Barriers to Recovery from Opioid Use Disorder Reported by Women During 2020: Insights for the Next Public Health Emergency

TL;DR

This study explores how the 2020 pandemic disrupted opioid recovery services for women in the U.S., offering insights to improve future public health responses.

Contribution

The study provides new insights into pandemic-related barriers to opioid recovery services specifically reported by women.

Findings

Community-level barriers included halting patient intake and fear of infection in treatment settings.

Interpersonal barriers included loss of childcare and transition to virtual services.

Pandemic worsened addiction crises and increased caretaking burdens for women in recovery.

Abstract

Public health relevance—How does this work relate to a public health issue?

This research describes how access to treatment and recovery services for opioid use disorder was disrupted in 2020, as reported by women in recovery in the United States.

By understanding these challenges, communities can better prepare to protect vulnerable populations from interruptions in treatment and support that can lead to recurrence of substance use problems and overdose during crisis situations.

Public health significance—Why is this work of significance to public health?

The findings provide crucial insights for members of the recovery community, healthcare providers, treatment facilities, and decision makers.

In the event of a future pandemic, these individuals should use a harm reduction approach to balance essential services for people with substance use disorders with important infection control measures.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?

Harm reduction is critical for pandemic planning in substance use recovery settings.

Lessons learned from 2020 can mitigate barriers to care and recovery in future public health emergencies.

This study seeks to inform emergency preparedness efforts by summarizing the pandemic’s impacts on access to opioid use disorder (OUD) recovery support as reported by women in recovery. In-depth interviews were completed with adult women in recovery from OUD. We used a primarily deductive approach to coding and analysis. Two coders analyzed transcripts; discrepancies were resolved through discussion. Seventeen women completed interviews from June to October 2020. Pandemic impacts primarily focused on engagement in care and retention at community and interpersonal levels. Community-level barriers to engagement included facilities’ halting intake of patients and fear of COVID-19 infection in treatment settings. Interpersonal barriers to engagement included loss of childcare support and the sudden transition to virtual services. Community-level retention barriers included perception of facility staff’s lack of adherence to infection prevention protocols and strict enforcement of infection prevention protocols on residents within facilities. Interpersonal barriers to retention included reduced availability of mutual aid meetings. Participants also highlighted how the pandemic worsened the addiction crisis and increased women’s caretaking burden. Leaders and administrators must be prepared to simultaneously balance responses for two public health crises: a novel infectious disease and addiction. Lessons learned from the pandemic can mitigate barriers to care and recovery when future emergencies arise.

Full text

1. Introduction

The onset of the pandemic in 2020 exacerbated another public health emergency in the United States: the opioid crisis. During the pandemic, drug overdose deaths increased more than what was predicted in its absence [1,2]. This increase has been associated with social isolation and insufficient care services which diminish an individual’s progress toward recovery and management of opioid use disorder (OUD) [3,4]. Additionally, access to medications for opioid use disorder (MOUDs) was disrupted [5,6].

Accessing OUD care for women has had long-standing barriers. These barriers have been documented in previous work and include fears related to child custody, insufficient childcare, stigma, discrimination related to the use of MOUD, lack of health insurance, and lack of adequate transportation [7,8,9]. The pandemic exacerbated these challenges. In Kansas, women recovering from substance use disorders reported that the pandemic negatively impacted their social relationships, which they identified as critical for their recovery [10]. In a study in North Carolina, before the pandemic, approximately half of responding clinics treating OUD reported accepting pregnant patients; during the pandemic, only 34% reported accepting pregnant patients [11].

Qualitative reports from people in recovery from OUD on the barriers to care and support they witnessed and experienced during the pandemic are critical to generating lessons learned for sustaining recovery support during future public health emergencies. The purpose of this study is to summarize the impacts of COVID-19 on access to care and recovery support for OUD as reported by women in recovery in the United States (U.S.) during the early months of the pandemic. By understanding participants’ experiences, decision makers and leaders can better prepare to protect vulnerable populations from treatment and recovery support disruptions during crisis situations in the future.

