Briefing note on substance use and addictive behaviours during the COVID-19
outbreak
20 March 2020
Coronavirus disease (COVID-19) is a disease caused by a novel coronavirus (SARS-CoV-2) that was
discovered in late 2019 and disseminated across the world at the level characterized as a pandemic by
the World Health Organization in March 2020. Countries were called to implement urgent andaggressive actions to change the course of the disease spread. Multiple measures have been taken on
global and national levels as part of efforts to ensure a balance between protecting health, minimizing
economic and social disruption, and respecting human rights.
While keeping this balance in mind, it is important to continue efforts to protect mental health andwellbeing of all people, including those affected with disorders due to substance use and addictive
behaviours, as well as ensuring public health protection against harms associated with substance use.
WHO developed this communication brief to highlight health issues related to substance use anddisorders due to substance use or addictive behaviours during the COVID-19 outbreak.

General population
1. Common signs of COVID-19 infection include respiratory symptoms, fever, cough, shortness ofbreath and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acuterespiratory syndrome, kidney failure and even death. Standard recommendations to prevent
infection spread are applicable to all population groups, including people using psychoactive
substances or affected by substance use disorders. These include regular hand washing, covering
the mouth and nose when coughing and sneezing, physical distancing, and avoiding contact withanyone showing symptoms of respiratory illness such as coughing or sneezing.
2. During the COVID-19 outbreak, fear, anxiety, isolation and overall instability may increase distressexperienced by people. It is important to avoid using psychoactive substances (drugs, alcohol) or
misusing prescription medicines to cope with stress and isolation. Instead, taking good care of yourmental health and wellbeing should be encouraged as a coping strategy (see more in Mental Health,
Substance Use and Psychosocial Considerations during COVID-19 Outbreak).
3. Alcohol consumption and psychoactive drug use may result in harms to health due to intoxication,
toxicity or long-lasting effects of substance use on health. Substance use and intoxication may
interfere with health-protecting behaviours, including compliance with hand hygiene, respiratory
etiquette and other transmission-based precautions for COVID-19 prevention, and can negatively
impact compliance with treatment regimens. Family members and other caregivers responsible forchildren, people with disabilities and the elderly should avoid engaging in psychoactive substanceuse.
4. Drinking alcohol, depending on a level and pattern of alcohol consumption, is associated with a riskof developing numerous health problems such as mental and behavioural disorders, including
alcohol dependence, major noncommunicable diseases such as liver cirrhosis, some cancers andcardiovascular diseases, as well as injuries resulting from violence and road crashes and collisions.
Harmful drinking can increase the risk of transmission of infectious diseases such as tuberculosis andHIV as well as complicate their course and worsen the treatment outcomes.
5. The use of psychoactive drugs without medical supervision is associated with significant health risks
and can lead to the development of drug use disorders. Drug use disorders, particularly whenuntreated, increase morbidity and mortality risks for individuals, can trigger substantial sufferingand lead to impairment in personal, family, social, educational, occupational or other important
areas of functioning. Drug use disorders are associated with multiple health conditions such as HIV
infection, hepatitis or endocarditis, which can compromise responses to infections and increase
vulnerability and risks of COVID-19.
6. It is important to rely on trusted sources of information on protection and prevention as incorrect
messages may be disseminated, including, for example, misleading messages that alcohol
consumption can protect against infection. There is no evidence of any protective effect of drinking
alcohol for viral or other infections or a positive effect on the course and outcomes of infectious
diseases. In fact, the opposite is true as the harmful use of alcohol and alcohol use disorders areassociated with increased risk of infection, less favorable course of diseases and worse treatment
outcomes. Besides, alcohol use can deteriorate the course of many noncommunicable diseases,
including cardiovascular and pulmonary diseases, which play a significant role in mortality risks of
COVID-19.
7. Direct marketing of psychoactive substances, gaming platforms and gambling opportunities throughdigital media and telephone is expected to rise sharply during the COVID-19 outbreak. Individuals
should determine the basic needs of their households in these difficult times and increase efforts toprotect especially minors and vulnerable members of the family from these marketing attempts.
