COVID-19 has disrupted addiction treatment: a neuroscientist answers our questions

Judith Grisel, Professor of Psychology and Neuroscience, Bucknell University, USA, speaking at the "The Science of Addiction" session at the World Economic Forum Annual Meeting 2020 in Davos-Klosters, Switzerland, 22 January. Congress Centre
Prof. Judith Grisel recovered from a decade of drug addiction before becoming a world-leading expert in the neuroscience of addiction.
Image: World Economic Forum / Christian Clavadetscher

Many of the services and treatments available to people recovering from drug addiction have been disrupted by the COVID-19 coronavirus pandemic, putting thousands of lives at risk. Countless clinics that provide syringe exchange services or daily addiction medication have closed or reduced their hours, while rehab centres have limited the number of new admissions, or even shut up shop for fear of spreading the virus.

To address this need, addiction treatment has become more flexible – something that addiction treatment advocates have been campaigning for, for years. In the United States, governmental restrictions have been relaxed, allowing doctors to supply patients with 28-day take-home doses of methadone – a normally heavily regulated medicine for opioid addiction – and give first-time prescriptions of other addiction medications over the phone.

Though perhaps not front-of-mind mind for everyone among the coronavirus chaos, the impact of the pandemic on addiction treatment was of immediate concern to Professor Judith Grisel, a leading expert in the neuroscience of addiction at Bucknell University. Having recovered from drug and alcohol dependency herself before becoming an academic, Judith shared her personal and professional experience of addiction at this year’s Annual Meeting in Davos.

We caught up with her to hear her views on the consequences that this disruption is having on the lives of people with substance use disorders.

What was your first thought when countries started introducing strict social distancing measures and lockdowns?

Instantly, I was very concerned for anyone who depends on addiction medication because I am fully aware that there are a lot of people in the world who are really one or two doses away from absolute desperation. If people can’t get access to addiction medication, they go into withdrawal, which is a kind of starvation for the brain. That gives you the same desperation you would feel if you were starving for food; there isn't much you wouldn't do to get your drug.

It's terrible under normal circumstances, but especially in a time where you're supposed to stay in isolation to avoid spreading a very infectious virus. If I were still using and I couldn't get what I wanted, I wouldn't be worried about my physical health and the possibility of catching or spreading the virus. I would be worried about alleviating my withdrawal state, which is what makes this a potentially explosive situation.

What is your reaction to the move from daily clinic visits to monthly prescriptions?

One big concern is the possibility of misuse and overdose. There is lots of evidence that methadone is misused, which is why the daily clinic visits have been the norm. And it is fairly straightforward to cook buprenorphine – another addiction medicine – in a way that it is easier to get high.

It's really a stressful, alienating time. For those of us who are healthy and may be able to work from home and have good social support, it's still stressful. But if you're somebody who's on the brink of succumbing to their addiction or working through it, it's asking a lot to give them a big pile of drugs, with directions to make them last a month.

What are your thoughts on virtual doctor appointments?

It’s encouraging to see medical professionals adopting telemedicine during these uncertain times. It's certainly not safe to have lots of people coming in and out of treatment centres. Especially because people with substance use disorders are probably more vulnerable to coronavirus, as they are more likely to be homeless, poor, smokers with lung or cardiovascular disease, under- or uninsured, or have experienced serious health and socioeconomic issues from drug addiction.

Image: World Economic Forum

In many ways they were already living close to the edge, and now that the edge itself has moved, it’s clear that if we want to mitigate consequences like relapse and overdose, some stopgap measures are necessary.

There could also be some advantages to video appointments, like for instance, doctors might be able to get a glimpse into their patients’ living situations for the first time, and help organise additional support if, for example, they realise that their patient is homeless. But of course, the underlying assumptions here are that people have access to smartphones – which is just not the reality for many – and that resources to help homeless people are available.

How will these regulatory changes affect people’s lives?

Addiction medications certainly have an important role to play, but they’re not really “treatment”. They are one tool of a large toolkit that we know can help people with substance use disorder. The importance of cognitive behavioural therapy and other kinds of vocational and medical help – things that can actually facilitate people becoming free of a drug – cannot be understated.

Drug addiction is like a leaky bucket. When the bucket runs out of water, it’s willing to do anything to get filled again, but substitute opioid prescriptions are like pouring more into the bucket, rather than repairing the hole.

Truly treating addiction requires a multi-pronged approach involving medical, psychological and social support. The world is full of people who’ve managed, with help, to patch the bucket.

I don't see these regulatory changes as treatment, or a big innovation. For the right person providing easier access to substitute therapies might help short-term, but they should not take the place for the kinds of things we know help long-term recovery, like support and opportunity. So, it’s these things that we need to work out how to do safely while the coronavirus still poses a health risk.

What is the bigger picture of mental health and addiction right now?

Stress is strongly correlated with anxiety and depression. One of the strategies to alleviate mental health challenges is to reduce stress in the environment by providing better coping strategies and a life that's easier to navigate. But it feels as if we've thrown that idea out the window right now – we're in the triage mode. We're just going to give people as many life preservers as we can and hope most of them stay afloat. I think that the stress caused by the fallout of the pandemic is going to make it more likely that people who are struggling with any of those succumb.

Recovery is not about avoiding desperation. Repairing the holes in the bucket requires connecting with other people. Our addictions thrive in alienation and so it's absolutely a challenge to figure out ways to cope and connect that are sustaining.

Map of the United States, with states colour-coded based on the projected additional number of
Estimated additional deaths of despair 2020-2029 due to the impact of COVID-19 on unemployment, isolation, and uncertainty.
Image: Petterson, Steve et al. “Projected Deaths of Despair During the Coronavirus Recession,” Well Being Trust. May 8, 2020. WellBeingTrust.org.

Should any of these changes stay in place after the pandemic?

Going forward, doctor video calls or even daily courier delivery of addiction medication could happen in tandem with the other aspects of treatment, which could be done in a physical or virtual setting. You really need to use the whole recovery toolkit.

I do think it needs to be based on an individual assessment with the whole support team, including social workers, psychotherapists and physicians. I don't think that this sort of blanketing the community with substitutes is in anyone’s best interest.

Is there anything you want to leave our readers with?

The changes that have happened, at least in the United States, are really just a short-term measure while we adapt to a new reality and are not synonymous with addiction “treatment”. And of course, we're talking about the people who hit the bottom and decided to get into recovery either by their own volition or being forced into it before the pandemic hit.

I have seen some people who are reaching out now for the first time now, and my heart goes out to them because it's hard enough when you can connect with people and then try to do things to change your life. But if you weren’t in the system before the pandemic hit, you’re likely to be lost.

On the other hand, maybe adolescents who would have ventured out on their own and come across mind-altering substances for the first time are more likely to be staying home with their parents and not picking up at this time. You certainly hope people wouldn't choose to try highly addictive drugs right now. Maybe it could balance out in the long run, but that doesn't really take account of the individual lives that are suffering.