Damian Sendler: Some studies show an increase in adolescent substance use during the COVID-19 pandemic; others show a decrease in binge drinking and vaping; and still other studies show no change. Only 8.3 percent of the 1.1 million adolescents with a substance use disorder sought outpatient treatment in 2019. As of this writing, 2020 treatment rates have not been released. Many outpatient substance abuse clinics were forced to close in March 2020 due to stay-at-home orders and social distancing guidelines. Considerations for working with adolescents during stay-at-home orders are discussed in light of this treatment suspension.
Damian Jacob Sendler: When it comes to social and emotional maturation, the adolescent years are critical. At this stage, it is crucial for children to establish their social identities, gain emotional and personal independence from parents and other caregivers, and begin the process of becoming self-sufficient. 1 As a result of the COVID-19 (coronavirus disease of 2019) pandemic, this process has been completely upended and thrown off balance. For the past three months, most teenagers have been unable to attend school, interact with their peers, or participate in sports and other extracurricular activities in person. Prom, graduation, and heading off to college have all been omitted as traditional life milestones. When their parents were at work, many teenagers were forced to take on the responsibility of caring for their younger siblings. Since students must spend so much time in front of screens, it can be difficult to stay motivated and interested during their time in distance learning. Teens are used to spending most of their time with friends, teachers, and coaches. Sheltering in place is a huge change for them. Adolescence’s crucial individuation process may be slowed by the lack of routine and few opportunities to take healthy risks or express developmentally appropriate independence. 2 Because of the pandemic’s effect on isolation, uncertainty, and fear and the heightened risk of substance use disorders among a new generation of adolescents, it is not surprising that depression, anxiety, stress, and boredom have increased.
Dr. Sendler: The use of alcohol, LSD, over-the-counter cold and cough medications, and heroin increased slightly from 2019 to 2020. Annual surveys on substance use have also been affected by the pandemic, so it’s unclear if these changes are connected to the COVID-19 pandemic. The MTF, for example, is typically administered between February and May, with results made public later in the year after administration. Only one-quarter of the usual sample had completed the survey in mid-March 2020 because of the pandemic. 8 There has been a decrease in the number of people using e-cigarettes to smoke nicotine and marijuana, according to data from 2020, which is considered nationally representative. Cocaine, MDMA, and heroin use among twelfth graders remained at a low level. Until the results of this year’s MTF survey are made public at the end of 2021, it will be impossible to predict whether these patterns will persist throughout the pandemic.
Alcohol, tobacco, and illicit drug use are all well-documented in the National Survey on Drug Use and Health (NSDUH). 13.2 percent of 12–17-year-olds reported using cannabis in the past year, and 9.4 percent reported using alcohol in the past year, according to the 2019 survey results. 9 In 2019, 1.4 million teenagers began using cannabis for the first time, which works out to 3700 new users every day. NSDUH and MTF surveys have different methodologies and different age groups, which results in different overall use rates (ie, the NSDUH groups 12- to 17-year-olds together and puts 18-year-olds, who generally have high rates of use, in an 18- to 25-year-old group, whereas the MTF groups by grade level). An additional disadvantage of interviewing teens in their homes is a potential underreporting of drug use. 10 It won’t be until fall of 2021 that the NSDUH 2020 results are published.
Despite the lack of data, it appears that the stress and isolation caused by months of lockdown and social distancing has led to an increase in adult substance use.
8 The Centers for Disease Control and Prevention found that 10% of 18-24-year-olds in their sample of 5412 online survey respondents increased their substance use in the past month (the survey was completed in June 2020), with the greatest increases observed at the younger ages of the cohort. 11 However, teens under the age of 18 were not included in this study. Only a few studies have examined the impact of the pandemic on young people’s substance use, including an online survey in Canada and an online survey on vaping from Stanford University. The aforementioned 12 to 14 These studies show that the pandemic’s effect on adolescent substance abuse is not yet clear.
