key: cord-0990490-7ybyw8xc
authors: Liese, Bruce S.; Monley, Corey M.
title: Providing addiction services during a pandemic: Lessons learned from COVID-19
date: 2020-10-02
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108156
sha: 66d7e1fb3c3ea36ec65b911ee8c3ccbb57ca2182
doc_id: 990490
cord_uid: 7ybyw8xc

During the COVID-19 pandemic, social distancing measures have made in-person mutual help groups inaccessible to many individuals struggling with substance use disorders (SUDs). Prior to the pandemic, stakeholders in our community had sponsored a program to train volunteers to facilitate local Self-Management and Recovery Training (SMART Recovery) groups. As a result, the community established seven weekly SMART Recovery groups, which more than 200 community members attended. In March 2020, the community discontinued these groups due to the COVID-19 pandemic. To provide SMART Recovery during social distancing, we developed a one-on-one phone-in service for people with SUDs and addictions: the SMART Recovery Line (SMARTline). In this paper, we share our experience training volunteers to facilitate SMART Recovery groups and SMARTline. As a result of our experience, we have learned to: (1) establish plans in advance to migrate services from face-to-face settings to remote platforms; (2) consider remote platforms that are easily accessible to the greatest number of individuals; (3) include as many stakeholders in the planning process as possible; (4) consider recruiting volunteers to help in the provision of services, especially since many people want to help fellow community members during crises; and (5) anticipate and prepare for crises well before they occur.

We are in the midst of the COVID-19 pandemic. More than one-third of adult Americans have reported high levels of psychological distress during the beginning months of this pandemic (Keeter, 2020) . Researchers have speculated that the stress and isolation that COVID-19 has caused will result in increased frequency and severity of mental health problems, including substance use disorders (SUDs) (Columb, Hussain, & O'Gara, 2020; Dubey et al., 2020; Marsden et al., 2020; Ornell et al., 2020) . In-person mutual help groups (MHGs), including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Self-Management and Recovery Training (SMART Recovery), and others are essential resources for millions of individuals struggling with addictions (Kelly & White, 2012) . Unfortunately, most in-person MHGs have been temporarily discontinued in response to COVID-19 (Hoffman, 2020) . Below, we share our experience establishing and facilitating SMART Recovery services in our community before and during the COVID-19 pandemic.

complete 20-hours of online training lead SMART Recovery groups. Participants provide support to one another and learn to use SMART Recovery tools (i.e., structured exercises) to support addiction recovery (Horvath & Yeterian, 2012) . The SMART Recovery national office reports that there are 3,500 active, in-person weekly meetings internationally, attended by at least 10,000 participants ("SMART Recovery Fast Facts," 2019). Participation in SMART Recovery has been associated with reduced substance use severity, reduced substance use-related problems, and greater abstinence from substances (Campbell, Hester, Lenberg, & Delaney, 2016; Hester, Lenberg, Campbell, & Delaney, 2013; Zemore, Lui, Mericle, Hemberg, & Kaskutas, 2018) .

To establish SMART Recovery groups in Douglas County, two major stakeholders (a community foundation and county government) agreed to support a volunteer SMART Recovery group facilitator training program. These stakeholders formed a program development committee to plan this program and recruit volunteer group facilitators. The committee recruited volunteers directly through social service agencies, education institutions, volunteer services, and health care facilities. Whenever possible, committee members visited institutions and agencies, to describe the proposed program, answer questions, and address concerns. The committee also sent press releases to local media outlets and published at least one full-length news article describing the program.

Volunteers were required to complete a three-stage training process prior to facilitating their own group. In stage one they had to successfully complete the standardized online SMART Recovery facilitator training program (www.smartrecovery.org). In stage two they had to complete a newly developed live training program. And in stage three they needed to cofacilitate SMART Recovery groups with a more experienced facilitator until both agreed that the As a result of the volunteer SMART Recovery group facilitator training program, our community had established seven weekly SMART Recovery groups (whereas none had previously existed in our community). These included four groups at various community institutions, one group for college students at a local university, one group for inmates at the county jail, and one group for clients at a community mental health center. We obtained participant data through naturalistic observation from five of the seven SMART Recovery groups as part of a quality improvement project that the Institutional Review Board at the University of Kansas Medical Center approved.

