research on substance use disorders during the covid 19 pandemic

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Substance Use Disorders and Behavioral Addictions During the COVID-19 Pandemic and COVID-19-Related Restrictions

Nicole m avena, julia simkus, anne lewandowski, mark s gold, marc n potenza.

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Edited by: Giuseppe Bersani, Sapienza University of Rome, Italy

Reviewed by: Ruben David Baler, National Institutes of Health (NIH), United States; Domenico De Berardis, Azienda Usl Teramo, Italy

*Correspondence: Nicole M. Avena [email protected]

This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry

Received 2021 Jan 15; Accepted 2021 Mar 11; Collection date 2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

COVID-19 was first identified in Wuhan, China in December of 2019 and appeared in the United States 1 month later. Between the onset of the pandemic and January 13, 2021, over 92 million people have tested positive for the virus and over 1.9 million people have died globally. Virtually every country in the world has been impacted by this virus. Beginning in March 2020, many U.S. state governments enforced a “quarantine” to respond to the growing health crisis. Citizens were required to remain at home; schools, restaurants, and non-essential businesses were forced to close, and large gatherings were prohibited. Americans' lives were transformed in a span of days as daily routines were interrupted and people were shuttered indoors. Mounting fear and unpredictability coupled with widespread unemployment and social isolation escalated anxiety and impacted the mental health of millions across the globe. Most (53%) U.S. adults reported that the coronavirus outbreak has had a negative impact on their mental health, including inducing or exacerbating use of alcohol, drugs, gambling and overeating as coping mechanisms. In this paper, we will examine substance use and addictive behaviors that have been used to manage the stress and uncertainty wrought by the COVID-19 pandemic. We review the changing treatment landscape as therapy pivoted online and telemedicine became the norm.

Keywords: COVID-19 pandemic, food addiction, gambling, mental health services, substance-related disorders, addictive behaviors

Introduction

COVID-19 appeared on January 15th, 2020 in the United States as a novel coronavirus about which scientists and doctors knew very little ( 1 ). In efforts to mitigate the spread of the virus and not tax healthcare resources, a “quarantine” began in March. Most state governments imposed stay-at home orders, requiring schools, restaurants, and non-essential businesses to close, forbidding large gatherings, prohibiting travel and enforcing spatial distancing. Nationwide restrictions did not start to ease until May, and as of this writing, many of these restrictions remain in place in certain regions of the country ( 2 ).

The COVID-19 pandemic and subsequent quarantine and lockdown restrictions have negatively impacted virtually every segment of the U.S. population. The healthcare system has been strained due to mounting COVID-19 cases 1 . Hospitals have suffered economic losses from reductions in elective procedures, limitations on routine medical services and the high cost of personal protective equipment (PPE) ( 3 ). Individually, people were faced seemingly overnight with fears over contracting this virus with unknown outcomes, altered life responsibilities including juggling home-schooling of children, worries about the health of their families and friends, and, in some cases, experiences of food insecurity, isolation and job loss.

It is important to note, while COVID-19 has often been referred to as a pandemic, and it is from a purely scientific standpoint, the term syndemic, coined first by anthropologist Merrill Singer in the 1990s has been used to describe this outbreak as well. The specificity of a syndemic is that it involves biological and social interactions and takes into account socioeconomic disparities that cause certain communities to be more heavily affected by the virus than others. These communities usually lack access to healthcare and tend to be low-income communities. They often have higher occurrences of comorbidities that make them more susceptible to the novel coronavirus. It is important to take this social aspect into account when tallying the effects of COVID-19 on the US population ( 4 ).

One of these tragic effects is the impact COVID-19 has had on the mental health of millions of Americans. Many individuals were already experiencing depression and anxiety “pre-pandemic,” with an estimated 9.5 percent of Americans utilizing mental health services in 2019. The pandemic likely exacerbated these conditions. Studies of the psychological impacts of quarantines during the SARS (severe acute respiratory syndrome) (2003) and Ebola (2014) epidemics demonstrated that individuals under government-imposed quarantines exhibited greater psychological distress ( 5 ), including higher levels of depression, stress, irritability, fear, exhaustion and insomnia ( 6 ). According to a study that assessed the psychological effects of quarantine measures in response to the SARS epidemic in Toronto, 31.2% of participants exhibited signs of depression and 28.9% exhibited signs of posttraumatic stress disorder. The study also showed that family and friends connected to infected individuals experienced heightened feelings of distress and depression ( 7 ). SARS was considered a serious epidemic that infected over 8,000 people worldwide and took 774 lives ( 8 ). In comparison, there have been over 22 million COVID-19 cases and over 379,000 deaths in the United States alone ( 9 ). It is also important to note, while not the main focus of this article, there has been evidence that shows that SARS-CoV2 can actually disrupt the central nervous system and create “acquired vulnerability” which can make an individual who is recovering from the virus more susceptible to developing psychiatric conditions after they have had COVID-19 ( 10 ). This is another element to consider when cataloging the impacts of COVID-19 on mental health.

When people experience increased psychological distress, they may rely on maladaptive coping mechanisms, including using alcohol and drugs, gambling and overeating. Over half of U.S. adults reported that the coronavirus outbreak has had a negative impact on their mental health. Of those adults, 12% reported an increase in alcohol or drug use ( 11 ). Gambling has also increased considerably between March and August of 2020 with Global Poker, a gambling research firm, reporting a 43% growth in the poker industry ( 12 ). Along with drugs, alcohol and gambling, Americans have turned to food to alleviate stress. A WebMD poll in May 2020 reported that 44% of women and 22% of men had already experienced weight gain just 2 months into government-imposed shutdowns. The “Quarantine 15” and #quarantineweightgain have been trending on social media since the early days of the pandemic ( 13 ).

