<p>The behavioral health impacts of COVID-19 on individuals are well-researched. Vulnerable populations that already experience behavioral health disparities, including rural communities, were hard-hit by COVID-19. Rural areas lack robust behavioral health systems, and are forced to create de facto systems, cobbling formal behavioral health with other formal and informal services. This study used syndemic theory, concerned with interactions of multiple epidemics in combination with underlying social and economic drivers, to examine the impact of COVID-19 on de facto behavioral health systems in six rural Georgia counties. This project was part of a larger study examining perceptions of opioid misuse in rural areas. Six focus groups were held with key stakeholders, and a thematic analysis of transcripts was completed. We identified five themes: 1) COVID-19 highlighted/exacerbated existing problems; 2) COVID-19 disrupted effective services; 3) COVID-19 disrupted communication among providers; 4) Dedicated work continued during COVID-19; and 5) Significant post-COVID-19 implications exist for these systems. In sum, our findings revealed a potent syndemic of opioid use and youth behavioral health problems, and drivers of poverty, isolation, and lack of resources, with COVID-19 as the “straw that broke the camel’s back”. COVID-19 increased demands on already-taxed systems and forced separation among providers who had crafted tenuous behavioral health systems through communication and collaboration. Although impacts of COVID-19 on rural behavioral health systems will be long-lasting, our analysis also revealed systems’ resilience and creativity, as well as potential for partnership to address the syndemic-exacerbated need of rural behavioral health systems.</p>