By Daliah Singer
Kara Bonham was already struggling with alcohol consumption, depression and anxiety when the pandemic forced her life into overdrive.
She had a high-stress job as a first responder in Fort Collins; on top of that, her older sister, who also struggles with alcohol, had recently been diagnosed with end-stage liver failure.
As Bonham saw it, her options were to continue drinking alone in her apartment—an easy decision, she notes, because liquor stores were still open—“or I could make the decision to pursue recovery and make it a very serious, lifelong decision,” she says.
Bonham opted for the latter and turned to a familiar space for help: The Phoenix, a nonprofit gym that offers free workout classes and outdoor excursions for participants who have been sober for at least 48 hours.
When Bonham had tried to get sober two years ago, she drove three hours roundtrip in traffic to work out at the organization’s downtown Denver location. (A Phoenix outpost has since opened in Fort Collins.) She quickly realized the commute wasn’t sustainable, and within a month of stopping the classes she began drinking again.
Connecting to the community was a lot easier this spring: Bonham simply logged in to the livestreamed classes from her computer.
“When you’re new to recovery, the effort that it takes just to get up—and get dressed, and get out of bed, and move, and go to a location—sometimes feels like the hardest thing in the world,” the 35-year-old says. “I knew all I had to do was sign on to my computer… that got me through some really hard days.” She’s been sober since April 1.
Like much of the world, substance use recovery programs had to pivot during the coronavirus-induced shutdown, moving the majority of their programming online. Private and group therapy sessions (limited to sizes that would fit on a single screen) were suddenly happening over Zoom; clinicians in rural areas were connecting with clients over the phone; even the Alcoholics and Narcotics Anonymous communities took their 12-step programs online.
“The ability to still connect with providers was really reassuring,” says Jennifer Silva, chief clinical officer of intensive services at San Luis Valley Behavioral Health Group, a community mental health center that serves seven counties in south-central Colorado. “There was a lot of anxiety around COVID already, but not having to come in and be around others was a huge relief… I think [that] took a lot of anxiety away.”
While residential programs had to reduce their capacities in response to physical distancing, and drug testing has remained a bit of a question mark, mobile and virtual services have surged. Preexisting mobile units have continued to provide medication-assisted treatment to individuals in areas across the state. Outpatient services have experienced a near-total shift to telehealth (both video and phone). And as recovery providers have acclimatized to the practice, they’ve discovered numerous benefits to the modifications.
Among the most obvious pluses in a geographically diverse state like Colorado is convenience. Clients no longer need to travel long distances to connect with providers in person; those with children, without cars, or struggling with physical disabilities that make meeting in person more difficult all benefit from the ease of telehealth.
“We really saw a change in some of our clients that we might have thought weren’t cooperative—they truly did have some transportation barriers that they weren’t sharing or stating,” says Rob Archuleta, chief innovation officer with Crossroads’ Turning Points, Inc., a substance use treatment provider with 15 offices in southern Colorado. “Even some of the clients with anxiety seem to feel a lot more comfortable doing telehealth.”
Online recovery can feel more approachable to some patients. They may be more at ease talking to a counselor from the comfort of home or starting with a phone call before transitioning to video.
“It’s easier to be vulnerable behind a screen. If they did have a lapse and did use, they’re able to share that, whereas in person people tend to run and don’t show up,” says Casey Lucarelli, a licensed social worker who is in charge of REACH, AspenRidge Recovery’s virtual intensive outpatient program. “It’s easier for them rather than going into a treatment center and saying, ‘I’m an alcoholic.’”
AspenRidge Recovery has treatment centers in Fort Collins, Lakewood and Lone Tree, but it’s the organization’s online program that has seen the most demand since the start of the pandemic: a 20% jump in attendance compared to typical in-person participation.
Donna Goldstrom, clinical director at Front Range Clinic, which has more than 50 locations throughout the state, calls telehealth the “silver lining” of the pandemic. “There’s almost no downside,” she says.