This article will address the various ways in which the past months' quarantine has impacted the mental health of many and led to detrimental behaviors including substance, gambling and food addictions. Although others have already written about the challenges (and opportunities) emerging from these interacting phenomena ( 14 – 17 ), this article will add to this discussion and also address how access to treatment for mental health has changed in this new, more virtual world. The research for this publication was conducted using PubMed (Medline) and United States government resources. The keywords used to find the sources that are cited include: COVID-19, lockdown, substance use disorder, alcohol use disorder, food addiction, mental health, depression.

Substance Use Behaviors and Disorders

Pandemic-related stress, anxiety and isolation, in addition to disrupted treatment and recovery programs, can increase the likelihood of substance misuse, addiction and relapse. Unemployment tends to contribute to increased spikes in substance abuse ( 18 ). As of May 2020, 39% of Americans lost their jobs or had their work hours curtailed due to the pandemic ( 19 ). The stress of financial uncertainty along with an increase in free time and the absence of employment repercussions can lead people to seek ongoing solace from illicit drugs. Data from the first quarter of 2020 demonstrate the effects of COVID-19 on substance abuse among Americans. From January to March of 2020, 19,146 people died from drug overdoses, compared to 16,682 people in the same quarter of 2019. The CDC estimated a record number of US drug-related deaths in 2020 ( 20 ).

A survey of 1,079 individuals with substance use disorders (SUDs) and SUD-impacted individuals was conducted by the Addiction Policy Forum ( 21 ). This study, which examined the impact of COVID-19 on individuals with SUDs, found that 74% of respondents said they had noticed changes in their emotions since the pandemic began ( 21 ). Twenty percent of respondents reported an increase in substance use, and 1% reported being impacted by experiencing a fatal overdose since the onset of the pandemic ( 21 ). Close to 5% (4.2%) of respondents reported an overdose. Other challenges that were identified included COVID-19 impacting treatment services and difficulties accessing specific services like naloxone and needle exchanges ( 22 ). The Addiction Policy Forum cited some perspectives from individuals in recovery or those with an active SUD. Some examples include: “During the last months I have felt more at risk of relapse than I ever have,” and “I have never felt true depression like I have in the past month. I know alcohol makes it worse, but I feel like I just want to make it through this time by staying comfortably numb” ( 21 ).

To make matters worse, seeking treatment for SUDs during quarantine has been extremely difficult for many. In-person treatment for opioid use disorder (OUD) and other SUDs has been offered virtually, but many who need these services do not have regular access to a computer or the internet. Unfortunately, the amount of attention healthcare providers can give to those in recovery, especially in the first few months of the pandemic, has been severely limited by the demand of attending to COVID-19 patients. PPE and hospital space are often difficult to spare for anyone not gravely ill with the virus ( 23 ).

Alcohol Use

Amid isolation, financial difficulties and lockdowns, many have turned to alcohol to cope with anxiety and uncertainties during the pandemic. There are positive correlations between exposure to stress and alcohol and SUDs. For example, in the months following the September 11 terrorist attacks, around 30% of surveyed New York City residents reported significant increases in their consumption of cigarettes, alcohol or marijuana ( 24 ). Although bars, restaurants, and liquor stores were closed at the peak of the pandemic in March and April, studies reveal a 54% increase in national sales of alcohol during the week ending March 15, compared to this same week 1 year prior, with online alcohol sales increasing 234%. Consumers are ordering alcohol in bulk to limit their purchase frequency and buying mostly brands that they trust, increasing the number of favorable alcoholic beverages in people's households ( 25 ). While working from home, people may have access to alcohol during all hours of the day, which may contribute to drinking in the morning or during lunch breaks. One study reported that on average, alcohol was consumed 1 more day per month by 75% of adults. The frequency of alcohol consumption among adults in this study increased by 14% from 2019 to 2020 ( 26 ). Heavy-drinking episodes increased by 41% in women since the COVID-19 lockdown ( 27 ). Additionally, many states have changed their policies on carry-out purchases of liquor to help restaurants cope with the impact on restaurant business during the pandemic. According to the New York State Liquor Authority, as of March 16th 2020, businesses that sold alcoholic beverages on premise were allowed to begin selling for off-premise consumption as long as the beverages were in closed containers ( 28 ).

While many people turn to alcohol to relieve their stress and worries, the relief is typically only temporary. Instead, alcohol generally increases the symptoms of anxiety and depression, often leading to binge drinking. Those who use alcohol as a coping mechanism are more likely to develop SUDs ( 29 ). Alcohol can have serious neurological impacts, especially when used heavily and for prolonged periods of time. Alcohol interacts with several neurotransmitter receptor sites in the brain including GABA, glutamate and dopamine. Alcohol temporarily stimulates brain reward regions thus promoting drinking, but over time alcohol tends to act as a depressant ( 30 ). A common result of long-term alcohol use is the development or exacerbation of depression ( 31 ).

Family Stress

The stress of the pandemic is taking a particular toll on parents with children at home. By the middle of March 2020, public and private elementary and secondary schools closed across the country and students were forced to transition to online learning. An August 2020 report by the U.S. Census Bureau stated that nearly 93% of households with school-age children reported some form of distance learning during the pandemic ( 32 ). Parents were often forced to facilitate online learning throughout the school day while juggling their own employment and attending to basic household needs. Over 70% of parents reported that managing distance learning for their children during the pandemic was a significant source of stress ( 33 ).

The American Psychological Association surveyed 3,000 adults between April 24 and May 4, 2020. The survey showed that the average stress level reported by parents of children under 18 was 6.7 out of 10 compared with 5.5 out of 10 for adults with no children living at home. Additionally, 46% of adults with children under 18 stated that their stress level was “high” (between 8 and 10) compared with 28% of adults without children reporting the same level of stress ( 33 ).

Gaming and Gambling

Physical distancing, lockdowns and self-quarantines amid the coronavirus outbreak have been associated with increases in online gaming and gambling, which in turn have placed people at risk for gaming and gambling disorders. In addition, financial difficulties and unemployment may encourage gambling as people are encouraged to gamble to win money. Global Poker reported that the number of first-time online poker players increased by 255% since stay-at-home orders began ( 12 ).

