“A Big Part of Recovery Is Dealing with Change”: Lockdowns, Telehealth, and Rehab
In April, Russell Gosselin, who was sponsoring his friend Sam as part of a substance use rehabilitation program, received a phone call from Sam’s father, who said he hadn’t heard from his son in several days. Gosselin drove to Sam’s apartment to check on him. A staffer at the leasing office at the South Florida apartment unlocked it, and inside Gosselin found his best friend’s dead body.
“It just destroyed me,” Gosselin said in an October 2020 interview with The Politic. “He had been doing good up until that point. He was eight months sober.”
Gosselin and Sam had met at a treatment center, where they had both been receiving care for substance use disorder. After Gosselin reached a year of sobriety, he became Sam’s sponsor. They were inseparable.
In April, a month into the COVID-19 pandemic, 12-step programs, which aid in recovery from addictive substances, in Florida had canceled meetings, leaving Gosselin, Sam, and others recovering from substance use disorder in a difficult place.
“Meetings stopped happening, and basically he stopped having the opportunity to do service,” Gosselin said. Helping others in their recoveries is often done to provide purpose and maintain sobriety. “And service is how we stay sober. He started doing drugs and alcohol again, and he died.”
Gosselin, who is 22, has been sober for over two and a half years following stays in ten different treatment centers and nearly a decade of substance use and setbacks. He said he does not “obsess” about drinking and doing drugs now, and does not worry about relapsing. But Sam’s death and the absence of support through community meetings have taken their toll on his mental health. “When my life gets really bad, when I start doing what I want to do rather than what God wants me to do, rather than drinking and getting high, I start thinking about wanting to kill myself,” he said.
Recovering from substance use disorder is fraught. According to a 2018 article by the National Institute on Drug Abuse, 40 to 60 percent of people with substance use disorder will relapse at some point during their recovery. “It is actually relatively common to relapse at some point after you get clean,” the American Addiction Centers website says, “so common, in fact, that relapse is often considered one part of lifelong recovery.”
A study by John Hopkins researcher Holly Wilcox and colleagues found that “[I]ndividuals with alcohol dependence and persons who use drugs have a 10–14 times greater risk of death by suicide, respectively.”
Gosselin has another way of describing relapses. “We say you step over a lot of bodies in this program,” Gosselin said. “People around you, that you care for dearly, are going to go out and take up drugs again and some of them are going to die,” he added. The same week in April that Sam died, four other people Gosselin knew died from overdose or other substance use-related causes as the pandemic exacerbated mental health and addiction crises and limited opportunities for social support.
“If no form of treatment is put in place, you’re going to die, every single one of us,” Gosselin said.
Never a Good Thing in this Field
Today, more than seven months after Sam’s death, treatment centers across the country still are not operating at the same capacity that they were before COVID-19 struck, and many have shut their doors to in-person outpatient services and twelve-step nonresidential programs entirely. From Florida to Ohio to Connecticut, residential programs have drastically cut enrollment in order to meet COVID restrictions and prevent infection in their dorms. For example, Community Assessment and Treatment Services (CATS), a nonprofit agency in the Greater Cleveland area that offers both residential and outpatient services from two locations, reduced its residential capacity to 37 percent at the beginning of the pandemic, and since September has hovered at about 50 percent capacity. All of CATS’ outpatient services have transitioned to virtual or telephone meetings.
According to CATS Director of Development Robert Newman, the center was unprepared to make the transition and had difficulty finding a virtual platform that complied with federal regulations related to healthcare privacy. There were about 30 days between the end of face-to-face meetings and the beginning of virtual meetings. During this time, outpatient services were conducted over the phone, Newman said in an interview with The Politic. But, because most of CATS’s clients face poverty and receive healthcare through Medicaid—which did not initially cover telehealth—getting phones for clients was “a huge financial drain.”
Additionally, most of CATS’s clients are referred to the center by courts, but the pandemic has postponed hearings. Far less people are being referred to CATS now, meaning the center is also losing significant amounts of public funding.
“We obviously were not budgeted to buy new cameras, extra phones, extra computers, the software needed to run these kinds of programs,” Newman said. He credited CATS’ frugality for sustaining the agency.
“We watched smaller agencies struggle for two or three months and have to lay off staff and ultimately close down, which is never a good thing in the treatment realm, because you want people to have access to treatment when and where they need it,” he added. “Suddenly people don’t have access to treatment right down the street or a phone call away. They have to find someone else.”
Throw in Social Isolation, Anxiety, and Stress of the Virus
Like other health services, substance use disorder treatment services did not foresee how dramatically and quickly life could and would change. While the financial losses precipitated by the pandemic have burdened treatment centers themselves, the ultimate cost of these losses, as well as the cost of sudden and abrupt change to nearly every feature of life, has fallen most heavily on those who are recovering from substance use disorder.
