Brief Addiction Update re: COVID

Charles Reznikoff, MD, FACPHennepin Healthcare

Charles.Reznikoff@hcmed.org

1. Controlled substance prescribing via telemedicine

Board of Pharmacy FAQ page

Evaluation of patient prior to initiating opioids can be done by telemedicine

“real time two-way audiovisual device”If prudent, refills are allowed again for schedule 3-5

For schedule 2, if prudent, three one-month prescriptions given simultaneously

Reminder that e.prescibing is preferred to in-person prescription pick up irrespective of COVID

file:///C:/Users/cprez/AppData/Local/Packages/microsoft.windowscommunicationsapps_8wekyb3d8bbwe/LocalState/Files/S0/21312/Attachments/FAQ-COVID-19-boardofpharm[33019].pdf

www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf

Helpful DEA website re: COVID www.deadiversion.usdoj.gov/coronavirus.html

Just because you can, does not me you should

Multiple warnings against detoxing people with opioid addictions

Hennepin Healthcare Opioid Prescriptions for Distinct Patients

Diminished visits leading to decreases in individuals given opioid prescriptions by 20%

Feb 2020

National drug shortages?

• Drugs required for sedation have been in shortage, including licit fentanyl

• ICU use is up, and hospitals are stockpiling• DEA has increased production limits • FDA is aware• AMA taskforce lobbying for action on this • A variety of channels available for expressing

concern and reporting events (contact me)

Advice prescribing controlled substances • Continue to prescribe controlled substances for

appropriate indications as before, by telemedicine • If safe and appropriate, refills of controlled substances

are legal • If adequate clinical information can be attained to

establish an indication, controlled substances can be initiated by telemedicine

• Do not detox patients addicted to opioids unless you are qualified/certified

• Check the PMP! • Shortages of sedatives and anesthetics should be

reported to federal agencies

2. Street drug, addiction, and treatment

COVID19 and Addictions• Social isolation • Financial hardship • Loss/changing insurance • Altered/diminished illicit drug supply • Changes to addiction assessments • Changes to addiction treatment delivery • Changes in needle exchange availability • Unequal access to telemedicine, internet • Communal and unstable living• Patient anxiety about leaving home

• Measures implemented to prevent the spread of COVID-19 are having a mixed impact on the drug supply chain

• Restrictions resulting from the lockdown could hinder the production and sale of opiates in major producing countries

• Measures are impeding cocaine production in the short term but a resurgence is likely in the event of economic crisis

• Drug trafficking by air is likely to be completely disrupted by the restrictions imposed on air travel

• Signs of increased use of maritime routes to traffic heroin to Europe• Indications of a reduction in the flow of cocaine is not yet affecting

seizures in destination markets• COVID-19 measures are likely to lead to the stockpiling of drugs• Indications the lockdown is increasing demand for cannabis• Drug shortages have been reported and could have negative health

consequences for people with drug use disorders• Economic difficulties caused by COVID-19 could change drug

consumption for the worsewww.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf

Virtual Addiction Recovery

• Many addiction services changed to telemedicine • 12 step groups (“alcoholics anonymous”) meeting by

telemedicine and in person distanced (outdoors)• https://aaminnesota.org/meetings/ (call the contact number) • Recommend: minimum one AA visit per week

• County approval for accessing addiction treatment, “Rule 25,” by phone or zoom, sometimes in person

• Outpatient addiction therapy groups often by telemedicine, some still in person groups

• Most inpatient addiction centers continuing to accept and care for patients as normal, with COVID precautions

Case 1: Reestablishing Care

• Heather is a 67-year-old woman with tobacco and opioid use disorder (OUD) who had 8 months successfully treated with buprenorphine for OUD

• She relapsed to street opioids and fell out of care• In April she called asking to resume care • She was scared to leave the house; oxycodone was

hard to find and more expensive• We reestablished care by telemedicine; she

(literally) cried with gratitude when we resumed buprenorphine

Decreased availability of street opioids

• Cost of street drugs increased 2-4X locally

• Some patients reluctant to leave the house

• Prescription opioids decreased

• Fentanyl and fentanyl substrates made in Wuhan

Street methadone availability increased • Federal/state agencies loosened methadone dosing

regulations to allow infection control• Clinics allowing more “take out” doses than normal• Each clinic balancing risk/reward differently• Clinic orders for liquid methadone surged, causing

brief “shortage”• There has never been this much methadone on the

streetmn.gov/dhs/assets/Modifications-to-substance-use-disorder-treatment_tcm1053-430202.pdf

Advice for care of opioid addiction during COVID19• Continue to refer to methadone and

buprenorphine treatment for opioid addiction• COVID not a reason to delay a referral

• Prescribe naloxone • Coverages vary usually nasal spray• Naloxone distributions sites next slide

• Needle exchange still available • Methadone Maintenance is not reported on PMP

• Methadone bottles have labels with prescriber and intended patients, report diverted doses to the clinic!