College students may be particularly vulnerable to stress during the pandemic due to changes in their social lives, uncertainties regarding career prospects and shifts to online learning. In a study involving about 400 college students, 50.8% reported that their gaming had increased during the COVID-19 lockdown ( 34 ). These students acknowledged that gaming helped manage their stress related to the pandemic. General and specific practices to promote healthy gaming and internet use more generally have been suggested ( 35 ).

Food Addiction

The term “freshman 15” is an expression that refers to the arbitrary weight that a student gains during his/her first year of college. Since the onset of the pandemic, the term “quarantine 15” has been used to refer to a 15-pound weight gain during self-isolation. Eating as a result of stress, specifically the stress during the outbreak of an infectious disease, is not uncommon among Americans ( 37 ). According to a 2013 study conducted by the American Psychological Association, 38% of adults reported overeating or eating more unhealthy foods due to stress, with 33% of these adults saying they do so because it helps distract them ( 36 ). Emotional eating tends to occur because when people are stressed, the stress hormone cortisol increases, which in turn, increases our appetite and motivations to eat ( 38 ). Eating may serve as a distraction or respite from pandemic isolation. Some highly palatable foods may trigger an addictive-like process in some individuals, activating reward-processing brain regions like drugs of abuse. Parallels exist between clinical and behavioral features of binge eating and substance use disorders ( 39 , 40 ). Similar to how individuals become dependent on drugs or alcohol to manage depression and anxiety, the reliance on highly palatable foods for comfort and stress reduction may be considered as aspects of a “food addiction” ( 39 , 41 ). Food addictions or eating disorders may include abnormal eating behaviors, such as excessive food intake or restriction and binging and purging, to cope with one's negative emotions. The National Eating Disorders Association reported a 78 percent increase in calls to their hotline and online chats in March and April this year compared to the same period in 2019 ( 42 ).

Among 602 Italians surveyed online between April and May 2020, almost half reported feeling anxious due to their eating habits and admitted to increasing their consumption of comfort foods to feel better. In addition, 86% of respondents reported that they felt unable to sufficiently control their diet ( 43 ). While emotional eating is not necessarily considered disordered, these habits may become problematic and unhealthy if one is routinely turning to food to manage stress and anxiety.

How the Pandemic Has Changed the Treatment Landscape

For individuals with SUDs, the COVID-19 pandemic has resulted in changes in treatment including access to therapy, physician availability and adjustments to medication schedules. Moreover, fears associated with contracting the virus combined with rigid screening of patients resulted in a sharp decrease in psychiatric emergency room visits early in the pandemic ( 44 ). Inpatients traditionally shared bedrooms and common spaces. COVID-19 has put this system in jeopardy and strict admission criteria – including vigorous COVID-19 testing – has in part led to a reduced number of voluntary admissions to psychiatric facilities ( 45 ). Disruptions in treatment and difficulties obtaining treatment have intensified emotional distress associated with the pandemic. On March 17, 2020, the US federal government waived regulations pertaining to telemedicine and loosened restrictions to enable physicians to cross state lines for treatment ( 46 ). The last week of March saw a 154% increase in telehealth visits compared to the same period in 2019 ( 47 ). While these unprecedented changes arguably increased access to treatment for many individuals, even slight adjustments to traditional mental health care can be traumatizing and magnify the risk for an exacerbation or a recurrence of symptoms ( 48 ).

Relative to in-person treatment, online therapy may result in poorer communication and lower quality for some. Online therapy is often not ideal for people who are homeless, lack regular cell phone access or work outside of the home. Individuals in recovery may be enduring particular hardships as support group meetings such as Alcoholics Anonymous are being held virtually instead of in-person ( 21 ). Data from communication science and telemedicine group therapy show that online recovery and support services are not as beneficial as in-person services ( 48 ). A survey by the Addiction Policy Forum on 1,079 individuals with or impacted by SUDs was conducted between April 27 and May 8. The findings revealed that 34% of respondents reported changes or disruptions in their treatment or recovery support services since the onset of the COVID-19 pandemic, with 14% reporting that they have been unable to receive their needed services ( 21 ). Individuals with poly-substance use may have been particularly impacted ( 49 ). Other drawbacks of online recovery-related services include the absence of in-person activities, a lack of peer-to-peer social and emotional connections, and online distractions interfering with patients' engagement ( 48 ).

Arguably, there have been advantages to switching to online therapy. According to the American Psychological Association, online therapy can be more accessible to people living in areas where psychologists and psychiatrists are scarce ( 50 ). Teletherapy can provide more flexibility for people who previously found it difficult to visit an office, a greater sense of anonymity than in-person services, and 24/7 access to social support ( 48 ). In addition, research by Simpson and Reid (2014) discussing the therapeutic alliance in videoconference psychotherapy suggests that the relationship between therapist and patient is generally as good for telemedicine as it is for in-person therapy ( 48 ). Teletherapy may be more flexible for people who previously found it difficult to visit an office ( 50 ). A recent study found evidence that supports the importance of teletherapy by documenting the changes in mental health of a sample demographic after the beginning of the pandemic. The results from this study concluded that there was an increase in stress, fear, and other states of poor mental well-being that began after quarantine in March 2020. The fact that a survey of this type was able to be conducted in a fully virtual format bodes well for the future of telemedicine during and after the pandemic ( 51 ). In short, mental health treatment has been significantly altered by the COVID-19 pandemic, and while online therapy may present some drawbacks, new opportunities also exist.

While the COVID-19 pandemic has negatively impacted essentially every corner of the U.S. population, there is a distinctly disproportionate effect on disadvantaged, vulnerable populations. Reports from state and city health departments have revealed that Black, Latinx, and Native Americans test positive for and die of COVID-19 at a higher rate than other racial and ethnic groups. For example, while black Americans represent only 13% of the U.S. population, about 30% of all COVID-19 cases occurred in this racial group. Or, Latinx Americans, who constitute 18% of the U.S. population, accounted for 34% of total COVID-19 cases ( 52 ).

