ADD5107: Week 9 Discussion 1: Harm Reduction

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Harris et al. Addict Sci Clin Pract (2021) 16:13 https://doi.org/10.1186/s13722-021-00221-1

COMMENTARY

Adapting inpatient addiction medicine consult services during the COVID-19 pandemic Miriam T. H. Harris1,2* , Alyssa Peterkin1,2, Paxton Bach3,4, Honora Englander5, Emily Lapidus1, Theresa Rolley1, Melissa B. Weimer6 and Zoe M. Weinstein1,2

Abstract

Background: We describe addiction consult services (ACS) adaptations implemented during the Novel Coronavirus Disease 2019 (COVID-19) pandemic across four different North American sites: St. Paul’s Hospital in Vancouver, British Columbia; Oregon Health & Sciences University in Portland, Oregon; Boston Medical Center in Boston, Massachusetts; and Yale New Haven Hospital in New Haven, Connecticut.

Experiences: ACS made system, treatment, harm reduction, and discharge planning adaptations. System changes included patient visits shifting to primarily telephone-based consultations and ACS leading regional COVID-19 emer- gency response efforts such as substance use treatment care coordination for people experiencing homelessness in COVID-19 isolation units and regional substance use treatment initiatives. Treatment adaptations included providing longer buprenorphine bridge prescriptions at discharge with telemedicine follow-up appointments and completing benzodiazepine tapers or benzodiazepine alternatives for people with alcohol use disorder who could safely detoxify in outpatient settings. We believe that regulatory changes to buprenorphine, and in Vancouver other medications for opioid use disorder, helped increase engagement for hospitalized patients, as many of the barriers preventing them from accessing care on an ongoing basis were reduced. COVID-19 specific harm reductions recommendations were adopted and disseminated to inpatients. Discharge planning changes included peer mentors and social work- ers increasing hospital in-reach and discharge outreach for high-risk patients, in some cases providing prepaid cell phones for patients without phones.

Recommendations for the future: We believe that ACS were essential to hospitals’ readiness to support patients that have been systematically marginilized during the pandemic. We suggest that hospitals invest in tel- ehealth infrastructure within the hospital, and consider cellphone donations for people without cellphones, to help maintain access to care for vulnerable patients. In addition, we recommend hospital systems evaluate the impact of such interventions. As the economic strain on the healthcare system from COVID-19 threatens the very existence of ACS, overdose deaths continue rising across North America, highlighting the essential nature of these services. We believe it is imperative that health care systems continue investing in hospital-based ACS during public health crises.

Keywords: Addiction, Inpatient, Consult, COVID-19, Substance use disorders, Homelessness, COVID-19, Social- distancing

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Addiction Science & Clinical Practice

*Correspondence: [email protected] 2 Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA Full list of author information is available at the end of the article

Introduction The Novel Coronavirus Disease 2019 (COVID-19) pandemic forced hospital inpatient addiction consult services (ACS) to rapidly evolve as hospitals modi- fied operations to care for people with COVID-19 and protect staff and other patients from infection. When

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hospital systems are overwhelmed there is a risk that people with substance use disorders (SUD) will be fur- ther deprioritized as well-known structural barriers to treatment, namely stigma, lack of clinician training in addiction, and clinician discomfort, may be exacer- bated [1].

It is critical to continue to prioritize and address sub- stance use in the hospital setting as people with SUD may be particularly vulnerable to the psychosocial and medical effects of the COVID-19 pandemic. Peo- ple with SUD may be at increased risk of relapse and acquiring infections such as HIV and HCV due to social distancing mandates causing isolation and stress, as well as disruptions to harm reduction and treat- ment services. Additionally, factors including home- lessness and increased rates of incarceration place people with SUD at higher risk of contracting COVID- 19, and higher rates of medical comorbidities also increases their risk of severe COVID-19 infection [2]. Alarmingly, opioid overdose rates in 2020 have already exceeded those of other years and continue to rise [3]. For all of these reasons, hospital-based addiction care, which has been shown to reduce substance use [1], improve patient trust in clinicians [1], increase addic- tion treatment retention [1], and reduce recurrent hos- pitalizations [4], remains of utmost importance during the COVID-19 pandemic.

