The Covid-19 pandemic presents a major challenge to healthcare services and the provision of care. A commentary on the Irish experience of challenges faced by people who use opioids (PWUO) and the service providers working with this vulnerable population was published in Heroin Addiction and Related Clinical Problems.1 The authors also describe and discuss the evidence guiding the measures implemented to reduce the risks associated with Covid-19 to Irish opioid agonist treatment (OAT) services. 

Various national and international bodies have highlighted additional dangers faced by PWUO and produced guidelines for drug treatment and harm reduction practitioners. To this end, the Health Service Executive (HSE) published guidelines for general practitioners and pharmacies providing OAT services to those at greatest risk at this time.2 

Changes to OAT services

Many Irish OAT services have adapted treatment delivery to reduce the emerging Covid-19 risks. These changes include:

• Restructuring OAT assessment and induction procedures to allow easy access to treatment and to avoid waiting lists
• Fast-tracking of patients requiring isolation to OAT
• Home delivery of OAT and other medications
• Reducing OAT supervision requirements
• Adapting virtual patient care and telemedicine
• Reducing/postponing non-essential services, including drug and blood-borne virus (BBV) screening and hepatitis
  C treatment
• Providing remote counselling support
• Providing virtual multidisciplinary team meetings
• Increasing access to overdose prevention training and naloxone
• Providing targeted interventions for homeless and more vulnerable patients, including increased access to more suitable accommodation and supports
• Reducing the prison population.

In common with all health services, reducing the need for face-to-face interactions is advised. By reducing this requirement, the potential risk of transmission is minimised, thus protecting staff and patients. 

Risk of drug overdose

Reduced supervision may increase street diversion and drug overdose; therefore, risk assessment and individualisation of care are critical. Providing information on OAT-related dangers and safe storage may reduce these risks. Irish overdose prevention and naloxone programmes have also been expanded to lessen the risks. Overdose education and naloxone programmes have been shown to reduce fatal opioid-related overdose.3 Overdose prevention programmes have conventionally recommended the use of cardiopulmonary resuscitation (CPR) and the administration of intranasal or intramuscular naloxone. Given the increased risks associated with Covid-19, training programmes have now been revised and delivered remotely, removing the endorsement of CPR and use of intranasal naloxone. 

Drug screening

Reducing OAT supervision requirements provides services with an opportunity to evaluate the practicality of drug screening and to adopt a more evidence-based approach in the post-Covid future. Currently, there is little published evidence on the efficacy of routine drug screening. Indeed, screening schedules tend to be philosophical and historical within services.4 

Telemedicine and opioid substitution therapy

Irish OAT services have adopted telemedicine to conduct risk triaging, assessment, reviews, counselling, and psychosocial support. Using telemedicine, OAT services have been able to offer patients quicker access to opioid substitution therapy (OST) and reduce waiting lists. OST induction is acknowledged as a high-risk period for overdose and caution should therefore be exercised. Establishing dependence and assessing tolerance are critical, as is dosing over the first four days.5 

Self-isolation

Given the risk profile of PWUO, many patients attending OAT services will be required or recommended to self-isolate. This presents difficulties for both service providers and patients. Irish OAT services have established a home delivery network informed by local resources, geography, and need. Staff redeployed from statutory and non-statutory services and An Garda Síochána have been engaged in providing risks assessments and supports, where necessary. 

BBV screening and treatment

OAT services have suspended routine BBV screening, vaccinations, and new hepatitis C treatment. In the short term this may have little impact but there may be medium-term to long-term costs for patients. Central to the work of OAT services has been the identification and management of BBVs. Prior to Covid-19 restrictions, OAT services had been engaged in increasing hepatitis C screening and treatment, with elimination of hepatitis C infection as their goal. Lack of testing and treatment, along with reduced supports and access to harm reduction services, may increase rates of reinfection and may impact negatively on ‘treatment as prevention’ initiatives.6 Irish OAT services have effectively used telemedicine for hepatitis C treatment, provision of psychological support, and other supports.7,8,9 

Wider usage of telemedicine

The wider usage of telemedicine has brought about a fundamental change in care delivery and work practices. While patients have adapted well to these changes, it has highlighted the need to have up-to-date phone contact details. Provision of phones to those without them is vital to capitalise on the benefits of these changes. Telephone consultations are adequate for most patients; however, video consultations may be more appropriate for patients with greater health and psychosocial needs.10 

It is worth noting at time of writing that the HSE has not yet agreed a common platform for use in telemedicine. However, it does not recommend the use of video-conferencing services for clinical purposes. 

Remote counselling services and supports

From the onset of Covid restrictions, residential drug treatment and aftercare services closed. This afforded the opportunity to redeploy staff to provide remote counselling services and other supports. At first, patients struggled to adapt to the situation but are now increasingly reporting satisfaction with this approach. 

New models of care

The authors note while it is important to focus on emergency efforts to manage, treat, and develop a vaccine to control this pandemic, it is also important that new models of delivering medical and social care are fully evaluated.11 Models developed during this time of crisis may have real benefits for patients and the healthcare systems in the future. It is also imperative to evaluate any potential negative impacts of these new models and work to decrease them.11 

Adequate resources for such evaluations should be factored into health budgets, as many of these new measures could have significant health benefits and cost savings in a post-Covid future. 

Conclusion

In conclusion, PWUO have greater health and social risks that make them more vulnerable during the current Covid-19 pandemic. OAT services can and have adapted to reduce the risks faced by this marginalised population. Measures adopted have both immediate and future benefits to this group. Ongoing evaluation of such measures is critical, as it can inform how health and social care are delivered across the health services. Many of these measures will also impact health and social care outcomes and potential cost savings in a post-Covid future. 

The report authors hope that these positive changes and learnings can address some of the social and health inequalities experienced by so many.

1 Crowley D and Cullen W (2020) Caring for opioid drug users during the COVID-19 pandemic: a commentary on the Irish experience. Heroin Addiction and Related Clinical Problems, Early online. https://www.drugsandalcohol.ie/32214/

2 Health Service Executive (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: Health Service Executive. https://www.drugsandalcohol.ie/31804/

3 Walley AY, Xuan Z, Hackman HH, et al. (2013) Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ, 346(7894): f174.

4 McEachern J, Adye-White L, Priest KC, et al. (2019) Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. Int J Drug Policy, 64: 30–33.

5 Sordo L, Barrio G, Bravo MJ, et al. (2017) Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ, 357: j1550.

6 Grebely J, Bruneau J, Bruggmann P, et al. (2017) Elimination of hepatitis C virus infection among PWID: the beginning of a new era of interferon-free DAA therapy. Int J Drug Policy, 47: 26–33.

7 Eibl JK, Gauthier G, Pellegrini D, et al. (2017) The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug Alcohol Depend, 176: 133-138.

8 Degenhardt L, Peacock A, Colledge S, et al. (2017) Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health, 5(12): e1192–e1207.

9 Marciano S, Haddad L, Plazzotta F, et al. (2017) Implementation of the ECHO® telementoring model for the treatment of patients with hepatitis C. J Med Virol, 89(4): 660–664.

10 Greenhalgh T, Koh GCH and Car J (2020) Covid-19: a remote assessment in primary care. BMJ, 368: m1182.

11 Brooner RK, King VL, Kidorf M, Schmidt CW Jr and Bigelow GE (1997) Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry, 54(1): 71–80.