ASAM is tracking federal guidance related to telehealth, including the following. Each state may have their own requirements and regulations concerning OTPs. A larger influx of new patients will likely present during the crisis as the it appears the opioid crisis is worsening in association with the COVID pandemic. Under current regulations, this process will look different depending on whether the patient starts on buprenorphine, naltrexone, or methadone.
As usual, the choice of medication should be made through consultation between the medical provider and the patient with full informed consent. Under the updated federal regulatory guidance, buprenorphine and naltrexone may be initiated during this crisis using telehealth or telephone-based appointments.
An in-person physical examination is not required. The evaluation, treatment planning, and patient education processes should be maintained at the same level as would be performed during a face-to-face encounter. This includes a complete history of substance use, past treatments and responses, periods of recovery, prior episodes of overdose, a medical history, psychiatric history, social history, family history, and review of systems.
During this in-person encounter, the medical provider should take steps to minimize any exposures to themselves or the patient, including having the patient wear a face mask and the provider using appropriate PPE, if available. According to 42 CFR Part 8. It is possible, however, under these regulations for another authorized medical provider, who is not the admitting physician at the OTP, to perform the examination; this exam must be face to face.
Dosing titration is more complex with methadone than with buprenorphine, and during the initiation phase it may not be appropriate to give take home doses, even though this would be permitted under the emergency federal guidance.
Close follow up and medical assessment is necessary during initiation in order to mitigate the increased risk of adverse events, including overdose, that patients are exposed to during this phase.
OTPs should consider giving extended take-home doses when clinically appropriate. Providing more take home doses without requiring frequent in-person visits is likely to reduce risk of exposure to COVID The benefit to the patient, peers, staff and the community of fewer clinic visits for dosing must be balanced against the risks of taking additional doses home in terms of adverse effects to patients and those around them.
Using the 8 decision criteria for dispensing methadone for unsupervised use under 42 CFR Part 8. Patients still using other CNS depressants such as other opioids particularly fentanyl , benzodiazepines, or alcohol may be at higher risk and may not be ideal candidates for extended take-home doses. Other considerations may include:. Based on this risk benefit analysis, the provider should determine if additional take-home doses are appropriate, and how many.
This plan can range from having the patient come in every other day instead of daily, to giving the full 28 or 14 days depending on whether the patient is considered stable or less stable , or anything in between.
Programs should also work to structure patient visits such that they spend the least amount of time possible in the facility. See the Waiting Room Precautions section below. Patients should be educated initially and, ideally, periodically concerning the importance of maintaining their medication securely and away from children and pets. They should be given clear dosing instructions and they should be counseled on the risk of overdose if they take more than their prescribed dose, or if they combine opioids and other CNS depressants, especially benzodiazepines and alcohol.
They should also be re- minded that the program cannot replace lost or stolen doses. However, decisions on replacing lost or stolen doses may be made on a case by case basis with appropriate documentation.
Some patients may be able to work with other trusted family members or a significant other to help monitor their doses, although it is important to be vigilant for dysfunctional or abusive family situations. If appropriate and the patient consents, the program should provide guidance and education to a responsible adult in the home who can help the patient appropriately manage take home medication.
This guidance should include education on safe storage, overdose risk, appropriate dosing, chain of custody procedures, and use of rescue naloxone. Preferably, the naloxone would be dispensed at the OTP, but if this is not possible then it may be accessed through local pharmacies. However, many pharmacies do not stock naloxone. The program should consider working with a local pharmacy or local naloxone distribution programs to ensure that their patients have the ability to fill the prescriptions they are given.
Lack of insurance or co-pay requirements can also hinder access to naloxone, and the program should follow up with patients to see if they were able to access naloxone. All patients granted extended take-home doses should have their contact and emergency contact information reviewed and updated. Some patients given extended doses at home will do well and others will struggle. Medical providers should contact patients regularly to assess for responses to medication, review medication lists, and identify any potential side effects such as sedation or constipation.
Patients who are relatively stable can be managed by telehealth. Those who are unstable may be better served by an in-person visit, again balancing the risk of COVID exposure with the benefit of in-person compared to telehealth contact. Examples of instability that would warrant an urgent in-person visit might include suicidal thoughts, new homelessness, interpersonal violence, difficulty dealing with the pandemic, or involvement of child protective services.
For stable patients, the risk of in-person visits is likely to outweigh the benefits of such visits. OTP personnel must use their clinical judgment in determining when an in-person visit may be beneficial. It is very important to maintain close contact with patients during this time of stress, anxiety, and social isolation.
Telehealth, including both telephone based and audio-visual based check-ins and visits, are an import- ant way of staying connected with and managing patients.
These changes should make it easier to incorporate telehealth. Communication with patients is key during any transition to telehealth services. Programs should continue working with patients to make sure they understand how to join a telehealth visit and should be prepared to adapt to any technical issues that arise.