COVID-19 introduces challenges and some poten- tial opportunities in caring for hospitalized people with SUD. In this perspective piece, we describe real world ACS adaptation experiences from: St. Paul’s Hospital in Vancouver, British Columbia; Oregon Health & Sciences University (OHSU) in Portland, Oregon; Boston Medical Center (BMC) in Boston, Massachusetts; and Yale New Haven Hospital (YNHH) in New Haven, Connecticut instituted during the COVID-19 pandemic. We reflect on our experiences to inform ACS responses during this current and for future public health emergencies and highlight areas in need of research.

Hospital‑based addiction consult service adaptations ACS adaptations context and timing In British Columbia, the first case of COVID-19 was reported on January 28th, 2020. Increasingly strict physical distancing regulations were implemented in the following months, but due to generally low over- all provincial case counts hospital personnel continued to deliver in person care at St. Paul’s throughout the pandemic. Oregon confirmed its first case of COVID- 19 on February 28th, and by March 13th OHSU had implemented COVID-19 modified operations includ- ing restricting all patient visitors and encouraging staff who could to utilize telemedicine to preserve personal

protective equipment (PPE) and promote physical dis- tancing. In Massachusetts the first case of COVID-19 was reported on February 1st, and in March BMC rapidly reorganized by shifting outpatient care to predominately telemedicine and recommending that inpatient hospital staff when possible work from home with patient visits being conducted by phone to similarly conserve PPE and protect staff from infection. Connecticut confirmed its first case of COVID-19 on March 8th, with comparable rapid reorganization occurring at YNHH in March to support PPE conservation and infection control.

Policy changes to medications for opioid use disorder (MOUD) access and administration were rapidly enacted in all settings to help fight the spread of COVID-19. In British Columbia increased flexibility for patients access- ing MOUD were first recommended on March 17th, 2020, with interim clinical guidance on the prescribing of pharmaceutical alternatives to illicit opioids (“safe sup- ply”) issued shortly afterwards [5]. Such policies were gradually adopted into the work of the ACS team at St. Paul’s Hospital over the year in response to rising case numbers and worsening of the overlapping overdose cri- sis. Following the public health state of emergency dec- laration in the United Sates (US) on January 31st, 2020 the Acting Drug Enforcement Administration and the Substance Abuse and Mental Health Service Adminis- tration stipulated in March 2020 that telemedicine could be used to initiate buprenorphine [6] and they developed new methadone opioid treatment program guidelines [7] that liberalized take home methadone dosing. ACS lead- ership at OHSU, BMC, and YNHH all quickly instituted ACS adaptations starting in March 2020 that incorpo- rated these policy changes and hospital wide infection control and PPE conservation efforts into new workflows, billing requirements, and modes of patient and team communication.

System & procedural adaptations Across most of our respective ACS, early in the pan- demic, patient visits shifted to primarily telephone-based consultation paired with ACS staff working from home to conserve PPE and promote physical distancing (please see Table 1 for all site-specific adaptations). However, both system level issues as well as patient-specific fac- tors necessitated in-person contact at times. Across all sites hospital room phones were often broken or absent and many patients did not have working cell phones, obliging in-person visits. Video capability was not yet established at the four ACS sites nor feasible in the beginning of the COVID-19 pandemic. Telephone visits also limited clinicians’ access to non-verbal information, therefore, in-person visits were helpful for patients with

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limited engagement, acute pain, somnolence or acute intoxication.

ACS teams were concerned that the reduced patient contact and visitation limitations would make hospitali- zation experiences more stressful. Therefore, at BMC, when possible, peer mentors increased contact with patients through daily tele-check ins. At all sites, ACS also enhanced their relationships with other care provid- ers, like the bedside nurse and primary team, who took over delivering wellness materials such as, art supplies, journaling resources, and readings in addition to provid- ing clinical updates regarding management of withdrawal and safety assessments to ACS teams.

At BMC and YNHH, during the initial peak of regional COVID-19 cases, ACS consult requests declined despite high overall hospital volumes. Because early engagement is critical to treat acute substance withdrawal, initiate effective SUD treatments, and reduce the risk of leaving prior to medical treatment completion [1], ACS teams at BMC and YNHH pursued proactive outreach by con- tacting primary teams where SUD was noted in patients’ problem lists, or where buprenorphine and methadone were prescribed, to address SUD and support therapeutic alliances between patients and primary teams [1].

