SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin

Adaptations and Innovations for 

Delivering Mental Health and Substance 

Use Disorder Treatment Services During 

the COVID-19 Pandemic

August 2022
CONTENTS

INTRODUCTION 3

DISRUPTION OF SERVICES DUE TO THE COVID-19 PANDEMIC 3

Delayed, Deferred, and Refused Care 4

Growing Unmet Needs for Mental Health Care and Substance Use Treatment 4

INNOVATIONS AND ADAPTATIONS FOR DELIVERING MENTAL HEALTH SERVICES DURING THE 

COVID-19 PANDEMIC 5

Definitions 5

Benefits and Challenges of Adopting Telehealth 6

Utilization and Acceptability of Telehealth for Mental Health and SUD Services 6

Other Innovations To Support Mental Health 7

INNOVATIONS AND ADAPTATIONS TO DELIVERING SUD SERVICES DURING THE COVID-19 

PANDEMIC 8

Telemedicine for SUD 9

Benefits of Telemedicine for Specific Populations 10

Take-home Dosing for MOUD 10

Changes to In-person Services for Outpatient Treatment 11

Changes to Residential and Inpatient Treatment Services 12

Changes to MOUD Provided in Jails and Prisons 12

New Technological Devices To Support MOUD 13

Online and Remote Peer Support Innovations 13

Adaptations for Providing Harm Reduction Supplies 14

OTHER PHYSICAL, MENTAL HEALTH, AND SUD TREATMENT SUPPORT INNOVATIONS 14

REMAINING CHALLENGES 15

Mental Health and SUD Services and the Digital Divide 15

Limitations of Remote Services 16

Limited Data on Mental Health and SUD Treatment and Service Innovations for Youth 16

Gap Between Mental Health and SUD Care and Broader Health System Highlighted by Pandemic 

Response 16

CONCLUSION 17

REFERENCES 18

The focus of the Supplemental Research Bulletin is to provide an overview of the current literature on a specific 

topic and make it easy to understand for disaster behavioral health professionals who are not otherwise exposed 

to the research. The product aims to assist professionals and paraprofessionals involved in all-hazards planning, 

disaster behavioral health response and recovery, and/or Crisis Counseling Assistance and Training Program 

grant activities.

Would you like to see a Supplemental Research Bulletin on a topic we haven’t yet covered? Contact us with topic 

ideas and feedback via email at dtac@samhsa.hhs.gov or phone at 1–800–308–3515.
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INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on adaptations and innovations in mental 

health and substance use disorder (SUD) treatment services during the COVID-19 pandemic. A previous 

issue of the Supplemental Research Bulletin (published in May 2021) reviewed preliminary research 

on the impact of the pandemic on mental health and substance use. This issue builds on that research, 

summarizing the adaptations that organizations have made to mental health and SUD treatment in the 

face of pandemic-related restrictions. 

Like other disasters, the COVID-19 pandemic has resulted in sudden, unexpected loss of life and has 

at times overwhelmed the capacity of the healthcare system to respond to medical needs. Unlike other 

disasters, infectious disease outbreaks can leave physical property intact but disrupt the social supports 

needed for mental wellness—for months or even years (Substance Abuse and Mental Health Services 

Administration [SAMHSA], 2021, Chapter 5). Since the last bulletin related to the effects of the pandemic, 

more studies have been published measuring the comparatively longer-term effects of the pandemic on 

mental health and substance use (through 2020 and into 2021). These effects will be covered in a future 

bulletin; the focus of this update will be the timely sharing of the creativity, resilience, and perseverance of 

mental health and SUD programs in the face of an ongoing pandemic.

We have also chosen to focus this Supplemental Research Bulletin on interventions to support patients and 

community members rather than healthcare personnel. Although the mental health impacts of the pandemic 

on healthcare practitioners and other healthcare facility staff have been profound (and they may be 

experiencing substance use-related impacts too), this topic requires a separate, in-depth review recognizing 

the additional challenges for those who provide care during a time of widespread, serious illness.

This issue of the Supplemental Research Bulletin is based on literature and scientific publications 

found through the National Center for Biotechnology Information and U.S. National Library of Medicine 

(PubMed) database. All research cited in this issue was published in English, and most was conducted 

in the United States (with exceptions where investigations included a multinational sample). This issue 

contains research published between January 1, 2021, and November 15, 2021.

With the focus on innovation, many of the publications cited in this bulletin are case studies/series, 

observational studies, or other narrative or quasi-experimental studies. Understandably, capturing data 

on patient outcomes competes for resources with implementing the innovations to minimize disruption of 

services. Where possible, outcome or effectiveness data are included along with the description of the 

innovation. Evaluation data that shows how, where, and for whom these innovations are most effective 

will be needed to strengthen the argument for sustaining these innovations and prioritizing investments for 

future pandemics or shorter-term disasters.

DISRUPTION OF SERVICES DUE TO THE COVID-19 PANDEMIC

Although pandemics are infrequent events, past research on pandemics, epidemics, and other disasters 

shows the harms caused by the intersection of increased disaster-related distress, the disruption of care, 

and the loss of access to coping strategies that support mental health and recovery (Kmeic, 2021; Li and 

Zhao, 2021; Murphy et al., 2021). 
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Delayed, Deferred, and Refused Care

Pandemics of contagious diseases are especially disruptive as people isolate to protect themselves: a 

survey conducted in June 2020 (Czeisler et al.) found that 40.9 percent of adult respondents had avoided 

medical care due to concerns about COVID-19, including 12.0 percent who avoided urgent or emergency 

care. Prior to the pandemic, one review of data from the 2007 Health Information National Trends Survey 

estimated that a third of respondents (n = 7,674) avoided necessary medical visits (urgent or emergency 

care was not specified) (Kannan and Veazie, 2014). Although there may be some overlap (people who 

avoid care for other reasons may also report avoiding care due to COVID-19), there is other evidence of 

increased medical avoidance: people who received naloxone for suspected overdose during emergency 

medical calls in Tucson, Arizona, were twice as likely to refuse transport to emergency departments 

during the pandemic compared to before (as cited in Striley and Hoeflich’s review, 2021).