In addition to the typical assessments and treatment modalities, during this crisis telehealth counseling sessions should address how the patient is responding to the COVID crisis, and should focus on reinforcing social distancing and hygiene practices. Counselors should help patients to problem solve around these issues. Counselors should also talk to patients about what they should do if they develop symptoms. If the patient is receiving additional take-home doses the counselor and medical provider should check in with the patient regularly to determine how they are managing.
Counselors and medical staff should reinforce the risk of overdose and the importance of safe medication storage. Patients should also be encouraged to participate in virtual support groups if appropriate for the individual. Providing services through telehealth does require clinicians to adapt their practices. Programs should encourage staff to participate in virtual trainings on how to effectively provide services through telehealth.
Federal regulations do not require an annual medical exam for patients in OTPs, however it may be required in some states. OTPs in states that require an annual medical exam should reach out to their State Opioid Treat- ment Authority if they have questions related to flexibility around this requirement during the COVID crisis. ASAM members are also encouraged to reach out to their state chapter if state level advocacy is needed. Patients should be connected with primary care practitioners with care coordination occurring with the OTP.
Medical exams by medical providers in the OTP can be conducted through audio-visual telehealth which is likely to yield many of the same benefits as an in-person exam. The provider should determine whether there are risks to the patient associated with either delaying the exam or conducting it through telehealth that outweigh the risks to the patient posed by an in-person visit and potential exposure to COVID The stress, anxiety, and social isolation associated with the pandemic response is exacerbating mental health and addiction symptoms in some patients.
OTPs should assess these symptoms and provide appropriate therapeutic responses on an individual patient basis. Programs should develop policies and procedures for making changes to medication dosages based on phone consultations. OTPs are still required to provide a minimum of 8 drug tests per year for each patient. For patients who are given extended take home doses and for whom there are concerns about stability, it may be reasonable to do additional drug screening to assess for the safety of continuing with more take home doses.
During this crisis many factors may increase the need for coordination with patient support systems including recovery homes and other caregivers. The program should consider assigning a main point of contact to manage these communications. These coordination channels should be used to:. Medicaid : Many OTP patients are covered by Medicaid, although this may vary from state to state and among clinics.
OTPs will need to work with their state Medicaid office in order to maintain reimbursement and clinic income streams during the crisis. Some states have implemented COVID specific codes for certain services, while others are using a bundled billing model. Medicare : For those patients who have Medicare, audio-video telehealth services are reimbursable.
Papers in academic journals tend to go unnoticed. Lacking both data and staff trained to analyze it, Willamette Family relies on the responses of partner agencies and patient surveys to gauge the quality of its work. While both measures consistently give the program excellent ratings, they provide neither an ideal level of assurance nor opportunities for strategic, precisely targeted improvement initiatives.
Stakeholder competition for access to treatment resources raises additional questions worthy of research. The queue for treatment is often long and patients who spontaneously seek assistance often are the last to gain entry. As client motivation affects appropriate treatment approach, length, and outcomes, admission delays potentially have significant consequences for overall program efficacy.
Research to assess the benefits and burdens of current admissions policies could point the way to beneficial adjustments. Such research would enable programs to strike an optimal balance in allocating beds or classes to patients referred by various stakeholders, and to present empirical justification for their admissions policies to courts and corrections agencies, employers, schools, and families. Finally, the demands and the push-and-pull exerted by different stakeholders influence staff morale.
Along with low pay, relatively low prestige, and the difficulty of the job, many of the tasks stakeholders impose and the concomitant diversion from patient care—which clinicians regard as their essential function—apparently contribute to the high turnover rate. Research to explore these relationships and generate strategies to minimize turnover could contribute substantially to program stability and enhanced treatment results.
Community drug abuse programs cooperate and contend with a remarkable number and variety of stakeholder organizations, institutions, and individuals. They invest substantial resources in building and maintaining effective collaborations with stakeholders and work with many facets of the community to meet treatment needs while complying with regulations, ordinances, and payer requirements. Researchers can greatly enhance drug abuse treatment in the Nation by addressing a number of issues that arise directly in relation to stakeholder expectations, demands, and conflicts.
In undertaking community-based research, they will enter an environment rife with expectations, demands, complexities, and conflicts. And, they will become stakeholders themselves. Most importantly, we thank the counselors and senior management at Willamette Family for their enthusiastic participation in the discussion and site visits.
National Center for Biotechnology Information , U. Journal List Sci Pract Perspect v. Sci Pract Perspect. Dennis McCarty , Ph. III, N. II, 2 Hillary Wylie , M. II, M. Greenlick , Ph. Merwyn R.
Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Ellos escuchan. They Hear You. Solr Mobile Search. Share Buttons. Misusing alcohol, tobacco, and other drugs can have both immediate and long-term health effects. Alcohol Data: In , Underage Drinking: Myths vs. In contrast, Specifically,
0コメント