The unequal access to health care, greater dependency on low-wage or hourly paid employment, heightened psychological distress, and less access to treatment among racial minorities in the United States became undoubtedly evident this past year. There were noticeable racial and ethnic disparities in outpatient visits for substance use disorders during the surge of COVID-19. In Massachusetts, for example, a state with an early and considerable COVID-19 outbreak, outpatient visits for mental health and/or substance use disorders decreased by Hispanics (−33.0%) and non-Hispanic Blacks (−24.6%) while visits by non-Hispanic Whites increased by 10.5%. This decrease in mental health and/or substance use disorder visits among certain ethnic minority groups is likely due to lower access to employer-sponsored commercial insurance as well as a lack of access to digital technology ( 53 ).

Conclusions

Nationwide closures and reduced mental health services have been detrimental to peoples, well-being. Many individuals will encounter repercussions from the COVID-19 pandemic for years to come. The U.S. will need to reevaluate how mental health treatment is provided during these times and when faced with future crises. The COVID-19 pandemic has demonstrated that many Americans may turn to maladaptive coping mechanisms when faced with significant disruptions to their daily lives. Future research should focus on creating adequate delivery of mental health resources and implementing strategies and methods to respond better when other crises occur ( Table 1 ).

Highlights and relevant sources.

Author Contributions

NA: drafted outline and sections of the paper and edited paper. JS: collected research and drafted sections of the paper and edited paper. AL: collected research and drafted sections of the paper. MG: drafted and edited sections of paper. MP: drafted and edited sections of paper. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1 Worldometer. Coronavirus Cases . (2021). Available online at: https://www.worldometers.info/coronavirus/ (accessed January 13, 2021).

Funding. MP was supported by the Connecticut Council on Problem Gambling. Beyond funding, the funding agencies had no further role in the writing of the report or in the decision to submit the paper for publication.

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Experiences with substance use disorder treatment during the COVID-19 pandemic: Findings from a multistate survey

Brendan saloner, noa krawczyk, keisha solomon, sean t allen, miles morris, katherine haney, susan g sherman.

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Issue date 2022 Mar.

Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Drug overdoses surged during the COVID-19 pandemic, underscoring the need for expanded and accessible substance use disorder (SUD) treatment. Relatively little is known about the experiences of patients receiving treatment during the pandemic.

We worked with 21 harm reduction and drug treatment programs in nine states and the District of Columbia from August 2020 to January 2021. Programs distributed study recruitment cards to clients. Clients responded to the survey by calling a study hotline and providing a unique study identification number. Our survey included detailed questions about use of SUD treatment prior to and since the COVID-19 pandemic. We identified settings where individuals received treatment and, for those treated for opioid use disorder, we examined use of medications for opioid use disorder. Individuals also reported whether they had received telehealth treatment and pandemic related treatment changes (e.g., more take-home methadone). We calculated p-values for differences pre and since COVID-19.

We interviewed 587 individuals of whom 316 (53.8%) were in drug treatment both before and during the COVID-19 pandemic. Individuals in treatment reported substantial reductions in in-person service use since the start of the pandemic, including a 27 percentage point reduction ( p <.001) in group counseling sessions and 28 percentage point reduction in mutual aid group participation ( p <.001). By contrast, individuals reported a 21 percentage point increase in receipt of overdose education ( p <.001). Most people receiving medications for opioid use disorder reported taking methadone and had high continuity of treatment (86.1% received methadone pre-COVID and 87.1% since-COVID, p =.71). Almost all reported taking advantage of new policy changes such as counseling by video/phone, increased take-home medication, or fewer urine drug screens. Overall, respondents reported relatively high satisfaction with their treatment and with telehealth adaptations (e.g., 80.2% reported “I'm able to get all the treatment that I need”).

Conclusions

Accommodations to treatment made under the federal public health emergency appear to have sustained access to treatment in the early months of the pandemic. Since these changes are set to expire after the official public health emergency declaration, further action is needed to meet the ongoing need.

Keywords: Opioid use disorder, Substance use disorder, COVID-19, Methadone, Buprenorphine, Treatment, Access to care, Telehealth, Surveys, Policy

Abbreviations: OUD, opioid use disorder; SUD, substance use disorder; DEA, Drug Enforcement Administration; HHS, Health and Human Services

Fatal drug overdose has been rising in the United States since the early 2000s ( Mattson et al., 2021 ), and accelerated during the COVID-19 pandemic ( Faust et al., 2021 ). In 2020, more than 90,000 Americans died of an overdose, three-quarters of these deaths involved an opioid ( Faust et al., 2021 ). Alongside an increasingly lethal drug supply dominated by synthetic opioids (i.e., fentanyl) ( National Institute on Drug Abuse, 2021 ), poor access and quality of drug treatment is likely to be a major contributor to current overdose trends. Conversely, increasing utilization of drug treatment is a critical strategy for reducing substance use and improving health among people with substance use disorders (SUDs) ( National Institute on Drug Abuse, 2018 ). Despite its effectiveness, only one-fifth of people with symptoms of an SUD used treatment in 2019 ( Substance Abuse & Mental Health Services Administration, 2020b ). Low utilization of evidence-based treatment is likely a major contributor to persistently high drug overdose rates.

SUD treatment was profoundly affected by the COVID-19 pandemic. Early in the pandemic, many programs opted to halt or reduce in-person services in order to prevent transmission of COVID-19 from occurring at treatment locations ( Blanco, Compton, & Volkow, 2021 ; Kleykamp, Guille, Barth, & McClure, 2020 ). This had an impact on treatment offered in a variety of settings, including counseling and mutual support meetings that are integral to many SUD treatment programs. The challenge of safely delivering in-person treatment during the COVID-19 pandemic has been compounded by the elevated prevalence of health and social conditions that exacerbate COVID-19 risk and severity (e.g., virally unsuppressed HIV infection, cardiovascular disease, and unstable living conditions) among people with SUD ( Allen et al., 2020 ; Wen, Barnett, & Saloner, 2020 ).