2. Materials and Methods

A larger qualitative study examining barriers to care for women with OUD was planned prior to the COVID-19 crisis. After it was evident the planned in-depth interviews would be conducted during the ongoing pandemic, a question specific to the impact of the pandemic was added to the semi-structured interview guide, following questions about the participant’s recovery experience and considerations women must take into account when seeking care for opioid use problems. The prompt was: “Now I’d like to ask you a question about current events. As you know, we are all currently experiencing the COVID-19 Pandemic. In your opinion, how do you think this may impact women seeking help for opioid use problems?” Here, we focus on the analysis of responses to this prompt.

Participants were women 18 years old or older who self-identified as being in recovery from OUD and resided in the U.S. Women were recruited using purposive (through recovery community organization networks) and snowball sampling (through word of mouth and referral from other participants) techniques. Confidential, in-depth, semi-structured interviews were conducted virtually through Zoom or phone, depending on participant preference and access. Interviews were transcribed verbatim. All participants provided electronic consent prior to the interview and all procedures were approved by the Florida International University Social and Behavioral Institutional Review Board.

We used a primarily deductive approach to codebook thematic analysis to examine responses to the prompt about the impact of the pandemic [12]. An initial codebook to analyze results was developed using two conceptual frameworks: the OUD Cascade of Care [13] and Levels of Influence as identified by the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework [14]. Additional themes related to the impact of the pandemic were added to the codebook as they emerged from the interviews. Two coders (MW and SC) independently analyzed interview transcripts; any discrepancies were resolved through discussion and consensus. NVivo 15 (Lumivero, Denver, CO, USA) was used to manage and code data. The study followed the Standards for Reporting Qualitative Research [15].

3. Results

A total of 17 women in recovery completed in-depth interviews from June to October 2020; participant characteristics are shown in Table 1. Participants resided in three U.S. regions: the South (n = 7, 41.2%), the Northeast (n = 7, 41.2%), and the West (n = 3, 17.6%). Interviews concluded when data saturation related to the broader study was achieved. Study participants described a range of impacts on them personally, including restricted activities, increased appreciation for MOUD, loss of employment, and loss of household income. One participant shared an anecdote demonstrating the pandemic’s impact on employment of people in recovery who work as peers in substance use treatment facilities: …as COVID started to hit…they had to let… I want to say 20 to 30 people go. Just because numbers were tanking, which isn’t usual for the trends here… my supervisor was like ‘Of course we want you back in here.’… And they love hiring people who are in recovery, just because it’s super helpful for them… I at first was like ‘Okay, well, I’m going to get to go back. I’m going to get to go back.’ And then… we have this second wave of COVID hitting, I’m like ‘I have no idea when I would get to go back.’

When describing the pandemic’s impact more broadly, participants’ comments primarily focused on two stages along the OUD Cascade of Care [13] at two Levels of Influence [14]: engagement in care and retention at community and interpersonal levels. A majority of comments focused on barriers to recovery support during the pandemic, although some participants also noted facilitators. Table 2 shows a summary of the themes that arose during interviews and demonstrative quotes. Additionally, participants noted the ways the pandemic worsened the addiction crisis, and the broader impacts of the pandemic on women.

3.1. Engagement in Care

At the community level, a major barrier to engagement in care discussed by participants was facilities’ halting intake of new patients. This was particularly concerning for women who needed admission to regain custody of their children. For example: …a lot of people aren’t accepting new clients, so there’s these women who are ready to get clean, who have lost their children. They’re ready to get them back. But these facilities aren’t accepting nobody because of the pandemic. I couldn’t imagine. I just really could not imagine.

Participants also noted the difficulties facilities faced when enforcing infection control and prevention measures, and clients’ subsequent fear of COVID-19 infection that could impact vulnerable family members: …none of the clients in the treatment center did wear the mask... So I think that can be a fear for people, especially if they do have children or family members they live with, you’re contracting the virus and bringing it back home.

