COVID19 and Medication-assisted Treatment of Opioid Use Disorder

Pretty But Dangerous

 

 

 

As the COVID19 debacle drags on, treatment for patients with opioid use disorder continues to evolve in some ways.

Last week, I saw my office-based patients via telemedicine rather than in my private office. It went well, for the most part, but out of the fifteen people I saw, two had such bad connections that I could barely communicate. The picture blurred, the voice distorted, and I felt frustrated.

I think patients with poor connectivity may not have the bandwidth to do telemedicine. I don’t know if this is a problem that’s easily fixable. I may have to resort to phone calls only in these cases. In fact, phone calls would have been much better than the telemedicine on these two patients.

However, I also gained some insights into my patients’ lives. I got a small peek into their everyday lives, in some cases. I saw how they dress while at home and saw a few details about their home in the background of the picture. Several seems much more relaxed than when I see them in my office. Others were more tense, struggling with the technology.

Overall, patients appreciated the convenience of telemedicine and appreciated not having to expose themselves to the outside world, with possible Coronavirus floating around. I know I did.

At the opioid treatment program where I work, I came to the facility on my usual days, but things have been slow. I didn’t have any patients wanting to do intake this week and saw only a handful of patients each day for other reasons, mostly dose adjustments.

Patients have not had to wait to dose at all, except for Monday. That day we had many people with extra take homes coming back to dose with us and to get more take homes. Our nurse manager is fine-tuning the schedule, to even out the number of people dosing on site as much as possible. I told him he has a very hard job, trying to juggle nearly 600 patients so that everyone has the least amount of wait time. Other than Monday, we had negligible wait times.

We renewed our blanket exception requests for extra take homes with the state, and I think this is something we will renew every two weeks until the COVID19 mess is over with.

Our rural county, population of a little over 68,000 people, has two confirmed COVID cases. However, few tests have been done. According to an article in our local paper, our Health Department has done 28 tests, with 24 negatives and four pending. This number didn’t count any testing done at the local hospital, though, where the two positive tests were done.

I’ve read the hospital records of a few of our OTP patients who went to the hospital over the last two weeks with acute respiratory failure, cough and fever. It appears they were given COVID precautions but were not tested. They were told to quarantine, though. We’ve dosed those patients in their cars and given take homes to keep them away from the OTP. Initially we decided we would do this only for confirmed cases, but that idea appears unworkable, both because not many patients are being tested, and because of the delay in results of a week or more. We must act as if those patients have COVID 19.

I find the reluctance to test patients with symptoms to be odd.

I’ve heard that local testing policies are based on CDC recommendations: people with symptoms who have traveled to areas with active COVID infections are being tested, and people who have been in close contact with known COVID patients are being tested. Perhaps reluctance to test any patient with symptoms is based on a lack of test kits. I don’t know, but I’m repeatedly struck by this reluctance to test. Even nurses with symptoms have not been tested for COVID.

We continue to wear what masks we have – paper disposable ones that we re-use day after day, or hand-sewn cloth masks that can be laundered frequently. We have sanitizing wipes and take turns wiping down doorknobs, chairs, reception counters, etc. We practice social distancing among staff and patients. We use our homemade hand sanitizers and wash our hands with soap and water too.

Patients can have either in-person sessions, sitting at least six feet from their counselors, or have phone sessions. Counselors are trying to call patients with extended take home doses weekly. That can be a problem, given than many of our patients have the disposable phones and they change numbers frequently. If they can’t be reached, counselors document that they tried to call, and we try to get a working phone number the next time the patient comes to dose on site.

We are doing all we know to do to keep our patients and ourselves safe.

We have weekly teleconferences for program directors and medical directors of OTPs. There’s been much debate around telemedicine capabilities. Under federal regulations, physicians (or other providers) can’t admit methadone patients to an OTP unless they have an onsite admission process. However, OTPs can admit patients to buprenorphine via telemedicine. I think regulators feel buprenorphine is much safer, and office-based providers even do home inductions, so an on-site interaction isn’t needed. But with methadone, which is more dangerous to start, particularly in the first two weeks, the provider needs to see the patient in person, face-to-face. That’s the way the federal regulation reads at present.

There’s a petition floating around OTP circles, asking SAMHSA to re-consider their block on methadone admissions via telemedicine. If this petition succeeds in changing federal regulations, prescribers still must obey their state laws on this topic.

I am not in favor of telemedicine admissions to methadone. I’m aware this isn’t a popular opinion at present, and I understand the benefit of making admission to OTPs as easy as possible and eliminating barriers.

However, I’ve been working at OTPs for nineteen years, and I’ve had methadone patients die during induction under the best of circumstances. Methadone is a different breed of cat than buprenorphine, and even though induction overdose deaths are still rare, they are devastating when they do happen. I think I could miss subtle signs of sedative intoxication via telehealth, which could make a big difference in my decision to start treatment. It may be difficult to discern subtle withdrawal signs. If there’s another medical professional on site to do the exam, that could fill in some information gaps, but will this professional be an RN? It would be (in my state) outside the scope of practice for an LPN, and certainly could not be done by a counselor.

