Behavioral health providers across the state are finding that difficulties introduced by COVID-19, including isolation, unemployment, disruption to routine and uncertainty about the future, have created a precarious situation for people struggling with addiction to drugs or alcohol. To comply with social distancing mandates, many addiction counselors have developed telehealth programming, but they have concerns about the limitations of that model.
Mary Windecker, executive director of the Montana Behavioral Health Alliance, said COVID-19 has created a “perfect, horrible storm” exacerbating behavioral health issues, including chemical dependency.
“Many of the people who were in substance use treatment at the start of this left — they just went home, they quit going to treatment … and many of them fell off the wagon,” she said. “There’s going to be this huge wave of people coming out of this crisis that are going to require behavioral health services.”
Meeting that need will be difficult, she said, because many behavioral health providers quickly depleted their meager cash reserves during COVID-19-related closures and have had to cut payrolls, part of a larger trend of layoffs in the health care industry. The behavioral health system was already in poor financial shape due to 2017 budget cuts, Windecker said, and the pandemic has further destabilized budgets.
Many of the providers that are still seeing patients have shifted to a telehealth model to deliver services remotely, but not without reservations.
Rimrock, a Billings-based nonprofit treatment provider, quickly invested in telecommunications infrastructure to support the switch.
“When this first came about we thought, ‘holy heck, we better stay in this game,’” said CEO Lenette Kosovich. “In 48 hours we had purchased every PC-attachable camera from Walmart in Laurel to Walmart in Billings Heights.” Since Rimrock runs one of the largest treatment facilities in the state, with approximately 175 employees, the price tag for the investment was significant: about $20,000.
Malcolm Horn, Rimrock’s director of special services, is continuing to see her clients remotely, but she says it isn’t the same: it’s harder to assess them, engage them, and keep them on track to recovery.
Horn described a client whose situation demonstrates the difficulty of maintaining sobriety under the conditions created by the pandemic. The client lost her job due to COVID-19 closures, and with it her health insurance. With schools closed, she’s educating her daughter, who has special needs, at home, which creates an additional stressor. It’s a situation primed for relapse, and that’s what’s happened.
“She is drinking when she gets up in the morning before she quote-unquote starts school with her kiddo, and she’s trying to hide it from her husband. … [She] takes more shots throughout the day, and at night when the kid goes to bed she drinks more,” Horn said of her client’s new routine.
Horn said such relapses have become more common during the pandemic.
Whereas Horn used to treat patients at her office at Rimrock, she now connects with them using a video-based platform. The technology has made counseling more convenient for some of her clients, Horn said, but it has also added a layer of difficulty to her job as a counselor. Since she can’t see them in person, smell them, or, in the case of her patients with anorexia, weigh them, she has fewer ways to gauge their condition and compliance with treatment plans. Virtual counseling also eliminates some of the tools she uses to help clients like the woman who is struggling with alcohol, which is the state’s most commonly abused substance and contributes to Montana’s stubbornly high suicide rate.
“I can see that she is not doing well, but I cannot physically do anything,” Horn said. “If she was in my office, I could say, ‘OK, why don’t we walk upstairs to the medical unit. Why don’t we have one of the nurses check you out, and can I give you a hug?’”
Horn said touch can be a powerful way to communicate safety and belonging. With physical contact discouraged by social distancing directives — Horn prefers the term “physical distancing” — a difficult time can feel even more challenging. Horn said many people are missing the benefits of oxytocin, a neurotransmitter that produces feelings of calmness and bonding when humans hug others close to them.
Being in the presence of others can also serve as a reminder of how much humans rely on social groups for survival. “As an animal, we are not wired to take care of ourselves very well outside of a group. We don’t have sharp claws, we don’t have sharp teeth, venom, or hard bony plates,” Horn said. “We are safer in a group [and] we need that connection.” Research bears this out: a 2015 study found that social isolation led to a 26% increased likelihood of death by all causes.
Participation in addiction recovery groups that encourage connection and accountability is a cornerstone of treatment for many of Horn’s clients. Those offerings have also changed in recent weeks. Rimrock’s group sessions switched to virtual delivery, and although there was some initial excitement among clients about the online sessions, compliance with group therapy has been down overall. Approximately 50% fewer patients are regularly participating compared to pre-pandemic levels, according to Kosovich.
Kosovich reported Tuesday that Rimrock’s leadership is in the process of developing a plan to safely return to face-to-face treatment, which she considers the most therapeutic model. At the same time, “our world is changed forever,” she said, adding that she thinks there will be increased room for teletherapy in the coronavirus-altered landscape.
Regardless of how it’s delivered, treatment that capitalizes on connection with others will continue to be an important part of addiction recovery plans.
“The opposite of addiction is connection,” Horn said, and safe, trusting and healthy relationships with others decrease the likelihood that someone struggling with an addiction will “choose the self-destruct button.”
While COVID-19 has changed much about Montanans’ daily lives, legal and illegal substances are still readily available. Patrons won’t be able to drink alcohol at restaurants, bars, breweries, distilleries and casinos in the state until May 4, but some of those businesses have been offering delivery and carry-out service, and retail outlets like liquor stores, grocery stores and gas stations remained open during the height of Montana’s response to COVID-19.
