COVID-19: Changing the Landscape of Substance Use

Note From the Editor

It is with great pleasure that I introduce this special JAPNA issue on Substance Use Disorders. The guest editors, Laura Leahy and Susan Caverly, have worked to craft an issue that while specific to substance use, details several disorders and populations. They reflect APNA’s ongoing support of psychiatric nursing efforts to combat and treat this serious problem in today’s world.

—Geraldine S. Pearson, Editor, JAPNA

This special issue of the Journal of the American Psychiatric Nurses Association (JAPNA) was conceptualized in the midst of the worldwide opioid epidemic (History.com Editors, 2020) and the ubiquity of substance use (Whitman & Olesker, 2021). Few individuals have been immune to the direct or indirect effects of substance use (Eske & Yellayi, 2020). Like all mental health disorders, substance use is without boundaries of age, gender, sexual orientation, race, ethnicity, health status, education, or social/economic circumstance. Health care had been poised, with the support of public and private funding, to launch campaigns for community and professional education, to implement evidence-based and promising interventions with outcome evaluation, and to find ways to mitigate the impact of stigma (Desantis, 2021). It was exciting to strategize bringing this JAPNA special issue on substance use disorders to mainstream practices where the usual care models involve primary care, pediatrics, perinatal care, geriatric care, or any area of specialization.

The onset of the COVID-19 pandemic interrupted treatment as usual and forced health care to focus on the threat of widespread, serious illness; the need for access to personal protective equipment; the search for a vaccine; and the hope for a medical cure (Holmes & Goosby, 2020). For a time, the focus shifted from substance use while professionals of all disciplines responded with innovative thinking and willingness to reconsider the structure and the process of providing care during a period of upheaval, transition to telehealth, staffing shortages, building closures, and resource diversion (Beaudin-Seiler et al., 2020). The resilience and creativity of the community of nurses, other practitioners, and participants in care has been profound. Highlighting substance use in this special issue of the JAPNA represents a step toward bringing current information to nurses from every practice specialty and level of licensure.

As we have experienced multiple surges and mutations of COVID-19, health care has in some ways become more capable of responding to disease prevention and physical health care needs (Narain et al., 2020). However, the exhaustion and trauma of the past 2 years has drawn the attention not only to COVID-19-related deaths but also to the increasing death rates related to suicide and substance vis-à-vis the COVID-19 pandemic (Vestal, 2021). These deaths have highlighted the ongoing need for prevention related to these deadly disorders (Collins, 2020).

The statistics of lost and damaged lives related to substance use overdose during this pandemic have been staggering. Currently, there are more than 19 million adults diagnosed with a substance use disorder; more than 47 million suffer from mental illness, and annually almost 10 million are diagnosed with comorbid psychiatric and substance use disorders (Mental Health America, 2021). Results from more than a half million urine drug test samples in the United States during the pandemic revealed a 10% increase in cocaine use, a 13% increase in heroin use, a 20% increase in methamphetamine use, and an astounding 32% increase in the use of nonprescribed fentanyl (Millennium Health, 2020). Alcohol sales during the pandemic increased by about 25%, with sales of spirits leading the rise (National Institute on Alcohol and Alcoholism, 2020). The provisional data on drug overdose deaths in the United States from January 2020 to January 2021 showed a more than 30% increase, with more than 95,000 individuals losing their lives to this epidemic during the COVID-19 pandemic (Ahmad et al., 2021). Add to these the additional 95,000 provisional alcohol-related deaths per year (Centers for Disease Control and Prevention, 2021) and the mortality related to substance use in our country accounts for more than half the number of deaths attributed to the COVID-19 pandemic in 2020. Yet substance use deaths occur year after year after year. While we anticipate that COVID-19 deaths will diminish with the advent of vaccines and treatments and the pandemic will find its natural end, the substance use and mental health epidemic rages on.

Staffing has become an exceptional challenge for agencies. Nurses, physicians, and substance use and mental health therapists are holding the trauma of their patient experiences as well as their own personal pandemic-related stressors (Vestal, 2021). Once again, we are forced to acknowledge that we must address the health care tragedy of substance use in our society. We hope you will agree that the publication of this special substance use issue of the Journal could not be timelier.

