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Deborah Howell (Host):  With a relentless focus on excellence in healthcare, Pullman Regional Hospital presents the Health podcast.

We've all experienced a brush with substance abuse, whether it be with a family member, friend or coworker and know the true heartache it can bring in any year, but in this year particularly. To talk about substance abuse during COVID-19, today we're joined by Dr. Chad Sanders, a Neuropsychologist with Palouse Psychiatry and Behavioral Health here at Pullman. Dr. Sanders, in your practice, are you seeing more people struggling with substance abuse over this last year during the COVID pandemic?

Chad Sanders, PhD (Guest): Yeah. It's a good question. I haven't actually seen a huge change in terms of the rate of people presenting with their primary concern being about substance use. But I definitely have noticed an increase with substance use being a secondary concern that's popped up kind of insidiously over time. It's definitely stuck out to me anecdotally about the kind of things that pop in where, "Yeah. you know, I've noticed that I've been spending more on alcohol lately or I felt gross the other day or got in a fight with my wife." It's that level of thing where it finds its way into therapy or even with some of the neuropsych testingevals. And so that's been more of a pop-up, is where it's been a secondary concern.

And the other thing I've noticed kind of interestingly, is I have also noticed an increase with people's emphasis on wanting to make healthier change rather than things that I bring into the room based on what they're reporting. So, there's more agency I've noticed with people anecdotally anyway with my practice.

Last week, actually, I had an individual who he and his wife had recently contracted COVID and they decided to cut out caffeine while they were sick, because there's kind of an old school thing about if you get the flu or the cold, it can be a good time to take a break from coffee because some of the symptoms will be kind of masked by the overall suffering. And so they just took advantage of it that way. But typically, in my practice, the most I've seen is kind of on the level of wanting a tolerance break or less, but not so much of a change with moderate or more severe substance use.

Host: And why do you think people are resorting to substances?

Dr. Sanders: The usual suspects still apply. Coping with stress is a predominant one and stress has definitely gone up with COVID. Ongoing stress with COVID has been a thing and COVID has been going on for months now. And so the whole COVID fatigue factor is playing in. At first, there was some acute stress with the initial part of COVID and the stay-at-home proclamation, but that also had some novelty to it around some people actually enjoyed it. It was kind of a staycation, a fun thing or a going to the grocery store becomes an adventure. Some of those novelties were there. But with time, COVID fatigue, it's not as fun for those people anymore. And for the majority of us, the stress is getting worse with time just because of the COVID fatigue.

And that's not to mention other factors. There's the whole political climate, the climate itself, a lot of other stressors as well. And that's all kind of the global factors or cultural level factors. There's also personal stress, individual factors, conflicts at home. This is another one that with COVID because of how much time we're spending at home, we're seeing things that are similar to like the retirement effect, that one of the highest factors correlated with divorce is mutual retirement. When both individuals enter retirement, we see the spike in divorce rates, which is really sad. But it's about kind of the sense that compatibility factors that have been masked by daytime apart, work endeavors on the side, when that goes away and you're spending so much more time together, incompatibility is going to rear its head, so that's factoring in.

But then also the combination of working from home, parenting, teaching as a parent, most parents aren't trained to teach, homeschooling and then contact precautions. The holidays are upon us and there's a lot of stress about do I, don't I, how to quarantine and then navigating conflict within family.

So, there's a lot of the typical stressors that have always contributed to substance use compiled with a lot of new things that are unique to COVID and secondary. So it's a mess. So there's a lot of things that are contributing. The stress itself is one factor but even taking stress aside, it's also just harder in certain ways now with COVID. There's an increase in just recreational use. And part of that is we don't have those other factors that have typically allowed individuals to avoid substance use as a primary kind of hobby. For example, boredom. Boredom is real. And it's been worse with COVID over time. You can't go bowling. You can't go to the movies. It's hard to be able to do things outdoors in established areas. Hiking is still a thing, obviously, but the idea of going into a restaurant, even going to the library, stuff like that is rough. And then you take away that variety of the out-of-home engagement, things that can keep you away from substance use and it dwindles down the list of things to do to fill your time. And then we've also lost our social networks in certain ways. And so, when you have less social interactions, you're again left with less things to do.