Other barriers to engagement at the community level included hesitancy to ask for ways to interact with providers in ways that may reduce disease risk and the discontinuation of in-person tours (see Table 2 for sample quotes).

At the interpersonal level, participants noted that the sudden loss of childcare assistance from support systems women could previously rely on impacted their ability to access treatment. For example: …a lot of women, even single moms… can’t even just count on their parents to maybe watch them that night and they go to a 30-day program… they don’t really have that option at all. They need somebody that’s going to be there 24/7 with the kids.

Participants emphasized the importance of interpersonal interactions for engagement in care and discussed how the sudden transition to virtual mutual aid groups posed difficulties in this respect. One participant noted that virtual meetings “can feel really out of place and weird for some people who are newly trying to get sober.” Another discussed how hard finding virtual meetings may be for those who are new to recovery or have limited access to cell phones: “Unless you have someone in the rooms that’s willing to walk you through that process or that’s willing to let you use their phone with them to check into a meeting, you’re screwed.” Others described challenges individuals experiencing homelessness may encounter when trying to access virtual meetings.

One facilitator to engagement in care noted at the interpersonal level was that stay-at-home orders might allow people requiring inpatient treatment to access it without explaining their absence to their acquaintances: “nobody will know because I’ve been quarantined for a few weeks anyway. I could just say I was quarantined…”

3.2. Retention

At the community level, one barrier to retention and potential loss of recovery was facility staff not adhering to infection prevention protocols when they were outside of the facility, resulting in exposure of clients and quarantine, causing in-person group meetings to be cancelled. Additionally, when this occurred, no alternatives to in-person meetings were offered (see Table 2 for example quotes).

Overly strict enforcement of pandemic rules was also mentioned as a barrier to retention. In the example below, a participant relayed an anecdote about the impact a playground closure had for a fellow resident in a supportive housing complex: …a mom left last Saturday because, they shut the playground down here and she wanted to take her son to the playground. So in the middle of the quarantine, she just had her son like hop the fence and played on the playground… of course the director drove out here and yelled at her about it. And she packed her stuff and left.

A facilitator at the community level included facilities’ ability to navigate and adapt to pandemic restrictions and prevention measures in order to continue providing MOUD (Table 2).

At the interpersonal level, participants described the detrimental effects of the reduced availability of mutual aid meetings, which they deemed as critical to maintaining recovery. They noted the difficulty of navigating and enforcing infection prevention measures when they held meetings in their homes to address this gap. They also discussed the loss of community and support they felt from in-person interactions when meetings shifted to virtual formats. They felt the shift to virtual meetings reduced the quality of their interactions with or ability to provide support to their peers in recovery. One participant noted how the lack of in-person meetings made it harder for women to find other women in recovery, which is important for building networks of recovery support: …somebody told me once the women in this lifestyle are going to be the ones to save your life… It’s not like all these women go to the same Starbucks… now if they’re not having those meetings because places are closed [because] of COVID-19... It’s really, really sad.

While participants highlighted the negative aspects of virtual mutual aid groups, they generally agreed that the widespread availability of virtual meetings was a good option to have, noting that the improved accessibility helped individuals who were homebound, elderly and residing in nursing homes, or individuals who were more introverted connect to peer support meetings. One participant shared how critical it was to her recovery during a period of quarantine when she did not have the ability or transportation to attend in-person AA meetings. This participant went on to describe how you can find a wide variety of virtual groups on the Intergroup AA website, hosted from locations around the world [16]. She had not heard of virtual meetings prior to the pandemic, and noted the importance of virtual meetings beyond the pandemic, particularly for mothers with childcare needs: …even some days… what, if it’s pouring rain one day or you don’t have a babysitter or something comes up, you can just plug in on your phone and get the spiritual fulfilling that you need for that day. So I really hope this stays on as long as I’m alive cause I know like I’m going to keep doing it.

An additional facilitator to retention at the interpersonal level was having existing networks for recovery support prior to the pandemic (Table 2).

