Treatment for people who use drugs is provided in a wide range of settings worldwide including community-based settings (clinics, health care centres, primary care, community pharmacies, ambulatory withdrawal), inpatient settings (hospital consultation-liaison services and inpatient withdrawal) and residential settings (withdrawal and rehabilitation). Internationally, services may be operated by state or national health services, non-to-profit organisations or private providers. In some jurisdictions, travel over long distances may be involved for people accessing care.
Opiate agonist (methadone and buprenorphine) treatment
Opiate agonist treatment requires significant resources due to the known risks of non-medical use of methadone including injection and overdose. Apart from buprenorphine treatment in the USA and France, many other countries’ opiate treatment system is based on supervised daily dosing as default, both for methadone and buprenorphine, with non-supervised or take-away doses being provided to stable patients assessed as being at reduced risk of non-medical use of these medications.
Given the need to provide treatment in many countries where home isolation is now very critical, planning alternatives to daily supervised dosing is important and imposes a major challenge. This is the case since daily supervised opiate treatment may involve significant waiting periods for patients, including people having to wait in queues for extended periods of time; and social distancing may not be practical due to the size of waiting areas and the number of patients.
Considering these issues and the availability of new long depot formulations, key strategies to best utilise resources during the COVID-19 pandemic is impacting on health services are the following:
Providing depot buprenorphine (e.g. Buvidal weekly and monthly and Sublocade) rather than daily supervised sublingual buprenorphine dosing or methadone dosing;
Providing additional take away (non-supervised) doses of both buprenorphine and methadone.
There are important safety advantages of buprenorphine over methadone with regards take away or non-supervised doses, as has been seen in France compared to other countries in Europe . Ideally, buprenorphine may be provided as buprenorphine-naloxone to minimise use by injection. While providing additional methadone take-away doses carries individual and public health risks, these can be minimised by ensuring access to take-home naloxone programmes with naloxone by nasal spray, pre-prepared injection or ampoules of naloxone. Hence, access to take-home naloxone programmes should be rapidly expanded.
Using a risk framework, in combination with assessing the level of patient treatment needs, is one method for stratifying current treatment needs, including the need for supervised OAT dosing. Patients on OAT may have high-level, moderate or low-level treatment needs. This system may assist in deciding the frequency of supervised OAT doses and take-away doses for individuals .
It is possible that other providers of opioid treatment, for example, general practitioners and community pharmacies, may not be able to continue to provide opiate treatment throughout the COVID-19 pandemic, due to the need to screen and treat SARS-CoV2, staff illness, or to reduce unnecessary congregation (e.g. in shopping centres or general practices). In this case, state-operated public clinics may be required to enhance their capacity to rapidly assess and treat opioid-dependent patients who can no longer be treated in primary or community care.
Further, additional issues may be faced by patients who must self-isolate for extended periods of time (e.g. 14 days). This, in turn, may require delivery of take-away doses to patient homes, presenting infection control challenges for staff (for example, can we obviate the need for patients to sign that they have received delivery of take-aways by using other means such as a photograph of a patient taking receipt), routine approaches to risk assessment for home visits (as in general, the delivery will not require entry into the person’s home) and ensuring staff as well as patient safety during this period.
OAT service provision in custodial settings may fall under extreme pressure during the COVID-19 pandemic. Many prisons are over-crowded and may struggle to ensure social distancing during this period. Further, it is possible jails may impose ‘lock-downs’ to further limit movement of for security reasons during the pandemic. Daily supervised dosing of methadone and buprenorphine may not remain possible at this time. Transfer to depot buprenorphine should be considered as a way to mitigate this risk and ensure ongoing OAT for people in custody.
Withdrawal services for people who use drugs may also need revision during the COVID-19 pandemic. Withdrawal services may experience additional demand, as people in the community experience interruptions to their use because of reduced supply.
In face of such large scale and unprecedented pandemic prioritised use of intensive and more costly inpatient services should be considered and used only where there is significant medical risk (e.g. risk of severe alcohol withdrawal or alcohol withdrawal seizures or benzodiazepine withdrawal seizures), mental health risk (e.g. significant deterioration of mental health problems) or lack of a suitable home environment to support ambulatory withdrawal. Some hospital inpatient units may be re-purposed by acute hospitals for use as respiratory or other overflow wards. If this is the case, where appropriate, ambulatory withdrawal services should be encouraged to avoid unnecessary admissions and patient congregation in residential or inpatient services. This imposes extra challenges to withdrawal services as additional resources in order to function adequately might be required. As possible measures to be implemented, the use of daily staged medication supply (i.e. daily dosing) during withdrawal should be reconsidered to reduce unnecessary patient travel/attendance at hospital and community pharmacies. In addition, alternative approaches such as increased telephone monitoring and use of carers in the treatment process (e.g. holding medications) may be required. Where opiate agonist treatment can be provided, this should be offered to patients in preference to short-term withdrawal treatment from opioids.
Relapse prevention medications
Certain treatment models such as the use of disulfiram for alcohol dependence have often been based upon regular attendance at a clinic for monitoring and supervised dosing. Alternative arrangements with increased use of carers, telephone or videoconferencing and monitoring should be explored to reduce the need for travel.
