The closures of businesses and states throughout the U.S. due to the COVID-19 pandemic have been stressful, costly and challenging for many.

But the restrictions do not affect everyone equally. Particularly vulnerable are those with substance use disorders. With schedules disrupted, medical and psychological care curtailed and support networks shut down, the COVID-19 pandemic may jeopardize their recovery.

The COVID-19 pandemic comes on the coattails of the U.S. opioid epidemic. Between 1998 and 2018, about 450,000 people died from opioid overdose.

Progress was being made until COVID-19 appeared. Those of us who work in the field of substance use disorders became concerned for those in recovery as the pandemic spread and social distancing was put in place. Social connection and support are key parts of recovery. Without them, relapse is more likely. When people with opioid use disorder relapse, there’s more involved than a loss of sobriety, ruinous as that is. Often there is a loss of life.

Right now, our team, including the three of us – an associate professor of psychology at IUPUI, an associate professor of sociology at Indiana University Southeast and a psychology professor at Indiana University South Bend – are trying to understand how people with substance use disorders are managing their recovery during the COVID-19 pandemic. Between March and April 2020, we spoke with 45 adults ages 28 to 73, half of whom have opioid use disorder. The other half have a combination of other substance and/or alcohol use disorders. Their stories reflect many challenges, but also some silver linings; they also suggest ways we can do better.

Stress, cravings, hopelessness

The interviewees rated their chances of infection from COVID-19 at 63%. That’s more than double the rating from members of the general community (about 30%). The higher numbers may reflect reality; nearly two-thirds (63%) of our participants report preexisting conditions (such as chronic respiratory illnesses) in themselves or someone in their household. This places them at higher risk for COVID-related complications.

Evidence also suggests that people with substance use disorders are disproportionately more likely to experience homelessness or incarceration, two more risk factors for higher COVID-related complications and death.

Adding to the problem: Diagnosing COVID-19 in people who use substances is not always straightforward. Withdrawal may worsen or mimic COVID-19 symptoms. In turn, a COVID-19 infection may aggravate the breathing impacts of opioids, benzodiazepines and alcohol.

We were not surprised that 78% of our sample reported higher stress than before the pandemic, due primarily to increases in job or family responsibilities (42%) and job losses or reductions (30%). These changes in routine, coupled with unstructured free time, make recovery more difficult for them. The added stress contributes to feelings of loneliness, frustration and hopelessness.

Stress can exacerbate substance cravings and contributes to relapse. About 20% of the sample reported increases in cravings, and 17% reported using substances since the pandemic’s start. This may foreshadow an increase in relapse rates as the pandemic continues and in its aftermath.

Less access to support

Study participants report closures of recovery houses, suspensions of in-person support meetings and premature dismissals from treatment centers. Restricting these critical supports creates significant challenges for maintaining sobriety. The majority of respondents indicated they are now attending support meetings online or by phone; a small percentage no longer attend meetings due to cancellations, perceived reductions of support or because meeting forums feel “chaotic” and “not the same.” Those who have lost the communal support of meetings are at substantial risk of relapse.

Overdose reversal medications save lives from opioid overdose. However, some localities are reporting decreased use of overdose reversal medications by first responders to limit COVID-19 transmission.

Many with opioid use disorder rely on lifesaving opioid replacement medications. These treatments often require regular urine monitoring; this is to make sure the medications are not being diverted. But those once-routine visits are now restricted due to COVID-19. Fortunately, the government has developed new guidelines to ease restrictions and enable continued treatment using these replacement medications despite limited monitoring.

On the positive side

Those struggling with drug and alcohol use are showing great resilience in the face of the pandemic; 83% of our sample have maintained sobriety. Many of our respondents say isolation is an opportunity to better connect with friends, family and support group members. Some say they now have more time for journaling, praying, cooking and spending time outside. One individual highlighted the new ability to attend more meetings via online formats. Thus, although these are challenging times, as one participant noted, “[My treatment facility] and Alcoholics Anonymous have prepared me very well for this time.”

What can we do to help those in recovery? Yale University’s Program in Addiction Medicine offers guidelines for treatment during the pandemic. Flexibility is key. Options include reducing monitoring requirements, which would allow extended take-home doses of opioid replacement medications. Still, individuals should be prepared for limited access to syringe exchange programs, and providers should heighten awareness of blood-borne diseases caused by sharing or reusing needles.

Based on our conversations, interpersonal connections remain at the core of recovery. Online meetings are far from universally helpful. Though it may seem old-school, phone calls, physical letters or other personalized contacts may have significant roles to play in maintaining support networks.

Individuals and groups looking for ways to contribute might contact local agencies to coordinate donations of letters, masks or other tokens of encouragement for distribution among clients. To ensure their sustained sobriety, we must support people in recovery who need access to health care, stable housing and community. And then it is our responsibility to remain mindful of those needs after the pandemic becomes a memory.

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Editor’s note: Katie Shircliff, research coordinator for the Long-Term Recovery project, contributed to this article.

Melissa Cyders receives funding from the National Institutes of Health (National Institute of Alcohol Abuse and Alcoholism) and the Indiana University Addictions Grand Challenge. She would like to acknowledge the work of Ms. Katie Shircliff and the whole Long Term Recovery Team, including Drs. Mary Jo Ratermann, Misty Gilbert, and Wei Wu, and Mr. Jeff Johnson, Ms. Christiana Prestigiacomo, and Ms. Melissa Liu, on this project. She would like to thank Ms. Katie Shircliff in particular for her significant research contribution to this piece.

Kevin L. Ladd receives funding from the John Templeton Foundation. He would like to acknowledge the significant role of Ms. Katie Shircliff in the conceptualization and writing of this article.

Melissa S. Fry receives funding from LifeSpring Health Systems (SAMHSA Primary and Behavioral Health Care Integration), CEASe of Scott County, IN (SAMHSA Drug Free Communities), the Scott County Community Foundation, and the Community Foundation of Southern Indiana. She would like to acknowledge the significant research contributions of Ms. Katie Shircliff and our community partners.