delve into this relationship, particularly in the context of escape versus coping motives in individuals with elevated hopelessness.

The results of the present study can be understood through the self-medication hypothesis in which individuals who are higher in anxiety sensitivity may game excessively as a way to cope with those negative emotions and sensations (Balhara et al., 2018; González-Bueso et al., 2018; Hallauer et al., 2021; King & Delfabbro, 2016; Liu et al., 2018; Vadlin et al., 2016; Wartberg et al., 2017). Within the context of the COVID-19 pandemic, studies have found support for this self-medication hypothesis with regards to a number of addictive behaviours including video game and smart phone use (Menendez-Garcia et al., 2022), alcohol use (Wardell et al., 2020), substance use (Schimmenti et al., 2022), and gambling (Cardwell et al., 2022). This study therefore adds to the wealth of literature supporting the self-medication hypothesis, while also adding to the literature surrounding the COVID-19 pandemic which has previously found that those who experience heightened anxiety are more likely to engage in excessive gaming behaviours (Rozgonjuk et al., 2022; Sallie et al., 2021; Xu et al., 2021). The current study’s results are unique in describing the directional nature of this established relationship and the role of coping motivations in this relationship Moreover, the mediating relationship was supported in a fully longitudinal test, overcoming the limits of many past studies that have relied on cross-sectional data.

The study’s results can also be understood through the I-PACE (Interaction of Person-Affect-Cognition-Execution) model, which posits that addictive behaviours develop through the interaction of predisposing individual factors, along with specific situational triggers (Brand et al., 2016, 2019). The I-PACE model helps to inform the interpretation of our results; in line with the model’s principles, the current study found the coping motivations, particularly in individuals with higher levels of anxiety sensitivity, predict future time spent gaming. This aligns with the I-PACE model’s focus on the relationship between affective responses, decision making, and the development of habitual behaviours in addictive contexts. The current study also echos the model’s perspective on the use of changing coping styles based on prior experiences of gratification along with relief from negative emotionality (Brand et al., 2019). While hopelessness was not found to be associated with coping motives longitudinally, as mentioned above, hopelessness has been previously associated with escape, recreation, and fantasy motives—this may also help to reinforce the I-PACE notion that specific behaviours have the poosibility to lead to diverse emotional outcomes.

The results of this study aids in our understanding of gaming during the COVID-19 pandemic, and how anxiety sensitivity as a stable personality trait may impact gaming behaviours. This understanding could help guide strategies aimed at identifying individuals at risk for problematic excessive gaming, considering those with elevated anxiety sensitivity. Moreover, given this study’s findings that excessive gaming seems to be fueled by coping motivations, future research may wish to explore positive coping methods that could help to mitigate the impact of coping motivations on excessive gaming behaviours.

This study had some limitations. Firstly, given that the data came from only one country, the results may not be generalizable to other countries, particularly countries outside of North America. Secondly, although there was a measure of time spent gaming at each time point, this is not necessarily a measure of problematic gaming in and of itself. Many individuals game on a regular basis, or even on an excessive basis, without accompanying symptoms that would make gaming problematic (e.g., distress, disruptions to functioning, etc.). Future studies measuring symptoms of gaming disorder may provide additional information as to how the participants’ time spent gaming is impacting their daily functioning and interpersonal relationships. Given that the current study examined only trait-like factors, it would also be worthwhile to track participants’ emotional distress over time with measures that have been shown to be sensitive to capturing short-term changes in mood and anxiety. Other studies may wish to examine factors beyond personality that might affect gaming, such as the social or contextual variables associated with the pandemic (e.g., employment status, remote working, living situation). It is also a limitation that for the current study, inferences surrounding the COVID-19 pandemic were made based on the context and timing of the study. As such, we are unable to draw firm conclusions about any COVID-19 specific factors, as they were not included in our model. Finally, the reliance on self-reported data in measuring time spent gaming is a noteworthy limitation of the study. Self-report is susceptible to a number of biases and inaccuracies including memory recall issues, social desirability bias, or the possibility of misrepresenting actual gaming time. As such, the results of this study may be influenced by the inherent limitations of self-reported data, and future research may wish to replicate the study using objective measures of time spent gaming (e.g., tracking software).

