On March 13, a dozen people gathered at a Cleveland outpatient clinic for their daily therapy group. They represented a patchwork of addictions: to alcohol, crack cocaine, methamphetamine, marijuana, heroin. They were freshly out of jail, out of marriages, out of work. The newest member had enrolled just a week earlier.
The three-hour morning session that Friday, reinforced with continually brewing coffee and snacks everyone brought to share (mini doughnuts, chips, cookies, pretzels) began with lights dimmed and a meditation. Shortly after noon, they locked arms, recited the Serenity Prayer, and said: “Be well, be safe, see you Monday.”
But the Monday session never came.
Instead, early that morning, Rona Huckabee, their therapist at Cleveland MetroHealth, called each one of them with hard news: Because of the coronavirus pandemic, meetings would have to be indefinitely suspended.
“They keep saying, ‘Please can we come in, we won’t touch anyone,’” said Dr. Huckabee, who now phones each patient daily.
For people who struggle with sobriety, for whom isolation is excruciating and group support essential, the ban on group gatherings to combat the spread of the coronavirus is pure hell. Some addiction experts worry that the situation will soon lead to an increase in overdoses, reversing declines of recent years.
“When we provide treatment, we talk about relapse triggers,” said Dr. Tim K. Brennan, director of the Addiction Institute at Mount Sinai West in New York. “I’m hard-pressed to think of a bigger relapse trigger than what we’re going through now as a country.”
The shock waves are hitting every strata of these communities, from people who rely on 12-step programs like Alcoholics Anonymous and Narcotics Anonymous, to those who go to clinics to receive doses of addiction treatment medication, to people living on the street who rely on community aid workers for clean syringes.
“The disruptions that the pandemic is causing can really risk devastating the gains we’ve made in addressing the opioid epidemic,” said Dr. David Fiellin, an addiction medicine expert at the Yale School of Medicine. “For some patients, we worry about them going back to what is familiar — using is their coping strategy. For others, we worry about disruptions in ongoing access to their addiction treatment medications.”
Treatment providers, support networks and even the federal government have begun to act. Last week, the federal Drug Enforcement Administration, the Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration issued new regulations and guidelines. They will now allow clinics to dispense extended quantities of the addiction treatment medications methadone and buprenorphine to patients whom providers deem stable, so they will not have to visit clinics daily. Regulations now also permit some medical assessments to be done by phone.
Dr. Fiellin said many doctors still needed to loosen office rules. “Some practices vary about whether counseling and providing urine is obligatory in order for patients to receive their buprenorphine,” he said.
Experts note that drug courts will need to adjust procedures too: Thousands of people are under orders to attend meetings and submit to regular urine screens, or risk incarceration.
Organizations like Alcoholics Anonymous, which had online meetings and phone counseling available for years, are urging local chapters to use those tools immediately. New apps are helping people stay sober with meditations, peer support and counseling.
But people are frightened. Last week, a Los Angeles woman, scarcely three months sober, dialed into an online Alcoholics Anonymous meeting, then shut off her computer’s camera and, as she listened, broke into her husband’s wine collection and started knocking back a bottle of red.
Her friend Monica, a 46-year-old former investment banker who has attended AA meetings on and off for 18 years, said she understood why.
“I’m having a hard time staying sober and I’ve been at this a long time,” said Monica, whose boyfriend is now very ill, possibly with Covid-19. “It is incredibly difficult not to pick up a drink right now for anyone who struggles with alcoholism, but especially difficult for those of us who are closer to our last drink.”
While people worldwide have been upended by social distancing, for many struggling with addiction the order to stay apart has thrown them back into the basements of loneliness where their addictions took root.
People in recovery are told not to isolate themselves. But now, said Joe Dinan, 41, an environmental consultant who attended meetings of SMART Recovery at Massachusetts General Hospital in Boston, “We’re being told to isolate again.”
“People are winding up at home with a lot of free time, boredom and social disconnection,” he said. The first 90 days of recovery are typically structured with activities to distract from drinking or using drugs, including two daily meetings, plus travel time. That’s done for now.
