This is the fourth installment of our 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, we will discuss identifying and treating substance use disorders in adolescents and adults in the aftermath of the COVID-19 pandemic in primary care.
A 45-year-old man presents to his primary care office at 9:00 am after he was asked to leave work the day before because he smelled of alcohol and had been acting erratically. He is told that he will need to be evaluated prior to returning to work. His behavior includes running back in forth at the shop yelling, “the holy spirit is in me.” He has been at his current employment for 3 months after being fired from his previous job after backing a forklift into loaded shelves at a nearby warehouse.
He reports he started drinking beer when he was 14 years old. In the past 2 years during the COVID-19 pandemic, his alcohol intake has increased to a 12-pack of beer nightly to get the “same effect” as he did last year. He notes that his drinking is now affecting his work and relationship with his wife. He states he knows that he needs to stop but feels ill (vomits and shakes) when he tries to lower his intake. He states, “when I was 22 years old, I had to be hospitalized after I tried to quit cold turkey and I was talking out of my head.” Several days a week he consumes 1 to 2 beers when he first awakes to “calm his nerves.”
His last drink was last night around midnight but he states, “I could use one right now.” He states, “I start off thinking I will only drink 1 or 2 beers but time gets away from me.” He further reports, “the pills my friend has been giving me have been helping me stay awake throughout the day.” He is unsure of the name of the medication but reports taking the pills almost daily over the last year.
Laboratory results show high levels of ammonia, glucose, carbohydrate-deficient transferrin, ethyl alcohol, and mean corpuscular volume (Table 1).1-4 Low white blood cell count, platelet count, and folic acid level are noted. Liver function tests are all elevated. Urine toxicology is positive for alcohol, cannabis, and amphetamine, and electrocardiography shows tachycardia (112 beats/min) with no ST segment abnormalities. Liver ultrasonography reports are pending.
Table 1. Laboratory Results of Markers of Alcohol Consumption1-4
|Normal Limits||Patient Values|
|Ammonia level, μ/dL||15-45||50|
|Basic metabolic panel, mg/dL||Glucose: 70-110||130|
|Complete blood cell count, cells/μL||White blood cell count: 4500-11000 Platelet: 150-350||4200 |
|Carbohydrate-deficient transferrin, mg/L||<60||105|
|EtOH level, mg/dL||<20||60|
|Folic acid, ng/mL||3-16||1.2|
|Hepatitis virus panel||Negative||Negative|
|Liver function tests, U/L||ALT: 10-40 |
|Mean corpuscular volume, µm3||80-100||105|
|Urine toxicology||Negative||+alcohol, + cannabis, + amphetamine|
|Vitamin B12, pg/mL||250-1500||450|
ALT, alanine transaminase; AST, aspartate aspartate aminotransferase; EtOH, ethyl alcohol; GGT, gamma-glutamyl transferase
Alcohol Use Disorder Screening Tools
Screening tools used to diagnose alcohol use disorder include the CAGE5, which is based on the 4 questions that ask:
- Have you ever felt the need to cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt guilty about drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
The patient has a positive response to 3 out of 4 CAGE questions. The Drug Abuse Screening Test (DAST-10) was also completed by the patient and he scored 6 indicating a need for further assessment.5,6
Another alcohol use screening tool that can be used is the AUDIT-C5, a shortened version of the AUDIT (Alcohol Use Disorders Identification Test) that includes 3 questions:
- How often did you have a drink containing alcohol in the past year?
- How many drinks containing alcohol do you have on a typical day when you were drinking in the past year?
- How often did you have 6 or more drinks on one occasion in the past year?
Significant Medical/Psychiatric History
The patient has a history of hypertension and is prescribed lisinopril 10 mg daily but is rarely compliant with taking medication. The patient admits to being diagnosed with COVID-19 approximately 1 month ago, but only experienced mild symptoms, which included headache and nonproductive cough for 3 days. He has increased his alcohol consumption over the last 2 years.
Table 2. Vital Signs
|Blood pressure, mm Hg||174/100|
|Heart rate, beats/min||112|
|Respiratory rate, breaths/min||18|
|Oxygen saturation on room air, %||95|
The patient’s family history includes a parental grandfather with alcohol use disorder; brother currently using methamphetamine and cocaine. The patient’s mother has type 2 diabetes and the patient’s father has hypertension and alcohol use disorder.