One area of particular concern has been treatment for opioid use disorder (OUD). Opioids – increasingly in combination with methamphetamines and cocaine – drove surging U.S. overdose deaths during 2020 ( National Center for Health Statistics, 2021 ). Overdose deaths during the pandemic have risen most precipitously among Black, Latinx, and American Indian populations ( Kaiser Family Foundation, 2021 ). Early in the pandemic when social distancing provisions were stringent and in-person clinical care was limited, a major concern was access to medications for opioid use disorder (MOUD). Buprenorphine and methadone are highly regulated by the federal government, and longstanding regulations have required in-person visits with a prescriber for buprenorphine patients and in-person visits to an opioid treatment program to receive dispensed methadone under supervision. Pre-pandemic guidelines from the US Department of Health and Human Services (HHS) and the Drug Enforcement Administration (DEA), substantially limited access to take-home methadone.

In March 2020, HHS enacted emergency regulations that allowed more widespread adoption of telehealth services. HHS, working with the DEA, waived the requirement for an initial in-person visit for buprenorphine prescription and increased the duration of take-home methadone to up to 28 days for the most stable patients and 14 days for less stable patients ( Alexander, Stoller, Haffajee, & Saloner, 2020 ). “Stability” under the federal guidelines is determined based on factors such as the presence of recent history of substance use, regularity of clinical attendance, length of time in a program, and assurance that patients can safely store medications ( Substance Abuse & Mental Health Services Administration, n.d. ). In addition to the federal changes, many payers broadened reimbursement for certain telehealth services and increased rates to parity with in-person rates ( Haque, 2021 ).

While these changes were all enacted to increase access to care, the experiences and challenges of people receiving SUD treatment during the COVID-19 pandemic are still relatively unknown, particularly among those who may have challenges such as homelessness or those who have active drug use. Existing studies using medical claims data indicate that telehealth provision related to mental health and substance use treatment rose dramatically in April 2020, while in-person encounters fell precipitously ( Ziedan, Simon, & Wing, 2020 ). Because of the offsetting increase in telehealth, the overall volume of SUD-related care did not decline nearly as sharply as other forms of medical care ( Ziedan et al., 2020 ). For example, prescriptions for buprenorphine held relatively steady overall, ( Nguyen et al., 2020 ) though fewer new patients started treatment ( Currie, Schnell, Schwandt, & Zhang, 2021 ; Huskamp et al., 2020 ). Further, a few studies have collected self-reported data from people who use opioids, ( Krawczyk et al., 2021 ) but these surveys have been relatively small in scale or focused on specific cities or clinical systems ( Jacka et al., 2021 ). Existing data from small geographic areas suggest that many, but not all, methadone patients have adapted to telehealth and take-home doses ( Figgatt, Salazar, Day, Vincent, & Dasgupta, 2021 ). There have also been important innovations in the delivery of services, with some programs offering new mobile treatment or medication delivery ( Samuels et al., 2020 ; Tracy, Wachtel, & Friedman, 2021 ). While these studies demonstrate that there have been adaptations in the delivery of SUD treatment during the pandemic, it is unclear whether the needs of patients are being adequately met during this period of heightened stress, particularly for those with limited connections to services.

The current study draws on a survey of clients of SUD treatment and harm reduction programs (i.e., programs that deliver services to promote the safety of people who use drugs, such as syringe services programs). There is a dearth of research that bridges treatment and harm reduction, despite the fact that harm reduction programs typically serve people with current drug use and therefore can provide additional insights into the needs of people who may be at the greatest risk of overdose. The study was fielded from late 2020 to early 2021. Data collection occurred in 9 states and the District of Columbia (DC), focused on areas with elevated drug overdose deaths. To our knowledge, this is the most comprehensive survey of individuals in SUD treatment during the COVID-19 pandemic. The primary aim of the study was to describe changing needs, substance use, and patterns of treatment among people with recent treatment experience. It also aimed to characterize treatment adaptations through telehealth and take-home methadone.

Data collection procedures

Study participants were recruited from a convenience sample of 21 drug treatment and harm reduction programs from DC, Maine, Maryland, Michigan, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and West Virginia. Most programs were from states participating in the Bloomberg Opioid Initiative, a campaign supported by Bloomberg Philanthropies to reduce overdose and were predominantly from regions with high overdose death rates. Programs that recruited participants for the study were nominated by partnering organizations involved in technical assistance efforts in these states, state health officials, or by other provider organizations. The technical assistance providers had typically previously interacted with clinicians or administrators at the recruiting sites, which enabled them to connect the sites to the study team. Sites served diverse populations, but were geographically skewed toward programs serving individuals in northeastern urban communities. As shown in the Appendix, compared to a nationally representative sample of people in substance use disorder treatment, the study sample was more likely to be older, African American, and to use opioids.

Interested programs were invited to an orientation phone call with a study coordinator and given an overview of study procedures. Each program needed to have staff available to assist with study card distribution. Staff at the programs were mailed 100–150 recruitment cards to distribute to their clients. The client recruitment card included the study logo, a study phone number, business hours for the study, and a unique study identifier, which reduced the possibility of non-recruited individuals participating in the study or repeat interviews from the same client.

People who expressed an interest in participating were instructed to call the study phone number during listed business hours to be screened for eligibility, provide informed consent, and take the survey. Interviewers had prior experience conducting surveys with vulnerable and hard-to-reach populations. Prior to data collection, all interviewers piloted the study survey instrument at least twice (once with another staff member and once with a client of a local service provider) to complete training. Eligibility criteria included being: (1) at least 18 years old; (2) currently a client of a referring organization; (3) able to provide informed consent; and (4) able to provide a valid, unused unique study identifier. A voicemail box was created that allowed individuals to leave a message requesting to take the survey if they either called after hours or when study phone lines were occupied. The survey took a median of 59 min to complete. Individuals who completed the survey received a $40 incentive payment, which was either mailed to an address of their choice or transmitted through the Venmo app.

