People Seeking Drug Treatment Weren’t Ready for the Pandemic—Here’s What We Learned About Relapse and Recovery
When Jamie Brown first tried Percocet, she didn't expect to become addicted. Brown, 28, wasn't a stranger to substance use. Though she had tried a variety of drugs throughout the years—alcohol, marijuana, Adderall, cocaine, ecstasy, psychedelics—taking those substances never became habitual.
But Percocet was different. The highly addictive prescription painkiller belongs to a class of drugs known as opioids, and is often prescribed to people dealing with chronic pain. Her then-boyfriend, who introduced Brown to the drug, was addicted to Percocet. Brown soon became addicted to the drug too, and with the couple abusing the same expensive drug—one that can cost as much as $25 per pill without insurance, and $10 per pill on the street—their habit became pricey.
To keep up with their addiction, the pair began looking for alternatives to Percocet that would give them a similar high at a lower price point. That's how they found street drugs laced with fentanyl, a dangerous (and often deadly) synthetic opioid far more potent than both heroin and morphine. According to the Centers for Disease Control and Prevention (CDC), fentanyl is so strong that it's normally only prescribed to treat severe pain—typically that of advanced-stage cancer patients. Unfortunately, this transition is common: When doctors refuse to refill an opioid addict's prescription, the addict will often take to the streets for an easier, cheaper high—one that fentanyl-laced substances provide.
Brown tried to get clean on her own multiple times to no avail, and so she checked into Foundations Recovery Center, a rehabilitation facility outside of Baltimore, in March 2020. But right around that time, as cases of COVID-19 began rising on the East Coast, states started issuing stay-at-home orders and shutdowns of all but essential businesses and organizations. Due to the isolation caused by the pandemic—and the inability to socialize and connect to others at her recovery center—Brown made it a little over 90 days in rehab before she relapsed again.
Prior to the COVID-19 pandemic, America was gripped by an epidemic of opioid use—resulting in a troubling rise in overdoses caused in part by the introduction of fentanyl to the country's illegal drug supply. 2010 saw 38,329 drug overdose deaths, according to the National Institute on Drug Abuse. Nine years later, that number rose to 70,630, per the CDC.
Now, evidence suggests that the rising trend may have been exacerbated by the pandemic this year: A report published by JAMA Health Forum shared that an estimated 19,416 people died of drug overdoses in the first three months of 2020, compared to 16,682 people during the same period the year prior. Those numbers came from the CDC, which also estimates that 81,000 overdose deaths occurred between May 2019 and May 2020. Should this rate of overdose deaths continue, the report concluded that "the United States is on track to reach a new all-time record for overdose fatalities within a calendar year."
The pandemic may very well be fueling this rate. "Stresses related to the COVID-19 pandemic, such as economic strains, as well as COVID-19–related isolation and other factors hindering treatment and support for people with substance use issues, may have contributed to the current rise in overdose deaths," states the JAMA report. The CDC has also acknowledged the pandemic's role in the rise in overdose deaths. In a December 2020 press release, the CDC posited that "while overdose deaths were already increasing in the months preceding the 2019 novel coronavirus disease (COVID-19) pandemic, the latest numbers suggest an acceleration of overdose deaths during the pandemic."
Though it's been less discussed, the COVID-19 pandemic has also likely led to a rise in relapse rates for those in recovery from drug abuse. Official data on this rise doesn't exist yet and likely won't for another six months to a year, Neeraj Gandotra, MD, the chief medical officer at the Substance Abuse and Mental Health Services Administration (SAMHSA), tells Health.
But anecdotally, experts in the drug abuse and recovery fields say they've witnessed a surge in relapses during the pandemic. Lindsey Staymates, a former supervisor at Foundations, tells Health she specifically saw "some spikes in relapses" even among patients who had been sober for five years. Timothy Brennan, MD, director of the Addiction Institute at Mount Sinai West and the Mount Sinai Morningside Hospitals in New York City, said the pandemic had an effect on his patients as well: "People have a foundation in recovery. When that foundation has been shaken it's really scary. I do think we've seen a lot of relapses."
