he pandemic is creeping into the colder months, something many of us hoped would never happen. The first time around, the surprise of lockdown meant that people who were alcohol-dependent risked not being able to access a regular supply, which meant they were potentially facing withdrawal, seizures and hallucinations, even death. As a result, those of us working in alcohol services – I’m a psychiatrist specialising in addiction – had to change our approach. We had to shift from detoxification and supporting sobriety to – what? Strangely enough, we found ourselves encouraging people to continue drinking, to not make any changes; some people had to be supplied with alcohol when they were unable to get it for themselves. Yet this kind of approach isn’t entirely unfamiliar. It’s a form of harm reduction, more commonly associated with treatment of people who depend on drugs. The curious thing is that we work with alcohol-dependent people to help them to stop drinking; but those who are dependent on opioid drugs are prescribed methadone or buprenorphine, both of which are strong opioids, to keep them stable. This difference isn’t about a moral judgment. Both drinkers and drug users are judged in the wider world, of course, but it does depend what they use and how. Cocktails and cocaine may be more acceptable – at least for a while – than cheap cider and heroin. But medically speaking, it’s primarily about what we have in our treatment arsenal. If we had a pill that we could safely prescribe that would replace alcohol, and not damage the liver, the brain and more, I would have prescribed it with enthusiasm during lockdown, and probably before. We have been drinking alcohol for millennia, enjoyably and disastrously. It is embedded in our lives, and also to relieve physical and mental pain. Alcohol is unavoidable. My patients tell me so, and I see it for myself as I walk down the street. I have no doubt that some people are more prone to developing alcohol problems. The reward evoked by alcohol in their brains, the relief of pain and trauma, is such that there can never be enough, and they come back for more, hungrily, ignoring any damage. Those to whom this doesn’t happen as intensely, or at all, can drink a glass and stop. There are many shades in between, but don’t judge others if alcohol doesn’t do it for you. When the first lockdown descended, the preexisting structure of the day cracked for many people. Working from home, caring for children, worrying about what the future might hold – all these changed the texture of everyday life. Many confessed to drinking more, but it was short-term, like a holiday. The time of the first drink drifted so that it was earlier in the day; weekends seemed less connected to the working week. But there was a sense that it would all go back to normal when lockdown ended. When it did end, we all started to realise that “normal” was still some way off. Restrictions hovered and descended again, just as the days were shortening, raising uncomfortable questions about what to do with the newly acquired “holiday” habits. Are we all drinking more alcohol during lockdown? The truth is we don’t know, although one recent survey suggests the over-50s are at particular risk. Finding out is extremely complicated when you have to account for the many ways in which alcohol can be acquired. You don’t need to go out to the pub, you can get it delivered. How can we possibly know who is drinking what and where? Minimum pricing was just starting to show signs of success in Scotland, where I work, but no one knows exactly what the effects of lockdown have been, and it will be hard to get that data. We can intuit some things, however. I worry about those who were drinking just a bit too much before who have now tipped into problem drinking. It doesn’t take a lot, and there are many on this uncertain edge. Stress levels are high, with fears about infection or economic insecurity taking their toll. Many of my patients who are already alcohol-dependent tell me they have relapsed due to boredom, and, even more importantly, lack of any human contact. When we talk about relapse prevention, we talk about seeing people, talking to people, going to groups, and all this is up the spout at present. There are groups online, but not everyone can access these. In any case, it’s not the same, as those of us who are all Zoomed out will testify to. Sometimes too much contact is the problem: families are forced together, something that can be hard even for the most loving partners or parents. Alcohol can be a form of mental, if not physical, escape. Whether newly dependent or relapsed, what’s clear is that people need help to get through this. It’s my hope there will be increased resources to implement effective interventions at all levels. There are a lot of people out there whose coping strategies, perhaps slender at best, have been whipped away. How do we find these people, and how do we help them? It can be hard to admit to problem drinking – it can be seen as a sign of weakness or lack of moral fibre. People fear losing their jobs, their friends, their driving licences. Women with children can find it overwhelmingly difficult, as the stereotypical assumptions about alcoholism don’t match their experiences. We clinicians need to examine our own views, even our own drinking, to change this. Do I think that people with alcohol problems have brought it on themselves? Do I see them as less worthy of treatment? If there’s even a pause answering this, I have a problem. Patients will pick up on this. If I say to the middle-class woman with depression – “You don’t drink more than 14 units a week, do you?” – then how can she say she does? My views are implicit in my question – that I do not believe it possible or worthy of her. We need skilled alcohol treatment services that can see people quicklywhen they need to be seen. But above all we need to reconnect people, in the flesh, as soon as possible. The pandemic has been a tragedy; lockdown – while it may be necessary – shouldn’t become a tragedy, too. Rebecca Lawrence is a consultant psychiatrist In the UK, Action on Addiction is available on 0300 330 0659. In the US, SAMHSA’s National Helpline is at 800-662-4357. In Australia, the National Alcohol and Other Drug Hotline is at 1800 250 015; families and friends can seek help at Family Drug Support Australia at 1300 368 186