A Crisis within a Crisis: Substance Use Outpatient Care and COVID-19

Widespread shutdowns due to the COVID-19 pandemic have put Americans with substance use disorder (SUD) at high risk for relapse. Alcohol misuse and drug overdose are on the rise. People with SUD are often vulnerable and marginalized, and many rely on in-person behavioral healthcare for addiction recovery. Oftentimes, clients are already dealing with unstable employment, food insecurity, and insufficient housing. Disruptions to the economy further risk damaging their recovery efforts. Unfortunately, restrictions and closures have also led to interruptions in SUD treatment, and outpatient facilities are scrambling to find safe ways to help their clients. Some disruption to care is inevitable, but the right planning can lessen the impact and provide a safer reopening.


Remote delivery of behavioral healthcare may increase access to treatment for isolated clients. The idea of providing therapy and medication assistance through teletherapy services has been around for a few years. In 2015, a drug treatment center in rural Maryland began using telemedicine for buprenorphine medication management. After three months, the majority of patients were still engaged with treatment, and 94% of those had stopped using illicit opioids. A second study found no significant difference in patient outcomes between teletherapy and face-to-face delivery of medication-assisted treatment. Going forward, virtual care offered through video conferencing may be the best bet for the continued treatment of isolated clients to ensure consistent care. 

Medication Management

One of the biggest threats to continued recovery is the sudden disruption in access to medication used to treat opioid addiction. Initial methadone doses require direct observation and careful stabilization; state and local restrictions have created barriers to medication distribution. In March, the Substance Abuse and Mental Health Services Administration (SAMHSA) released guidance for take-home medication for opioid treatment to help provide clarity. 

In some cases, a vetted friend or family member may pick up medication and supervise home use. There are also automated pill dispensers that unlock daily medicine and alert staff to tampering or missed doses. Other programs use video to confirm that the client is taking medication at home. With this ever-changing crisis, providers need to track medication distribution accurately and approve modifications quickly. A robust, behavioral health-specific EHR lets you customize medication management for these types of unique circumstances. 


Many states are relaxing stay-at-home orders and shutdowns. However, the COVID-19 pandemic is far from over. Any reopening efforts require coordinated action to mitigate damages from the epidemic. Clients need comprehensive care and integrated services now more than ever, so clinicians, social workers, and policymakers must work together to ensure emergency pathways for Medicare waivers, housing, and social services. 

Any reopening plan needs to consider the safety of staff, clients, and the community. Outpatient treatment facilities need ample supplies of medication, equipment, and PPE in stock, in case of shipment delays. For the protection of lab staff, avoid running any oral fluid toxicology tests at this time. When taking in new patients, balance the risk of untreated SUD with the risk of coronavirus exposure. In severe cases, the risk of overdose death is higher than the risk of contracting COVID-19. And as an alternative, consider scheduling non-urgent appointments via teletherapy to promote physical distancing measures. 

Infection Control

Outpatient clinics need to follow strict infection control guidelines when seeing clients in person. The main goals of infection control are to protect clients and staff from contracting COVID-19, while maintaining access to treatment for people with substance use disorder. This means going above and beyond typical cleaning standards. Custodial staff needs to thoroughly sanitize tables, counters, and high-touch areas. Each area must be properly equipped with hand sanitizer, tissues, and trash cans. Place waiting room chairs 6 feet apart. Also provide instructions on proper hygiene and cough etiquette. The Centers for Disease Control (CDC) has these resources available to print.

Outpatient centers can protect staff and visitors by screening everyone before they enter the building. Take temperatures using a non-contact infrared thermometer and ask about respiratory symptoms such as cough or difficulty breathing. Educate staff on the proper use of PPE, and encourage sick employees to stay home. Offering paid sick leave for COVID-related absences provides an incentive that helps keep everyone safe. The American Society of Addiction Medicine (ASAM) has an extensive list of recommendations for infection control in outpatient settings. 

Additional Resources

As the pandemic continues to evolve, it’s crucial to stay up-to-date on state and local requirements for outpatient treatment facilities. Check regularly with the CDC and your local health department for updates. Here are some other resources to consider:

The COVID crisis, coupled with the opioid crisis is a double blow for people with substance use disorder. Outpatient care providers must find ways to mitigate the disruption of care for their clients. The right planning goes a long way in supporting these most vulnerable patients. The use of technology, including teletherapy that’s integrated with a behavioral health EHR, can help operations continue as “normally” as possible during the pandemic.

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