Prior to the COVID-19 pandemic, 229 different participants attended these new groups.

Approximately one-fifth of these participants attended five or more groups, and the most active participants attended more than 50 group sessions. During sessions, participants sought help for a wide range of chemical and behavioral addictions, including addictions to alcohol, methamphetamine, cannabis, opioids, nicotine, and gambling. Some participants also asked for help with binge eating, compulsive sexual behavior, and compulsive shopping. Most participants (83%) attended SMART Recovery to achieve or support abstinence from addictive behaviors.

The remaining 17% expressed a desire to "control" addictive behaviors. Thirty percent of participants reported multiple addictions and one-third reported additional mental health problems (e.g., depression, anxiety, PTSD). SMART Recovery reached those who would otherwise have had difficulty accessing professional addiction services; approximately 22% of our participants were unemployed or receiving disability and approximately 3% were homeless.

In March 2020, our community introduced social distancing measures, and community agencies where SMART Recovery meetings were held (e.g., the public library) suddenly closed without notice. As a result, all in-person group sessions were immediately terminated. Because participants' contact information had not been collected, there was no established mechanism for contacting SMART Recovery group members. After considering these circumstances, community leaders and trained facilitators agreed to an alternative method for delivering services to community members-they established a telephone-based SMART Recovery line (SMARTline).

SMARTline is a one-on-one phone-in service, based on SMART Recovery principles and practices, that operates daily for all community members seeking help for addictions. Similar to SMARTline facilitator training is adapted from live SMART Recovery group facilitator training, with adjustments made for differences between services. For example, because SMARTline is delivered to individuals rather than groups, greater emphasis is placed on developing rapport between individuals, compared to greater focus on group processes in SMART Recovery group facilitation. Also, because SMARTline involves only audio contact, volunteers are encouraged to incorporate SMART Recovery tools without the benefit of diagrams, handouts, or worksheets common with SMART Recovery groups. Accordingly, facilitators assist participants in guided discussion, asking questions such as, "What are some advantages and disadvantages of quitting or continuing your addictive behavior?" Volunteers engage in weekly group supervision to discuss challenges, receive feedback, and develop facilitation skills.

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Moos (2008) outlines potential mechanisms of change (i.e., active ingredients) for inperson MHGs. These include social control (e.g., bonding, cohesion, goal direction, structure or monitoring), social learning (e.g., imitative modeling, expectations of positive and negative consequences), behavioral choice (e.g., non-addictive activities, alternative reinforcers), and coping (e.g., identifying and responding to stressors, building self-efficacy, developing effective coping skills). Kelly, Hoeppner, Stout, & Pagano (2012) focus on similar mechanisms of change in a sample of AA participants. These include improvements in social networks, social selfefficacy, and negative affect self-efficacy. Kelly, Magill, and Stout (2009) hypothesize that these mechanisms are present to varying degrees in all in-person MHGs. Yalom and Leszcz (2005) propose 11 therapeutic factors associated with group therapy and MHGs participation: instillation of hope, universality, imparting of information, altruism, corrective recapitulation of the primary family group, developing social skills, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors.

While we have not yet formally assessed potential mechanisms of change or therapeutic factors associated with SMARTline, we assume that at least some are functional during SMARTline calls. For example, by discussing experiences with a trained facilitator on the phone, individuals are likely to feel supported, gain hope, receive useful information, and consider alternatives to engaging in addictive behaviors. Because SMARTline does not provide a group experience or continuous relationships, callers are less likely to benefit from many of the group dynamics that Yalom and Leszcz have described. Nonetheless, SMARTline is designed to provide at least brief exposure to the most salient mechanisms of action and therapeutic factors.

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Studies have found that SMART Recovery is likely to help those who attend meetings (Campbell et al., 2016; Hester et al., 2013; Zemore et al., 2018) . One longitudinal study, comparing four MHGs (AA, SMART Recovery, Women for Sobriety, and LifeRing), found SMART Recovery to be as effective as AA at six-month follow-up (Zemore, 2018) . Researchers have conducted only one randomized trial of SMART Recovery (Campbell et al., 2016; Hester et al., 2013) . At three-and six-month follow-up, Hester et al. (2013) and Campbell et al. (2016) found participation in SMART Recovery to be effective in increasing percent of days abstinent, reducing drinks per drinking day, and reducing alcohol related problems. However, this study compared three groups that all received some adaptation of SMART Recovery. Without the presence of a control group, the effectiveness of SMART Recovery remains unknown. Hence, SMART Recovery is promising, but current research support for its effectiveness is limited (Beck et al., 2017) .

