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You can feel the stress through the screens. Every Wednesday, from their home offices, members of the California Consortium of Addiction Programs and Professionals hear updates from business owners across California. During this weekly check-in, business owners talk about the destabilizing effect of COVID-19 on their treatment programs for substance use:

Another patient tested positive for COVID. Telehealth is helping younger patients, but the older ones feel disconnected. Our county won’t send us more patients if we require that they’ve been tested and cleared. We have empty beds. We don’t have enough counselors. We don’t have enough space to move patients around.

Many businesses deemed nonessential by the state of California have struggled to survive during the coronavirus pandemic. But programs to help people dealing with addiction are fighting a different battle. Across the U.S., reports show alarming spikes in drug overdoses since March 2020. Evidence points to continued isolation, the imploding economy and disruptions to the drug trade as key factors. When the borders closed,  authorities expected overdoses to go down. But studies reveal that substance use has increased as people try to cope with the coronavirus and its devastating ripple effects of lost lives, lost jobs and a host of mental health issues. 

With the pandemic monopolizing government time, energy and resources, treatment programs with limited support are left to feel around in the dark. “We need more real-time data like they do for COVID patients,” says Sherry Daley, communications director for CCAPP. “We don’t know how many people need help with addiction and died from addiction. There just isn’t a plan right now to expand services or see where the need for services is growing or not growing … why isn’t the same level of attention focused on these deaths that we know are coming?”

The challenge for treatment programs can be broken down into four parts: lack of workforce, limited capacity, timing conflicts and insurance issues.

Making Adjustments in Hard Times

In California, many workers at these programs are not licensed. This means they’re considered paraprofessionals. The lowest paid among them collect food stamps, and amid the pandemic, they’ve been required to go to work even though they’re struggling to pay for child care, Daley says.

For a short time, the state government allowed them to get free child care, but that option expired June 30. In August, the state’s Department of Health Care Services announced that programs can increase pay for staff as long as total costs don’t exceed 150 percent of usual costs, Daley says. This adjustment (which will last until the governor or both houses of the Legislature must declare the pandemic has ended), might help offset child care costs and encourage workers to stay in their positions, according to Daley.

Another issue is capacity. Half of California’s treatment systems have six-bed facilities, she says. In larger programs, owners can isolate a person with COVID-19, but six-bed facilities have no spare rooms, which makes owners reluctant to admit new clients with unknown infection status. Many close to new admissions when even one client tests positive, Daley says. There are two ways CCAPP hopes to address this.

First, if a business owner has multiple facilities, CCAPP wants to have patients who have COVID shift to another location to keep the virus from spreading or keep them isolated while waiting for testing. This can only happen if Gov. Gavin Newsom raises the bed capacity above six for local zoning purposes during the pandemic, Daley says.

Second, CCAPP has been exploring the option for owners to enter into short-term rental agreements with property owners nearby, which can serve as temporary housing for patients with COVID. In November 2020, after months of collaborative planning with the Department of Health Care Services, CCAPP released recommendations on how programs can procure short-term rental space for overflow, quarantine or isolation capacity.

But timing is also a factor. If a patient wants help, they first need to make sure they don’t have the virus. The lack of timely testing, then, becomes a big deal because the patient who doesn’t want to wait may not get the help they need. “When someone is ready to get treatment, there’s a limited window to take advantage of,” Daley says, “but if they can’t get a COVID test, you’ve lost that client. You’ve lost your chance.”

Getting Care for Substance Use

The issue of insurance goes beyond treatment programs. Most employers with more than 50 employees offer a health insurance package. Those packages vary in terms of the kind of coverage they offer for treatment of substance use disorders. It’s rarely the employee who picks the health plan packages the employer offers. The employer picks the plans. Employees select from a limited range. 

“If employers have good coverage for treatment of substance use disorders, employees can get better treatment, get better faster and there’s less impact on work,” says Dr. Martin Leamon, an addiction psychiatry specialist associated with UC Davis Health.

According to Leamon, it’s much harder to get care when health insurance is tied to a job, where someone could lose health care in the middle of a pandemic because of a job loss. Some people whom Leamon sees come to get treatment pay the same copay to see a primary care doctor. For other insurance programs, they can’t see him because it’s too expensive, he says. If he prescribes medication, a handful can be used to treat substance use disorders. Access to substance use disorder medication can be much more limited compared to medication for diabetes or asthma because of restrictions imposed by the insurance plan. Those restrictions can vary widely from plan to plan, Leamon says.

