key: cord-0879473-2u9njv2k authors: Bergman, Brandon G.; Kelly, John F.; Fava, Maurizio; Eden Evins, A. title: Online recovery support meetings can help mitigate the public health consequences of COVID-19 for individuals with substance use disorder date: 2020-09-16 journal: Addict Behav DOI: 10.1016/j.addbeh.2020.106661 sha: 8da965e6337efbbd044c9fa6a2052c28c8b3ce78 doc_id: 879473 cord_uid: 2u9njv2k The COVID-19 pandemic puts people with current and remitted SUD at increased risk for symptom exacerbation and relapse through added stressors and reduced service access. Critically, individuals can adhere to public health guidelines for social distancing by physical distancing while engaging with ongoing social support and connection via free, online recovery support meetings. Given the potential benefits, in context of barriers and risks that may be partially addressed, we believe the risk-to-benefit ratio of online recovery support meeting participation is favorable. Particularly during this time of limited access to empirically-supported services, these digital recovery support services may help address COVID-19-related risks and thereby mitigate the overall public health burden of this pandemic. The COVID-19 pandemic carries particular risk for individuals with current and remitted substance use disorder (SUD). Beyond direct risks of contracting COVID-19 that may be elevated, 1 these individuals are also at risk for SUD symptom exacerbation or relapse via negative affect and increased life stressors. Social distancing-related closures, while in line with public health guidelines, have also disrupted treatment and recovery support service access for these individuals just when they need it most. The confluence of these indirect risks for millions with current and remitted SUD makes reduced service access a key public health issue within a larger public health pandemic. Participation in mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA) and SMART Recovery, is the most common form of SUD help-seeking in the US. [2] [3] [4] In response to service reductions caused by social distancing closures, local AA and other 12-step MHOs have migrated their meetings to online video platforms. Also, recovery community organizations have banded together to offer peer-based recovery support for an array of recovery pathways (e.g., 12-step, secular, and medication-assisted) to help meet the needs of individuals in, or seeking to achieve, SUD remission. Access to online recovery support meetings, which had already extended the reach of in-person resources, 5 is rapidly expanding. In the absence of studies that can directly inform clinical and public health recommendations related to online recovery support meetings, a brief review of relevant literature, in context of barriers and potential drawbacks, suggest the risk-to-benefit ratio of participation in these free, digital recovery support services is favorable. 1. Online recovery support meetings are likely to mobilize the same therapeutic mechanisms as empirically-supported, in-person MHOs. Twelve-step MHO participation improves substance use outcomes for individuals with alcohol use disorder and stimulant use disorder, as well as opioid use disorder after receiving, or in tandem with, opioid agonist medications like buprenorphine and methadone. 6-8 AA participation, specifically, promotes these better outcomes by enhancing a) recovery-supportive social network changes such as adding supportive individuals to, and dropping risky individuals from, one's network, b) coping skills, c) abstinence self-efficacy, and d) abstinence motivation. 9 These mechanisms of behavior change are consistent with theorized targets of other psychosocial approaches including cognitive-behavioral therapies. 10 Pending more rigorous research, existing data also suggests MHO participation in secular (i.e., non-12-step) groups like SMART Recovery may be associated with benefits similar to 12-step MHOs. 11 One might also hypothesize secular MHOs mobilize mechanisms similar to AA, given the overlap among different MHOs in their most core therapeutic elements (e.g., shared experience, social support, etc.). Like in-person groups, online meeting participation could also help boost coping, selfefficacy, and motivation through combinations of new information and ideas, ready access to active support, and peer-based vicarious learning. Online recovery support meetings may also offer opportunities for adaptive social network changes, albeit to a lesser extent than in-person groups. The US Department of Health and Human Services is actively supporting and encouraging the use of telemedicine in response to COVID-19 social distancing precautions. SUD telemedicine generally produces substance use outcomes that rival those of in-person therapy for individuals with alcohol use disorder, as well as individuals with opioid use disorder when provided with opioid agonist medication. 