ACS led and adopted hospital and regional initiatives in response to SUD systems’ disruptions. The YNHH ACS team developed reference guides [8], and OHSU, BMC, and YNHH created electronic catalogues, and electronic medical record templates that were constantly updated to reflect the rapidly evolving community treatment land- scape. These were shared with patients and other primary hospital teams. OHSU ACS leadership convened com- munity SUD leaders through a SUD COVID-19 Response ECHO tele-mentoring program to support an integrated, collaborative pandemic response, partly to support com- munity treatment access statewide. At BMC, in order to minimize readmissions, ACS proactively offered enhanced peer outreach and treatment system navigation to patients after discharge.

Treatment adaptations Regulatory changes in the US and Canada [5–7, 9] instituted to adapt outpatient treatment of SUD to the COVID-19 pandemic had perceived impacts on our inpa- tient addiction treatment experiences. For example, for patients continued or initiated on buprenorphine in the hospital, clinicians commonly paired longer buprenor- phine bridge prescriptions at discharge with telemedicine follow-up appointments [9]. At OHSU, this flexibility was associated with perceived increased interest in buprenor- phine and engagement from hospitalized patients. At BMC, a local opioid treatment program with close hos- pital ties relaxed intake procedures regarding the type

of photo identification accepted for intake, which we believe resulted in methadone access expansion for inpa- tients. To mitigate interruptions in methadone treatment in patients who were infected with COVID-19, YNHH worked with local opioid treatment programs to facilitate delivery of methadone to patient’s homes or other treat- ment settings made possible by the liberalization to take home methadone. In Vancouver, Canada, restrictions were relaxed on take-home opioid agonist treatments (methadone, buprenorphine, and slow-release oral mor- phine) and in select cases physicians at St. Paul’s hospital were encouraged to consider prescribing pharmaceutical alternatives to illicit substances (i.e. “safe supply” e.g. pre- scribed hydromorphone tablets for consumption and not treatment of OUD) in order to help promote physical dis- tancing recommendations [5]. In St. Paul’s, ACS felt that these changes helped increase engagement for hospital- ized patients, as many of the barriers preventing them from accessing care on an ongoing basis were reduced.

People with alcohol use disorder requested more out- patient detoxification, rather than traditional placement to a detoxification facility or residential treatment pro- gram. Therefore, across most sites ACS recommended completing benzodiazepine tapers or benzodiazepine alternatives for patients who could safely detoxify in the outpatient setting. Outpatient detoxification were only completed if patients initially requiring hospitalization for alcohol withdrawal were clinically stable at discharge [9], had safe place to complete the detoxification, and had an outpatient clinician who could complete a follow up assessment.

Harm reduction adaptations COVID-19 challenged traditional inpatient harm reduc- tion recommendations and supports. Messages like “don’t use alone” contradicted new physical distancing mandates. COVID-19 specific harm reduction recom- mendations messages were adopted by all ACS and dis- seminated to inpatients [10]. Messaging included keeping extra naloxone on hand or cleaning syringes with bleach when access to sterile needles were not available [10]. In Vancouver, innovative strategies such as virtual super- vision methods which could call 911 to a pre-specified location should someone become unable to respond to prompts provided by their cell phone were devel- oped to monitor for unintentional overdoses. If inter- ested, patients were connected to these resources while hospitalized.

Discharge planning adaptations Discharge planning was particularly challenging early in the pandemic for people with SUD infected with COVID-19. Few community detoxification, sober homes,

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residential programs, and shelters accepted people who were COVID-19 positive, leading to higher rates of unsafe discharge plans (e.g. discharging to the street). At all sites temporary isolation and recovery unites were eventually established for people unable to safely isolate (e.g. person’s experiencing homelessness) to recover from COVID-19 and reduce transmission in the shelter sys- tems, on the street, and within crowded housing. These units offered some patients with SUD a place to go fol- lowing their acute care hospitalization. The establish- ment of the units required intensive ACS support to aid with the rapid development of SUD protocols to ensure withdrawal and SUD treatment in these units, care coor- dination for hospitalized patients, expansion of telemedi- cine consultations, coordination with opioid treatment programs to deliver methadone, and SUD care continu- ation post discharge.