Those who sought to receive care faced barriers from closures and distancing restrictions. A review by 

Murphy and colleagues (2021) on the impact of the pandemic on mental health found difficulties with 

medication management and reduced access to face-to-face mental health services and supports due to 

physical distancing restrictions and closures. For people with preexisting mental illness and/or SUD, stayat-home or shelter-in-place orders can exacerbate conditions that lead to poor outcomes: 

• Living in an unstable or unsupportive situation (or losing housing entirely) (Harris et al., 2021b)

• Losing supportive routines (including loss of employment and subsequent financial difficulties) 

(Murphy et al., 2021) 

• Losing access to treatment and harm reduction services due to closures (Seaman et al., 2021; 

Taylor et al., 2021) 

• Experiencing isolation in residential treatment facilities (Kedia et al., 2021; Pagano et al., 2021) 

Growing Unmet Needs for Mental Health Care and Substance Use Treatment

In addition to presenting problems for those with existing mental health and SUD treatment and service 

needs, the pandemic has increased unmet need for mental health care and SUD treatment. Alexander 

and colleagues (2021) found capacity and infrastructure limits prevented new patients from successfully 

accessing medication for opioid use disorder (MOUD) during the pandemic. Among respondents to a 

June 2021 survey of a nationally representative sample, 70 percent of those who provided unpaid care for 

someone else reported one or more adverse mental health symptoms, and a third of unpaid caregivers 

reported starting or increasing substance use (Czeisler et al., 2021). Hochstatter and colleagues (2021) 

collected survey data among users of a mobile health app for people living with HIV/AIDS that showed 

an increase in substance use (specifically, heroin, prescription opioids, cocaine, methamphetamine, and 

sedatives), an increase in being around people using drugs, and a decrease in confidence in ability to not 

misuse substances during the pandemic. Kedia and colleagues (2021) saw disruptions in court referrals 

to MOUD treatment for new clients as legal proceedings moved online (and judges were not always 

aware of available treatment options).

Even as of the publication of this newsletter, the COVID-19 pandemic continues. Effective vaccines 

and treatments have greatly reduced the risk of acquiring, transmitting, or becoming seriously ill or 

dying from COVID-19. Adaptations in the face of public health restrictions—such as changes in policy 
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and creativity from mental health and SUD prevention, treatment, and recovery organizations—have 

mitigated some of the challenges seen in the early part of the pandemic. The lessons learned from the 

innovations summarized below will be needed to respond to ongoing challenges and build resilience for 

future disasters.

INNOVATIONS AND ADAPTATIONS FOR DELIVERING MENTAL HEALTH 

SERVICES DURING THE COVID-19 PANDEMIC

The single biggest area of change mentioned in the research literature is policy change involving 

expanded access to telehealth (Haque, 2021), most notably changes in the Health Insurance Portability 

and Accountability Act of 1996 (HIPAA) that allowed for widely available video calling software (such 

as Apple FaceTime) to be used for telemedicine (Notification of Enforcement Discretion, 2020) and 

changes to payment and billing that make it easier for providers to bill and be reimbursed for providing 

telehealth services, including mental health and SUD services (U.S. Department of Health and Human 

Services [HHS], 2022). Some payers, such as TRICARE, the healthcare program for uniformed service 

members, retirees, and their families, increased access by approving payment for audio-only care and 

waiving payments/cost-sharing for mental health and SUD services during the public health emergency 

(Defense Health Agency, 2018; Clark, Fan, et al., 2021). While state policy and private payer decisions 

vary (including as to whether they will be made permanent), this shift has allowed mental healthcare 

professionals a way to deliver services at a distance.

Definitions

The rapid expansion of telehealth has resulted in new terms to describe remote health care, many of 

which include or overlap with other terms. Below are some definitions suggested by leading medical 

associations and HHS. These definitions are used throughout the bulletin unless otherwise specified by 

the authors or the implementers of an intervention. 

Telehealth: Use of electronic and telecommunications technologies and services to provide health 

care and services at a distance. Includes telemedicine, mental and SUD-related telehealth 

(telepsychiatry, teletherapy), and other services (American Academy of Family Physicians 

[AAFP], 2022).

Telemedicine: The practice of medicine using technology to deliver clinical services remotely 

(AAFP, 2022).

Mental health and SUD-related telehealth: This application of telehealth to mental health and SUD 

services includes remote mental health services (teletherapy, telepsychiatry) and remote treatment 

for SUD (U.S. Department of Health and Human Services, n.d.).

Telepsychiatry: A subset of telemedicine that can involve providing a range of services including 

psychiatric evaluations, therapy, patient education, and medication management (American 

Psychiatric Association, 2020).

Teletherapy: Delivery of individual (one-on-one) or group therapy using electronic and 

telecommunications technology. It can include virtual talk therapy, text therapy, and user-directed 

technologies like chatbots or apps with tools to support self-management (HHS, 2021a, 2021b).
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Benefits and Challenges of Adopting Telehealth

Sadicario and colleagues (2021) detail a case study of an integrated women’s healthcare and SUD 

treatment team that transitioned to telehealth services during the pandemic. In this case study, providers 

note benefits for patients (elimination of transportation barriers, flexibility in scheduling) and challenges 

in building rapport and trust with new patients. The authors recommend specific telepsychiatry training 

and mentors/peer supervisors for providers new to the process, as well as developing processes for 

maximizing the benefit of coordinated care between distanced providers. In a commentary, Carlo, Barnett, 

and Unützer (2021) suggest that a collaborative care model like the one in the Sadicario et al. case study 

could utilize the expansion of telehealth to deliver collaborative care by connecting providers across 

facilities, better integrating mental health care into primary care.