Data collection commenced on August 19, 2020 and concluded on January 29, 2021. The peak data collection month was November 2020. Over this period, a total of 3200 cards were mailed to providers and 587 interviews were completed (i.e., 18.3% of all mailed cards led to a completed interview). The main analytic sample for the current study is 316 individuals who reported engaging in SUD treatment prior to and since COVID-19. We include individuals who indicated continuous SUD treatment regardless of whether they were recruited from a treatment or harm reduction program – clients of harm reduction programs represent an important, but often overlooked population in treatment. An additional 61 individuals exclusively reported engaging in treatment only prior to COVID-19 and 60 only since COVID-19 and were excluded from the main analysis; select outcomes for this larger sample are reported in the Appendix. The study was approved by the Johns Hopkins School of Public Health Institutional Review Board. Study protocols, including the survey instrument, were reviewed by an external advisory board comprised of service providers and national substance use experts.

Treatment utilization outcomes

Individuals were first asked whether they had received any drug or alcohol treatment prior to the onset of the COVID-19 pandemic (before March 2020). If yes, they identified settings where they had received treatment, services received, and frequency of treatment received prior to the pandemic. Patients were asked if they were undergoing treatment for OUD, and if yes, were asked whether they were receiving any of the three approved MOUDs. If applicable, individuals were also asked about changes in take-home methadone or length of buprenorphine prescriptions. Finally, they were asked about whether their treatment provider had adopted telehealth and other safety precautions since the pandemic.

Covariates included several socio-demographic and structural vulnerability factors including age, sex, self-reported race and ethnicity, employment status, insurance coverage, current homelessness, and food insecurity (i.e., going to bed hungry at least once per week). Respondents also answered detailed questions about recent drug use (e.g., types of drugs used, frequency, and route of administration) and changes in self-reported substance use since the COVID-19 pandemic. These questions were modeled on other studies of people who use drugs ( Allen et al., 2019 ; Sherman et al., 2019 , 2021 ).

We calculated the mean percentage of the sample reporting each outcome. For questions where individuals were queried on changes before and since the pandemic, we calculated t -tests and indicate whether the difference is significantly different between pre versus post differences ( p <.05). We also calculated t-tests to compare differences in means between treatment and harm reduction clients in Table 1 .

Demographic and socioeconomic status of study sample by referring provider type.

Notes: Sample restricted to individuals who said that they were referred from harm reduction only services ( N  = 219) and treatment services ( N  = 97). P-value is calculated from t-tests between each of the groups. NH=Non-Hispanic, HS=high school.

P <.001.

Table 1 displays characteristics of people with SUD treatment experience both pre and since COVID-19 overall, and stratified by whether the individual was recruited from a primarily harm reduction program ( N  = 219) versus a treatment program ( N  = 97). The main differences between the two groups is that individuals who were recruited from harm reduction versus treatment programs were more likely to be over age 50, to be non-Hispanic black, to have a serious health condition, to have less education, but less likely to be under age 40 and have current food insecurity.

Across the full sample, 63.9% of people receiving treatment reported any drug use in the past month. Table 2 summarizes current substance use among people who reported using any drugs in the month they took the survey. The most common route of administration was smoking a substance, followed by injection, snorting, and swallowing. Among those using drugs, 67.8% were using opioids, 65.7% were using marijuana, 34.7% were using cocaine, 15.8% were using methamphetamines, and 31.2% were using some other drug (e.g., prescription sedatives or hallucinogens). For all routes of administration, more people said that they were using more often since the COVID-19 pandemic. The difference was largest for injection (38.5% more often versus 24.2% less often).

Drug use since the COVID-19 pandemic among people in treatment pre- and since-COVID.

Notes: Sample restricted to individuals who said that they were in treatment both pre and since the COVID-19 pandemic, N  = 316. Each route of administration was asked about separately. Opioids include heroin, fentanyl, prescription opioids, and buprenorphine. Cocaine includes crack. “Other” drugs include non-opioid prescription medications (e.g., sedatives, tranquilizers, stimulants), and hallucinogens. MJ=marijuana and meth=methamphetamines. Cells are blank if the drug is not relevant to the route of administration.

Fig. 1 displays the overall differences in types of non-medication psychosocial services received among individuals who were in treatment before and since the COVID-19 pandemic. The most commonly received psychosocial service pre-COVID was individual counseling with a therapist, which decreased from 93.4% to 88.6% ( p =.037 for difference). Group counseling with a therapist decreased from 73.4% to 46.5% ( p <.001), consultation with a physician or nurse practitioner for a substance use disorder decreased from 66.1% to 36.4% ( p <.001), and attendance at mutual aid groups (e.g., SMART Recovery or Narcotics Anonymous) decreased from 54.4% to 26.9% ( p <.001). Help with housing and social needs provided by a drug treatment program decreased from 30.1% to 18.4% ( p <.001). The only service that increased was overdose education, which increased from 43.0% to 63.9% ( p <.001).

Types of Non-Medication Substance Use Disorder Services Received Pre- and Since COVID-19 Pandemic.

Notes: Sample restricted to individuals who said that they were in treatment both pre and since the COVID-19 pandemic N  = 316. All differences between bars were statistically significant at the p <.05 level.

Table 3 shows that among people in treatment for OUD pre and since COVID-19 ( N  = 287), the majority consistently received some MOUD. The most common medication received was methadone: 86.1% pre COVID-19 and 87.1% since COVID-19 ( p =.71). Other medications were less common: buprenorphine, 12.5% pre COVID-19 and 10.5% since COVID-19 ( p =.43) and naltrexone, 1.4% pre COVID-19 and 0.7% since ( p =.41).