The temporary loosening of regulations at the state and federal levels that was implemented early in the pandemic helped make these initiatives viable. It became easier for providers to bill insurance for telehealth and expand their scope of covered services to include telephone and group video therapy. (The cost of getting these programs up and running—like buying cameras—has not been passed along to patients, providers note.)
That’s not to say telehealth is perfect. Clinicians worry they may miss critical clues about patients’ mental states when they’re limited to telecommunication because they can’t read body language as well through the screen. In group sessions held online, the energy and camaraderie can be diminished. And there’s the fact that working all day via a screen is exhausting (there’s a name for that now: Zoom fatigue).
“Nothing is better than face-to-face,” says Denise Kidd, addiction recovery services manager at Pueblo Community Health Center.
Clients have concerns, too. It may be difficult to find private or safe spaces for their therapy sessions, which can impede progress. Some say they miss the opportunity to escape their day-to-day lives through office visits.
“This is their opportunity to get out of their environment and come to treatment. It’s a break from their home environment, a de-stress process to take care of themselves,” says Jessica Russell, director of Pueblo-based Crestone Recovery Services at Health Solutions. Russell says she has heard some patients describe virtual therapy as “impersonal.”
Access to the necessary technology can also be an impediment due to economic factors, poor broadband service or life circumstances, like being recently released from the criminal justice system. (Ten Colorado counties have broadband coverage below 50%; 37 have less than 80% coverage.) In response to those worries, Crossroads’ Turning Points and the San Luis Valley Behavioral Health Group both handed out phones to some clients so they could continue treatment.
“It’s kind of like when people want to do an online class,” says Randy Evetts, public health director of the Pueblo Department of Public Health and Environment. “For some people, it works really well; for some people, it just doesn’t work.”
Rachel Marquez-Escarcega has experienced firsthand the difficulties of virtual recovery. The 23-year-old lives just west of Steamboat Springs and has been sober since September 2019. Early in the pandemic, video wouldn’t work on her phone and she had to call in to her Thursday evening group video counseling sessions with Mountain Medical Injury and Pain Professionals.
“When you’re on the phone and everyone else is on Zoom, it’s harder to be part of the group because people kind of forget you’re there because they can’t see your face,” she says. “On days when I really felt like I needed to get something out and my phone wasn’t working on the Zoom, I was like, ‘No, no, no, work. I need to talk about these things.’” Though Marquez-Escarcega thinks in-person visits are more beneficial, she still finds virtual therapy to be a “good alternative.”
Those working in the recovery community believe a second wave of demand for their services may be on the way, because of pandemic-related mental health concerns. They foresee more individuals seeking help with substance abuse and mental health as a direct result of the forced social isolation, stress and anxiety of the current public health crisis, all of which can make people more susceptible to increased substance use or relapses.
Early on, “we did see quite a few people who had years of recovery come back into programs because they couldn’t maintain the same structure they had that was helping them stay sober,” Archuleta says. May and June were two of the largest service enrollment months in Crestone Recovery Services’ history.
State and federal data lag, but there is some recent evidence that substance use is up. Colorado state officials are bracing for an increase in deaths from drug overdose, with deaths involving fentanyl set to far surpass 2019 numbers. Market research firm Nielsen found that weekly in-store spending on alcohol was up by anywhere from 16% to 54% in March and April, compared to the same months in 2019, and online sales more than quadrupled during much of the same time period. A 3,000-person study by Alcohol.org found that 35% of respondents “are likely to drink more alcohol while self-isolating.” The New York Times reported that, as of mid-July, “drug deaths have risen an average of 13 percent so far this year over last year.” The newspaper’s research found that drug-related deaths in Colorado were up 30% through March, which included the first few weeks of the pandemic’s impact on the state.
In May, the Well Being Trust, a national foundation focused on mental, social and spiritual health, released a report entitled Projected Deaths of Despair from COVID-19. It estimates that 27,644 to 154,037 additional people could die from drugs, alcohol or suicide because of the pandemic. Estimates for Colorado put the state 14th highest nationwide for potential casualties. (A one-point jump in unemployment rates has been shown to increase suicide rates by up to 1.3%.) These should be viewed as “the epidemic within the pandemic,” the report says.
