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With Meetings Banned, Millions Struggle to Stay Sober On Their Own

Updated: Jun 14, 2020

Addiction experts are calling the coronavirus pandemic a national relapse trigger. Online support groups, doctors and even federal agencies are rushing to aid people in recovery.

Rona Huckabee, an addiction therapist at MetroHealth Broadway Community Health in Cleveland, taking calls from patients after the clinic’s meetings were suspended.Credit...Maddie McGarvey for The New York Times

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.”

Dr. Huckabee has been checking in by phone with patients four times a week, but knows deeply that a half-hour telephone call is no substitute for a three-hour daily group session. Credit...Maddie McGarvey for The New York Times

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.

Felanie Castro of Glide, a community outreach organization working with Project Dope in San Francisco, delivered harm reduction kits to people without housing in the Tenderloin District.Credit...Aaron Wojack for The New York Times

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.

  • Frequently Asked Questions and Advice Updated June 12, 2020

    • What’s the risk of catching coronavirus from a surface? Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • Does asymptomatic transmission of Covid-19 happen? So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • How does blood type influence coronavirus? A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.? The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus? Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • How do we start exercising again without hurting ourselves after months of lockdown? Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out? States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus? Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying? If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How do I take my temperature? Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.

    • Should I wear a mask? The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick? If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How do I get tested? If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.

“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. Huckabee, left, with Redell Waters, a psychiatry assistant as Dr. Huckabee checked on others working at the Broadway Community Health in Cleveland.Credit...Maddie McGarvey for The New York Times

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.”

Jan Hoffman writes about behavioral health and health law. Her wide-ranging subjects include opioids, vaping, tribes and adolescents. @JanHoffmanNYT

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