Market research regarding substance use during the COVID-19 pandemic is alarming. For instance, alcoholic beverage sales increased dramatically by about 55%in March 2020 compared to March 2019. Similarly, sales of combustible cigarettes have increased across several countries during the pandemic, with survey respondents indicating tobacco use as their primary stress reduction strategy. Similar concerns have been raised about other substances. According to the American Medical Association, by July 2020, more than 35 states reported an increase in opioid-related deaths, particularly those linked to fentanyl products. The Overdose Detection Mapping Application Program (ODMAP) indicated an increase of 42% in opioid overdoses nationally by May 2020 compared to the previous year, with a 17.6% increase in overdoses between March and May 2020. The Pennsylvania Department of Health data indicate similar increases in opioid related EMS calls with an increase of 15.3% in April, 22% in May, and a 14% in June 2020 compared to corresponding monthly rates a year earlier.
In this post, I will discuss the complex issue of substance use during the COVID-19 pandemic with a specific emphasis on the likely negative impacts on the family unit. I also offer recommendations to help support individuals and families.
Substance use increases risk for infection
Almost all substances of abuse increase pandemic related health risks. For instance, heavy drinking weakens the immune system and reduces the ability to cope with infection – raising concerns about specific pandemic related personal and societal costs associated with alcohol. This relationship is dose dependent – greater alcohol consumption increases susceptibility to viral infections. Similarly, use of combustible cigarettes increases risk for adverse outcomes related to COVID. Individuals with opioid use disorder who often experience a multitude of mental and physical health risks are more likely to experience negative COVID related outcomes and face greater barriers to health care. Moreover, parents’ substance abuse and associated risks may also weaken compliance with pandemic prevention practices, further compromising the health and adjustment of parents and their children. For instance, there is ample evidence that alcohol use is associated with different forms of risky sexual behaviors that increase risk for HIV infection and interference with prevention practices (i.e., condom use). Results indicate double the risk among binge drinkers and 87% increased risk for HIV-incident-infection if alcohol was used at the time of sex. Clearly, hazardous drinking promotes impulsive decision making and may also impact decisions to comply with pandemic safety measures. Thus, parents with substance abuse problems are at higher risk for pandemic related negative health outcomes that may have cascading effects on family processes and on the wellbeing of children.
COVID-19, Substance Abuse, and the Family
The primary non-pharmaceutical intervention to reduce transmission risk for infectious disease epidemics like COVID-19 is social distancing. However, while being critical for reducing transmission risk, social distancing also leads to greater social isolation that may be particularly debilitating during pregnancy and postpartum, when there is greater need for social support. Social isolation increases perceptions of even everyday stressors as being more intense and decreases restorative and repair physiological functioning. Pandemic stress and anxiety and the stress of social isolation undermine mental health, increase relationship conflict, and exacerbate alcohol and other substance abuse. Indeed, stress is an established risk factor for the onset and maintenance of hazardous drinking, smoking, and other substance use, and social isolation and loneliness predict increasing problematic substance use and difficulty reducing use. Those with partners may be at even greater risk – married people reported being more emotionally affected during the SARS epidemic as well as experiencing greater family stress, including fear about cross-infection and worry about family members’ well-being. Cohabitation or being married did not protect against mental health problems during the SARS quarantine. Such emotional stress may be even greater among individuals preparing to start a family.
Maternal Substance Use in Pregnancy
The prenatal period is a time of enhanced vulnerability during which a range of influences can have a long-term impact on children’s physical and mental health, and risk behaviors. Maternal substance use in pregnancy reflects a condition of high fetal stress due to lack of nutrients to the fetus. Pregnancy substance use may also lead to changes in brain and biological development, contribute to birth defects such as Fetal Alcohol Spectrum Disorder, contribute to withdrawal symptoms after delivery such as Neonatal Opioid Withdrawal Syndrome, and have other, more subtle negative effects on development. For example, use of combustible cigarettes in pregnancy increases risk for conduct disorder in children – that includes persistent behavioral and emotional problems such as such as difficulty following rules, respecting rights of others, and following societal rules of social conduct. Cocaine use in pregnancy increases risk for regulating reactivity or arousal during emotionally arousing or frustrating situations.
Many women with substance use problems are spontaneously able to reduce or quit using substances once they realize they are pregnant. Persistent substance use after pregnancy recognition is often associated with increased risk for other adversities including poverty, maternal stress, lack of family support, and maternal mental health issues. These may contribute to a cascade of developmental processes that increase risk for poor health outcomes and risk behaviors across the lifespan. There is accumulating evidence that maternal stress and comorbid risks during pregnancy also have long lasting effects on developmental outcomes. Children of substance using mothers may experience placement in out of home care and may have frequent changes in caregiving situations – a known marker for lifelong adverse outcomes.
