SEATTLE ― The spread of COVID-19 has presented a unique challenge to those fighting another life-threatening epidemic: substance use disorders, which affect about 20 million American adults each year. Residential treatment centers, which are based on a model of group therapy and interaction among patients, are scrambling to adapt to the Centers for Disease Control and Prevention’s guidelines.
Those treatment centers are also facing a more existential threat: As potential patients stay away for fear of contracting the coronavirus, many smaller and publicly funded centers could run out of money and close their doors at a time when social isolation is driving many people with addictions to relapse.
“Historically, whenever there’s a crisis in the U.S., alcohol sales and illicit drug sales increase dramatically,” said Dr. Marvin Seppala, the chief medical officer at the Hazelden Betty Ford Foundation in Beaverton, Oregon. “Day-to-day things are suddenly stressful …. In the long run, there’s going to be an increased need for treatment.”
Treatment centers are considered “essential critical infrastructure” under the federal guidelines that most states are using to determine which services are exempt from requirements to shelter in place. But in order to keep people safe, they’re being forced to adapt in ways that go against normal methods of treatment, forgoing things like group meetings, family visits and open-door policies.
Melody McKee, who until last week was the clinical program director for Olalla Recovery Services in Olalla, Washington, said her treatment center made “the difficult decision” to implement a triage system for admissions.
“The way it will work is, like, ‘Is this person literally not going to make it if they do not enter this location?’” said McKee.
A person experiencing homelessness with no ability to access tele-health would rank high on the triage list, as would someone leaving detox who seems likely, based on their medical history, to go out and drink or use again.
Other factors that might push someone to the front of the line: frequent falls, past failure to follow through with opiate replacement therapy, suicide attempts and meth-induced psychosis. Those who don’t rank high on this kind of triage list may be turned away from treatment.
It’s a brutal calculus and a stark shift for treatment providers and advocates who have spent decades arguing for treatment on demand.
“No one can just walk up to a treatment center anymore,” said Dr. Paul Earley, president of the American Society for Addiction Medicine, which put out its own COVID-19 guide for providers. “The overarching issue here is to balance the risks of the two illnesses: the risk of contracting coronavirus and developing COVID-19 versus the risk of not getting treatment for the disease of addiction.”
Inpatient Facilities Make Tough Choices
McKee said the need to implement social distancing — for example, by reducing the number of patients who sleep in the same room — can be hard to balance with the desire to take care of as many patients as possible.
“Do you know what kind of burden it is to say, ’We know this person needs this level of care, but we also have people right here who are sitting ducks [for infection]?” she said.
If tests for COVID-19 were available, she said, her treatment center would be able to admit or reject patients. For now, all they can do is screen for symptoms and hope for the best.
The tight quarters at residential treatment centers and the medically fragile condition of most people with serious, long-term addiction make them ideal breeding grounds for infection. Long-term intravenous drug users often suffer from a heart infection called endocarditis; people who smoke crack, meth or marijuana may have diminished lung capacity; and heavy drinkers may have multiple organ failure and a suppressed immune system.
“These are not healthy individuals,” said Lauren Davis, executive director of the Seattle-based Washington Recovery Alliance. “People whose disease is advanced enough that it would necessitate inpatient treatment are pretty much universally in the high-risk category.”
To keep the virus out, treatment centers are cleaning more thoroughly and often, checking both staffers’ and patients’ temperatures regularly, and implementing social distancing in all group activities. That means putting space between chairs in group therapy, spacing out or canceling mass lectures, discharging some patients early if they seem stable enough to leave without relapsing, banning hugs and eliminating visits from friends and family, among other measures that fundamentally change the nature of rehab.
Fears of the growing coronavirus pandemic have changed rehab treatment, including close-contact group therapy sessions.
At Hazelden, they’re even requiring new patients to come prepared with a discharge plan just in case they get infected and need to leave treatment early. “If we get this, we want to catch it as early as possible and try and prevent that [initial] transmission,” Seppala said.
Scott Munson, the CEO of Sundown M Ranch treatment center outside Yakima, Washington, said eliminating family visits has been the hardest change to swallow. “We’re really known for the quality and extent of our family involvement, and unfortunately we’ve discontinued that.”
Evan Haines, the co-founder and director of Alo House Recovery Centers in Los Angeles, said his staff is mostly still coming in to work, but many therapy sessions have moved to online platforms. Haines called the remote sessions a “stopgap” measure. “Addiction treatment is something that could never be done remotely on a long-term basis because the whole nature of addiction is rooted in isolation.”
Another struggle is finding the supplies to keep facilities safe amid the COVID-19 crisis. Treatment center directors, advocates and industry groups all said that inpatient facilities are facing critical shortages of supplies needed to prevent COVID-19 transmission among their vulnerable patients — everything from N95 respirator masks to bleach wipes to alcohol-based hand sanitizer, which many treatment centers don’t usually keep on hand because patients occasionally drink it.
Sundown M Ranch has no personal protective equipment, or PPE, of any kind. Olalla has just “10 to 15 masks” on hand, according to McKee, and is also short on thermometers and cleaning supplies. Hazelden is hoping to get hand sanitizer from one of the distilleries that has shifted production from whiskey to grain ethanol.
“It’s an unusual place for us to find supplies,” he acknowledged wryly.
And treatment programs aren’t just running out of supplies; with fewer patients, many smaller rehabs, particularly those that take Medicare and Medicaid patients, are blazing through their funds. Earley said that, unlike much of the medical system, “addiction care is woefully underfunded. We’re in the middle of one of the worst addiction epidemics that we’ve had in my career, and centers are closing. It’s definitely a huge issue.”
Munson, from Sundown M Ranch, said that any state or federal stimulus package needs to include funding to help keep addiction treatment providers afloat. The $2.2 trillion emergency stimulus package that passed the Senate on Thursday includes funding for mental health clinics, but experts in the industry say it’s unclear how much if any of that will trickle down to residential treatment centers.
Without outside help, Munson said, “you’ll lose beds, you’ll lose capacity and ultimately you won’t be able to replace that capacity.” The treatment industry is very capital-intensive, he said, and many facilities don’t have the reserves to retain staff if there’s a major reduction in patients. They’d likely shut down.
In the last two months, at least five treatment centers in Washington state have shut down or are about to close — three 16-bed detox centers, a rehab for low-income Native Americans and a private treatment center for women.
Davis, with the Washington Recovery Alliance, said it isn’t just treatment centers and their staff who will suffer if they have to close their doors; patients who may have spent years working up the nerve to go to treatment will go without care.
“Sometimes we call it the gift of desperation,” Davis said. “If we can’t provide individuals with this particular life-threatening brain disease treatment” at the moment they finally decide they’re ready, “we may never have another chance of supporting them in recovery.”
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