8. In challenging times such as the COVID-19 outbreak, it can be easy to fall into unhealthy patterns of
behaviour and use psychoactive substance use or gaming and gambling as coping strategies to relivestress or panic caused by the situation or to pass time if self-isolating, in quarantine or lockdown.
However, excessive gaming can cause multiple problems and elevate the risk of gaming disorderthat is associated with reduced sleep or day-night reversal, malnutrition, aggression, deep-vein
thrombosis, headaches, neck pain, verbal and physical violence, low self-esteem and attention
problems.
9. Many schools and daycare facilities have been closed to prevent the spread of COVID-19 and, as aresult, children are staying at home with their parents. Between online school work, trying to occupy
children while parents work from home, and dealing with self-isolation, quarantine or lockdown,children may be spending more time than usual looking at screens. Recommendations for 1-year old
infants suggest that sedentary screen time (including playing video games) is not recommended, andfor those aged 2–4 years of age, sedentary screen time should be limited to no more than 1 hour perday. While it may be challenging to follow these guidelines currently, everyone is encouraged tokeep screen time in moderation, ensure adequate breaks and engagement in other activities. For
children and adolescents, it is important to explain that any additional screen time is temporary,otherwise, if limitations around addictive games are relaxed too much and without explanation, it
may be challenging to manage when normal routines resume.
10. With a state of emergency declared in many countries and jurisdictions, land-based casinos andother gambling venues are closed, and major sporting events have been suspended. Coupled withthe masses of people being required to stay home, this may increase the popularity of online
gambling (as well as online gaming) and subsequently increase the risk of developing gambling
disorder. Gambling disorder is associated with a range of problems, including relationshipdifficulties, physical health problems, cognitive difficulties, suicidality, lower quality of life, andfinancial and legal difficulties. While financial concerns may be particularly acute at this time as
many businesses have been required to stop trading amid the COVID-19 outbreak, leaving manyjobs in jeopardy, gambling should not be seen as a means of earning money, but rather asentertainment or a distraction. During these challenging times, talk to someone if you are feelingworried about your gambling habits; support and guidance is also available online.
11. To avoid psychoactive substance use and excessive gaming or problem gambling and theirassociated harms, individuals can spend more time engaging in activities that they enjoy and findrelaxing, such as keeping busy with activities such as cooking, reading or online learning. If an
individual is well, exercise at home, on a balcony or in the garden is a good option. Individuals
should keep regular sleep routines, eat healthy food and drink enough water.

People with disorders due to substance use or addictive behaviours
12. Currently, there is limited evidence to make any definite conclusions or recommendations on
specific preventive measures and risk factors for COVID-19 among those with disorders due tosubstance use and addictive behaviours. Nevertheless, based on existing WHO resources, several
issues can be emphasized as important elements in times of the current pandemic crisis.
13. People with substance use disorders may have a higher risk of acquiring the infection due to several
associated factors, such as housing insecurity, poverty, unemployment, sharing objects for
substance consumption (tableware, pipes for smoking, syringes), gathering in public places, andgreater likelihood of arrest and incarceration. These factors can expose people to contact withothers who might also be at higher risk for infections. Standard recommendations to prevent theinfection should be included in communication and promoted among all groups of people in contact
with health and social service providers, including those with substance use disorders.
14. While we are still learning about how COVID-19 affects people, older persons and persons with preexisting medical conditions (such as high blood pressure, heart disease, lung disease, cancer ordiabetes) appear to develop serious illness more often than others as a result of contracting COVID19. People affected with substance use disorders may be vulnerable to more severe cases of COVID19 because of a higher prevalence of comorbid health conditions (HIV, TB, hepatitis, cardiovascular,liver, respiratory, kidney diseases, etc.) and other risk factors (under- or malnutrition, poor physicalfitness). Preliminary evidence from China indicates that severe cases include a high proportion offormer and current tobacco smokers as well as people with chronic respiratory disease, suggestingthat affected lung function is among the key risk factors for a more severe disease course. Whileevidence is limited, it is likely that use of any other substances by inhalation (smoking and vaping)will have a similar effect in worsening the prognosis of COVID-19 by undermining lung function.
