Stress, Fear, Anxiety, and Addiction During COVID-19

By Patricia Strach, Elizabeth Pérez-Chiqués, Katie Zuber, Trevor Craft, and Serita Lewis

This analysis is part of the “Epidemic in a Pandemic” series that looks at what has happened to substance-use treatment access and effectiveness during COVID-19.

For many people, COVID-19 and resulting state shutdowns have been difficult, disrupting daily routines and leaving many without jobs. The pandemic has taken an emotional toll, too. According to the CDC, it can cause fear, anxiety, and stress. An April 2020 Kaiser Family Foundation poll found nearly half of Americans reported their mental health had been negatively affected by the pandemic. Although this is true across the country, it can be especially problematic for people with substance-use disorders (SUD) and the frontline workers who are there to help them. In a previous blog, we showed how substance-use service providers have responded to changing regulations. Here, we interviewed 14 providers across New York State to understand stress, fear, and anxiety for people who need help and the people who provide it.

Stressors increase the risk of developing addiction and relapse

Stress is an important factor in drug use. Researchers have shown that major stressors (e.g. death of loved ones, isolation, abuse) increase the risk of developing an addiction as well as the risk of relapse. Generally, substance-use service providers we spoke with were concerned that people will turn to drugs and alcohol to cope with the stress of job loss, family illness/death, and isolation associated with the pandemic.

One provider explained: “I can’t imagine what some of them have been through, and then the financial stressors and everything on top of that, for many people, in addition to whatever else they’re going through, loss of family members or people they care about.”

“‘Is the world coming to an end?’; ‘How bad is this?’; ‘Is it going to get any better?’ [T]he level of the anxiety was palpable in our client population.”

Pandemic-related stress was especially problematic in New York City, which was an early epicenter of COVID-19. According to one NYC-based provider, clients were asking: “‘Is the world coming to an end?’; ‘How bad is this?’; ‘Is it going to get any better?’ [T]he level of the anxiety was palpable in our client population.”

The pandemic makes it hard to get help

While stress may increase the risk of developing an addiction or relapse, fear and anxiety associated with the pandemic can also make it harder to access help. Hospital healthcare professionals we spoke with, who have seen the number of all patients drop, worry that people who need help with their substance-use disorder are not coming or are coming too late.

According to one provider, “a lot of people don’t want to go to the hospital because… they’re fearful of what they might find. A lot of people don’t want to go to a medical facility at all.” According to one hospital-based provider, everybody was afraid. Fear became a big factor in how potential patients respond: seeking help, seeing doctors, getting support from care providers. Even those people who could ordinarily maintain or manage their SUD programs found it difficult to cope because they were afraid to seek help.

The result was fewer patients coming to the hospital. One hospital provider noted, “[W]e started to notice that there’s [a] phenomena of people just simply not seeking emergency care when they needed it, including those with substance-use disorders, and specifically those that would need MAT [medication assisted treatment].” The number of patients seeking care dropped precipitously. “[W]e went from seeing about 140 to 160 patients a day to seeing sometimes between 40 and 60 patients a day. And all of those were COVID. So, you know… it was rare that we were seeing anything outside of COVID.”

When they did come, patients seeking care had delayed so long they were in serious condition: “when we did see someone who was coming in with an overdose, unfortunately, it seemed like, you know, they weren’t surviving it.”

Frontline workers, too, face additional stress, fear, and anxiety

Stress, fear, and anxiety have increased, too, for people on the frontlines of substance-use services. On March 22, 2020, when New York State Governor Andrew Cuomo put the state on “PAUSE,” non-essential employees were sent home and non-essential businesses were closed to the public. But, frontline substance-use service workers were deemed essential staff. As one provider explained: “And, while they battled the anxiety that I think that nation battled” they then realized “that they were essential staff.” Frontline workers at hospitals faced the gravest danger. A hospital provider noted, “we knew that all of us were going to be in the acute stress phase. And, certainly, frontline employees were going to be impacted the most when it comes to how people manage their stress.”

Stress increased because healthcare workers, generally, and substance-use service providers, specifically, had to be at work. In New York City, frontline workers watched as they, their colleagues, and their clients became sick. But stress also increased because healthcare workers were asked to take on essentially new jobs: hospital secretaries were now running supplies 24-hours a day and community health providers were now working to electronically connect COVID-19 patients with their loved ones, who were not allowed in-person visits to prevent further spread.

Outside the hospital, frontline workers in community-based facilities had to learn to do their existing jobs differently, using full personal protective equipment (PPE) and social distancing, without the full ability to comfort people in distress.  They worried that the loss of physical contact with clients compromised their ability to perform traditionally supportive roles as counselors or social workers. As a community-based provider explained, “The staff here was really struggling with the idea that, if someone was sick, it would be difficult to physically comfort them in a way… that we would traditionally do.” When offering emotional support, verbal and non-verbal communication were both important. “When you’re doing a session with someone who’s grieving, to be able to offer your hand on their forearm just to try to help ground them, or feel that human compassion and empathy, or to just be present with someone in their silence and be able to reflect in your own body language that you’re connected with them on a deeper level.”

They worried that the loss of physical contact with clients compromised their ability to perform traditionally supportive roles as counselors or social workers.

Even community-based providers who were grateful for the functionality of telehealth noted that it wasn’t the same as the in-person connection they had when they went to people’s homes and communities or when people with substance-use disorders came to their facilities. Generally, they worried about the people who were not seeking help and even the ones that were. When we asked a provider what they were worried about, they responded: “Just losing that connection [to people with substance-use disorders], that scares me.”

The fear of dying alone

Anecdotal evidence suggests that people are not seeking help at hospitals and medical centers not only because they are afraid of contracting COVID-19, but they are also afraid of isolation in the hospital away from loved ones. They are afraid of dying alone.

The pandemic had brought that very fear to life for people with opioid-use disorder, for whom community is the key to success and isolation is particularly harmful. Although group therapy and 12-step meetings can go online, if people are using drugs—particularly opioids—alone it can be deadly. One of the key harm-reduction strategies for opioid overdoses is the reversal drug, naloxone (commonly referred to by the brand name Narcan). Yet, it only works when somebody is there to administer it. One provider explained, “When you overdose, there’s nobody there to give you the Narcan, you can have the Narcan sitting right next to you, you’re out, you’re gone.”

For people with substance-use disorders, the COVID-19 pandemic layered increased stress, fear, and anxiety on top of an opioid epidemic that already isolates. “The quarantine has… increased the isolation of those people who, because of their drug dependence, isolate.”

Yet, for all of the fears we don’t actually have a systematic, accurate, consistent picture of what is happening with overdose deaths because of the data lag in overdose death reporting. Instead, we have warning signs. Providers are—in one’s words—“prophets of doom. Like we have a crystal ball and we’re saying, you know, here’s what’s going to happen next. Watch the domestic violence. Watch the suicide. Watch the overdose deaths spike during this period.”

COVID-19 didn’t displace the opioid epidemic, COVID-19 magnified it, increasing stress, fear, and anxiety for people with substance-use disorders and the workers on the frontlines helping them.


Patricia Strach is a fellow at the Rockefeller Institute of Government
Elizabeth Pérez-Chiqués is a fellow at the Rockefeller Institute of Government
Katie Zuber is a fellow at the Rockefeller Institute of Government
Trevor Craft is a graduate research assistant at the Rockefeller Institute of Government
Serita Lewis is an undergraduate research assistant at the Rockefeller Institute of Government