3.3. Additive Effects: The Pandemic and Addiction

Participants described the additive impact of the pandemic in relation to the addiction crisis: …we have this health crisis, but people are literally dying from untreated alcoholism and when we isolate addicts even further… we take away their 12 step meetings and we limit the treatment centers they can go to… It’s almost contributing to people not being able to get help.

A participant succinctly summarized the impact of losing access to social networks: “it’s easier to die right now… isolation is very terrible for addicts.” Another participant noted that individuals with substance use disorders may underestimate the urgency of getting help: “…all nonessential appointments were canceled… if I was still using, I could easily just be like, ‘Oh, well, this isn’t essential. There’s a pandemic, I should just deal with this later.’” Participants also described how unemployment caused by the pandemic could exacerbate substance use by simultaneously creating more free time for substance use and by limiting the financial ability to enter treatment: …a lot of people are out of work, so you have a lot more time to acquire drugs and get high… a lot of places that are just not working right now, or if you’re… laid off, I think that that could definitely play a part in one, not having the money to seek treatment centers, and two, just having too much time on your hands.

3.4. The Impact of the Pandemic on Women

In addition to exploring the ways the onset of the pandemic disrupted engagement and retention in care and support, participants also pointed out the negative impacts of the pandemic on women-led occupations, such as waitressing, and the challenges caused by the increased caretaking burden women experienced. This was summarized by one participant: I think that women are feeling the impact of COVID-19 more because… they carry a lot more than men… they carry an energetic weight of things… they’re probably working and they’re probably having to take care of their children at home. And they’re probably cooking and they’re probably cleaning and they’re probably doing everything that they did before, but like ten times more and also more stressed out because of everything that’s going on in the world…

4. Discussion

We sought to examine the impacts of the early months of the pandemic on access to care and recovery support for OUD as reported by women in recovery. Participants provided first-hand accounts of the pandemic’s now well-documented impact on substance use and behavioral health services. It exacerbated existing barriers to care, particularly for individuals with OUD and other substance use disorders, who faced intensified challenges such as financial instability, social isolation, and heightened stress [17]. Healthcare providers and clients faced significant information gaps and inconsistencies in infection control guidelines, often due to conflicting messages from government agencies, the media, and other sources [18]. Behavioral health providers encountered further complications in implementing these measures due to the nature of their services, the vulnerable populations they interact with, and their often limited resources [18]. Structural limitations, such as the physical space needed for social distancing, staffing shortages, inadequate quantities of personal protective equipment (PPE), and limited access to rapid testing, further impeded service delivery [18,19]. Treatment centers reduced bed capacity by as much as 50%, creating financial difficulties for facilities reliant on bed-based reimbursements [19]. Additionally, restrictions on in-person support meetings and visits contributed to feelings of isolation, leading some clients to leave treatment earlier than recommended [19].

In response to these barriers, providers adopted multiple strategies to sustain service delivery while reducing the spread of disease. As described by Baloh and colleagues, standard infection control practices included symptom screening at entry, enforcing mask use, enhancing hand hygiene, and implementing social distancing measures [18]. Some facilities installed physical barriers, upgraded ventilation systems, and adjusted facility layouts to improve safety [18]. Residential treatment programs discontinued in-person visitations and adjusted housing arrangements to increase spacing between clients. Some required negative test results before admission, particularly as testing availability improved [18]. Many outpatient programs transitioned to telehealth services, using a mix of electronic record systems, Health Insurance Portability and Accountability Act-compliant teleconferencing software, and telephone-based services [18]. While in-person services were still necessary in some cases, such as for MOUD and drug screening, providers attempted to limit risks by incorporating telehealth when possible [18]. To ensure continued access to counseling and peer support services, many providers utilized telehealth for both individual and group sessions [20]. However, group services were often subject to additional restrictions, including limitations on the number of participants and specific telehealth requirements, such as the prioritization of video over audio-only communication [20].

