Falling through the cracks in quarantine

The coronavirus quarantine means different things to different people: A necessary inconvenience. A fusion of work and home life. A leap into social media, or virtual meetings once held face-to-face. For some, it’s possible to see a silver lining: more time with one’s family, and a change to the regular routine. But for people who suffer from substance use disorder, gambling addiction, or problematic video gaming—otherwise known as internet gaming disorder—the quarantine is fraught with danger.

“People will likely be practicing social distancing per the government’s recommendation,” said Marc Potenza, PhD ’93, MD ’94, HS ’98, professor of psychiatry, who directs Yale’s Center of Excellence in Gambling Research, the Women and Addictive Disorders Core at Women’s Health Research at Yale, and the Yale Research Program on Impulsivity. “Oftentimes stress is linked to addictive behaviors, and there can be little question that the social distancing around coronavirus or COVID-19 has been a stressful interruption of routine for many.”

For people in treatment for substance use disorder, COVID-19 could lead to the type of stress and isolation most likely to result in risky behavior.

“Everyone is trying to protect the vulnerable from COVID-19, and the only way to make that happen is social distancing,” said Ellen Edens, MD, MPH, associate professor of psychiatry. “But social distancing can also be especially harmful for people with mental conditions or substance use disorder.”

According to Edens, there is a related concern: those who depend on medications to treat a substance use disorder may fall through the cracks. Like those with an opioid use disorder who take methadone or buprenorphine, both of which block cravings, treat opioid withdrawal and prevent opioid overdose; or those with a prescription for disulfiram, a medication that causes people to become sick if they drink alcohol and is most effective when taken under direct observation. Disulfiram is unavailable nationwide, according to Edens, though the intensively monitored in-person treatment often required for best outcomes, particularly early in treatment, is also unlikely in the current context.

Edens also notes that the most vulnerable moment for someone with substance use disorder is at the beginning of treatment, when they are deliberately and intensely plugged into group therapies and peer support groups like those popularized by Alcoholics Anonymous or AA. “With social distancing, one of the key components of addiction treatment—the reforging of family, social, or professional connections that may have been severed, exemplified by ‘network therapy’ or a ‘community reinforcement approach’—is lost,” she said. “The psychiatric community is doing what it can to make up for the sudden disruption of tested and effective in-person programs with things like old fashioned telephone calls. But between the technology gap with older patients and specific challenges faced by patients for whom disconnection is essentially the greatest danger, it’s difficult. Many AA groups that have closed their doors to comply with the injunction against gatherings of numerous people, and while it’s certainly prudent, it also leaves many attendees adrift.”

Another possible fallout from COVID-19 stems from the shutdown of casinos across the United States, coupled with the postponement or cancellation of professional sporting events including the NBA, NHL, MLS, and MLB (suspended), the Masters (postponed), the Boston Marathon (postponed), and the NCAA men’s and women’s basketball tournaments (cancelled). Although gambling and sports gambling have been online and lightly regulated for years, there has never been an absolute vacuum of physical gambling locations. It’s likely that in the absence of a physical space in which to gamble, and without many of the typical outlets for gambling in place, some people with gambling addiction will make their way to the internet.

The rise of e-sports is one possible place where online gambling and problematic video gaming could converge. A growing field with audiences for a single event in the millions, and over $1 billion in revenue as of 2019, e-sports, in which people play video games online competitively, requires no crowds, and can be accessed by anyone with a smartphone or laptop.

“A quarantine, particularly at home, may lead to bingeing on video games, alcohol, or drugs given the significant change to routine life. It could also lead to a relapse for those who had been doing well previously. Second, those who may have been considering coming to treatment now may suddenly be hesitant given possible exposure to the virus in a hospital or treatment setting and have decided to delay getting help,” said Brian Fuehrlein, MD, PhD, FW ’13, associate professor of psychiatry and director, Psychiatric Emergency Room, VA Connecticut Health Care System. Fuehrlein was careful to echo his colleagues in underlining the necessity of home quarantine and the importance of following it, and was unequivocal about the dangers posed to vulnerable populations like those who will be significantly economically impacted by social distancing.

There has already been an observable change in normal behavior at the VA, according to Fuehrlein—and the opposite of what one might expect, which is more cases. Fewer patients have been coming in for any reason, which does not bode well for long-term mental wellness. “Currently, we are seeing an uptick in those who were considering treatment for substance use disorder but have now decided to stay home instead (and thus are likely continuing to drink or use). Our census in the psych ER has actually been running lower than average,” said Fuehrlein.

In the long run, this will almost certainly turn into a large problem, or even a secondary epidemic for people already suffering from the various diseases of addiction. “I think in the long run we will see a sharp increase in depression, anxiety, and addictions of all types as a direct consequence of the current pandemic,” said Fuehrlein. “This may be due to the death of a loved one, a financial crisis, the loss of a job or housing, or some related tragedy. At the moment those consequences have yet to play out.”

Potenza echoes Fuehrlein and Edens’ concerns for people suffering from substance use or gambling problems at home, away from the usual forms of treatment. He brought up another population that will be at risk—in addition to the tens of millions of American workers (over 18% of the work force, according to an article published March 17, 2020 in the Los Angeles Times), millions of school children who have been cut loose with weeks of unstructured time. Without supervision, these groups will be especially vulnerable to what the DSM-5 defines as internet gaming disorder, on top of the better-known associated substance use disorder.

Said Potenza, “Oftentimes, it appears that people who are experiencing negative mood states or life stressors may turn to gambling, gaming, or use various substances including alcohol and drugs. COVID-19 is almost certainly creating more stress, and while health professionals and the government are mobilizing to address the threats posed by the virus, some of the recommended actions like social distancing and staying at home seem likely to lead to more gambling, more gaming, and more substance use.”

Almost 20 million American adults suffered from substance use disorder in 2017, while nearly 10 million American adults struggled with a gambling problem as of 2016. Both groups, in which there is almost certainly some overlap, rely on a therapeutic model that relies on person-to-person meetings. Potenza, Edens, and Fuehrlein all agreed that patients suffering from mental illness and substance use disorder could receive effective treatment via phone or computer, and that technology was racing to keep up with the changing demands of quarantine and the patient population. Any mechanism by which a connection could be forged, according to them, was preferable to isolation during the search for an effective vaccine and perhaps a cure.

“Ultimately,” said Potenza, “we don’t know what will happen. And that’s a source of stress for most if not all of us.”