As 2020 has shown, COVID-19 isn’t just one singular catastrophe; it’s multilayered—the first domino setting off a series of other tragedies. Not only has it claimed over one million lives (and counting) around the world and upended the economy, it’s also causing what many are calling a mental health crisis. In the background of this year in which the hits just keep on coming, the opioid epidemic is still present, and as reports are showing, more serious than ever.

According to the National Institute of Environmental Health Services, there is no real-time national counting of opioid overdose deaths, but at least 30 states have reported increases in opioid fatalities since the start of the pandemic. A June analysis released by ODMAP (Overdose Mapping Application Program), an overdose tracking database run by the University of Baltimore, found that there was an 18 percent increase in overdose deaths reported between March 19 and May 19 compared to the weeks before. The analysis also found that after March 19, over 60 percent of participating counties experienced an increase in overdoses.

Not only has the pandemic led to more reasons why people turn to opioid misuse, including increased anxiety, depression, loneliness, and boredom, the hurdles for treatment are higher than ever. But in the midst of this deadly storm are experts who are doing everything in their power to meet the needs of people in recovery where they are.

Why there’s been such a sharp increase in opioid-related deaths during the pandemic

“When it comes to alcohol and substance [misuse], isolation, broadly speaking, is the most savage symptom [people] struggle with psychologically,” says Kevin Gilliland, PsyD, a licensed clinical psychologist and the executive director of Innovation360, an outpatient counseling service that works with people living with substance use disorder. This is one major reason he says there’s been such a spike in opioid use and opioid-related deaths during the pandemic. “Isolation is terrible for humans, for our mood, for anxiety, and for substance [misuse] or dependence.”

Dr. Gilliland says that for those in recovery, human interaction is vital for maintaining sobriety. “[During the pandemic,] so many people have become disconnected to things in their life that were just good medicine, such as seeing familiar faces in their neighborhoods at the store, going to the gym, and attending religious services,” he says.

Additionally, the same factors that contribute to loneliness, like confinement, loss of usual routine, and reduced social and physical contact with others, can all create an increased risk of boredom. That, Dr. Gilliland says, is a big problem for people in recovery. “Boredom has long been a trigger for people in recovery. Humans don’t do well with [it],” he says. “First there’s this layer of boredom, and then on top of that are feelings of uncertainty, anxiousness, or depression, and that can lead to a greater risk of [misusing] opioids,” he says.

Further complicating matters is the fact that addiction treatment has become much harder to access due to the pandemic. Casey Dillon, the managing director at Advocates for Opioid Recovery, an initiative focused on supporting survivors of opioid use disorder, says that treatment centers haven’t escaped the financial strain of the pandemic. “Many rehab and treatment centers are operating at a lower capacity or they’re closing completely,” she says. Additionally, Dillon says the first COVID-19 stimulus package, the CARES Act, included some funding for behavioral health providers but left out opioid treatment providers. Fewer people may also be admitted to a treatment facility due to social distancing standards, which further limits access.

The pandemic has also impacted outpatient recovery care. Medication-assisted treatment (with drugs such as methadone and buprenorphine), for example, has been shown to help reduce opioid use and associated symptoms in those who take it. (Opioid use changes the brain, which is why an abstinence-only treatment plan doesn’t work for some in recovery.) Dillon explains that these medications must be administered by a medical professional, but fear of contracting COVID-19 has kept many from getting their medication—which could be another reason why the opioid epidemic has worsened.

Ayana Jordan, MD, PhD, who is a professor of psychiatry at Yale University, says access to medication-assisted treatment during the pandemic has been especially difficult for Black Americans. Although opioid use disorder rates are comparable between Black and white Americans, Dr. Jordan says that Black people are less likely to receive treatment for it (thanks to a variety of factors including cost barriers and health insurance access). But the pandemic adds another barrier for this community since more Black people are being hospitalized for (and dying from) COVID-19 than white people.

“If you look at cities like Chicago, there has been a spike in people with opioid use disorder having difficulty keeping themselves out of withdrawal because they weren’t getting access to the medication they needed,” Dr. Jordan says. “They were also having higher rates of COVID-19 infections because of living in overpopulated areas. If you look at who is more likely to live in housing projects in major cities, it’s Black people; they are not able to socially distance. Many of my physician colleagues in big cities have been telling me, ‘We can’t even think about [opioid] treatment right now. We’re just focusing on harm reduction.'”

While medication isn’t always a part of someone’s recovery, support group meetings and counseling almost always are. Yet many in-person meetups of both types have of been limited in numbers due to social distancing. The American Society of Addiction Medicine recommends groups be kept to 10 people or fewer, in keeping with the CDC’s social distancing mandates. This is yet another new barrier for those in recovery, especially Black Americans. “At the beginning of the pandemic, many treatment centers went virtual, requiring access to a phone and Internet, which Black people are less likely to have access to than white people,” she says.

Besides suddenly being cut off from support groups, she says going virtual has made receiving care at inpatient rehabilitation programs more difficult, too. “While before you could walk into a treatment center and talk to someone about getting a bed, suddenly you couldn’t do that,” Dr. Jordan says. “You need access to a computer and internet to fill out forms online. Or you need minutes on your phone so you can call every day for a bed, because if you don’t call every day, they will assume you’re not interested. But if someone doesn’t have a lot of minutes on their phone, they’re going to use it to call loved ones or a dealer, not an in-patient rehabilitation program.”