And then working from home, studying from home, in most cases, students, professionals often go into the office. And with COVID, there's a lot more of that kind of work being done in home. And when you're at home sometimes like, "Can I study with a buzz? Can I do my report? Can I do my work with a little buzz on?" And that kind of thing can start off insidiously, but it can become a problem because you get used to it.

And then the thing with substance use is it's also really normalized right now through social media. There are countless memes about white wine in the morning and drinking while you're on a FaceTime or Zoom call or students pulling pranks and being stoned in the background. And that's funny. But it does serve to normalize too, this kind of incidental time in our culture's history around opportunities for substance use during what typically have been incompatible activities.

And then tolerance breaks were being normalized. And this was happening before COVID. But even the term tolerance break, that becoming normalized is not so good, because we don't want to normalize the idea of developing tolerance to substances. So there's those factors that are contributing as well. So, it's the combination of everything that's really a big factor with this.

Host: Yeah, 2020 is really piling it on, isn't it?

Dr. Sanders: 2020. Yep.

Host: What's the danger of affiliating use of substances with being at home under the stay-at-home order?

Dr. Sanders: That's a great question. It's a unique time for this, with COVID and our history and spending this much time at home, particularly when we don't want to. We do know that overall there's an increase in drug overdoses during the pandemic and increase in substance abuse. Delivery services are a new thing with the pandemic. And one thing about pandemics is we always learn and we learn new things about culture. Delivery is something that it's probably not going to change when COVID stops. And so delivery services for substance use, it might not be so great to get used to that. Because when COVID is done, it's still easy to get stuff delivered to your doorstep. And that's kind of problematic when we think about operant conditioning. And so operant conditioning is the big one, I think, is important with the danger of using substances at home during COVID.

Operant conditioning is all about associating reward and reinforcing rewards. So, when you think about substance use, it's hard for most other things to compete with the inherent reward of a substance. It's immediate, it's fast, it's strong and it's easy. And basic operant conditioning is any behavior is going to increase with reward, especially if there's not competition. So, when you're at home and there's not anything else to do and all those factors we talked about earlier, an immediate, quick, easy buzz is going to become appealing. And the more you do it, the more it becomes conditioned.

And that's where the other part of this comes in is the environment. So normally if you distribute your substance use behaviors across environments, you know, if it's Friday night and you go to a friend's house and you have a couple of beers, or if you go bowling, or if you go to the movies and you have a drink with dinner beforehand. Those different environments, because of the diversity and frequency don't really get associated that much with drinking. The bar is a good example that historically does get conditioned the more people frequent, because you're there more often, you're doing the same rewarding behavior, it starts to become associated.

But otherwise, if we kind of diversify what we do enough, it doesn't really happen. But because of COVID, we're spending a ton more time at home. So, when you're using substances at home with the level of recurrent frequency that's kind of forced on us, if you're using substances regularly, being at home, you start to condition that environment with substance use.

Most people, for example, with smoking cigarettes, smoke in the same place, a certain chair, porch, backyard, et cetera. And when you do that over and over and over again, that location, that stimuli becomes associated with reward. And over time, that location and the objects would then start to prompt the urge to use substances. So, you'd get home from work every day and you have a few drinks, let's say, and you do that with COVID, you do that every day, you do it over time. And then on a Saturday at noon, you might sit in that same chair and notice that it sounds kind of good to have a glass of whiskey where you might not normally and that's because of conditioning. That's an investment in problems in the future because the more you do that, the harder it is to decondition that environment.

And so, another problem with that is that once COVID resolves, all that stuff is still conditioned. So, you might be going to work now instead of working from home. But when you get back, you sit in that chair and same thing happens. And so, what we can potentially be investing in now by conditioning our home environment is problems down the road well after COVID resolves.

The other thing with that is the secondary problems that come from substance use. Things like harm to relationships, job problems, et cetera, those don't just go away when COVID resolves either. And so, if we're doing increased substance use and we're dealing with associations in the environment now, and we're also creating these secondary problems where we're going to work hung over, causing problems in our relationships Just because we're free to leave the house so to speak when COVID is over, those things are still going to be present. So, it's important to try to think long-term and critically about the things we do in our home environment given we're stuck there so often when it comes to operant conditioning,

Host: Dr. Sanders, is there an acceptable level of substances?

