Coronavirus: Policy Change for Opioid Addiction

In the face of the US COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) has announced further policy changes with respect to at-home treatment of opioid use disorder (OUD).

UPDATED MARCH 20, 2020 -- In the face of the US COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) has announced further policy changes with respect to at-home treatment of opioid use disorder (OUD).

Last week, the agency issued a directive to allow some patients in opioid treatment programs (OTP) to take home their medication, announcing that states may request "blanket exceptions" for all stable patients in an OTP to receive a 28-day supply of take-home doses of medications such as methadone and buprenorphine, for treatment of opioid use disorder (OUD).

The agency also said states are now allowed to request up to 14 days of take-home medication for patients who are less stable but who can, in the judgement of OTP clinicians, safely handle this level of take-home medication.

"SAMHSA recognizes the evolving issues surrounding COVID-19 and the emerging needs OTPs continue to face," the agency writes.

In its new guidance, the SAMHSA also acknowledges that because of the pandemic, many substance use disorder treatment provider offices are now closed, and many patients are unable to present for in-person treatment services because they are quarantined or in self-isolation. This situation, the agency notes, has intensified the need for telehealth services and/or telephone consultations, making it difficult for providers to abide by current patient privacy regulations.

As a result, SAMHSA has relaxed existing regulations requiring providers to obtain written patient consent for disclosure of substance use disorder records, which "would not apply in these situations to the extent that, as determined by the provider(s) a medical emergency exists." An FAQ section on the SAMHSA website offers detailed, up-to-date guidance for providing methadone and buprenorphine treatment.

"SAMHSA affirms its commitment to supporting OTPs in any way possible during this time. As such, we are expanding our previous guidance to provide increased flexibility," the agency said.

A "Lifesaving" Decision

Commenting on the initial SAMHSA policy change for Medscape Medical News, Richard Saitz, MD, professor and chair of the department of community health sciences, Boston University School of Public Health, Massachusetts, said, the policy "is not only a good idea, it is critical and lifesaving."

"This approach had to be done now. With the reduction in face-to-face visits, patients with opioid use disorder need a way to access treatment. If they cannot get opioid agonists, they would withdraw and return to illicit opioid use and high overdose risk and it would be cruel," said Saitz.

"It is possible that there will be some diversion and some risk of overdose or misuse, but even for less-stable patients the benefit likely far outweighs the risk," he added. Saitz believes policy changes like this should have been made prior to a crisis.

"Honestly, this is perhaps a silver lining of the crisis" and could lead to permanent change in how OUD is treated in the US, he said.

"Just like we are learning what can be done without a medical in-person visit, we will learn that it is perfectly fine to treat patients with addiction more like we treat patients with other chronic diseases who take medication that has risks and benefits," Saitz said.

Last week, the Drug Enforcement Administration (DEA) also announced relaxed dispensing restrictions for registered narcotic treatment programs in cases where patients are quarantined because of coronavirus.

Typically, only licensed practitioners can dispense or administer OUD medications to patients, but during the COVID-19 crisis, treatment program staff members, law enforcement officers, and National Guard personnel will be allowed to deliver OUD medications to an approved "lockbox" at the patient's doorstep. The change applies only while the coronavirus public health emergency lasts.

"This is also an excellent idea," Saitz said.

ASAM Also Responds

In addition, the American Society of Addiction Medicine (ASAM) released a focused update to its National Practice Guideline for the Treatment of Opioid Use Disorder (NPG).

The update is "especially critical in the context of the ongoing COVID-19 emergency, which threatens to curtail patient access to evidence-based treatment," the organization said in a news release.

The new document updates the 2015 NPG. It includes 13 new recommendations and major revisions to 35 existing recommendations.

One new recommendation states that comprehensive assessment of a patient is critical for treatment planning, but completing all assessments should not delay or preclude initiating pharmacotherapy for OUD. Another new recommendation states that there is no recommended time limit for pharmacotherapy.

ASAM continues to recommend that patients' psychosocial needs be assessed and psychosocial treatment offered. However, if patients can't access psychosocial treatment because they are in isolation or have other risk factors that preclude external interactions, clinicians should not delay initiation of medication for the treatment of addiction.

Expanding the use of telemedicine might also be appropriate for many patients, ASAM announced.

They note that the NPG is the first to address in a single document all medications currently approved by the US Food and Drug Administration (FDA) to treat OUD and opioid withdrawal, including all available buprenorphine formulations.

"All of the updated recommendations are designed to both improve the quality and consistency of care and reduce barriers to access to care for Americans living with OUD. The updated recommendations aim to support initiation of buprenorphine treatment in the emergency department and other urgent care settings," the society said in the release.

"In addition, [the recommendations] provide greater flexibility on dosing during the initiation of buprenorphine treatment and for initiation of buprenorphine at home (which is also an important change in the midst of the COVID-19 crisis)."

The full document is available online.

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