1054 Canadian teenagers (aged 14–18) were surveyed online about their alcohol, cannabis, and e-cigarette use in the three weeks leading up to and the three weeks following the start of the COVID-19 stay-at-home orders. Overall, fewer teens reported binge drinking, vaping, or using cannabis after COVID compared to prior to COVID, and alcohol use remained stable. ‘ In contrast, among those teens who did use substances, the mean number of days they drank alcohol (0.76–0.96 days) and smoked marijuana (0.94–1.1 days) increased significantly after COVID.12
Intriguingly, usage patterns shifted following the introduction of COVID. Solitary drug use was the most common mode of consumption for these respondents (49 percent), followed by social media (42 percent), and face-to-face interactions (32 percent) (24 percent ). This finding is surprising given the prevalence of adolescent substance use as a highly social behavior. Increased anxiety about COVID-19 and depressive symptoms were both linked to solitary use. Adolescents may use substances as a means of coping with pandemic-related stress and isolation, according to researchers. 12 Teens are more likely to use drugs to cope with stress and more likely to use them alone than previously thought. (15) and (16) In light of the link between teen substance use and poor mental health, these new use patterns are particularly concerning. 17
Also distressing is the fact that 26% of the teens who reported drinking with their parents reported binge drinking, which is a significant number. As a known risk factor for risky substance use,18 parents who engage in this behavior are also likely providing their teens with alcohol. When drinking with their parents, teens are more likely to use alcohol in moderation. However, when drinking alone, they are more likely to use alcohol in high-risk ways. 19 and 20
As a result of this social distancing, it is not surprising that teens would engage in substance use with their peers via video chat or post photos of themselves engaging in substance use on social media. Finally, 24% of teens reported using substances in front of their peers, despite emergency stay-at-home orders, which is alarming. The study does not indicate if parents were aware of or allowed their children to engage in social interactions with their peers. As a result, it is possible that adolescents were more willing to put their health at risk because of their lack of knowledge about the dangers of severe coronavirus symptoms. These preliminary findings on COVID-19-related substance use trends may not be conclusive because the study was conducted so early in the pandemic that usage patterns may not have yet been established.
The pandemic has been linked to a decrease in substance abuse in other studies. Vaping rates may have fallen because of fewer commercially available and easily accessible vape products, according to some research. 20 In May 2020, two months after the stay-at-home orders were issued, a survey on self-reported vaping habits was conducted. Nearly three-quarters of the 1442 participants ages 13 to 24 who used e-cigarettes reported reducing or quitting their habit in the two months since the pandemic began. Concerns about lung function, the inability to purchase products, and anxiety over parents finding out were cited as some of the reasons for this shift. Because most teens get their e-cigarettes from friends or brick-and-mortar retail stores rather than the internet, stay-at-home orders that shut down vape shops and reduced social contact prevented many teens from getting their e-cigarettes from stores or friends, resulting in lower rates of vaping. 21
In the first two weeks following the closure of non-essential services in Canada, an online survey of 622 youth and young adults in established clinical and community settings found that social distancing may have contributed to a decrease in substance use.
13 A lack of data on the types of substances used, the frequency and quantity of use, and the findings were not reported by age groups was a major drawback.
For now, even in these extraordinary circumstances, we can use well-known risk and protective factors for substance use to anticipate and plan for future needs for treatment even if the effects of the pandemic are not yet fully understood. These include factors such as drug availability, a lack of parental supervision, boredom, and the ability to deal with negative emotions, among others, which have been shown to increase a person’s likelihood of using drugs. Protective factors include parental monitoring, lack of negative peer influence, academic success, and strong family and community ties.. In spite of the pandemic’s potential to increase substance use among adolescents, it is possible that pandemic-related restrictions will reduce known risk factors and reduce substance use. , 22, 2
The COVID-19 pandemic has undoubtedly disrupted daily life and raised stress and anxiety levels in adults and adolescents alike. Due to an increase in adult drinking during the pandemic, teens may be more exposed to their parents’ alcohol use, which could lead to easier access to alcohol and other drugs in the home. 23 Teenagers who have a wide variety of substances available to them at home may be more likely to engage in substance abuse. In the United States, 87% of reports to poison control centers in 2019 involved exposures in the home among individuals aged 13 to 19. A wide range of prescription and over-the-counter medications, as well as illicit substances like cocaine and methamphetamine were found to be the most common substances these adolescents were exposed to. Nearly two-thirds of those who were exposed did so knowingly. 24 Stress-relieving substances are more likely to be used by teenagers if they see their parents using them to cope with stress, manage negative emotions, and cope with social isolation. Furthermore, older siblings in the home may also facilitate younger siblings’ use by co-using or giving their younger siblings access. 22 Other possible causes for the post-COVID rise in alcohol and cannabis use among adolescents include an increase in unstructured time due to asynchronous remote learning and a lack of extracurricular and other leisure activities, and also social isolation, boredom, and life stress. Four and twenty-five
The pandemic, on the other hand, appears to have a lower risk of substance abuse because of a variety of factors.
