Make sure you have enough medication. Follow infectious disease protocols. Protect your workforce and patients.
These are some of the recommendations from the American Association for the Treatment of Opioid Dependence (AATOD) on how Opioid Treatment Programs (OTPs) should respond to coronavirus/COVID-19 in their facilities. The guidance, issued March 20, came at the end of a week of notices from the Substance Abuse and Mental Health Services Administration (SAMHSA), loosening restrictions on take-home doses of methadone, and on other rules for OTPs (see separate story).
Maintain Adequate Supplies
Take stock of your medication needs. With more patients taking advantage of take-home doses, you’ll need to have more medication available. You’ll also need enough medical supplies on hand.
Also see CDC guidance: Steps Healthcare Facilities Can Take Now to Prepare for COVID-19, and Interim Guidance: Public Health Communicators Get Your Community Ready for Coronavirus Disease 2019 (COVID-19).
Follow Infectious Disease Control Standards
OTPs already have standards for infection control, but these should be maintained throughout all public access points, AATOD urges. This includes:
- Using clean water when mopping floors
- Making sure all patient and staff bathrooms are equipped properly (soap, water, towels/drying equipment)
- Making sure hand sanitizer is available
- Posting federal, state, and local advisories
- Thoroughly cleaning tables, counters, and all surfaces
- Ensuring that enough cleaning supplies are in your inventory
Protect the Workforce and the Patients
To protect the OTP workforce, you should:
- Screen patients and visitors for symptoms of acute respiratory illness (eg, fever, cough, difficulty breathing) before they enter your health care facility.
- Ensure proper use of personal protection equipment (PPE). Health care personnel who come in close contact with confirmed or possible cases of COVID-19 should wear N95 masks when possible. This is not as easy as it sounds. Masks and gowns are just part of PPE. Explore different strategies if necessary.
- Sick employees should stay home. This means anyone who has a cough or shortness of breath. Your sick-leave policies should be flexible.
- Separate patients who have respiratory symptoms so they are not waiting among other patients seeking care. They should wait in a separate, well-ventilated area.
- Use telephones to deliver messages to incoming callers about when to seek medical care at your facility, when to seek emergency care, and where to go for information about caring at home for a person with COVID-19.
- Adjust your hours of operation to include telephone triage and follow-up of patients during a community outbreak.
- Use telephone and video conferencing.
Consider Testing Patients for SARS-CoV-2
Many OTP patients are already susceptible to infection by the virus that causes COVID-19, because of immune system issues, HIV, and other problems. OTPs should consider testing patients for the virus, once the test becomes available. This is especially important for patients who are older, or pregnant, or have a history of respiratory or cardiac disease, diabetes, or other chronic illnesses.
It may be “prudent” to test staff who are in high-risk categories, said AATOD.
It is recommended that oral fluid toxicology testing be suspended.
Patients with positive test results should be provided take-home medication, using the exception process carved out by SAMHSA, in coordination with the State Opioid Treatment Authorities (SOTAs). SAMHSA now permits blanket exemptions in states with declared emergencies. In states that have not declared emergencies, SOTAs can obtain blanket exemptions as needed, but OTPs need to communicate with their SOTA.
Staff members who have positive test results should be sent home under self-quarantine for 14 days, unless they require medical intervention.
Follow SOTA Instructions for Curbside Dosing
Symptomatic patients can pick up medication without coming into the facility, but only in accordance with your SOTA’s instructions. Suggestions for how to do this, from AATOD:
- The nurse can prepare the dose, put it in a locked box, and dose the patient outside the clinic area.
- Employees can prepare take-home doses consistent with your clinic protocols, and provide them to patients.
- For patients you deem ineligible to manage take home doses safely, consider identifying a patient’s family member or stable support. Then, with the patient’s informed consent, educate that person about safe storage, chain of custody procedures, and dosing instructions for administering the patient’s dose.
Follow Guidelines for Take-home Medications
Many patients in treatment are not clinically stable, and that is why they visit 6 or 7 days a week to get their medications. However, programs may consider staggered dosing days, and limiting the number of patients in waiting areas. Also, practice safe social distancing whenever possible. As states and cities impose curfews, programs will need to follow their guidance as well.
Take care if providing substantial amounts of take-home medications to unstable patients. “As a reminder, we are still in the midst of a changing opioid epidemic, with many opioid-related overdoses each day,” AATOD notes. If unstable patients are being given take-home medication, they should also be given access to Narcan (naloxone) kits. Some states or counties may have rules about OTPs passing out naloxone; and this will present challenges.
There are considerations regarding reimbursement that should be discussed with the SOTAs. If a patient was coming in 6 days a week and is now coming in every 14 days, you will be losing income. SOTAs are working on this. However, protecting public health, patients, and staff comes first, AATOD notes.
Medicare, however, will reimburse OTPs for up to 28 take-homes. This is not true with Medicaid, because states create their own policies. “My colleagues are working with their state systems to determine if they will expand reimbursement as they provide more take-home medication,” Mark Parrino, AATOD president, told AT Forum. “It is too early to tell,” he said, on March 23. “I will continue to be in contact with my board colleagues, and will provide a system-wide update once I have reliable information.”
The Addiction Technology Transfer Centers (ATTCs) are assisting with communication. “We will be working with the ATTCs, and they will set up a network to track frequently asked questions from the field,” said Mr. Parrino.
In the Trenches in NY
Meanwhile, in New York, OTPs are looking carefully at the take-home provisions. Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA), told AT Forum that this is a “balancing act.”
“The guidance is pretty clear that can’t just take someone who is getting a daily pickup and give them two weeks” of take-homes, she said. “That is an enormous amount of medication to give someone. Even in this situation, you can’t go from 0 to 100. There’s no logic behind that.” What Schorr does in her clinic is to increase take-homes by 50%. So a patient who is getting a 14-day supply now would get a 28-day supply. Someone who is coming in 6 days a week would come in only 3 days a week. “That’s a big-enough change.”
The fear, of course, is not only diversion—it’s that the patient might take too much and overdose. So it’s up to the OTP to decide how to manage this balance.
As for PPE, there was not enough personal protective equipment as of March 23. “We do not have enough masks, certainly not in New York City and the immediate hot-spot areas,” said Ms. Schorr.
SAMHSA has 8-point criteria for making take-home decisions, but in many cases, the patients won’t meet all the criteria and still be eligible for take-homes under this new system. “It’s a matter of the clinician taking a look and making a judgement call,” said Ms. Schorr. “Few people meet those criteria. It’s just not human, it’s so cut and dried.”
Ms. Schorr would like to see the overall system be more supportive of stable patients. The increase in take-homes is a step in that direction.
But Ms. Schorr said that unstable patients are the ones to worry about. “The bigger fear that I see on the horizon is going to be the patient who has been exposed and has to be isolated; how do we get the medication to them? The system is not set up for that.”
The New York City Department of Health said there are about 15,000 potential methadone patients in that category—needing to be isolated, and needing medication. That is half of the total methadone patient population of the city. “There’s going to have to be some kind of methadone van, but with that kind of volume, this is beyond the scope of what our providers can do,” said Ms. Schorr. “We don’t have this kind of resource. I believe this is something that will have to come from outside agencies, and must be coordinated on a broader level. We’re going to need some kind of help, maybe from the National Guard.”
For SAMHSA’s 8-point criteria for take-homes go to https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/dear_colleague_letters/2008-colleague-letter-unsupervised-take-home-doses-opioid-treatment.pdf