Use of medications for opioid use disorder.

Notes: Restricted to individuals treated for opioid use disorder pre and since-COVID ( N  = 287) . Columns sum to more than 100% because individuals could endorse multiple medications.

Fig. 2 reflects changes in treatment for individuals who reported currently receiving methadone or buprenorphine. Among persons receiving methadone: 78.6% reported counseling was switched to video or phone, 76.1% reported more take-home days, 21.8% decreased urine drug testing. Overall, 92.6% reported at least one of these changes to their methadone treatment. Among persons receiving buprenorphine, 77.8% reported more medication management visits by phone or video, 40.7% more prescribed days, and 37.0% had decreased urine drug screenings.

Changes to Buprenorphine and Methadone Treatment.

Notes: Sample restricted to individuals who said that they were in treatment both pre and since the COVID-19 pandemic who used either buprenorphine ( N  = 27) or methadone ( N  = 243).

Source: Authors’ analysis of the COVID HARTS survey.

Fig. 3 displays perceptions of treatment for all people receiving SUD treatment and perceptions of telehealth for those receiving any telehealth. Patients generally had positive perceptions of treatment: 89.4% reported that the staff let clients know how operations changed, 87.6% that they had someone to talk to about if they had new cravings, 86.6% that the provider “understands the challenges I'm facing in my life right now”, and 80.2% that they were able to “get all the treatment I need right now.” Overall, 67.8% endorsed all positive responses to all these questions. Patients using telehealth also had positive perceptions of telehealth. For example, 92.8% said that they had the internet/phone connection they needed, 88.6% said they got clear instructions about how to connect, and 84.5% said “it is going pretty well.”

Experiences with Treatment Overall and with Telehealth.

Notes: Sample restricted to individuals who said that they were in treatment pre and since the COVID-19 pandemic ( N  = 286) and those who had recent experience with telehealth ( N  = 238).

This study documents the impact of COVID-19 on SUD treatment among people receiving treatment in nine U.S. states and the District of the Columbia during the first year of the pandemic. Participants reported decreases in the use of a variety of in-person services, particularly group counseling, consultation with a clinician, and mutual aid groups. Despite these decreases, for people in OUD treatment, access to MOUD remained relatively stable, and most reported that they were able to take advantage of new flexibilities offered under the pandemic such as increased days of take-home methadone. Overall, participants reported relatively high satisfaction with their current treatment and those using telehealth modalities were likewise relatively satisfied with how the technology was working.

Participants reported that many programs adapted their service delivery model to the necessities of social distancing during the pandemic. Reported changes, particularly shifts to telehealth and declines in in-person visits, have also been identified in other studies. For example, studies using administrative data have also shown that there has been continuity in medication treatment for opioid use disorder ( Currie et al., 2021 ; Nguyen et al., 2020 ) similar to what we show. Adaptations such as greater use of telehealth likely improved continuity of treatment for the individuals in our study. Concerns have been raised that telehealth, especially those requiring smart phone technology, could leave behind vulnerable populations, such as lower-income, older, publicly-insured, and less educated populations ( Ramsetty & Adams, 2020 ; Wang et al., 2021 ). However, it is notable that these changes were generally reported to be successful among our sample respondents, a group with large proportions over the age of 50, homeless, Medicaid enrollment, and low levels of education. During the COVID-19 pandemic, programs serving low-income individuals undertook efforts to bridge the lower levels of digital literacy and technology access challenges of their populations, and it is possible that these efforts supported individuals in our study ( Wang et al., 2021 ). Extending the benefits of technology will require reaching groups that may have disconnected from treatment during the pandemic (and were therefore not in our study), including people previously served by programs that may have terminated operations rather than adapting care.

Furthermore, it is unclear whether treatment is adequately addressing newly arising changes in substance use and overdose risk during COVID-19. On net, individuals in the study sample were reporting more frequent drug use since the start of the pandemic. These findings should be examined in the broader context of heightened overdose risk since the start of the pandemic ( Faust et al., 2021 ; Friedman, Beletsky, & Schriger, 2021 ). Overdose deaths surged to unprecedented levels in 2020, a complex situation that has likely been exacerbated by the conditions of isolation, rising fentanyl presence in the illicit drug supply, and increased economic insecurity arising during the pandemic. Programs likely undertook efforts to counteract this increase in overdose risk. Indeed, the only service that individuals reported receiving more frequently since the pandemic was overdose education, which may reflect targeted efforts by service providers to address the instability many of their patients are facing during the pandemic. Further, it is likely that naloxone distribution accompanied take-home methadone, which is a proven harm reduction strategy recommended for opioid treatment programs ( Katzman et al., 2020 ; Substance Abuse & Mental Health Services Administration, 2020a ). As shown, drug use often continued among people in drug treatment. Programs can address ongoing health risks by adopting harm reduction principles, partnering with harm reduction programs or offering harm reduction services directly, especially naloxone distribution, which is sometimes provided to clients of methadone programs. Ensuring that patients have adequate medication dosage can also reduce drug use and overdose risk by reducing the likelihood of uncontrolled cravings or withdrawal ( Fareed, Vayalapalli, Casarella, & Drexler, 2012 ).

The study also makes an important methodological contribution, by illustrating the potential of a novel approach to rapid data collection with a vulnerable population during a pandemic where face-to-face data collection was infeasible. The study recruitment card approach and remote study hotline had the advantage of being accessible to a multi-state population and was successful in reaching people who are typically difficult to recruit to surveys. Notably, active drug use was highly prevalent among this group of people currently in treatment (63.9%), which may reflect the inclusion of low-threshold treatment programs. While the multi-state study design was not nationally representative, it does include participants from many communities, including areas where there may have been more versus less COVID-19 related disruptions to services.

