Home > Community and inpatient services - COVID-19 guidance for clinicians.

Royal College of Psychiatrists. (2020) Community and inpatient services - COVID-19 guidance for clinicians.

External website: https://www.rcpsych.ac.uk/about-us/responding-to-c...

People who use drugs

The following information may change in line with national guidance. People who use drugs may be at greater risk from COVID-19 than the general population, for the following reasons:   

Thus far, deaths and serious illness from COVID-19 seem concentrated among people who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19. People with a history of problematic drug use have a significantly higher prevalence of chronic respiratory disease (asthma and COPD) than the general population.   

Other risks for people include decreased access to health care, housing insecurity, and greater likelihood for imprisonment or detention in hospital. Limited access to healthcare places people with addiction at greater risk for many illnesses. If hospitals, clinics and ancillary health systems are pushed to their capacity, people with addiction - who are already stigmatized and underserved by the healthcare system - will experience even greater barriers to treatment for COVID-19.   

Homelessness or imprisonment can expose people to environments where they are in close contact with others who might also be at higher risk for infections. Reduced stability due to unmanaged opioid dependence increases these risks.    

Other important considerations are:  

• Drug-related deaths and harm are at their highest on record.  

• Access to traditionally traded street opioids may be impacted by global restrictions on movement (as has already been seen in the street SCRAs/’Spice’ market) leading to a possible acceleration of the emerging synthetic potent opioids such as fentanyl and related analogues.  If supply chains are disrupted, we may see more acute withdrawal from a variety of street drugs. 

• Services for the most vulnerable members of our community, such as homeless services may become more difficult to access or be completely unavailable. This may lead to an increased and unexpected demand on addiction services. Those with substance use disorders are also more likely to be immunosuppressed. 

• Therefore, we should consider people who use drugs as having the potential to be considered one of the high-risk groups with respect to COVID-19, and tailor our treatment delivery accordingly.   

Our current advice for psychiatrists and staff working in addiction services is:  

For individuals on Medication-Assisted Treatment (MAT)  

• The clinical priority currently is to safeguard delivery of life-saving clinical treatments such as opioid Medication-Assisted Treatment (MAT) such as methadone and buprenorphine.   

• Another priority area is access to harm reduction measures such as needle and syringe supplies for those who inject 

• Under normal circumstances these treatments are delivered in the community, require people to be able to move freely while feeling comfortable making frequent trips out of their home, and depend on other elements such as routine access to community pharmacies and reliable supply of essential medications.   

• As the external environment changes, it is likely that the disruption we are already noticing will increase and make it more challenging for individuals on MAT, particularly those on more restrictive MAT regimes, to continue receiving treatment as usual. We know that pharmacies have already started to restrict access for our service users due to reduced capacity and other reasons, even refusing to provide supervised consumption. This will probably become an even greater issue as the situation progresses.  

• People on MAT have raised concerns about frequent attendance at pharmacies, in some cases choosing to stop their treatment rather than increase risk of exposure and potentially put themselves or their loved ones at risk.   

• At this time, and wherever possible, it would be appropriate to consider relaxing the usual requirement for people to frequently attend community pharmacy, and to consider how treatment can be continued. Engagement with treatment in this population is challenging, so removing barriers to access and making treatment regimes acceptable to people will be a vital consideration.   

• It is almost always safer for opioid-dependent people to have MAT available to take-home, than to be off MAT and feel compelled to use street opioids with all the risks that entails. MAT does have the potential to cause harm if not taken as directed, but on balance is far more likely to benefit individuals. It is a lifesaving and harm-reducing intervention that is safer than using street opioids of unknown potency and purity. Safeguarding of children needs to remain a consideration. 

Pharmacological considerations for people using drugs 

Buprenorphine formulations are partial opioid agonists and have a better safety profile compared to full agonists such as methadone with respect to overdose. They are also less likely to cause harm to opioid-naive people should they be consumed inadvertently. This may be a more suitable option in situations where there are safeguarding concerns or other risks in the patient’s immediate environment.   

• The choice of MAT depends on individual circumstances, and choice is a key factor in adherence. Wherever possible continue the current MAT drug.  

• Consider providing individuals who already take-home medications with a longer duration of take-home medications. Two weeks supply could be considered and extended depending on external circumstances.   

• Robustly consider whether people on supervised consumption can move to unsupervised and be provided with take-home supply. In some places supervised consumption may cease to be an option, and its utility should be balanced against the risk of compelling people to make more trips out of the home than they would otherwise wish to do.   

• Take the opportunity to optimise dose as appropriate.  

• If only remote assessments are possible, and people are unable to have access to/provide a drug test – consider proceeding with buprenorphine titration based on an adequate assessment. This is unlikely to be possible for methadone but consider on a case by case basis.   

• Opioid detoxifications and dose reductions should be deferred, with people encouraged to maintain stability during this period of uncertainty. However, if individuals need to detox, then support accordingly.   

• If people are advised to self-isolate (but not treated in hospital) they could be asked to nominate an individual to collect the prescription on their behalf and could be provided with a longer supply of medication. If they cannot nominate an individual to do this, where possible, a member of staff could collect and deliver the medication.   

• The above should be supported with a) Provision of Take-home Naloxone b) Safe storage boxes c) Harm reduction advice d) Regular communication with first-line support. 

See also sections on:

 - Assessment and management and management of suspected and confirmed cases

 - COVID-19 and psychotropic medication

 - Prison healthcare

 - Older peopel

 - Pregnant women and those in the perinatal period

 - Managing home visits

 - IAPT, outpatients and day patient services

 - Inpatient services

 - Information about Electroconvulsive therapy

 - Residential care

 - Supported living settings

 - Capacity and demand management


[See also, Covid-19 HSE Clinical guidance and evidence]

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