A January 2021 article published in The New York Times added even more anecdotal evidence. The piece recounted the experience of Jackie Ré, a woman who runs a substance-use disorder facility in New Jersey. At the outset of the pandemic, Ré gathered the 12 women living in her facility to let them know what was going on—that the pandemic had forced the facility to limit its contact with the outside world. The women were upset by this news, and over the next six months, nine left the program against staff advice, and all but one relapsed. Ré told the Times she had "never seen anything like it," regarding the string of relapses.
Though a lot of fields benefitted from the increased use of telemedicine during the pandemic, people in treatment for substance use disorders were more likely to suffer.
For a June 2020 report by the Addiction Policy Forum, researchers surveyed 1,079 respondents in a nationwide network of patients with substance use disorder, individuals in recovery, and family members. The survey found that more than one in three individuals, or 34%, reported changes or disruptions in accessing treatment or receiving recovery support services; 14% said they were unable to receive their needed services at all.
For those in recovery, in-person 12-step or support groups are essential to their success. But the shutdown of these vital services due to the COVID-19 pandemic was listed as a primary concern among the survey participants. Survey respondents specifically commented on this issue, noting that they had "no ability to socialize/connect or to get peer support." Others shared that "meetings have all been reduced to Zoom and it has had an impact on feeling supported by peers and getting a good recovery message," and that "doing online meetings [is] not the same as going to a meeting."
Staymates, who worked directly with Brown on her recovery, also says this was among the most difficult challenges the COVID-19 pandemic presented to treatment facilities. "We were unable to see clients face to face. That caused a huge breach in the closeness with clients [that is] necessary to developing a relationship with them," she explains.
While telehealth services became a substitute for in-person doctor visits and medical appointments during the pandemic (and surveys suggest both patients and doctors found telemedicine to be successful), virtual visits for addicts just don't work as well. "Unlike a lot of other fields, substance abuse treatment wasn't telehealth-friendly," Sheila P. Vakharia, PhD, deputy director of research and academic engagement at the Drug Policy Alliance, a nonprofit that seeks to advance human rights-centered drug policies, tells Health. "Those who were connected to treatment as part of their early recovery did experience disruptions in care."
For Brown, those disruptions in care and lack of in-person meetings were hugely detrimental. "I was able to get a sponsor, but I only met her once in person," Brown says. And Zoom therapy sessions—meant to provide some face-to-face contact—were often distracting. "You're Zooming—but you're doing your laundry. It's just a bunch of strangers on a computer screen," she says. "People will send you phone numbers and stuff, but you're not getting that connection. I didn't call them. Not one."
Jerry Smith, another patient at Foundations Recovery Center who sought treatment there for fentanyl addiction last August, also felt the impact of not being able to socialize with other addicts. In-person meetings are a huge part of the program, Smith, 55, tells Health. But when those meetings went virtual, his recovery got tougher. "You want to be around like-minded people, people in recovery," he says.
In January, just five months after he checked into rehab, Smith relapsed after he couldn't get ahold of anyone in his program. "You have to rely on your phone. Your network is not available. My sponsor was unavailable," Smith says, adding that he didn't have the option of going out and meeting up with other people in recovery—or anyone else at all, for that matter—given the threat of the coronavirus. Smith, who is admittedly "not tech-savvy," faced another obstacle: He had difficulty connecting to others via smartphones and devices.
For those in outpatient therapy—meaning they stayed at home rather than inside a treatment facility—recovery in a pandemic posed additional challenges. While those in inpatient therapy were often provided with internet access for online counseling (which didn't necessarily work the way in-person counseling does), people in outpatient therapy didn't always have that option. Even if internet access was available, some patients in recovery live in places without steady service or WiFi. "Their only phone may be a landline [instead of] a smartphone," Vakharia says. That's a big deal, since some treatment providers only get compensated for audiovisual appointments, not phone calls, making them more likely to provide audiovisual appointments only, she adds.
Patients outside of treatment facilities also had a harder time establishing a new, COVID-era routine—and a healthy routine is an essential part of the recovery process. Without any semblance of a structured day (since the stay-at-home orders forced many people to work and live in the same small space each day), boredom and isolation set in, making sticking to a recovery program even more difficult. "Sometimes boredom is a factor with substance use," Akhil Anand, MD, an addiction medicine specialist at Cleveland Clinic's Center for Behavioral Health, tells Health. "If you're isolated at home and have nothing to do with no meaning, it's easy for patients to slip back to bad habits."