How much Montanans have been imbibing during the pandemic is hard to gauge. Market research firm Nielsen reported a 55% increase in alcoholic beverage sales nationwide during a seven-day period in mid-March when the country’s COVID-19 response was ramping up, but recent sales are returning closer to normal. The week ending April 18 saw a 16% increase in alcohol sales at grocery stores, convenience stores and liquor stores across the U.S. compared to the same week a year ago. E-commerce alcohol sales have really taken off, however. Between March 7, 2020, and April 18, 2020, e-commerce alcohol sales grew by 234% over the same period last year, according to an email from Nielsen.
The way Montana collects taxes on alcohol makes it difficult to get a week-by-week breakdown of consumers’ alcohol-purchasing habits, but there’s some insight to be gleaned from monthly alcohol sales reported by the state Department of Revenue. From March 1 through March 30, the state shipped 82,630 cases of liquor, which represents a 20% increase over the same month last year. (Given the reduction in commercial alcohol orders caused by dine-in closures at restaurants and bars, which started in some counties on March 16 and were implemented statewide by March 20, it’s likely that retail sales at other outlets were quite high. Nielsen attributes the increase to a shift in spending habits, with people who frequently drink at bars and restaurants now spending more on alcohol purchases at retail establishments.)
Illicit substances are also still available, Horn said. “Drug dealers are obviously still working, those marketplaces have not closed down. … I don’t think anybody’s had any problem getting [meth, opiates and other drugs].”
Kosovich said that even as existing patients have become slightly less likely to comply with their treatment plans and Rimrock revenues are trending down, there’s significant interest in the center’s most comprehensive treatment offerings.
“Our phones haven’t stopped ringing for people [interested in] inpatient and residential treatment,” she said.
In Bozeman, Alcohol and Drug Services of Gallatin County (ADSGC) reports fielding an increased number of crisis calls from individuals who aren’t currently clients, but are interested in receiving treatment.
ADSGC’s existing clients are also feeling the strain of COVID-19. The office closed to the public for a week and a half in mid-March to set up a telehealth system. When clients reconnected with addiction counselors via Zoom starting March 26, they were “desperate to talk,” Director Shelly Johnson wrote in an email to Montana Free Press.
“Individuals in recovery need to stay busy,” she said. “A lot of our clients were laid off of their jobs and had to apply for unemployment. They were told to shelter in place, so they are isolated, feel bored, and think about using [drugs or alcohol]. This can all lead to relapse. [Alcoholics Anonymous and Narcotics Anonymous] have a lot of meetings online, but individuals in recovery are used to meeting up and talking, socializing and getting support from like-minded people. … Many clients have talked about wanting to use, and there have been several clients who have relapsed.”
Johnson said some of the recent calls to ADSGC are from people being held at the Gallatin County Detention Center for substance use violations. Some of those people will likely find themselves in Gallatin County Treatment Court, one of 32 courts in the state oriented toward chemical dependency treatment and supervision rather than incarceration. If and when they do, they’re likely to engage with the justice system quite differently than they would have just two months ago.
Gallatin County Treatment Court coordinator Steve Ette said he can’t say for certain whether COVID-19 has led to higher relapse rates among the court’s 27 participants — there are currently quite a few defendants who are just starting the program, and they tend to be more prone to relapse — but how those individuals interact with the judge and meet testing requirements has definitely changed.
To comply with social distancing mandates, Gallatin County Treatment Court is conducting hearings with Judge John Brown via conference calls, and many defendants are doing remote drug testing. (Court Services, which administers a handful of pre-trial and post-sentencing programs in Gallatin County’s justice system, handles drug testing for about 350 people in Gallatin and neighboring counties, including people on probation.)
In response to COVID-19, the county recently invested in 125 breathalyzer devices that interface with a smartphone app called CheckBAC to provide real-time blood-alcohol content readings. The app uses facial recognition technology to discourage attempts to cheat the test. Court Services personnel are alerted if a reading is skipped or indicates its user has been drinking.
It’s more expensive to do it this way — the CheckBAC app requires a monthly $65 subscription, which the county currently pays, in addition to the initial breathalyzer purchase — but some treatment court participants prefer the new method since it removes the need to drive into Bozeman two or three mornings per week from as far away as Ennis to provide samples in person.
“I had a guy [recently tell me] he would rather pay the $65 per month to use that device because it’s so much cheaper for him [than to] drive in from Manhattan and miss work,” Ette said. “Some people really like it.”
Gallatin County has also added to its collection of other drug and alcohol monitoring devices, including SCRAM ankle bracelets that can detect possible alcohol use violations and patches worn for up to two weeks at a time that detect drug use.
All together, Ette said, the initial investment totals about $47,000, and it will cost an additional $26,800 per month to maintain and operate the new tools. He said he thinks the county could receive grants and coronavirus-related federal funding to offset the increased expense. (Some participants are still submitting breath or urine samples in person; the county has set up a temporary testing facility at the Gallatin County Fairgrounds that allows for more distance between individuals.)
Ette added that he anticipates that Court Services will continue to use the CheckBAC devices after social distancing directives loosen, and its personnel will be ready to go if another round — or multiple rounds — of COVID-19 necessitates remote testing in the future.
“COVID’s going to come back, from everything I’ve read,” Ette said. “The next time it comes back, we don’t have to put out the money to purchase these devices. … We’re going to save them. We’ll have our COVID kit all ready.”