Substance using mothers often have substance using partners, thereby increasing risk for poor outcomes in children. For instance, hazardous father drinking has significant negative implications for family functioning, including long-term costs to children. Growing up in a household with a parent who misuses alcohol is a significant risk factor for later alcohol problems. Indeed, children of fathers with alcohol problems (COAs) are four to 10 times more likely to have clinically significant levels of alcohol problems themselves, to have earlier onset of drinking, and to progress from alcohol use to abuse additional substances. Thus, COAs are a large and critical component of the underage drinking population. These results cannot be attributed to genetic link alone, as noted in studies using genetically informative designs. Results from longitudinal studies spanning infancy to adolescence indicate that fathers with alcohol problems and their partners (who were mostly light drinking/abstaining mothers) displayed lower warmth and sensitivity toward their infants during parent-infant play interactions. Parental warmth and sensitivity in infancy was a critical step in the pathway to adolescent substance use. Indeed, low parental warmth and sensitivity in infancy set the stage for a cascade of parenting and child risks, leading to underage drinking and substance use by late adolescence. COAs are also more likely to engage in behaviors that increase health risks and have poor health outcomes.
Substance Abuse and Parent Adjustment (Depression, Stress, Anxiety).
Substance abuse is linked to an inter-related complex set of problems in individual adjustment such as depression. Some substances of abuse have acute effects on increases in anger and hostility that are likely exacerbated by pandemic anxiety, stress, and social isolation. Additionally, many parents are facing disruptions in work, loss of jobs, and extreme anxiety due to uncertainties in job and living conditions. Some are essential workers and facing significant risks for infection. Others are working at home for the first time and having to handle dual responsibilities of child-care and work at the same time. Some are living in intergenerational households and having to care for their parents or elderly relatives while coping with pandemic related issues. Many have few supports and are isolated. The combination of stress and anxiety from these multiple ongoing issues and using substances as a primary coping strategy may significantly impact parenting quality and increase family conflict and aggression. These co-occurring risks may also have increase family morbidity and mortality due to COVID-19.
Family and Community Processes
During the pandemic, increase in substance use is also associated with change in the context of use – with many parents using more substances in the home context. This increase in substance use at home given the context of the pandemic is particularly troublesome because of associations with greater risk for family conflict and negative health outcomes for children (e.g., through second-hand smoke exposure or other drug exposure). For instance, there are robust associations between fathers’ heavy drinking and father to mother intimate partner conflict, and between parental engagement in illicit substance use and greater child exposure to family and community violence . Fathers’ moderate to heavy drinking was prospectively predictive of increased partner conflict among community samples. Results of meta-analyses indicate that the risk for conflict among moderate to heavy drinkers is twice that of light drinking or abstaining fathers, and even higher for binge drinking (drink more than 5 drinks on one occasion) fathers. This is likely exacerbated as a consequence of social isolation, loss of social support, and pandemic stress and anxiety, given prior literature on increased risk for aggression and conflict when couples experience low social support. Increasing rates of physical and emotional partner violence have been reported during the COVID-19 pandemic. A large body of literature and theory supports the significant predictive role of the couple conflict and relationship quality for parenting quality and major child outcomes, including behavior problems at home or at school.
Maternal substance use in pregnancy is also often a marker of larger risk for continued substance use in the postnatal period, often single parenthood, greater exposure to community violence, and instability in quality of caregiving. Children of substance using mothers may be more biologically vulnerable and need greater support and engagement with health care, that may be more difficult in the context of continued maternal substance use. Children who are placed in out of home care may be often being cared for by older adults who are more vulnerable to pandemic related health risks. Children placed in foster care often experience more than one foster care situation and in the context of the pandemic and limits on availability of substance use treatment, their parents may experience greater difficulty meeting requirements for reunification.
Online parenting classes designed to provide parenting support and treatment for parents with substance abuse problems may be well suited to addressing the complex and difficult issues surrounding parental substance abuse. For some, anxiety related to health during the pandemic may be a powerful motivator for change. Thus, providing access to treatment may be especially beneficial in the context of the pandemic for those who are motivated to change substance abuse behaviors due to health concerns. Interventions for substance using mothers and fathers during the transition to parenthood may be particular effective – providing an incentive for behavior change during a major life transition.
In conclusion, parental substance abuse is a significant risk factor for adaptive functioning for both parents and children. This may be exacerbated with the stress and anxiety associated with a pandemic – but may also provide an opportunity for change. There is an increased need for safe and accessible substance abuse treatment services during this time.
A list of resources for parents and families can be found here, including national and state food security resources; substance abuse support services for tobacco, alcohol, and other substances of abuse; mental health services for anxiety and depression; and national, state, and local domestic violence support services.