COVID19 pandemic and people with opioid use disorder: innovation to reduce risk.

The Covid-19 pandemic is creating a vast and growing number of challenges for all. People with a history of opioid use disorder (OUD) also may be exposed to additional risks. Piedmont one of the areas most severely affected by the Covid-19 pandemic, with large numbers of people infected and related mortality. In the region, specialists responsible for OUD care identified the risk that the existing care system exposed patients to. Teams designed and implemented innovation approaches to enable continuation of care and reduce the inherent system risk to patients with OUD.

Introduction

The COVID19 pandemic is a huge challenge for society including all health and social care systems. There are many challenges including the management of a high number of hospitalized or home-treated patients, the identification of therapeutic protocols, the research for an effective vaccine, the measures to prevent infection spread in general and in healthcare professionals. In many instances a reorganization of the healthcare system is ongoing. This change includes the services which provide care for people with problems related to addiction.

People with a history of opioid use disorder (OUD) have the same risk from COVID19 as the general population but maybe exposed to additional risks. People with a history of OUD are often marginalised and face stigma making it difficult to access health care services; they have increased physical and psychological comorbidity (Volkow, 2020). Risk may be increased by behaviours associated with drug use and its setting, or system of OUD care service delivery. Many are required to attend specialist healthcare facilities to collect medicines or engage in observed therapy.

Measures introduced to limit reproduction of COVID19 in the general population including social distancing and isolation reduce the mortality rate, burden on health and social care systems. These measures have a direct impact on patients treated for OUD. The nature of the interaction between patients and the specialist services providing care has changed.

In Piedmont, a region of 4M in northern Italy the situation is acute. In the general population there are more than 20,000 cases of COVID19 infection and 2,500 deaths (http://www.salute.gov.it).

Services for substance use disorders in the region include 75 Specialist Treatment Services (called Ser.D in Italian) with 112 outpatient services, 65 units for social rehabilitation and 4 low-threshold, drop in centres. There are approximately 10,000 patients engaged with treatment programs for OUD including pharmacotherapy.Relazione annuale al Parlamento sul fenomeno delle tossicodipendenze in Italia anno 2019.

In the region, specialists responsible for OUD care identified the risk that the existing care system exposed patients to. This included the need to attend care services for medicines collection or observed therapy.

The Regional/Local Crisis Management Unit, at the specialist treatment centre in Biella (responsible for 1,000 patients, 70% engaged with treatment programs including methadone or buprenorphine therapy) developed an innovative program of different actions in order to reduce risk for its patients and prevent the spread of COVID19.

Measures implemented to reduce risk in OUD care provision

Standard protocols for hygiene in care locations with prominent advice and equipment for hand washing and disinfection.

Provision of “talking-based”, psychological and social support services by internet video services.

Dedicated phone/video service for new patient assessment and triage.

Postponement of certain instances of some services such as family therapy.

A risk mitigation program for essential admissions to rehabilitation services including planned quarantine.

Provision of masks, hand gels and essential information on COVID19 for attendees at drop in centres.

Attendance for care services on site only at pre-scheduled times with social distancing measures.

Planned limits to the number of patients, social distancing in service waiting areas.

Increased options for take home of medications for OUD.

Planned home delivery of medications for OUD.

Improving harm reduction strategies.

Future considerations

It is the aim to ensure access to as safe as possible services for OUD care during this period both the pandemic and after the acute initial phase (Marsden et al, 2020).

The planned changes implemented in Biella have been effective with no cases of COVID19 infection in patients and healthcare professionals. There are also important negative effects: increased access to medication at home is associated with risk of overdose, the consumption by others, greater rates of the misuse and diversion rate of methadone, buprenorphine, benzodiazepine and alcohol (Testino et al., 2020).

As a priority it is now necessary to continue improving the approach to OUD care and minimize system-based risk for those patients electing to engage with OUD care during the COVID19 pandemic.

Prolonged-release buprenorphine (PRB) products are approved in Europe for opioid dependence. Such products provide proven treatment levels of medication with weekly or monthly injections. Treatment does not require attendance for observed therapy nor dispensing of large quantities of take-home medication. Diversion is not associated with PRB. These options have been at the front of the response to COVID19 risk in other countries. Patients in Italy should be granted the option of treatment with the approved forms of medications (Rosenthal, 2019) and national approval procedures should be accelerated to make this possible.

Conclusions

This experience emphasises the need for continuing innovation. Access to approved medicines such as the prolonged release buprenorphine products must now be prioritised to further reduce the risk for individuals in care.

Authors’ contribution

The Authors contributed equally to the preparation and revision of the manuscript.

Declaration of Competing Interest

L Somaini has served as a consultant/advisory board member for Molteni Farmaceutici, Indivior, Gilead and Camurus. All the other Authors declare that they have no competing interests.