Online recovery support meetings can help mitigate the public health consequences of COVID-19 for individuals with substance use disorder.

For people with current and remitted substance use disorder (SUD), the COVID-19 pandemic increases risk for symptom exacerbation and relapse through added stressors and reduced service access. In response, mutual-help groups and recovery community organizations have increased access to online recovery support meetings. However, rigorous studies examining online recovery support meeting participation to inform best practices have not yet been conducted. In the absence of such studies, a review of relevant literature, considered in context of potential barriers and drawbacks, suggests the risk-to-benefit ratio is favorable. Particularly given limited in-person SUD service access resulting from COVID-19 precautions, online recovery support meetings may help mitigate a key public health problem during an ongoing, public health pandemic.

Introduction

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 (Volkow, 2020), these individuals are also at risk for SUD symptom exacerbation or relapse via increased negative affect and life stressors. Social distancing-related closures, while in line with public health guidelines, have also disrupted SUD treatment and recovery support service access for these individuals 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 during an ongoing, 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 (Grant et al., 2015, Grant et al., 2016, Kelly et al., 2017). 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 online recovery support meetings for individuals recovery with an array of recovery pathways (e.g., 12-step, secular, and medication-assisted). While access to in-person, empirically-supported SUD services is declining, access AA to online recovery support meetings, which had already extended the reach of in-person resources (Bergman, Greene, Hoeppner, & Kelly, 2018), is rapidly expanding.

In the absence of rigorous studies that can directly inform clinical and public health recommendations, a brief review of relevant literature, in context of barriers and potential drawbacks, suggests the risk-to-benefit ratio of participation in these free, digital recovery support services is favorable.

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 (Kelly et al., 2020, Weiss et al., 2005, Weiss et al., 2019). 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 (Kelly, 2017). These mechanisms of behavior change are consistent with theorized targets of other psychosocial approaches including cognitive-behavioral therapies (Larimer, Palmer, & Marlatt, 1999). 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 (Zemore, Lui, Mericle, Hemberg, & Kaskutas, 2018). 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 recovery support meeting participation could help boost coping, self-efficacy, 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.

SUD telemedicine is an empirically-supported alternative to in-person interventions

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 (Lin et al., 2019). The fact that SUD telemedicine is a viable alternative to empirically-supported in-person SUD treatment analogs, suggests that online recovery support meetings are also likely to be viable alternatives to their empirically-supported, in-person MHO analogs.

Barriers to engagement and drawbacks of participation can be partially addressed

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 (Zemore, Kaskutas, Mericle, & Hemberg, 2017), those with drug use disorder who are new to treatment (Humphreys, Barreto, & Alessi, 2020), and those taking agonist medication (Monico et al., 2015) may experience more challenges engaging with 12-step MHOs. These individuals may experience similar challenges engaging with online 12-step MHO meetings. While the availability of online 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 meetings and may be more difficult to locate.

Additional drawbacks, including risks, to online recovery support meeting participation are important to mention. First, while evidence shows SUD telemedicine is an effective alternative to in-person interventions (Lin et al., 2019), which 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 (Simpson & Reid, 2014), it is possible that the positive effects of SUD telemedicine may not translate to online recovery support meetings. In situations where individuals may only have access to online digital SUD services, however, the positive SUD telemedicine data are informative. Second, privacy breaches could occur if another individual observes a participant’s screen, for example, or if online platforms themselves collect or share data from participants. Breaches from indirect observation are difficult to address, though privacy risks can be partially managed through participation only on encrypted platforms and ensuring the host is taking advantage of privacy options (e.g., requiring a password and host permission to enter the meeting). Lastly, broadband internet access continues to divide individuals along socioeconomic lines (Pew Research Center, 2019). For those who lack access to broadband internet needed for online video streaming, referral to meetings accessible by telephone is an available option.

Summary

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 SUD services, online recovery support meetings may help address COVID-19-related risks and thereby mitigate the overall public health burden of this pandemic.

Contributors

Dr. Bergman conceptualized the commentary and wrote the initial draft, while Drs. Bergman, Kelly, and 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. All authors contributed to, and have approved, the final manuscript.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.