15. COVID-19 epidemy can influence the mental health and emotional state of people, increasing fear,
anxiety, bringing instability and potentially leading to worse clinical outcomes among those withchronic conditions requiring long-term treatment. For people with substance use disorders this canbe a trigger for relapse and/or increasing substance use, influencing help-seeking behaviour, andcontributing towards disengagement from treatment due to the fear of being infected.
16. Severe withdrawal syndromes due to alcohol or other psychoactive drug use can be dangerous,
even life-threatening, and can result in delirium, seizures and dysregulation of vital functions. People
who are beginning to experience serious withdrawal symptoms, need to have access to help in asafe environment. During coronavirus-related shutdowns it is advisable for people with substancedependence to gradually reduce the use of alcohol or other substances, rather than stop their use
abruptly.
Healthcare and social services
17. It is crucial to pay attention to vulnerable populations in times of crises, such as the COVID-19,
including people affected with substance use disorders. Disruptions in the provision of prevention,
harm reduction, treatment, and care services can have life-threatening consequences if appropriate
care and support are not available. Strengthening support provided through primary health andsocial care services can be a solution in times of crisis. The MhGAP Intervention Guide for mental,
neurological and substance use disorders in non-specialized health settings can be used for these
purposes.
18. Stigma, discrimination and barriers to treatment and care that people with substance use disorders
often face, may increase during this period of COVID-19 infection due to overloaded health andsocial services, overall uncertainty, fear and anxiety in populations. Restrictions for public gatherings
as a preventive measure to stop coronavirus spread can be a barrier for access to treatment andcare for people with substance use disorders, such as access to community-based outreach, harm
reduction services (such as provision of sterile injecting equipment) , pharmacological (such as
opioid agonist maintenance treatment) and psychosocial interventions (group therapy sessions, selfhelp and peer-support groups). Alternative ways of communication (virtual meetings) can beconsidered to ensure sustainability of psychosocial support until restrictions for face-to-facemeetings are over. Proper measures to protect patients’ confidentiality should be in place in case of
telehealth consultations.
19. Due to travel and trade restrictions as well as increased demands on healthcare services, countries
and jurisdictions may experience shortages in supply of medicines and medical equipment. It isnecessary to ensure continued access to critical interventions for people with substance use
disorders, such as outreach services, harm reduction with needle and syringe programmes,
management of acute health conditions such as overdose, withdrawal syndromes, as well as
treatment of substance dependence and support for those in recovery. Ensuring continuity of
medical and health commodities is essential, including methadone and other medicines for the
management of opioid dependence, sterile needles and syringes, alcohol swabs, diagnostics andmedicines for the testing and management of major coinfections (such as HIV and viral hepatitis)and other comorbidities.

20. Any interaction of health and social care staff with clients should be used for providing valid
information and advice on effective prevention of COVID-19 and early identification of healthconditions and risk factors that can increase vulnerability of individuals to COVID-19 infection andcomplicate its course if it develops, including substance use, substance use disorders and associatedhealth conditions.
21. All employees of health and social services for people with disorders due to substance use or
addictive behaviours should be properly informed about COVID-19 and trained about prevention,
early recognition and management of COVID-19, as well as about implications of substance use andsubstance use disorders for COVID-19 prevention and management.
Opioid Agonists Maintenance Treatment (OAMT)
22. It is pivotal that treatment and care for people with substance use disorders continue during timesof physical distancing, quarantine, ‘lockdown’ and health service disruptions. It is particularly
important for those receiving Opioid Agonists Maintenance Treatment (OAMT) with methadone orbuprenorphine.