While therapy sessions—one-on-one or in group settings—were for many addicts a casualty of the pandemic, so was access to medications to help stave off a relapse. Methadone and buprenorphine are two FDA-approved drugs given to patients to treat opioid use disorder. The meds are administered in small quantities, normally at clinics, where patients can go each day to receive their dose.
When the pandemic hit, the SAMHSA loosened those guidelines, allowing patients to take home 14 to 28 days of methadone at a time. But Vakharia says this effort looked better on paper than in practice—the loosening was simply a guideline to follow, not a mandate. That meant methadone clinics could simply choose to overlook the suggestion and continue operating as usual, forcing many patients to either risk catching COVID-19 or choose to socially distance and thus forego their necessary medication.
Even when methadone clinics followed the SAMHSA guidelines, those in recovery met another challenge in obtaining their medication: cost. "A lot of people have to pay out-of-pocket cash copays for methadone," Vakharia says. That means people have to shell out for 2-4 weeks of doses at once. Just one week of methadone treatment can cost $126, according to the National Institute on Drug Abuse, putting the option out of reach for many of those who need it—especially when buying multiple weeks of the medication at once.
The COVID-19 pandemic laid bare just how difficult it is to seek and maintain treatment for drug abuse—and shows that recovery, too, needs to be considered a crucial part of health care.
During the pandemic, the demand for behavioral health services (like drug rehabilitation facilities) increased, but the supply deceased, research shows. In a survey conducted by the National Council for Behavioral Health, a nonprofit association that advocates for health care for those with mental health or substance use disorders, 52% of the more than 300 institutions polled said they saw a rise in a need for services—but 54% of institutions had to close programs, and as many as 65% had to cancel, reschedule, or turn away patients in need.
The survey also found that these organizations lost 22.6% of their revenue during the pandemic—money needed to keep institutions open and running at full capacity. And while provider-relief funding given by the government helped a bit, only 32% of the community behavioral health care services surveyed received any relief from the first round of funding. In a statement published with the survey, Chuck Ingoglia, president and CEO of the National Council for Behavioral Health, stated that these organizations must also be considered essential. "Congress and the administration have created dedicated funding streams for critical access hospitals, nursing homes, federally qualified health centers. It's time to level the playing field and add behavioral health organizations, which are just as critical, to the funding stream to ensure they can continue to provide care for millions of Americans," he said.
In addition to considering these behavioral services as essential care, the pandemic has also brought to light some inefficiencies in how former addicts are able to receive treatment, even when it's available to them. COVID-19 has shown that the process of obtaining methadone and buprenorphine is stricter than it needs to be, experts believe. "The sky doesn't fall when you loosen restrictions," Vakharia says. Making naloxone more readily available may also help, she adds. Naloxone (commonly known by its brand name Narcan) is an FDA-approved medication that can reverse the effects of an overdose, but it can be difficult to access when prescribed due to high copays or decreased chances of getting life insurance after a prescription, she explains.
After Brown relapsed in July 2020, it took a near-fatal car crash a month later to make her realize she was in danger again—and that she needed to recommit to treatment. "I hadn't taken from anyone. I hadn't overdosed," she says. But the accident showed her that she had "woken the beast back up." Brown returned to her treatment facility in August and has been sober ever since. "I kind of had to come back with my tail between my legs," she says. "I do need that accountability of being drug tested [at the facility]."
Luckily, she says her second try at recovery has been easier, especially due to loosening restrictions from COVID-19. "We have softball on Sundays. We get coffee again," Brown says, adding that she feels different than before. "There's no significant epiphanies I'm going to have, but there's a program that can help me not feel guilty, not feel ashamed. I'm a lot more invested now."
Smith, too, has found ways to stay rooted in recovery during the pandemic, including the use of Facebook to socialize with others who are in the same boat. "One thing that's now in place: Foundations has [an] alumni association through Facebook that's a little more interactive," he says. He's also come to terms with the understanding that, while getting sober anytime is hard, getting sober during a pandemic is even tougher. "I've got to be more careful. I've got to be more vigilant," he says. "The next alternative for me is death. That's what I'm looking at." He's even got a plan in place, should he fall back into his dangerous addiction: Start over, go right back to recovery, and remind himself: "Don't be embarrassed. You have a disease."
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