Mental Status Examination
The patient presents with unkempt hair, dirty clothes, and a scruffy beard. He continuously clinches his fists and taps his feet, appearing anxious. He is mildly diaphoretic and wipes sweat from his forehead every couple of minutes. Mild bilateral hand tremors a noted as he held out his return to work form. He is alert and oriented to person, place, and time. He voices frustration that he must be cleared before returning to work since he has gone to work after drinking in the past and it was never a big deal. He acknowledges he may be drinking a bit more recently but states, “I am getting these pills from a friend that keep me wired for hours and sometimes days. I really don’t function well without them.”
He describes his mood as “frustrated” and reports he has been more irritated lately. He reports having a lot of energy after taking the pills. His thoughts are organized and logical. He denies any hallucinations and does not appear to be responding to internal stimuli currently. He does not verbalize anything that could be considered delusional. He denies suicidal or homicidal ideations and has not had these thoughts in the past. He reports a period of euphoria associated with “the pills” that may last up to 3 days. His attention is intact but his judgment is impaired due to showing up to work smelling of alcohol. His speech is loud at times but with normal rate and nonpressured speech. He has fair insight into his alcohol use and wants to quit but has limited insight into the substances he is taking from his friend.
The patient in this case is diagnosed with alcohol use disorder (Table 3),7 severe alcohol, withdrawal, amphetamine use, macrocytosis, and elevated liver enzymes.8 He agrees to sign a formal voluntary admission form and wants to attend a 28-day program after detoxification.
Table 3. DSM-5 Signs and Symptoms of Alcohol Use Disorder7
|In the past year, have you: |
1. Have you drunk more than intended or longer than usual?
2. Wanted to cut back more than once but could not?
3. Spent a lot of time recovering from alcohol use or drinking?
4. Craving to use and unable to think about anything else?
5. Drinking or hangover interferes with home or work?
6. Continue to drink even though it was causing relationship issues?
7. Limiting activity that was important or gave you pleasure to drink?
8. Increase in dangerous behavior?
9. Continued drinking even if made you feel anxious or depressed or added to another health problem?
10. Had to increase the amount of alcohol to get the same effect?
11. Experienced withdrawal symptoms such as nausea, increased heart rate, insomnia, or shaking?
|A patient needs to answer at least 2 symptoms for a diagnosis of alcohol use disorder. |
The severity depends on the number of symptoms:
Mild: 2 to 3 symptoms
Moderate: 4 to 5 symptoms
Severe: 6 or more symptoms
The effects of COVID-19 on mental health and substance use can be compared with the effects of a disaster (natural or environmental), war, or traumatic event.9-11 For example, following the September 11th terrorist attack, 30% of New York City residents reported increased use of alcohol, marijuana, and cigarette use.12
When experiencing psychological distress, some people may initially rely on drugs, alcohol, gambling, or overeating.13 According to Avena et al, more than 50% of adults in the United States reported that the COVID-19 pandemic negatively affected their mental health since.13 During the COVID-19 pandemic, the increase in substance use led to the highest drug overdose rates since 2019 with an increase from 31% between 2019 and 2020.14 In the period from September 2020 to September 2021, overdose deaths exceeded 100,000, representing a 50% increase over the previous 2 years.15 The increased death rate by overdose is primarily attributed to the rising rates of synthetic opioid use such as illicitly manufactured fentanyl.16 A 38.4% increase in synthetic overdose deaths was reported between June 2019 and May 2020.16 Most overdoses occur when the person is home alone,17 and only 13% of people with substance use disorder seek treatment.18
At the beginning of the COVID-19 pandemic, many clinics and community-based programs closed, which initially caused an increase in the amount of alcohol consumption and sleep aid use among people unable to obtain medical cannabis.17,19 However, a shift toward telemedicine use occurred when most insurance companies lifted telehealth restrictions on substance use and mental health visits.17 Additionally, community-based programs like Alcoholics Anonymous and Narcotics Anonymous started meeting virtually.17
Higher alcohol consumption risk levels are associated with lower socioeconomic classes in both the general population and people with a history of alcohol use disorder.11 Additionally, stress and anxiety increased alcohol consumption during the COVID-19 pandemic.10 In a systematic review, Roberts et al found mixed findings on the effects of the COVID-19 pandemic on alcohol use with some studies showing an increase in alcohol use ranging from 21.7% to 72.9% while others reported a decrease in alcohol use and some reported a variation.20 However, the overall finding among all the reviewed articles showed at least some increase in alcohol consumption during the COVID-19 pandemic.20 A survey conducted by the Research Triangle Institute in May 2020 concluded that the average monthly alcohol consumption increased from 36% to 39% and binge drinking increased from 26% to 30% during the pandemic.11
Substance use among adolescents was also affected by the COVID-19 pandemic. Temple et al examined 1188 ethnically diverse adolescents and found that if adolescents did not limit their socialization during the pandemic, they were more likely to use alcohol, marijuana, hard drugs, prescription drugs, and e-cigarettes.22 Addiction can begin as early as childhood so screening in the primary care setting is imperative.22
Treatment for Substance Use Disorders
Treatment for substance use disorders depends on the agent being used.23-27
Alcohol Use Disorder
- Monitor for intoxication and withdrawal
- Withdrawal can occur 4 to 12 hours after the last drink and resolve in 4 to 5 days
- Severe withdrawal symptoms may require intravenous fluids, thiamine, and benzodiazepines; in some cases, anticonvulsive agents, clonidine, or antipsychotics are warranted along with hospitalization
- Pharmacologic treatment
- Naltrexone or long-acting naltrexone is indicated for moderate to severe alcohol use disorder (50 mg/d or long-acting 380 mg intramuscular monthly). Naltrexone is contraindicated in patients with acute hepatitis or hepatic failure and is not recommended in individuals who also use opioids or have an anticipated need for opioids.