Dr. Sanders: This is a good question. It’s functional impairment, I guess, is probably your go-to compass with this, functional impairments on a continuum. And so, for work, for example we’ve all heard that term functional alcoholic. Well, it's kind of problematic because your benchmark is in my showing up for work Is attendance my basic benchmark? That's not such a good benchmark, just because you show up, that doesn't mean you're okay. "I got to work, so I'm fine." Well, you can still be impacted.

You know, are you feeling gross when you get there? Do you need two cups of coffee? Are you irritable? Are you dehydrated? So you're skipping out from your desk to go get water, go to the bathroom. Are you feeling only sharp come noon, one o'clock? You're still being impacted. So functional impairment versus functional impact, they're both concerning. And so you want to be proactive about both.

In a perfect world, substance use would be elective and it would be elective vise. Your body doesn't need it, so it's successive, so to speak, but that doesn't mean it's inherently bad. You just want to gauge it around "is it working for you?" You know, if it's about primary kind of avoidance or reactive coping, maybe don't do it. Or if you do notice that you're doing it to stave off withdrawal, whether that's psychological or physical, that's a big red flag.

And otherwise, yeah, functional impairment or impact are both things to consider. And ultimately you want to be proactive. Don't wait until functional impairment rears its head. If you do notice, like, "Man, Thursday, I got to work and I was feeling gross" and maybe have that be your cue to like, "Yeah, I'm going to take a little break. I'm gonna make some change, replace," kind of that kind of thing. But don't let it build up. And so it's important to be proactive and notice when it's at the level of impact before it becomes impairment.

Otherwise, if you can, through your due diligence, really kind of sit back and say like, "Yeah, none of that stuff's going on. I just want to have a couple beers while I watch the Super Bowl." Great. It's a personal kind of thing, but you do want to weigh those factors out, not to mention the main physical health factors too, of course.

Host: Sure. What are some healthier ways to deal with substance use?

Dr. Sanders: Yeah, there is a lot. We won't have time to go through all kind of want to talk about things focused with that. So, when it comes to operant conditioning, if you're aware that like, man, things are getting associated with substance use, it's becoming more of a habit. It's getting to be where I'm having a little bit of tension with not drinking tonight. Like I sometimes tell patients that in a perfect world, substance use is the equivalent of like should I have a burger or a taco? Where it's really a choice. And if you're starting to feel weighted one way or the other, that might be your indicator to pull back a bit.

And so if you're in that place where you want to make those healthier changes, there's a number of things you can do. A broad stroke thing to consider is avoid punishment-oriented strategies. Discipline does not work. We know that. The classic research paradigms have proven that if there's a button to push, we're going to eventually push it. We just don't do well with discipline. It's a safe bet to not account that we will be able to orient ourselves to discipline and that'll carry us through.

An example specific to substance use is the idea of prolonged contingency. So, you get home from work at five, you'd noticed you've been having a couple drinks every day at five. "Okay. I'm going to wait 'til seven. I'm not going to give in." And so you're sitting there, you're watching TV. You might be making dinner and you're thinking about like, "Man, I really want to have a drink, but no, I'm doing the right thing. It's 5:30. Oh, man. Okay. I'm going to wait 'til seven. This is good. I'm glad I'm doing this." But it's kind of on your mind. You keep waiting. Time goes by. It's about five till seven and you're getting pretty stoked to have a drink. Seven o'clock hits and you have that drink and it feels so good. You did the thing, you had the discipline, you made it. The problem is, when we experience withdrawal including psychological withdrawal and that ramps up, anything that immediately extinguishes that withdrawal actually further reinforces the behavior in the first place.

So, when you wait and then you give in, it's problematic. And so that's also a problem with discipline. In a nutshell, if you're going to do discipline, you really need to wait until you have your benchmark change in time. Like if you can wait until you go to sleep and then it's the next day, that's mission accomplished. But if you just wait a few hours and give in, it's not really going to work for you.

So those kinds of strategies, they're harsh and they just don't necessarily work. The best ones are things like stimulus control and reward. So stimulus control is about controlling things in the environment that can work to reinforce and maintain reward that then maintains behavior. So, one thing is deconditioning the environment.

So I've mentioned a lot about how you can associate items in the environment, your routine with substance use. So change it up. One of the basic parts of stimulus control is get rid of substances, sterilize the environment. And if you don't have anything in your house, it's not going to be as much about discipline versus the steps you'll have to take to go and get a substance. And that sometimes can be your saving grace, so to speak.