Participants’ comments reflected both a fear of infection due to exposure from treatment and recovery facilities (along with fears of subsequently exposing vulnerable family members) and the dangers of social isolation for people with substance use disorders. For these women in recovery from OUD, social support was deemed a critical service; community was considered as important as medication for OUD. In practice, during the pandemic, healthcare administrators and providers treated social support as elective care. This is an important lesson that must be translated to pandemic preparedness, since the end of the Public Health Emergency Declaration on 11 May 2023 does not preclude us from experiencing another infectious disease outbreak or global pandemic in the future [21,22].

Harm reduction strategies for OUD continue to grow in popularity, and a harm reduction approach is critical for pandemic planning in substance use treatment and recovery settings as well [17]. If individuals with OUD require social interaction as part of their recovery, administrators can use lessons learned from the pandemic to plan for such interaction in the context of future infectious disease outbreaks [23]. For example, when interaction is needed, outdoor settings should be encouraged, and for indoor settings, strategies to improve ventilation and indoor air quality should be emphasized as necessary resources to maintain essential services [24,25]. High quality face masks should be made available, and health communication strategies should be used to highlight the importance of masks for keeping others safe, particularly in indoor spaces and for those who may be immunocompromised or have immunocompromised household members [24]. If vaccines become available, vaccination should also be promoted as a harm reduction strategy, although communication strategies must recognize that this community has great distrust of the pharmaceutical industry due to the role it played in the opioid crisis. In the context of a novel infectious disease, communication strategies should also highlight uncertainty and the potential for shifting guidelines as expert knowledge changes and improves [24].

Furthermore, to strengthen the resilience of substance use disorder treatment systems, providers should have greater access to PPE, sanitization supplies, and rapid testing capabilities [18]. Long-term planning should prioritize infrastructure modifications, including the expansion of housing for individuals in recovery, the creation of private spaces for telehealth services, and adjusting outdoor spaces for socially distanced meetings and visits [19]. Virtual recovery options can expand access for individuals who face ongoing barriers to in-person care, such as transportation, mobility, caregiving demands, or residence in rural areas with limited providers. Investments in digital infrastructure and digital literacy training will be crucial for sustaining telehealth accessibility, particularly for underserved populations. Policy adaptations that emerged during the pandemic, such as relaxed telehealth regulations and expanded insurance coverage, should be evaluated for long-term implementation to improve care accessibility and continuity.

Participants highlighted how difficult the rapid transition to virtual services was, particularly for individuals who were newly seeking care and support and for those who did not have access to devices required for virtual services. Again, using lessons learned, treatment and recovery settings should create plans to ease a sudden transition to virtual services and maintain equity in service availability in case it is required in the future. Participants’ discussion of how the pandemic increased women’s caretaking burden aligned with other reports documenting this phenomenon [26]. Strategies to address additional barriers to recovery women may face during a public health emergency, such as heightened caretaking responsibilities, should also be an essential component of emergency planning.

A major strength of this study is its focus on women’s lived experiences navigating OUD recovery during the early pandemic in 2020. Additionally, data were collected within the first year of the pandemic, when impacts were actively being experienced by participants. The qualitative descriptions offered here provide depth and detail unavailable through quantitative data. This study is also subject to several limitations. While the experiences provided by participants provide an important contribution to the literature on the challenges related to the provision of care and support for OUD during the pandemic, our small sample size limits generalizability to the general population or to more heterogenous groups. Furthermore, the parent study originally planned to explore barriers to care for women with OUD; since it was designed prior to the onset of the pandemic, the original research objective did not include the pandemic’s impact on participants. Additionally, since the in-depth interviews were conducted virtually due to pandemic restrictions, it is possible that the nature of the interactions with participants may have been improved if the interviews were conducted in person.

5. Conclusions

Participants commented on a number of areas related to engagement in care and retention that highlight the importance of emergency pandemic planning. Leaders and administrators must be prepared to balance responses for two potentially deadly public health crises: a novel infectious disease and addiction. This is a challenging balance to achieve, because the interventions for one may interfere with the interventions for the other. However, lessons learned from the pandemic can mitigate barriers to care and recovery when future emergencies arise.