- Acamprosate (666 mg 3 times daily): Start after detoxification; not used if the patient has severe renal impairment
- Disulfiram (250 mg/d) for moderate to severe alcohol use in patients who want to achieve abstinence;
- Gabapentin or topiramate: indicated for patients with moderate to severe alcohol use who do not respond to naltrexone or acamprosate
- Motivational enhancement therapy (MET): A combined therapy approach of cognitive, client-centered, and social-psychological
- Cognitive-behavioral therapy (CBT): Focuses on dysfunctional thoughts and maladaptive behaviors
- Multidimensional family therapy (MFT): was developed for adolescents with abuse and addresses the function of the family
- Motivational interviewing: addresses the readiness to change behavior
- Motivational incentives: uses positive reinforcement to discourage drug use
- Alcoholics Anonymous (AA): daily meetings available; 12-step program, sponsorship, and fellowship core to its success
- Residential programs
- Long-term therapy program: 6 to 12 months
- Short-term, 28-day rehabilitation stay
- Sober living houses
Cannabis Use Disorder
- No pharmacologic management is indicated for withdrawal or dependency
- Psychosocial: motivational interventions; coping skills
Cocaine Use Disorder
- Intoxication and withdrawal: supportive care unless hypertension, tachycardia, seizures, or persecutory delusions; may require benzodiazepines
- Topiramate, disulfiram, or modafinil may be helpful
- CBT or 12-step AA or Narcotic Anonymous (NA) program
Opioid Use Disorder
- Methadone: synthetic opioid agonist
- Buprenorphine: partial opioid agonist. Available in 2 forms: alone or in combination with naloxone (opioid receptor antagonist)
- Naltrexone: opioid antagonist; patient must be fully detoxed first
- Lofexidine: the FDA recently approved this medication, a nonopioid designed to reduce opioid withdrawal symptoms
- Psychosocial and residential programs
- 12-step NA program
- No pharmacologic treatments
- Motivational interviewing
- Contingency management
The patient will follow up after he completes his 28-day residential program. At that time, the provider will evaluate his medication regimen to see if it meets his long-term goals.
During the COVID-19 pandemic, increased use of alcohol and other substances lead to an increase in overdose rates. During this time, patients with occasional drug and alcohol use may have developed substance use disorders. Substance abuse is a complex treatable disease that involves identifying the problem using assessment and screening tools. The first step of the treatment process is detoxification, which may require hospitalization. Once safely detoxed, initiating or continuing medication and ensuring referral to treatment is based on patient needs.
Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.
Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.
Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.
The next installment in the mental health series will be on nonsuicidal ideation. Previous articles include:
- Fischback FT, Fischback MA, Stout K, eds. A Manual of Laboratory and Diagnostic Tests, 11th edition. Wolters Kluwer; 2022.
- Peterson K. Biomarkers for alcohol use and abuse: a summary. Alcohol Res Health. 2004-2005;28(1):30-37.
- National Institute on Drug Abuse. Laboratory evaluation: testing for alcohol and substance use. Accessed December 2, 2022. https://nida.nih.gov/sites/default/files/LaboratryEvaluation.pdf
- Fontanarosa P, American Medical Association, Christiansen S. AMA Manual of Style : A Guide for Authors and Editors. Oxford University Press; 2007.