In Colorado, there will be less money to help if these trajectories continue. Approximately $26 million that was intended for drug abuse prevention and treatment programs has been chopped from next year’s state budget. However, there is some more immediate help on the way: In June, the Colorado legislature approved $15 million of the state’s $70 million in CARES Act relief funds to be allocated to behavioral health services; the money must be used by Dec. 30, and thus won’t offset the reductions slated for 2021.
The state ranks in the top 20% nationally for per capita use of cocaine, marijuana, opioids and alcohol. But stigma, cost and insurance issues prevented more than 95,000 Colorado adults from seeking needed care for substance use disorders in 2019, according to the Colorado Health Institute (a Colorado Trust grantee). This number could rise: Many providers express concern that they’re missing large numbers of people who need to be connected to services because they’re not interacting with typical points of referral, like physicians and case managers, and may not know they can get help without having to risk contracting COVID by walking into a provider's office.
As substance use treatment providers prepare for an increasing and enduring crisis, they’re continuing to rely on virtual services. Even with its challenges, they say telehealth in the behavioral health space is here to stay and is a valuable offering that can complement in-person visits. “It’s giving us another tool to reach clients,” says Archuleta of Crossroads’ Turning Points.
“We’re realizing we probably should have been offering this a long time ago,” says Scott Strode, the Denver-based founder and executive director of The Phoenix, of online classes.
Recognizing the importance of and continued need for telemedicine services, on July 6, Colorado Gov. Jared Polis signed Senate Bill 20-212 into law. The legislation makes permanent some temporary changes to telemedicine access and reimbursement that had been put in place early in the pandemic. For example, telehealth over the phone was previously not eligible for reimbursement, but it is now—a boon for those in rural areas or who don’t have the means to access a phone or laptop with video.
Specifically for Medicaid clients, the state is now required to reimburse rural health clinics, the federal Indian Health Service and federally qualified health centers for telehealth at the same rate as it would for in-person services. The bill also expanded the type of services that can be offered via telehealth to include things like speech and physical therapy. (Legislation has also been introduced at the federal level to continue some coronavirus-inspired changes to telehealth.)
Senate Bill 20-212 increases access to telehealth for the privately insured, too, by prohibiting insurance companies from refusing to reimburse for telemedicine services based on certain criteria. For instance, patients no longer need to have a previously established relationship with a provider in order to engage through telehealth and have the service covered.
“There are a number of different spheres where restrictions were relaxed or made broader, which is good for providers who are now able to be reimbursed for those kinds of services,” says Julia Gilbert, a research analyst with the Colorado Health Institute. “On the patient side… that provides more meaningful access to care, both during COVID and under normal circumstances.”
Questions still remain about what precisely reimbursement will look like for venues beyond the categories named in the 2020 Colorado legislation, as well as how many patients will seek out telehealth when COVID concerns are reduced, and how expanding telehealth will impact costs now and in the future. For now, though, the relaxed regulations have made telehealth a viable option on both sides of the screen, and providers and clients see that as good news.
Bonham, the Fort Collins first responder, is among those benefiting. To keep herself in check, she takes one or more online classes per day with The Phoenix—typically, a 5 a.m. morning meditation and an afternoon fitness class, as well as attending weekday “social hours.” Because the online classes are continuing, she’s able to attend even when she’s on the road in the converted van she calls home.
Though Bonham has attempted sobriety a handful of times over the past five years, she says, “this is the first time I’ve felt like I wasn’t white-knuckling my sobriety and just trying to get by minute-to-minute.”
“I feel like my life is more fulfilling,” she adds. “I have more joy than I’ve ever experienced before in any other attempt at sobriety and even just in my life.”
Crestone’s Russell sees this as perhaps one of the biggest benefits of this pandemic-induced transition: “People are able to balance their day-to-day life with their recovery in a new way.”