Hospital drug and alcohol consultation-liaison services
Hospital consultation-liaison (CL) staff may need additional resources to assist emergency departments and acute hospital units in response to COVID-19. Acute services will have to prioritise screening, assessment and treatment for people presenting with respiratory symptoms. Reducing service demand by ensuring people who have acute substance-related problems are efficiently managed (e.g. early management of alcohol withdrawal to prevent complicated alcohol withdrawal/alcohol withdrawal delirium for those at risk) may require an expansion of hospital CL services. Also, avoiding multiple re-presentations of people who use substances and present to hospital emergency departments may be another principal task for CL staff as well as hospital avoidance programmes for people, where these exist.
Counselling services for people who use drugs may experience changes in demand, either increase or decreases during the COVID-19 pandemic. Counselling services could relatively easily be re-oriented to provide non-face-to-face (i.e. telephone/videoconference) services where possible to minimise patient needs to travel, contact with staff and time in waiting rooms. If there is a reduction in demand for counselling services, these staff may be considered for secondment part or full time to other parts of the service requiring additional staff (e.g. in opiate treatment under surge conditions and providing additional telephone assessment services to assist intake services in meeting demand).
Group counselling should be restricted for only a limited number of participants to facilitate social distancing, or alternately, groups should be cancelled.
Minimising the risk of blood-borne virus outbreaks during the COVID-19 period is a priority. Ensuring people who inject drugs continue to have access to clean injecting equipment and other harm reduction services is important. As the demand may increase, services should be prepared to ensure needle syringe and other product availability by providing bulk numbers of needles and syringes (e.g. requests for large supplies 100 syringes and other sterile injecting equipment). Where face-to-face services cannot be provided, vending machines are an efficient method to maintain service delivery around the clock with reduced staffing requirements.
Current harm reduction policies/strategies should be updated and extended so appropriate harm reduction advice can be provided to reduce the spread of COVID-19 and to reduce the consequences of erratic drug markets and supply (e.g. sharing of equipment or drugs such as glass pipes, joints, water pipes (‘bongs’), cigarettes, cash, and straws for ‘snorting’ drugs). Harm reduction services could encourage good hand hygiene by providing patients with education and use of soap and water or hand sanitiser if hand washing is not possible. Hygiene around drug preparation (prepare own drugs) and handling of balloons/baggies (avoiding internal concealment) as well as handling of money should be promoted. As an example of peer harm reduction information, see the INPUD website .
Further, opiate users may be at increased risk of overdose given the respiratory impact of SARS-CoV2. People who use opioids could misinterpret SARS-CoV2 flu-like symptoms, including fever (with sweats), aches and pains and fatigue as symptoms of opiate withdrawal. These issues combined could increase overdose risk during this pandemic. People who use drugs by smoking/inhaling may need to consider changing their route of administration (e.g. snorting or rectal use) to reduce the risk of respiratory impact of substance use.
Extended access to take-home naloxone should impose as a key element to be implemented as the risk of opioid overdoses is largely increased due to the current circumstances and described impact in people treatment modalities and access.
Principles to inform adjustments to D&A services in the face of an impending pandemic include the following:
Staff health and welfare. Critical to service continuity for D&A services is to work with frontline staff to ensure that they are supported to continue working, comply with policies to not attend work, home-isolate and be SARS-CoV2 tested if they have respiratory symptoms or meet the criteria for a suspected case. Ensure adequate supplies of personal protective equipment, examine measures to limit staff face to face contact with COVID-19 cases where possible, provide videoconference consultations and avoid travel (e.g. via airports) that expose staff to greater infection risks, identify staff with particularly increased vulnerabilities (pregnancy, chronic diseases, advanced age) and consider redeployment. Staff who live with family at high risk are also presented with the challenge of potentially self-isolation at home or being unable to return to their homes. There is considerable ‘COVID-19 anxiety’ and staff frustration with cancellation of leave or the imposition of additional duties. Consideration of opportunities to improve staff welfare should be a focus where possible particularly if the pandemic becomes protracted. Monitoring of the health of health care workers is important. A study of health care workers in Beijing, China, that followed up staff who worked during the SARS epidemic in 2002/2003 identified an association between health care workers who worked in high-risk locations, such as SARS wards, and subsequent PTSD or alcohol use problems .
Clear communication. Draw on established risk communication principles to keep patients and staff informed as trusted partners . Communicate early, with clarity and transparency, acknowledge current problems, discuss achievements with humility and pay attention to expressed and unvoiced concerns. Ensure communications have a clear call to actions required, as well as what D&A services are doing to manage risk and ensure business continuity.
Early intervention. The earlier that strategies are enacted to reduce SARS-CoV2 transmission and exposure for both patients and staff, the lesser impact services are likely to experience, enabling service continuity and managing fear and anxiety.
Social distancing, reduced congregation and hygiene/infection control enhancement. The rationale for this is to reduce the risk of community transmission via confirmed/unconfirmed case contact during this pandemic. This strategy reduces the effective reproductive rate of the pathogen . The principles for this include culture change in terms of standard precautions for infection control, limiting unnecessary gatherings, analysing root causes to prevent congregation and enhance movement of patients through a service. Alternative approaches to service delivery including patient contact by telephone or videoconferencing will reduce the need for travel and reduce the risk of congregation.