COVID-19 has forced those who work with individuals trying to combat substance use to carefully reexamine ways in which care is delivered to this vulnerable population (Abramson, 2021). The neuroscience-based model of care, including pharmacotherapy and laboratory testing, has overtaken psychosocial interventions as the preferred treatment for many (Verdejo-Garcia et al., 2019). The pandemic necessitated social distancing and quarantine, requiring health care providers in all disciplines to find different ways to offer care. The urine drug screen, peer facilitated groups such as Alcoholics Anonymous and Narcotics Anonymous, and in-person methadone distribution required creative alternatives to care provision. Pandemic-associated emotional distress has affected even those who had attained long-standing recovery from substance use (Galea et al., 2020), making it even more important that practitioners address psychological symptoms as a means of diminishing risk of relapse (Avena et al., 2021).

While there have been few “bright spots” during the pandemic, access to care has increased for many. The suspension of barriers to practice facing advanced practice nurses (such as collaborative and supervisory agreements) and the expansion of telemedicine have positively affected our capacity to reach patients (Nelson, 2021). Virtual meetings were implemented for peer recovery groups; individuals now have options to find a group across the globe 24 hours a day (Oesterie et al., 2020). Regulatory barriers such as the requirement for in-person examination were lifted, allowing individuals to more quickly start on medications for opioid use disorder (Radfar et al., 2021). Individuals maintaining their recovery through the use of methadone found that “take-home” doses were more frequently prescribed and available. This allowed the maintenance of social distance and decreased the exposure to the COIVID-19 virus by reducing the daily in-person dosing at the clinic (Radfar et al., 2021). Similarly, options for in-home, virtual buprenorphine induction became available (Radfar et al., 2021). Concerns regarding the safety of such accommodations have not come to fruition. Finally, the relaxation of the DATA 2000 (aka: “X waiver”) waiver requirements allowed more advanced practice registered nurses, physicians, and physician assistants to more readily obtain their waiver to treat opioid use disorder with buprenorphine in an outpatient setting (Substance Abuse and Mental Health Services Administration, 2021).

Nurses are ubiquitous in all areas of health care. As the Year of the Nurse & Midwife, 2020 resulted in unprecedented visibility of nurses in the media, workplaces, and communities. Nurses from all specialties, especially those of us committed to the provision of behavioral and substance use health care, have been central in responding to the care and treatment of individuals with substance use during this public health crisis caused by the COVID-19 pandemic (Guilamo-Ramos et al., 2020). This collision of COVID-19 and substance use disorders has contributed to the rise in overdoses and deaths (Safai, 2020), and has placed nurses on the front lines of treatment and the development of guidelines, policies, and procedures to address substance use within practices (Lopez-Pelayo et al., 2020). Screening for substance use while screening for COVID-19, and vice versa, should be the standard of care in the same way that we now integrate screening for substance use and mental health symptoms. Substance use has existed for centuries in our society, but it is now more visible given the impact of the pandemic (Niles et al., 2021). While stigma continues to pervade our society as well as our profession, many individuals experience less shame when seeking treatment through telehealth as opposed to presenting for care at brick-and-mortar facilities (Dannatt et al., 2021).

Our lives have all been deeply affected by COVID-19; however, the public discourse has recognized the related exacerbation of substance-related overdose and death (Kumar et al., 2021). Exploring new and innovative treatment models for those with substance use is essential. Nurses who care for patients holistically; who ask the difficult questions; who listen with an empathetic, compassionate ear; and who practice motivational interviewing rather than directive interventions hold great potential to make a difference in the lives of patients, families, and communities. As you read this special substance use disorders issue of JAPNA, we hope you will consider ways in which you and your organization might most effectively respond to the substance use epidemic within the pandemic. The APNA Addictions Council (https://www.apna.org/about-apna/councils/join-a-council/addictions-council/) invites you to refer to our resource page or to contact us for the resources and support you may require in order to best meet challenges you may encounter in treating individuals with substance use disorders.