Keep Receiving Treatment During the Covid-19 Outbreak

Telehealth and Online Mental Health Resources During COVID-19 Pandemic

The COVID-19 pandemic threatens not only health, life, and the economy. It threatens recovery from substance abuse.

When an individual is ready to tackle their substance use disorder, time is of the essence. Any delay might derail their willingness or desire to abstain from alcohol or drugs. Once treatment has started, any interruption might derail the rehab process. And even after rehab, aftercare services such as therapy and support groups are needed to help prevent relapse.

The COVID-19 pandemic costs time, taxes willpower, and denies access.

The COVID-19 pandemic threatens not only health, life, and the economy. It threatens recovery from substance abuse.

The COVID-19 pandemic costs time, taxes willpower, and denies access.

What Is COVID-19?

COVID-19 is one of many viruses that cause respiratory illnesses in people, including some forms of the common cold. Although it has similar symptoms to some strains of influenza, COVID-19 is caused by a different type of virus.

COVID stands for coronavirus disease. This novel coronavirus was discovered in Wuhan, China, in December 2019. In four months it has become a pandemic, a worldwide epidemic.

By March 22, 2020, more than 335,000 COVID-19 cases were reported worldwide, of which almost 15,000 had died. In the United States, more than 33,000 cases were reported by that date—about half in New York state—with more than 400 deaths.

To flatten the curve of new cases and avoid overwhelming the health care system, much of the United States is in virtual lock down due to social distancing: work from home if possible, stay six feet away from other people, make no unnecessary physical contact, and avoid public places and groups of 10 people or more.

People with symptoms of possible COVID-19 are told to self-isolate so they won’t spread the virus and overwhelm available services needed for emergencies. That includes staying away from doctors’ offices, clinics, and hospitals. Individuals with a substance use disorder (SUD) are usually not considered emergencies unless they are experiencing an overdose.

Rehab centers also want to avoid overcrowding and risking COVID-19 infection. Alcoholics Anonymous and similar groups—famous for welcoming everyone and having meetings almost every day, and often several times a day—are limiting the number who can attend, foregoing the communal snacks offered at many meetings, or canceling face-to-face meetings indefinitely.

Social distancing is making many people feel more isolated. When someone with substance use disorder (SUD) is cut off from support and services, or even the promise of them, they may feel more isolated, mentally as well as physically. That’s when they are most likely to turn to the bottle (booze or pills) or the needle to cope.

According to the U.S. Centers for Disease Control and Prevention (CDC), individuals with mental health conditions, including substance use disorder, are less likely to handle stress well. Their inability to cope may have triggered their SUD in the first place.

They also may have poorer health due to their SUD, which may make them more susceptible and less able to fight off the coronavirus and other health problems.

Why Can’t People Meet Face-to-Face?

It is not known exactly how long COVID-19 lingers in the air or on surfaces because it is different times for different materials: up to three hours in the air, four hours on copper, 24 hours on cardboard, three days on plastic and stainless steel. Symptoms may not occur for between three and 13 days after exposure, though five days seems to be average.

No one with a seasonal type of flu should engage in the sort of behavior or contact that social distancing is meant to prevent, either, but the reasons COVID-19 requires more extreme measures are:

Because COVID-19 is a novel (new) coronavirus, the human body has no natural immunity to it.
Because COVID-19 seems to be twice as contagious as the flu.
Because COVID-19 symptoms take longer to show, people may be infecting others before they realize they have it themselves.
Because there is no vaccine available, there is no buffer of protected people.

Without these precautions, it is estimated that as many as 2 million people in the United States could die. According to one simulation model, more than 1 million could still die unless social distancing and other measures continue until a vaccine is available.According to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), the earliest a vaccine will be ready is “a year to a year and a half, no matter how fast you go.”Hopes that COVID-19 is seasonal and will go away on its own in the warmer months do not seem likely, either.So, what should a drug-addicted or alcohol-addicted person do in the time of a pandemic such as the COVID-19 novel coronavirus? There may be options as close as your palm, lap, or desktop: telehealth.

