Update on COVID 19 at an Opioid Treatment Program

 

 

 

This pandemic hasn’t struck all places in the U.S. at the same time. Back when I was watching the horrors faced by New York City, I felt relief things weren’t like that in my rural community, but also worried we would eventually face something similar.

Now COVID 19 has come to town. For now, it hasn’t been as awful as I saw on the news in the cities, but we’ve had many more people testing positive.

Part of this could be that testing has really ramped up. Early in the pandemic, not much testing was being done, either because there weren’t many test kits or because local health department officials were following the CDC’s relatively restrictive testing guidelines. As I’ve posted before, we had a few patients hospitalized with respiratory failure who weren’t tested for COVID 19. I read their hospital records. They were tested for influenza and when those tests were negative, were told to assume that they had COVID and isolate for two weeks.

After people who work at the meat processing plant in our county tested positive for COVID, suddenly there’s been extensive testing for people who work there.

According to our local paper, the total number of COVID 19 cases remained at four known cases from April 5 until April 21. During the last weeks of April, the number of people testing positive rose slowly, then more quickly. As of today, with businesses re-opening under Phase 1, we have two hundred and sixty-one people in our county testing positive for COVID 19, out of a population of around sixty-eight thousand people.

Our opioid treatment program had to decide how to respond to this new information. Last week, the staff petitioned me dose all our patients who work at this facility in their cars. They wanted potentially infected people to be kept out of our facility. I balked, thinking the risks of car dosing those people outweighed the benefits. Now, after talking to some other doctors about the situation, I’ve changed my mind. We intend to car dose all patients who work in high-risk environments with multiple people testing positive, like the meat packing plant.

It’s not as bad as it sounds. Many of these patients have been stable for months or years and were already on advanced take home levels. Under the blanket exception allowed by federal and state authorities, a significant minority of the only come once per month. Others need to come daily, with most patients coming to the OTP a few times per week.

Our facility got some N95 masks from our parent company. I’ve worn mine for the last three weeks. It still works, though the elastic is getting frayed. We also got a few hundred paper masks that are somewhat helpful. We’ve asked patients to wear masks or other face coverings while at our opioid treatment program. Nearly all patients have supported our request, but a few grumbled about it. We won’t refuse to dose patients who don’t wear masks, but we encourage them to do so. I still bring my Breath Buddy respirator mask to work with me each day, in case I need to see a patient sick with acute COVID 19 symptoms.

Every few hours, there’s an announcement over our intercom to ask for help wiping down our waiting room. Any staff member who isn’t busy with patients comes to pitch in and wipe down chairs, keypads, door handles, bathrooms, etc, with antibacterial liquid meant to murder Coronavirus. It doesn’t take long with many people helping. It’s become part of the daily routine. Patients have voiced repeated appreciation for our actions, which makes me feel good.

I’ve been dealing with patients who appear to have mismanaged their extra take home doses. Around nine patients have had some problem with their take homes. Some patients returned early, when they should still have take home doses, and can’t explain what happened. Some have had bottles missing, lost, spilled, or damaged in some fashion. No one has died from extra take homes, and so far as I know, there have been no close calls with overdoses among our patients from extra take homes.

In most cases, I can’t be sure what happened. The situations came to light either when patients returned early, or when they had drug screens that didn’t contain the medication we are prescribing. In one case, the patient said she was doing fine with weekly take homes, but when she suddenly got 27 take homes under the blanket exception for our COVID 19 situation, she was unable to take them as prescribed. She took extra medication compulsively, even though it didn’t make her feel any different. She ran out of medication a week early. I was happy she told us what happened, and we dropped her back to weekly take homes. Thankfully, she was on buprenorphine and not methadone.

I’m sure these nine cases are the tip of an iceberg. Most patients likely won’t tell us if they’ve mismanaged their extra take home doses.

Patients are at risk both ways: if we decrease the number of take home doses, their risk of contracting COVID 19 increases; however, extra take home doses (especially methadone) can de-stabilize patients accustomed to more accountability with their dosing. We try our best to balance the risks.

We’re still doing intakes for patients, both to methadone and buprenorphine. These patients must dose daily during their induction onto medication, as do patients who aren’t doing well, who have continued alcohol or benzodiazepines drug use.

I feel uneasy about the Phase 1 opening of businesses this week, because we are only now seeing the number of cases increase. I know this could be from accelerated testing recently, and that we must live with some degree of risk.

No matter what happens, our OTP plans to continue to be open for admissions and established patients. We want out patients to know we aren’t closing, that we will be here to provide care for our patients.

We plan to keep doing all we can to keep our patients healthy, both from opioid use disorder and from COVID 19.

3 responses to this post.

  1. Dear Jana,

    Just wanted to let you know I enjoy your blog ever so much, so informative, kind, pointed and an inspiration.

    I work and live in Myanmar, where my organisation runs 15 clinics in most remote rural conflict areas, in our 54k cohort are 3.5k MMT clients, most of then now on THD. The COVID-19 response is clearly way more advanced here than in the US. My heart goes out to you all, the fact that you used your N95 for weeks is a gotspe. Consider to steam clean your mask 20 seconds holding it over boiling water.

    Take good care and again thank you for your inspiration

    Warm regards and respect from Yangon

    Reply

  2. Greetings from Minnesota I had one N95 mask, tried dipping in boiling water. Melted the glue holding the metal strip, and the adhesive for the strap. Didn’t bother to try and resurrect it after that.
    Now using a homemade cloth mask.

    Reply

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