Difficulty getting necessities, experiencing more negative mental health effects, and greater worry about one’s children’s well-being was associated with greater depression and anxiety symptoms. In multi-variable models, controlling for demographic characteristics, negative mental health effects of the pandemic were the strongest correlate of substance use problems, depressive symptoms, and anxiety symptoms. Participants with high scores on this measure reported frequently thinking about COVID-19, worrying about their health and/or the health of their family and friends, experiencing stress due to changes in social contacts and their lifestyles, worsening of their mental/emotional health, and sleep disruptions. Findings suggest that the COVID-19 pandemic is producing major concerns that may contribute to mental health symptoms, including problematic substance use. Many individuals are using substances to cope with stress and uncertainty around the pandemic . A nationally representative sample of U.S. adults conducted early in the pandemic identified increased risk of depressive symptoms among people with lower income, fewer savings, and more stressors . People with problematic substance use may also be at elevated risk for depressive symptoms. While some evidence suggests that pandemic-induced psychological distress is lessening in the United States , people with problematic substance use are vulnerable to the negative effects of the pandemic . In this study, participants with more substance use problems were less likely to avoid bars and large gatherings, corroborating concerns that substance use may increase risk of contracting COVID-19 . Participants struggling to control their substance use may have found it difficult to avoid settings in which they use. Paradoxically, individuals with greater substance use problems also perceived greater personal growth from the pandemic in the forms of strengthened relationships, new possibilities, awareness of personal strength, spiritual change,vertical grow rack system and increased appreciation of life. People with problematic substance use often experience intense emotions . Experiencing intense emotions may have led individuals with substance use problems to be deeply affected by both positive and negative pandemic-related changes.
Additionally, perceiving greater personal growth was associated with lower likelihood of struggling with responsibilities at home and lower likelihood of avoiding large gatherings. Participants who perceived personal growth may be a subset whose daily lives were less strongly affected by the pandemic. Study data are cross-sectional, and causal pathways cannot be determined. There may be bidirectional relationships between substance use problems and pandemic-related mental health symptoms and stressors. While pandemic-related stress may have worsened mental health symptoms and substance use, it is also plausible that individuals with preexisting mental health symptoms and more substance use problems were negatively impacted by the pandemic than those with milder symptoms. Longitudinal research is needed to fully understand how substance use and pandemic-related circumstances may impact one another. The study was exploratory and was intended to be hypothesis-generating rather than hypothesis-confirming. Results are also subject to recall bias, as all measures were self-reported. Participants may have had difficulty accurately reporting their substance use and mental health symptoms from the past two weeks. Data were not collected on general life stressors unrelated to the pandemic. Individuals with high levels of stress may have experienced more pandemic-related stressors, mental health symptoms, and substance use problems. Lastly, the sample was predominantly non-Hispanic white. People of color are at increased risk of contracting and experiencing complications from COVID-19 . Moreover, Hispanic and Black individuals were more likely to report increased substance use than non-Hispanic white or Asian adults, potentially due to increased stress . Different vulnerabilities may interact to influence experiences of the pandemic. All participants were enrolled in a clinical trial, were not experiencing severe medical problems from their substance use, owned smartphones, and were proficient in English. Hence, findings may not generalize to more impoverished, medically complicated, or diverse groups. Future research into pandemic-related stressors and substance use should aim to recruit a more diverse sample. We explored correlations between trauma and mental health symptoms , and SSIS substance use scores . Our study indicated high rates of ACEs, substance use, and current mental health symptoms among homeless TAY in San Francisco.
Although substance use was not significantly correlated with trauma, it was significantly correlated with mental health symptoms, suggesting that a person’s response to trauma, and their lack of resources to process the trauma, may lead to unhealthy coping through substance use. This population may have even fewer resources than their housed counterparts to cope in healthy ways. These findings are consistent with existing scientific literature . TAY experiencing homelessness in this study reported a mean of 5.9 adverse childhood experiences before the age of 18, and over three-quarters of participants reported more than 4 ACEs. This finding parallels other research on childhood trauma exposure among these youth . Participants also reported high rates of mental health symptoms, with many reaching diagnostic thresholds for PTSD, depression, and/or anxiety, again similar to existing research . Most participants lived in and around San Francisco’s Tenderloin neighborhood, an area with high rates of poverty and violence, which may have contributed to their experiences of trauma and mental health symptoms. Although we measured experiences of trauma prior to the age of 18 years, and all participants were over the age of 18, living in an area with high rates of poverty and violence puts individuals at additional risk for trauma. This serves as a barrier to accessing care for the sequelae of traumas experienced previously. Homeless TAY frequently have difficulty accessing services such as shelter, medical care, mental health services, and employment due to stigma, a lack of knowledge about available resources, and a lack of services targeted to young individuals . Rates of substance use among our participants were high, and while much of their use fell within the range of moderate-risk of harm, adolescence and young-adulthood are times of life during which the risk of developing substance misuse problems and disorders is high, making even moderate-risk use worrisome . At the same time, youth misuse of substances may increase their risk for experiencing trauma, violence, and injury, and for contracting communicable diseases such as HIV and Hepatitis C . TAY whose substance use behavior falls within moderate-risk levels of harm are a population in high need of monitoring and interventions to minimize substance use as well as co-occurring issues. Our findings also indicated that substance use was significantly correlated with current PTSD symptoms. An integrative review examining literature on the relationship between early life stress, childhood trauma and abuse, substance use, and addiction found strong evidence that interpersonal childhood trauma is associated with an increased vulnerability to substance use disorders .
