Episode 26 – California Sober
Dr. Ashish Bhatt ❘
California sober isn’t actually sober at all, but some state that it works for them. This could be dangerous for those in recovery.
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Hayley: Hello, everyone. This is Straight Talk With The Doc. I’m your host Hayley, and I’m here today with addiction medicine specialist, Dr. Bhatt.
Dr. Bhatt: Hi Hayley, how are you?
Hayley: I’m doing good, thank you. Dr. Bhatt, I’m excited to talk to you today because you offer a unique perspective on our topic today. Your professional life is in the addiction medicine community, so you know what’s really going on when most of us are just gathering our own news and not living in it day to day. Right now, over 49 percent of Americans are vaccinated against COVID-19. Although the risks of COVID are not over, a lot of people have been able to return to a more normal life with mask mandates lifted in certain areas and some businesses being able to open back up. But even if COVID was completely gone today, a lot of the damage that has already been done is irreversible. Over 93,000 people died from a drug overdose last year and some experts say that this is in part due to impacts from COVID, like isolating those with an addiction and making it difficult to get treatment. Dr. Bhatt, now that things are starting to change in our society with COVID, what is it like in the world of addiction medicine currently?
Dr. Bhatt: Well, you gave a lot of statistics there and I appreciate that background. With addiction, by virtue of the disease itself, when somebody suffers from an addiction they’re going to look to find ways to use substances. I think early on when the pandemic first hit, we did see a lot of people when they were socially isolating, probably not having access to drugs or alcohol, but that quickly changed. Because as whatever factors that led to further worsening of the way they felt, they also were able to come up with ways to obtain drugs and alcohol. And also for the drug dealers, they probably found ingenious ways to get the drugs to people willing to buy. We saw that, and as a result, we saw such a spike in overdoses especially when it came to Opioids. We know we’ve been dealing with that for quite a long time, for many years. With that stat, or that situation we’re dealing with now, of how many people are vaccinated and where are we going to go, well, I believe there’s this other inertia. Another group of people that are going to celebrate when they’re now getting free and they’re able to return back to normalcy. And if somebody is suffering from addiction or is somewhat ready to use or abuse, well they’re going to use this as an opportunity to go out and use more. Now, I don’t think it’s going to turn back in any way, it’s kind of like a double-edged sword. Yes, there was a problem from isolating and quarantining and not having access to the people who support us in a healthy way, and that led to people getting more depressed, more anxious, and using. Similarly, I think people who want to use the opening up of things again as a way to celebrate. They’re also going to use this to rebound from that and pursue drugs and that is the nature of addiction. We come up with whatever cognition needed and whatever it is that we need to end up using to serve the purpose and fuel the addiction that we have. Unfortunately, that’s the part of why addiction is so detrimental. Because whatever rationalization we need to provide to our heads, to our minds, we will put it in place. One thing I wanted to add to you though is we’re probably going to see pockets of this because of that statistic about how many people are vaccinated. It’s not evenly spread. We have people that are more vaccinated in certain states than in others and that is why we have a rise right now. We are seeing an increase of COVID cases in many parts of the country. And my fear is that it’s going to transmit to areas all over the country. In those unvaccinated areas, more are going to suffer, at least statistically from what science we’re seeing. It’s going to be very hard to predict where this is all going to go.
Hayley: I want to talk about that. One of the surveys I read found that 40 percent of respondents indicated that their substance use had increased during COVID. If COVID cases increase in certain populations, say unvaccinated populations, do you think substance abuse will increase as well?
