COVID-19: Potential Implications for Individuals with Substance Use Disorders

From National Institute on Drug Abuse
March 24, 2020


As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have Opioid Use Disorder (OUD) face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

Vulnerable Populations

The most vulnerable to Covid-19 among substance abuses is going to be the crack-smoking homeless. The homeless are vulnerable just by being homeless, but add to that the lung damage from smoking crack and the risk is compounded. As Dr. Volkow points out, tobacco and marijuana smoking are also more prevalent among those who are homeless. This is going to be an important area of research.


How People with Substance Use Disorders (SUDs) Can Lend a Needed Hand in Addiction Research

April 22, 2019


One of the major challenges in health science today is that not enough patients participate in clinical trials and similar studies. Without volunteers willing and able to participate in studies testing new treatments or therapeutic approaches for cancer or Alzheimer’s, for example, researchers cannot test their effectiveness. There are many reasons for the lack of participation in medical research: Patients often are not aware of studies, or they don’t see any direct benefit from participating. Many clinical trials for new cancer treatments, for example, have been delayed or even cancelled altogether because of the difficulty of recruiting participants.

Drug Lab Research

In research testing new medications or behavioral treatments for substance use disorders, the obstacles to recruiting study volunteers are even more daunting. Just finding participants can be a challenge, since they may not intersect with the healthcare system for their addiction, the same way someone with cancer or Alzheimer’s would. Only a fraction of people with substance use disorders receive care from physicians who may be in a position to know about or link them to research studies being planned. Most recruitment for clinical trials related to opioid addiction medications, for instance, is done via ads placed at large opioid treatment centers where patients on methadone receive their daily doses. 

People with substance use disorders already face stigma and the fear of further social or legal consequences of their addiction, and this deters potential volunteers from signing up to participate in research. Some distrust the medical profession altogether. Many people with addiction do not want or believe they need treatment at all. Additionally, because many people with addictions who might otherwise want to participate in a trial are unemployed, poor, or homeless (perhaps as a result of their substance use), they may lack the resources or access to transportation necessary to visit a hospital or research center regularly. Often as many as half or even more than half of participants recruited for a trial are not able to complete it.

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Scientists studying new treatment approaches for addiction must always be thinking about how they can make their research studies more practical and feasible in the real world. They must make study participation easy and appealing and the studies accessible—including access at odd hours or weekends for those whose jobs or school prevent participation during regular work hours. Also, people with addictions often use multiple substances, and this commonly excludes them from studies testing treatments for a single substance, due to strict criteria on who can be included in a trial. Yet the reality is that addiction is complex, and often involves not only use of multiple drugs but also co-occurring mental and physical illnesses. Designing more inclusive studies and clinical trials that can take this complexity into account will be necessary for scientific advancement in treating and preventing addiction.

An all-hands-on-deck approach is needed in order to confront America’s current drug crisis, and the needed hands must include families and individuals directly affected by substance use disorders. By increasing participation in research by those who most stand to benefit, we can find solutions to the complex addiction issues facing our nation today. It is also an opportunity for individuals suffering from addiction to participate in clinical research, just as people with other medical conditions do.

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For more information on the benefits of participating in a clinical trial—for addiction or any other disease—please feel free to visit Are you a provider? You can learn about trials to recommend to your patients here:


The following website can help you find substance abuse or other mental health services in your area: If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: In addition, you can find contact information in your phone book or online for Alcoholics Anonymous, Narcotics Anonymous, Celebrate Recovery, or other 12-step programs.



Youth in Crisis

Research tells a statistical horror story of what is happening every day in America regarding our youth. 1,000 unwed teenage girls become mothers. 1,106 teenage girls get an abortion. 4,219 teenagers contract a sexually transmitted disease. 500 adolescents begin using drugs. 1,000 adolescents begin drinking alcohol. 135,000 kids bring a gun or other weapon to school. 3,610 teens are assaulted, 80 of which are raped. 2,200 teens drop out of high school. 2,750 kids watch their parents separate or get a divorce. 90 kids are taken from their parents’ custody and placed in foster care, a group home, or institutional care. 7 kids age 10-19 are murdered. 7 juveniles age 17 and under are arrested for murder. 6 teens commit suicide. Every day!

