Craving variations in patients with substance use disorder and gambling during COVID-19 lockdown: The Italian experience

INTRODUCTION

Following the development of the coronavirus disease-2019 (COVID-19) pandemic in Italy, a strict lockdown was imposed from March 9 to May 5, 2020. In the general population, problems such as depression, anxiety, post-traumatic stress symptoms,insomnia, and adjustment disorder symptoms increased[1]. The risks of selfmedication through alcohol or psychoactive substances abuse were also increased, as well as the tendency to adopt pathological behaviors, such as gambling and internet addiction[2,3]. Stressors are essential in the inception and protraction of substance use disorder (SUD). Many stressors are associated with lockdown conditions such as prolonged home confinement, depression and panic related to the disease's uncertainties, working from home, and fear of job loss. People exposed to these stressors may take refuge in addictive substances, increasing SUD incidence among the general population[4] in a post-modern society that is increasingly oriented towards the use of substances, favoring the development of symptoms of psychopathological interest[5]. The COVID-19 pandemic and lockdown are risk conditions for developing internet, videogames, or other addiction, decreased physical activity and related health issues, altered eating habits, and disrupted circadian rhythms. King[6] and Király[7] demonstrated how these behaviors increased during the lockdown, often generated as a coping strategy to stressful situations.

本研究發現，第2代320排螺旋CT機較第1代CT機輻射劑量(CTDI、DLP及ED)顯著減小(P<0.01)，降低幅度約46%，更符合利用盡可能低的放射劑量達到臨床診斷(as low as reasonably achievable，ALARA)的要求。此外，兩代320排螺旋CT機之間的肝臟灌注參數值(PAF、PVF及PI)差異無統計學意義，具有可比性，說明可以用這2臺CT機對同一病灶進行動態監測、隨訪。

In patients with pre-existing mental disorders, the symptomatology may flare up or worsen, generating increased suicidal ideation as a possible consequence[8-10].Substance users and gamblers are groups at risk of developing psychopathological symptoms in a lockdown situation. The phenomenon is likely due to various reasons,including: (1) The limited availability of illegal substances on the black market; (2) the insufficient presence of active treatment programs and the low availability of substitute drugs; and (3) the greater psychopathological susceptibility and lower resilience in a period of reduced economic resources and financial hardship[11,12].

In this study, we evaluated the impact of the COVID-19 pandemic and associated containment measures on craving, a prominent risk factor for relapse[12] in a group of patients suffering from SUD and/or gambling disorder (GD) who were in treatment in outpatient units or in residency programs as inpatients.

MATERIALS AND METHODS

This study was commissioned by the Italian Society of Psychiatry and conducted at the University "Gabriele d'Annunzio" of Chieti-Pescara during the Italian lockdown phase that lasted from March 3 to May 5, 2020. Recruitment centers were randomly chosen among all the structures providing services for SUD and GD patients in regions of Northern (Piemonte, Lombardia), Central (Lazio, Marche), and Southern Italy(Abruzzo, Calabria) (see Appendix A: List of recruitment centers). Randomization procedures were computerized (see Appendix B: Explanation of randomized procedures). Three online meetings were held to train clinicians to the administration of the questionnaire, before the study started. In each recruitment center, a clinician introduced the survey to all the eligible subjects. No compensation was provided for participation in the study. Of the 253 subjects recruited, 153 (mean age 39.8; 77.8%male) gave their consent and anonymously completed the questionnaire. Forty-one subjects completed a pencil and paper questionnaire during the interview. The clinician provided an online questionnaire to 112 patients who had virtual assessments due to lockdown restrictions. Questionnaires were anonymous and each subject was identified through a unique code with no other identifying data. Anonymity was maintained by placing the completed questionnaires in a box by the subject himself, so that the clinician could not associate the subject with his/her questionnaire. All participants provided informed consent. The inclusion criteria were: (1) Diagnosis of SUD or GD according to The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders; and (2) being older than 18 years. The exclusion criteria were: (1)Diagnosis of dementia; and (2) refusal to give informed consent.

Our survey was organized into two sections. In the first section, we collected anamnestic and clinical variables (see Appendix C: List of anamnestic and clinical variables). In the second section, using a visual analogue scale (VAS), we asked the subjects to indicate the craving level for the primary substance of abuse and how much their craving and habits have changed from the beginning of lockdown. We chose to use the VAS because of its immediacy and extensive utilization to evaluate craving in addicted patients[13,14]. We investigated changes of: (1) Craving for substances and gambling; and (2) quality of life and life habits (Table 1). A VAS ranging from 0 (I do not use it/I do not do this anymore) to 10 (I use it/I do this much more than before)was employed. To assess changes in quality of life, we utilized a VAS ranging from 0(my life is much worse than before) to 10 (my life is much better than before) (see Appendix D: Questionnaire).