What Is Telehealth?

Telehealth, also known as telemedicine, is the use of video, audio, and sometimes other remote devices to deliver long-distance clinical health care to people who cannot or should not travel to a doctor’s office, clinic, or hospital.

Using two-way interactive communication—smartphone, electronic tablet, or computer—health professionals can speak with, examine, diagnose, and sometimes treat clients at a distance. With the right equipment, a surgeon can perform surgery by remote control.

With telehealth, individuals who can’t get to a doctor can bring the doctor to them electronically via video: ask questions, talk to a therapist, receive prescription medicines or treatments, and receive health news updates and tips.

Though it is mostly used in rural areas where physicians are far away, telehealth also can be used to minimize the transmission of COVID-19 during the pandemic. Substance abuse treatment has lagged behind other specialties, including mental health in general.

In 2017, although one-third of all telemedicine “visits” were for mental health treatment, only 1% was for substance use disorder treatment. That’s one reason why on March 17, 2020, the U.S. Department of Health and Human Services made it easier for Medicaid recipients to use telehealth services, including for substance use disorder.

That’s promising, but it’s not the first time the current government tried to jump start telehealth for substance abuse treatment. In 2018, the U.S. federal government passed the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.

Among other things, the SUPPORT Act was supposed to make it easier for health care providers to use telehealth for SUD, but health care providers still feared investigation and prosecution for any opioid prescriptions (including medication-assisted treatments), so the act made little change.

How Is Substance Use Disorder Treated?

The most effective means of treating substance abuse are behavioral therapies—psychotherapy that teaches those with SUD how to cope without drugs or alcohol—and medication-assisted treatment (MAT)—using less harmful drugs or maintenance doses of drugs of addiction—to control withdrawal pains without getting people high and help individuals end their substance abuse gradually.

SUD is also a mental health issue and often co-occurs with other mental health issues such as depression, anxiety, and trauma. When individuals have both, it is called a dual diagnosis or a co-occurring disorder. Sometimes substance abuse begins as a means to cope with a mental health issue, and sometimes substance use can cause a mental health issue.

When such co-occurring disorders are detected, both need to be treated, whether face-to-face or through telehealth.

Unfortunately, some physicians are reluctant to use MAT approaches because they still believe substance abuse is a moral failing or that MAT is just exchanging one addiction for another, or that they may face investigation or prosecution for prescribing MAT drugs.

MAT drugs include buprenorphine (Suboxone), methadone, and naltrexone (Vivitrol).

The consensus is that SUD is a chronic disease such as diabetes or hypertension. It may sometimes require long-term medication to control it, but physicians aren’t afraid to prescribe insulin because it’s exchanging one addiction for another.

On March 20, 2020, the Drug Enforcement Administration (DEA) announced it would allow MAT prescription through telemedicine without an initial in-person visit first.

There are no such compunctions associated with behavioral therapies. Since these therapies primarily involve talking, they are well-suited for telehealth, provided one finds a therapist who uses such teletherapy.

The main behavioral therapy for SUD is cognitive behavioral therapy (CBT). Substance abuse at its core is usually a means to suppress unwanted thoughts or feelings (negative emotions, chronic pain). CBT teaches better, healthier ways to cope or deal with them. Those lessons can be helpful to everybody during pandemic-induced social distancing.

Other behavioral therapies include dialectical behavior therapy (DBT), a variation of CBT that is sometimes used for women with alcohol use disorder, borderline disorder (BPD), and motivational enhancement therapy (MET), which is sometimes used with CBT to overcome resistance to SUD treatment.

Online Groups

The first recovery tool that many people try for SUD is a 12-step program such as Alcoholics Anonymous or Narcotics Anonymous. These programs aren’t treatment and don’t claim to be, but they do help some people abstain from drugs and alcohol.