Dr. Bhatt: I definitely see- anything that’s happening right now, we see it in the economy, first of all. Many people are living like it’s this bucket-list living. They’re living like it’s the end of the world. They’re coming out of the pandemic with all this pent-up frustration because we have this inability to delay our own gratification even if it’s to our own benefit. Many people are out there spending money, living life, doing things where traditionally at this time of the year we would see certain tourist areas slowing down and certain tourist areas going up, but people are traveling. People are getting together. People are doing things and it’s not going to be much different when it comes to substance use. I think with substance use, you’re going to see that continued usage amongst people who are vaccinated and unvaccinated. Only time can tell what that result can be without being too speculative. Can it cause more damage? Yeah, if you’re unvaccinated and get COVID and you’re socially interacting with people, there’s of course an increased likelihood that you can catch something. But that can happen with any sort of airborne illness, not just necessarily COVID. That risk is there. People are going to be out there. They’re going to start to use again. They’re going to start to use in groups. If you’re unvaccinated and somebody around you has COVID, your increased likelihood to get it is present.
Hayley: From the same survey, I saw that 47 percent of people said that they started sharing syringes or other paraphernalia during COVID because they didn’t have access to harm reduction or needle exchange programs. Have these programs returned to full capacity or has COVID changed how they operate?
Dr. Bhatt: Well, things have started to return and have returned. We even shifted the way we bring programs back to life. One was about the way we provide services, things did transition to Telehealth- everything from treatment programs to private practices, to AA and NA groups. As it pertains to needle exchange and other things, they have started to come back and are in place. Many people are still asking to wear masks when it comes to certain situations where the mixture of vaccinated and unvaccinated people exist, especially indoors. There is a push for everybody to have source control and wear a mask. Things have started to come back in place, and again, using technology and using other methods to help provide these services. Again, it’s sad; it’s ironic. When people are ending up using and ultimately their use is going to cause negative effects, needle exchange situations. It’s all harm reduction and that access was stopped. Hopefully if they are going to use- I hate to even say this, but when we talk about harm reduction we’re just talking about if you’re going to do it, we want you to be as safe as possible. Even though knowing that using it is not safe. But I think this is a public service endeavor; it is prevention and hopefully these programs get back up to speed as much as possible. Because, of course, we need to support people but not support the addiction, unfortunately.
Hayley: In regards to those harm reduction programs, 38 percent of people said that they believed they were at a higher risk of overdose during COVID. Do you think the availability of the vaccine may help reduce these rates in the next year?
Dr. Bhatt: As we saw and as we see with the disease of addiction, addiction, unfortunately, causes us to develop a lot of cognitive distortions. We will use when we’re addicted, any form, any rationalization, any situation to further perpetuate our substance use. It can be the pandemic being a situation as to why we’re using and then now the coming out of the pandemic as to why we’re using. If somebody’s on the right path to recovery, I think they can use any sort of situation to be the catalyst to continue seeking sobriety and trying to achieve recovery. Can the vaccine help? Of course. I think the vaccine can help keep people safe from getting COVID, and if COVID can be prevented, or at least exposure is minimized, or if you end up getting it the severity of the disease is not as severe, this can all help anybody not have any sort of morbidity, sickness, illness. There’s one less reason to have an excuse or rationalization to go use- “Oh, can you believe I’m dealing with this? Now I might as well use to cope with this.” It really depends on the individual. We know that the disease of addiction is an interpolate, interaction between these cognitive distortions, emotions, thoughts, related brain neurochemicals- that motivates us to seek a reward. It depends where we are within our disease. Can the vaccine help? Yeah, it can help reduce potentially getting COVID, but how will that manifest in the person’s behavior to seek out drugs or not seek out drugs? Well, that will have to be determined.
Hayley: It really depends on the individual and their motivation for substance use.
Dr. Bhatt: I definitely think that’s a big part, because what trajectory was that person on? Somebody can use something negative to end up being a catalyst for change, or some people can see it as a positive and end up going out, and again, celebrating. It really depends on the person’s perspective, and again, where they were and what trajectory they were going on up until that moment. Because situations are what we react to and if we have bad coping mechanisms and lack of support and structure around us, it can really play out differently for each individual.
Hayley: At the beginning of COVID, there was definitely a decreased access to substances. I think that’s kind of leveled out now. But even during that time, substance use remained the same and even increased for some people. Why didn’t a decreased access decrease rates of substance abuse?