Arnold and colleagues (2021) found that adopting telehealth for their community-based organization 

(CBO) serving men who have sex with men reduced no-show visits. In addition to reaching their clients 

remotely, they provided a private, isolated space at the CBO location for “in-person” telemedicine 

visits where clients could use a laptop to access video calls with a provider. Langabeer, Yatsco, and 

Champagne-Langabeer (2021) observed a small increase in participation in individual therapy and peer 

recovery groups when they switched their SUD treatment organization to a telehealth model. Komaromy 

and colleagues (2021) observed a decrease in no-show rates from 40 percent (prior to the pandemic and 

implementing telehealth) to 30 percent when they converted their multidisciplinary program for youth with 

SUD to a telehealth model. (This intervention also included text messaging and “on the fly” telehealth 

check-ins for crisis management, which is unique among the innovations in this review.) For Sadicario 

and colleagues, telemedicine did not reduce no-shows, but they noted that other factors may affect 

attendance (such as childcare emergencies).

Although telemedicine can reduce patient barriers to participation, several studies found that telemedicine 

generally did not save time for clinicians. Sadicario and colleagues encountered late or missed 

appointments even with telehealth, which resulted in needing to make quick changes to tight schedules. 

Langabeer, Yatsco, and Champagne-Langabeer were not able to find any increased efficiency to serve 

more patients, even after getting experienced delivering telehealth.

This section summarizes some of the challenges for mental health and SUD service and treatment 

providers and organizations in adopting telehealth. Policy changes have increased access to telehealth 

for those clients who possess the information technology to connect to telehealth systems; disparities in 

technology and internet access can become healthcare disparities in telehealth approaches (Darrat et al., 

2021). These disparities and additional considerations for telehealth—including the limitations of remote 

services and the needs of special patient populations such as youth living with parents—are covered in 

the Remaining Challenges section at the end of this bulletin.

Utilization and Acceptability of Telehealth for Mental Health and SUD Services

Telehealth can offer patients and clients flexibility in participating and increase participation in treatment 

and services. Through a survey of members of a general mental health Facebook group, Costa and 

colleagues (2021) found that 8 percent of respondents had started therapy with a new practitioner by 

video session, and 33 percent had switched from in-person to video sessions. However, 33 percent of 

respondents preferred in-person to video sessions, compared to only 3 percent who preferred video to 
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in-person sessions. Clark, Fan, et al.’s analysis of U.S. service members’ utilization of mental health and 

SUD telehealth (2021) found that telehealth visits in 2020 remained higher than telehealth usage in 2019 

and in-person outpatient visits, even after visits increased following the first 2 months of the pandemic. 

For counseling as part of SUD treatment, telemedicine may offer patients flexibility that helps boost 

participation. Hughto and colleagues (2021) were able to provide telehealth services for new patients who 

were otherwise unable to utilize their outpatient MOUD clinic; however, they also observed disparities in 

the ability to access telehealth at home and noted that providing equipment for telehealth at the clinic did 

not remove many of the barriers to access (transportation, COVID-19 exposure risk) for those patients. 

Sugarman and colleagues (2021) found that 90 percent of those in an SUD program that switched to 

telehealth were very satisfied with individual teletherapy counseling, less so with group therapy (only 60 

percent were very satisfied). The majority of respondents preferred strongly or slightly preferred telehealth 

only, but a significant portion preferred a mix of telehealth and in-person visits for individual therapy (25 

percent), group therapy (19 percent), and medication management (22 percent). In the case series by 

Komaromy and colleagues (2021), most patients in a program for co-occurring mental illness and SUD 

preferred a telehealth option. 

Martin and colleagues (2021) examined acceptability from the perspectives of counselors working in 

opioid treatment programs (OTPs) across Rhode Island. While the vast majority (69 percent) reported 

being somewhat or very satisfied with providing telephone counseling, the most frequently mentioned 

concern was the difficulty building rapport and observing nonverbal communication in phone calls. 

However, they appreciated that this distanced option was also more convenient for clients, and only 

9.5 percent of counselors reported that a client relationship had worsened since introducing telephone 

counseling. While many of the authors in this review acknowledge the drawbacks to mental health 

and SUD-related telehealth, two (Bergman et al., 2021; Fiacco, Pearson, & Jordan, 2021) noted that 

telemedicine allowed organizations to offer some form of services during the pandemic.

Other Innovations To Support Mental Health

In addition to telepsychiatry or tele-counseling, digital mental health tools, self-management innovations, 

and other approaches intended for lay people to boost mental health have been used by many during 

the pandemic to cope with distress. For example, an online therapy company (Talkspace) saw a 65 

percent jump in new users in May 2020 (Masand et al., 2021). Sorkin and colleagues (2021) found 

that those experiencing symptoms of depression or anxiety were three to six times and two to three 

times as likely to use digital mental health apps, respectively, during the pandemic. The benefit of these 

interventions is that they may be more quickly accessible than traditional mental health and SUD care 

(which depends on facility and practitioner availability for new patients). Sorkin and colleagues also point 

out that “accessibility” of digital or mobile health (mHealth) tools requires being aware of the resource, 

having the resource available in accessible language (plain language as well as languages other than 

English), and having the needed technology and skills to use the tools successfully. Additionally, few 

mobile app developers have published peer-reviewed evidence of apps’ feasibility or effectiveness 

(Sorkin et al., 2021).

Kunzler and colleagues (2021) reviewed community mental health and psychosocial support strategies 

for highly contagious disease outbreaks (such as Middle East respiratory syndrome [MERS] or 

Ebola), finding relatively few examples of effective interventions and low-quality evidence overall. 
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(Understandably, many interventions responding to the COVID-19 pandemic have not yet published 

results.) The component of mental health or psychosocial interventions that had the strongest supporting 

evidence was a combination of providing factual information while teaching psychological strategies to 

manage distress (training to strengthen resilience factors and coping strategies). Kunzler and colleagues 

note that higher levels of COVID-19 knowledge and resilience factors have been shown to be protective 

against pandemic-related distress in other studies, and they recommend these as a starting point for 

individual-, organizational-, or community-level interventions.