If it's not there, it's not going to remind you and that’ll work in your favor. Change the routine. If you have the same thing, like you come home from work and you walk right out to the kitchen counter and you pour a drink, maybe don't do that. Maybe do something different first. Take a shower. Bring food home instead of cooking and don't go into the kitchen. Simple things like that. Move your furniture around. For smokers for example, if you have the same chair all the time, don't sit in it or move it to another room, change it up. Don't go out back, don't go on the porch, things like that.

And then if you can embed activities in your environment that are incompatible. So, if there's things that you can do that really don't jive with substance use, like aerobic exercise, if you have an elliptical or something and you're on that, most people don't drink a beer while they're working on an elliptical. And so if you can do things that are incompatible, that will work in your favor as well.

Aside from stimulus control, reward and competition. So, alternative reward is always going to be better than punishment. And so if you can-- and this is where you have to get creative-- but if you can think of activities or endeavors that are going to be equally or even better that are more rewarding than substance use, that will win out.

It's never been a concern that people will get addicted to things they don't like. That just doesn't work like that. So, if you don't like mayonnaise, if you eat it every day, you're not going to become addicted to it per se. And so it's the things that we really like, and that are rewarding that we'll get addicted to. And it's hard to compete with substance use. Like I mentioned earlier, it's fast, it's quick, it's easy, it's intense.

And so things that are health-related tend to be more about delayed gratification, losing weight, working out, learning a skill, reading a book, those things are about delayed gratification. And impulsivity by definition is about things right now, quick, easy, et cetera. So, the rewards have to have that level of competition, but ideally, they also have to have value. If a person's been drinking every day to the point of tolerance, saying that they can have an Oreo or a piece of cake is probably not going to compete. But if you offer them a car, yeah, most people would probably stop, but a car is not realistic usually.

So, you have to get creative about tailoring the reward to counteract the substance use behavior. And then you want to tailor it to the individual. For some people, the idea of cozying up with a book might be really rewarding. And for other people, that might be why they use substances. And so, it has to be individual to the person. If you like video games, awesome. If you like certain foods, whatever it is, be creative and try to think through the different things that can be alternatives and are rewarding.

As far as what you do, all things that are incompatible with substance use are key. COVID has been limiting for this. This is why this is another layer to COVID that's kind of tough. But in general, things like going camping. Camping can be compatible with substance use, but it's still one step from kind of coming home from work and just drinking in your kitchen.

Staycations, going to a hotel, changing up the environment. It's a new environment, so you won't have any of that environmental kind of conditioned contribution to urges to use. Going to church, being in controlled environments, anywhere you can go where substance use or anything you can do where substance use isn't really compatible, those are going to be helpful as well.

And then also look at the contributing factors and eradicate those things. Don't procrastinate. Procrastination has been kind of newly conceptualized as being basically a type of anxiety issue. And so if procrastination is leading to substance use, don't do it, which is easier said than done, obviously.

But there's various strategies for that. And I won't go into too much detail, but there's things like mindset motivation. So, if you really get into the mindset of what you're going to feel like the minute you're done with whatever task you're avoiding, try to hold onto that feeling and let that help get you going because what's been shown is that procrastination has nothing to do with work ethic. It's a problem with initiation.

So, if you can just get going, that's usually the big thing. And then people sometimes can kind of flow and keep going. And then if it's different things that are contributing to avoidance for substance use, get them done so to speak. Also aerobic exercise, yoga and then all the other primary kind of contributing factors, stress, anxiety, mood issues, et cetera. And there's lots of resources for that, psychotherapy, group support, et cetera. But focus on those things too. You don't only have to focus on cutting down on substance use, but look at the contributing factors too.

And then the last thing I would say is social support. There's been a ton of money in research into the role of community and social support with substance use. Again, COVID can be a little bit limited because we can't just have access to our typical social network in our typical way, but social support can be big for this. And so, inviting individuals to help with stimulus control. And this is kind of a harsh truth, but it is more difficult to cut back on substance use going solo than it is if you have social support.