- Pilowsky D, Wu LT. Screening for alcohol and drug use disorders among adults in primary care: a review. Subst Abuse Rehabil. 2012;3(1):25-34. doi:10.2147/SAR.S30057
- Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007;32(2):189-198. doi:10.1016/j.jsat.2006.08.002
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR). American Psychiatric Association; 2022.
- Morgan MY, Camilo ME, Luck W, Sherlock S, Hoffbrand AV. Macrocytosis in alcohol-related liver disease: its value for screening. Clin Lab Haematol. 1981;3(1):35-44. doi:10.1111/j.1365-2257.1981.tb01307.x
- Galea S, Merchant RM, Lurie N. The Mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817-818. doi:10.1001/jamainternmed.2020.1562
- Avery AR, Tsang S, Seto EYW, Duncan GE. Stress, anxiety, and change in alcohol use during the COVID-19 pandemic: findings among adult twin pairs. Front Psychiatry. 2020;11:571084. doi:10.3389/fpsyt.2020.571084
- Barbosa C, Bray JW, Dowd WN, Barnosky A, Wittenberg E. SF‐6D utility scores for alcohol use disorder status and alcohol consumption risk levels in the US population. Addiction. 2020;116(5):1034-1042. doi:10.1111/add.15224
- Vlahov D, Galea S, Ahern J, Resnick H, Kilpatrick D. Sustained increased consumption of cigarettes, alcohol, and marijuana among Manhattan residents after September 11, 2001. Am J Public Health. 2004;94(2):253-254. doi:10.2105/ajph.94.2.253
- Avena NM, Simkus J, Lewandowski A, Gold MS, Potenza MN. Substance use disorders and behavioral addictions during the COVID-19 pandemic and COVID-19-related restrictions. Front Psychiatry. 2021;12:653674. doi:10.3389/fpsyt.2021.653674
- Centers for Disease Control and Prevention. Drug overdose deaths. Accessed July 29, 2022. https://www.cdc.gov/drugoverdose/deaths/index.html
- Volkow ND. Strengthening federal mental health and substance use disorder programs: opportunities, challenges, and emerging issues. National Institute of Drug Abuse. Accessed August 1, 2022. https://nida.nih.gov/about-nida/legislative-activities/testimony-to-congress/2022/strengthening-federal-mental-health-and-substance-use-disorder-programs-opportunities-challenges-and-emerging-issues
- Centers for Disease Control and Prevention. Increase in fatal drug overdoses across the United States driven by synthetic opioids before and during the COVID-19 pandemic. Health Alert Network (HAN). Published December 17, 2020. Accessed December 2, 2022. https://emergency.cdc.gov/han/2020/han00438.asp
- Abramson A. Substance use during the pandemic. American Psychological Association. Accessed July 30, 2022. https://www.apa.org/monitor/2021/03/substance-use-pandemic
- Volkow N. Making addiction treatment more realistic And pragmatic: the perfect should not be the enemy of the good. Health Affairs Forefront. January 3, 2022. Accessed December 2, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20211221.691862/
- Boehnke K, McAfee J, Ackerman J, Kruger D. Medication and substance use increases among people using cannabis medically during the COVID-19 pandemic. Int J Drug Policy. 2020;92:103053. doi:10.1016/j.drugpo.2020.103053
- 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(Part A):109150. doi:10.1016/j.drugalcdep.2021.109150
- Temple JR, Baumler E, Wood L, Guillot-Wright S, Torres E, Thiel M. The impact of the COVID-19 pandemic on adolescent mental health and substance use. J Adolesc Health. 2022;71(3):277-284. doi:10.1016/j.jadohealth.2022.05.025
- Matson PA, Ridenour T, Ialongo N, et al. State of the art in substance use prevention and early intervention: applications to pediatric primary care settings. Prev Sci. 2021;23(2):204-211. doi:10.1007/s11121-021-01299-4
- Reus V, Fochtmann L, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86-90. doi:10.1176/appi.ajp.2017.1750101
- National Institute for Health and Care Excellence (NICE). Alcohol-use disorders: diagnosis and management of physical complications. NICE. Updated April 12, 2017. Accessed December 5, 2022. https://www.nice.org.uk/Guidance/CG100
- National Institute on Drug Abuse. Medication to treat opioid use disorder research report. NIDA. Published December 2021. Accessed December 5, 2022. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview
- Kleber H, Weiss R, Anton R, et al. Practice guidelines for the treatment of patients with substance use disorders. 2nd ed. American Psychiatric Association; 2010. Accessed December 16, 2022. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf
- National Institute on Drug Abuse. How do medications to treat opioid use disorder work? National Institute on Drug Abuse. Published December 2021. Accessed December 13, 2022. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work