Update: Coronavirus at Opioid Treatment Programs

 

 

It’s only Wednesday but it feels like the week should be over already.

Our opioid treatment program is making sure that our patients know that as a healthcare facility, we will be open, and that we have enough medication to treat everyone as usual. Federal officials have stated that no shortages of methadone or buprenorphine products are expected. I hoped we have relieved patients’ worries with these reassurances. They will not be abandoned.

But treatment may look a little different.

On Monday, our OTP instituted social distancing by placing chairs in our lobby at least six feet apart. Someone in administration (not me) decided to let only ten people into our building at a time, while the rest stood in a line outside, standing at least six feet apart from each other. It wasn’t terribly cold that day, but some patients were uncomfortable and not prepared to wait in cold weather. Thankfully our forecast is for warmer temperatures this week. There was a little grumbling from a few patients about waiting outside in the cold. But more patients thanked us for taking precautions to reduce their risk.

Over the weekend, I decided, with input from our nurse manager, that I would no longer ask patients dosing with buprenorphine to wait in our lobby until dissolved. Since I recently found out that most other North Carolina OTPs already allow patients to place their buprenorphine dose beneath their tongue and leave before the dissolving process is complete, I thought it was reasonable to suspend observed dissolving of buprenorphine for now, until the risk of Coronavirus in gone.

Ten days ago, I sent in a bunch of exceptions for medically fragile patients whom I felt were stable enough for advancement of levels, so at least that issue was already resolved. Some medically fragile patients aren’t safe for extra take home doses, so we decided that when they come to the opioid treatment program, they get expedited dosing. This means they go to a separate area to wait, away from other patients, to reduce risk of virus transmission.

I worked a normal day on Monday, and did only one admission, which was a little slow. But I was able to do a few yearly physicals on established patients, and saw more patients for follow ups, dose adjustments, and the like. Between each patient I washed my hands with soap and water (we were nearly out of hand sanitizer) and wiped down the patient’s seat, my desktop, and door handles with Sani-wipes. In my few spare moments I paced the lobby and wiped down every doorknob I could find. I chatted with patients and all of them seemed to be calm, handling the situation well.

We had case staffing as usual, after closing at our usual time. We sat at least six feet from each other and talked again about plans to do some blanket exceptions for take homes for patients meeting certain stability criteria.

Over the weekend, SAMHSA issued statements to guide decisions about advancing take home doses, particularly for patients who are diagnosed with COVID, to help us make sure they get their usual medication despite being put into isolation either at the hospital or at home. They made it clear that previous barriers would be suspended to allow for continued care.

Then yesterday, our state SOTA also helped, both by issuing statements and holding a conference call. It was a very well-attended conference call; I think nearly all our state’s OTPs had representatives on that call. Requests for exceptions for extra take homes were discussed, as was the option of doing counseling sessions on the phone or some sort of teleconferencing. Our OTP’s previous decision to suspend group counseling to reduce risk of viral transmission was supported by our state officials, which made me feel better.

Later yesterday, I was on a conference call with the medical director of our company, and he crafted some blanket exceptions which were submitted to our state’s SOTA today and were approved. Starting tomorrow, we have permission to implement plans to give reasonably stable patients extra take home doses. These will have to be phased in over the next week, and the number of extra doses varies, depending on how long the patient has been in treatment and overall stability.

We are giving a lot of extra doses to patients. Even though I think it’s the right thing to do in order to reduce our patients’ risk of contracting COVID19, it makes me nervous. I don’t want to lose a patient from a methadone overdose from inappropriate consumption these take home doses, either.

So far, there are no positive COVID tests in our county. This isn’t because we have all healthy citizens, but rather because patients aren’t being tested unless they have traveled to a high-risk area or have known exposure to someone with a confirmed COVID diagnosis. People with only cough or intermittent fever aren’t being tested. They are being told they don’t meet criteria for testing. You can read more about this nationwide dilemma here: https://www.theatlantic.com/science/archive/2020/03/who-gets-tested-coronavirus/607999/

Medical professionals in this area don’t have enough test kits yet. We won’t know how many infections we have until symptomatic people can get tested. And what do we tell people with symptoms but no test? Should they isolate themselves? For how long? Word has it that our county is expecting to get test kits soon, so this situation will (hopefully) resolve soon.

