Interviewer: Tiffany Morgan, Project Manager for Siyan Clinical Research
Interviewee: Dr. Anish Shah, CEO at Siyan Clinical Research and Project Director for Project Hope
Topic background: Substance Abuse and COVID-19
The COVID-19 pandemic has us all reeling, and a lot of people are facing unexpected challenges. Unfortunately, people in recovery from substance use disorders are disproportionately affected, and those who rely on opioid replacement therapy (ORT) to manage opioid addiction will face additional risks and challenges as society learns how to adapt to the pandemic.
1. Can you give us a bit of background on the nature of addiction in relation to the current COVID-19 pandemic?
To understand the potential consequences of COVID-19 on people with substance use disorders, it might be helpful to understand some of the things that happen in the brain during addiction. And, although coffee isn’t a drug of abuse, it has some very similar effects that most people will be familiar with, so it’s a useful analogy.
Do you remember the first time you had coffee? If you were like me, you were bouncing off the walls. Now, lots of us need a cup or two every morning to get out the door. Some of us might even get a headache if we don’t have our coffee.
When we need to drink more coffee to get the same effect, we’ve developed tolerance. And if we get a headache without coffee, it’s because our brains have become dependent on caffeine and without it, we have caffeine withdrawal. These symptoms: tolerance, dependence, and withdrawal, are hallmarks of addiction.
Drugs of abuse hijack the reward system, which releases dopamine in response to pleasurable stimuli. Normal stimuli (food, water, sex) cause some dopamine to be released, and the brain remembers that those are good things. Drugs of abuse cause dopamine to flood the brain, which leads the brain to incorrectly deduce that the drug has a really positive effect on health and wellbeing.
With regular drug use, addiction can become impossible to manage. Opioids (e.g. heroin, oxycodone, fentanyl), alcohol, benzodiazepines, cocaine, and nicotine are among the most challenging drugs to quit, and withdrawal symptoms can persist for months, even years after someone quits. For many people, relapses aren’t driven by a desire to use; rather, a desire to avoid withdrawal symptoms is the primary motivator.
People who are in recovery from substance use disorders often find support and solidarity by participating in treatment groups and 12-step programs. These programs can’t make withdrawal any less miserable, but when people who are going through withdrawal are surrounded by peers who understand what they’re going through, it can make the process a little less daunting.
- Does substance use increase COVID-19 risks?
We’re still learning how coronavirus interacts with substance use disorders, but evidence suggests that people with respiratory damage or disease are at increased risk for serious, even life-threatening COVID-19 symptoms. Smoking, vaping, and inhaling other drugs exposes delicate respiratory tract tissues to harmful chemicals. When someone with smoking-related respiratory tract damage gets COVID-19, their lungs are less able to manage and recover from the virus .
People with opioid use disorder face a different kind of risk when they get COVID-19. Opioids act by slowing brain function in certain areas, including the part of the brain that controls breathing. Since chronic respiratory disease impairs lung capacity, someone who uses opioids is at risk for dangerous respiratory depression (slow, irregular breathing). Experts believe that COVID-19 will similarly increase the risk for potentially fatal overdoses .
- How is COVID-19 affecting people with substance use disorders?
Because it attacks the lungs, the coronavirus could be an especially serious threat to those who smoke tobacco or marijuana. People with methamphetamine use disorder may also be vulnerable due to its effects on respiratory health.
Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these pose unique challenges regarding transmission of the coronavirus to law enforcement officials and jails .
Coronavirus attacks our lungs and causes problems with oxygen flow to our body. Since opioids act in the brainstem slowing down our breathing, their use not only puts people at risk of life-threatening overdose, it may also cause a harmful decrease in oxygen in the blood in turn causing increase mortality with patients with opioid abuse.
- What are some barriers to substance abuse treatment during the current crisis?
Although many treatment centers currently remain open for limited business, the requirement for social distancing makes getting care challenging. Treatment groups that may normally have a couple dozen participants are now limited to very few patients and a counselor. Many therapy groups and 12-step programs have suspended meetings altogether, leaving members without support. For some people, this will dramatically increase the risk that they will relapse.
People who want to start treatment face new barriers to care as well. Rehab facilities that used to admit new inpatients regularly are now offering intensive outpatient and telehealth treatment almost exclusively .
- What are some resources for someone seeking 12-step group therapy?
