Patient centered cared (PCC) has become a core principle in many medical fields, with health organizations, institutions and regulatory bodies acknowledging the importance of integrating the patients as partners in the medical decisions that directly impact their lives(20, 21). Although it varies across disciplines and settings, the principles of PCC most commonly include(22) 1) shared power and responsibility between the patient and health care provider with shared decision-making (e.g., communication); 2) an individualized approach by focusing on the patients’ unique goals, needs and preferences with an understanding of the whole person; and 3) emphasis in the quality of the therapeutic relationship with the provider. Yet, addiction medicine struggles to incorporate these principles, particularly in the presence of prescription of opioid medications(23). Honoring patients’ preferences in the medications they would choose to take, the setting and the format of the treatment are sometimes limited by the restrictive regulatory structures(24) (e.g. drug scheduling), unfavorable physical conditions (e.g. lack of housing), or lack of providers’ training in PCC in addictions (e.g., leading to stigmatizing care).
The rapid measures taken by the health care system in some settings to protect the public from the spread of COVID-19 has allowed OUD patients to access treatment and approaches to care long-time needed, such us more flexibility with take home medications or carries. During the surge of COVID-19 several settings revised their policies, through provisional public health exemptions, allowing prescribers more flexibility prescribe OAT, including risk mitigation options and to offer carries (25, 26).
The global standard for iOAT (excluding the small group of patients receiving iOAT from pharmacies in the UK) is that is it excluded from any clinical guideline for take home “privileges” due to safety concerns (to the patient and diversion). This is blanket policy that does not allows for any shared decision making or consideration of the patient as a whole, including individual needs and preferences, directly contradicting the PCC values that medical science is committed to uphold.
In the present case, the patient received his 400 mg of injectable diacetylmorphine twice a day in temporary setting for self isolation due to COVID-19. At the end of his isolation period the patient went back to his SRO, clearly indicating (and confirmed by clinical assessment) that the optimal course of treatment for him would have been to receive carries that allowed less visits to the clinic, due to his lengthy prior medical conditions (e.g., physical challenges, fatigue). However, this was not possible due to restrictive regulatory structures, out of the control of provider (e.g., prescribe for take home) and the patient (e.g., setting to receive the medication). If providing iOAT carries was possible as a risk mitigating measure during COVID-19, this case shows that it is possible to consider carries for iOAT outside the scope of a COVID-19 infection case. While there are many other factors to be consider for carries, this presents an opportunity to consider carries for clients that have shown 1) willingness or record of adhering to the medication, as a way for the clinical team to assess that this is the formulation the person prefers and will continue using outside the premises; 2) evidence the patient will tolerated the dose for the time considered, and bearing in mind that there is constant consultations with the clinical team and shared-decision making if circumstances change (e.g., aggravation of COPD) and 3) patients needs and preferences regarding coming to clinic due to physical health, in this case, that makes it difficult to daily access the site where their trusted connections with the healthcare system are located.
One of the major factors driving the hospital team’s effort to quickly titrate opioids and to resort to IV fentanyl (since diacetylmorphine was not available in hospital), was the fear that the patient might self-initiate discharge from hospital to access street drugs, thereby breaking isolation and risk of overdose. To our knowledge, there is no previously published literature on the use of IV fentanyl in the context of hospital admission for patients with OUD. While this practice was used as a last resort in this specific case, providing as close of a pharmacologic agent to what patients are using in the street can be a way to support them staying engaged in acute treatment. This might allow to meet patient’s most immediate medical needs, whether those are related to COVID-19 self-isolation or any other emergency. While further research is certainly mandated before implementing more broadly such an approach, the flexibility and patient center care deployed here were crucial in keeping this patient engaged in the therapeutic alliance and allowed for collaboration in planning for a safe hospital discharge.
Over the years, the concern on what will happen with Scheduled I and II medications once they leave the premises have limited the quality of the care provided in addiction medicine. There are uncontested negative associated consequences, for the individual and the community, when medications such as opioids are not used as directed, either by the patient or others(27). These include for example poor treatment outcomes (e.g., low treatment adherence), fatal overdoses, increase in crime (e.g., theft to pharmacies), “doctor shopping”. However, while most of the emphasis in research and policy has been around tougher measures of control such as of the medications (e.g., special licenses to prescribe them), new formulations (i.e., “deterrents”), or increased patient monitoring, it has come at the expense of patient autonomy(28). There is little attention paid (and little is known) to the motivations and factors that contribute to diversion at the patient level(29, 30). In the present case, considering take home doses for a patient in care, studies suggest the patient centered-cared approach would be a more valuable strategy(10, 31), through understanding the specific circumstances of the patient as a whole and addressing other needs (when possible) that could be interfering with the treatment and leading to the diversion of the medication. These needs could be but not limited to physical and medical comorbidities, other substance use, partners or friends in need of medication, and overall financial stress.
Singling out iOAT from the option of carries introduces a lack of equity for a group of patients without considering their specific circumstances and needs, and responds only to restrictive policies. Moreover, allowing iOAT carries in such a restrictive way that those that really need it cannot access it, is also lack of equity (e.g., carries can only be prescribed to people with stable housing). In the present case we demonstrated that it is feasible to provide iOAT outside the community clinic with no apparent negative consequences. While the dispensation was witnessed by the health care providers still, this will not be needed once the patient and providers are comfortable with the process, making it less expensive and time consuming. In Switzerland, currently due to COVID-19, patients are allowed to take seven daily doses of carries(17). A first step in our context will be to work with the local authorities and include patients in iOAT that could benefit from carries, in the sense of optimizing their quality of care, without burdening the system with unnecessary monitoring, such us direct observed treatment and twice daily deliveries. Patients in iOAT come two to three times a day, and over time they report a strong need of less visits but maintain the connection with the clinic(32) (as in the present case). Allowing flexibility based on individual assessment anchored in PCC can support patients’ needs and quality of care.
To date, our community iOAT clinic has seen 7 cases of COVID-19, this been the first that received injectable diacetylmorphine in the transition housing during the isolation period. At the clinic, all staff wears medical grade masks and goggles. At that time, patients were encouraged to wear a mask, although now require all clients and staff members to wear medical grade masks while in clinic. Social distance within clinic is maintained and engagement is 100%. There have been no COVID-19 transmissions.
A public health emergency of this extent and complexity requires a comprehensive response that embraces innovation while exhausting evidence-based approaches. The overdose crisis, now aggravated by the COVID-19 pandemic as it rapidly evolves, makes this a critical time for iOAT normalization within the addiction treatment system. The street supply is growing even more unpredictable as normal supply channels are disrupted (e.g., difficulty finding sources due to social distancing), and supports for people who use drugs are strained. The failure to deliver effective treatment for opioid use disorder translates in loss of in-person treatment options. This case illustrates that the system is in a position to provide continuation of iOAT care to people in the midst of this new public health emergency, but also that we can do so after, as long as processes are in place to support the patient and the community, in a sustainable way. People with OUD struggle to adopt COVID-19 best practices (e.g., physical distancing) for diverse reasons (e.g., living in shelters, clinic visits). This can affect their safety and treatment progress by, for example, reducing their time spent in treatment, or increasing the sense of insecurity. As data shows, the COVID-19 epidemic has tremendously affected the incidence of opioid overdose but is bringing us opportunities to reduce overdoses by improving treatment and enhancing linkage to care.