Based on the evidence linking mental health to exercise and physical activity, many distress selfmanagement interventions have suggested ways to safely increase physical activity (such as Ghram and 

colleagues’ recommendations for older adults, who are at heightened risk for COVID-19 and increased 

sedentary behavior). However, the effectiveness of physical activity alone on managing distress may 

be limited: Giuntella and colleagues (2021) found no impact on depression symptoms from a short-term 

(2-month) intervention to reverse drops in physical activity among young adults during the pandemic. 

Similarly, many well-intentioned recommendations focused on creative ways to maintain a social network 

to support mental health during physical distancing and isolation. Sahi and colleagues (2021) examined 

different aspects of a “virtual social network” to understand which were most associated with improved 

mental health. They found that, for the university students in their study, having a larger social network 

(more individuals) and spending time with virtual connections on a weekly basis were associated with 

better mental health outcomes (frequency of contact was not as important as total time spent on a 

regular basis). Although this research focused on young adults (who may have different social needs 

and relationship priorities than people in other life stages), fostering a larger virtual social network may 

mitigate the loss of casual social interactions when routines are disrupted (such as being a regular 

customer at a neighborhood restaurant).

Kahlon and colleagues (2021) designed an intervention to create these social ties among participants in a 

Meals on Wheels program in Texas. Young adult volunteers were trained on empathic listening techniques 

designed to engage program participants over the phone in conversation on participants’ topics of choice. 

Calls were initially designed to last 10 minutes but were not time-limited, and many did run longer. In the 

first of the four intervention weeks (July–August 2020), participants received five calls, after which they 

could choose their frequency (between two to five calls per week). Compared to the control group (who 

received the baseline Meals on Wheels services), participants in the intervention group showed greater 

decreases in reported loneliness and in depression and anxiety scores. (Participants in the control group 

experienced a slight increase in depression and anxiety scores during the study period.) Ultimately, 

Kahlon and colleagues found this intervention to be easily deployable, scalable, and effective.

INNOVATIONS AND ADAPTATIONS TO DELIVERING SUD SERVICES DURING THE 

COVID-19 PANDEMIC

As described above, policy and payment changes opened up the widespread use of telehealth modes 

for mental health and SUD services. For SUD treatment and MOUD in particular, specific policy changes 

allowed practitioners to initiate and maintain prescriptions by video- or audio-only appointments and to 

dispense telephone or faxed prescriptions (Clark, Davis, et al., 2021; Li and Zhao, 2021; Livingston et 

al., 2021; Quiñones et al., 2021). Other policy changes allowed for take-home supplies of methadone 
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and pickup/drop-off by a trusted person other than the patient (Cantor and Laurito, 2021). Due to the 

ongoing opioid use epidemic, the majority of the articles about SUD treatment in this bulletin focus on 

treatment of people with opioid use disorder (OUD), but the bulletin also includes some examples of 

treatment of people with tobacco dependence, alcohol use disorder, and SUD in general (including but 

not limited to OUD).

Telemedicine for SUD

Access to SUD treatment services, especially MOUD, reduces the risk of overdose and other opioidrelated harms (Wakeman et al., 2020). In a cohort study of Massachusetts overdose survivors, receiving 

buprenorphine or methadone maintenance therapy in the year following an overdose reduced opioidrelated mortality as well as overall, all-cause mortality (Larochelle et al., 2018). 

As described above, implementing telehealth allowed SUD treatment facilities to maintain services and 

accept new patients when the strictest physical distancing measures were in place. When Fiacco and 

colleagues (2021) converted their care of patients with SUD to telemedicine, they reduced no-show rates 

(including achieving a zero no-show rate for new patients in May 2020). Hughes and colleagues (2021) 

compared patient characteristics after the implementation of telemedicine for office-based OUD treatment 

and found that patients with the farthest driving distance were more likely to use telemedicine for visits. 

Not surprisingly, the clinic also saw the largest increase in MOUD patients from rural counties within their 

catchment area, reflecting the benefit of telemedicine for those patients. Kotsen and colleagues (2021) 

successfully transitioned from in-person to telehealth modes for the counseling portion of a tobacco 

treatment program for tobacco-dependent cancer patients at Memorial Sloan Kettering. When controlling 

for the date of the appointment (before or after the pandemic), a telehealth visit had 2.3 times the odds of 

completion compared to an in-person visit.

Several studies examined the impact of changes in buprenorphine prescription guidelines that allowed 

providers to initiate treatment regimens based on video- or audio-only appointments. Clark, Davis, and 

colleagues (2021) describe a partnership between the Rhode Island Department of Health and the 

Department of Behavioral Health, Developmental Disabilities, and Hospitals that used telehealth to 

quickly connect patients to buprenorphine treatment. The partnership established a 24/7 buprenorphine 

hotline that offered callers the ability to be connected to a waivered practitioner for an initial assessment 

via telephone. (If appropriate, patients are co-prescribed buprenorphine and naloxone and are emailed 

induction instructions and local resources for harm reduction, community support, and mental health and 

SUD treatment.) Hospitals also partnered to refer patients who were treated in the emergency department 

for an overdose but who were not currently connected to an MOUD program. Although this program has 

not been evaluated, hotline callers have shared that this innovation allowed them to enter treatment, and 

the primary outpatient clinic has seen a 50 percent reduction in no-show rates for follow-up telehealth 

appointments. As described in Komaromy and colleagues (2021), connecting people to services quickly 

after their decision to seek treatment has positive effects on engagement and retention.

In a case series of two harm reduction programs from Wang and colleagues (2021), telehealth initiation 

of buprenorphine reduced wait times from local organizations that had suspended or reduced their 

buprenorphine services during the pandemic. Wang and colleagues are also developing a similar program 

to the one described in Rhode Island that would connect people being treated for overdose to a real-time 

assessment for buprenorphine initiation.
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Caton and colleagues (2021) found that primary care clinics offering OUD treatment in California were 

more likely to offer telehealth appointments for follow-up MOUD appointments than for initial MOUD 

appointments (40.4 percent clinics vs. 23.1 percent of clinics, respectively), with 7.7 percent of clinics 

requiring initial medication visits be in-person only. While 31.6 percent of clinics found it easier to engage 

patients, 26.3 percent found it harder, and 24.6 percent saw no change. 

