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.