The study does have important limitations, however. First, as compared to surveys with a defined sampling frame, it is difficult to gauge how respondents may have differed from non-respondents. Individuals who called the survey hotline may have had more reliable phone access, greater self-efficacy, and higher levels of trust in research than non-respondents, though the survey could also have skewed toward people who were more financially precarious and seeking incentive payments. As compared to a traditional survey with a defined sampling frame, we are unable to assess the potential biases of our select sample. The survey strategy also necessarily excludes people who were disconnected from any services at the time of the study. As such, study findings can only be generalized to people who were retained in treatment during the pandemic, and do not address the challenges and concerns of people who chose to leave treatment or otherwise lost access to care. Second, some study measures have not been specifically validated using psychometric testing. Measuring care satisfaction in surveys in susceptible to “ceiling effects”, particularly as patients often generously rate their health care providers ( Voutilainen, Pitkäaho, Vehviläinen-Julkunen, & Sherwood, 2015 ). Finally, the study is limited by the cross-sectional design, which asks individuals to self-report their current substance use and treatment utilization, and how these changed since the pandemic. These changes may be subject to recall and social desirability bias. COVID-19 lockdowns occurred at different times in the study states, and the survey did not provide anchors for time periods (e.g., “prior to COVID-19”). This could lead to differences in how respondents interpreted and responded to questions about changes in behavior.

Ensuring access to treatment for substance use disorders during the COVID-19 pandemic has been a major policy and logistical challenge, especially as overdose rates have reached historically high levels. In a multistate sample, we find that patients accessing treatment through accommodations to federal regulations made for the public health emergency are generally satisfied with their care. These accommodations are slated to be phased out after the federal public health emergency, however, there are opportunities to continue these policies through further adaptations to the regulations that could be accomplished without passing new federal legislation ( Connolly, McBournie, & Doyle, 2021 ). Continuation of these regulations could be combined with efforts to further tailor treatment to the emerging risk factors confronting people who use drugs, such as unstable housing or greater isolation. Further, there is important work to be done focusing on harm reduction for people who may be engaging in continued use while in treatment, such as regular access to safer drug use supplies and naloxone. All of these changes could have substantial public health benefits as the U.S. seeks to recover from the COVID-19 pandemic and beyond.

The study was supported by Bloomberg Philanthropies. STA is also supported by the National Institutes of Health (K01DA046234). The funders were not involved in the collection of study data, the drafting of the manuscript, or the decision to submit the study for publication.

Declarations of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

The authors gratefully acknowledge the assistance of colleagues at Vital Strategies and Pew Charitable Trusts, the study advisory board, and programs that helped distribute client cards.

Table A1 and Table A2 .

Demographic and socioeconomic status of study sample by current treatment status.

Notes: Sample restricted to individuals who said that they were in treatment pre or since the COVID-19 pandemic N  = 61 pre only, N  = 316 pre and since, and N  = 60 since only. P-value is calculated from pairwise t-tests between each of the groups relative to the pre-COVID only group.

Comparing COVID HARTS and NSDUH treatment samples.

Notes: NSDUH sample represents respondents to the 2019 National Survey on Drug Use and Health who said that they had received substance use disorder treatment in the prior year.

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Experiences with substance use disorder treatment during the COVID-19 pandemic: Findings from a multistate survey

Affiliations.

• 1 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States. Electronic address: [email protected].
• 2 NYU Grossman School of Medicine, United States.
• 3 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States.
• 4 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, United States.
• PMID: 34871945
• PMCID: PMC8602971
• DOI: 10.1016/j.drugpo.2021.103537

Background: Drug overdoses surged during the COVID-19 pandemic, underscoring the need for expanded and accessible substance use disorder (SUD) treatment. Relatively little is known about the experiences of patients receiving treatment during the pandemic.

Methods: We worked with 21 harm reduction and drug treatment programs in nine states and the District of Columbia from August 2020 to January 2021. Programs distributed study recruitment cards to clients. Clients responded to the survey by calling a study hotline and providing a unique study identification number. Our survey included detailed questions about use of SUD treatment prior to and since the COVID-19 pandemic. We identified settings where individuals received treatment and, for those treated for opioid use disorder, we examined use of medications for opioid use disorder. Individuals also reported whether they had received telehealth treatment and pandemic related treatment changes (e.g., more take-home methadone). We calculated p-values for differences pre and since COVID-19.

Results: We interviewed 587 individuals of whom 316 (53.8%) were in drug treatment both before and during the COVID-19 pandemic. Individuals in treatment reported substantial reductions in in-person service use since the start of the pandemic, including a 27 percentage point reduction (p<.001) in group counseling sessions and 28 percentage point reduction in mutual aid group participation (p<.001). By contrast, individuals reported a 21 percentage point increase in receipt of overdose education (p<.001). Most people receiving medications for opioid use disorder reported taking methadone and had high continuity of treatment (86.1% received methadone pre-COVID and 87.1% since-COVID, p=.71). Almost all reported taking advantage of new policy changes such as counseling by video/phone, increased take-home medication, or fewer urine drug screens. Overall, respondents reported relatively high satisfaction with their treatment and with telehealth adaptations (e.g., 80.2% reported "I'm able to get all the treatment that I need").

Conclusions: Accommodations to treatment made under the federal public health emergency appear to have sustained access to treatment in the early months of the pandemic. Since these changes are set to expire after the official public health emergency declaration, further action is needed to meet the ongoing need.

Keywords: Access to care; Buprenorphine; COVID-19; Methadone; Opioid use disorder; Policy; Substance use disorder; Surveys; Telehealth; Treatment.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Publication types

• Research Support, N.I.H., Extramural
• Buprenorphine* / therapeutic use
• Opiate Substitution Treatment
• Opioid-Related Disorders* / drug therapy
• Opioid-Related Disorders* / therapy
• Surveys and Questionnaires
• Buprenorphine

Grants and funding

• K01 DA046234/DA/NIDA NIH HHS/United States