Naloxone services:• Red Door Clinic 612-543-5555 www.reddoorclinic.org/more-services• Rural Actions AIDS Network (RAAN) raan.org/

St. Cloud 800-966-9735Duluth 218-481-7225Mankato 507-345-1011

• Steve Rummler Hope Foundation952-943-3937 steverummlerhopenetwork.org/

• Indigenous Peoples Task Force (IPTF) 612-870-1723 indigenouspeoplestf.org/contact-us/

• Lutheran Social Services (LSS), Street Works 612-354-3345 www.streetworksmn.org/

• Northwest Indian Community Development Center (NWICDC) 218-759-2022 www.nwicdc.org/

• Ka Joog 612-255-3524 www.kajoog.org/• Twin Cities Recovery Project (TCRP) 612-886-2045

twincitiesrecoveryproject.org/• St. Louis County-Public Health 218-725-5260

www.stlouiscountymn.gov/departments-a-z/public-health-human-services

• City of Minneapolis – Public Health 612-673-2301 www.minneapolismn.gov/health/toolkit/opioidresources

3. Alcohol Use Disorder and Withdrawal

Case 2

• 37-year-old man with alcohol use disorder and past alcohol withdrawal seizures laid off from work at a bar, unable to navigate the unemployment application

• Stayed at home and drank hard alcohol until he ran out of money.

• Took the bus to our ED; had an alcohol withdrawal seizure outside of our lobby

• After the seizure, had refeeding syndrome

Alcoholism in quarantine

• Consumption of alcohol at bars and restaurants down

• Purchase of alcohol from liquor stores increased 55%

• Hoarding? Binging? Or just compensating for not going to bars?

• Probably all of the above

• https://www.forbes.com/sites/joemicallef/2020/04/04/how-the-covid-19-pandemic-is-upending-the-alcoholic-beverage-industry/#19a688744b0b

Ind Psychiatry J. 2013 Jul-Dec; 22(2): 100–108.

Alcohol withdrawal is not one thing!

Patients may have none, one or many of these manifestations of alcohol withdrawal

Maldonado alcohol June 2014 48(4)

Wood JAMA 2018; 320 (8) p825

A high score indicates risk

A low score does not rule out risk

Ind Psychiatry J. 2013 Jul-Dec; 22(2): 100–108.

Should this patient be referred to the ED for W/D?

Further reading: Saitz JAMA 2018; 320 (8) p766

Outpatient treatment of mild alcohol withdrawal

• Do not prescribe benzos (Librium Valium Ativan)• I give a ten-day prescription for

• Thiamine rich multivitamin • Gabapentin 300-600 TID• Clonidine 0.1 TID

• I call patient often first 72 hours • Post detox, I transition to treatment

recommendations

Outpatient Treatment of Alcohol Use Disorder • Refer to AA or outpatient groups • Offer FDA approved and effective medications

• Decrease alcohol use and harm from alcohol use • Can be used for “controlled drinking” if patient unwilling to cease • I try each, one at a time or in combo:

Naltrexone 50 mg a day• Nausea, contraindicated w opioids, need recent LFTs

Gabapentin 300-600 TID• Renal adjustment, sedation at first

Acamprosate 666 TID • Renal adjustment, less evidence of efficacy• Not for controlled drinking

4. Tobacco Use Disorder

Case 3 hospitalized patient wishing to smoke• Hospitalized COVID+ patient wishes to go outside

to smoke a cigarette• The patient has mild hypoxia, fever, and is

otherwise stable

• Are they holdable?• If they go for outside to smoke, how do they

reenter the building?

Tobacco and COVID

• Ever-tobacco use is a risk factor for COVID• Likely due to lung or vascular disease

• Current tobacco use not a proven risk factor • Obtaining cigarettes itself a risk • Sharing cigarettes, lighters is common; smoking

together is common• Now is a good time to quit tobacco • Minnesota Quitline includes phone support

https://www.health.state.mn.us/communities/tobacco/initiatives/mnquitlines/index.html

Review tobacco treatment options • Nicotine replacement “NRT” - patch plus gum/lozenge

• Safe and effective, commonly underdosed, no need taper • Caution with inhaler– one does not “inhale”• Nasal spray often causes sneezing

• Varenicline • Renal adjustment, contraindicated in pregnancy • Very well tolerated: nausea and dreams • Best evidence for success quitting

• Bupropion • Many contraindications (bipolar, eating disorder, seizure

pregnancy, renal failure et c)• Works well combined with either varenicline or NRT

Summary

• Most of addiction medicine continues as before• Patients may be uniquely vulnerable in this time• We have good tools to treat and prevent harm from

alcohol, opioid and tobacco addictions