2 The more time parents spend with their children at home, the lower their risk of injury or death is likely to be. Parents and caregivers are likely to be more aware of their children’s activities, which may reduce the likelihood of them engaging in unhealthy behaviors like substance abuse. It is possible that having parents and caregivers at home most of the time could reduce binge drinking and the use of vaping products and other substances by teenagers, as well as curtail activities that encourage binge drinking, such as parties. 26 It’s also important that teens who have been placed on home-detention have fewer opportunities to hang out with their peers who are engaging in risky behaviors like drug use, as socializing with other drug users is a major risk factor. 27
Remote or hybrid learning is less stressful for teenagers who have experienced academic or social pressure at school. Teens who take drugs to cope with stress and negative affect may have used less as a result of the lessened stress. Furthermore, because remote learning does not necessitate early morning starts, sleep deprivation, a risk factor for substance abuse, is minimized. 2
Teens who have not yet started using drugs or alcohol may be delayed in their use due to fewer opportunities to engage in risky behavior or restricted access to alcohol and drugs because parents are at home and social distancing. Given the effects of drugs on the developing adolescent brain, prevention strategies focus on delaying the onset of substance use. 28 Adults who begin using drugs or alcohol at a young age are more likely to develop an addiction later in life. 29 To put it another way, social isolation may be reducing the likelihood of future substance abuse.
COVID-19 seems to affect young people less frequently than it does the elderly, but it is unclear whether substance abuse or a substance use disorder increases a person’s susceptibility to coronavirus transmission or the likelihood of a severe infection being contracted.
30 Immune, pulmonary, and respiratory function can be compromised as a result of alcohol and other drug use, making it more difficult to fight off infection. It’s either 31, or 32. The immune system can be affected by alcohol consumption, which can lead to chronic weakening of the lungs, increasing the risk of pneumonia. 33 Drugs that cause vasoconstriction, such as cocaine and methamphetamine, are dangerous because they can harm the lungs and cardiovascular system. Opioids can slow breathing and cause hypoxia at high doses, putting the user at risk of an overdose and death. Even adolescents may be at risk of severe illness from COVID-19 if they smoke or inhale drugs such as nicotine or cannabis, which can worsen respiratory conditions such as asthma. Smoking and vaping, according to new research, can irritate, inflame, and damage the lungs, raising the possibility of contracting a virus. In order, 34, 35 and 36. Young people who smoke or use e-cigarettes are at greater risk of developing coronavirus-related illnesses, such as pneumonia or acute respiratory distress syndrome (ARDS). Viral transmission can be exacerbated by the habits associated with smoking or vaping. Vaping, for example, can cause a person to exhale quickly and loudly, making it impossible for them to wear a face mask while doing so. Aside from sharing blunts, joints, and vaporizers, smoking and vaping habits often include the sharing of these items, which increases exposure. 37
Using a population-based, cross-sectional online survey, Gaiha and colleagues14 investigated associations between COVID-19 and e-cigarette use. It was found that youth who used e-cigarettes were 5 times more likely than nonusers to contract COVID-19 illness, and youth who used e-cigarettes and tobacco cigarettes together were 7 times more likely to contract the illness. The survey included 4351 adolescents and young adults (aged 13–24). 14 Smoking and vaping have been linked to an increased risk of COVID-19 illness, which makes it imperative that health care providers screen all young people, including those with COVID-19 infection, for cigarette and e-cigarette use.
Damian Sendler
Adolescents in the United States had a significant increase in the number of those who met diagnostic criteria for a substance use disorder in 2019, according to the most recent NSDUH data.
