Treating Opioid Addiction During Major Disruptions to Care

We conducted a study to investigate opioid agonist therapy (OAT), a treatment for opioid addiction, during major disruptions to medical care. We identified several major themes and established possible action items based on reports from included papers. Action items can be implemented or explored in order to better prepare OAT for future disruptions to medical care.

Action items generated through discussion and reflection with Nova Scotia Health, Saskatchewan Health Authority, and the Institute for Safe Medication Practices with the COVID-19 context in mind are indicated with *

This study was funded by the CIHR Operating Grant: Knowledge Synthesis: COVID-19 in Mental Health and Substance Use. For more information on how this study was conducted, please visit at the journal publication and/or CIHR report.

Disaster Response Planning 
(action items to be integrated into disaster plans)

Communication:

• Design a clear communications strategy for use before, during, and immediately after a major disruption*
• Provide OAT clinic patients with contact information of clinic staff and of alternative OAT programs
• Establish a 24-hour hotline with backup for PWUDs and clinic staff, and for providers external to the clinic who may need to verify medication and dosage information for PWUDs in guest clinics or in emergency rooms
• Record a voicemail message with directions to alternative OAT clinics*
• Create an online presence of OAT clinics using websites and social media*
• Establish a relationship with at least two local radio stations
• Facilitate the expedited approval of critical bulletins and news aimed at PWUDs, providers, and the general public*

Accessibility and Transportation:

• Develop transportation strategies through links with public and private transport companies
• Discuss with OAT clinic patients the feasibility of walking or bicycling to the home program and other geographically accessible programs should the need arise
• Utilize mobile outreach teams to evaluate PWUDs and administer OAT medications when patient transport to a physical clinic is not possible*

Mental Health Support:

• Offer early and timely screening for mental, neurological, and substance use disorders (particularly PTSD and depression) to OAT patients, along with adequate referral and treatment, to avoid exacerbation of psychological sequelae and mitigate worsening substance use
• Encourage partnerships with local community or social service organizations along with peer networks and counseling by peer mentors to help mitigate fear, anxiety, and frustration in PWUDs*
• Offer extended breaks or additional vacation days to providers to mitigate the effects of stress caused by emergencies*
• Offer providers support that addresses their daily needs such as groceries and other provisions*
• Create awareness of potential tensions between individuals (both PWUDs and providers) of an evacuated clinic and those of a “guest” institution, and integrate this information in emergency planning procedures*

Data storage/protection:

• Design detailed protocols for the management, access, protection, storage, and removal of patient records and program data, with a particular focus on privacy and confidentiality
• Create centralized, web-based databases with essential information regarding PWUDs in all OAT programs within a jurisdiction, such as up-to-date contact information, their medical records, their medications and dosages, treatment plans, and level of monitoring, and their take-home privileges
• Frequently back-up frequently patient records with multiple electronic copies protected with state-of-the-art encryption or other security methods and with printed hard copies stored securely offsite
• Develop an emergency plan for pharmacists that includes a list of OAT patients and information on temporary backup locations, alternative pharmacies to which patients can be sent, and a backup medication stock
• Consider the use of personal dosage information cards with the photo of the user or patient and encrypted information of dosage and takeaways

OAT Clinic and Site Preparedness
(action items for clinic and site leadership to implement ahead of the next disruption to care)

Coordination and Integration:

• Create a network of “sister” OAT clinics located close to patients’ homes that provide mutual support during an emergency, including honouring previously established dosing, scheduling, and medication regimens
• Create an online community of OAT providers that enhances communication among them and offers peer support during a major disruption*
• Establish links with relevant local, provincial, and federal agencies to prepare for and address emergency situations

Disaster Preparedness:

• Develop and widely distribute a standardized, uniform template for emergency manuals, guidelines, and plans that:
  • is flexible and context-sensitive
  • prepares PWUDs and providers for a variety of emergency scenarios
  • includes solutions related to communication, transportation, guest provisions, and take-home plans
  • includes the views and opinions of key stakeholders such as community pharmacists and PWUD representatives
• Update emergency manuals, guidelines, and plans frequently
• Designate an OAT clinic staff member as a “Disaster Preparedness Deputy” in charge of updating: Program voicemail, Patient cell phone and email information, OAT clinic website and social media, News media with information about changes in OAT scheduling and on location of guest services
• Provide OAT clinic staff with identifications that attest to their emergency personnel status during emergencies
• Create a network of mentors or “coaches” who can support prescribers of OAT medication with an addiction medicine consult service*
• Facilitate a “buddy system” that links patients with similar needs so that they can help each other obtain relevant information and resources as quickly as possible in the event of an emergency
• Ensure that admission criteria to enrol in OAT are flexible during major disruptions*
• Prepare an Emergency Kit that includes:
  • Emergency procedures, the communication plan, the transportation plan, contact information of “sister” OAT clinics and of Disaster Preparedness Deputy, take-home plan, and dosage information that patients would need to receive guest medication at another site
  • Solar phone chargers
  • Naloxone, with instructions for its use
• Advocate for the creation of a deputy-level position responsible for addiction services in all provincial disaster preparedness offices

Medication stocking and Distribution:

• Stockpile OAT medications amongst geographically or otherwise connected services, or with the stock distributed to regional hospitals
• Improve transparency for OAT medication supply chains and potential limits or restrictions of their distribution to reassure PWUDs and providers about the availability of OAT medications during and after a major disruption to health care*

Reducing Regulatory, Policy, and Governmental Barriers to Care
(action items for regulators, policymakers, and governing bodies to implement for the next disruption to care)

Regulations:

• Design flexible regulatory frameworks related to OAT programs
• Waive initial in-person assessment for initiation of OAT medications
• Allow blanket exceptions for OAT patients to receive several weeks of take-home doses
• Grant OAT clinics flexibility to provide take-home doses to patients with accessibility limitations
• Consider continuing regulatory adjustments implemented after a major disruption to improve ongoing care*

Certification and Accreditation:

• Enable the rapid accreditation of providers, allowing them to prescribe OAT medications in the context of a major disruption
• Enable the transfer of the accreditation of an existing physical OAT program to an alternative location in case of closure
• Enable the rapid certification of mobile clinics

Methadone vs Buprenorphine:

• Consider the use of long-acting depot buprenorphine*
• Address barriers to the prescription of buprenorphine, such as exemption requirements for prescribers, and concerns in both PWUDs and providers about transitioning from methadone to buprenorphine*

Telehealth and the Pandemic Context:

• Harness telemedical approaches to expand access to care for hard-to-reach and underserved populations with restricted mobility due to mental, medical, or geographical challenges*
• Change regulations to permit authorized providers the use of telemedicine to conduct medical evaluations to start patients on OAT medications during and after a major disruption*
• Prioritize the allocation of public and private funding and resources to expand the implementation of telemedicine during and after a major disruption, and its integration across multiple clinical settings, including primary care*
• Expand insurance coverage for telemedical procedures and lift restrictions on reimbursements*
• Temporarily suspend restrictions on licensure requirements to practice telemedicine across jurisdictions*
• Design measures to minimize the risk of exposure to highly infectious agents to providers working in OAT clinics and to PWUDs seeking treatment*