During the COVID-19 pandemic, experts are highlighting the ongoing barriers to recovery and treatment people with substance use disorders face while social distancing dissipates personal safety nets. Time Magazine ran a piece on June 22, sharing the story of Sara Wittner, a 32-year-old who relapsed when her appointment for medication to combat opioid craving was extended from 30 to 45 days. It wasn’t just a delayed appointment that was problematic but also that suddenly, her other supports—the in-person Narcotics Anonymous meetings she went to as well as conversations with friends and her addiction recovery sponsor—were no longer there. Wittner died the day before her appointment. While her father believes she died of a fentanyl overdose, he told Markian Hawryluk of Kaiser Health News that what actually killed her was the pandemic. Decreased access to help is not uncommon during or in the aftermath of a disaster. The difference, of course, is that the spread of COVID-19 is ongoing, making it especially pressing to address these challenges within the pandemic landscape.
Robert Morrison is no stranger to the impact of disasters on people struggling with mental health or substance abuse disorders. He began his role as the executive director and director of legislative affairs at the National Association of State Alcohol and Drug Abuse Directors (NASADAD) just two weeks after 9/11. At the time, there was a nominal understanding of the long-term impact of disasters, and the behavioral health field was woefully unprepared for what was to come. The focus was on immediate effects and “helping kids and families access help to process what happened.” Morrison says that many people fell through the cracks, especially those newly in recovery or who were on the cusp of addiction. “Substance use tends to increase during a disaster, but it can happen gradually over time.”
Today, experts know that after a disaster, there are increases in domestic violence, substance abuse, divorce, and traumatic grief. April Naturale, Ph.D., traumatic stress specialist on disaster recovery, told us in May that the latter is when “the grief stays with the person, stopping them from functioning.” In the fall of 2001, though, none of that was yet known, and the research, notes Morrison, slowly came out illustrating the dire need to address risk factors for substance use disorders during a crisis. By the time Hurricane Katrina hit the Gulf Coast, experts knew far more what people in a crisis needed. One critical problem was that the Stafford Disaster Relief and Emergency Assistance Act (Stafford Act), the 1988 federal law to provide public assistance programs to states, tribes, and local governments after a disaster, doesn’t explicitly include substance use disorders. Under the act, if the president has issued a disaster declaration in an area, FEMA is authorized to fund mental health assistance and training activities in that area.
Sec. 416. Crisis Counseling Assistance and Training (42 U.S.C. 5183) The President is authorized to provide professional counseling services, including financial assistance to State or local agencies or private mental health organizations to provide such services or training of disaster workers, to victims of major disasters in order to relieve mental health problems caused or aggravated by such major disaster or its aftermath.
In the aftermath of Katrina, Morrison notes that many FEMA Crisis Counseling Assistance and Training (CCP) applicant states were omitting actions related to substance use disorders because the language of the Stafford Act was unclear. The consequence was that CCP activities were limited, leaving people sidelined without easy access to medication that they needed to keep them from relapse. “I don’t blame states for wanting to make sure they geared the application to the statute, but it shows how critical it is for language to be precise in public policy and legislation in articulating the inclusion of substance use disorders.” That’s why, says Morrison, NASADAD recommended that substance use disorders be added to the Stafford Act and elevate references to them in the CCP grant application. Neither happened, but the Substance Abuse and Mental Health Services Administration (SAMHSA), which manages the program, stepped in to close the gap. “In the end, A. Kathryn Power, M.Ed., director of SAMHSA’s Center for Mental Health Services (CMHS) at that time, messaged the issue without it having to be legislated.”
Over the years, there have been legislative pushes to amend the Stafford Act, but the bills all stalled out. The reason, says Morrison, was due to concern that the change would result in additional costs. He says that increases wouldn’t likely happen because the “CCP program isn’t necessarily providing treatment as much as quick triage.” The issue is that the statute has not kept up with the times, creating a chasm that has been closed by SAMHSA’s coordination but could resurface in the future. “The practical effect isn’t known because you never know each time there is an application if the language had an impact or not. Though SAMHSA has done a good job to reiterate that it should be substance use disorders and mental health issues, the language must be looked at and addressed.”
Morrison points out that without express addition, leaders could quickly default to a literal interpretation of the Stafford Act during administrative changes or those in roles that oversee the program. That would result in people with substance use disorders to experience further marginalization. “Every day, I see people with substance use disorders face barriers, whether on a job or housing application. All are a direct byproduct of stigma and discrimination. Memorializing the lack of inclusion is not wise policy, and we are still dealing with it.”
Often, it takes a crisis to move public policy and legislation. A look back at the opioid epidemic illustrates the time it took for people to grasp “the grizzly nature and sheer volume of death that was happening” when heroin had been a crisis in Chicago, New Jersey, and Connecticut for decades. By the mid-2000s, states were picking up increases in admission to treatment for prescription opioids. In 2018, 128 people in the U.S. died every day from opioid overdose, including prescription pain relievers, heroin, and synthetic opioids like fentanyl. During the COVID-19 pandemic, there have been reports of increases in opioid-related deaths in more than 30 states. Morrison says that to combat the opioid crisis, states have become innovative over the years, opening up 24-hour access points and increasing peer roles, but there must be sufficient funding and support. “There can’t be a gap in awareness and federal action. States can’t wait.”