Although they are called 12-step programs, attendance or membership does not require that you “work” or practice the 12 steps. Progressing through the steps is encouraged, but attending meetings regularly—one popular saying is 30 meetings in the first 30 days—is the true benefit.

Unfortunately, while it may be possible to work the 12 steps while practicing social distancing, physically attending meetings may not. Even if government authorities haven’t banned meetings of more than 10 people, many 12-step groups have stopped them on their own during the COVID-19 pandemic.

Twelve-step meetings involve sitting together in small rooms, sometimes with more than 10 people and less than six feet between each person. Communal food is consumed. And members sometimes want or require human contact—shaking hands, hugging.

Fortunately, many 12-step groups and similar organizations offer virtual meetings online: via video conferencing or Skype, speakerphone, email, or text. It’s not the same as face-to-face contact, but such communication may be a welcome lifeline.

Alcoholics Anonymous

Alcoholics Anonymous, the original 12-step program that meets in churches, hospitals, and community centers also has a visible online presence:

AA Online Meeting is a Skype-based (voice only), English-language AA meeting in three different time zones in Europe and Asia.
The e-AA Group has email recovery meetings and discussion forums.
The Alcoholics Anonymous Online Intergroup lists more than 150 English-language AA groups, about a dozen with audio or audio-optional meetings.

Narcotics Anonymous

Based on AA, this group uses a similar 12-step program and meeting structure but is open to individuals who are addicted to substances other than alcohol. It has more than 150 groups with online meetings.

SMART

Self-Management and Recovery Training (SMART) Recovery is an explicitly secular alternative to 12-step programs that states it is evidence-based and “self-empowered.” Online meetings are held every day, including text, audio, or video.

Women for Sobriety (WFS)

This women-only group has “online chat meetings” led by women who are “certified as chat leaders”, “are well-versed in the WFS New Life Program,” and have been continuously sober for at least a year.

LifeRing Secular Recovery

LifeRing offers three types of online meetings via smartphone, electronic tablet, and laptop or desktop computer. Most are text only, but some have voice and video. It is recommended you arrive early for your first meeting as you may have to download and install an app (Adobe Connect for text, sometimes an add-in, and Zoom for voice/video). In addition to the scheduled online meetings, there is also a 24-hour chat room.

XRHealth

In response to the isolation caused by the COVID-19 pandemic, the Virtual Reality (VR) telehealth company XRHealth is scheduling VR telehealth support groups, including for substance abuse, as soon as April 1, 2020.

Mobile Apps

Although an article in the Journal of Medical Internet Research found only seven out of 74 commercially available recovery apps had evidence-based features, and some might encourage substance abuse behaviors, the piece discusses a large and rapidly changing field. New apps are emerging all the time and the article only discussed a few.

Here are two apps that seem promising and were not included in JMIR’s analysis:

reSET-O. This is a prescription cognitive behavioral therapy app. It is not a replacement for treatment with a health care provider but a supplement to increase how long individuals with opioid use disorder (OUD) stay in outpatient treatment programs. It is also intended to be used in conjunction with other treatments, such as MAT with buprenorphine and contingency management (an incentive program that rewards clean drug tests with prizes).
HipoChat. This mobile app lets individuals in recovery keep in contact with all the people who help them stay sober—designated relatives, friends, support group members. It allows recovering people to alert others that they need urgent support with just the touch of a finger. People can also use this app to schedule online treatment sessions.

It’s not just those with substance use disorder who will have trouble waiting for COVID-19 to go away on its own or for a vaccine to be available. Everybody will have to find ways to cope with increased levels of stress, depression, anxiety, and fear.

Understandably, being cut off from social interaction, daily routines, and possibly income may cause loneliness, boredom, cabin fever, anger, and—if the individual has a SUD—the desire to use drugs or alcohol to mask the feelings.