其次，提請憲法解釋的主體不明確。我國現行法律制度中沒有關于誰有權提請憲法解釋的明確規定，而《立法法》《全國人大常委會議事規則》都規定了特定的立法提案主體，在參考上述規定的前提下，《憲法解釋程序法(專家建議稿)》又吸納了《立法法》關于法律解釋提請主體、法規審查提請主體的相關規定，將提請憲法解釋的主體規定為各國家機關和武裝力量、各政黨和社會團體、企業事業單位和個人。提請主體范圍較廣，對于推動我國憲法解釋工作開展具有較強的推動力，但也需避免因提請主體過多，影響憲法的穩定性和權威性問題發生。

七要加大水利科技推廣力度，加快農村水利信息化建設。健全水利科技創新體系，強化基礎條件平臺建設，加強基礎研究和技術研發，廣泛推廣轉化水利先進實用技術。盡快制訂、修訂技術標準和規程規范。加快實施國家防汛抗旱指揮系統二期工程、國家水資源管理信息系統、農村水利管理信息系統建設，進一步完善水文站網體系，搞好第一次全國水利普查工作，建立國家基礎水信息平臺，以水利信息化帶動水利現代化。

Among 153 subjects that completed the questionnaire, the primary substances of abuse or pathological behavior are reported in Table 1.

Statistical analyses were performed using Statistica version 8.0. Quantitative parameters are presented as the mean ± SD and qualitative parameters as number and percentage per class. The Kolmogorov-Smirnov test was used to check for normality of distributions. Analysis of variance and Duncan post hoc test were employed to analyze differences among subgroup means. The associations between variables were measured using Pearson's correlation. Avalue of < 0.05 was considered significant.

The level of craving was significantly higher (= 4.36;< 0.05) in outpatients (=97; mean = 3.8 ± 3.1) living in their own home during the quarantine compared with inpatients (= 56; mean = 2.8 ± 2.8) in residential programs. Craving for tetrahydrocannabinol was the greatest (4.94,< 0.001) among various preferred substances(Figure 2).

RESULTS

①在立模上用墨線彈出標高線。以人工均勻攤鋪，虛鋪厚度一般為實際厚度的1.05～1.20倍。攤鋪時應找準平整度與排水坡度，施工時對邊角處特別注意有無缺料現象，要及時補料進行人工壓實。

鼻科醫師應該認真對待每一次醫學模型中的解剖訓練。在模擬標本操作前，鼻科醫師應當首先熟練掌握鼻腔鼻竇、鼻顱底、鼻眶相關解剖的理論知識，并仔細閱讀鼻鼻竇CT，了解鼻腔鼻竇解剖異常情況，需要充分熟悉鼻內鏡鼻竇手術相關的器械特點和性能。具體操作過程中，必須注意規范化鼻內鏡技術操作，明確掌握技術要點。我們推薦的鼻內鏡鼻竇手術規范化操作步驟如下。

Sixty-seven (43.8%) of the participants reported a comorbid psychiatric condition,especially mood disorders (depression, bipolar disorder) and anxiety. In this subsample, a psychopharmacological treatment was reported by 94% of subjects. The variation in craving between the present and the month before showed VAS-related reductions of craving in 57%, increases in 24%, and no significant change in 19% of the sample (Figure 1).

將拌好的育苗床土裝入盤或育苗缽中，新裝的盤壓在已經裝好的盤上，一層層地壓，下邊壓實的再拿到上邊壓新裝土的盤，使育苗床土填實，再利用刮板從穴盤一方刮向另一方，使每個空穴都能平整的裝滿育苗土。

Patients with a dual diagnosis (= 67; mean craving VAS = 3.9) did not show a significant difference in the levels of craving [(1; 150) = 2.43,> 0.121] with respect to patients without psychiatric comorbidities (= 86; mean craving VAS = 3.1).

Overall, we observed an increased consumption of coffee and cigarettes in about half of the sample. In contrast, symptoms indicative of behavioral addictions and other substances' consumption remained almost stable (Table 2). Changes in life habits are shown in Table 2. Reduced quality of life due to COVID-19 driven by the lockdown was present in 51% of the patients; 25.5% declared no significant changes, and,surprisingly, 23.5% increased quality of life. Low levels of quality of life correlated with high craving scores (= -0.226,= 0.005).

DISCUSSION

One hundred and fifty-three patients completed a structured questionnaire evaluating craving and other behaviors using a visual analogue scale (VAS).Forty-one subjects completed a pencil and paper questionnaire during the interview. The clinician provided an online questionnaire to 112 patients who had virtual assessments due to lockdown restrictions. Statistical analyses were performed using Statistica version 8.0. Quantitative parameters are presented as the mean ± SD and qualitative parameters as number and percentage per class.The Kolmogorov-Smirnov test was used to check for normality of distributions.Analysis of variance and Duncan post hoc test were employed to analyze differences among subgroup means. The associations between variables were measured using Pearson's correlation. Avalue of < 0.05 was considered significant.

