[Review Article] Drug Use Disorder and Coping Mechanisms Due to COVID-19 Pandemic Measures: A Cross-Sectional Survey

Background: The COVID-19 pandemic presented numerous obstacles to people of different health status and capabilities. There is scarcity of information on the coping mechanisms for people with substance use disorder during the COVID-19 pandemic in Arab nations. This study aimed to identify behavioural mechanisms and factors associated with how the COVID-19 pandemic measures imposed among people with substance use disorders in Oman. Methods: Survey data on demographic and behavioural factors from 61 respondents out of the target sample of 73 persons with substance use disorder receiving treatment at a specialised hospital. Changes in behaviour related to substance use due to the COVID-19 pandemic measures were investigated using demographic and modifiable factors. For the specific study evaluation, the variables studied included; age, family size, marital status, employment status, suicidal thoughts, and ways of substance abuse, family responsibilities, hospitalisation tendency, and change of behaviour. Findings: On average, the participants were 16-48 years old (mean age 31.5 years, SD=6.82). The study findings show that the consumption of morphine as the main drug compared to others (OR = 0.03, p =0.003) resulted in a reduction in the odds of feeling increased effects of COVID-19 measures among individuals with substance use disorder. Furthermore, the increase in effects was significant among the participants who opted to be hospitalised to reduce drug use (OR=9.97, p =0.017) and those who took overdoses (OR=8.17, p =0.008). Conclusion: The study findings indicate that due to the measures taken during the COVID-19 pandemic measures, individuals with drug use disorders switched to different types of drugs, such


Introduction
The global Coronavirus pandemic (COVID-19) posed significant healthcare challenges at individual and social-structural levels. [1]Although the epidemic posed a threat to everyone, the COVID-19 pandemic has presented several challenges for people with substance use disorders (SUD), including disruption of treatment services and the likelihood of relapse. This may have driven people to seek alternative or more dangerous drugs, with all the consequences that this may entail.Individuals with SUD have been associated with an increased risk of communicable infections in the past. [4]It is also well known that people with SUD are more vulnerable to infection by the virus [5] that causes COVID-19 and its consequences due to direct challenges to respiratory health.Furthermore, individuals with SUD who got infected with COVID-19 may have found it more difficult to receive treatment due to not accessing services or simply using healthcare to address the sequelae of COVID-19.Similarly, ongoing social distancing tactics would also have created a distinct difficulty for those who need help to overcome viral infection.
According to the literature, drug intake increased during the COVID-19-related lockout compared to the period before. [6]Between April 2021 and April 2022, the CDC estimates show that more than 99,000 people died from drug overdoses in the first full year of the epidemic in the United States.Furthermore, synthetic opioids such as Fentanyl were responsible for over 75% of deaths due to overdose in the first year of the pandemic. [7]Since the epidemic began in early 2020, a surge in the abuse of numerous other drugs has been observed, including heroin, methamphetamines, and cocaine. [7]According to previous research, drug misuse did increase during the COVID-19-related lockdown compared to the period before. [8]Conceptually, COVID-19 disrupted the normal operation of trends in different behaviors, including among people with drug use disorder.Many developed creative ways of survival to adapt to the new dictated modes of life by using inferior substitutes, some of which resulted in serious side effects. More specifically, during the COVID-19 pandemic, a number of measures taken, which often tended to lock-in or reduce mobility affected individuals with SUD in a way that forced them to adjust their ways of livelihoods.This study aims to address this gap in the existing literature by investigating the experiences of Omanis with SUD during the COVID-19 pandemic.The specific objectives of the study were to: 1) identify the coping mechanisms of people with SUD due to the COVID-19 pandemic measures; 2) determine the effect of Morphine as the main drug on the tendency for people with SUD to be affected by the COVID-19 pandemic measures.3) assess the effect of the following factors; drug overdose, sleeping out, tendency for hospitalization, escaping from home and tendency to kill self as consequences on people with SUD due to the COVID-19 pandemic measures.