We ran out of hand sanitizer yesterday. But this was no problem. This being Wilkes County, famous for home brew and moonshine, my Program Director decided to make her own. As it turns out, there are simple recipes on the internet to make hand sanitizer. All you need is some aloe vera gel and rubbing alcohol, or ethanol, and mix them together in a certain ratio to form hand sanitizer. She poured her concoction into empty sanitizer containers and they worked well. The alcohol content is adequate (more than adequate by the smell) to do the job. One problem solved, at least.

She’s inspired me. I like to do crafts, so I think I will make some fabric face masks over the weekend.

We will get through this. For however long this contagion lasts, we will take all the precautions we can, and strive to be examples of courage and calm in the face of difficult uncertainties.

Above all else, we must reassure patients that they won’t be abandoned.

9 responses to this post.

  1. Posted by Larry Lovelace on March 18, 2020 at 11:50 pm

    Thanks for all you do Doc. I’m a medical Director at an OTP and I look forward to every bit of info I can get from you. I’ve been “in the Biz” for 3 years now; I can tell you I learned more reading your blog than reading all of the relevant T I P S put together.

    Reply

  2. Posted by Don H on March 18, 2020 at 11:57 pm

    It looks like you are doing very well as an OTP and perhaps better than some. However, have you talked about or even thought about what happens if this continues for months, people lose their jobs and their income? I’m not talking just your patients but those addicted to opioids in general who have not gone into treatment. If they have no money to buy on the street, what will they do? Will they start robbing? Start breaking into or holding up places that have opiods in one form or another? Stealing take homes from your patients? We all know that just because their money supply dries up, their OUD will not. What about the 10% (best guess) of those with OUD who have been keeping their disease at bay exclusively through 12-step or other meetings? Will going online and removing the human interaction help to cause relapse? No doubt, no one knows the answers. I know I don’t. However, has anyone even thought about this happening? If as many truly live pay check to pay check as is reported, they won’t last much past a month without income. There is always unintended or un-thought of consequences to government actions. Just like curbing prescribing and reformulating oxycontin caused all sorts of unintended shifts to even more dangerous drugs like heroin and fentanyl, trying to shut down the United States may cause a huge fallout. Even the stress of it all may cause more patients to relapse. I wish I had the answers. Not expecting you to either but it needs to at least been talked about and planned for.

    Reply

    • Unfortunately right before this virus came to us, we got word that the grants from the state are running out of money by May, and we were breaking the news to patients. So this is happening at the worst possible time.
      Lots of questions about payment – for example, will patients getting extra take homes have to pay for them up front? I don’t know the answers to this, and with people out of work, it’s a tremendous burden.
      Perhaps it’s time to talk about a better healthcare system?

      Reply

  3. Thank you for a clear description of what is happening at OTP’s. Will new patients, annual physicals, and sick visits proceed as usual? Or, will there be plans to move those towards a telemedicine mode?

    Reply

    • So long as I am well, I will work usual hours at our OTP to see new patients, annual physicals, and sick visits.
      New patients have to come to the OTP to dose anyway, but established patients could be seen by some sort of telecommunication method if needed – either to decrease exposure risk or if they are sick.
      If I get sick, I can still work via telecommunication.

      Reply

  4. Posted by Roger on March 19, 2020 at 12:43 am

    Making people stand outside is against the law , Hippa comes to mind but common sense should as well , people do not want or need someone that knows them from work or a parent who will go and bad mouth the person , it’s bad enough people are forced to beg for their medication for life never mind being treated less than human made to stand outside not for our protection but the staff inside because let’s face it that’s the only reason it’s being done . How about opening all the windows at one time or giving people who have takes homes a 30 day supply

    Reply

  5. I mean even if I did offer this criticism. I would try to be polite and offer it in a positive, constructive way. The tone of someone’s post can seem harsher than intended when one reads them online, but this seems rather rude. I enjoy your blog Jana. Keep up the good work!

    Reply

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