38 There has been no significant increase in the number of adolescents seeking treatment for a substance use disorder despite the fact that more of them are abusing substances. This survey found that only 8.3 percent of these adolescents had received treatment for substance abuse in the preceding year. 38 98.5 percent of those who didn’t receive any treatment said they didn’t need it, even though they met the criteria for a substance use disorder diagnosis (Substance Abuse and Mental Health Services Administration, 2020). 38 As a result, when selecting an intervention for a particular adolescent with a substance use disorder, clinicians must take their needs and motivation into account. Adolescents with varying levels of need and readiness for treatment can benefit from the following research-based treatment approaches for substance use disorders.
All of these approaches to treating substance abuse have been found to have strong research support by Division 12 of the American Psychological Association, including cognitive behavioral therapy, motivational interviewing, contingency management, and motivational enhancement therapy. Both the adolescent community reinforcement approach (A-CRA), as well as 12-step facilitation therapy, have been approved by the National Institute on Drug Abuse (NIDA). 39
Damian Jacob Markiewicz Sendler: Adolescents who are struggling with substance abuse can benefit greatly from cognitive behavioral therapy (CBT). By using cognitive behavioral therapy, therapists hope to help young people anticipate and prepare for situations where they may be at risk of substance abuse. 39 As part of MI, the therapist acts as an intermediary between the patient and themselves, facilitating the patient’s desire for and commitment to change. Adolescents who are on the fence about abusing drugs or alcohol may benefit the most from this approach. 40 Based on MI principles, motivational enhancement therapy incorporates feedback from an individual’s assessment of their progress. This therapy is designed to help adolescent drug addicts develop a motivation and desire to participate in treatment. Motivational Enhancement Therapy (MI) and Motivational Enhancement Therapy (MET) are typically used in conjunction with Cognitive Behavioral Therapy (CBT). 39 and 40, respectively
In order to reduce substance abuse, CM employs the principles of reinforcement. In the majority of cases, CM for substance abuse involves monitoring drug use behaviors and rewarding desired behaviors (such as treatment participation, meeting specified goals, not using drugs, etc.) with tangible rewards. Psychosocial treatments like CBT and EMDR are often combined with CM to achieve the best results. 39 and 40, respectively
It is a treatment that aims to replace the positive reinforcements for substance use in the patient’s life with more effective social, educational or vocational reinforcements. Another goal of 12-step facilitation therapy is to increase the likelihood that adolescent substance abusers will join a 12-step program like Narcotics Anonymous.
Adolescents’ families are a part of their substance abuse treatment in family-based therapeutic interventions. Adolescent substance abuse, family conflict, co-occurring disorders, and academic difficulties are all addressed in these methods. Adolescents may benefit from interventions that involve their families because they are likely to live with at least one parent or guardian. 39
Family-based interventions have been shown to be effective in the treatment of adolescents’ substance abuse.. Problem behaviors are seen as the result of dysfunctional family interactions, and the goal of brief strategic family therapy is to change those patterns of interaction. Family behavior therapy combines the principles of CM and behavioral contracting to reduce problem behaviors, such as substance abuse, in the family unit. Problem behaviors are seen as responses to unhealthy family functioning, and behavioral techniques are used to enhance family communication and problem solving. CM principles are also incorporated into functional family therapy. 39
Adolescents with substance abuse issues can benefit from multidimensional family therapy, which integrates family and community resources. Adolescents and their families can work together more effectively in school and the justice system when they have access to multidimensional family therapy. ‘Multidimensional family therapy’ is frequently used to aid in the reintegration of juvenile offenders back into society. Furthermore, multisystemic therapy incorporates family and community-based interventions into its practice. The adolescent’s substance use is not only viewed from the perspective of the adolescent and their family, but also from the perspective of peers, school, and neighborhood characteristics.
Outpatient treatment was preferred by the vast majority of adolescents receiving treatment for a substance use disorder in 2019; only 9.1 percent received nonhospital inpatient care, and 1.3 percent received inpatient care at a hospital setting.
38 These percentages are consistent with data from reports dating back to 2009 and continuing through 2017. Adolescents who are receiving treatment for a substance use disorder in outpatient facilities are expected to remain the most common mode of care in 2020.