BENEFITS OF TELEMEDICINE FOR SPECIFIC POPULATIONS

While telemedicine addresses some barriers people have faced before and during the pandemic (e.g., 

lack of access to transportation, lack of childcare, the need for physical distancing to reduce the spread 

of COVID-19), it is not appropriate for everyone, as it requires a degree of familiarity and facility with 

telemedicine technology and an internet connection sufficient to support telemedicine. To address some 

of the barriers telemedicine entails, interventions have been developed that combine mobile services and 

telemedicine, one of which is described by Weintraub and colleagues (2021) as a way to reach a rural 

population in an area with no public transportation. The team reports on a study of the intervention, which 

involves a mobile services unit (a modified recreational vehicle with telemedicine technology) with clinical 

staff (a nurse, peer recovery specialist, and substance use counselor) that can be deployed to rural areas 

as a hybrid, mobile clinic offering some care via telemedicine. This mobile clinic reduced driving distances 

by an average of 6.52 travel miles (compared to nearest permanent MOUD facility) and had comparable 

outcomes in opioid use reduction and treatment retention to brick-and-mortar MOUD treatment in other 

rural communities (a reduction of use by one-third, and a 60 percent retention rate at 3 months).

For youth with SUD, telehealth offers opportunities to engage families in the MOUD treatment process 

and improve patients’ outcomes. Hogue and colleagues (2021) describe cases where telehealth was used 

to conduct initial outreach and planning for family-supported MOUD, educate parents and family members 

about MOUD, build family members’ skills in providing psychosocial support, and help family members 

participate in long-term follow-up.

Pregnancy can be a major motivation to initiate SUD treatment (Jones et al., 2021), but it can be 

challenging to access treatment when pregnant: a survey of North Carolina buprenorphine clinics found 

that, prior to the pandemic, nearly half had turned away pregnant patients, increasing to two-thirds during 

the pandemic (Lensch et al., 2021). Changes in prescribing guidelines and increased use of telehealth 

can be particularly beneficial for pregnant patients who wish to begin a buprenorphine treatment regimen 

but are unable to access it locally. Patton and colleagues (2021) successfully integrated telemedicine for 

buprenorphine into their clinic’s hybrid model for providing coordinated SUD treatment and prenatal care 

and suggest that pregnant patients be recommended for take-home medication status.

Take-home Dosing for MOUD

Prior to the pandemic, regulations on MOUD included strict criteria regarding which patients were eligible 

for take-home medication, with consideration of such factors as absence of recent drug use, stability 

of social relationships, and ability to safely store MOUD (SAMHSA, 2015). Joseph and colleagues 

(2021) also note that OTPs are incentivized to maintain dosing through in-person attendance because 

of reimbursement policies and the benefits available in a clinical setting (such as wraparound care and 

referrals). In response to the pandemic, states could request exceptions to these criteria (up to 28 days of 

take-home medication for stable patients, and up to 14 days for less stable patients) (SAMHSA, 2020). 
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Joseph and colleagues (2021), working in the State of New York, began with reducing clinic visits (and 

increasing take-home dosing) for patients at greatest risk of death from COVID-19. The clinics also 

eliminated toxicology testing from their guidance for MOUD dosing schedules, instead focusing on 

treatment engagement and accomplishment of goals set with patients. Dosing could also be quickly 

adjusted in case of incidents of misuse or diversion. From March 16, 2020, through May 31, 2020, over 

3,600 patients were maintained in MOUD treatment with 6 nonfatal overdoses and no fatal overdoses. 

(In the period just prior—January 1, 2020, to March 15, 2020—there were 2 nonfatal overdoses and 1 

fatal overdose.)

Changes to In-person Services for Outpatient Treatment

Almost all clinics and facilities mentioned in this bulletin had to suspend or reduce in-person services, 

especially during the early part of the pandemic when the most stringent distancing measures (such 

as shelter-in-place orders) were in effect. Many OTPs still needed to provide some in-person services, 

especially as the pandemic continued, and adopted the following adaptations to reduce risk but 

maintain service.

Many clinics reported reducing patient volume in order to accommodate distancing protocols and reduce 

the risk of exposure events (Becker et al., 2021; Kedia et al., 2021; Quiñones et al., 2021). Clinics also 

provided personal protective equipment (PPE) to staff and implemented sanitization protocols, but they 

often faced challenges in acquiring needed supplies (Quiñones et al., 2021). As described earlier, many 

clinics shifted in-person visits to telehealth where possible (to reduce in-person volume), and many 

implemented “virtual” visits using isolated telemedicine stations at clinic locations. To mitigate exposure 

risk, many OTPs suspended their peer recovery coaching and volunteer programs (in order to reduce 

the number of individuals on site and coming into contact with patients) (Kedia et al., 2021; Kleinman et 

al., 2021). In addition to potentially putting additional burden on staff, the loss of opportunities to provide 

peer recovery services disrupted an important, meaningful part of those patients’ treatment plans. As 

with clinical and counseling staff, peer recovery coaches or volunteers may need training and support to 

transition their activities (where appropriate) to a remote or hybrid model.

Patients with SUD who did not have stable housing were particularly challenged during the pandemic, 

and the isolation sites set up for people experiencing homelessness were not always equipped to provide 

SUD services. In Puerto Rico, a clinic serving a large number of unsheltered people began outreach 

programs combining COVID-19 education with harm reduction strategies (Quiñones et al., 2021). Tringale 

and Subica (2021) describe adaptations to a syringe services program (that also provided medication 

for addiction treatment), which set up private “booths” at the building entrance to conduct medicationassisted treatment (MAT) visits. This program also partnered with local pharmacies to boost the capacity 

for dispensing buprenorphine prescriptions, reducing wait times and crowding for patients. 

