Alcohol and drug use behaviors are also likely to independently increase the probability of contracting coronavirus through a number of mechanisms including sharing substances, inhalation of substances, direct and indirect immu- nosuppressing effects
(particularly when used heavily and chronically) and increased engagement in risky behav- iors. The lack of access to adequate hygiene supplies and consistent sanitation facilities, along with limited access to healthcare are factors that may increase
the risk of transmission and spread of COVID-19 among unsheltered populations3.
For these reasons COVID-19 infection is likely to spread rapidly among people experiencing homelessness, particularly among those who have addiction. In addition, homelessness and addiction are both likely to be independently associated with a more severe
course of COVID-19. People with addiction, and those experiencing homelessness have high rates of chronic health conditions (e.g. respiratory disorders, cardiac disorders, chronic infections [HIV, HCV, infective endocarditis]) that confer risk, and
many individuals experiencing homelessness are over age 502. A recent analysis suggested that individuals experiencing homelessness who are infected by COVID-19 would be twice as likely to be hospitalized, two to four times as likely to require critical
care, and two to three times as likely to die than the general population.3
In addition, homelessness and addiction are both likely to be independently associated with a more severe course of COVID-19. People with addiction and those experiencing homelessness have high rates of chronic health conditions (e.g. respiratory disorders,
cardiac disorders, chronic infections [HIV, HCV, infective endocarditis]) that confer risk, and many individuals experiencing homelessness are over age 50.4 A recent analysis suggested that individuals experiencing homelessness who are infected
by COVID-19 would be twice as likely to be hospitalized, two to four times as likely to require critical care, and two to three times more likely to die than the general population.5
The CDC has released guidance for Homeless Service Clinicians and Programs to Plan and Respond to COVID-19 and
for people experiencing Unsheltered Homelessness. These guidance documents both highlight
the need for and continued linkages to “medical, mental health, syringe services, and substance use treatment, including provision of medication-assisted therapies (e.g., buprenorphine, methadone maintenance, etc.).”.
Continuity of care is critical for patients during this time. The relationship with a supportive treatment clinician/ program may be one of the most stable relationships in the life of a person experiencing homelessness, so disruption of this relationship
can be especially difficult.
Increased regulatory flexibility during this public health emergency is supporting increased access to treatment for addiction, including medications, through telehealth and increased access to take-home doses of methadone. However, individuals experiencing
homelessness may not have access to a reliable phone, minutes, data plan, internet, or other technologies that would be needed to access telehealth services. In addition, they may not be able to safely store and manage a substantially increased number
of take-home doses of methadone.
Recommendations
- Treatment Clinician and Program Partnerships to Support Patients During COVID-19
- Treatment clinicians and programs should work with outreach workers, emergency depart- ments, harm reduction service programs to identify people and engage them in care.
- Be ready to engage as people may be experiencing withdrawal at higher frequency if their drug supply has been disrupted.
- Treatment clinicians and programs should work with their state and community leaders to identify strategies for supporting access to addiction treatment services during COVID-19. For example:
- Providing phones (with minutes) to support engagement in telehealth
- Partnering with street outreach teams, harm reduction service programs, jails and prisons, and other homeless service clinicians and programs to connect patients with addiction who are experiencing homelessness to treatment, including methadone
or low barrier initiation of buprenorphine for those with opioid use disorder6.
- Ensuring ongoing access to harm reduction services such as syringe services and nalox- one.
- Treatment clinicians and programs should work closely with isolation and quarantine facilities to provide addiction treatment to patients with, and those suspected of having, COVID-19.
- Isolation and quarantine can be very stressful for people with addiction. Treating cli- nicians and programs may consider short term interventions to help patients tolerate staying in isolation and quarantine facilities.
- For patients dependent on benzodiazepines, either prescribed or through illicit use, consider offering medications by prescription in order to prevent withdrawal.
- For patients with stimulant use disorders, clinicians may consider treating patients with prescribed stimulants. Even though such treatment has not been shown conclusive- ly to improve the course of stimulant use disorder, the goal during
this public health crisis is different, namely to help patients to tolerate staying in isolation and quarantine facilities for the limited period of time necessary to protect the patient and the broader community.
- Treatment clinicians and programs should work with local jails and prisons, many of which are expediting release for low-level offenses, to ensure that people with substance use disorders who are also experiencing homelessness are linked to addiction
treatment and housing ser- vices.
- Treatment Clinician and Program Adjustments to Clinical Services During COVID-19
- Treatment clinicians and programs should do everything they can to ensure patients have con- sistent access to their addiction treatment medications.
- If a patient is in need of care but does not have access to the technology needed to engage in telehealth the treating clinician/program should either provide in person care or facilitate on site telehealth. Patients can access a phone or computer
at the clinic, or through a partnering organization, while connecting to a clinician in a different room or organization to minimize risks to both patient and staff.
- In areas of community spread, addiction treatment clinicians and programs should assume that all patients accessing the facility may have been exposed to COVID-19.