Many outpatient substance abuse clinics experienced partial closures and were forced to suspend certain types of treatment following the March 2020 stay-at-home orders and social distancing guidelines. As a result of social distancing, group therapy may have been halted or moved to online formats such as video conferencing. Adult patients with substance use disorders may benefit from telehealth interventions, according to new research. Telehealth services for substance use disorders are now available through the Houston Emergency Opioid Engagement System (HEROES). Initial studies show that this system has maintained patient engagement and even seen an increase in attendance at some virtual recovery group meetings with this system in place. 41
Damien Sendler: Some other researchers have been working on developing various digital platforms to help those with substance use disorders, such as RAE. (Realize, Analyze, Engage). RAE is a wearable device that measures biomarkers of stress and craving as part of a digital treatment for substance use disorder. Dialectical behavior therapy interventions are also included in the platform, as is a connection to a clinician when assistance is needed, as well as a clinician-facing portal for transferring client data to a treatment team. Throughout 2021, clinical trials will be conducted to better understand the platform’s efficacy. 42
It’s important to keep in mind that only adults were used in these studies. Telehealth services for adolescents with a substance use disorder may have unique considerations. Adolescents, unlike adults, typically live with a parent or guardian and other members of their family, which can limit their privacy. Adolescents may be reluctant to open up to health care workers if they fear that their conversations will be overheard by family members. According to the National Survey on Drug Use and Health, one in eight children in the United States lives with a parent or caregiver who has a substance use disorder. 4 and 43 In the case of a parent with a current substance use disorder, a child may feel particularly uneasy about receiving treatment in their own home because of their parent’s history of substance abuse. When working with a young person experiencing homelessness, the lack of access to face-to-face outpatient services can make it difficult for service providers to connect them with the community resources they need. Instead, adolescents may be reluctant to seek treatment in person because they fear exposure to COVID-19.
Damian Jacob Sendler
In the event of a COVID-19 pandemic, adolescents who belong to high-risk groups may face additional difficulties in receiving treatment. The pandemic appears to have worsened the lives of impoverished and homeless youth, for example. Many of these adolescents may not be able to access telehealth services because they lack internet, phone, or computer access. Mental health and substance abuse treatment may be harder to access if in-person services are discontinued and fewer people are admitted to community service providers and shelters. Homelessness/poverty and substance abuse disorder both put these adolescents at increased risk for COVID-19 infection, but the lack of treatment may lead to an increase in risky behaviors to obtain substances. 44
As a result of the pandemic of COVID-19, LGBT youth may be at a higher risk of contracting the disease. LGBTQ adolescents are more likely to be physically and sexually abused, and stay-at-home orders may inadvertently increase contact with abusers in the home. Having an abuser in the home is likely to decrease telehealth treatment involvement for those adolescents. This risk, coupled with the possibility of increased victimization, may lead to an increase in the number of LGBTQ adolescents abusing drugs and alcohol,44
Finally, the opioid crisis has not spared our young people. Prescription opioids, heroin, and fentanyl overdose deaths among under-20-year-olds increased by 95 percent, 405 percent, and 2925 percent, respectively, between 1999 and 2016. 45 During the COVID-19 pandemic46, an increase in opioid overdoses has been observed among Black Americans, according to recent findings. 47 Nonfatal opioid overdoses have also increased dramatically since the pandemic was discovered in March 2020, according to data collected by the Centers for Disease Control and Prevention48 from more than 42 states. Since their peak in May of this year, heroin overdose rates have been steadily declining, though in September of this year (the most recent month for which data is available), they were still higher than they were for almost the entire year of 2019. Pre-pandemic 2020 and any month of 2019 saw a slight decrease of nonfatal opioid overdoses in July and August, respectively, but September saw a higher rate than any other month in 2019. 48 Adult and adolescent opioid overdose rates increased significantly in the pre-pandemic years, despite the fact that these COVID-19–related findings did not separate the two groups. According to the data from COVID-19, fatal and nonfatal opioid-related overdoses among adolescents have increased significantly. Some of the reasons for the rise in opioid overdoses include treatment interruptions, an increase in mental health stressors, and a rise in the prevalence of lone substance use, which reduces access to help.