Our clinic currently offers group therapy via telehealth. I understand remote group therapy lacks the personal connection of in-person sessions; however, virtual group dynamics do develop given some time. It is important for those in recovery to have consistency with their program, especially during times of high stress and uncertainty as we are in now.
- Why are people with OUD most disproportionately affected by the current crisis?
Among drugs of abuse, opioids like heroin and oxycodone are singularly addictive and notoriously hard to quit. In some cases, debilitating withdrawal symptoms can persist for years, making long-term recovery very challenging. Three highly effective FDA-approved medications are available to treat opioid use disorder (OUD): buprenorphine, methadone, and naltrexone . However, access to these medications is strictly regulated by the federal government, and many patients who would benefit from a prescription are unable to get one.
- Why is it so important to prioritize mental health right now for those with substance abuse disorder?
Substance abuse and mental health disorders often go hand-in-hand, with depression, anxiety, and post-traumatic stress disorder being among the most common comorbidities. People who have been successfully managing symptoms associated with a psychiatric disorder may not be prepared to deal with the dramatic societal upheaval and widespread fear that COVID-19 is causing.
As people feel like they are losing control of their lives, drugs and alcohol can seem like an escape. People who have lost jobs are at particular risk, and it is possible that we will see a sharp increase in homelessness among people with substance use and mental health comorbidities.
Unfortunately, in a time when more people than ever need access to substance abuse treatment and mental health care, fewer and fewer options are available. Telehealth options can provide support for some people, but social isolation, fear of COVID-19, rising unemployment and falling access to healthcare mean that people who are recovering from substance use disorders face a very real relapse risk, with all of the long-term ramifications that go along with it.
- What are some of the main mental health issues you see arising in your practice since the onset of COVID-19? And… What do you see may occur in the future as it related to Mental Disorders?
Social isolation, fear of being infected by the coronavirus, rising unemployment, economic distress and falling access to healthcare are some of the key issues that global community is experiencing at this time. We have seen rise in clinical depression, anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder. I also see some of the psychotic illness may also increase with time.
Moreover, we always have to vary about increase in suicide and overdose related deaths. This is truly a worrisome scenario. Paradoxically, I have also seen few patients doing better during initial shelter at home orders, as they are close to their loved one and have social support through their family.
As we progress, certain factors will increase causing a societal strain including: COVID-19 cases, hospitalization, deaths and more over largely unknown factors such as treatment availability, predictability about future outbreaks, limited testing resources and also overall economic distress to global community. We as a community, government agencies and providers need to worry and think about increase in psychiatric issues and need for resources for mental well-being.
- What are some daily coping mechanisms you are recommending to patients?
Coping through in current pandemic is a very important issue that one should pay attention to. Coping mechanisms are key in preventing development of full-blown psychiatric illness episodes.
- Please do not watch excessive news and social media. I recommend limiting media exposure to 2 hours a day.
- Please rely on only known sources for information. For example: CDC or local county government
- I recommend that about 30-minute walk 2 times a day and some form of exercise routine daily.
- Please also communicate with your family and friends. Talk to them on phone other video conferencing software.
- Try well balanced meal. For example: add healthy fats, cut the sodium, add variety of vegetables and fruits in your plate and bump up your fiber.
- One thing I tell to all my patients is to “Remain in Present” think about today, this week. Plan for the future but limit your catastrophic worry sessions about the future which largely is unknown to all of us to once a day if possible. Remind yourself that I will limit my worry sessions to only once a day about the uncertainties for which I don’t have control over.
- Please read a book, watch one TV show you always like or meditate for 15 minutes couple of times a day.
- Please ensure that you take all your regular medications as scheduled.
- If you are spiritual or believe in a faith, spend few minutes daily to your usual prayer and spiritual practice.
One of the key messages I would give it to listeners is please do not ignore your emotional struggle, accept them, take one healthy action to solve these problems. I however will also say that if you experience serious depression, uncontrollable anxiety, concentration and memory issues, continue restless feelings, sleep problems or if you see yourself turning into unhealthy coping such as use of alcohol or illicit substance please contact your mental health providers.
- What are some resources for someone seeking mental health services?
I tell all the community members who has preexisting depression, anxiety or any diagnosed psychiatric illness is to stay connected with their mental health providers. If you have a provider who you are working with over the years or have contacted in the past than please call them to set up an appointment. You can also call your insurance company to give you a list of providers who provide services through telehealth.