Many of America’s 28 million teens face struggles and crises that most adults would find difficult to bear. For example, one in eight has an alcoholic parent. One in five lives in poverty. More than one in five (22%) live in single-parent homes. More than on in fifty live with no parent at all. Moreover, research and experience reveal that teens in evangelical churches are by no means immune to such problems. A survey of twenty-three national Christian youth leaders involved in denominational and parachurch ministries identified such issues as premarital sex, pornography, sexual abuse, emotional abuse, abortion, parental divorce, alcoholism, drug addiction, and suicide as issues faced by their kids – church youth, Christian youth. Issues those leaders consider both important and urgent for today’s youth and the adults who care for them.

Youth leaders helped identify the fifty most basic, pressing problems faced by adolescents today. Problems that range from emotional issues (like loneliness and depression) and relational issues (such as love, dating, and peer pressure) to sexual issues, abuse, addictions, and vocational issues (like finding God’s will and choosing a career or ministry).

The teen years are vital to establishing a strong foundation for adulthood. Problems such as addiction, mental illness, violence, pregnancy and suicidal thoughts are tough enough to face as adults. They are compounded in teens by emotional immaturity, lack of experience and judgment, impulsiveness, confusion, bullying, broken homes, academic pressures, and finding their place in society. Kids are quite vulnerable at this phase of their development. It is truly sinful that some adults prey on these vulnerabilities. What can be more evil than trafficking drugs to teens, taking advantage of their sexual curiosity, or manipulating them through playing on their emotions? Working with adolescents as an addictions counselor or mental health worker can be both frustrating and challenging, but it is some of the most vital work we can undertake as adults.

Drunkenness is a sin. The Bible is clear on this point. But once a person is an alcoholic, once he has allowed his will to be taken hostage by alcohol, he is sick. He can no longer help himself. To tell an alcoholic to shape up and stop drinking is like telling a man who has just jumped out of a nine-story building to fall only three floors. It just isn’t going to happen. If we define alcoholism as a physical disease, without including a spiritual dimension, we completely miss the fact that alcoholism affects a person physically, mentally and spirituality. An alcoholic will not get well unless he is treated on all three levels.

There is no single reason for teenagers to start using drugs and alcohol. They see their parents and other adults drinking alcohol, smoking, and, sometimes, abusing other substances. Also, the teen social scene often revolves around drinking and smoking pot. Sometimes friends urge one another to try a drink or smoke something, but it’s just as common for teens to start using a substance because it’s readily available. They see all their friends enjoying it. In their mind, they see drugs and alcohol as a part of the normal teenage experience.

Many factors influence whether an adolescent tries drugs, including the availability of drugs within their neighborhood or school, and whether their friends are using them. Family environment is also important. Exposure to violence, physical or emotional abuse, mental illness, or drug use in the household, increase the likelihood that an adolescent will use drugs. Also, an adolescent’s inherited genetic vulnerability, personality traits like poor impulse control or a high need for excitement, mental health conditions (such as depression, anxiety, or ADHD), and believing drugs are cool or harmless, make it more likely that an adolescent will use drugs.

Most teens do not escalate from trying drugs to developing an addiction or other substance use disorder, but even experimenting with drugs is a problem. Drug use can be part of a pattern of risky behavior, including unsafe sex, driving while intoxicated, or other hazardous, unsupervised activities. In cases when a teen does develop a pattern of repeated use of drugs or alcohol, it can pose serious social and health risks, including school failure, problems with family and other relationships, loss of interest in normal healthy activities, impaired memory, increased risk of contracting an infectious disease (like HIV or hepatitis C) via risky sexual behavior or sharing contaminated needles, mental health problems, and the the real risk of suffering a fatal overdose.