In order to explain this controversial data, we propose the hypothesis of a perceived lack of availability of substances and gambling areas. Practical difficulties in sources of supply, such as the unavailability of the usual dealing spaces, may have interrupted the development of the craving priming. Craving is usually determined by the possibility to obtain a substance. When external measures limit this possibility, cravingitself could be dramatically reduced, as the case of the strict lockdown. Second, we hypothesize the presence of decreased social pressure on a group of subjects who are usually excluded and stigmatized. Social exclusion is indeed a psychosocial stress factor[22] that can increase craving and drug use[23]. As social identification is the self-definition of a person in terms of group membership[10], the period of lockdown because of the COVID-19 pandemic can favor personal feelings of being part of a group facing a common danger and sharing a common fate. Therefore, this new social identity might overshadow the sense of exclusion and rejection in the abuser,ultimately with the positive outcome of reducing craving and substance abuse. This possibility is consistent with data from a survey released by the Israel Democracy Institute that showed how the sense of belonging and unity increased during the COVID-19 outbreak among groups usually sidelined[24]. In this direction, the use of a specific strategy such as telepsychiatry acquires great importance for careful monitoring of the patient’s clinical and psychopathological conditions, in order to prevent relapses and to promote social integration[25].

Our data also indicates that residential treatment in containment facilities during the quarantine is an effective procedure that positively impacts craving levels,probably reinforcing the first hypothesis regarding the unavailability of the substance as a means to reduce craving.

In line with other studies, our data showed an increase in the consumption of coffee and cigarettes. Increased cigarette use could be explained as a natural response to stressful events, especially as a consequence of depressive symptoms; the consumption of coffee could be determined by the tendency towards sugary foods and drinks, in order to find quick relief in stressful times[26,27].

It is also interesting to note that a relevant part of the sample reported reduced quality of life during the strict lockdown, with a negative correlation between craving and perceived quality of life. This data leads us to hypothesize that despite a substantial reduction in the perceived quality of life, the levels of craving have in any case been reduced, as a counter-proof of how much the unavailability of the substance and the increase in social integration may have had a direct positive effect on the reduction of craving.

Limitations

The main limitation of our study is the high prevalence of cocaine abusers. This demographic feature is different from other treatment-seeking cohorts where alcohol is generally the main substance of abuse. This discrepancy is probably because our recruitment centers are specialized in the treatment of cocaine use disorder. Another limitation of the study is the use of a VAS instead of validated scales. We chose to use VAS because of its immediacy to homogenize and accelerate the completion of the questionnaire, making it suitable also online during the virtual assessments due to lockdown restrictions. Our results are difficult to generalize because of the brief time of observation, and further studies are needed.

CONCLUSION

Our data suggest that craving was globally reduced in a period that could be highly stressogenic. This unexpected result may be explained by: (1) A perceived lack of availability of substances and gambling areas that interrupted the development of the craving priming; and (2) the presence of a decreased social pressure. Our results can lay the groundwork for future treatment policies in the direction of strategies that limit the availability of the substance and in parallel towards strategies that aim at greater social integration of subjects affected by addiction disorders.

好好給我捻船，我一分錢都不虧你，從今天起，每天給你加一百。王鯰魚說著，嘴里刁著一顆軟中華，腳下喀嚓喀嚓幾聲，就消失在碼頭那邊的陽光里。

Our data suggest that craving, regardless of whether determined by substances or behaviors, was globally reduced in a period that could be highly stressogenic. This data leads us to hypothesize that despite a substantial reduction in the perceived quality of life, the levels of craving have in any case been reduced, as a counter-proof of how much the unavailability of the substance and the increase in social integration may have had a direct positive effect on the reduction of craving.

Our results can lay the groundwork for future treatment policies in the direction of strategies that limit the availability of the substance and in parallel towards strategies that aim at greater social integration of subjects affected by addiction disorders.

APS-C單反都可以使用同品牌全畫幅單反的鏡頭，但反過來卻不一定可以。佳能的EF-S系列鏡頭只能在旗下的APS-C機身上使用，而尼康的全畫幅相機則可以使用DX系列鏡頭，但相機會自動切換到DX模式。無反相機的卡口與單反不同，但可通過轉接環轉接其他系統的鏡頭。

The authors wish to dedicate this manuscript in memory of Dr. Sepede. Her energy and scientific keenness will continue to be a reference model for us. The authors also wish to thank the “CO-dip group” for the help in carrying out the study: Ceci Franca,Lucidi Lorenza, Picutti Elena, Di Carlo Francesco, Corbo Mariangela, Vellante Federica, Fiori Federica, Tourjansky Gaia, Catalano Gabriella, Carenti Maria Luisa,Concetta Incerti Chiara, Bartoletti Luigi, Barlati Stefano, Romeo Vincenzo Maria, and Valchera Alessandro.