- Symptom screening, while important, will be of limited utility in identifying asymptom- atic individuals or pre-symptomatic patients due to the long incubation period of the virus. Identification of symptomatic individuals for the purpose
of helping them access needed medical care, however, is still recommended.
- If rapid testing is available it can be used to cohort residents living in congregate set- tings, keeping those who test COVID-19 positive away from those who test negative in order to reduce exposures.
- For patients with confirmed or suspected COVID-19, residential or inpatient treatment pro- grams should work with their local public health department to have patients tested and iden- tify an isolation site where they can access the ongoing care
that they need for both addiction and COVID-19 if the residential treatment program is unable to provide sufficient isolation/ quarantine space.
- When discharging patients who lack stable access to housing and are not suspected of having COVID-19, the treatment program should:
- Work with treatment clinicians and programs in the community to ensure that the patient is effectively engaged in the appropriate level of outpatient care.
- Work with the community housing services, as well as local recovery homes, to identify housing and other recovery support services available to the patient.
- Make sure the patient has a mask.
- Ensure patients who might be at risk for opioid overdose have naloxone.
- Opioid treatment clinicians and programs should work with shelters and alternative care sites to explore options for take-home doses of methadone and telehealth-based appointments.
- Opioid treatment clinicians and programs should coordinate with shelter managers and staff at alternative care sites to ensure medication continuity for patients treated for OUD.
- Opioid treatment programs should be prepared to deliver doses of methadone to es- tablished patients in shelters and alternative care sites, utilizing alternative medication delivery systems if those are available (e.g. mobile dispensing units,
OTP staff or law enforcement-based delivery systems).
- DATA-waived clinicians able to prescribe buprenorphine for patients with untreated OUD should make themselves known and available to shelters and alternative care sites through locally developed systems of care.
- Detachment from treatment and recovery support groups can be particularly difficult for peo- ple experiencing homelessness, as they may be less likely to have the ability to access online support groups. Treatment clinicians and programs should
consider options for supporting access to support groups.
- On site groups that maintain physical distancing.
- Provide technology for virtual support groups.
- Patient Guidance during COVID-19
- Medical clinicians should counsel patients with addiction about strategies to minimize their risk of transmission including physical distancing; hand hygiene when possible; not sharing cups, bottles, utensils, etc.; not sharing cigarettes, e-cigarettes,
joints, etc.; and not sharing other drug use equipment (e.g. syringes, cookers, cottons).
- Patients should also be advised on where to seek care if they develop COVID-19 symptoms, as well as where to seek care if they experience withdrawal or other potentially serious health issues related to their substance use.
- In areas of significant community spread, advise patients that emergency services may be slow- er to respond.
- Emphasize importance of access to naloxone and having someone who can check in on them when using alcohol and substances.
- Ensure patients have access to overdose education and naloxone kits- either through your agency, through community naloxone distribution programs, or pharmacy dispensing.
- Hospitals and emergency departments should continue to screen for substance use disorder and with- drawal risk and should assess housing status before discharging patients with or suspected of having COVID-19. When possible, hospitals and emergency
departments providing care to patients with opioid use disorder should:
- Offer initiation of buprenorphine (or methadone for inpatient services) prior to discharge and ensure linkage to community-based treatment provider.
- Offer naloxone kits (or if not possible, naloxone prescription) to anyone who may be at risk for opioid overdose.
Re-Engineering Medication Delivery
Treatment clinicians and programs should consider new strategies for getting medications to patients, including those in isolation or quarantine, while minimizing the risk to patients, staff, and public health . This will likely involve close coordination
with community safety net clinicians and programs and isolation and quarantine sites. Some communities are currently exploring
the use of mobile dispensing units to deliver buprenorphine, methadone, and other medications to patients that cannot or should not come to an in-patient visit.7
The DEA released guidance related to alternative medication delivery systems
for methadone on March 16, 2020 during the COVID-19 pandemic. The guidance allows for “door-step” delivery of controlled medications, specifical- ly methadone, from OTPs to patients in need of isolation or quarantine. This delivery method
requires that either an OTP staff member, a law enforcement officer, or a member of the National Guard deliver a duly ordered and dispensed amount of methadone to a patient in a locked box or container while maintaining appropriate physical distancing.
Practically, this guidance means that the person delivering the medication must witness the patient or an approved member of the household retrieve the locked box/container from the doorstep. Deliveries of medi- cation to patients unable to present
in-person to an OTP can also be done through established chain-of-custody protocols with a responsible adult.
Infection Control and Mitigation when Telehealth is not an Option
CDC recommends that, “For street medicine or other healthcare staff who are providing medical care to cli- ents with suspected or confirmed COVID-19 and close contact (within 6 feet) cannot be avoided, staff should at a minimum, wear eye protection
(goggles or face shield), an N95 or higher level respirator (or a facemask if respira- tors are not available or staff are not fit tested), disposable gown, and disposable gloves. Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated. Healthcare
clinicians and programs should follow infection control guidelines.
Also see ASAM’s COVID-19 Guidance on Infection Mitigation in Outpatient Settings.