To our knowledge, live community-based training of lay volunteers in SMART Recovery group skills is a novel process; we were unable to find other examples of such training in the literature. We assume that such training enhances standard SMART Recovery online training by providing opportunities for skill practice and direct feedback. While SMART Recovery facilitators are typically current or past group members in recovery, lay volunteers also include a wide array of individuals who simply wish to help other community members. We are in the process of developing a fidelity instrument to measure the degree to which facilitators in our community are reliably delivering SMART Recovery, and we certainly hope to measure the impact of training community volunteers to facilitate SMART Recovery groups.

We searched for one-on-one telephone services like those offered through SMARTline J o u r n a l P r e -p r o o f Journal Pre-proof (i.e., adapted from SMART Recovery), and did not find any service like SMARTline in the literature. Given that SMARTline is a novel approach, we are only beginning to understand feasibility, accessibility, utility, sustainability, and logistical issues. As with our community SMART Recovery groups, we have been tracking basic SMARTline use patterns and will continue to do so. We hope that such tracking will enable us to modify our processes to make SMARTline further accessible and beneficial to the community. We will be particularly  To what extent are remote services like SMARTline scalable to other communities?

 How do services such as SMARTline most effectively function and collaborate with existing conventional addiction treatment services?

The COVID-19 pandemic has resulted in profound challenges. Like other crises, this pandemic has necessitated innovation. Thus far, our attempts to innovate have taught us at least the following lessons:

 Addiction services can be made available during a crisis, when conventional J o u r n a l P r e -p r o o f Journal Pre-proof resources are not available;

 Community agencies are willing to partner with stakeholders to provide addiction services;

 Volunteers are eager to contribute to the sustainability and growth of addiction services; and  Resources such as SMART Recovery provide a framework for training volunteers to deliver addiction services.

Based on our experience providing addiction services in the midst of the COVID-19 pandemic, we recommend the following for providing addiction services during a public health emergency:

 Establish advance plans to migrate services from face-to-face settings to remote platforms;

 Consider remote platforms that are easily accessible to the greatest number of individuals (including simple telephone hotline-like services);  Include as many stakeholders in the planning process as possible;

 Consider recruiting volunteers to help in the provision of services, especially since many people want to help fellow community members during crises; and  Anticipate and prepare for crises well before they occur.

At the time of this writing, we are beginning to implement SMARTline. We hope that this resource, analogous to a suicide hotline, will provide ongoing services to those with addictions.

During the COVID-19 pandemic, many substance use and addiction recovery services, J o u r n a l P r e -p r o o f Journal Pre-proof including MHGs, have turned to delivering services remotely. Prior to this pandemic, we developed a novel volunteer facilitator training program to develop and support local SMART Recovery groups. As a result, our community established seven weekly SMART Recovery groups between October 2018 and February 2020. More than 200 community members, struggling with a wide variety of chemical and behavioral addictions, some of whom were homeless or unemployed, attended these groups.

Unfortunately, due to the COVID-19 pandemic, the community discontinued all inperson SMART Recovery groups. To resume SMART Recovery services, we developed a oneon-one phone-in adaptation of SMART Recovery: SMARTline. The purpose of SMARTline has been to provide social support, encourage hope, and stimulate potential coping skills to replace addictive behaviors. Our experiences with SMART Recovery and SMARTline programs should enable us to evaluate the sustainability and accessibility of these services. Furthermore, we hope to determine how sustainability and accessibility of these services were impacted by the COVID-19 pandemic.

Systematic review of SMART Recovery: Outcomes, process variables, and implications for research

Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 2: Six-Month Outcomes of a Randomized Controlled Trial and Qualitative Feedback From Participants

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Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis: AA mechanisms

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A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD

We would like to acknowledge community partners vital to the development of SMART Recovery and SMARTline in Douglas County. Douglas County Community Foundation and the Douglas County Office of Behavioral Health Projects provided support for facilitator training, and Lawrence Public Library and Mirror Inc. provided access to their facilities for in-person