At BMC peer mentors and social workers also increased discharge outreach for high-risk patients, in some cases supported by the hospital providing prepaid

cell phones for patients without phones. Cell phones provided to patients were flip phones pre-loaded with 1500 min; capabilities included calling, texting and inter- net access. At OHSU, lack of patient phones was a com- mon barrier to telemedicine follow up and outreach early in the pandemic; however, through ACS advocacy with payers, pre-paid phones were made available later in the pandemic. At YNHH and St. Paul’s resources for phones were not provided to patients which limited access to both inpatient and outpatient telemedicine.

Financial impact Despite the increased impact of COVID-19 on peo- ple with SUD, the pandemic’s financial impact to the health service sector has threatened financial stability of ACS teams. Inpatient ACS remain limited across the continent and historically have operated on extremely restricted or unstable budgets. YNHH and BMC ACS teams were asked to redeploy physician staff for COVID-19 initiatives, necessitating back up coverage or

Table 1 Incremental cost utility ratio (QALY obtained from Index Value) Institutional ACS Locations St Paul’s, Vancouver OHSU, Portland BMC, Boston YNHH, New Haven ACS adaptation timing 03/2020* 03/2020* 03/2020* 03/2020* System/procedural adaptations Shifted to predominately telemedicine visits

Proactive use of EMR to find new consults

Increased coordination and communication with bedside nursing and primary teams Reference guide, electronic catalogue, and EMR template development ACS led regional SUD COVID-19 response initiatives

Supported SUD management in COVID-19 Isolation Units

Telemedicine billing expansion to the hospital setting

Treatment adaptations Longer Buprenorphine prescriptions

Prioritized buprenorphine due to telemedicine access

Outpatient benzodiazepine tapers for alcohol withdrawal

Increased hospital peer and social work in-reach

Harm reduction adaptations COVID-19 specific harm reduction counseling

Prescribing of pharmaceutical alternatives to illicit substances (“safer supply”) Connection to virtual supervision methods

Discharge planning adaptations Coordination with COVID-19 isolation and recovery units

Increased outreach post discharge

Increased connection with community outreach teams

Enhanced ability to distribute prepaid mobile phones

COVID-19: Novel Coronavirus Disease 2019; ACS; addiction consult service, OHSU; Oregon Health & Sciences University, BMC; Boston Medical Center, YNHH; Yale New Haven, EMR; electronic medical record, SUD; substance use disorder *Changes that were ins tuted star ng in March have been dynamic based on local case rates and guidance from local hospital leadership and publ ic health departments

*Changes that were instituted starting in March have been dynamic based on local case rates and guidance from local hospital leadership and public health departments

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a reduction in ACS services. At YNHH, hiring freezes halted the filling of open positions. At OHSU and BMC, ACS expansion efforts have been significantly delayed or cancelled. This is despite a perceived surge of hospital SUD related admissions in all settings following the first wave of the pandemic. In the US, billing for services was also limited without in-person consultation in the early pandemic, so many ACS saw a temporary reduction in revenue.

Recommendations for the future Our experiences, across four hospitals in North America, highlight critical challenges to providing care to hospital- ized people with SUD during the COVID-19 pandemic and responses to these challenges (Table 1). As efforts to maintain physical distancing and preserve personal protective equipment are likely to remain for months to come, we believe that hospitals must invest in telehealth infrastructure within the hospital and consider cellphone donations for people without cellphone access to help with post-discharge follow-up. We see such concrete steps to maintain access to care by integrating or provid- ing telemedicine tools as critical components to provid- ing equitable care to patients such as those with SUD experiencing homelessness who have limited access to technologies needed for telemedicine. BMC ACS is cur- rently evaluating its cellphone distribution program. Further studies evaluating telehealth and other inclu- sive approaches to telecommunication technologies are needed to understand current gaps and potential impacts of telehealth, particularly with regards to vulnerable populations.

