COVID-19 and Increased Alcohol Use: A Secondary Public Health Crisis?

In an open letter published last week in the Journal of General Internal Medicine, public health scientists Dawn Sugarman, PhD, and Shelly Greenfield, MD, of McLean Hospital at Harvard University warned that an increase in alcohol use in response to the stress caused by the coronavirus pandemic raises “significant public health concerns.”

The two doctors cited observed increases in alcohol consumption in the U.K. and Australia as potential indicators of similar increases here at home. They highlight the disturbing treatment gap for people with alcohol use disorder (AUD). In the U.S. only 7.9% of people diagnosed with AUD receive the specialized treatment they need to address their disordered alcohol use.

They go on to point out that increased drinking is a common response to trauma, stress, and events involving large-scale suffering, injury, or death. A study published in 2009 analyzed the use of alcohol and drugs in response to one of the most infamous mass-trauma events in U.S. history – the 911 terrorist attacks – and concluded the following:

  • 3% of a population can be expected to increase alcohol consumption in the first two years following a terrorist event
  • There is a 20% probability that 14% of a population will increase alcohol consumption following a terrorist event
  • An estimated 16.3% of a population can be expected to increase use of both prescription and narcotic drugs following a terrorist event

Evidence from the aftermath of the 911 attacks is relevant because, although the coronavirus pandemic is not a terrorist attack, it is a mass casualty scenario. At the time of writing, over 200,000 people in the U.S. have died of complications related to the SARS-COV-2 virus. Sugarman and Greenfield make another critical point: unlike the 911 attack, the coronavirus pandemic is ongoing.

Stay-at-Home Orders, Isolation, and Stress

The ongoing nature of this public trauma cannot be understated. Whereas single-incident events cause significant distress and trauma, their finite nature allows people who experience them to process the experience and move forward. That’s not to say that their trauma does not persist. Rather, it means they can contextualize and understand the traumatic event with the benefit of hindsight. This is not the case with the coronavirus pandemic. Sugarman and Greenfield identify five layers of ongoing stressors that can lead to increased alcohol consumption.

COVID-19 Stress Factors: Alcohol Risk

  1. Fear of contracting SARS-COV-2 itself. This stressor brings knock-on anxiety such as:
    1. Worry of contracting a serious case
    2. Worry of transmitting virus to family
    3. Concern over medical bills
    4. Concern of lack of contact with loved ones in extreme cases, due to the necessity of quarantine
  2. Shelter-in-place/stay-at-home orders can lead to psychological distress caused by lack of social contact, including increases in anxiety and depression
  3. Shelter-in-place/stay-at-home orders can reduce participation in social support groups such as Alcoholic Anonymous (AA)
  4. Social distancing and other measures can impact access to specialized treatment for AUD, which can increase chance of relapse.
  5. Job loss, income insecurity, and worry about finances can increase risk of excess drinking, sleep disruption, changes in eating habits, and elevated levels of depression

These five groups of potential stressors increase the risk of heavy and/or disordered drinking. This, in turn, can lead to significant physical and emotional problems. Negative physical consequences of excess drinking include liver disease, cancer, high blood pressure, stroke, impaired immunity, and fatalities from drunk driving accidents. Negative emotional and psychological consequences of excess drinking include increased risk of depression, suicide, intimate partner violence, child abuse, and child neglect.

According to Sugarman and Greenfield, this is our current situation. We’re in a minefield of stress that may lead to a nationwide alcohol consumption crisis. This alcohol crisis could turn into a secondary public health emergency, in addition to the coronavirus pandemic.

Steps to Take: Awareness, Assessment, and Treatment

In light of the heightened risk of problem drinking related to coronavirus-related stressors, Sugarman and Greenfield recommend a series of proactive steps we, as a nation, can take to “moderate and reduce alcohol consumption in the face of this pandemic.” They reiterate that the full scope of the pandemic is unknown, and remind us to look to the data provided by researchers in other countries in order to prepare for the potential collateral damage the pandemic may cause in the U.S.

Here’s what they recommend:

Step 1:

We should recognize that stress related to the coronavirus pandemic creates a population-level risk of increased alcohol consumption, and that this increase poses a general public health risk.

Step 2:

We should understand that our response to this risk needs to be nuanced, multi-faceted, and comprehensive.

Step 3:

We should embrace responsible public health messaging. This is crucial. Public media outlets should work to counter the cultural messages (present in the form of social media posts and memes) that celebrate alcohol consumption as a necessary or desired pandemic coping mechanism. Public officials should prioritize messaging efforts that promote managing anxiety and stress without alcohol and substances, encourage safe consumption, and remind the public that social distancing – which can break down in social events involving alcohol – is a key strategy for containing the spread of coronavirus.

Step 4:

We should prepare for a surge in the need for treatment across a “continuum of severity” that includes “drinking-related exacerbation of other co-occurring medical conditions.”

Step 5:

In primary care settings, we should enhance assessment efforts by adding screening for risk factors for increased drinking such as job loss, and add enhanced alcohol screening for people diagnosed with mental health conditions such as depression, anxiety, and trauma.

Step 6:

We should prioritize targeted interventions for people with AUD at risk of relapse, and expand access to telehealth, virtual therapy, and online social support communities for people in recovery. Increased access to these services and expanded insurance coverage for mental health/substance use treatment should last through the pandemic and beyond.

Integrated Effort with Full Collaboration

The open letter published by Sugarman and Greenfield – addressed to the medical community as a whole –  is an important reminder that while we strive to manage our response to the primary health crisis, the coronavirus pandemic, the secondary effects of the pandemic, such as misuse of alcohol and an increase in AUD, can create severe, chronic physical, emotional, and social consequences that may persist years after we get COVID-19 under control. The sooner we can identify at-risk individuals, offer accurate diagnoses of AUD when necessary, and provide appropriate treatment and support, the more likely those individuals are to achieve and maintain sustained, long-term sobriety. Any steps we take in this direction will help to contain the scope of harm caused by the ongoing coronavirus pandemic, and give people hope by offering a lifeline of support during this stressful time.