Dr. Bhatt: Because people are very smart. People will go through many different efforts and attempts to obtain their drugs. Once we’re hit with an obstacle, people find a way to go around it. People were opening up accounts. Drug dealers were finding a way to communicate and gain access to people who maybe initially didn’t have access to them. They were using methodologies that we were using to provide treatments and communicate. They were doing the same thing, online, through video services, people were gaining access. It’s like anything in life, if they have to find a way to go underground. If they have to find a way to circumvent, people come up with very genius ways to get access. It was only a temporary obstacle and has unfortunately been circled back today.
Hayley: Unfortunately, that’s something we see. Just the extreme lengths that people will go to in order to get their drug of choice.
Dr. Bhatt: Exactly. By virtue of addiction in itself, you’re not looking out for negative consequences or you don’t recognize them as well. That’s part of the barrier of where the insight lacks of why we continue to use. Addiction is so multifactorial. There’s so many different things that influence somebody to continue to use. But I repeat, there’s an interaction of cognition, memory, motivation. The related brain circuitry that starts to change and that award that we obtain, and unfortunately, no matter what is going on, if we want that drug, we’ll get up and go and find a way to get it.
Hayley: I want to switch to another topic within this topic. Something I read is that those with substance use disorders are at a higher risk for contracting COVID. Can you talk about that a little bit?
Dr. Bhatt: Anybody who engages in dangerous behavior, again, look at all of the factors of why people who use substances are prone to other types of diseases and illnesses. The one we tend to not care about or not recognize the negative things around us: we’re not protective of ourselves. We often will share needles. Needles can contract illnesses and blood borne illnesses. We tend to often start to neglect our hygiene and our self-care. I think things that can be transmitted just by touch will continue to happen. We drive, or we ride, or we operate motor vehicles while under the influence. The point is that there’s such risky behavior and there’s a lack of recognition of that risky behavior that any ways that could protect us from COVID could be thrown out of the window. So, yes, there’s an increased risk to develop this just because they might not say, “I need to social distance.” They might not recognize that somebody who is coughing all over or sneezing all over needs to be stayed away from. The person themselves could go out and if they’re coughing or sneezing, might not get a COVID test or any sort of test to see if they’re ill in any sort of way. Because self-preservation is not number one on their hierarchy. Euphoria, or escaping from pain, that’s the number one motivation to continue to use. When you look at positive and negative reinforcement and drugs become the number one thing you’re pursuing, there’s going to be a lot of collateral damage because you’re not going to be looking out for yourself per say. You’re looking out for that euphoria. You’re looking to get high or you’re looking to escape from whatever withdrawal symptoms or pain that you’re suffering from. Either way, it puts us in harm’s way and COVID could be something that they put themselves in front of or protect themselves from.
Hayley: Substance use really puts you at risk for a lot of health issues, not just COVID.
Dr. Bhatt: Definitely, a lot of risks.
Hayley: For somebody who has a substance use disorder, maybe they’re in recovery or they’re still abusing the substance, do they need to disclose that before they receive a COVID vaccine?
Dr. Bhatt: I don’t believe anywhere it’s stipulated or states or mandates that anybody has to disclose anything, except are you allergic to probably any ingredient in the vaccination. From my understanding, there is no such requirement, stipulation, or disclosure regarding that. People might think that people might want to come up with that. People might say that to rationalize not to go and get something, and again, I’m not just speaking about the vaccine, about anything. Because people are feeling guilty. They’re embarrassed. There’s a lot of shame and it’s hidden. If that was the case, I’m sure people won’t go out and get it. They’ll look for whatever reason they need to in order to hide it, and rightfully so. Nobody’s really proud to be suffering with addiction. Anyway, I don’t believe there’s anywhere that stipulates that you have to disclose that and that should not be an obstacle if someone indeed wants to get vaccinated.
Hayley: I want to talk about the mental health effects of COVID. That’s something we hear about all the time. What kind of long-term mental health problems can occur after maybe having COVID or being around someone with COVID?
