In the first UK lockdown, Alcoholics Anonymous recorded a 300 per cent increase in requests for meeting information, with calls to its helpline also growing by 22 per cent, and in October, the British Liver Trust reported a 500% rise in calls to its helpline since lockdown began in March 2020.
This snapshot of people seeking support certainly indicates that lockdown has adversely affected people who are recovering from alcoholism, or has been a trigger that has caused others to develop a problem with drinking. So, what is behind this?
What is addiction?
“You can think of addictions as the way in which people respond to things in their environment,” says James Elander, Professor of Health Psychology at the University of Derby. “We get exposed to risk of addiction in life through being given opportunities to drink, take drugs or engage in other behaviours that are addictive, like gambling.
“Humans are strongly influenced by their environments and changes like lockdown can have a big impact on people’s risk of addiction. There is a classic study called Rat Park, which showed that if rats in cages are given cocaine, opiates or nicotine drugs, they will take them and they will become addicted. They will learn to press levers and engage in behaviours to get the next dose.
“But the study also looked at rats in different environments and found that when they were in a stimulating environment, with a chance to interact with other rats and opportunities to play and explore, they didn't behave in the same addictive way. It was being in an impoverished environment that seemed to drive their behaviour to take drugs.
"There is a parallel with the way our environments have changed during the pandemic, because we're spending more time in restricted environments with less opportunity to interact with other people and activities. I think it has put us all at greater risk of addictive behaviours.”
James believes that alcohol is an obvious candidate for addictive behaviour during the pandemic. It has been shown that anxiety and tension is a stimulus for drinking, so people will often have a drink to try to calm themselves and relax.
“Lockdown has isolated people so there is less chance for friends or family to feedback to them when their drinking has increased or there are other changes in their behaviour. Also, the normal breaks we usually have in our routine that give us some perspective, like taking a trip or seeing a friend, are now very difficult to do so it’s easier to get locked into negative patterns of behaviour.”
What’s in a unit?
Many people who previously didn’t have an alcohol problem or drank well within the NHS’ recommended weekly units have, for some reason, slipped into new patterns of drinking more during the pandemic.
“When you have a glass of wine, you get a nice, relaxed feeling,” explains Gerri Mortimore, Senior Lecturer at the University. “But if you're drinking a glass every night because perhaps you think ‘I haven’t got to be up as early’ or ‘I’m feeling stressed’, by the end of the week you’ll probably need two glasses to get that same feeling, then three the next.
“It used to be 28 units of alcohol a week recommended for a man and 14 units for a woman, and it’s now been reduced to 14 units for men and women. But while people are aware of the term ‘alcohol units’, it’s difficult to grasp what they actually mean.
“When these alcohol units were first devised, a unit was half a pint of beer or a small glass of wine. But interestingly a small glass of wine meant 125mls of 8.4% alcohol by volume (abv) wine. I challenge anyone to find an 8.4% bottle of wine now. Most are 12% and above, and 15% for some of the red wines.
“Say for example you’re going to have a large 250ml glass of red wine, a common size served in hospitality. In your head you’re thinking perhaps two units, but at 15% abv its actually closer to four units, so people are drinking but not necessarily realising how much.”
Are people drinking more?
Gerri teaches advanced practice skills to health professionals and works closely with advanced practitioners on the Liver Ward at Derby NHS Foundation Trust, so can give an insight into what she has experienced over the last year.
“After the first lock down, when people started to return to work, anecdotally the liver ward saw an exponential increase in admissions of middle-aged people with alcohol withdrawal symptoms, including fitting and seizures.
“That’s because during lockdown, while furloughed, some people will have started drinking more than usual. Talking to some patients, they were drinking three bottles of wine a day while off work. When they returned to work, they stopped drinking this amount but unfortunately, because it had been several months of drinking to that extent, they then ended up having acute alcohol withdrawal.
“Some people don't seem to be affected by withdrawal, while others can suffer from delirium tremens (DTs) or alcoholic hepatitis, where the liver can become enlarged and inflamed causing jaundice and sickness.
“Now don't get me wrong, a few months of heavy drinking wouldn’t cause liver cirrhosis, this is obviously something that takes years, but certainly at the end of last year we saw an increase in newly diagnosed cirrhotics, aggravated by the fact that people were drinking more.”
David Henstock is the Clinical Lead Nurse for Alcohol and Drugs within the Derbyshire Healthcare Liaison Team, which is embedded at Chesterfield Royal Hospital in Derbyshire. He explains how Covid-19 has affected people with drug and alcohol abuse problems in Derbyshire and how it has impacted their recovery journey.
“There has been some preliminary research into alcohol use during the pandemic through national alcohol charities, such as Alcohol Concern, which reported that more than a quarter of people think they have drunk more during lockdown. Overall, during the pandemic, alcohol use does seem to have gone up. However, it’s important to say that it’s not as simple a picture as that.
“When you break that down, what you see is that health-conscious people, who previously drank within recommended limits anyway, are actually drinking even less. You then have the other extreme, where people who probably drank slightly more than they should, are now drinking even more. Figures for alcohol sales and taxation, and data from lifestyle surveys, echo this too.”