The current study examined a specific time period during the pandemic in which lockdown and other measures were being lifted. During this time, many changes were still in effect due to the COVID-19 pandemic, and stress levels remained high for many people (Kastalskiy et al., 2021; Manchia et al., 2022).

These findings aid in our understanding of gaming behaviours and gaming motivations during the COVID-19 pandemic. This longitudinal study not only provides information regarding how anxiety sensitivity relates to time spent gaming during the pandemic, but also how these individuals used gaming as a means to cope with their emotional distress. Understanding these patterns may be valuable for mental health professionals or policy makers in order to better address the emotional needs of individuals during challenging situations, such as pandemics or other difficult events. This study underscores the need for continued research in this area, particularly in determining how gaming habits and motivations evolve over time, especially in response to external stressors. Furthermore, future research should aim to understand how the relationships between anxiety sensitivity, coping motivations, and time spend gaming exist in the context of symptoms of gaming disorder and functional impairments that exist due to excessive gaming.

Conflict of Interest

The authors have no conflicts of interest to declare.

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Copyright © 2024 Rebecca Lewinson, Jeffrey D. Wardell, Joel Katz, Matthew T. Keough

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Experiences of people with opioid use disorder during the COVID-19 pandemic: A qualitative study

Affiliations.

• 1 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
• 2 School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
• 3 Vancouver Coastal Health, Vancouver, British Columbia, Canada.
• 4 Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
• 5 British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.
• 6 Department of Emergency Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
• 7 Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.
• 8 Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
• 9 Department of Family and Emergency Medicine, University of Montréal, and Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
• 10 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
• 11 Inner City Health Associates, Toronto, Ontario, Canada.
• 12 Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
• 13 Department of Emergency Medicine, University of British Columbia, Vancouver, British Columba, Canada.
• 14 Vancouver Area Network of Drug Users, Vancouver, British Columbia, Canada.
• 15 Portland Hotel Society Community Services Society, Vancouver, British Columbia, Canada.
• 16 Providence Health Care, Vancouver, British Columbia, Canada.
• 17 British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.
• PMID: 34324589
• PMCID: PMC8320992
• DOI: 10.1371/journal.pone.0255396

Aim: To capture pandemic experiences of people with opioid use disorder (OUD) to better inform the programs that serve them.

Design: We designed, conducted, and analyzed semi-structured qualitative interviews using grounded theory. We conducted interviews until theme saturation was reached and we iteratively developed a codebook of emerging themes. Individuals with lived experience of substance use provided feedback at all steps of the study.

Setting: We conducted phone or in-person interviews in compliance with physical distancing and public health regulations in outdoor Vancouver parks or well-ventilated indoor spaces between June to September 2020.

Participants: Using purposive sampling, we recruited participants (n = 19) who were individuals with OUD enrolled in an intensive community outreach program, had visited one of two emergency departments, were over 18, lived within catchment, and were not already receiving opioid agonist therapy.

Measurements: We audio-recorded interviews, which were later transcribed verbatim and checked for accuracy while removing all identifiers. Interviews explored participants' knowledge of COVID-19 and related safety measures, changes to drug use and healthcare services, and community impacts of COVID-19.

Results: One third of participants were women, approximately two thirds had stable housing, and ages ranged between 23 and 59 years old. Participants were knowledgeable on COVID-19 public health measures. Some participants noted that fear decreased social connection and reluctance to help reverse overdoses; others expressed pride in community cohesion during crisis. Several participants mentioned decreased access to housing, harm reduction, and medical care services. Several participants reported using drugs alone more frequently, consuming different or fewer drugs because of supply shortages, or using more drugs to replace lost activities.

Conclusion: COVID-19 had profound effects on the social lives, access to services, and risk-taking behaviour of people with opioid use disorder. Pandemic public health measures must include risk mitigation strategies to maintain access to critical opioid-related services.

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Conflict of interest statement

The authors have declared that no competing interests exist.

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