Data Source and Sampling
This was a cross-sectional study stemming from the observational analytical arm of an epidemiological study design that used data collected from people with drug use disorders admitted at the Al Massara Hospital, a tertiary care hospital, Muscat Governorate, Oman.The study site is the only tertiary hospital for psychiatry in Oman, with a bed capacity of 221 beds and comprehensive services for people with alcohol and drug misuse. [13]rvey data on demographic and behavioural factors from a sample of 61 (n = 61) patients admitted to health centres were collected and analysed.The change in behaviour among people with SUD caused by the COVID-19 pandemic was investigated by assessing the following potential factors, including: age, family size, marital status, employment status, suicidal thoughts, way of drug abuse, family responsibility, hospitalisation tendency, and change of behaviour.
A question on the coping mechanism(s) adapted by the study participants was asked to identify the level or extent of the COVID-19 effect.The question was a multiple response type with an option for others to be specified, if such an option was not listed among the response categories.
The sample size of 73 was calculated using the Cochran formula for the unknown population.Based on the assumption that the proportion of patients with SUDs affected by the COVID-19 epidemic was 0.95, estimates were made at a 95% CI with an acceptable error margin of 5%.The sample size (n) was calculated using the standard sample calculation formula for the proportion. [14] The realised sample of 61 of the 73 study participants was enrolled, implying a response rate of 84% was achieved, despite the limitations caused by the unpredictable effects of COVID-19.The study used a questionnaire to collect data from a random sample of consenting patients who reported at the hospital with cases related to drug use disorder until a sample of 61 was realised.The data were collected during the second half of the year 2020 (June-December, 2020) after the COVID-19 pandemic was declared in Oman.

Statistical Analysis
Data were analysed using descriptive and inferential statistics by generating frequency tables and Chi-square tests at the bivariate level, while at the multivariate level, the logistic regression model was fitted to assess factors associated with the change in behaviour among people with SUD caused by the COVID-19 pandemic.Associations were determined as being statistically significant at the predetermined 0.05 level of significance.Using the principle of parsimony, only those factors with a p-value less than 0.3 at the bivariate level of analysis were selected for inclusion in the logistic regression analysis. [16][17]The factors evaluated were classified as demographic or behavioural, that is, those identified to be directly related to drug use disorder.The rationale for selecting binary logistic regression was its ability to identify and test the hypothesis that there is no relationship between the potential predictors identified and the effect of the COVID-19 pandemic on drug abuse. [18]The study outcome was a binary variable, with two categories, that is indicating COVID-19 measure effect (1) and No COVID-19 measure effect (0).All statistical analyses were performed using the R programming language. [19]All p-values were two-tailed and statistical significance was set at 0.05 level of significance.
The study used interview data gathered from human individuals.Every patient gave their consent.The research was conducted during the COVID-19 pandemic, and the institute director examined and approved the study's execution.
Informed consent was obtained from each participant, and the Helsinki Declaration was upheld in the conduct of this research.

Description of study participants
A total sample of 61 people with SUD fully responded to the study, which constitutes a response rate of 90%.The majority of them were unemployed (69%, n=42) [Figure 1 (A)], while most of the respondents were single (72%, n=44), the others (28%, n=17) were married or divorced [Figure 1      approximately 50%, n=30 attempted to kill themselves, while 67%, n=41 were hospitalized.Most of the participants with drug use disorder (98%, n=60) tried to take other drugs available and reported that these drugs were generally available during the pandemic (98%, n=60).However, other effective behavioural changes included taking overdose (44%, n=27), sleeping out of home (60%, n=37), escaping from home during drug search (80%, n=49) and some even preferred to report to the concerned healthcare authorities so that they could be helped stop drug abuse (20%, n=12).

Modifiable factors associated with the COVID-19 pandemic among persons with SUD
Although the most abused drug was identified as Morphine, our findings suggest that due to the effect of COVID-19, most people with drug use disorder switched to other drugs (n=14, 45% versus (n=17, 55%).Similarly, among those who reported the effect of COVID-19, there was an increase in escaping home during lockdowns to find drugs (n=29,94%), preference for hospitalisation to reduce drug abuse (n=25,81%) and taking overdose (n=19,61%).The other factors, though not statistically significant, resulting from the COVID-19 effect among participants with drug use disorder include; having suicidal thoughts and exploring different channels to obtain drugs.
In Table 2 we present detailed findings on the effect of the COVID-19 pandemic on drug use and the associated factors among patients with drug use disorder using the logistic regression model.As indicated before, the dependent variable was whether COVID-19 affected the way people with drug use disorder behaved, where 51% (n=31) of the respondents reported an effect.Our proposed model predictors included all the factors presented in Table 1 with probability values less than 0.3.In the final model, taking Morphine as the main drug compared to other drugs (β= -3.50, p=0.003), resulted in a significant reduction in the chances of feeling the effect of COVID-19, while the increased effects were significant between these two predictors, that is; being hospitalised to reduce drug abuse (β= 2.30, p=0.017) and overdose (β= 2.10, p=0.008).
However, these findings were the same in magnitude and direction for both the proposed and final models, respectively.

