COVID-19 Webinar 20: Substance use
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health organises a series of regular webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Shekhar Saxena, Professor of Global Mental Health, Harvard University
Speakers:
Alexander Baldacchino - Professor of Medicine, Psychiatry and Addictions, St Andrews University Medical School, President-Elect of International Society of Addiction Medicine
Vladimir Poznyak - Unit Head (Alcohol, Drugs and Addictive Behaviours), Department of MH and Substance Use, WHO
Olga Belyaeva - Program Coordinator of the Eurasian Network of People who Use Drugs
Nirvana Morgan - President, Network of Early Career Professionals working in the area of Addiction Medicine
Key points made:
Olga Belyaeva - medical experts give support to our friendly doctors in Eastern Europe and Central Asian countries - we need help and support from other countries to explain how to organise programmes in a professional approach with a compassionate approach.
Nirvana Morgan - the time for judgemental attitudes towards people with addictions is over. Addiction is a serious mental health condition that should be treated as such.
Alexander Baldacchino - if we truly have a patient centred service then we need to support patients accordingly not homogenise them [but address their various co-morbidities and social needs].
Vladimir Poznyak - It is impossible to speak about mental health without speaking about substance use and we need to achieve a situation where drug and alcohol issues are treated as a public health issue and addressed in parity within mental health.
Shekhar Saxena
Opened the meeting and introduced the panel and then the topic.
Substance use means alcohol, drugs including prescribed drugs. People take them to alter their mental state; and if they take them at high levels for a long period of time then this becomes a mental health disorder. There are a lot of co-morbidities; people with mental health disorders tend to use substances more often and vice versa. The same professionals that treat substance use disorders tend to also treat other mental health disorders. COVID-19 is affecting substance use just as it is other mental health issues.
What are the interactions that we observe clinically in populations experiencing mental health and substance misuse related problems. What has been the impact of COVID19 on these populations?
Alexander Baldacchino
Conditions tend to be concurrent or one after the other. COVID-19 has accentuated the disparity and inequalities experienced by very vulnerable populations. Key factors include: a reduction or no signposting of where to find help; physical obstacles to attend usual services e.g. crisis centres; reduction in contingency plans; and increases in stigma. This has resulted in an increase in psychological conditions and in physical health conditions such as heart diseases. There has also been an increase in overdoses and suicides in this population.
Shekhar Saxena
It is understandable people are experiencing a lot of challenges but these have been neglected. What are the key messages WHO has passed on to governments and populations?
Vladimir Poznyak
The WHO website has guidance on prevention and management of COVID-19. Messages for the general public, those with key health conditions and mental health providers. For the general public, the key message is that neither alcohol or drug use will help address COVID-19 but instead may negatively impact COVID-19 prevention and treatment. Avoid using substances during xOVID-19 and lockdowns. Be aware of potential increases in advertising/marketing of alcohol, online gambling etc. People are encouraged to continue with their therapy, support groups and prescribed medicines. Governments are encouraged to continue with prevention and management of drug overdose and substance induced health conditions. For service providers, WHO has recommended upholding policy regulations and continued access for critical interventions for people who use drugs etc. It also recommends adjusting existing policies where needed e.g. on take home medicines, and the availability of medicines in different clinical settings.
Shekhar Saxena
Do you have feedback on whether people are taking note and following this advice?
Vladimir Poznyak
We have lots of channels for communications including the Inter-Agency Standing Committee - including through our partners and social media.
Shekhar Saxena
I know over 555 people registered for this webinar and nearly 200 are online watching right now - that shows it is a successful way to engage people.
Olga, from the perspective of people who use drugs and related services, what are the main challenges with regard to their health and well-being?
Olga Belyaeva
Over the past few years there has been a replacement of natural drugs with synthetic drugs. And there have been problems with access to treatments. During COVID-19 there is a high level of stress that means people use more drugs. Access to methadone is limited and there are doctors who say things like, “get on your knees and apologise and then you can get methadone.” Doctors usually have goals of numbers treated but users have a goal of getting high without drugs. 70 people died in Dnepropetrovsk in Ukraine during the 1 month of quarantine. Most of the people had high levels of stress due to social and medical problems with no connection to mental health services.
Shekhar Saxena
Thank you Olga, particularly for highlighting the importance of respectful and supportive provision of services which is something I hope all those listening who provide services will take note of. This is as recommended by WHO.
Nirvana, what are the challenges with treating substance use disorders in daily medical practice, especially in lower resourced settings?
Nirvana Morgan
I did a PhD study of 300 heroin users in an in-patient facility in South Africa at 0, 3 and 9 months. At 3 months only 2 had seen a psychiatrist and only 3 were on psychotropic drugs, almost none had HIV/AIDS or Hepatitis tests and almost none had been enrolled in out-patient support. This occurred because services were so fragmented not because the users didn’t need the services. It is difficult to provide a continuity of care without a holistic approach. Challenges included the high threshold for people with substance use disorders to enter psychiatric facilities - users often face stigma and struggle to access treatment.