We believe that ACS were essential to hospitals’ readi- ness to support systematically marginalized patients during the pandemic. ACS supported SUD manage- ment and care coordination in COVID-19 isolation and recovery units and led regional SUD care coordination efforts. ACS further leveraged the interdisciplinary team approach during the pandemic where social work and peer services enhanced inpatient and post discharge out- reach. Qualitative studies evaluating the impact of this active outreach strategies on the hospitalization experi- ence would be helpful to gain a nuanced understanding of the pros and cons of more active outreach. Addition- ally, research evaluating the impact of contact with ACS during the pandemic on substance use and other health- related outcomes could quantify its role in supporting hospitalized people with SUD during public health crises. For example, we encourage other ACS leaders and addic- tion clinicians to track metrics that may be impacted by ACS, such as rates of discharges against medical advice among COVID-19 positive patients with SUD who con- nected with ACS versus those that did not.

Regulations loosened during the COVID-19 pandemic, for example tele-buprenorphine access in the US and safer supply programs in Canada, resulted in perceived increased engagement in care during hospitalization as some barriers preventing patients from accessing ongo- ing care were reduced. Due to The Controlled Substances Act, safe supply programs currently undergoing evalu- ation in Canada remain illegal in the US. While studies evaluating the impact of the regulatory changes to safe supply in Canada and MOUD in the US are in progress, we believe that, in the absence of evidence, diminishing barriers in the community to MOUD and harm reduc- tion are critical and had positive impacts on the inpatient management experience.

Conclusion Despite regulatory changes and rapid adaptations, our hospital-based ACS teams were not able to compensate for the larger systemic gaps in the substance use treat- ment system that persisted and were undoubtedly exacer- bated by COVID-19. Ongoing studies at our institutions and others will guide future evidenced based ACS adap- tations, but while we wait for empirical data, we hope the experiences shared here, from four ACS impacted early in the COVID-19 pandemic, may serve as a roadmap for other areas who are more recently facing a surge of COVID-19 admissions. As the economic impact threat- ens the very existence of ACS, overdose deaths continue rising across North America, highlighting the essential nature of these services [3]. In light of these disturbing statistics, we believe that it is imperative for health care systems to continue investing in addiction care, including hospital-based ACS, during public health crises.

Abbreviations COVID-19: Novel Coronavirus Disease 2019; SUD: Substance use disorders; ACS: Addiction consult services; OHSU: Oregon Health & Sciences University; BMC: Boston Medical Center; YNHH: Yale New Haven Hospital.

Acknowledgements Not applicable.

Authors’ contributions The lead author MTHH developed the manuscript idea and lead manuscript writing. ZMW, the last author, oversaw MTHH work and provided guidance and support in addition to substantively contributing to the manuscript content. All other authors contributed content, expertise, and aided with editing and manuscript development. All authors read and approved the final manuscript.

Authors’ information Author represent leaders and members of addiction consult services (ACS) across four hospital sites in North America. Dr. Weinstein is the director of the ACS at Boston Medical Center, in Boston, Massachusetts, where Drs. Peterkin and Harris and Emily Lapidus (social worker) Theresa Rolley (well- ness and recovery advocate) also work. Dr. Englander is the director of the ACS at Oregon Health & Science University Hospital in Portland, Oregon. Dr. Weimer is the director of the ACS at Yale New Haven Hospital in New Haven,

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Connecticut. Dr. Bach is an attending physician on the ACS at St. Paul’s Hospi- tal in Vancouver, British Columbia.

Funding Miriam Harris is supported by the Research in Addiction Medicine Fellowship NIDA (R25DA033211-Samet) and the International Collaborative Addiction Medicine Research Fellowship (NIDA R25-DA037756-Fairburn). Paxton Bach receives support from the Michael Smith Foundation for Health Research.

Availability of data and materials Not applicable.

Ethics approval and consent to participate Was not sought given the commentary nature of the study.

Consent to publish All authors provide their full consent to publish and affirm findings presented here are honest, original, accurate, and transparent.

Competing interests None.

Author details 1 Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA. 2 Clinical Addiction Research and Education (CARE) Unit, Section of Gen- eral Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA. 3 British Columbia Centre on Substance Use, St. Paul’s Hospital, Vancouver, BC, Canada. 4 Department of Medicine, University of British Columbia, Vancouver, BC, Canada. 5 Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA. 6 Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA.

Received: 1 November 2020 Accepted: 4 February 2021

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