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The development and implementation of a rapid‐access long‐acting injectable buprenorphine clinic in metropolitan Melbourne during the COVID ‐19 pandemic

2020; Wiley; Volume: 40; Issue: 4 Linguagem: Inglês

10.1111/dar.13161

1465-3362

Adam Straub, Adam Pastor, Martyn Lloyd‐Jones, Helen O’Neill, Yvonne Bonomo,

HIV, Drug Use, Sexual Risk

Transmitting via droplets, contact and potentially aerosolised particles [1], the current COVID-19 pandemic presents a number of challenges for ensuring the safety of people seeking opioid agonist treatment (OAT) and their health-care providers [2, 3]. Specifically, the requirement for frequent attendances to a pharmacy, where contact with other members of the community is inevitable, poses increased risk and stigma from accessing treatment to people with opioid use disorders (OUD) when they are being asked by governments to socially isolate. The risk of OAT prescribers and pharmacies being closed due to illness or quarantine also raises concerns about access to treatment. Furthermore, travel restrictions and reduced international travel may affect the quality and supply of illicit opioids which could increase the risk of opioid overdose and motivation to seek treatment. Some proposals, including home delivery of medications, would add prohibitive expense, labour impost and carry risk to the delivery person [4]. Long-acting injectable buprenorphine (LAIB) may alleviate some of these issues by reducing contact with community pharmacies, frequency of travel, periods of withdrawal or overdoses. It has been shown to be equally efficacious and acceptable when compared to sublingual buprenorphine [5, 6]. However, at most 5% of Victorian prescribers have transitioned to providing LAIB, minimising access to this form of OAT [7]. With these issues in mind, we established a rapid access LAIB clinic for treatment of people with OUD during the COVID-19 pandemic at a public hospital in Victoria, Australia. To understand the issues surrounding access to treatment during the COVID-19 pandemic, we considered feedback received from members of multiple services during state-wide meetings from an extended community of practice (Project ECHO, echo.pabn.org.au) [8] and used this to guide the development of our clinic. Primary among the many priorities identified was timely access and minimal cost of treatment. We accepted a wide range of referral sources, including self-referral. Consideration was made regarding treatment capacity, ensuring adequate space and staffing to support additional patient numbers. There is no cost to people attending the clinic, including for administration of LAIB. A sophisticated triage process, performed by a specialist alcohol and other drugs nurse, ensures that LAIB is available to as many people as possible, and minimises physical attendance to only those times when the product itself is being administered. Telehealth consultation with a staff addiction medicine specialist is available if required to assess suitability. People requiring transfer from methadone to buprenorphine-based treatment may require admission to a residential withdrawal unit. Prior to the initial appointment, a review of all available history including a review of permits and dispensing history on SafeScript (Victorian government's real-time prescription monitoring service) is performed. With regards to pandemic considerations, the clinic has clear COVID-19 screening methods, available personal protective equipment and proximity to a fever clinic for appropriate referral of potential cases. The layout of the clinic considers COVID-19 precautions including physical flow and physical distancing, minimising contact and length of time of each visit. A level of personal protection similar to hospital phlebotomists (pathology collectors) is used for procedures such as physical examination, blood taking and injection administration, to reduce the risk associated with close contact for a vulnerable population. This includes wearing eye protection in the form of safety glasses or a face shield, surgical face masks, scrubs uniform and gloves as well as standard precautions in the form of hand hygiene and physical distancing [9] (see Supporting Information, Figure S1). High-value health care that reduces the need for contact with other providers, minimising potential community contact and spread of illness is provided. Pathology is not required to commence treatment unless concerns are raised on history or examination. Oral fluid testing can aid in cases where the history is unclear or where no confirmatory evidence of opioid use is available on SafeScript. Focussed physical exams are conducted. Additional services such as influenza vaccination, blood-borne virus testing (via on-site pathology services) and treatment and take-home naloxone are available. Consideration is made regarding other specialty services such as housing, social work and mental health clinicians. Comprehensive, contemporaneous records are kept at all points of contact via a specially designed database, ensuring that all aspects of patient care are reviewed (see Supporting Information, Figure S2). To our knowledge, this is the first clinic specifically designed for the provision of LAIB to respond to the COVID-19 pandemic for people with OUD. The literature currently available describes broad guidelines to change existing practices [2, 10], suggesting that the provision of LAIB in place of daily supervised dosing would improve resource allocation. However, much of the current system of daily supervised administration of OAT remains unsuitable for social distancing. We acknowledge that other services may have other priorities of care such as a needle syringe programs, case management, extended hours for a medically supervised injecting facility, home delivery or vending machine dispensing of OAT or others. We recognise that the lockdown period of this pandemic carries additional mental health risks and consideration should be made to the delivery of appropriate care. While our service does not have a provision for home visits at this time, a model could be developed to administer monthly LAIB to those in quarantine or unable to attend if required. We will be evaluating whether our model is attractive for people with OUD and the outcomes through the Australian Treatment Outcome Profile, which will further help to inform service delivery. Overall, service providers will need to respond to the COVID-19 pandemic with increased flexibility and the development of a range of alternatives to meet the needs of people with OUDs. We would like to thank the Inclusive Health Innovation Fund as part of St. Vincent's Hospital Melbourne for their support and funding of this project. The authors have no conflicts of interest. Figure S1. Flow of consumers through the clinic on the day of the appointment. LAIB, long-acting injectable buprenorphine. Figure S2. Data collected at each point of contact. ATOP, Australian treatment outcomes profile; LAIB, long-acting injectable buprenorphine. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.