A Primary Care Response to COVID-19 for Patients with an Opioid Use Disorder.

The Coronavirus Disease of 2019 (COVID‐19) has prompted adaptations and restructuring of almost every institution in the nation. While these efforts to mitigate the spread of COVID‐19 affect everyone, patients treated with buprenorphine/naloxone for an opioid use disorder (OUD) will feel these disruptions more acutely, especially in rural communities. Many of our patients rely on hourly employment, which has been reduced or eliminated. School systems have moved to virtual platforms, which leaves parents with employment outside of the home navigating the balance between childcare and work obligations. Primary care providers are rescheduling stable, chronic disease management visits, yet many patients with stable OUD must see their buprenorphine/naloxone prescriber monthly. To meet patients’ needs, providers are shifting to telehealth options, yet many of our patients have unreliable cell phone service or limited broadband Internet access. Mutual aid groups are the cornerstone of recovery for many patients, yet gatherings of more than 10 people are restricted. Pharmacies are encouraging patients to maintain at least a 2‐week supply of medications, yet early refill requests are often deemed “red flags” for patients taking buprenorphine/naloxone. Judicial systems have temporarily closed, which delays the resolution of outstanding legal issues. Homeless service providers are adjusting operations within shelters and the provision of meals, upon which patients in early recovery often rely. Compounding all of these challenges is the stigma patients treated for an OUD often experience, as well as the depression and anxiety that accompany social distancing. At this crucial time, we must adapt to ensure that our patients maintain access to medications for OUD in a safe, non‐judgmental, patient‐centered way.

We are a large family medicine and obstetrics and gynecology residency program serving rural, western North Carolina in the Appalachian Mountains. We have been caring for patients with an OUD in the outpatient setting since 2015. Between our 2 settings, we currently have 234 active patients receiving treatment with buprenorphine/naloxone. Prior to the COVID‐19 pandemic, our standard procedures included office visits every 1–2 weeks for patients during inductions or for those with higher acuity. We saw patients in the maintenance phase of treatment monthly for office visits. At every visit, patients completed a urine drug screen and had the ability to meet with a behavioral health provider or peer support specialist. We hosted group medical visits 4 times per month.

As of March 31, 2020, we have less than 100 confirmed cases of COVID‐19 in our region. In anticipation of further cases, we have adjusted our procedures as follows. At this time, all group medical visits are temporarily on hold. For low acuity patients, we have proactively rescheduled all appointments for 6–8 weeks and electronically prescribed buprenorphine/naloxone to reach that appointment time. A behavioral health provider will call the patient to offer a telephone visit, but we do not require this. For moderate acuity patients, we are requiring a visit every 2–4 weeks. We give patients the option of an in‐office or telephone visit with either a behavioral health provider, medical provider, or both. For high acuity patients, which we consider as those who have used in the past 30 days, new to care, in the third trimester of pregnancy, or waiting to transfer to the regional alcohol and drug treatment center, we will continue with regularly scheduled, face‐to‐face appointments. For all patients, the scheduling staff will communicate the plan with the patient as outlined above. The scheduler will then send a message through the Electronic Health Record to the prescriber to alert them to the need to send the buprenorphine/naloxone prescription for the appropriate duration of time. Providers check the state Prescription Drug Monitoring Program and document accordingly. All providers will ensure the patient has an active prescription for naloxone. At this time, we are rapidly creating avenues for telehealth services.

As we developed this process, a vigorous debate ensued about the need for the face‐to‐face visit, especially as it pertains to the urine drug screens. Some providers were concerned patients would return to use without that screen. Ultimately, we felt the “harm reduction” approach more aptly applied to minimizing harm related to COVID‐19. As primary care providers, we have seen a large influx of suspected COVID‐19 cases in our offices. We decided not to require an in‐office visit and urine drug screen for our low and moderate acuity patients as it could unnecessarily expose our patients with OUD to potential patients with COVID‐19. We continue to assess the risk versus benefit for our high acuity patients. In these extraordinary times, we think this is the correct action.

National organizations are providing guidance on how to meet the needs of patients during the COVID‐19 pandemic. Though we speak specifically to the nuances of office‐based opioid treatment, recommendations for how opioid treatment programs should respond are also available. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources on how to maintain continuity of substance use treatment services while meeting the Centers for Disease Control and Prevention's (CDC) recommendations regarding social distancing. This includes evolving guidance on ways to adhere to regulations while implementing creative treatment models. The Drug Enforcement Administration maintains a COVID‐19 page that offer updates on any medication supply shortages, guidance on electronic prescribing of controlled substances, and telehealth during the public health emergency. In lieu of a face‐to‐face visit, many are shifting to telehealth visits. Many insurance companies are adjusting policies to allow for reimbursement. , Access to medications is a main concern expressed by our patients. Many boards of pharmacy house guidance regarding insurance rules for early refills and extended fills during a state of emergency. , The CDC and SAMHSA offer guidance on ways to reduce stress and anxiety in this time of uncertainty. , The CDC provides resources for homeless services providers to mitigate the spread of COVID‐19. Harm reduction organizations are supporting people who use drugs by outlining ways to use safer in the setting of this pandemic. , Finally, the American Society of Addiction Medicines houses a portal of links to pertinent federal and state entities involved in the response to COVID‐19. This is particularly useful as a centralized location to find resources regarding billing, telehealth regulations, and compliance with state and federal rules.

This pandemic offers us the opportunity to reassess how we prioritize patients’ needs and access to services. It challenges our traditional ways of delivering caring and asks, “Can we do it differently?” while still addressing key health indicators like decreasing overdose deaths and increasing access to medications for OUD. It is a time for us to prioritize creating a safe space for health care teams to share challenges that we are facing across systems and discuss the innovative solutions we are putting into action. Despite our 6 feet of distance, it is a time to communicate more now than ever.