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Substance Use and Responses
During COVID-19: New York
City Department of Health and
Mental Hygiene
Denise Paone, EdD
Senior Director of Research & Surveillance
Michelle Nolan, MPH
Senior Epidemiologist
Bureau of Alcohol and Drug Use Prevention, Care and Treatment
NYC Department of Health and Mental Hygiene
Outline
• Background: COVID-19 in NYC
• COVID-19 pandemic and substance use
• NYC DOHMH responses
– Guidance
– Supporting SSP programming
– Methadone Delivery System
• Modeling demand
• Implementation
• Challenges and lessons learned
• Next steps
COVID-19 IN NYC
Total cases, hospitalizations, and
deaths (as of 5/17, 1:45PM)
Source: New York City Department of Health & Mental Hygiene
Racial disparities in COVID-19 cases,
hospitalizations, and deaths
Source: New York City Department of Health & Mental Hygiene
*updated May 14, 2020
Daily number of people admitted to
NYC hospitals for COVID-19-like
illness
Source: New York City Department of Health & Mental Hygiene
Percent of NYC residents who
test positive for COVID-19
Source: New York City Department of Health & Mental Hygiene
COVID-19 PANDEMIC AND
SUBSTANCE USE
COVID-19 pandemic and
substance use
• Coronavirus disease 2019 (COVID-19)
pandemic has shifted:
– Substance use routines and settings
– The way substance use-related support and
resources are provided
How does the COVID-19 pandemic
affect substance use?
• Isolation, physical distancing
• Loss of income
• Barriers to resources and material needs
• New Yorkers are experiencing:– Increased anxiety
– Increased probable depression
– Above average financial stress
• Result: potential increase in chaotic substance use and coping with substances
How does the COVID-19 pandemic
affect People Who Use Drugs
(PWUD)?
• Underlying health conditions increase risk
for severe illness
• Some housing environments (congregate
settings, housing instability of any kind)
make it difficult or impossible to follow
COVID-19 prevention measures
• Social distancing measures may increase
risk of fatal overdose
– More people are using drugs alone
Disruptions for PWUD
• Drug market – Increased risk of withdrawal due to changes in drug
availability
– Unstable drug markets contribute to chaotic drug use
– Result: increased risk of overdose
• Syringe Service Programs (SSPs)– Limited program operations (staff shortages, lack of
PPE, lack of soap and hand sanitizer)
– Limited supply of sterile drug use equipment and naloxone may result in increase in blood-borne infections and fatal overdose
– HIV and hepatitis C virus testing services suspended at some SSPs
PRELIMINARY DATA ON DRUG-
RELATED HEALTH CONSEQUENCES
DURING COVID-19
Drug-related emergency
department visits• Concerned about a potential increase in
drug overdoses during the pandemic
• Number of non-COVID-19 related ED visits in NYC below expected in the last month
– Rates in drug-related ED visits have substantially decreased
– Despite recent uptick in drug-related ED visits, rates are still below the 2019 average
• Continuing to monitor drug-related ED visits through syndromic surveillance
NYC HEALTH DEPARTMENT
RESPONSES
ALCOHOL-RELATED
GUIDANCE
Mindful drinking
• Stressful events like the current COVID-19 pandemic may change the way people consume alcohol
• If possible, practice mindful drinking:
– Take note of how much and how often you drink alcohol
– Space drinks over time and alternate with food and water
– Avoid mixing drugs (such as sleeping or pain pills) and alcohol – it can lead to overdose
GUIDANCE FOR SAFER DRUG
USE
Overdose prevention
• Stock up on naloxone and sterile drug use
equipment
• Avoid using alone but maintain physical
distance with people you are with
• If you live with others, let them know you
are using, and create an overdose safety
plan that includes having naloxone visible
COVID-19 prevention among
PWUD
• Use disinfecting products to wipe down packing, supplies and surfaces before use
• Prepare your drugs yourself
• Contact your local SSP to see if they are delivering sterile supplies and naloxone
• If you inject: avoid sharing works, rinse supplies thoroughly if reusing and do not lick the needle
• If you use pipes, bongs, straws or e-cigarettes: avoid sharing, and use an alcohol swab to wipe down parts that touch the lips, nose or hands
SYRINGE SERVICE
PROGRAMS
How SSPs are responding
• New York State Department of Health considers syringe services an essential service
– Distributing additional safer drug use supplies per interaction
– Increase in food distribution
• Changes vary across SSPs but include:
– Suspension of in-person groups
– Reduced services and hours
– Increased number of syringes given to participants
• Most buprenorphine services continue (virtually or in-person), and many can add new participants
Supporting SSP programming
• NYC Health Department secured masks,
non-latex gloves, hand sanitizer, sanitizing
wipes and garbage bags to provide to the 14
SSPs in NYC
– Masks are for staff and SSP participants
• NYC Health Department is conducting
regular check-ins with contracted SSPs and
released operational guidance for SSPs
BUPRENORPHINE AND
METHADONE TREATMENT
DURING COVID-19
Treatment with methadone and
buprenorphine reduces overdose risk
compared to other treatment
Major changes to buprenorphine
regulations
• March 31, 2020: Telemedicine can be used for buprenorphine induction and prescribing
– In-person examination requirement for new patients has been waived.
