Introduction
In response to the Covid-19 pandemic, the Irish Government implemented unprecedented measures restricting the movements, activities, and social contacts of the population. These restrictions, which came into effect on 12 March 2020, have greatly disrupted people’s lives, with many unable to pursue their usual occupational, educational, social, and recreational goals, or to access healthcare as before. Health professionals have raised concerns about the possible public health impacts, including changes in levels and patterns of alcohol use associated with increased stress and anxiety, as well as social isolation, loneliness, and boredom.1,2,3 These predictions are supported by data from a recent Central Statistics Office (CSO) survey, in which 22.2% of respondents reported increasing their alcohol consumption since the introduction of restrictions.4
Alcohol-dependent persons and those who may develop harmful patterns of alcohol use are at risk under the restrictive conditions.1,3 Persons already in treatment or recovery risk relapse as a result of increased stress and decreased access to the usual supports, such as Alcoholics Anonymous.2,3 With physical distancing restrictions and pressures on health services due to Covid-19, people may experience a delay in accessing care or may delay contact with services due to fear, with potential longer-term health impacts and increased pressure on services.
While some persons with alcohol dependency will require inpatient or other residential detoxification, others can safely detoxify at home with appropriate supervision and support.5,6 The Health Service Executive (HSE), in line with 2011 National Institute for Health and Clinical Excellence (NICE) principles, issued guidelines recommending community-based assisted withdrawal where possible for persons presenting with alcohol withdrawal symptoms during the crisis.7,8 Community alcohol detoxification (CAD) programmes aim to provide safe and controlled withdrawal in the community for persons who are alcohol dependent.9,10 For persons with mild-to-moderate alcohol dependency, the community is considered a safe, successful, and cost-effective setting in which to reduce alcohol use and associated harms.5,6
Covid-19 has challenged treatment providers to ensure continuity of services in an environment that is safe for service users and the staff who support them. Doing so has required timely adaptation and innovation on behalf of providers. The impact of Covid-19 on a CAD programme in the northeast of Ireland is described below.
Turas CAD programme
Based in Dundalk, Turas (meaning journey) has been providing a CAD programme since 2011. The CAD process includes motivational support, medical detoxification, relapse prevention, and counselling, followed by SMART Recovery for those who wish to avail of it. A key feature of CAD is the provision of individually tailored programmes with wraparound supports, which are provided while enabling the individual to maintain education, work, and family responsibilities. Another key feature is that CAD requires a support person, usually a family member or friend, whose role is to support the detoxification client through withdrawal at home. Access to the programme starts with a general practitioner referral and acceptance is based on medical assessment. Turas CAD is provided by two project workers; a clinical manager; a counsellor; and a specialist detoxification nurse, who manages the programme with general practitioner oversight. Approximately 40 persons complete the CAD programme with medical detoxification annually.
Impact of Covid-19 on service provision
Like other frontline providers, Turas has had to reconfigure itself in order to continue delivering its services, including CAD, throughout the crisis. Manager Nicki Jordan explained that following the closure of the offices on 12 March, the aim was to provide an effective and successful programme remotely, with staff and client safety to the fore. Face-to-face sessions were replaced with telephone, video, ‘walk-and-talk’, and ‘car-to-car’ meetings, where possible. Physical distancing meant group-based interventions could not be continued; instead, meetings were held using video conferencing. With distancing, it was not possible for CAD nurse Patricia Kelly to carry out baseline observations, breathalyser checks, haematology screening, and BMI checks as before. Instead, additional assessment tools were incorporated and carried out by telephone where relevant, with greater reliance on the client’s own general practitioner to ascertain the client’s physical health needs.
With reduced access to the usual social outlets and distractions, loneliness and boredom have increased among clients. In some cases, mental health issues have emerged or intensified. In response, the programme is focusing more intensely on the client’s self-care and on structuring, planning, and relaxation. Daily online meditation has been added to the programme, and resources have been updated to include distraction exercises and videos on topics such as relapse prevention and anxiety management. Where possible, clients are linked to online peer-to-peer support meetings. Kelly explained that some clients have little or no social contact outside of CAD staff and that these clients expressed genuine relief that the service remained open, albeit remotely. Staff have been proactive in contacting past clients at risk of relapse and placed a notice in the newspaper to communicate that services are available. A significant challenge, however, has been the reduced access to other treatment and aftercare services, mental health services, and beds in residential services. Also, in some instances, clients have refused to attend for emergency medical treatment due to fear of Covid-19.
Over the period, the number of clients remained stable or increased across Turas programmes. From a staff perspective, working in a more diverse and flexible way has been key to maintaining the service and client engagement. For staff, Covid-19 protocols, extended operational hours, and more frequent team meetings have meant that self-care has been more important than ever.
There is a lack of published research to inform CAD via remote delivery. Staff plan to undertake an evaluation to determine which adaptations and processes have been effective and for whom. While teleworking has worked well with some clients, it is less suitable for others, such as those without the necessary technologies and some clients for whom English is not a first language. Going forward, Turas is likely to provide a blended approach for clients to complement existing services. Although this will not suit everyone, it will work effectively for some, including clients who do not need face-to-face contact or who experience transport barriers in accessing the service.
Conclusion
Measures to control Covid-19 have implications for public health, the provision of services, and targeting of support within public health guidelines. SARS-CoV-2 continues to circulate, while the full impact on alcohol use, alcohol-related harm, and service delivery is not yet known. Research is needed to address the impact of Covid-19 on those at risk of harmful drinking and those already dependent. It should also aim to identify best practice in service delivery through remote and blended approaches.
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2 Columb D, Hussain R and O’Gara C (2020) Addiction psychiatry and COVID-19: impact on patients and service provision. Ir J Psychol Med, 37(3): 164–168.https://www.drugsandalcohol.ie/32062/
3 Drinking alone: COVID-19, lockdown, and alcohol-related harm [editorial] (2020) Lancet Gastroenterol Hepatol, 5(7): 625.
4 Central Statistics Office (CSO) (2020) Social impact of COVID-19 survey April 2020. Cork: CSO. https://www.drugsandalcohol.ie/31956/
5 Davis C (2018) Home detox – supporting patients to overcome alcohol addiction. Aust Prescr, 41(6): 180–182.
6 Nadkarni A, Endsley P, Bhatia U, et al. (2017) Community detoxification for alcohol dependence: a systematic review.
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7 Health Service Executive (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: Health Service Executive. https://www.drugsandalcohol.ie/31804/
8 National Institute for Health and Clinical Excellence (NICE) (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. National Clinical Practice Guideline 115. London: NICE. https://www.drugsandalcohol.ie/14743/
9 Mannix M (2006) Drug and alcohol detoxification services: a needs assessment for Cork and Kerry 2015. Cork: Department of Public Health and HSE South (Cork and Kerry). https://www.drugsandalcohol.ie/6047/
10 Substance Abuse and Mental Health Services Administration (SAMHSA) (2006) Detoxification and substance abuse treatment. A Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Substance Abuse and Mental Health Services Administration. https://www.drugsandalcohol.ie/14171/