So, for those that do have access to social support, inviting key individuals to be your gatekeeper can be helpful. And so, having an individual like a loved one, a partner or family member, giving them permission and inviting them to be your gatekeeper. And sometimes it's evidence-based to even write out a contract so, that if there's things like, "Okay, you are going to meet my booze gatekeeper," then you have to go through them to be able to have access. And if you invite them and you contract, sometimes when psychological withdrawal kicks in and we're really feeling that craving, we might get pissed or it might get irritable or kind of get mean and snotty.

And if our gatekeeper can remind us, "Hey, this is what you wanted. This is that thing we talked about" and even flash the contract in front of you, sometimes that can help you surf the moment and kind of get you through it because, "Yeah, I might be feeling like really upset with you, but you're reminding me about that conversation we had. This is what I want. This is rough, but it'll pass." So external incentive, gun-to-the-head motivation, that's always been helpful for any behavioral change including substance use.

There's also a lot of business models that actually play into this. I can't remember the company, but I've seen commercials about basically you deposit money and then with weight loss and then if you meet your benchmark goals, you get some of your money back and then more. But if you don't meet your benchmark goals, you start to lose money. And gyms and certain fitness businesses are doing the same thing. When you sign up, you deposit 300, 500 bucks, and then if you don't meet these benchmarks, they keep a chunk of it. And that's an external incentive as well.

And then back to the primary environment stuff for loved ones and caring individuals who maybe share the space or just close to the person and close friend, et cetera, allow negative consequences to occur. Sometimes we can be really well-intended, but when we buffer the blow that substance use issues cause for a person, we end up reinforcing the substance use because we're not allowing reality to kind of come into play.

And so if a person's really hung over and like, "Oh my God, I don't want to go to work. Babe, would you call for me?" Don't do it. And remind the person like, "No. You need to call if that's what you're going to do." But we have to allow natural negative consequences to occur as well. That's different than punishment. We don't want to create consequences per se, but allowing negative natural consequences to occur is important.

And then the flip side, reward positive change, reward positive behavior. And when a person you care about is doing those positive changes with substance use, reinforce it, jump on it, throw in those incentives, et cetera. So, those are all in a nutshell some good ones that can go right into the operant conditioning perspective on making c Sounds good. Final question to you because we're out of time for today. What should someone do if they continue to struggle with substance abuse?

Chad Sanders, PhD (Guest): Yeah. If these kinds of primary things we've been talking about, if you do all those things, you're doing your due diligence and it's just, "Man, it's not working. “Be seen. Services are here for you. There's a lot of services in the area. One thing that can keep people from seeking services is stigma.

And so when that comes up and that's common most people are going to be a little bit hesitant to be like, "Man, should I really make a primary care appointment to talk about concerns I have about drinking too much?" Do it. Your primary care provider is not going to think less of you. They will think more of you. Most people don't do it because of stigma. So lean into it and do it.

The other thing I think about with this is this metaphor I'd love to talk about, is that going to the gym. Most people don't stigmatize people for going to the gym to get well. You know, if you have some cardiovascular issues, you have your annual physical and your weight's up, your BMI's up, your blood, pressure's up. If you make the decision, like, "I'm going to join the gym, I'm going to go to work," most people don't hesitate. In fact, that's probably empowering.

And so going to a therapist or going to a primary care provider to talk about medications, it's the same thing. It doesn't mean it's an admission of weakness and thereby failure, those kinds of things. It's a health-focused decision and change, and it should be viewed just like going to the gym. That it's a good thing. It shouldn't be stigmatized.

And there's a number of medication considerations. There’re things like Chantix for smoking; naltrexone, which I won't go into it, but if people want to look into it, the Sinclair method for alcohol use is gaining a lot of attention broadly. If the basic things aren't working for you, go nuclear. Don't focus on one thing at a time to make it work. Do it all. See your primary care provider, go to a therapist, keep doing the things we talked about. Hit the gym, all that stuff. Enlist to social support army. The more things you can do to increase the likelihood of success, the more successful you'll be.

Deborah Howell (Host): Yep. And watch the quality of your life just improve every single day. Dr. Sanders, we so appreciate your time and for everything you do. Thanks for being with us today.

Chad Sanders, PhD (Guest): Absolutely. Thanks for having me.

Deborah Howell (Host): For more information on mental health and Palouse Psychiatry and Behavioral Health, as well as more episodes, visit PullmanRegional.org. This has been the Health podcast from Pullman Regional. I'm your host, Deborah Howell. Thanks for listening and have yourself a terrific day.