“With healthcare, unfortunately most clinical settings were underprepared or not prepared for the rapid changes in…delivery,” Dr. David Fiellin, Director of the Yale Program in Addiction Medicine at the Yale School of Medicine, said in an interview with The Politic. “It’s very unfortunate to hear that [some treatment centers] were not able to change access or forced to restrict or deny access to treatment. These types of changes can only have a negative short term or potentially long-term impact in addiction.”
The pandemic also exacerbated the already-dismal drug crisis. According to the Centers of Disease Control (CDC), there were 71,999 fatal drug overdoses in the United States in 2019. According to data collected by the New York Times, as of July, drug overdose deaths have risen by 13 percent in 2020.
Although the risk of COVID is great, in-person meetings are necessary for some patients, especially those seeking residential treatment. Residential treatment is prescribed for a variety of factors, such as removing a patient from potential triggers that might cause them to continue to use drugs. Outpatient treatment may consist of meetings with a counselor and/or in a group setting, like Narcotics Anonymous meetings or other twelve-step programs. It is usually prescribed to patients who are more stable in their recovery.
For outpatients, the isolation caused by the pandemic has made recovery, an already-difficult task, even more difficult, and not simply because of canceled meetings.
“I really think the biggest issue has been the isolation piece of it,” Newman said. “No one wants to get sick and potentially die from the virus obviously, but so many of our clients—I’d say it’s in the high 90s percent of our clients—that rely on their social network and rely on the group meetings, rely on the twelve step meetings, rely on their sponsors to help them get through difficult times. This is in everyday life without social isolation. And you throw in social isolation and the anxiety and stress of the virus.”
While telehealth has alleviated some of the burden for those in recovery, Newman doesn’t believe it’s enough.
“A phone call here and there is great, but humans are social animals. We need that interaction, physical face-to-face interaction, to really connect with people,” he said. “And our clients are more vulnerable and more susceptible to having that taken away. That is far and away the biggest challenge our clients face.”
“Some people who have or struggle with addiction also have co-occurring mental health challenges, like depression or anxiety,” said Miriam Delphin-Rittmon, Commissioner of the Connecticut State Department of Mental Health and Addiction Services, in an interview with The Politic. “And one thing that we’re hearing is that the pandemic has exacerbated a lot of that. For many people, their mental health challenges or their anxiety or even addiction challenges, have increased. For some people, absolutely, I think COVID has made the recovery process even more challenging.”
This isolation extends beyond therapy and group meetings, though. As COVID cases continue to rise in Ohio—on December 8, the state reported a record 25,721 new cases—activities remain in limbo, and clients cannot as easily explore healthy hobbies or meet new people. According to the website for the Substance Abuse and Mental Health Services Administration (SAMHSA), finding purpose in “daily meaningful activities,” including jobs, and forming community and healthy relationships, are integral parts of substance use disorder recovery.
With an economy paralyzed by the virus and gyms, bowling alleys, movie theaters, restaurants, and a host of other businesses shuttered, it’s more difficult to secure employment, and harder to find meaningful activities. When hobbies are no longer readily accessible, counselors are uncertain how to direct clients towards healthy pursuits.
“Most of the clients are struggling more with depression because of it,” Julia Kurek, a counselor at CATS, said in an interview with The Politic. “Being able to go to outpatient, I usually typically would be like, ‘This is the fun part of sobriety, you get to figure out what you like, you get to find new hobbies, you get to go meet new people.’ And that was not something I could even say, because everybody’s isolating.”
Increasing Access: Telehealth Here to Stay
However, in some ways, telehealth has also improved substance abuse treatment in that it has made it easier to reach clients, and easier for parents or working people to seek counseling.
“Some of our clients would have to take two or three buses, have an hour ride just to get to the facility for outpatient treatment, which isn’t always convenient, especially if they have children,” Newman said. “Telehealth remediates the need to travel and allows them to engage basically wherever they are.”
“I think it’s been a really good thing for the field, is the ability to provide services on an outpatient basis using telemedicine or e-services to where they could actually be at home or at work but receive counseling services in the form of group or individual services while off-site,” said Marvin Coleman, Vice President of Legislative and Community Affairs at Operation PAR, an opioid treatment center in Florida, in an interview with The Politic. Coleman added that Operation PAR had been encouraging telemedicine before 2020, and that the pandemic opened it to being used as a viable recovery option.
Operation PAR had started using telehealth in treatment three years ago, Coleman said, and the organization helped the Florida Certification Board, which certifies treatment facilities in the state, train providers for utilizing telehealth. Coleman added that family, jobs, and other external stressors can make recovery more difficult, and that telehealth makes treatment and counseling more accessible for those who might be too busy or otherwise constrained to devote time to in-person treatment.
