Clinician Wellbeing During the COVID-19 Pandemic | ASAM.org

CLINICIAN WELLBEING DURING THE COVID-19 PANDEMIC

A guide for addiction treatment clinicians and programs working to treat patients with substance use disorders safely and effectively during the COVID-19 pandemic1.

For additional recommendations for the Ongoing Management of the Continuum of Addiction Care during COVID-19, please click here.

CLINICIAN WELLBEING DURING THE COVID-19 PANDEMIC

Purpose of the document

Like many clinicians, those that treat addiction have been under tremendous stress during the COVID-19 pan- demic. They are often serving a patient population at increased risk for contracting the coronavirus and for severe COVID-19 illness, including patients with justice-system involvement and those who are unhoused. Furthermore, the COVID-19 pandemic is superimposed on an ongoing epidemic of drug overdose deaths. Clinicians are trying to balance the risks of two potentially deadly diseases, often forced to make complex medical decisions with po- tential life and death consequences without sufficient information.

While critically important, the rapid adaptations needed to ensure continued access to treatment have also added to the stress. The transition to telehealth has made a tremendous impact on access to care, but it has not been simple or easy to adapt practices to this model. In addition, residential and inpatient programs (ASAM Levels 3 and 4), have struggled to continue to provide care while managing risks for COVID-19 transmission. Many pro- grams put a hold on accepting new patients and others closed. As a result, many clinicians are working longer hours, worried about their patients, their staff and/or living with uncertainty around what comes next.

In addition, clinicians experience the same stresses and anxieties that are affecting much of society. They are wor- ried about their own risks for severe illness or potentially bringing the virus home to their families and others in their lives. Many are coping with childcare, home schooling issues, elderly parents in nursing homes, or the effects of social isolation. The social unrest happening across the country has exposed the stress already felt by some on a regular basis. Clinicians operating with reduced internal and external supports are at risk for burnout, which can have significant detrimental effects on the individual clinician’s wellbeing and their ability to provide effective pa- tient care. It is essential that clinicians, treatment facilities, programs and healthcare systems take steps to protect clinician wellbeing during this public health crisis and beyond.

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Updated: 09/18/20

Topics

Reopening

While many places across the country are starting to relax physical distancing restrictions, the COVID-19 pandemic is not over. Communities and treatment programs across the country remain at risk for increasing population prevalence over time.

Clinician burn-out was already a significant issue prior to the COVID-19 pandemic. Over the several months since COVID-19, many clinicians across the country have been working longer hours, under increasingly stressful circumstances, to adapt their practices to protect their patients and colleagues from coronavirus transmission and support continued access to quality addiction treatment. Many are wondering how much longer they can keep up this pace.

Simultaneously, many clinicians who were not practicing in specialties directly related to treating COVID-19 and its manifestations were either side-lined or re-deployed into more primary intensive hospital medicine practice by their health systems. Many, including addiction treatment specialists, have felt the implication that their specialty is considered ‘less important’ as facility resources were re-purposed. And many clinicians who were laid off during their community’s surge face financial as well as professional identity issues.

Addiction treatment clinicians, particularly those who entered the field prior to the opioid crisis, have long been in the position of caring for patients who are undervalued by society, providing care that was not financially valued and under outdated regulations that created significant clumsiness in the delivery of care. Witnessing patients being stigmatized by other practitioners, health care systems, and insurers, contributes to moral injuries that lead to burn out. Additionally, as our country goes through a paroxysm of reckoning with racial and ethnic injustice, physicians treating SUDs may have a special view of the backlash against marginalized populations. Addiction treatment clinicians should be encouraged to share their own experience of racial, ethnic, and/or gender identity discrimination without fear of retaliation.

Many clinicians are struggling to cope with the stress, exhaustion and ethical burden associated with making clinical decisions outside of their normal practice pattern and balancing the risks a given patient is facing from both addiction and COVID-19. Healthcare system leaders and individual clinicians each have a role to play in addressing these burdens to maintain the highest possible level of both clinician well-being and clinical care, regardless of the size or complexity of their practice structure. Supportive leadership, team cohesion, and training can make a profound difference in how clinicians respond to periods of extreme stress. (See the section on Building Resilience in Healthcare Teams).