He has friends who are live-streaming yoga classes and putting together online support groups. But irritability, anxiety and urges are mounting, he said.
Chuck Krumroy, who facilitated the SMART Recovery meeting at Massachusetts General until two weeks ago, falls deep within the demographic groups at high risk should they contract the virus. He is 71, H.I.V. positive and has a chronic kidney disease. He has decamped to a relative’s home in a small Maine town but is continuing to communicate remotely with his group.
In those sessions, Mr. Krumroy identified the association of trauma with relief-seeking behaviors, like drinking and using drugs, that has scarred so many members, himself included. For him, the trauma that led to his own excess drinking was the AIDS epidemic, when he lived in San Francisco during the height of the crisis. Now he is fighting to quell the reverberations that the coronavirus pandemic is setting off.
“These Google groups and individual phone calls are going to be crucial to helping us all acknowledge how traumatic the coronavirus potentially is,” Mr. Krumroy said. “We need to tell each other that our reactions are normal and understandable and not something to be ashamed of. And with that mutual support, I’m hopeful that most of us will be able to resist any urge to re-engage in our behavior.”
But Kristen Marshall, who manages the DOPE Project in San Francisco for the national Harm Reduction Coalition, is not nearly as hopeful. To help prevent overdoses, the project distributes clean syringes, addiction medications like naloxone and Narcan, snacks and water bottles to programs working directly with people without housing. She is considered an essential worker who does not have to heed the state’s orders to shelter in place, so she is moving about the city with other health workers, to aid people without housing who are suffering from addictions and health crises, ordered to scatter, their belongings confiscated.
“Closing or limiting programs designed to support them puts them at even higher risk for overdose and overdose death,” Ms. Marshall said.
She added: “For so many of our folks, their contact with our programs are some of their only opportunities for socialization and connection. So workers and their organizations are desperately trying to balance keeping themselves healthy and safe while also refusing to close their programs’ doors.”
The business shutdown orders rolling through the country are hitting some in the recovery community in ironic ways. On the Facebook group Harm Reduction Abstinence Moderation Support, which accepts many people who handle substance issues by reducing use instead of abstaining, some worry that with some liquor stores closing, they will have to withdraw cold turkey and plunge into delirium tremens — or the “DTs,” with hallucinations, vomiting, fever and high blood pressure. And then they fear they won’t be admitted into overcrowded emergency departments. Or will be exposed to Covid-19 in those waiting rooms.
“Many of our members have laid in a supply of alcohol so they won’t crash immediately,” said Kenneth Anderson, the founder of the group.
Indeed, some states have included liquor stores on the roster of essential businesses that can remain open, out of concern for those with substance use disorders — and also to prevent a black market for alcohol sales. Gov. Tom Wolf of Pennsylvania said he may rescind his initial order to close the state’s wine and spirits stores.
Dr. Anna Lembke, who sees patients at Stanford’s Addiction Medicine Dual Diagnosis Clinic, is new to online platforms and sees silver linings. “We have lots of patients who struggle to get to our clinic in person and could really benefit from remote visits,” she said.
An added bonus: By seeing patients in their homes, she is getting more information about how they live. “I’ve told a few of my patients to clean their rooms,” she said.
In Cleveland, Dr. Huckabee has been checking in by phone with patients four times a week. So far, most are hanging in, but she fears for a woman who had only been in the program a week, after struggling with heroin.
“She says she is OK, but I know she’s not,” Dr. Huckabee said.
Dr. Huckabee knows deeply that a half-hour telephone call is no substitute for a three-hour daily group session. Many of her patients are facing relatives who don’t understand what they’ve been through. They need the solace of the group. She repeatedly tells them, “I’m your No. 1 fan.”
A week from now, she predicts, a few will simply show up at her office.
But what about social distancing?
Dr. Huckabee chose her words carefully. “I’m not telling them to come in, but I’m not telling them not to. They need that connection, to know someone cares,” she said.
“So when they show up, we’ll wash our hands and we’ll sit down together,” she added. “And we’ll talk.”
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