Dr. Bhatt: I think the first thing people have faced- people who don’t have an underlying condition, who don’t have an underlying mental illness, who don’t have an underlying substance abuse condition, people are anxious about this. I think the first thing we saw is people worry- what is it? It’s the unknown. When we’re not aware of something, we don’t know what it’s capable of doing. And such mixed messages came out- it was like a continuous bombardment of conflicting information and inconsistencies from our government to our military bodies. It made people who are even sure of themselves, question what’s real and what’s not. Then we had this other side of people throwing conspiracy theory origins of this whole thing. The bottom line is it created a lot of uncertainty and anxiety was there, and I think anxiety still persists. And after the adrenaline and the hype and everything starts to settle down, we will see persisting anxiety in many people or worsening of anxiety for people who had it. And again, there’s always nuances and people who could be in treatment and have developed coping skills and resiliencies that might make them more resilient to certain things because they’re preparing themselves. But the anxiety we see is going to be a big one. Of course, depression. On the flip side once you’ve figured out that there’s maybe nothing you can do about it or you look at this as something that’s changed your whole life or whatever insult that is perceived. It can cause people to become very isolated, depressed, and I believe that you’re going to see a lot of this as a fallout. Post-traumatic stress disorder– it might not fit that prototypical definition of the harm, the criteria that could be caused, but just the chronic stressor of this ongoing unknown. People are deathly afraid of this and they should be to a certain degree. This is something that could potentially kill somebody, but for a normal healthy person the likelihood is lower. But, again, because it’s unknown and there’s so much variation and so many mixed messages that have been out there. I think we will see a lot of trauma related fallout because of this. I know it’s sort of early still because it hasn’t ended. It’s kind of perpetuant, and what do we see in clinical practice- we do see a lot of people who are anxious, who are depressed, and who are suffering from trauma. Not so much as it relates to COVID-19 in an inpatient residential situation, but we have seen it as it relates to people who are seeking outpatient services. We have seen a lot of this. This is going to be very interesting on how this is going to play out. But, people can take control. One of the things that people can do is try and take control to minimize the negative outcomes of things by being preventative, cautious, following certain guidelines that can help you stay safe.
Hayley: It’s interesting that you mention the anxiety that’s brought on by all the inconsistencies that people see, because that’s actually something I was reading about. People open up their phones or they get on the internet and every time they do that, they see something different.
Dr. Bhatt: It’s not like we can blame anybody, because people are trying. Agencies are trying, the CDC, the WHO, they’re trying to get a grip on it themselves. It’s one of those things that we want to alert you but we don’t want to falsely alert anybody. And when you get caught between those decisions- and I know we hold government agencies and certain agencies to a certain standard because they’re supposed to be experts. They have to be able to gage this stuff, they should not have to be instructive on how to prepare for this because of money and support. They’re trained to detect these types of things. I think there could be a lot of criticism. There is a lot of criticism out there as to who’s doing what and why, but at the end of the day we also have to use our own judgement here. This is something that was very strange for me as a physician and as a psychiatrist. I could say, “How come the world didn’t look at this as one united front?” Again, if this was an alien or something foreign that was attacking us and it could destroy us equally, yes, some people might have some underlying risk factors. But why didn’t we have a unified stance? It’s because we were given non-unified messages. I don’t want to get into the politics of that whole thing. But I think the fact that we’ve had people who we look to for guidance and support send such conflicting messages, it’s created a lot of anxious, depressed, and stressed out people across the world. It’s very sad.
Hayley: I can see how that would trigger a lot of anxiety. Are some people more susceptible to that anxiety or other mental health problems?
Dr. Bhatt: I go back to resilience. Resilience is our ability to overcome and resist and end up not being as susceptible to certain things. People who do have better, healthy coping skills, don’t have underlying substance or mental health issues, who have good social supportive networks, who do have a secure employment and stream of steady income- things that would generally allow us to be more resilient to other things that we cannot control. We tend to be more resilient when facing any obstacle in life that way. When you don’t have those supportive mechanisms around you, you have increased risk for developing some sort of negative effect to this. But this is something that we haven’t seen before in most people’s lifetime; it’s unprecedented for many people. It’s very hard to have a barometer of what people should and should not react like. It’s very hard to then determine what resiliency is, because how resilient should you be when there’s no real bench mark for this type of situation. Again, it’s very difficult, but usually if you have a lot of supportive, protective factors in general and security that that person perceives within them, those people will then react better to any sort of negative circumstance.