Resources

Individual clinicians have responsibility for managing their own psychological and physical health. This involves self-monitoring and ‘intervening’ as necessary through self-management techniques and reaching out to others for help when needed. Seeking support from others is especially important when these common but difficult feelings begin to feel overwhelming.

During this pandemic, clinicians are dealing with many challenging situations that can lead to difficult feelings. For example:

  • Fear: Clinicians have many legitimate fears related to COVID-19, including fears:
    • For their own health.
    • Of transmitting the disease to their family members.
    • Of redeployment to a care setting they do not feel comfortable practicing in.
    • Of losing their job (with financial and multiple other ramifications).
    • Of losing their program.
    • Of losing their life’s work.
    • Of losing their patients to worsening addiction disease, COVID-19, or to violence in the community and/or in the streets.
    • Of worsening addiction in their communities due to social isolation or worsening racial injustice.
    • Of return to pretreatment use in those they treat.
    • Of who will take care of their patients if they get COVID-19.
    • For the future as more is learned about this virus and our system's responses.
  • Uncertainty: Many people, including clinicians, would like reassurance that “things are going to be okay”. But we still do not have enough data to accurately understand the risks for ourselves, our families, or our patients.
  • Isolation: The physical distancing measures taken to reduce the spread of the novel coronavirus increase social isolation during a time of particularly high stress.
    • Clinicians may have reduced contact with their peers.
    • Isolation is a hallmark of increased risk for substance use including risky use and substance use disorders
    • Some staff working from home may be craving contact.
      • Managers should consider rotating in person time for critical tasks to reduce isolation and create opportunities to serve an important purpose.
  • Demoralized: At the height of the COVID-19 crisis many healthcare systems deprioritized addiction care. Some hospitals shut down their addiction treatment units, some withdrawal management and treatment programs either temporarily closed or stopped taking new patients. Some clinicians felt the implication that addiction treatment and patients with addiction are less important – that their work was deemed less important than that of other physicians. Addiction clinicians have spent decades fighting the stigma against addiction within the healthcare system, establishing the legitimacy of addiction medicine. Some may wonder if we will be able to regain footholds we have made in our systems. This is especially true when considering other specialties like cardiovascular medicine where campaigns were created to encourage people experiencing symptoms of severe disease like a myocardial infarction to appropriately engage with the healthcare system.
  • Stress: Many different sources of stress exist during this crisis. For example:
    • Increased work demands.
    • Rapid changes in clinical care (i.e. the transition to telehealth).
    • Home stressors:
      • How to protect their loved ones, particularly those at high risk.
      • Childcare.
      • Managing home schooling.
      • Caring for elderly parents and spouses.
      • Being there for your children and other loved ones in a time of high stress.
    • Disintegrating barriers between home life and work life.
      • Not having the daily structure of the office.
      • Lack of cues for when breaks are needed.
      • Having work confrontations in spaces that are intended to be peaceful and safe.
        • Bearing witness to the trauma in patients’ lives in those safe spaces may feel like a violation.
    • Clinical trainees – including students, fellows, and residents – may be concerned about their ability to do rotations. This pandemic may impact their education, training, and career trajectory.
  • Guilt
    • For not being on the front lines.
    • For negative outcomes among their patients.
    • Feeling like they are not giving their best clinical care.
  • Grief:
    • Over the loss of patients.
    • Over the loss of loved ones.
    • Over the loss in income, professional role, or practice.
    • For their community, their country, and the world.
  • Frustration or anger over forced changes and limitations beyond their control.