12 The fact that SUD telemedicine is a viable alternative to empirically-supported in-person analogs, suggests that online recovery support meetings are also likely to be a viable alternative to their empirically-supported, in-person MHO analogs. Data suggesting MHO participation is associated with better substance use outcomes are balanced by data suggesting there may be participation barriers for key groups. Individuals with non-abstinence goals, 13 those with drug use disorder who are new to treatment, 14 and those taking agonist medication 15 may experience more challenges engaging with 12-step MHOs and, in parallel, their online recovery support group analogs. While the availability of groups that cater to specific populations (e.g., Medication Assisted Recovery Anonymous; MARA) may offset, in part, these limitations, they are not as widespread as online 12-step MHO recovery support groups and may be more difficult to locate. Additional drawbacks, including risks, to online recovery support meeting participation are important to mention. First, while evidence showing SUD telemedicine is an effective alternative to in-person interventions 12 suggests online recovery support meetings may be an effective alternative to in-person MHOs, more research is needed on SUD telemedicine in its own right. Also, in light of emerging data that group telemedicine for psychiatric disorders, more generally, may be less likely than in-person group therapy to promote positive alliance, 16 observation are difficult to address, though privacy risks can be reducedin part -through participation only on encrypted platforms, and ensuring the host is taking advantage of privacy options (e.g., toggling off features that track whether the user is attending to the video, requiring a password and host permission to enter the meeting, etc.). Lastly, broadband internet access continues to divide individuals along socioeconomic lines. 17 For individuals who lack access to broadband internet needed for online video streaming, referral to meetings accessible by telephone is an available option. The COVID-19 pandemic puts people with current and remitted SUD at increased risk for symptom exacerbation and relapse through added stressors and reduced service access. Critically, individuals can adhere to public health guidelines for social distancing by physical distancing while engaging with ongoing social support and connection via free, online recovery support meetings. Given the potential benefits, in context of barriers and risks that may be partially addressed, we believe the risk-to-benefit ratio of online recovery support meeting participation is favorable. Particularly during this time of limited access to empirically-supported services, these digital recovery support services may help address COVID-19-related risks and thereby mitigate the overall public health burden of this pandemic. Collision of the COVID-19 and Addiction Epidemics Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Epidemiology of DSM-5 Drug Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy Expanding the reach of alcohol and other drug services: Prevalence and correlates of US adult engagement with online technology to address substance problems Alcoholics Anonymous and other 12-step programs for 10 Relapse prevention: An overview of Marlatt's cognitive-behavioral model A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD Telemedicinedelivered treatment interventions for substance use disorders: A systematic review Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study: Differences in membership characteristics and group participation, cohesion, and satisfaction Impact of 12 step mutual help groups on drug use disorder patients across six clinical trials Buprenorphine treatment and 12-step meeting attendance: Conflicts, compatibilities, and patient outcomes Therapeutic alliance in videoconferencing psychotherapy: A review Fact Sheet. Pew Research Center: Internet & Technology Bergman conceptualized the commentary and wrote the initial draft Fava provided key feedback to enhance commentary implications as pertaining to the field of clinical psychiatry. All authors contributed to, and have approved, the final manuscript. Role of Funding Sources Dr. Bergman is supported by an early career development award from the NIH (National Institute on Alcohol Abuse and Alcoholism Kelly is supported by a midcareer investigator award from the NIH (NIAAA; K24AA022136), and Dr. Evins is supported by a midcareer investigator award from the NIH Bergman conceptualized the commentary and wrote the initial draft Evins each helped write and edit the manuscript. Dr. Fava provided key feedback to enhance commentary implications as pertaining to the field of clinical psychiatry Dr. Bergman is a member of the board of directors for Unity Recovery, a nonprofit recovery community organization that partners with other recovery community organizations and the technology startup company WEConnect to offer free, online recovery support meetings and other digital recovery support services. Dr. Bergman receives no compensation from, nor has any financial stake in, Unity Recovery or any of its partners.