Poor coverage means employees either won’t come in for care or have limited care, which can hurt the organization’s productivity due to more impaired workers. “To have an insurance plan that doesn’t provide coverage for treatable disorders doesn’t make a lot of economic sense,” Leamon says.

Decreased medical costs for employees and their families mean the employer pays more upfront, he adds, but in the long term the employer saves money because health costs go down and productivity goes up.

Productivity everywhere took a hit as the virus forced businesses to close or recalibrate. For drug-treatment programs, telehealth (health-related services and information distributed via technology) has become a critical way to connect with patients at a time of social distancing.

“Our top priority continues to be access to treatment,” says Chris Arnich, regional vice president for Acadia Healthcare. He oversees the Western U.S. region, including all clinics in California. “During COVID-19, that meant quickly pivoting to incorporate telehealth as a service delivery option.”

Setting up the technology happened fast, he says, but many patients needed help learning how to use the service. To address this, Acadia started telephonic counseling to talk patients through the process. Since then, telehealth has become part of the health care provider’s culture, allowing patients to continue treatment without visiting the clinics. Acadia Healthcare is working with state and county partners to find a path forward to offer telehealth services long-term, after the pandemic, for stable patients, Arnich says.

The Employer Dilemma

In general, employers are reflective of individuals, says Greg DeLapp, CEO of the Employee Assistance Professionals Association, based in Virginia. DeLapp has been involved with employee assistance since the 1970s. In those decades, he developed a drug and alcohol profile and found that the last area affected was work. When someone showed up intoxicated at work, he says, they were deep into the process of addiction, if not late-stage. But things have changed. With opioids, for instance, a person can go from first use to overdose to death in six to eight months, he says.

Alcohol and drug testing excludes prescription drugs. Looking ahead, DeLapp expects a spike in employees staying at home or returning to work heavily medicated. “If we acknowledge that anxiety, depression and isolation have gone up,” DeLapp says, “are we going to be a guard at the door or reach out in advance?”

Typically, employers say the employee has the responsibility to not come to work if they’re not in a fit condition. But will that still be a red-line statement? “Employers have a real dilemma,” he says. “If you’re the employer and you’re essential and you’ve been working through all this, how are you handling the testing policy when you know it’s going to be hard to replace someone in this environment?”

Addiction isn’t easy to hide at work. If you show up late, forget assignments or you’re moody, employers and managers will notice. But these behavioral cues aren’t so obvious when people are working from home or furloughed, dealing with the stress of potentially losing a job, getting evicted and getting sick, and dealing with a lack of public resources to address all of that.

“As an employer, we know stress is the biggest precursor to substance use,” says Jonathan Porteus, CEO of WellSpace Health. “Ambiguity and mixed messages feed that stress.”

Public systems like WellSpace and Sacramento County as a continuum of care will have to find a way to respond because employers can’t, Porteus says. At WellSpace, which has stayed open during the pandemic, an array of services built over the decade include integrated behavioral health, counseling, psychiatry and substance use services. WellSpace has also pivoted to telehealth where appropriate, so patients can receive treatment from home. WellSpace has about 1,000 employees, 700 full time, throughout the counties of Sacramento, Placer and Amador, and partners beyond.

Porteus says he is most worried about communities more susceptible to major lifestyle changes. For instance, people from diverse communities are less likely to rebound quickly and more at risk of losing employment, he says. In addition, research from the American Medical Association highlights that, compared with white patients, Black patients diagnosed with COVID-19 and substance use disorder had higher mortality and hospitalization rates.

“It’s uncertainty on top of uncertainty,” says Sean Benedict, director of Integrated Behavioral Health at WellSpace Health in Sacramento. “People don’t know when this is going to end, and they don’t know when they’re going to know. … From a treatment point of view, it’s a scary time to think of all these things we know that can contribute to substance abuse happening at once.”

Benedict says that risk factors that make you more likely to contract COVID-19 — high-blood pressure, Type 2 diabetes, asthma — can be treated, but you have to be able to see a doctor. “If you can’t see a doctor, that adds another level of stress,” he says. “It’s a recipe for people finding their own way to feel better.”

One strategy Benedict suggests is for employers to find ways to structure the workweek that makes things predictable, especially for people working remotely. Because much of the stress comes from the unknown, providing a framework with benchmarks may help employers keep track of workers, so if there are changes, the employer can check in. “When an environment is predictable,” Benedict says, “it feels safe.”

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