There have been reports in the media that waiting lists for hospital treatment have reached record highs since Covid-19 appeared. Seeing a doctor, going to a clinic, or meeting with a counsellor may have been delayed or made more challenging due to social distancing or other restrictions. Could we be on the potential brink of seeing more untreated problems in the future among people experiencing addictive behaviours now?
“When we look at hospital admissions for alcohol and drug abuse, again it’s not a simple picture. At some points, up to a third of people in general hospitals have been there for Covid treatment, which has meant that some people who would have been there for alcohol and drug related problems haven’t been coming to hospital.
“On the other side, we’ve seen people who had made a decision to address their drinking, back in hospital with severe liver disease, and for me these are some of the saddest cases. These people had a recovery plan in place and were doing activities to support this, such as swimming, yoga, meeting non-drinking friends, and this has all gone now. They were already in what I call ‘early recovery’, doing well, but still in the initial stages where relapse rates are 50-70% for both alcohol and opiates like heroin. They have struggled the most because the wider societal support they need has broken down.
“Charities and organisations like Alcoholics Anonymous, Smart Recovery, and locally, Intuitive Recovery, have done well to adapt to how they work to ensure people are appropriately supported.”
Covid and relapse
Between 2018 and 2020, David Best, Professor in Criminology at the University, led a four-nation study of pathways to drug addiction recovery in Scotland, England, Belgium and the Netherlands. The initial study followed a cohort over one year and the success of this study allowed the research team to obtain follow-up funding to follow the same cohort through the first year of Covid-19 and lockdown.
“Our initial findings would suggest that Covid-19 has destabilised many recovery journeys. In our first wave (before the pandemic), overall in our sample across the countries, the relapse rate was just over 10% pre-Covid,” says Professor Best. “Although we are still collecting data for the study over the last year, we are already seeing that this has approximately trebled.
“This has been in entirely predictable ways in the main. People in long term stable recovery (more than five years) aren’t generally relapsing, but people in the early stages of recovery are much more likely to have relapsed during the pandemic, not only to drugs but also to excessive and dangerous drinking.
“A significant proportion have also suffered from severe psychological health problems, including anxiety, depression, loneliness and isolation. This is partly because recovery is a social process. People have, and do, derive benefit from online mutual aid meetings, like Alcoholics Anonymous and Narcotics Anonymous, but the general consensus has been that it is support without fellowship, and so has not met all of their needs.
“For some people it has really opened doors and allowed them to attend meetings remotely, particularly for individuals who live is smaller towns and villages where they often feel a stigma around attending local meetings. But the vast majority of people have said that the benefits are much fewer than face-to-face meetings bring.
“We have also seen substitute addictions, including high-levels of alcohol consumption. Our sample was exclusively illicit drug users, not problem drinkers, but a substantial proportion now have an alcohol problem where they have never previously had one. And there is also a kind of seepage into process addictions like gambling, pornography, social media and even things like exercise. People can potentially just switch from one addiction to another, and this is a common finding in early recovery.
“So, what we have essentially seen is a group of people who have been highly reliant on mutual aid fellowships, networks and support who have largely lost that and it has had a significant impact on their wellbeing.”
Recovery after Covid
As restrictions ease with the roll out of the government’s roadmap it will be important to carefully monitor what affect Covid has on relapse and recovery rates in the weeks that follow and act accordingly.
“I think acute addiction services will see a massive increase in demand, and it will be for a wide range of disorders,” Professor Best continues.
“Demand for recovery services is increasing, so one of the big challenges is how specialist treatment and peer-based recovery support services create innovative blended approaches to continue to reach people who have engaged with online versions.
“Addiction is sadly not exclusively or even primarily a physiological process. It’s people who have been through trauma, adversity or predisposed psychological health problems, who were already in a vulnerable category, who are significantly more likely to pick up a range of addictive behaviours and the more cumulative the damage the more challenging their recovery journey will be.”
With people more vulnerable to alcohol and drug abuse during the pandemic, and those in recovery experiencing so much change, questions are being asked about what the long-term impact could be.
“I know some people are going to develop drug and alcohol problems because of the impact of lockdown,” adds David Henstock.
“People are already reporting that they never had a problem before, but now they have because of trying to cope, financial worries and social isolation. We know that historically once that pattern of abuse is there, for some this will carry on even after circumstances change. We have seen this repeatedly, for example, if someone has a bereavement and drinks to cope, they can move on from the bereavement, but the alcohol problem remains. I anticipate that in the decades to come when they tell us their story of how it all started, it will have been during the pandemic.
“My hope is that there will be increased public awareness and empathy about mental health and substance abuse because of this experience. I think it has become more obvious to us all that we know someone who has a mental health, or a drug or alcohol problem, and that at times we have felt vulnerable to these things ourselves. This will hopefully lead to a change in public attitudes, and this will feed into politics and how we respond to this as a nation to make sure we have appropriately funded services.”
For advice on any of the issues raised in the article visit the NHS Derby Drug and Alcohol Recovery Service.