Here are some some suggestions from the Substance Abuse and Mental Health Services Administration (SAMHSA):

Practice relaxation techniques—stretching, going for a walk, exercising, meditating, or praying—that you enjoy.
Engage in a fun activity, especially after doing something stressful or difficult.
Talk with someone—a friend, coworker, or family member—by phone or Skype.
Keep a journal of positive or hopeful things.

If an individual experiences intense symptoms of anxiety, worry, fear, depression, or post-traumatic stress disorder (PTSD) for two weeks or more, they should consider consulting their health care provider, if available, or a mental health or suicide prevention hotline.

References

who.int – Q & A on coronavirus (COVID-19)
jamanetwork.com – What Is A Pandemic?
worldometers.info – COVID-19 Coronavirus Pandemic
cdc.gov – Mental Health and Coping During COVID-19
health.harvard.edu – Coronavirus Resource Center
vox.com – Why COVID-19 is worse than the flu in one chart
npr.org – How The Novel Coronavirus And The Flu Are Alike … And Different
imperial.ac.uk– Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand
newyorker.com – How Long Will It Take to Develop a Coronavirus Vaccine?
ccdd.hsph.harvard.edu – Seasonality of SARS-CoV-2: Will COVID-19 go away on its own in warmer weather?
healthit.gov – Telemedicine and Telehealth
modernhealthcare.com – Telemedicine underused in treating addiction- Telemedicine underused in treating addiction
congress.gov – H.R.6 – SUPPORT for Patients and Communities Act
findtreatment.gov – Treatment options
katu.com – DEA exemption allows for telemedicine addiction treatment during coronavirus outbreak
mayoclinic.org – Cognitive behavioral therapy
ncbi.nlm.nih.gov– Dialectical Behavior Therapy: Current Indications and Unique Elements
drugabuse.gov– Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine)
aaonlinemeeting.net – AA Online Meetings
e-aa.org – Meeting and Event Links (The e-AA Group)
aa-intergroup.org – Online Meetings Directory (Online Intergroup, Alcoholics Anonymous)
na.org – Narcotics Anonymous Meeting Search Results
smartrecovery.org – Online Meetings & Events (SMART Recovery)
womenforsobriety.org – Community (Women for Sobriety)
wfsonline.org – Women For Sobriety Online
lifering.org – Joining a Meeting
lifering.org – Online Meeting Schedule
benefitspro.com – Instant Insights: How the Coronavirus Affects HR, Benefits, and Retirement Professionals
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drugabuse.gov – Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine)
healthcareitnews.com – DrFirst and GoHipo partner to combat substance abuse relapse via mobile telehealth
samhsa.gov – Tips For Social Distancing, Quarantine, And Isolation During An Infectious Disease Outbreak
samhsa.gov – Disaster Distress Helpline
findtreatment.samhsa.gov – SAMHSA Behavioral Health Treatment Services Locator
findtreatment.gov– Types of Treatment
suicidepreventionlifeline.org – National Suicide Prevention Lifeline
cdc.gov – Mission, Role and Pledge
emergency.cdc.gov – Coping with a Disaster or Traumatic Event
cdc.gov– Coronavirus (COVID-19): Manage Anxiety & Stress
cdc.gov – Coronavirus (COVID-19): What You Need to Know
nami.org – NAMI Updates On The Coronavirus
nami.org– COVID-19 (Coronavirus) Information And Resources
nih.gov – National Institutes of Health (Home)
nih.gov – Coronavirus (COVID-19)
who.int/en – World Health Organization
who.int – Constitution
forbes.com – Addiction Treatment Facilities: Are They Prepared For The COVID-19 Coronavirus Outbreak?
latimes.com – Amid coronavirus, recovery community urges: Even if you skip 12-step meetings, stay connected
psychcongress.com – Under Coronavirus Threat, Patient Connection Will Take on Different Form
usatoday.com – “The only thing missing are the hugs”: How people fight addiction amid coronavirus social distancing

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