Unfortunately, teenagers who lack confidence report that they’ll do things under the influence of drugs or alcohol that they might not do otherwise. This is actually part of the appeal of drugs and alcohol; it gives the user courage to dance, or to kiss a girl they’re attracted to. Alcohol and other drugs tend not only to loosen inhibitions, they also alleviate social anxiety. Getting drunk or high with other teens makes you feel you have something in common with them. There is the mentality that if you do or say anything stupid, everyone will just think you had too many drinks or smoked too much weed.

The high produced by drugs represents a flooding of the brain’s reward circuits with much more dopamine than natural rewards generate. In fact, oxycodone is 20 to 30 times more potent than dopamine. This creates an especially strong drive to repeat the experience. The adolescent, already struggling with balancing impulse and self-control, is more likely to take drugs again without adequately considering the consequences. If the experience is repeated, the brain will reinforce neural links between pleasure and drug-taking, making the association stronger and stronger. Chronic drug use not only realigns the user’s priorities, but also may alter key brain areas necessary for judgment and self-control, thereby reducing the ability to control or stop getting high. This is why, despite popular belief, willpower alone is typically insufficient to overcome addiction. Drug use compromises the very part of the brain that make it possible to say no.

When substance use disorder occurs in adolescence, it affects key developmental and social transitions, and can interfere with normal brain maturation. These potentially lifelong consequences make addressing adolescent drug use an urgent matter. Chronic marijuana use in adolescence, for example, has been shown to lead to a loss of IQ that is not recovered even if the individual quits using in adulthood. Impaired memory or thinking ability and other problems caused by drug use can derail a young person’s social and educational development and hold him or her back in life. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences of the United States of America Oct 2;109(40):E2657–E2664 (2012).

Adolescents are less likely than adults to feel they need help, and usually won’t seek treatment on their own. Given their shorter history of using drugs (as well as parental protection), adolescents may have experienced relatively few adverse consequences from their drug use; their incentive to change or engage in treatment may correspond to the number of such consequences they have experienced. Also, adolescents may have more difficulty than adults seeing their own behavior patterns (including causes and consequences of their actions) with enough detachment to tell they need help. Only 10 percent of 12- to 17-year-olds needing substance abuse treatment actually receive any services. When they do get treatment, it is often for different reasons than adults. By far, the largest proportion of adolescents who receive treatment are referred by the juvenile justice system. Given that adolescents with substance use problems often feel they do not need help, engaging young patients in treatment often requires special skills and patience.

When substance use disorders are identified and treated in adolescence, especially if they are mild or moderate, they frequently give way to abstinence from drugs with no further problems. Relapse is a possibility, and should not be seen as a sign that treatment failed. Rather, it should be seen as an occasion to engage in additional or different treatment modalities. Averting and detecting relapse involves cooperation by the adolescent, monitoring by parents and teachers, and follow-up through outpatient treatment providers. Although recovery programs are not a substitute for formal evidence-based treatment, they may help some adolescents maintain a positive and productive drug-free lifestyle that promotes meaningful and beneficial relationships and connections to family, peers, and the community both during and after treatment. Whatever services or programs are used, an adolescent’s path to recovery will be strengthened by support from family members, non-drug-using peers, the school, and others in his or her life.

This is truly a battle we must win. The future of our children depend on it. I feel both honored and challenged by the calling God has placed on my life to counsel teens and young adults who are struggling with addiction and mental illness. Rather than cry about how my life has turned out to this point as a result of nearly four decades of drug and alcohol abuse, I plan on focusing my attention and energy on helping teenagers avoid  a lifetime of substance abuse and the literally hundreds of complications that usually result. Please join me in praying for the young adults and their families being decimated by addiction.