As the Coronavirus Strains Addiction Treatment, New Strategies Emerge

Andrew Tatarsky is done with coronavirus jokes, like the ubiquitous one about “quarantinis.” How do you make one? The same way you make a regular martini, except you drink it in your house alone.

In the house. Alone.

For Tatarksy, who’s spent more than three decades working as a counselor and psychologist specializing in addiction treatment, it hits a little too close to home. After all, he says, that’s exactly what’s going on with a large percentage of the 250 patients his practice is treating right now. They’re at home, alone and isolated. They’re anxious or depressed. Maybe a spouse or relative who lives with them has triggered an old trauma. Suddenly, they’re drinking or using again.

“I worry that we’re going to see a horrific increase in drug-related problems,” Tatarksy says. “Even people who’ve been stable for 20 years are now returning to substance abuse. Entire lives have been swept away.”

Although data are still rolling in, plenty of evidence suggests that the coronavirus outbreak has caused a spike in cases of substance abuse, relapses, and addiction-related deaths—fatalities, it’s worth noting, that aren’t being counted toward the coronavirus death toll. According to the national public health group Well Being Trust, these “deaths of despair,” as they’re sometimes called, could eventually top 75,000 in number.

In June, the Overdose Detection Mapping Application Program, a federal initiative that collects data from ambulance teams, hospitals, and police, reported that overdoses jumped 18 percent in March, 29 percent in April, and 42 percent in May, compared to 2019 figures. Approximately 61 percent of counties surveyed reported an increase in overdoses coinciding with stay-at-home orders. In August, the American Medical Association reported that more than 40 states have seen opioid-related deaths skyrocket since the pandemic began.

These spikes in substance abuse have been heavily taxing addiction counselors and other behavioral healthcare workers, now dealing with a surge of new and relapsing clients while struggling to transition their normal caseloads to telehealth. For treatment-center owners like Tatarsky, who employs seven other therapists, that includes worrying about possibly having to scale back operations or furlough staff. Luckily, he’s been able to pay the bills so far, but it hasn’t been easy.

“I’ve been living with a tremendous amount of anxiety and concern, and paying $17,000 a month in rent for a space we’re not using is hard to stomach,” he says of his Center for Optimal Living, based in New York. While the business has stayed afloat, he worries about the long-term impact of the pandemic on his clients’ well-being and the survival of treatment centers like his. “Honestly,” he admits, “I fear that the bottom could fall out at any moment.”

Sure enough, other providers haven’t been so fortunate. Clinics across the country have had to close their doors or drastically scale back operations due to financial hardship or new safety protocols. In July, the Salvation Army announced it would be closing several of its 100 adult rehabilitation centers. In late March, the Recovery Centers of America, which sees 1,000 patients a day at centers in Massachusetts, Pennsylvania, New Jersey, and Maryland, announced it would be suspending education days and family visits.

Meanwhile, the federal government has urged treatment providers to continue services. The Substance Abuse and Mental Health Services Administration (SAMHSA) has corralled dozens of handbooks, recommended guidelines, and other provider tools in its online COVID-19 Resource Center, including The Disaster Planning Handbook. “At-risk populations (e.g., children, senior citizens, pregnant women, those with chronic medical disorders, those with pharmacological dependencies) may face unique hardships and challenges if suddenly deprived of their program’s support,” it warns.

Amid all the commotion, some addiction specialists are asking a critical question: Why weren’t we better prepared for this? And where do we go from here?

Fault Lines Exposed

Paul Brasler, a clinical social worker, considers himself one of the lucky ones. Just months before the pandemic struck, he decided to take a hiatus from therapy to lead online substance-abuse treatment trainings for doctors, nurses, and other healthcare workers. “Everything happened so fast,” he says of the virus. “Boom! Everything shut down. It was extremely jarring for those of us in the helping profession.”

In his current work, Brasler has had a direct line to dozens of addiction therapists facing the current addiction crisis head-on. Initially, they celebrated some strong victories, he says. Not only did many patients take easily to telehealth for the flexibility it allowed, but in March, the Department of Health and Human Services announced it would be removing restrictions designating HIPAA-compliant telehealth platforms, opening the door for therapists and clients to use more mainstream—though perhaps less private—forms of digital communication, like Zoom and FaceTime. In late April, the Centers for Medicare and Medicaid Services (CMS) announced that therapists doing telehealth, including by phone, would receive the same Medicare reimbursement rates they’d received for in-person services.

“It was a game changer,” Brasler says of the decisions. “The positive response to telehealth from government, providers, and clients alike has been overwhelming.”

At the same time, he cautions, the pandemic has exposed some glaring, longstanding inequities in addiction treatment. For one, outside large cities, internet accessibility remains an issue, even in 2020. This is corroborated by the FCC, which reports that nearly one-fourth of people in rural areas, or 14.5 million Americans, still lack access to high-speed internet.

“This pandemic has shown the need for broadband access in rural areas,” Brasler explains. “Before coronavirus, I would’ve thought, Okay, whatever, so you can’t get Netflix. But it’s not that simple. Broadband access is now an essential part of the healthcare system. How are you going to do telehealth if you can’t even get access?”

Still, even therapists and clients who do have access to telehealth are dealing with a flaw in addiction treatment, Brasler says: as popular as teletherapy has become over the past six months, too many clinicians still don’t know how to do it well.

“Too many therapists are troubleshooting tech issues in the middle of sessions and haven’t worked out issues around privacy, scheduling, and building trust and rapport,” he explains. “Too often, when it comes to treating substance abuse, we react to it rather than plan for it. This is just another instance where we’re reacting.”