Things to Consider

  • Allow yourself to experience and express these feelings, including grief.
  • Peer support can relieve the sense of that these feelings are abnormal or the sense that others are coping much better with this extraordinary stress.
  • Communicate your needs to your managers and organizational leaders.
  • Make time to engage in the things you need to meet your physical, emotional, and spiritual needs.
  • Make time to engage in activities to relieve stress.
  • Seek help for COVID-19 related mental health problems
    • Consider accessing your Employee Assistance Program (EAP)
    • To find a mental health treatment provider try:
      • A referral from your primary care provider
      • A referral from your health plan
      • For those without health insurance, the SAMHSA Treatment Locator: https://findtreatment.samhsa.gov/locator
      • For those without insurance, contact your state’s Department of Health and Human Services
    • Share your experiences with your peers to normalize seeking help.
    • For clinicians who have or who have recovered from COVID-19, consider that there is brain involvement that may contribute to new or worsening psychiatric symptoms.
    • If you are feeling suicidal, contact the National Suicide Prevention Lifeline at 1-800-273-8255

During this crisis you may be forced to practice in ways with which you are not comfortable. You may need to make medical decisions with potential life and death consequences with insufficient information, choosing between alternatives with differential risks related to addiction vs. COVID-19. Unless there are enough resources to meet the medical needs of every patient and community, you may have to make difficult decisions about how to allocate scare resources. Some clinicians are uncomfortable with more transparently making these rationing decisions. You may feel like you are not able to provide care that is consistent with your ethical preferences. It is not un-ethical care to do the best we can with the resources available, but the change in resources and resource demands are likely to bring about strong and difficult feelings, and internal conflict.

Medical care in the U.S. has been moving from an ethical framework of “do everything possible for the patient in front of you” to a “population based” healthcare ethic in the past few decades. Under conditions of disaster, this more utilitarian ethic may rapidly be deployed and expanded, including using disaster triaging measures. Understanding that this practice is not an ‘immoral’ approach, but a different ethical framework, may be helpful. However, it is also important to understand the additional stress this places on clinicians.

Good decision making is not determined by the outcome – it is determined by the processes used and whether the relevant factors have been considered. When you decide between two alternatives that each have risks for the patient, it cannot be known what would have happened had the alternate been chosen. As with all serious medical decision-making, the most robust processes can still lead to significant moral distress because of the complexity of these decisions and the gravity of the consequences.

Things to Consider:

  1. Having a consistent approach to medical decision-making helps provide fairness and reassurance for physicians, patients, and staff.
  2. Include trusted team members to provide feedback on difficult decisions.
  3. Participate in informal consultations with colleagues, including ongoing activities such as Project ECHO or other interactive group education where feedback is given on individual cases or medical decision-making approaches during COVID.
  4. As this crisis evolves, we must learn from the natural experiments that are taking place. Case studies and quality improvement projects will help to guide our decision making as we move forward.

Early data suggest that there has been a large increase in drug overdose deaths during the COVID-19 crisis. Clinicians in communities with high infection rates may also be coping with the death of patients due to COVID-19. They may themselves have lost family members or loved ones to COVID-19. It is important to take the time to grieve and to seek out support if you need it.

Things to Consider:

  • Be aware of your own grief cycle.
  • Share your grief with your team.
  • Grieve with any family members that you are in contact with.
  • Be open about feelings of loss.
  • Ask for help if you need it.
  • Connect with peer support.

The unique factors of grief connected to COVID-19 crisis may include: being unable to be with a loved one when they die, or unable to mourn someone’s death in-person with friends and family.

Resources:

If you have lost a loved one during the COVID-19 pandemic https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/stress-coping/grief-loss.html

Stress, anxiety, and social isolation are all risk factors for return to pretreatment use, including for clinicians in recovery. The profound stresses and challenges clinicians are facing in addressing the COVID-19 crisis may be challenging even for those in long-term stable recovery. Clinicians in recovery should consider:

  • Checking in with their care provider more frequently.
  • Accessing more support, including peer support.
  • Find ways to unplug and get distance from the news.

Research has shown that professionals with frontline experience responding to disasters experience less post-traumatic stress disorder if their teams are characterized by high levels of camaraderie, supportive leadership, and good on the job training for the task. (See Peer Support in Health Care and Prevention: Cultural, Organization- al, and Dissemination Issues: https://pubmed.ncbi.nlm.nih.gov/24387085/)

Support and understanding from peers and other team members who are experiencing similar challenges can be a powerful source of resilience. Leaders and managers of healthcare organizations should focus on strengthening teams (which may be defined as either multi-disciplinary or single-discipline groups) by:

  • Encouraging team members to share difficult feelings.
  • Acknowledge that people cope with stress in different ways; let team members tell you what they need.
  • Let team members know that they do not need to make challenging decisions on their own; Encourage them to consult with one another on difficult decisions.
  • Continue to hold daily scrum meetings.
    • Increasing interactions among both health care team members and intradisciplinary providers is important.
    • Staff need consistency even in a rapidly changing environment, even if only a consistent approach to stressful situations.