“Some of our clients, if they have children [will] have to provide daycare to have treatment. If they have jobs where there are conflicts, transportation issues—all of those things will impact a person being able to maintain and manage and stay in treatment,” Coleman explained. “However, if they’re able to do it there with their children at home, and they can do it at home, or at work, [telehealth] has really impacted the field so more people are able to get help by accessing technology.”
“Normal life has moved in that direction, so it was an easy transition,” Coleman added. “So easy, in fact, I think it surprised us.”
Operation PAR isn’t the only center to find that telehealth improved their services. The Connecticut Community for Addiction Recovery (CCAR) offers telephone recovery support in Spanish and English, and offers online enrollment. CCAR has conducted telephone recovery support for “many years,” explained Tom Russo, Communications Manager at CCAR, in an interview with The Politic. “We started promoting that as best as we could.”
CCAR also collaborated with In The Rooms, a virtual online recovery community that has over 650,000 members. According to its website, In The Rooms began “with a simple goal in mind: to give recovering addicts a place to meet and socialize when they’re not in face-to-face meetings.” While not all 650,000 members are active, the organization facilitates over 130 live meetings each week for those interested in pursuing virtual recovery, facilitates blogs and discussions, and connects members with treatment options.
Furthermore, addiction researcher Dr. Fiellin believes some measures the federal government has taken have helped to soften the impact of the pandemic on substance use treatment, such as efforts to allow those with a history of substance use disorder to have easier access to medicine-assisted treatment.
“There are certainly reports around the country of increased spikes in fatal and nonfatal overdoses,” Fiellin said. He continued that increases in overdoses likely resulted from lack of access to treatment, changes in drug supply (especially the highly potent synthetic opioid fentanyl), and changes in access to medications like methadone and buprenorphine. Methadone and buprenorphine are two narcotics frequently prescribed in medicine-assisted rehabilitation to decrease dependence on stronger and more dangerous opioids, like heroin, fentanyl, and OxyContin.
However, in the spring, federal regulation on methadone and buprenorphine dispensation was loosened to reduce in-person contact. SAMHSA, a branch of the U.S. Department of Health and Human Services, changed the rules to permit treatment centers to prescribe buprenorphine to new patients without a physical examination, although the regulations still require in-person medical evaluations for methadone prescription to new patients. SAMHSA also determined that treatment centers could continue to prescribe and dispense methadone and buprenorphine to existing patients via telehealth or over the phone. And treatment centers were even permitted to provide up to 28 doses of both methadone and buprenorphine at a time to minimize the amount of in-person contact required to continue medication-assisted treatment.
“Some of that flexibility has been in the desire for people who are in treatment to continue to have access to that treatment, and people who are interested in getting into treatment can continue to do so,” Fiellin said. Connecticut Mental Health and Addiction Services Commissioner Delphin-Rittmon agreed that loosening restrictions facilitated much-needed access.
“I don’t think they’re going to go away,” Newman said, referring to telehealth and virtual meetings. “There’s a larger percentage of the population that we deal with that seems to benefit from that ready, easy access. There’s plenty of benefit from that, so I think it’s here to stay.”
Before the pandemic, medical boards of 49 states and the District of Columbia had restrictions on telehealth. The primary restriction was that a provider must be located in the same state as the patient being treated. Since the pandemic began, all 50 states and the District of Columbia have temporarily waived that rule. Now, a doctor can provide treatment to someone in another state via telehealth without being licensed to practice in that state. Additionally, Medicaid has been expanded in all 50 states and Washington, D.C. to include more robust telehealth coverage.
It’s unclear now whether these measures are here to stay, but in a time when access has been desperately needed, the loosened restrictions have been welcomed. Still, the expansion isn’t the cure for all the hardships in recovery that the pandemic has prompted.
“I think we’re going to have to change things, the way we interact with others,” said one of CATS counselor Julia Kurek’s clients, Katie. Katie entered CATS during the pandemic for detox and has since transitioned to outpatient care. She meets with Kurek regularly via telehealth. Though Kurek notes that Katie is a “rare case,” Katie said she believes she has made enormous progress in isolation.
“My addiction in itself was very self-isolating,” Katie said in an interview with The Politic. “In a weird way, I’ve actually opened up more in [virtual] groups…. I’m actually accomplishing more for myself and how I interact with people.”
“I’ve gone through a lot of changes this year, a lot of growth, when you don’t think it’s really possible because of things that are going on,” she added. In January, Katie is due to welcome a baby boy. “But I’m glad that I’m able to. 2020’s a real test for everyone’s will and sobriety. It’s been a real test.”
“A big part of recovery, too, is being able to deal with change and adapt to change,” Russo, CCAR’s Communication Manager, said. “And people that are in recovery are good at that.”