Still, Brasler says he’s optimistic that therapists will catch on quickly. “That’s been my mission with these trainings,” he explains. “Coronavirus took an entire system and shook it up. Anytime that happens, it’s going to expose weaknesses. Now it’s time to fix them.”

Getting Back to Work

Neeraj Gandotra, SAMHSA’s chief medical officer and former medical director of Addiction Treatment Services at Johns Hopkins University School of Medicine, doesn’t dispute that there are gaps in addiction treatment that need to be fixed. Small, private facilities that don’t receive government financial support or have space for social distancing have been disproportionately affected, he says.

He cautions that improvements may come slowly. After all, “some changes will only come through legislative action, and policy modifications need to be made in agencies like CMS and the DEA,” he says. “But all things considered, most clinics have rebounded pretty quickly.”

Gandotra points out several new strategies that have helped. Some medication-assisted treatment programs have allowed clients to take home and self-administer drugs, like buprenorphine, that treat opioid dependency, withdrawal, and cravings. Inpatient treatment centers are isolating new clients to ensure they won’t spread the virus if they’re carriers. And perhaps most impactfully, Gandotra says, he’s seeing an increased push for integrated care, where a client can get an immediate referral to another specialist in the same building, and sometimes, a same-day appointment.

As for teletherapy, “it presents both opportunities and challenges,” he adds. “It’s a way for therapists to safely care for clients while also protecting themselves. But while many clinics were willing to embrace telehealth, not all were poised to do so. As with any healthcare encounter, risks and liabilities remain.”

In essence, maintaining standards and providing the same quality of care as in pre-COVID times means therapists need to adapt and grow certain clinical skills. It’s something Whitney Howzell, clinical director of the Claudia Black Young Adult Center in Wickenberg, Arizona, understands well.

In May, her 24-bed inpatient treatment center saw a surge in admissions, including three relapses, and had to place a handful of prospective clients on a waitlist. The center’s four therapists went from each treating five clients per day—normally a full caseload—to six or seven.

“For the first time in a long time, many young adults struggling with addiction are out of work and at home with parents or caregivers who finally see up close just how ill they are,” Howzell says. “All their resources have been taken away—their coping skills, their distractions. They’re in the house with the door closed. They’re isolated. Some are returning to abusive or traumatic families of origin. It’s no wonder things have gotten worse.”

Quickly, the center’s therapists got to work. Besides implementing social distancing measures inside the center, they moved intensive sessions with family members online so they could keep in-person sessions with residential clients in place, and established weekly video check-ins with parents. There’s renewed determination here, Howzell contends. “This pandemic has forced clinicians and clients alike to be very intentional about developing healthy coping strategies in a way they weren’t before. When the unexpected happens, traditional trauma work isn’t going to cut it.”

The Road Ahead

It’s hard to find a silver lining in this pandemic, but it’s there, Howzell says, particularly in regard to a surge in her therapists’ motivation. In their free time, more and more are enrolling in online trainings to ensure they bring their best selves to treatment, and more are seeking supervision when they feel overwhelmed. Others who’ve traditionally done individual therapy have shifted to group therapy to pick up the slack.

“We can look at all the negatives about having to adjust business plans, or we can look for opportunities,” she says. “We’re trying new interventions and approaches, things we might not have done had we not been forced to. I encourage therapists struggling right now to take this time to invest in themselves as clinicians.” And don’t forget self-care, she adds, “because this stuff is heavy. Just as much as you take care of the client, you’ve got to take care of yourself.”

Tatarsky shares Howzell’s optimism. Although his center’s caseload fell sharply in March, as with many clinics, he says it’s been “full speed ahead” over the past couple months to meet the growing need. He’s also buoyed by his clients’ resilience and eagerness to get back to work.

“A lot of them have been able to shift from feeling overwhelmed and potentially traumatized by what’s happening to being laser-focused on self-care,” he explains, “finding new ways to structure their lives and replace what’s been lost with what they have control over.”

Tatarsky says his team wants to work with that momentum and become a prominent voice in the sea change addiction treatment is undergoing as it rises to meet old problems in a new climate. In recent years, Tatarksy says, there’s been a movement in the field toward Integrated Harm Reduction Psychotherapy, the model his team follows, which proponents say is more client centered, validating, and humanistic than traditional abstinence-only models.

“This pandemic has shown that lots of people who’ve never had a problem with substances are now feeling out of control. If you consider the harm-reduction perspective that it’s natural for us to look for something soothing when we get overwhelmed, it normalizes substance use and lets us begin to discuss how we can help people regain control.”

On the first day a client walks into Tatarsky’s office, he does what they call a microanalysis, asking the person to tell him the story of how they use drugs or alcohol, how much it’s been a part of their life over the past week or month or year. When does it help them? When does it become problematic?

“Instead of labeling them an addict, we offer new ways of thinking about their problem that makes sense and means something in relation to their life experience,” he says. “Then we can get to work, talking about things like self-care and medication and identity.”

Tatarsky still worries about the future, but his convictions remain strong. He knows that, even with the challenges posed by the coronavirus, they’ll weather the storm. After all, this isn’t just a public health issue, he says: it’s a social justice one. Entire communities—people who’ve long been relegated to the margins of society—still don’t have access to high-quality care.

Slowly but surely, that’s changing. Virus or no virus, Tatarksy and other like-minded therapists—activists, really, he says—will be on the front lines of the epidemic, in pop-up clinics, community centers, and fully rigged vans that hand out more than just a clean needle and a pamphlet: a new pathway to recovery.

“We’re doing outreach. We’re in these communities. We’re meeting a need,” he says. “In these uncertain times, we’re meeting people on their own terms.”

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