23. Take-home doses of medications can be provided for longer periods of time in situations ofquarantine, self-isolation or lockdown and health service disruptions. The maximum periods of time
for take-home doses of medications are recommended when the dose and social situation arestable. Clients should be properly informed about the changes in the practice and receive
appropriate support in case of uncertainty and concerns.
24. Access to medicines should be arranged for those patients who are not eligible for take-homemedication (e.g. providing medications in supervised settings such as nursing homes or otherofficially recognized health facilities), those who live in long-term institutions, those in prisons or
hospitalized for in-patient treatment or rehabilitation. Relevant health, social care and custodial
facilities should provide uninterrupted access to opioid agonist medicines and medicines for
management of comorbid conditions for patients in treatment with involvement of trained
personnel employed there.
25. In case a client with opioid use disorder receiving OAMT is quarantined at home or self-isolatingwith suspected COVID-19, it is important to ensure he/she has uninterrupted access to medicines.
Methadone or buprenorphine should either be provided for the whole duration of isolation as takehome medication or delivered periodically to the client’s home by a nurse, doctor, or local pharmacy
employee (a “doorstep” delivery) with proper consideration of staff safety and potential ofdiversion. Whenever necessary and feasible, consideration should be given to prescription ofextended-release formulations of opioid agonists for treatment of opioid dependence. Additional
psychosocial support can be provided to those in isolation via web-based services or phones.
26. Increased dispensing of take-home medications within relatively short periods of time may result inincreasing demand on supply of medicines that should be taken into account at different stages ofsupply planning and management.
Measures to prevent opioid overdose
27. It is possible that the risk of drug overdose (especially opioid overdose) can increase during the
COVID-19 outbreak, and contributing factors include: use of drugs in solitude because of social
isolation and quarantine, affected lung function because of COVID-19 infection, changes in strengthand quality of a drug due to changes in supply chains and disruption of social networks, limitedaccess to treatment and care. During the COVID-19 outbreak, it is important to ensure access toopioid antagonist naloxone for all those at risk, as recommended in WHO Guidelines on Community
management of opioid overdose.
Patients with disorders due to addictive behaviours
28. Patients with gaming disorder or gambling disorder should continue their treatment if possible. In
the event that a patient is isolated or quarantined at home because of the outbreak, they areencouraged to keep in touch with they therapist or other medical caregiver by email, phone or otherremote communication methods.

WHO Resources
Stay informed:
Find the latest information from WHO on where COVID-19 is spreading:https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
Advice and guidance from WHO on COVID-19
https://www.who.int/emergencies/diseases/novel-coronavirus-2019https://www.epi-win.com/
Briefing note on addressing mental Health and Psychosocial Aspects of COVID-19
https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocialsupport-emergency-settings/briefing-note-about
WHO resources for protection of health workers and emergency responders

https://www.who.int/news-room/detail/09-03-2020-covid-19-occupational-healthCoping with stress during the COVID-19 outbreakhttps://www.epi-win.com/all-resources/coping-with-stress-during-the-covid-19-outbreakHome care for patients with suspected novel coronavirus (nCoV) infection presenting with mild
symptoms and management of contacts
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infectionprevention-and-control

Additional resources on substance abuse:
Management of substance abuse homepage
https://www.who.int/substance_abuse/en/
mhGAP Intervention Guide (Version 2.0) for mental, neurological and substance use disorders in nonspecialized health settings
https://www.who.int/publications-detail/mhgap-intervention-guide---version-2.0
WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence
https://www.who.int/substance_abuse/publications/guidelines_opioid_dependence_2009/en/
WHO Guidelines on Community management of opioid overdose.
https://apps.who.int/iris/bitstream/handle/10665/137462/9789241548816_eng.pdf?sequence=1&isAll
owed=yASSIST: The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the self-help
strategies for cutting down or stopping substance use: a guide
https://www.who.int/substance_abuse/publications/assist/en/
AUDIT: the Alcohol Use Disorders Identification Test : guidelines for use in primary health carehttps://www.who.int/publications-detail/audit-the-alcohol-use-disorders-identification-test-guidelinesfor-use-in-primary-health-care