Shekhar Saxena
Alex, what should be the major systemic responses for delivering services for substance users? What have we learnt from COVID-19? Can ‘building back better’ health services post-COVID include these services for substance users?
Alexander Baldacchino
Yes if you try [we could make services for substance users part of the build back better agenda]. We surveyed our members - 170 clinicians from 70 countries. There were five recommendations. The clinicians reported they were trying to continue their services; everyone was aware of their guidelines but few were able to implement them. So the guidelines need to be better tailored. Second, a meaningful business continuity plan should be developed based on the experiences of COVID-19 response. Third, there should also be a contingency plan on access to medicines including issues such as transport etc. Fourth, we should include harm reduction strategies as integral to an evidence based treatment services. And last, we need to focus on the most vulnerable populations e.g. migrant population. Disparity between high and low income countries.
Shekhar Saxena
The WHO has a Special Initiative on UHC and mental health, that was launched pre-COVID-19. To what extent is substance use a part of this initiative, and the broader WHO efforts to promote mental health?
Vladimir Poznyak
The Mental Health Special Initiative is a flagship programme for the WHO to provide ethical, quality care for millions of people with mental health conditions within the concept of Universal Health Coverage (UHC). It includes services for people with mental and neurological substance disorders. The needs are huge yet often people only have access to treatment through psychiatric hospitals. In the past 12 months 2 billion people used alcohol and ¼ billion used drugs. This means we need strong global partnerships to address all public health issues related to substance use including prevention as well as treatment. We have the Sustainable Development Goals to guide our work to 2030. These reflect the commitments made by governments including one on prevention and treatment of substance abuse. Hopefully we will all contribute to progress made between now and 2030.
Shekhar Saxena
Referring to the difficulties that people are undergoing now. Olga, how could you and people like you shape the response to substance abuse problems? What would you like to do?
Olga Belyaeva
We want to transform the attitude towards us of doctors and other professionals. For example, methadone should be available. We want to advocate for basic services for all. We want to see reductions in stress and negative attitudes among the expert medical community towards us.
Shekhar Saxena
Thank you for volunteering for taking part in the response to substance use and to working with others. Vladimir - what attempts are you making for governments to better collaborate with people who use drugs to determine services etc.
Vladimir Poznyak
The WHO guideline development process requires inclusion of people with lived experience, in this case people who use drugs. As Olga has said there is so much to be done at the country level. Particularly the relationship between the public health and criminal justice sector.
Shekhar Saxena
What are the key challenges for young researchers working in addiction medicine?
Nirvana Morgan
We run a network of early career professionals. We held a series of support calls with members and a survey. These showed the key theme was that members were fighting for equal space in the health sector during the pandemic. Senior management didn’t see addiction services were essential or necessary so services were interrupted. Patients couldn’t access treatment. Virtual services were encouraged but many patients don't have internet, or connection via landline or cell phones. So our members were worrying about how to ensure patients received treatment. Education and training is always difficult in addiction medicine but one specific that was new was training in the field of telemedicine i.e. what to do to support patients in this context. Members also reported they did not have access to PPE compared to other members of the health sector and they felt this was unfair given they were dealing with populations that are vulnerable and at high risk of contracting COVID-19. Furthermore members reported that many of the beds planned for patients for treatments such as detoxification had been reallocated to COVID-19. This meant beds were lost and there are questions as to whether they will be returned to use by addiction services.
Shekhar Saxena
Therefore the main concerns of professionals have been whether or not it is possible to deliver services rather than their own health.
A question from the audience - how can we sustain and promote services for people living in remote areas? Do you have any tips?
Alexander Baldacchino
One tip is to provide a service that is co-produced and co-designed by service users. So understand the populations that are going to use the services. For example in remote areas of Scotland we have remote units - buses and vans - to visit regions and areas of deprivation where people do not have adequate transport.
Shekhar Saxena
In such remote areas telemedicine could help.
Another question from the audience. What are the options for quality in-patient services based on a harm reduction, not abstinence-based, model?
Nirvana Morgan
Several of the standard guidelines by WHO and UDC set out these options. The problems are issues of stigma so efforts are not made to implement the strategies. Motivational interviewing is a successful harm reduction strategy along with screening for co-morbidities etc. We have evidence and explanations of how to implement such strategies but at regional level we need to get on and implement.
What is one key message?
Olga Belyaeva - medical experts give support to our friendly doctors in Eastern Europe and Central Asian countries - we need help and support from other countries to explain how to organise programmes in a professional approach with a compassionate approach.
Nirvana Morgan - the time for judgemental attitudes towards people with addictions is over. Addiction is a serious mental health condition that should be treated as such.
Alexander Baldacchino - if we truly have a patient centred service then we need to support patients accordingly not homogenise them [but address their various co-morbidities and social needs].
Vladimir Poznyak - It is impossible to speak about mental health without speaking about substance use and we need to achieve a situation where drug and alcohol issues are treated as a public health issue and addressed in parity within mental health.