Harris and colleagues (2021a, 2021b) describe the integration of addiction consult services into recovery 

and isolation sites for COVID-19 patients with SUD, developing safe isolation and recovery programs 

and connecting discharged patients to MAT to close the gap between acute treatment (for COVID-19 and 

managing withdrawal) and programs for housing and treatment support for people with SUD that were 

not set up for COVID-19-positive patients. Komaromy and colleagues (2021) developed a temporary 

residential treatment facility for patients with co-occurring SUD and COVID-19 that could be managed 
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in an outpatient setting. Patients were supported with medication as part of SUD treatment through 

their COVID-19 recovery and connected to outpatient SUD treatment following their discharge from the 

COVID-19 recovery unit.

Changes to Residential and Inpatient Treatment Services

Residential treatment programs were particularly disrupted due to distancing restrictions, which changed 

workflow for practitioners and prevented families, sponsors, counselors, and support groups from visiting 

existing patients in person. Changes that reduce in-person staff can increase feelings of isolation, 

as found in Clair and colleagues’ qualitative study of participants in a U.S. Department of Veterans 

Affairs (VA) residential treatment program (2021). In this case, shifts to telemedicine were not well 

communicated, leaving patients feeling “cut off” from providers and limited by changing information (and 

policy implementation) depending on which staff members were working on site. 

Residential OTPs also reduced patient census as part of their distancing protocols, which decreased 

available beds for new patients. Kedia and colleagues (2021) observed both of these in their case report 

from Appalachian Tennessee and noted that the loss of reimbursement for services required several 

agencies to take loans in order to cover operations. Throughout the pandemic many treatment facilities 

developed creative solutions that mitigated some of the social isolation: providing spaces for accessing 

telehealth services, investing in broadband internet for videoconferencing, and creating outdoor meeting 

and socialization spaces (Kedia et al., 2021). One important lesson highlighted by Kedia and colleagues 

is that disaster plans for residential treatment facilities should include long-term plans for patients who 

cannot be safely discharged during a disaster. Especially during highly contagious disease outbreaks, 

epidemics, or pandemics, people who lose access to stable living situations can also lose access to 

housing services if they become infected or exposed (as highlighted by Harris and colleagues [2021b]).

Changes to MOUD Provided in Jails and Prisons

Access to MOUD in correctional facilities was already limited at the beginning of 2020, and the disruptions 

of SUD treatment due to the pandemic increased acutely with facilities’ COVID-19 responses, which 

included rapid decarceration, quarantine of those who tested positive for COVID-19, and suspension 

of mental health and SUD services to reduce in-person contact or because locations were needed for 

isolation and recovery areas (Donelan et al., 2021; Duncan et al., 2021; Rowell-Cunsolo et al., 2021). 

Donelan and colleagues describe the response in Franklin County, Massachusetts, where MOUD was 

delivered in housing units (rather than a group setting) or directly to cells for individuals under quarantine. 

The jail obtained technology grants to set up individual teletherapy appointments and provided individual 

workbooks after group therapy sessions were cancelled. Recognizing that individuals who were rapidly 

released (either because of greater risk from COVID-19 or because of court policy rulings) could lose 

access to MOUD, the Franklin County Sherriff’s Office successfully advocated for extension of Medicaid 

coverage through this period, added telehealth options to the post-release program, provided take-home 

medication more widely under the new guidelines, and secured housing for recently released individuals. 

In Hennepin County in Minnesota (Duncan et al., 2021), the implementation of telemedicine and changes 

in buprenorphine initiation policy allowed the jail to provide buprenorphine (either initiation, maintenance, 

or taper dosing) during short-stay periods (36 hours or less), which had historically been challenging. 
| Page 13

However, Duncan and colleagues also noted that the jail was limited in its ability to follow up with 

individuals post-release and that responding to the COVID-19 pandemic required resources that may be 

difficult to sustain without policy changes to increase reimbursement for MOUD and telemedicine services 

provided in jails and prisons.

New Technological Devices To Support MOUD

Dunn et al. (2021) conducted a randomized controlled trial of an electronic pillbox for dispensing splitdose methadone for take-home dosing. These electronic pillboxes open at a programmed time to promote 

medication adherence, and the timing could be adjusted by consultation with staff. The pillbox also 

sent dosing reminders to patients’ and staff’s cell phones and could send alerts (via text or email) about 

unexpected events (such as loss of connection, low battery, or failure to take the dose). In a participant 

survey, the majority of patients liked the pillbox (86.3 percent) and said they would recommend it to 

others (95.4 percent), but only half (52.4 percent) continued using the pillbox during the “choice” part of 

the trial (where patients could resume their usual dosing or keep using the electronic pillbox). Dunn and 

colleagues theorize that the requirement to bring the pillbox to daily appointments may have influenced 

the decision to keep using it and note the potential of this innovation for longer periods with take-home 

patients who face challenges in safely storing MOUD.

McDonnell and colleagues (2021) offer a digital health technology intervention at their clinic that consists 

of (1) a wearable device to detect biomarkers of craving and stress, (2) a mobile app of dialectical 

behavior therapy-based interventions and immediate connection to clinicians, and (3) a clinicianfacing portal showing insights to the care team. Clients with alcohol use disorder are also offered a 

wireless breathalyzer that reports results or missed tests to their care team. McDonnell and colleagues 

acknowledge that more data on the efficacy of these tools are needed, but the remote data collection 

capabilities have supplemented the shift to telehealth necessitated by the pandemic.

Online and Remote Peer Support Innovations

Online peer support groups preceded the pandemic and range from formal, structured groups linked to 

a clinic or OTP to general support forums maintained on social media. During the pandemic, however, 

these resources had the benefit of being immediately available (and often at no cost to participants) as 

organizations developed ways to mitigate the loss of in-person services (Bergman & Kelly, 2021).

