Opioid Use Disorder (OUD) in the COVID-19 Context

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The Opioid Use Disorder (OUD) in the COVID-19 Context resource is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Last reviewed: November 16, 2020

Last updated: October 21, 2020

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Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

This tool has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for patients living with OUD. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.

Seek support: The following information is for primary care providers who are proficient in OUD management. If you need support providing the best care possible for your patients, consult specialists via OTN eConsult or by contacting the physicians at your local RAAM clinic.

Key takeaway

Individuals living with OUD are at greater risk of overdose, withdrawal and other harms due to limited or toxic illicit drug supply during the COVID-19 outbreak. It is therefore important to put measure in place to ensure continuity of care and uninterrupted access to OAT medications for patients living with OUD during this time (BC Centre on Substance Abuse, March 11, 2020).

Click on the sections below to get started:

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What's new, what's changed

Use virtual care approaches when possible to conduct regular assessments in order to support physical distancing and reduce overall risk. Frequency of assessments should be based on when clinical decisions are being made (e.g. doses and take home doses are being adjusted) and when support is needed for patients who may no longer have access to meetings, groups or counselling.

It is noted that the 2011 MMT guidelines (CPSO, 2011) require a physical exam to be performed shortly after initiation of methadone. The guideline group at CAMH/META:PHI/OMA (August 14, 2020) have suggested that the requirement to implement the physical exam be determined using clinical discretion during the COVID-19 pandemic, and have stated their support for deferring the physical exam in to support physical distancing when necessary.

Putting it into practice

Inquire into how the patient is doing. Provide non-judgmental and supportive care approaches.
Ensure availability of naloxone kits and training on their use.
If you are newly prescribing opioid agonist therapy (OAT) for a patient with OUD, see the Opioid Use Disorder Tool (CEP, 2018) for steps. Contact the patient’s local RAAM clinic to check if they are accepting patients for on-site OAT induction during COVID-19. If a local RAAM clinic is unable to offer on-site OAT induction, ask if the RAAM clinic physician can provide you/your patient with support implementing a home induction (CEP, 2018). Alternatively, seek support via OTN eConsult.

Adapted from: BC Centre on Substance Abuse (March 31, 2020).

Treatment

A number of changes have been put in place to support providers to ensure uninterrupted access to OAT medications for their patients (BC Centre on Substance Abuse, March 31, 2020):

Control substance prescription exemptions
Urine drug screening no longer required for prescribing
Exceptional OAT take home doses allowed

Putting it into practice

Control substance prescription exemptions

During the pandemic, exemptions have been put in place to permit providers to verbally provide prescriptions for controlled substances and allow home delivery of controlled substances to patients (Government of Canada, 2020). See New OHIP codes and updates to prescribing rules and regulations for details.

Urine drug screening no longer required for prescribing

Urine drug screens are not required and should only be performed at the time of a clinical visit when the results can be discussed to guide care and not as a requirement for prescribing. Clear/negative urine drug screens are not needed with either of buprenorphine-naloxone or methadone (CAMH/META:PHI/OMA, August 14, 2020).

Exceptional OAT take home doses

During COVID-19, exceptional OAT take home doses should be considered. Balance the facilitation of physical distancing by reducing pharmacy and clinic visits with considerations of patient and community safety (CAMH/META:PHI/OMA, August 14, 2020).

Assess patient’s suitability for exceptional OAT take home doses based on their social stability, access to safe housing and ability to manage and safely store take home doses (i.e. a locked box) (CAMH/META:PHI/OMA, August 14, 2020).

Patients not suitable for take home doses if:

Intoxicated or sedated when assessed.
Unstable psychiatric comorbidity (acutely suicidal or psychotic).
Has had a recent overdose.
Currently using illicit substances in high-risk ways; particular caution to be exercised with methadone if patients are using alcohol or benzodiazepines in high-risk ways or injecting high-dose intravenous illicit opioids.

Is patient deemed suitable for take-home doses?

Adapted from: COVID-19 Opioid Agonist Treatment Guidance (CAMH/META:PHI/OMA (August 14, 2020).

Buprenorphine-naloxone take home-doses

Prescribe up to four weeks of take home doses, regardless of how long patient has been on buprenorphine-naloxone. Buprenorphine-naloxone take home doses are considered differently from methadone due to safety profile with overdose risk and diversion, therefore patients can receive longer duration take home doses.
Use clinical judgment to determine whether to be progressive with take home doses (e.g. advancing from one to four weeks).
Very stable patients may be assessed less frequently (e.g. every six to 12 weeks).