Discussions
Substance use disorder (SUD) develops over long-term administration of various 'addictive' drugs, which can lead to physical, psychological, and social effects. [20][21]The negative effects of SUD can become even more difficult during a pandemic due to restrictions on mobility.This can make it harder for SUD individuals to manage their condition and obtain the necessary support and treatment.It underscores the importance of addressing the unique needs of this population during public health crises such as the COVID-19 pandemic.
This study aimed at exploring factors associated coping strategy among Omani with SUD during COVID-19 pandemic and to identify the shift in the potential factors associated with drug usage.We tested the following potential factors against the COVID-19 effect, which are; the main type of drug use, suicidal thoughts, marital status, hospitalization, escaping home during lockdowns to find drugs, taking an overdose and sleeping out to find drugs.The choice of these factors was made based on several investigations carried out by other studies. [22][23]Among these factors, the following were found to have significantly changed among persons with drug use disorder in Oman; the main drug, hospitalization and overdose.
According to the findings, individuals with SUD who took Morphine as their main drug were three (OR=0.03,p=0.003) times less likely to report that COVID-19 affected their pattern of abuse than those who took other drugs. [23][24]This finding implies that the source of supply of Morphine remained almost unchanged, but that of other drugs was reduced, hence the observed effect.On the other hand, when SUD patients are hospitalised, the chances of drug abuse are reduced.The study revealed that hospitalised individuals with SUD were 9.97 (OR=9.97,p=0.017) times more likely to have been affected by COVID-19 than those not affected. [20][22]Furthermore, the overdose was found to be directly associated with the effect of COVID-19 in such a way that those who took the overdose were 8.17 (OR=8.17,p=0.008) times more likely to have been affected by COVID-19 than those who did not. [21][24]Taking an overdose was associated with quenching the drug thirst now such that one takes longer to need more.It is a common technique adopted by individuals with SUD during times of drug scarcity.

Study limitation
The study's sample size may appear limited at first glance.However, it is worthwhile to note that the choice of a smaller sample was deliberate and well-suited to the study's objectives.Instead of aiming for a larger and more general representation of the national population with SUDs, the study specifically focused on individuals who were admitted to SUD treatment.This precise targeting allowed for a closer examination of the behaviors and factors related to this specific group.Second, the outcome measures were not derived from the established questionnaire.It was specifically designed to suit socio-cultural issues relevant to Oman.It should also be noted that the main dependent variable was based on participants' self-reports and therefore bound to subjective perceptions.Nevertheless, our results agree with those of other similar studies, suggesting that self-reports were actually consistent across countries.Future studies should examine the present survey for its psychometric properties.Thirdly, it is important to note that this study is facility-based, which means it focused on individuals within a healthcare setting.For future research, there is an opportunity to expand the scope by including a broader representation of the community.This is especially pertinent because a significant portion of people with SUD tend to remain outside the purview of healthcare services.Expanding research beyond healthcare facilities could provide a more comprehensive understanding of the prevalence and behaviours of SUD in the general population.

Conclusion
The specific objective of our study was to identify behavioural changes and factors associated with the effect of the COVID-19 pandemic among people with drug use disorder in Oman.Several potential factors related to the effect of COVID-19 were tested, including; the main type of drug abuse, suicidal thoughts, marital status, hospitalisation, escape home during lockdowns to find drugs, taking an overdose, and sleeping out to find drugs.Our study identifies that individuals with SUD who took Morphine as their main drug were less likely to report that COVID-19 affected their pattern of drug abuse.However, behavioural factors such as hospitalization and taking overdose were very likely to impact a

Figure 1 .
Figure 1.Distribution of Employment Status (A) and Marital Status (B)

Figure 2 .
Figure 2. Distribution of Number of Family Members (C) and Number of Sons (D)

Figure 3 .Figure 4 .
Figure 3. Distribution of Method of Abuse (E) and Major Type of Drug (F)

Figure 5 .
Figure 5. Behavioral changes among patients with drug use disorder Qeios, CC-BY 4.0 • Article, February 28, 2024 Qeios ID: FZOV08.2 • https://doi.org/10.32388/FZOV08.2 11/14 significantly positive on persons with SUD due to COVID-19 pandemic.In conclusion, one would recommend to promote community-based services and making them more accessible to patients with drug use disorder during the COVID-19 pandemic.Availing other drugs through outreach programmes would probably reduce the tendencies towards overdose as well as hospitalization, and subsequently a reduction in the effect due to any future pandemics among persons with drug use disorder.

Table 1 .
Factors Associated with effect of COVID-19 among Persons with Drug Use Disorder * Significant at 0.05 level of significance

COVID-19 Effect Proposed Unadjusted Model Final Adjusted Model
^ Reference category, * Significant at 0.05 level of significance