Bunting and colleagues (2021) studied early pandemic activity on forums on the social networking site 

Reddit.com. Forum members shared how their daily lives had changed, offered or asked for advice, 

and provided mutual aid to each other. This mutual aid could take the form of general psychosocial 

support, connecting other members to local support resources, providing advice on and experience with 

accessing MOUD during the pandemic, sharing scientific information on MOUD and SUD, and offering 

ideas or stories for how to support recovery (such as reminders to engage in exercise or ideas for 

entertainment/distraction).

Prior to the pandemic, Liese and Monley (2021) had established mutual help recovery programs in 

Douglas County in Kansas that were staffed by volunteers (including community members, mental 

healthcare professionals, peer support specialists, and individuals who had participated in other peer 

support groups). During the pandemic, volunteers developed and conducted training on adapting the 
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group programming to one-on-one telephonic interventions. Although Liese and Monley acknowledge 

that this study lacks data on efficacy of the adaptation, they provide an example of how volunteers can 

be leveraged for outreach, follow-up, and education with minimal investment (beyond what is needed 

for training). 

At the time of publication of this bulletin, data on the efficacy of teletherapy or remote peer support groups 

(for recovery or other positive outcomes) during the pandemic is lacking. Bergman and colleagues (2021) 

summarize the evidence for digital support programs before the pandemic, concluding that they offer 

benefits for mitigating the public health burden of the pandemic (but not necessarily replacing services 

lost during the pandemic). When considered as part of a broad social network, these peer recovery 

groups may offer the mental health benefit of having a large, diverse, and regularly connected virtual 

social network described by Sahi and colleagues (2021).

Adaptations for Providing Harm Reduction Supplies

The closure or reduction of in-person services also required creativity in distributing harm reduction 

supplies like sterile syringes or naloxone. For organizations that maintained in-person distribution, this 

included providing PPE for staff, requiring masks, sanitizing surfaces, moving services outside, and 

creating workflows to maintain 6 feet between individuals (Seaman et al., 2021). In rural areas, some 

syringe providers continued services or switched entirely to mobile distribution to protect clients (Ostrach 

et al., 2021). Seaman and colleagues also found that individuals who utilized syringe services programs 

engaged in their own risk reduction strategies, such as obtaining larger amounts of syringes to reduce the 

need for visits and prioritizing safer injection to avoid needing additional medical care. Courser and Raffle 

(2021) describe the changes to a take-home naloxone program—such as hosting “drive through” events, 

outdoor training sessions, and promoting mailed naloxone—that increased distribution rates of naloxone 

above pre-pandemic levels. 

One study (French et al., 2021) and one review (Barnett et al., 2021) describe mail-based naloxone 

and clean syringe distribution through the Needle Exchange Technology (NEXT) Distro program. NEXT 

Distro began in New York City in 2017 to offer safe, mail-based needle exchange (including materials for 

handling used syringes), but now has partnerships in 32 states for naloxone distribution as well. In French 

and colleagues’ study of NEXT Distro participants in Philadelphia, the most common barrier to naloxone 

access was not knowing how to access it (in spite of local regulations that all pharmacies are required to 

stock naloxone). Barnett and colleagues also cite misperceptions about the legality of obtaining naloxone 

(including the stigma of requesting it from a pharmacy). This may be related to the complex patchwork 

of regulations around purchasing safe injection supplies, including store policies, quantity limits, and 

paraphernalia laws (Barnett et al., 2021; Peckham et al., 2021).

OTHER PHYSICAL, MENTAL HEALTH, AND SUD TREATMENT SUPPORT 

INNOVATIONS

Evidence from integrated healthcare systems that include mental health and SUD treatment and services 

and social supports, such as the VA, show that these comprehensive services can dramatically improve 

outcomes in the face of a pandemic. Kelly and colleagues (2021) examined COVID-19 outcomes 

among individuals with behavioral risk factors who obtained care from the VA and found that social 

and behavioral support programs eliminated the associated mortality risk. Several programs described 
| Page 15

in articles included in this bulletin purposefully integrate SUD treatment into medical care, and more 

programs have used the trusted relationships from SUD care to address needs during the pandemic: 

Komaromy and colleagues (2021) added a mobile vaccination unit to their SUD program for parents of 

infants and toddlers to reduce any drop in childhood vaccination rates due to the pandemic. They also 

distributed cell phones to patients in an office-based SUD treatment program who would not otherwise 

be able to access telehealth modes of care. Ostrach and colleagues (2021) utilized their syringe services 

programs to provide PPE, sanitization supplies, and COVID-19 prevention information to clients.

REMAINING CHALLENGES

Just as the risks for COVID-19 are unequally distributed (from co-occurring conditions or circumstances 

that put individuals at greater risk for exposure and greater risk for poor outcomes), the benefits of 

adaptation and innovation can be unequally received, and those most at risk for poor mental health 

and SUD-related outcomes are also the least able to take advantage of these shifts. Nguemeni Tiako 

(2021) observed racial disparities on MOUD that were perpetuated during the COVID-19 pandemic, 

including reduced access to buprenorphine for individuals of other races compared to White individuals; 

comparatively lower use of telehealth for mental health or SUD services; and decreases in visits from 

Black and Hispanic (but not White) patients when in-person services reopened.

Mental Health and SUD Services and the Digital Divide

Across studies and commentary included in this review, authors acknowledge a “digital divide” that 

perpetuates health disparities through technological disparities. Many communities have been left out of 

investments in broadband internet and cell service, resulting in areas where receiving telehealth at home 

is not possible, even if devices are provided. As of 2020, 22.3 percent of rural residents and 27.7 percent 

of residents of tribal lands lacked high-speed internet (Federal Communications Commission, 2020; 

Murphy et al., 2021). Even when the infrastructure is available, such as in urban and suburban areas, 

this does not guarantee access to the information technology needed for telehealth. A recent study of 

structural barriers and COVID-19 mortality by Lin and colleagues (2022) identified higher mortality rates 

in rural, suburban, and urban locations with limited internet access. Mental health and SUD treatment 

professionals operating in these areas can face the same bandwidth challenges in providing mental 

health and SUD services via telehealth for clients, and they also need to invest resources in technology 

purchases, physical space, and staff training to successfully implement telehealth programs (Kotsen et 

al., 2021; Pagano et al., 2021).