We at Siyan Clinical have a large staff of licensed mental health providers including psychiatrists, Nurse Practitioners, Physician Assistant, psychotherapists delivering evidence-based behavioral healthcare remotely. If you are interested in scheduling an appointment please call us at 707-206-7268 or you can visit us on www.siyanclinical.com or HopeMat.org.
- What does the telehealth process look like for a patient receiving services from your clinic?
This is a relatively novel process for most of our patients. Telehealth process is fairly easy way to stay in contact with your provider and receive treatment for your mental health and substance abuse issues. In telehealth, you can do a video call with your provider and speak to them about what you are experiencing. Provider can evaluate psychological symptoms, provide psychotherapy, prescribe medication if needed in telehealth sessions. Most telehealth software or applications can be downloaded on smartphone, tablets or desktops. You generally get a link on your phone or email from your provider and once you click on it you join them in the session.
- If patients do need to come on-site, what are some of the precautions your clinic is taking to prevent the transmission of COVID-19?
Our recommendation for all our patients is to stay home during this crisis. We are fortunate that most of our patients have been able to recognize the importance and utilize Telehealth. We have very few patients (less than 1%) who are very sick and can’t manage any audio-visual communication comes to our clinic. We have implemented protocol for essential business given to us by Sonoma county. We keep 6 feet distance and sanitize our clinic every few hours. We also take temperature for all visitors and all staff wear face masks at this time.
- Do you have personal perspective you can share as a way to view the COVID-19 crisis overall?
These are difficult time for all of us as global community. I remind to myself daily that this crisis makes all of us feel helpless, vulnerable and takes us to thinking about a journey unknown…I think during this time what can I could do today to decrease my worry and concern. I also remind myself that our community in Sonoma County has had many catastrophic experiences like wildfires and I find remembering that this crisis will also pass and we will be fine puts things into perspective.
I am also inspired by learning through struggle and success stories of lots of my patients, employees and family members. I cherish when they succeed or accomplish during this time.
We will emerge stronger through current pandemic crisis. I schedule 15 minutes a day for an introspection session with myself. I ask myself what is in my control? What is not in my control? I make a list of items in my control and take some actions about them. I feel accomplished most days.
For more information, please visit our website at www.siyanclinical.com or www.HopeMat.org.If you are interested in scheduling an appointment please call us at 707-206-7268 or you can email us at firstname.lastname@example.org.
Stay safe, be well. Take care of yourselves and each other!
Thank you to our sponsors:
Substance Abuse and Mental Health Services Administration (SAMHSA) &
Center for Substance Abuse Treatment (CSAT)
Disclaimer: This product was supported [in part] by grant number TI081478 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The content of this publication does not necessarily reflect the views or polices of SAMHSA or the U.S. Department of Health and Human Services (HHS).
- Stromberg, J. This Is How Your Brain Becomes Addicted to Caffeine. 2013 [cited 2020 April 2]; Available from: https://www.smithsonianmag.com/science-nature/this-is-how-your-brain-becomes-addicted-to-caffeine-26861037/.
- COVID-19: Potential Implications for Individuals with Substance Use Disorders. Nora’s Blog 2020 [cited 2020 April 4]; Available from: https://www.drugabuse.gov/about-nida/noras-blog/2020/03/covid-19-potential-implications-individuals-substance-use-disorders.
- Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19 Epidemic. 2020 [cited 2020 April 2]; Available from: https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf.
- Information about Medication-Assisted Treatment (MAT). 2019 [cited 2020 April 2]; Available from: https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat.
- Levander, X.A. and S.E. Wakeman. Covid-19 will worsen the opioid overdose crisis if we don’t prepare now. First Opinion 2020 [cited 2020 April 2]; Available from: https://www.statnews.com/2020/03/17/covid-19-will-worsen-the-opioid-overdose-crisis-if-we-dont-prepare-now/.
- Fiscella, K. and S.E. Wakeman. Deregulating buprenorphine prescribing for opioid use disorder will save lives. 2019 [cited 2020 April 2]; Available from: https://www.statnews.com/2019/03/12/deregulate-buprenophine-prescribing/.
- Opioid Treatment Program (OTP) Guidance. 2020 [cited 2020 April 2]; Available from: https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf.