This content was published on April 6, 2020 following a session of the BC ECHO on Substance Use about caring for patients on opioid agonist therapy (OAT) during the COVID-19 pandemic. Clinical guidance is rapidly changing in the context of COVID-19. For up-to-date information, please see https://www.bccsu.ca/covid-19/.
A PDF of this text can be downloaded here.
Q: We know that pharmacists can deliver controlled drugs – can anyone else deliver medications?
A: As of March 19, Health Canada has issued exemptions under the Controlled Drugs and Substances Act which permit pharmacy staff to support the delivery of controlled medications. However, in BC at present, only pharmacists are permitted to deliver OAT medications. Guidance on operationalizing these exemptions is available on the College of Pharmacists of BC (CPBC) website.
Health Canada has also made Section 56 exemptions that permit nurses to transport narcotics, including OAT. Individual health authorities and employers in BC are exploring how to operationalize these exemptions. At this time CPBC policies do not permit nurses to pick up medications for patients.
Q: What sort of personal protective equipment (PPE) should community partners be using when responding to an overdose? Currently, wearing gloves and surgical masks while applying low flow oxygen and administering Narcan (naloxone) are some precautions, but is there any further guidance?
A: The BCCDC website provides information for people who use substances and links to other resources. This site recommends (as of April 1, 2020) using gloves and the face shield/breathing barrier in naloxone kits to give rescue breaths, which has a one-way valve and large impermeable area which protects the responder from respiratory secretion. Using the face shield/breathing barrier may not fully protect against COVID-19 transmission. This guidance continues to change, so it is advised to continue to check the BCCDC website.
The BCCDC also has a clinical care page for health care professionals treating people who use substances, which can be found here.
Guidance continues to evolve and new resources will continue to be released.
Q: What if telehealth is not a feasible method to reach my patients (e.g., patients don’t have access to a phone)? Is it appropriate to extend prescriptions for people who I haven’t seen to make sure they don’t run out?
A: Yes, in the context of COVID-19, it’s especially important to support people to stay on OAT. You can check PharmaNet for missed doses, as well as call and discuss with the pharmacist who can let you know how the person is doing, that they are alert and if they would like a dose adjustment. In the event you are not at your clinic practice site, it may not be possible to access PharmaNet and you may need to make alternative arrangements with your clinic to access this information or connect with your pharmacist colleague. As before, Pharmacists can offer an emergency supply of prescription drugs (including narcotics) for continuity of care, under Professional Practice Policy 31 within their scope, if appropriate.
Q: What does “clinically stable” mean for providing carries?
A: This term is intentionally non-specific, to allow for each health care provider to document how “clinically stable” has been defined on a case-by-case basis. Prescribers must weigh the benefits of prescribing carry doses with the risk of overdose, diversion, or risk to household members. If prescribing carries, prescribers should also ensure that the patient is able to safely store their medication, has a naloxone kit, and has been trained on how to administer naloxone.
Q: For people on methadone or slow-release oral morphine, would it be appropriate to provide carries to individuals who are still using illicit opioids?
A: If a patient is continuing to use non-prescribed opioids, the health care provider should think about strategies to minimize risk to the individual. In the Fraser and Vancouver Coastal Health regions, the environments in which patients access illicit opioids is becoming more dangerous as the supply decreases. Where clinically appropriate, providing carries can be an option to help ensure that these patients continue to have access to their medications and reduce their opportunity for exposure to COVID-19.
Q. We have heard safe supply guidance may be coming. Any updates?
A. The BCCSU has published interim clinical guidance, Risk Mitigation in the Context of Dual Public Health Emergencies, for reducing risk of withdrawal and exposure to COVID-19 for individuals who use drugs.
Q: What is the current advice regarding pharmacy contact during OAT delivery? Specifically, around pharmacists having to sign and the potential for COVID transfer via pens and other things?
A: Pharmacists should refer to the College of Pharmacists of BC (https://bcpharmacists.org/covid19) for guidance on patient and pharmacy staff safety, including reducing the spread of the coronavirus through signing the OAT accountability log. Take all precautions you can, including disinfection, restricting contact, etc. If you are makingprocedural changes in the best interest of your patients and your staff’s health, ensure you document your temporary policy and that it is understood by all staff.
Q: Can you change doses or initiate prescriptions through a phone call?
A: The College of Physicians and Surgeons of British Columbia currently supports the increased use of telemedicine (i.e. phone or video consultations) with patients in the context of COVID- 19, including changing doses and initiating prescriptions.
Physicians who use phone or video appointments should continue to document all key information in medical charts, including measures taken in the interest of patient safety. Obtain consent at the beginning of the conversation for discussing medical information over the virtual platform.
For example, when initiating a new opioid or OAT start, ask questions about current use, such as:
- Tell me about your opioid use? IV/Smoking/oral?
- How much money do you spend per day?
- How old where you when you first used? At that time was it IV/Smoking/oral
- How long after that did you start using daily?
- When did you change to IV/Smoking/oral?
- What is the longest period you have gone with no opioids at all?
- For treatment, what was the dosing and timeline of: methadone, Suboxone, Kadian?
- Have you had any overdoses?
- Do you have HIV/Hep C?
Ask about a history of the physical exam findings of withdrawal and use history to determine a potential diagnosis. For example, document:
A/P severe OUD
COVID protocol – no UDT
OAT options discussed
Started: Kadian 300mg PO DWI April 1 – 23
In the absence of having patients in a monitored setting, be judicious about starting doses and always practice with patient safety in mind. Refer to the following resources for guidance on virtual care.
Q: Can we be assured that liquor stores will be deemed essential services and remain open?
A: Currently in British Columbia, liquor retail is considered an essential service, meaning the Provincial Health Officer has encouraged the service to remain open, where possible. While larger alcohol retailers are anticipated to remain open, smaller, independent shops may close, making it more difficult for patients to access alcohol by traditional means. Further, non- beverage alcohol supplies may be interrupted. Based on the high percentage of alcohol present in non-beverage alcohol, these individuals will be at high risk for severe withdrawal.
The BCCSU has guidance forthcoming on managing AUD during COVID-19, as well as preliminary guidance in Risk Mitigation in the Context of Dual Public Health Emergencies. The Canadian Managed Alcohol Program Study (CMAPS) has also published a resource on safer drinking during COVID-19.
- BCCSU COVID-19: Information for Health Care Providers Regarding Alcohol Use Disorder and Withdrawal Management (forthcoming)
- Safer Drinking Tips During COVID-19
Q. Are there any updates on the Kadian shortage?
The BCCSU has published a bulletin on the Kadian shortage here. Updates will be published here.
Resources
- BCCSU Bulletin COVID-19: Information for Opioid Agonist Treatment Prescribers and Pharmacists
- Harm Reduction Coalition fact sheet on COVID-19 for harm reduction providers
- BCCDC: COVID-19 guidance on harm reduction and overdose response
- Section 56 exemptions
- The BC College of Nursing Professionals has specific standards for nurse practitioners prescribing narcotics via telehealth on their website—see NP scope/practice/prescribing/principle 13. BC College of Nursing Professionals: Prescribing Drugs: Standards
- There are standards on the BCCNP website for nurses dispensing with pharmacist involvement. BC College of Nursing Professionals: Dispensing Medications
- PHSA Virtual Health COVID-19 accessible solution toolkit
- College of Pharmacists of British Columbia – temporary authorizations for controlled drugs and substances
- College of Pharmacists of British Columbia – Novel Coronavirus (COVID-19)