Writing in the “Points of View” section of the New England Journal of Medicine in January, Joshua A. Barocas, M.D., assistant professor of medicine at the Boston University School of Medicine and Infectious Disorders says that people with substance use disorders (SUDs) have not only be disproportionately affected by COVID-19, but are not prioritized for early vaccination, unlike people with other health care vulnerabilities. Supply chain problems involving the vaccines, first available just a couple of months ago, and personal protective equipment (PPE), available starting when the pandemic began almost a year ago, have plagued addiction treatment programs, but not general health care facilities.
Why are patients with SUDs, and treatment providers who treat them, often put at the bottom of the list for vaccines (patients) and PPE (providers)? Dr. Barocas blames stigma, often, he says, fueled by the medical profession itself. For patients, this means they distrust medicine and turn to illegitimate information, falling “prey to conspiracy theories.” Therefore, he points out, it is “naive to believe that people with SUD will unquestioningly and willingly line up for vaccinations.” Patients, as well as drug users who are prospective patients, also face structural barriers to vaccination, Dr. Barocas added, noting transportation and technology. If it’s difficult for them to obtain the first dose, it’s even more difficult to get the second, due to tracking problems and unstable housing.
Vaccine distribution happens on a state-by-state basis, and in some states, more eligible people have been vaccinated than others. This problem has been attributed to the lack of vaccine, the chaotic distribution from the federal government, and chaos within states themselves.
Support from Trump and Biden administrations
On April 23, 2020, the ONDCP clearly stated that the White House position was that SUD treatment providers “serve in a critical capacity and will require personal protective equipment (PPE) during unavoidable face-to-face patient interactions.” In accordance, then-president Trump said SUD treatment was an “essential medical service,” and PPE requested by facilities was for a “legitimate need and purpose.” This came on top of the decision to allow more flexible take-homes for methadone, a highly successful initiative (see https://atforum.com/2020/07/extended-methadone-take-homes-during-covid-nothing-but-success/) and buprenorphine inductions (see https://atforum.com/2020/03/otp-regulations-loosened-due-to-pandemic/). For those patients who did have to interact with the treatment staff, staff needed this PPE to avoid becoming infected themselves.
Staff also need to be the first vaccinated. Just as with other health care workers, who were first in line for vaccination (so that treatment staff existed for ill patients), SUD treatment staff should be vaccinated.
But what’s happening with that now? The Biden Administration is going to use the Defense Production Act to ramp up production of vaccines and PPE. This will help the logjam everywhere.
In recommendations for outpatient SUD treatment programs issued last fall, the American Society of Addiction Medicine (ASAM) urged that all screening of patients for COVID_19 be done through an app survey such as https://www.va.gov/covid19screen/ or in person by someone wearing appropriate PPE (facemask and face shield at a minimum, gown and gloves if available). All individuals entering a facility should wear a mask, and masks should be considered mandatory as long as patients are in the facility (facilities should have masks on hand to provide).
Any patient suspected of having or being exposed to COVID-19 should be placed in a private room with the door closed.
PPE is also important because it enables in-person contact between patients and staff. Quarantine is, by definition, isolating, and addiction is a disease of isolation, which itself can be a trigger for increased substance use.
More from ASAM:
While staff not providing physical care to patients should maintain distance and wear a face covering (either cloth-based or surgical mask) while in the healthcare facility, according to the CDC, the PPE to be worn when providing physical care for a patient with known or suspected COVID-19 includes:
- Respirator or facemask covering nose and mouth
- Eye protection (i.e., a disposable face shield that covers the front and sides of the face; goggles are no longer recommended by the CDC)
- Isolation gowns
Staff should be trained in the appropriate use of PPE before caring for a patient. This includes how to remove the equipment, and how to disinfect it.
Also from ASAM: Universal precautions for staff caring for patients should include at least a surgical mask or other medical-grade mask that covers the nose and mouth. A face shield, if available, in addition to a facemask, will also protect the eyes and mouth. At minimum PPE should include a surgical mask. Masks with exhalation valves or vents are not recommended as they do not provide source control of respiratory droplets. Signs in staff lounges, restrooms, conference rooms, or other common areas can help remind staff about the importance of wearing face coverings and washing hands immediately before and especially after any contact with their face covering.
Building trust in the community – patients and drug users
It’s paramount to build trust and disseminate accurate information about vaccines, said Dr. Barocas in the NEJM article. For example, listening sessions can be conducted by health professionals at local shelters, SUD treatment or detox centers, or syringe services programs. “Trusted people such as peer navigators, recovery coaches, and harm-reduction service providers could be asked to serve as vaccine ambassadors,” he wrote.
Health departments should plan to administer vaccines at opioid treatment programs (OTPs), SSPs, and AA and NA meetings, said Barocas. Vaccinating people “at places where trusting relationships exist and where people regularly obtain care will make it easier for people to receive both doses of vaccine.”
For Dr. Barocas’ article, go to https://www.nejm.org/doi/full/10.1056/NEJMpv2035709.