Posts Tagged ‘opioid use disorder and COVID19’

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.