When all of these factors are considered together, it creates a clearer picture of why the opioid epidemic has seemingly worsened during the larger COVID-pandemic. But this is not a tragedy without hope. Many therapists and recovery groups are changing the way they operate to meet people’s evolving needs not just now, but long after the pandemic ends.

A virtual recovery coach with you at all times

For those in recovery who do have access to a smartphone, technology has progressed greatly in the last few months, meeting needs in whole new ways. One such way is through SoberBuddy, a free, evidence-based virtual drug and alcohol recovery coach that was three years in the making. The app was created by Paul Brethen, who has over 20 years of experience as a certified addiction specialist. “We were going to launch in June regardless, but…we knew [the pandemic] made it more crucial of a resource,” Brethen says. Since June, the app has grown to include over 15,000 users.

SoberBuddy provides small challenges for its users to work through, depending on where they are in their recovery. (There are seven different challenge journeys, spanning the spectrum of newly into recovery to having been in recovery for many years.) “One example of a challenge is to keep a schedule,” Brethen says, adding that this helps someone stay focused, busy, and creates routine—all of which are important for people in recovery. “Other challenges focus on things like managing cravings or learning relaxation techniques,” he says. The app’s challenges are based on principles of cognitive behavioral therapy (CBT), which challenges negative thought patterns with the goal of altering unwanted behaviors. (Research has shown that CBT, in conjunction with physician-managed care, can help improve recovery outcomes for people with opioid use disorder.)

While the app is relatively new, Brethen is already thinking about how it will continue to evolve. He’s hoping to include a chat room feature in the future to help people connect to each other. He’s also planning to launch content in more languages so people all over the world can use the app.

Virtual community connections

One app that already has a community-focused approach is Loosid, a free digital platform for the sober community. Loosid highlights sober-friendly events and places while simultaneously providing support through community members and vetted experts. “There are millions of people who are in need of finding a sober life and the only way to reach a need of that scale is through your phone,” says co-founder and CEO MJ Gottlieb. The app has grown to include over 81,000 people since its launch in 2018.

There are multiple ways to connect with other people who use the app, through virtual community forums (which are monitored by trained addiction specialists and a sober dating app. The community forums are places people can connect through common interests or goals. There are groups for runners, people who work in the restaurant industry, people looking for help after a relapse, and those specifically for people recovering from opioid use. “We saw a 70 percent increase in the number of messages being sent in the community groups within the first three weeks of COVID-19,” Gottlieb says. In addition to the community groups, there is also a hotline, in case someone is in need of urgent help at any time.

Dr. Gilliland says community groups like what Loosid offers are crucial for people in recovery. “Connecting with people who encourage us, inspire us, and hold us accountable is good medicine,” he says. “The key to becoming successful at something is surrounding yourself with people who are successful in that area,” he says, adding these connections can be made virtually. “If you want to run a marathon, what does virtually everyone do? They join a running group. Recovery works the same way. You want to be around people who are doing what you want to do.”

Meeting traditional recovery therapy needs during COVID-19

For some in recovery, attending group therapy is beneficial. Many in-person groups have changed format and use Zoom or other video platforms instead. The Substance Abuse and Mental Health Services Administration put together a resource guide listing where people in recovery can attend meetings virtually, including those hosted by Narcotics Anonymous, Refuge Recovery, and Sober Recovery.

But there are, of course, pitfalls with recovery groups going virtual. One is that unless you are quarantining alone, privacy is not guaranteed. “Privacy is incredibly important for people in recovery,” Dr. Gilliland says. He explains that, like anxiety and depression, opioid use disorder and recovery is stigmatized in American culture, so it’s crucial for people to have safe spaces where they can speak openly about what they are going through.

Another downside, as Dr. Jordan pointed out, is that virtual-only groups require Internet access, which can create a barrier to entry, particularly for those of a lower socioeconomic status. “Not everyone can attend virtual support groups and the people who can’t attend are typically the worst off,” Dr. Jordan says. “It’s very important to still have in-person support groups meet in a safe way, where people are six feet apart and wearing masks.” Dr. Gilliland says this is one reason why his outpatient treatment center, Innovation360, has maintained in-person therapy groups during the pandemic, reinforcing social distancing during the meetings.

Dr. Jordan adds that it needs to be easier for people to access in-patient rehabilitation programs without needing a phone or computer. She says some cities have worked around this by installing free WiFi on buses and in housing projects, which can make it easier for folks to make appointments, find treatment centers or support groups, and more. Similarly, she has seen many churches or places of worship set up tech sites inside for people to use. Dr. Jordan says these more creative solutions help people get the help they need where they are, rather than making them jump through hoops to get help.

Having a variety of options available is key for people finding the treatment they need. “Not everyone in recovery needs the same tools, so [treatment] needs to be individualized,” Dr. Gilliland says. It’s also important that policies are in place to ensure therapy and medicine-based treatment (when necessary) is funded and accessible for those most in need. In May, Advocates for Opioid Recovery launched a letter-writing campaign for grassroots advocates to encourage the next round of COVID-19 funding package to have money set aside specifically for opioid treatment programs. Dillon says it’s too early to tell if these efforts will be successful (especially since Congress has yet to pass a new round of recovery aid after the CARES Act expired on July 31), but she is hopeful.

Despite not being a perfect solution, the experts interviewed for this article agree that the growing ways support is going virtual is a win that will help people in recovery long-term—not just during COVID-19. “The pandemic has changed what recovery looks like in so many ways, and those changes will be long-lasting,” Brethen, the SoberBuddy co-founder says. “There are so many new resources available to people and even more that are continuing to be created. And that’s definitely a positive.”

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