Team leaders at all levels set the tone for the rest of the team and serve as role models in acknowledging and responding to stress. Leadership within every discipline – administrative, medical, clinical, nursing, pharmacy – have a responsibility to provide support and guidance during stressful and difficult times.

Things to consider:

  • Ensure alignment among system leadership (administrative, medical, nursing, all levels of care within the specific system). A lack of consistency across leadership in guidance and messaging will undercut efforts to provide support.
  • Leaders with well-functioning teams are more effective in giving permission to share feelings and ask for help.
    • It is often more effective and efficient to provide this type of support through a team than on an individual basis.
  • Encourage clinicians to get help for COVID-19 related mental health problems. It is important that leaders provide consistent, honest messaging – acknowledging uncertainty.
  • Demonstrate a commitment to healthcare worker safety.
    • While SAMHSA has stated clearly that addiction treatment clinicians and programs are essential health services and therefore should have access to personal protective equipment (PPE), there are multiple reports of addiction treatment clinicians without access to PPE.
    • Lack of PPE and test/track/isolate capacity puts workers at risk, particularly those who must come in close physical proximity to patients at risk for or with COVID-19.
    • Acknowledge the risks to clinicians providing care, the challenges to providing the safest possible working conditions, and legitimize feelings of fear while transparently and proactively improve policies and procedures to ensure safety.

Changes in delivery of health care services can be uncomfortable for clinicians, particularly when these changes are happening rapidly with insufficient evidence to guide decision making. However, this is necessary in periods of disaster. In these circumstances, clinicians need to do the best they can with the resources and knowledge available. Providing trainings is important for ensuring clinicians in your system have the most up to date knowledge on what is known, as well as what is not known, and where they will need to rely more heavily on their clinical judgement.

Things to Consider:

  • Hosting regular trainings.
    • Bring in local experts in infectious disease and other relevant topics.
  • Incorporating case reviews into daily meetings.
  • Providing updates and trainings in multiple different formats and storing materials where they are easily accessible.
    • Repetition is important.
  • Acknowledging that things are changing rapidly; guidance used yesterday may be out of date today.

Peers in the workplace can provide a supportive environment for healthcare providers to share common experiences and normalize the reactions to them. This reassurance can improve the individual’s response to challenging situations. Peers may also help identify those who are not doing well emotionally, perhaps more effectively than standardized screening tools. Referral and connection with treatment may also be more effective when implemented by peers. (See Managing Traumatic Stress: Evidence-Based Guidance for Organizational Leaders and Guidelines for Peer Support in High-Risk Organizations: An International Consensus Study Using the Delphi Method).

Things to Consider:

  1. Every clinician is making do with the limited information we all have.
  2. Localities, practices, and states differ – so what may be appropriate in one area or practice may not apply in another.
  3. When choosing between two opposing actions we will not be able to know what would have happened if we made the other choice.
  4. Physicians are as vulnerable to the impacts of the pandemic as anyone else – we are not superhuman.
  5. There may be value in both types of peer support services – those which are focused on interdisciplinary teams and those which are focused on those with specific roles (e.g. nurses, physicians, non-medical positions such as counselors or therapists, etc.)

This resource was developed by a Task Force appointed by ASAM’s Executive Council. To enable more rapid development and dissemination it was not developed through ASAM’s normal process for clinical guidance development that is overseen by the ASAM Quality Improvement Council.

CONTENT DISCLAIMER

This Clinical Guidance (“Guidance”) is provided for informational and educational purposes only. It is intended to provide practical clinical guidance to ad- diction medicine physicians and others caring for individuals with substance use disorders during the COVID-19 pandemic as it unfolds. Adherence to any recommendations included in this Guidance will not ensure successful treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results.

The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances pre- sented by the individual patient, and the known variability and biological behavior of the medical condition.

This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies may require revisions to the recommendations in this Guidance to reflect new data. ASAM does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.