Reasons for this may be due to the permanent changes to the brain’s stress circuitry formed by early life stressors . This may help explain at the individual-level why our findings show a significant relationship between trauma symptoms and substance use. Interestingly,vertical growing system in our sample we did not identify correlations between ACEs and most types of substance use, although this has been observed in other literature. A community study recruiting youth ages 18-25 years found specific scores and types of ACEs to be significantly associated with substance use . Participants who have high or multiple exposures to ACEs were at higher risk for alcohol related problems, current substance use, and mental health symptoms when compared to participants who have none to low ACEs . The lack of correlation in the current study may be due to the high number of ACEs reported by our participants, on average. While there was little correlation between ACEs and substance use, there was a significant correlation between the longer-term consequences of trauma – PTSD, depression, anxiety – and substance use. We conducted a cross-sectional study, which limits our ability to conclude whether exposure to trauma or experiencing mental health symptoms directly influences participant use of substances. We also recruited participants using convenience sampling, which increases the risk for selection bias. In examining potential selection bias, we found that our participant demographics largely mirrored the 2019 homeless youth point-in-time count, with the exception of gender; in our study, 67% of participants identified as male, but only 48% identified as male in the point-in-time count . This could affect generalizability to the larger homeless TAY population in San Francisco. Additionally, since the study was conducted in San Francisco, these results may not be generalizable to other locations. One limitation of data collection instruments such as the NIDA-Modified ASSIST is their validation for use in adult populations rather than transitional-aged participants, which may affect reliability. Participants were asked intimate questions about their childhood trauma, mental health symptoms, and current and past use of substances which may have resulted in an under reporting of trauma, mental health symptoms, and substance use due to social desirability bias. The CBO suggested that data collection be completed through face-to-face interviews, and this may have resulted in social desirability bias.
Future research with this population should consider data collection methods that allow for both confidentiality and participation of individuals with lower reading skills. Our study did not categorize ACEs into types of trauma nor did we separate ACEs scores into low moderate and high categories due to our sample size. Our findings could be influenced by our methodology and sample size, potentially resulting in a type II error. Another limitation in determining links between childhood trauma and substance use is the proximity in time between adolescence and young adulthood. It is difficult to determine which adverse experiences began and ended prior to the age of 18 years and which have not. This is one possible reason why we did not find any significance between ACEs and substance use when studies among older populations have found such a relationship . Due to the length of the survey, we did not measure all potential sources of trauma . Thus, we are unable to assess whether recent trauma or specific types of trauma are more correlated with substance use than generalized adverse experiences in childhood. Health care reform in the United States has had major implications for people with substance use disorders , including greater opportunities to enroll in private insurance coverage, increased access to services, and changes in health care costs . The Affordable Care Act established state insurance exchanges to promote and offer health coverage, and mandated SUD and psychiatric disorder treatment as essential benefits. Practitioners expected these ACA mandates, implemented in 2014, to increase access to care . Following ACA implementation in 2014, the overall number of individuals living without insurance dropped . Evidence suggests a positive impact of the ACA on both SUD and psychiatry coverage , including an increase in insurance choices . The number of individuals with identified SUDs enrolled in health plans increased . But access to services remains a major concern , and much is still unknown regarding how ACA-associated enrollment through insurance exchanges and cost-sharing structures are associated with access to and use of SUD treatment and other health services in this complex patient population.Specific characteristics of the ACA, such as enrollment via new state insurance exchanges and increased patient cost sharing via higher deductibles, may influence treatment differentially for people with SUDs who may be new enrollees . Patient cost sharing may adversely impact both initiation and retention. If SUD treatment and psychiatry services are viewed as discretionary and less essential than primary care, they may be especially vulnerable to cost-sharing mechanisms . A previous evaluation of SUD patients enrolled in the same California healthcare system found that compared to a pre-ACA enrollment cohort with SUDs, post-ACA SUD patients had more psychiatric and medical conditions and greater enrollment in high-deductible plans. Although this prior work did not examine patterns of health service utilization, the findings suggest that newly enrolled patients post-ACA may have greater clinical needs as well as increased financial obstacles to accessing services . It is important to not only evaluate SUD treatment initiation and retention over time following implementation of the ACA, but also to evaluate how factors related to the ACA may influence utilization of other health services. The current study aimed to extend what is currently known about the consequences of healthcare reform by examining the potential relationship of ACA exchange enrollment and high deductible health plans to trends in health service utilization in a cohort of individuals who were newly enrolled in a healthcare system and had a documented SUD.