Methadone take home doses

Use the Methadone carries table (CAMH/META:PHI/OMA, August 14, 2020) in the Opioid Agonist Treatment Guidance document to determine the number of take home doses to be provided during COVID-19 based on the number take home doses authorized before COVID-19.

Continue with regular OAT witnessed doses.

For patients with suspected or confirmed COVID-19

For patients with suspected or confirmed COVID-19, all reasonable measures should be explored to support patients to remain in self-isolation (CAMH/META:PHI/OMA, August 14, 2020):

Pharmacy delivery services
Virtual witnessed dosing
Designated agent to pick up or receive take home doses

Putting it into practice

Pharmacy delivery services

Arrange delivery of prescriptions where feasible through pharmacy delivery services. See Patient resources below for pharmacies in your area (CAMH/META:PHI/OMA, August 14, 2020).

Virtual witnessed dosing

Leverage virtual care approaches to support witnessed dosing (CAMH/META:PHI/OMA, August 14, 2020).

Designated agent to pick up or receive take home doses

If pharmacy delivery is not available, support patient to arrange a reliable, designated agent (e.g. family member or friend) to pick up or receive the take home doses or closely coordinate patient attendance with pharmacy staff so that appropriate precautions can be taken (CAMH/META:PHI/OMA, August 14, 2020).

Opioid overdose prevention

Overdose risk

During the COVID-19 outbreak, individuals who use opioids (authorized and unauthorized use) may be at greater risk of overdose, withdrawal and other harms due to limited or toxic illicit drug supply, as well as increased stress and anxiety. Factors that may increase an individual’s risk of opioid overdose during the pandemic are (WHO, 2018; McMaster, 2017):

Using opioids beyond prescribed limits or unauthorized use (e.g. opioids that were not prescribed for patients or obtained from illicit or unknown drug supply) use.
Relapse or use after a period of not consuming drugs.
Concomitant use of alcohol and/or other medications (e.g. antidepressants, sedatives, anti-seizure medications).
Active or prior substance use disorder and serious mental illness.
Taking a higher dose than the individual is used to (see table below). Fatal and non-fatal overdose risk increases with dose, but is significant at doses as low as <20 mg morphine equivalents daily.

Dose

>100 mg MED/d
50-99 mg MED/d
<20 mg MED/d

Fatal overdose

0.23%/yr
0.18%/yr
0.1%/yr

Non-fatal overdose

1.8%/yr
0.7%/yr
0.2%/yr

Adapted from Opioid Manager (2017) Tool.

Fentanyl and other opioids can slow a person’s breathing rate, so a COVID-19 infection may increase the risk of overdose death from opioids (BC Centre for Disease Control, July 8, 2020). Some underlying medical conditions such as chronic lung disease and serious heart conditions seem to increase risk of severe illness from COVID-19. If the patient’s drug use has affected their health (e.g. worsening cardiac and lung diseases, hepatic disease, HIV, seizures) they may be at increased risk of severe illness from COVID-19 (CDC, July 7, 2020).

Overdose prevention

Opioid prescribing

Counsel that there is an increased risk of overdose if opioids are used together with alcohol and/or medications (e.g. antidepressants, sedatives, anti-seizure medications).
Counsel patients on importance of adhering to prescribed use.
Counsel patients on importance of safe storage and safe disposal (ISMP Canada, 2020):
- Storage: Choosing a location that is out of sight from children and visitors, avoiding leaving pills on countertops, tables and nightstand and keeping opioid medications in a case instead of an easily opened plastic bag.
- Disposal: Bringing unused medications to the local pharmacy. For a list of pharmacies that are in the patient’s area, see CEP’s Local Services resource.
Counsel patients who you may be aware is using opioids that you did not prescribe for. Direct them to addictions treatment facilities (see META:PHI), counsel them about increased risk for overdosing and how to procure naloxone.
All patients on opioids should be encouraged to obtain take-home naloxone (kit or intranasal spray) from their pharmacist. This is particularly important for patients on doses of >50 morphine equivalent dose (MED)/day, and those with a history of overdose or concurrent benzodiazepine use (CEP Opioid Use Disorder Tool, 2020). Direct your patients on where to get a free naloxone kit in Ontario (MOH, 2020).

Opioid tapering

A long-term taper is a slow process. During the pandemic, clinicians should decide whether to start or continue a taper for a given patient on a case-by-case basis based on the individual’s needs and goals. If the patient is interested in continuing the taper and unauthorized use (e.g. street drug use) is not an issue, it is reasonable to consider continuing the taper during the pandemic (BC Centre on Substance Use, April 17, 2020).

Taper slowly. Abrupt stoppage of opioids may trigger unauthorized use and create risk for overdose.
A patient at higher risk of seeking out street drugs while tapering is at higher risk of overdose. It may be prudent to pause the taper. (BC Centre on Substance Use, April 17, 2020).
Tolerance of previous doses of opioids is lost after 1-2 weeks. Advise patients not to increase their current dose without supervision to help with withdrawal symptoms or pain, as this could result in possible overdose.

For assistance with opioid tapering, see CEP’s Opioid Tapering Template (2018)

Opioid use disorder

Screen for opioid use disorder in patients who had been prescribed opioids, and those with confirmed or suspected unauthorized use (e.g. history of opioid use disorder, recent discharge from substance use program, recent release from incarceration, etc.). See Opioid Use Disorder (OUD) in the COVID-19 Context > Screening for additional guidance on screening for OUD.
Emphasize community supports to individuals with opioid use disorder:
- Continue to use overdose prevention services (OPS), supervised consumption sites (SCS) and supportive housing OPS sites during the pandemic. Regular cleaning occurs at these sites to help reduce the risk of COVID-19 infection.
- For a list of rapid access addiction medicine clinics (RAAM clinics), see META:PHI.
- For a list of all local services with updated COVID-19 hours, including pharmacies, community housing, food banks and more, see CEP’s Local Services resource.

Responding to an opioid overdose

It is important to advise patients and/or their family to recognize the signs and symptoms of an overdose. Signs and symptoms of an opioid overdose (AHS, 2020):

Respiratory depression (slow/ineffective breathing)
Loss of consciousness
Choking or throwing up
Making gurgling sounds
Cold and clammy skin

Steps

1. Call 911

2. Follow the SAVE ME steps

Stimulate – Check if responsive. If unresponsive, call 911 if haven’t already.
Airway – Remove anything blocking the airway.
Ventilate – Help them breathe. Plug the nose, tilt the head back and give one breath every 5 seconds.
Evaluate – Do you see an improvement? Is the person breathing? If not, prepare naloxone.
Muscular injection – 1 dose (1cc) into a muscle
Evaluate and support – Is the person breathing? Naloxone usually takes effect in 3-5 minutes. If the person is not awake in 5 minutes, give one more 1cc dose of naloxone.

For more detailed instructions, see Responding to an Overdose (BC Centre for Disease Control, July 8, 2020).

3. Keep in mind risk of COVID-19 transmission

There is a risk of transmission of COVID-19 in responding to an overdose – particularly if rescue breaths are given without protective equipment. The gloves and CPR face shield included in each naloxone kit should be used. Taking basic precautions will minimize the risk of infection of both the person overdosing and the responder (BC Centre for Disease Control, July 8, 2020).

Resources

For patients

Pharmacies

North: North West, North East
West: Erie St. Clair, South West, Waterloo Wellington, Hamilton Niagara Haldimand Brant
Central: Central West, Central, Mississauga Halton, North Simcoe Muskoka
East: Central East, South East, Champlain
Toronto: Toronto Central

Other resources

For providers

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Acknowledgement and legal

The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach. They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

Clinical Working Group

A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:

• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP

In addition to our clinical working group the CEP also obtained feedback from others, including:

• Arun Radhakrishnan, MSC, MD, CM, CCFP
• Central Region Primary Care Leadership
• David Daien, MD, CCFP
• David Makary, MD, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH

Lastly, for certain sections, the CEP also obtained feedback from others, specifically:

Readiness assessment for delivering in-person care
Operational requirements for in-person care
COVID-19 Provincial Primary Care Advisory Table
• David Price (Chair), MD
• Andrea Sereda, MD
• Annelind Wakegijig, MD
• Beth Sweeney
• Cathy Faulds, MD
• David Daien, MD
• David Kaplan, MD
• Kamila Premji, MD
• Kelly Van Camp
• Kim McIntosh, MD
• Michael Green, MD
• Rebecca Carson
• Sarah Newbery, MD
• Thuy-Nga (Tia) Pham, MD
System stakeholders
• Registered Nurses Association of Ontario
• Association of Family Health Teams of Ontario

Thank you to everyone who supported the development of this resource.

The Opioid Use Disorder (OUD) in the COVID-19 Context resource is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Opioid Use Disorder (OUD) in the COVID-19 Context resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).

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