Hayley: Would you say it depends more so on the individual and their support system, or does having COVID at some point put you at risk for developing a mental health disorder? Does it depend on the person?
Dr. Bhatt: Yeah, definitely, it’s very individualized. But, again, I think if we extrapolate from what we know about things that keep us healthier, if you have somebody who’s there that you look at as a support system- a spouse, a boyfriend, a girlfriend, significant other, family. If you are somewhat spiritual or you have a sense of community, you go to church- again, I’m not saying that people who don’t do these things or have these things are not resilient. I’m not saying that. But we do show outcomes when you have employment, when you have a source of income, when you have good health, when you have all of these factors in place. No presence of any significant medical problems or mental health problems. When things are thrown at you, you tend to tap into those resources that help you overcome them. So, having COVID right then can be negative and is negative, but if you have these protective factors and support systems in place, your chance of overcoming if we keep all of the variables fixed, is probably higher with those people that have those types of protective factors.
Hayley: Right, because bad things are going to happen. That’s just life but building up that support system is crucial especially in a time like this.
Dr. Bhatt: That’s valid, but I don’t think people were prepared for this. And, really, how can you be prepared? I think we’ve seen a lot of infections in the past. We’ve seen other types of epidemics happen. People heard about certain other illnesses that resemble Coronavirus- COVID-19, but it never really affected the world in its entirety. Other diseases were captured earlier or they were somewhat contained better. This thing has spread. And it’s spread to a degree that like I said, that people haven’t faced before. It’s going to test the resiliencies of many, many people, and as a result, that’s why we’re seeing these risky types of behaviors even amongst people that don’t suffer from addiction, because we need to undo this somehow. We need to undo this trauma that affects everybody. We need to do this by returning back to normal even if it’s not safe in certain situations. And again, I’m not saying that we need to go out and just live in a bubble- no way. I’m all about protecting ourselves. We have to inoculate ourselves in order to gain that immunity to what life throws at us. And that means get out there and try to be normal, do it in a safe way. It does depend on the individual. It does depend on the individual’s history. But having a substance abuse issue, we know that that’s affecting the way we think. Unfortunately, making smart decisions or decisions that are protective for us can definitely be skewed when we have a substance that alters the way we think on board, so it doesn’t help in any way.
Hayley: I mean one thing’s for sure. What you said, none of us were prepared for this or expecting this. Before we close out, Dr. Bhatt, is there anything else on this topic that you think people should know?
Dr. Bhatt: There’s a certain amount- a balance has to exist. I think it’s hard especially in these difficult times about not letting negative media- negative propaganda get in your way. I do advise people who are suffering with a mental illness, who are suffering with an addiction, or anybody in general, that you limit how much negative exposure to certain things on social media, the news, and through talking with other people. Because that does not help the situation, if we’re exposed to continuous negative dialogue. It definitely can wear down anybody, even the strongest individuals with the highest resiliency. It can wear you down. Try and continue to live healthy, protect yourself, get your information from reliable and reputable sources, try not to jump on conspiracy theory bandwagons. These all are fuel for us to act out and often act out against us. And, unfortunately, I always say with addiction: it’s not the drugs that we abuse, the drugs abuse us. That being said, the help is out there, try to get it from reputable, reliable individuals and sources where you get your treatment, and where you get your information.
Hayley: 100 percent. Thank you for breaking this down today Dr. Bhatt, and to our listeners, addictioncenter.com has information on the connections between addiction and COVID, as well as advice and information for those who may be interested in learning about treatment for themselves or their loved ones. You can check out more podcast episodes on Addiction Center, as well as SoundCloud, Spotify, and Apple Podcasts. Thank you for listening to another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.