Another aspect of “access” is familiarity/fluency with the technology needed to participate in telehealth 

visits. Kotsen and colleagues (2021) found that older participants (those age 65 to 80) had the most 

difficulty successfully participating in tele-counseling for tobacco dependence and SUD. Due to their 

increased risk for COVID-19, older adults (especially those in residential or long-term care facilities) 

are most likely to be subjected to the strictest isolation protocols, making them uniquely vulnerable to 

absence of social support (Bethell et al., 2021). Rosen (2021) recommends tackling this divide precisely 

because of these vulnerabilities and the potential for benefit that virtual social support and medical care 

could provide. 
| Page 16

Limitations of Remote Services

Even for those who are able to access telehealth, there are drawbacks to a remote approach to mental 

health and SUD treatment services via telehealth that need to be weighed against the benefits of potential 

for expanded access. Hughto and colleagues (2021) warn that the intensity of treatment programming 

(such as day programs with several hours of activities) may be “overwhelming” when delivered via 

telehealth. Lack of stable housing or a private place to make calls is a major barrier (Boldt et al., 2021; 

Davison et al., 2021; Hughto et al., 2021), especially for mental health and SUD care where privacy 

concerns may be higher than for other health conditions (Murphy et al., 2021). Several authors also raise 

concerns about the ability to assess risks for violence in the home during telehealth sessions (Boldt et al., 

2021; Jones et al., 2021).

Although telehealth delivery of mental health and SUD services may be preferable to a complete absence 

of services, the vast majority of authors expressed desire to return to some in-person activity, citing 

the value of in-person connection for establishing trust with new patients (Jones et al., 2021); offering 

structure and socialization for volunteers and peer recovery specialists (Kleinman et al., 2021); and 

creating social spaces for culturally important activities that are part of the healing process, such as 

religious and spiritual practices. (Bethell et al., 2021; Wendt et al., 2021). For harm reduction services, the 

ability to offer screening for HIV and the hepatitis C virus along with offering naloxone or sterile syringes 

can only happen with in-person services (Seaman et al., 2021; Taylor et al., 2021; Wenger et al., 2021).

Limited Data on Mental Health and SUD Treatment and Service Innovations for Youth

Most of these innovations focused on mental health and SUD services for adults, or at most, young 

adults (i.e., older teens) as the primary patient. For parents of younger children, telemedicine diagnosis 

of mental or physical healthcare or SUD treatment needs is difficult, and telehealth cannot replace 

the loss of community services (Aishworiya and Kang, 2021). A review by Okuyama and colleagues 

(2021) found limited data on interventions for children and adolescents during disasters that created 

similar restrictions on school and social routines, and two other observational studies included in this 

bulletin (Perkins et al., 2021; Rosen et al., 2021) make recommendations based on survey findings, 

not implementation: strengthening routine (especially sleep hygiene) and building a sense of “social 

connectedness” (a feeling of belonging, availability of friendship) among peers (in Perkins and 

colleagues’ study, school/classmates). As with mental health and SUD interventions via telehealth, 

investments in remote learning may offer opportunities to build resilience interventions. Sarvey and 

Welsh (2021), in their recommendations for increased screening for SUD in adolescents, noted that 

increased use of telemedicine for SUD treatment may offer opportunities for more participation among 

adolescents, as it has for adults (due to access to a wider geographic range of professionals and 

elimination of the need for transportation).

Gap Between Mental Health and SUD Care and Broader Health System Highlighted by 

Pandemic Response

Finally, this bulletin provides evidence to support the importance of integrating mental health and SUD 

treatment and services into the broader system of both physical health and social support (Kelly et 

al., 2021). Pagano and colleagues (2021) briefly describe how the fragmenting of SUD treatment and 
| Page 17

services led to challenges in obtaining PPE and cleaning supplies for SUD treatment facilities. In their 

survey of MOUD practitioners in the VA, Kelley et al. (2021) cite lack of protected time for MOUD as the 

biggest barrier to providing MOUD services among practitioners who are not dedicated SUD specialists. 

Peckham and colleagues (2021) provide recommendations for leveraging community pharmacists 

to expand access to MOUD (citing precedent for pharmacists administering long-acting injectable 

medications), but note that the institutional, regulatory barriers around opioid prescriptions (ostensibly to 

monitor and reduce misuse) create disincentives to treat MOUD like other medications and SUD like other 

health conditions.

CONCLUSION

In the face of a protracted disaster such as the COVID-19 pandemic, mental health and SUD services 

displayed resiliency and creativity in adapting their services to continue providing care while reducing 

their patients’ risk for acquiring or transmitting COVID-19. For many patients, widespread adoption of 

telehealth was a welcome benefit that eliminated barriers to getting into and staying in care. For other 

patients left behind by the digital divide, seeing the same benefit will require organizations’ investments 

in technology, training, workforce, and programming. Important policy and payment changes have made 

many of these adaptations feasible for the first time, and many authors included in this bulletin expressed 

uncertainty over whether these changes will become permanent. As organizations begin and continue to 

resume “pre-pandemic” services, the most meaningful lesson learned may be that thoughtful investment 

(including building an evidence base) is the best way to build resilient, interconnected systems of care 

that improve outcomes before, during, and after future disasters.

SAMHSA is not responsible for the information provided by any of the web pages, materials, or organizations 

referenced in this communication. Although the Supplemental Research Bulletin includes valuable information 

and links, SAMHSA does not necessarily endorse any specific products or services provided by public or private 

organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed 

by such sites or organizations nor does SAMHSA warrant the validity of any information or its fitness for any 

particular purpose.
| Page 18

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