To our knowledge, this is the first multicenter study that reported the impact of COVID-19 lockdown on the availability, accessibility, street pricing, and quality of alcohol and drugs in India. The main findings of our study were as follows. During the first phase of the lockdown, 75%, 65%, and 60% of respondents with alcohol, tobacco, and opioid dependence, respectively, reported a reduction in the availability and access. In the second phase, respondents with alcohol and tobacco dependence reported greater availability than those with opioid and cannabis dependence. The reported price of all substances increased more than 50% during the first phase of lockdown and remained higher throughout the second phase. Deterioration in purity was reported by more than half of the opioid users. A lesser proportion of participants reported poorer quality of alcohol and cannabis.

Alcohol sales in India are regulated and sold through government-licensed shops. As the lockdown was announced, owing to the ambiguity, alcohol shops remained open at most places in India for the initial few days, followed by complete prohibition. In our study, 75% reported limitation in alcohol availability, while 80% reported some difficulty in accessing alcohol during the first phase of lockdown. Such an abrupt disruption in alcohol availability has been documented to result in an increased presentation of complicated withdrawals in the past[20] and during the current pandemic[9] as well. Increased risk of such detrimental outcomes and in the absence of a national-level alcohol policy, debates ensued among health professionals to consider providing alcohol as an emergency provision.[1421] By the second phase of the lockdown, alcohol availability and accessibility improved, as only 50% of the respondents reported such issues. One of the interesting findings is that even during the first phase of the lockdown, one-fifth of the individuals had access to alcohol, which further increased to one in two during the next phase of the lockdown. This seems to suggest that despite the complete closure of the alcohol shops, alternate channels sprouted and ensured alcohol availability from illicit channels. This, in turn, would have impacted the prices, which 80% of respondents confirmed in our study. This high street price persisted during the subsequent phase of lockdown as well. The abrupt prohibition pushed people to seek desperate measures as a significant increase in the relative search volume was observed for alcohol withdrawal, extracting alcohol from sanitizer, offline and online alcohol home delivery.[15] The Global Status Report on alcohol observed that nearly half of the per capita alcohol consumed in the South East Asian Region countries was unrecorded alcohol, that is, obtained from alternate (including illicit) sources (WHO, 2019). It is likely that to meet the demands and maximize profits, a concoction of illegal liquor and Indian-made foreign liquor would have been sold.[20] Almost one-third of the respondents reported deterioration in the quality of alcohol. The impact of such spurious practices has been observed in later periods of the pandemic as well, where incidents of hooch tragedy (poisoning due to illicit liquor) are being reported in different parts of India.[21]

Tobacco, being a nonessential commodity, was prohibited for sale. But despite such restrictions, two-fifths of our patients did not report any significant issues with the availability or access of tobacco and related products during the first phase of lockdown. This subsequently had improved during the later phase. Thus, just like alcohol, it is very likely that alternate channels opened up to ensure availability at premium prices. In fact, our study finds that over 80% of people reported a hike in prices, with over 10% reporting almost doubling of prices. Such increased pricing persisted during the later phase as well. A survey of tobacco users in treatment found that 45% reported decreased availability, with 27% reporting increased prices.[1] In the wake of the pandemic, some countries mandated tobacco products as essential commodities to ensure regular availability.[21] However, as reports emerge linking smoking with adverse COVID-19 outcomes, calls to use pandemic as an opportunity to control the tobacco epidemic have been made.[22] As lockdown measures restricted tobacco products’ availability, it was speculated that may have motivated people to finally quit. Our findings suggest that indeed the majority of individuals found it difficult to access tobacco and those who did had to pay a premium. Thus, it is likely that lockdown may have put people into forced abstinence, but it remains unclear how many of those sustained their abstinence once lockdown was called off.

Over 70% reported difficulty in accessibility, while 65% reported decreased availability of opioids during the initial phase of lockdown, with a slightly lesser number reporting such challenges during the later phase. This suggests that the lockdown impacted the supply chain, which persisted throughout the lockdown period, unlike alcohol, tobacco, or cannabis. Further, this impact was visible in the prices of opioids, as about 90% reported an increase in the price of opioids during the whole lockdown period, with more (39% vs. 30%) reporting a doubling of prices during the first phase. In a European drug survey conducted during April, half of the respondents reported drug shortage and 40% reported increased prices.[23] Two-fifths of addiction professionals from over 75 countries reported decreased availability and increased prices of opioids during the lockdown.[8] Our findings suggest that the shortage of opioids and pricing changes was more acutely felt in India than available evidence from other countries. Such changes in opioid availability and pricing understandably led to poor quality. Over 50% reported deterioration in the quality of available opioids in our study, which again is a figure higher than other international findings. It is very likely that the strict lockdown imposed in India severely restricted the movements and significantly impacted the opioid market. This would have caused shortages of opioids with no clarity on future consignments, and as a result, dealers ended up mixing the available drugs to meet the local demands.

Reports suggest that under certain circumstances, lockdown restrictions can actually work in favor of drug dealers and may make drug trafficking easy, as law enforcement may be diverted toward pandemic-related service.[724] In our study, a small minority reported easy availability and better accessibility of drugs and alcohol, especially during the second phase of the lockdown. Drug dealers would likely have adopted innovative ways to reach out to their clients, despite strict restrictions.[25] Anecdotal evidence from our clinics suggests home delivery of drugs and alcohol was one of the most favored approaches. There is a possibility that such alternate routes may have continued to flourish even after the lockdown measures, making drugs more accessible to vulnerable populations.

The following are the strengths of our study. (i) This was a multi-site study with centers from the northern, eastern, western, and central parts of the country. All these publicly funded treatment centers have a wide catchment area, spanning across the neighboring states. The heterogeneity offered by such a diverse sample should increase the generalizability of our study findings. (ii) Direct interviews of the end-users should make the study results more reliable and valid than the impressionistic reports of professionals and media houses. (iii) Use of uniform survey questionnaire, administered by a trained psychiatrist with at least 1 year of clinical experience in addiction psychiatry, has further added to the reliability of our results. (iv) Minimal missing data, too, adds to the credibility of the study findings. (v) Finally, our sample comprised individuals with drug and alcohol dependence. People who continued to use substances throughout the COVID-19 lockdown periods were more likely to have a better understanding of aspects of the market related to supply of their drugs of concern. Reports from this group would possibly be more reflective of the ground reality than reports from occasional users.

There are certain limitations in our study. Firstly, since data was collected a few months after the lockdown period, recall bias could not be ruled out. Secondly, our scope was only limited to alcohol, opioids, tobacco, and cannabis, as other substances were reported rarely. Thirdly, we were not able to establish any association between the availability of different substances and quitting behaviors. Fourthly, ours was a clinic-based study on the treatment-seeking population; hence, the results may have limited population-level generalizability. The convenience sampling, too, might have affected the generalizability of the study results. Fifth, we did not do any objective assessment of drug and alcohol use; hence, the possibility of false reporting owing to social desirability could not be denied. Finally, we did not gather information regarding the age of the participants, other comorbidities, duration of substance use, and other clinical details. Lack of these information may limit the generalizability of our results.