We talked about the prohibition of telehealth admissions for methadone on our OTP phone call today, and most providers voiced the opinion that it would be perfectly safe to do this, so I’m clearly in the minority with my opinion. Fortunately for now, I’m able to work on site at my OTP, so it’s not an issue.

On our phone call, there were some interesting ideas about what OTPs are doing around the country. One state apparently asked agencies to agree to share staff. That is, if one OTP has all their nurses out sick and unable to work, a nurse or two could be brought in from another OTP that has all of its staff able to work. That would be great, and such a policy would be in the best interest for all patients… but would require a great deal of cooperation between organizations that are accustomed to competition.

We talked about financial hardship policies; in other words, what to do about patients who, suddenly out of work, can’t pay for treatment. Some programs said they would work with such patients and try to help them make a budget or agree to a financial contract. Some programs agreed to allow patients to charge part of their daily fee, to be paid back later. Our OTP is allowing patients to charge for take home doses, hoping they will be able to pay again at some point. It sounds as if other programs are doing similar.

Unfortunately, state funding for patients unable to pay, under the SORs grant, was set to run out of money in early May, at the worst possible time for our patients who’ve just been laid off from work due to COVID 19 shutdowns. It now appears that some extra money may be found, but there’s much uncertainty now. I pray it works out, because we have many patients who are doing well in treatment, at risk for relapse if their grant for treatment runs out.

 

7 responses to this post.

  1. Posted by soraya kamran on April 4, 2020 at 1:57 pm

    This echoes our experiences and reflections on our OTP and OBOT processes.
    1. Testing: I think the reluctance to test is purely unavailability of tests, nothing more.
    2. In person admission processes for MMT: Is your main concern sedation? As it stands we do not feel safe doing a physical given exposure ( trying to figure that out even though SAMHSA allows 14 days, it will exceed 14 days, clearly). Yes and LPN, a counselor would be present in the OTP and the patient can be asked to do maneuvers to determine sedation, and doses can be very low to start. Beyond the first day of methadone induction do you assess patients on day two? If not, then the same concept would apply, no? Just thinking out loud.
    3. In one of our programs a weekend dosing nurse who was asymptomatic, gloved and masked and working alone when she was last in the clinic just tested positive for COVID-19. Our plan is to inform every patient she dosed but awaiting state guidance.

    Thank you for blog – its nice to know others are thinking through this.

    Reply

    • Thanks!
      I have no problem doing the physical exam in person, at least if the patient isn’t spewing secretions and terribly sick. Even then, I have a lapidary mask that I can use, as good as an N95.
      But if I get sick, I couldn’t come to work and then I’d have to do admissions via telehealth. As you say, one could start the patient at a really low dose, to be safe, and then the patient would have to be seen daily until at a stable dose. Even so, I’d worry about missing things. In my very limited experience, telehealth doesn’t give me the same information as in-person.

      Reply

      • Telehealth, to me, has been looking like the future for some time. I see my provider via Zoom or RingCentral. We can see and hear each other incredibly clearly. She can experience me so clearly—I fly it straight. I can use my iPhone or iPad—and I’m pretty sure other operating systems work as well.

  2. Dr. Burson would it help with tele-admissions of methadone patients to send them the swab-drug-screen?

    I have CHF, among other things, I’ve seen my provider via telemedicine for a year now. Two months ago, my insurance asked for a urine screen—which I provided. My provider said if they ask for another considering the big issue we have, she will mail me a swab-test.

    Also, there is a pharmacy (national) called Genoa—they’re mail-order, they’re amazing, and take almost all insurance. My provider orders my meds and I literally have them the next day. Controlled ex’s need a signature—but USPS Informed Delivery allows you to provide a signature online for all signature-required packages. This means no trip to pharmacy with a bunch of ill patients and all you need to do is disinfect your package/meds. Please consider this information.

    Reply

    • We use saliva testing but the technology isn’t as good, and confirmatory testing can’t be done with this method. We’ve had so many false positives and negatives that I prefer urine drug screen. But you are right – it’s better than nothing.

      Reply

  3. Posted by Tony Keen on April 5, 2020 at 6:32 pm

    Just curiosity here, but with the state grant running out in May, would this be a case for one of the small business loans due to COVID-19? It would definitely be a loss of income to your business and have severe health implications to your patients, all of which directly relate to COVID-19 and the government mandated shutdown. It is hard for those of us that are addicts. I have great insurance and almost 2 years of sobriety, but I have already started worrying about where will I be able to get whatever I need to stay “straight” and not in withdrawal if I can’t get my Sublocade or Suboxone. This is after everyone says there isn’t a shortage and won’t be, but offices may close and my doc may not be available suddenly. Such is the mind of an addict, and I can tell you that many of your patients will relapse if the money dries up, and I know you already knew this and it needs not be said. You sound like a FANTASTIC physician that really cares about your patients and community. I enjoy following your blog and seeing the other side of treatment. Thanks for all you do.

    Reply

  4. […] medicine physician who works at an opioid treatment provider in North Carolina, wrote on her blog that they were offering curbside dosing and take-home doses to patients who had symptoms of […]

    Reply

Leave a Reply to RachelAnne Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: