Clinical Adjustments During COVID-19 for Outpatient Substance Use Treatment in a Sample of Men Who Have Sex With Men

The COVID-19 pandemic is affecting multiple aspects of health and well-being, particularly among people with a substance use disorder (SUD). Disasters (traumatic, natural, or environmental) are associated with increases in psychological distress, which can lead to increased substance use and associated disorders. ¹ The recommended social distancing guidelines are essential to prevent transmission of SARS-CoV-2, the virus responsible for COVID-19; however, these guidelines have negatively affected social life, employment status, income, and daily routines. ² The mental health consequences of these social distancing measures along with other pandemic-related stress include irritability, anxiety, fear, and sadness, ³ which are known to increase the risk of relapse among people with SUDs. ⁴ Addressing the mental health effects of COVID-19 in clinical treatment settings requires novel strategies to adapt for the effect of the pandemic. Mental health professionals working with people who have an SUD could benefit from protocols on how to address patients’ problems while also accounting for the additional stresses of the pandemic.

A population that may be at high risk for increased distress and associated increased substance use during the COVID-19 pandemic are men who have sex with men (MSM). ⁵ Research suggests a higher prevalence of SUDs among MSM compared with their heterosexual counterparts. ⁶ A literature review highlights the following motivations for substance use among MSM: to have a sense of belonging, to cope with everyday stressors, and to enhance pleasure. ⁶ These motivators are likely heightened by the effects of the COVID-19 pandemic. We describe the successes and challenges of a group of clinical psychologists who offered substance use treatment for MSM during the COVID-19 pandemic as part of a Substance Abuse and Mental Health Services Administration (SAMHSA)–funded program. The SAMHSA program offered behavioral health treatment in Rhode Island at a sexually transmitted disease (STD) clinic and at a collaborating community-based organization (CBO) that offers harm reduction services to people who use substances and people at risk for acquiring HIV or living with HIV.

Our SAMHSA-funded substance use treatment program is tailored to address concerns among gay, bisexual, and other MSM who use substances and are at high risk for acquiring HIV and/or living with HIV and at risk for transmission of HIV based on their behaviors. ⁷ As part of the program, clinical psychologists provide psychotherapy to meet the unique needs of this population by integrating minority stress theory ⁸ with empirically supported counseling techniques primarily derived from motivational enhancement therapy and focused acceptance and commitment therapy. Patients in our SAMHSA-funded program report substantial psychosocial consequences as a result of their substance use and a strong desire to stop using or cut back to improve their lives. Many patients use multiple substances, including alcohol, marijuana, cocaine, and methamphetamines. The team of 4 psychologists (T.A., B.G.R., A.S.S., M.P.) met weekly starting at the onset of the COVID-19 pandemic (March 2020) to discuss and document changes in symptomology, treatment adjustments, and the outcomes of treatment adjustments. Discussions among the team of 4 psychologists did not include other staff members. This commentary describes the clinical adjustments made in the treatment protocols to address the mental health effects of the COVID-19 pandemic and discusses implications for other substance use treatment programs.

Recruitment Settings and Sample Characteristics

We recruited participants from an STD clinic or CBO in Rhode Island during 2019-2020. We offered participants the option to receive therapy at the STD clinic or the CBO.

STD Clinic

The STD Clinic is located in an urban setting and provides testing and treatment to people presenting with various sexually transmitted infections. It is the primary STD clinic in Rhode Island, and patients are ethnically and racially representative of the state; however, MSM comprise a large percentage of the patient population. Patients travel from throughout the state to receive care at the clinic; therefore, the sample is representative of a larger geographic area than the urban setting alone.

Community-Based Organization

Our SAMHSA-funded program works in partnership with a CBO that provides harm reduction services to people who use substances and people at risk for or living with HIV. The focus of the CBO’s work is on outreach to street-based sex workers and people who use substances. The program serves sex workers across the spectrum of gender and sexuality; many patients are male sex workers. The CBO has a drop-in center that is open 5 days per week where clients can obtain basic necessities (eg, food, clothing), harm reduction supplies (eg, clean needles, fentanyl test strips, naloxone, condoms), and case management services. Participants recruited from the CBO were eligible for subsidized sober housing, transportation to detoxification and residential treatment facilities, and peer support services. People enrolled at the CBO site were also able to obtain our counseling services.

Sample Characteristics

Our program included MSM who reported substance use, psychosocial consequences as a result of that use, and a strong desire to stop using substances or cut back on using to improve their lives. Most participants reported using multiple substances including alcohol, marijuana, cocaine, opioids, and methamphetamines. Enrolled participants included MSM who are at high risk for acquiring HIV or living with HIV. As of November 2020, our program had enrolled approximately 80 participants, ranging in age from 20 to 64. Forty clients (20 from the STD clinic and 20 from the CBO) had engaged in ≥1 counseling session with a therapist, and 40 clients had engaged in multiple counseling sessions.

Description of Clinical Symptoms and Treatment Adaptations

Pandemic-Related Symptomology

An immediate and reactionary increase in relapse and severity of substance use occurred after the onset of COVID-19 and social distancing recommendations. We observed multiple themes related to increased use and relapse in the patient population. Many patients reported increased feelings of loneliness with the decrease of physical intimacy as a result of social restriction regulations. Loneliness is a trigger for substance use and sexual compulsivity in general and specifically among MSM. ^6,9,10 We observed that feelings of loneliness led some of our patients to seek anonymous sexual partners via hookup applications (apps), and they subsequently relapsed into substance use behaviors as a result of the sexual encounters. For many, feelings of loneliness were compounded by feeling “unloved” because of a lack of contact with family or friends. Feeling “unlovable” or thinking “I am not able to be loved” is a common core belief among both MSM and people with SUDs and is often the target of cognitive behavioral therapy treatments. ¹¹ The isolation experienced during the pandemic heightened and reinforced these core beliefs, leading to relapse.

Some patients also expressed feelings of guilt for staying safe and removed—similar to survivor’s guilt—as they perceived they were “not doing enough” to help others during this time. These patients often had a substantial history of trauma, and the pandemic was internalized as another trauma they were surviving but others were not surviving. Although guilt-related thoughts can be valuable, excessive guilt can negatively affect addiction recovery and serve as a relapse trigger.

Finally, because many of our patients’ substance use often occurred in social and sexual contexts (eg, “chemsex”), many patients expressed concern for friends and acquaintances who were still using substances and/or also newly in recovery. Patients reported having anxious thoughts about their peers relapsing. These anxious thoughts often led to more anxious thoughts about peers and family members dying from COVID-19. The increase in anxious thoughts often triggered urges to use substances.

Pandemic Logistical Adjustments

Increasing the flexibility of substance use treatment programming was critical during the COVID-19 pandemic. Adaptations made to our logistics are cited elsewhere and are briefly detailed hereinafter. ¹² Clinical adjustments began in March 2020 and were ongoing as of February 2021. We transitioned clinical treatment sessions to telehealth (telephone and secure web-based video conferencing) in line with recommendations made by the American Psychological Association. ¹³ Because clinical treatment had previously been offered at a CBO, we purchased a laptop for the CBO, and staff members worked to set up a private telehealth space in a small office located in the drop-in center. All but 2 participants chose to participate in secure web-based video conferencing sessions from their homes. One participant had difficulties with technology during the first few sessions and chose telephone for the remaining sessions. Another participant did not have access from his home and was able to attend secure web-based video conferencing sessions using the telehealth space at the CBO.

We transferred clinical notes from paper records to an online storage system via the REDCap data management system (Vanderbilt University). We offered clinical treatment sessions more flexibly during this time because many patients requested increases in the number of sessions to help offset their increases in distress, anxiety, depression, and thoughts of substance use. We also increased the number of sessions to support people undergoing high-stress transitions related to the pandemic (eg, moving, losing jobs, working from home) and relapses (if and when they occurred) and decreased again once patients felt they were able to maintain their treatment gains without the additional support. In addition, the program tailored relapse prevention content to address aforementioned symptomology.

Pandemic Clinical Adjustments

We emphasized and tailored support-oriented approaches to address the pandemic (ie, increasing virtual social support and assessing the positive aspects of the situation). ¹⁴ Before the pandemic, patients selected social support people (friends, family, sponsors) to help maintain sobriety. Because of changes in workplace policies, a statewide shutdown, discontinuation of in-person 12-step recovery meetings, and restrictions in communal gathering spaces, many patients felt isolated and alone. As a result, we encouraged patients to gain support from people in their immediate physical environment (perhaps more than would ordinarily be encouraged), including roommates and family members, by sharing their feelings about urges to use substances and situations that trigger use. This strategy—of disclosing their emotional states to key people in their immediate environment—was important for many patients because they often had long histories of concealing their sexual identity, which leads to shame and poor mental health. ^{15 -17} Disclosure reduced shame, allowed essential emotional support in their recovery, and corrected earlier concealment experiences. We offered pragmatic, values-driven suggestions for coping, including checking in on them and offering support while in social isolation to patients who expressed concerns or anxious COVID-19–related thoughts about community or family members. We offered mindfulness and other distress tolerance skills as immediate techniques to tolerate emotional distress and practice acceptance of emotions. We also encouraged patients to decrease their use of dating apps to reduce the risk of COVID-19 exposure and the risk of relapse during sexual encounters with unknown partners. Finally, our program incorporated pandemic-specific intervention targets from a transdiagnostic pandemic mental health maintenance intervention: regular routines, stress management, engagement in pleasant activities, sleep hygiene, and normalization and acceptance of emotional responses. ¹⁸

Changes for the Field

Our SAMHSA-funded program promptly adapted and developed protocols for delivering treatment flexibly to facilitate retention of patients in care and reduce the occurrence of relapse. We tailored evidence-based treatment approaches to include treatment targets that were relevant to MSM with SUDs, notably concerns about isolation and community-based influences on substance use. We also addressed broader pandemic-related treatment targets regularly. Patients reported that treatment addressing isolation, guilt, and pandemic-related stress decreased urges to use substances. Our team extended flexibility to treatment delivery as we initiated remote treatment via telehealth platforms (either telephone or web-based video conferencing). The delivery of mental health services via telehealth has similar efficacy to in-person care in treating depression, anxiety, and trauma disorders and offers distinct advantages for people who may feel too impaired to leave home. ¹⁹ For patients with SUDs, telehealth can increase engagement immediately after relapse, when patients often do not feel well enough to attend in-person sessions. We noted a decrease in “no-shows” and cancellations, which may point to telehealth as a beneficial tool in engaging people who are actively using substances, who are often described as a hard-to-reach population. Some patients reported that video telehealth (vs telephone alone) motivated them to resist using substances, because their appearance would make substance use more evident by video than by telephone. Patients provided fewer excuses for missed sessions and, as a result, attendance at telehealth sessions was better than in-person attendance. What remains to be seen is whether flexible scheduling via telehealth can continue to be advantageous in the treatment of SUDs more broadly, because environmental triggers, including disasters, often present challenges to the clinical management of SUDs.