Patients line up to pick up medication for opioid addiction at a clinic in Olympia, Wash., that is currently meeting patients outdoors and offering longer prescriptions in hopes of reducing the number of visits and the risk of infection due to the outbreak of the new coronavirus. The coronavirus pandemic is challenging the millions who struggle with drug and alcohol addiction. (AP Photo/Ted S. Warren)

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Coping with alcohol or substance abuse problems is hard on a normal day. 

But coping with it during the times of Covid-19 and social distancing is even harder, especially so for those in rural areas.

By her own account, Sophie spends about four to five hours a day talking to her boyfriend John. (EDITOR’S NOTE: We are using pseudonyms for Sophie and John because of the sensitive nature of alcoholism and addiction.) 

He’s located in a rural area in eastern North Carolina. She’s located in the Upstate of South Carolina in a town called Mountain Rest.

Nightly, he talks to her on the phone, struggling with the isolation of being quarantined in a hotel room and dealing emotionally with his alcoholism.

He’s trying to quit, she says. But there’s no help available as resources in rural areas for behavioral health are stretched thin during the stay-at-home orders states are using to prevent the spread of Covid-19.

Behavioral health providers were scarce in rural areas even before the coronavirus pandemic hit. Now, however, the need for their services is rising while access to providers is declining.

For John, it’s a hard time. Isolated and stressed, he’s sought treatment for his alcoholism but has been unable to find a provider. Now that peer support groups aren’t meeting, Sophie says, John has struggled to find treatment.

“He said no one would take him into the intake,” she said. “They’re telling him since he’s not a resident of the state, he’s not first in line. Instead, he’s in the process right now of trying to self-detox.”

But, without professional help, she questions his ability to succeed. In the meantime, he turns to her for support, often calling several times a day. She estimates she’s on the phone with him two hours a day before their four kids go to sleep at night, and then another two to three hours after bed.

For people with substance abuse problems in rural areas already under-served by mental health and behavioral health professionals, getting access to treatment is even more difficult as clinics close, practitioners move to telehealth, and funding for services runs out, experts say.

Carrie Henning-Smith, Ph.D., a researcher on rural issues with the University of Minnesota School of Public Health, said the mental health of rural residents is undoubtedly being impacted by lack of access to mental and behavioral health professionals.

“It would be disingenuous to talk about mental and behavioral help in the time of Covid-19 without centering it on rural populations,” Henning-Smith said. “All of the things that are making Covid-19 particularly volatile for mental health – things like economic stress, anxiety, grief over losing loved ones, concerns for your own house – all of those I would argue are heightened in rural areas where they were already more economically vulnerable, where the population is older and you have more underlying health conditions. It could only make mental health issues worse.”

And that’s a problem in rural communities, she said, where access to mental health and behavioral health services are already diminished when compared to other areas.

For example, about 91,000 of West Virginia’s 1.9 million residents reported a substance abuse problem in 2019, but only 18,115 of them said they had received any treatment, according to the  U.S. Substance Abuse and Mental Health Services Administration.

In an effort to combat the lack of access, several members of Congress have urged Congress and the Trump administration to ensure that rural communities have resources directed at mental and behavioral health in any future stimulus package.

On May 1, U. S. Rep. John Katko (R-NY), along with a bipartisan, bicameral group of lawmakers, asked Congressional leaders to include $38.5 billion in emergency funding for mental and behavioral health care providers in the fourth round of stimulus bills now being debated in Congress.

But shoring up access for behavioral health clinics isn’t enough, Henning-Smith said. That’s because most rural residents who do get mental health services get it from their primary care provider.

“When we’re talking about bolstering up the mental health care workforce, there isn’t a huge mental health care workforce in rural areas,” she said. “Primary care providers are on the front lines of mental health care in rural communities. Unfortunately, they are also on the front lines of Covid-19 and every other issue that’s happening in rural communities right now too. It’s putting an enormous burden on them to think about how they can help support the physical, emotional, social, and mental well-being of the entire population that they serve.”

Getting funding to take care of those with existing problems may not be the bigger concern, some say.

Erica Hanner, a substance abuse treatment specialist with LifeSkills Community HealthServices in Bowling Green, Ky., said getting access for substance abuse is harder now during the Covid-19 pandemic. Covering Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, and Warren Counties in Western Kentucky, the center provides services for mental health issues, addiction, and substance abuse.

Fear of being exposed to the virus if one goes in for treatment is just the beginning of the problem, she said.

“We’re an inpatient facility so we’re seeing a drop in numbers of patients coming to our facility,” she said. “There is a lot of fear and stuff that comes with going into treatment. We’ve got all kinds of precautions to decrease the exposure of our patients, but of course, they’re scared.”

To combat patients not coming in for direct, in-person appointments, her organization has worked to keep its doors open, and using no-contact protocols allows patients to have access to computers for telehealth check-ins.

“We know that not everyone in this area has internet connections, so we’re making our computers available to them so that they can have those telehealth appointments,” she said.

But with courts closed, and police focusing on other crimes, referrals to their programs are down, she said.

But more worrisome to her are the effects Covid-19 lockdowns will have on people who previously didn’t do drugs than lack of access to care. While those with existing addiction issues will continue to struggle with them, those in recovery may slide back into addiction, and those not using before may find themselves with new habits.

“People are locked in their house with nothing better to do, you know?” she said. “So they go out and get alcohol. And they’ve got access to drugs. I live in a smaller area of town and I can see it’s the dealers who are actually making money. I’ve had multiple clients talking about how they will deliver the drugs right to your door now.”

Three factors that lead to increased drug use, she said, are isolation, an excess of money and boredom. Lockdowns, unemployment, and economic stimulus money may combine to create a perfect storm of influences on someone’s drug use, she said.

In fact, in recent months, opioid overdose deaths have increased dramatically in Ohio during the pandemic. From January to April 15 of this year, urban Franklin County saw a 50% increase in fatal overdose with 62 people dying of overdoses in April alone. But rural counties have seen an uptick as well. In rural Coshocton County, population 36,600, 10 people died of overdoses between March 15 and April 15, more than double the amount over the same time frame in 2019. 

And the precursors for people seeking treatment aren’t there either, she said. With people staying at home, they may not see family and friends who tell them something is wrong. Without having to go to a job, they don’t suffer the consequences of their substance abuse. And without consequences, it’s harder to see that there’s a problem. 

Henning-Smith pointed out that more and more adults in rural areas are living alone. With no access to family and increased isolation, those in rural areas may be immune to the consequences of their actions. 

Hanner thinks it’s a growing tidal wave of substance abuse that we won’t see as a problem for several months.

“I definitely feel like it’s heating up,” she said. “The (substance abuse) epidemic has been there and I think that it’s increasing. This (Covid-19) is only fostering a growing epidemic because the consequences aren’t there to stop them.”