In this study, the recruited group of patients with a diagnosis of SUD represents a real-life sample that reflects the Italian addiction scenario, including patients known by local services of seven different representative Italian regions. The evaluation of craving scores during the first phases of the COVID pandemic represents a relevant point, given the presence in that period of strict lockdown restrictions. Although other studies evaluated the psychopathological burden of alcohol and substance users during the strict lockdown[15,16], the specific evaluation of craving represents a novel and relevant aspect, given the crucial role of craving in treatment strategies. Different studies[17,18] have proposed that, together with negative affect states, cognitive factors, interpersonal problems, and lack of coping, craving is one of the leading risk factors for relapse[19]. 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 was unexpected, and is in contrast with other studies reporting increased levels of anxiety, depression, and psychotic symptoms during the early phase of the COVID-19 pandemic[20,21]. Moreover, in alcohol and substance users, other detrimental factors can act synergistically during the pandemic period: Psychological discomfort from social isolation, restricted freedom, and a quantitative and qualitative reduction in the addiction services’ assistance and in the stretching of their service.

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, craving itself 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.