Treatment providers may benefit from preparing for an increase in the number of adolescents who need treatment for a substance use disorder as services begin to return to in person following the pandemic of COVID-19. Pregnant women, children, and adolescents should be screened for substance abuse during routine checkups by their pediatricians and primary care providers. 4 Even adolescents who do not meet the criteria for a substance use disorder may benefit from some substance-related treatment, so clinicians providing general psychological services to adolescents should consider including some type of substance-related programming. 39 Due to barriers to telehealth treatment, treatment providers who serve impoverished, homeless, or LGBTQ adolescents may see an increase in demand for in-person services.
In the meantime, families and clinicians can help adolescents with substance use disorders. For parents and caregivers, a stay-at-home order offers a unique opportunity to establish and maintain order in the household. For example, they can implement a morning routine, encourage family bonding activities, and promote open, nonjudgmental communication within the home to assist adolescents in their recovery efforts. Adolescents should also be monitored by parents and caregivers for signs of substance abuse or withdrawal. According to J. Wolfe, parents and caregivers should report any signs of substance abuse to health care professionals. Adolescents who are socially isolated may have difficulty controlling their emotions or experience extreme mood swings as a result of both withdrawal and continued substance use. Adolescents who attempt to isolate themselves at home may be trying to conceal their drug-seeking or drug-using behaviors. A person may isolate themselves by sleeping all day, locking themselves in their room, or simply avoiding contact with family members. The adolescent’s repeated arguments about leaving the house to be with friends or sneaking out behavior may also indicate that the teen is attempting to obtain or use substances. It’s also possible that an adolescent or their room smells strangely, which could be an indication of ongoing substance abuse. Skunk-like aromas can be found in the smoke of marijuana, for example. The use of a vape or the consumption of sweet drinks mixed with alcohol can result in a sweet aroma. The use of air fresheners, perfume or cologne to mask the odor of substances may also be used as a cover-up tactic. You may want to talk to your pediatrician about possible treatment options if you’re concerned about your teen’s substance use.
Adolescents with a substance use disorder can benefit from remote treatment if the provider makes an effort to check in with them about their safety and any difficulties they are having at home. Health care workers should also encourage adolescents to seek out a private location from which to conduct remote treatment if possible. While following social distancing guidelines, treatment providers should consider resuming in-treatment services if adolescents cannot openly discuss problems they are experiencing because of lack of privacy or fear of safety (ie, staying 6 feet apart, wearing masks, and washing hands and surfaces).
Tobacco cessation, including smoking and e-cigarette use, may also be a focus for health care workers during this time. Due to stay-at-home orders, adolescents may have more difficulty obtaining various substances, such as cigarettes and vapes. So treatment providers can use this time to increase motivation for quitting and doctors or other health care providers may prescribe nicotine replacement treatments for adolescents who are experiencing cravings or withdrawal symptoms. 50 More and more AA and NA meetings are being held online, as well as other 12-step support groups like Alcoholics Anonymous and Narcotics Anonymous. In addition to providing information on how to find and join a virtual meeting, their respective websites now feature entire pages dedicated to virtual meetings. It may be beneficial for adolescents who have experienced a break in their in-person treatment to receive this kind of support.
We can gain insight into how the COVID-19 pandemic affects adolescent substance use by examining its various effects on adolescent use of substances. Social isolation and boredom appear to increase the risk of substance abuse in pandemic-related life changes. Other changes, such as increased family time, parental monitoring, and reduced access to substances, appear to reduce the risk.
As the pandemic spreads, longitudinal studies are needed to track changes in teen substance use patterns over time, as well as mental health outcomes associated with those patterns. The long-term effects of school closures, remote and hybrid learning, social distancing, and quarantining should be examined, given the important role that peer pressure and social group dynamics play in determining teen drug use and experimentation. Research is also needed to determine whether or not the pandemic has resulted in an increase or decrease in the use of drugs by teens and members of their families.
A study by Sumas and colleagues in the early weeks of the pandemic should also look at parental permissiveness, which allowed parent-teen drinking and binge drinking behavior.
Parents may have relaxed some rules during the shutdown, perhaps deeming it safer for their teens to drink with their parents than to go out and drink with friends, but this co-use drinking behavior may have long-term consequences because parental permissiveness has been linked to higher rates of substance use.