– Primary care providers and SSPs are using telehealth
– Health + Hospitals opened a virtual buprenorphine clinic for current and new patients
Methadone treatment
• Despite being a gold-standard treatment for OUD, methadone is highly regulated and only available at specialized Opioid Treatment Programs (OTPs)
• Individuals in methadone treatment may experience withdrawal symptoms if they miss a dose
• Anyone with COVID-like symptoms unrelated to a preexisting health condition must stay home
• NYC has a large methadone population: approximately 28,800 methadone patients; over half are ages 45 and older
Methadone regulations have
been relaxed due to COVID-19
• DEA permits doorstep delivery of methadone to people in quarantine or isolation.
• SAMHSA permits methadone programs to provide medication under blanket exception. – Up to 14 doses for clinically less-stable patients
– 28 doses for clinically stable patients
• NYS OASAS guidance recommends 28 days of doses for patients with COVID-19 – Up to 28 doses for patients with comorbidities;
age 50+
– 7-28 doses for patients already qualified for take home doses
0% 5% 10% 15% 20% 25% 30%
1x month
2x month
1x week
2x week
3x week
4x week
5x week
6x weekMore
frequent visits
Less frequent
visits
Reporting frequency: Weekly
Lag time: 1-2 weeks
Individuals in methadone treatment at 21 NYC DOHMH funded opioid treatment programs, by frequency of methadone clinic visits, April 12 – April 18, 2020
66% of patients receive 7 or more
days of medication per dose
METHADONE DELIVERY
SYSTEM
Isolation presents a problem for
methadone treatment
• Anyone with COVID-like symptoms that are not due to a preexisting health condition may have COVID-19 and must stay home
• Individuals in methadone treatment may experience withdrawal symptoms if they miss a dose
• Critical to prevent methadone treatment disruptions while observing COVID prevention guidelines
Methadone Delivery System
• DOHMH is delivering methadone to
individuals who are in isolation or
quarantine because they have COVID,
COVID-like symptoms, or are at high risk
of experiencing serious illness if exposed
to COVID
MODELING DEMAND FOR
METHADONE DELIVERY SYSTEM
Assumptions for modeling (1)
• Reproductive rate
• Infectious period
• % of infections are asymptomatic– Asymptomatic individuals will continue to pick up
• % of infections are symptomatic– All symptomatic individuals will need delivery
services
Assumptions for modeling (2)
• 80% of symptomatic individuals are isolated for the duration of their illness– These individuals need delivery services for 10-21
days
• 20% of symptomatic individuals will need delivery services for the initial 11 days of symptoms. Individuals are admitted to a hospital on day 12. – Once hospitalized (either in a typical hospital or a field
hospital), the hospital assumes methadone dosing
– Individuals discharged from the hospital do not need delivery services
Assumptions for modeling (3)
• Once symptomatic, individuals will remain
on same dosing schedule
Approach
• SIR compartmental model coded in R– S = susceptible
– I = infected
– R = recovered
• Findings shared with Office of Addiction Services and Supports (OASAS)
• Model used to inform programmatic decisions
• Model revised to account for programmatic changes
Findings
• Number of individuals needing methadone
delivery highly sensitive to methadone
dosing schedule
• Less sensitive to epidemiologic
assumptions around reproductive rate and
infectious period
IMPLEMENTING METHADONE
DELIVERY
Methadone Delivery System (MDS)
• DOHMH worked with OASAS and COMPA to develop a Methadone Delivery System
• DOHMH staff are delivering methadone to methadone patients who are in isolation in hotels or at home
• Ensures that individuals who are diagnosed with COVID, experiencing COVID-like symptoms, or are 65 years of age or older and have comorbidities can continue to access methadone treatment safely
Eligibility criteria
for methadone delivery• COVID-positive or experiencing COVID-
like symptoms OR
• 50 and older AND have a chronic health
condition AND OTP willing to provide a
minimum of 7 days of medication OR
• At the discretion of the OTP Medical
Director
Logistics• Medical Directors at licensed Opioid Treatment Programs (OTPs)
identify eligible patients
• For isolation hotels, site supervisors or agencies referring individuals to hotels identify eligible patients
• DOHMH receives the names of patients who require delivery from OASAS and OTPs and dispatches a courier and a driver to fulfill the request
• DOHMH staff pick up methadone doses from OTPs and deliver it to patients in their homes or in Isolation Hotels
• The methadone arrives in a lock box for safe keeping along with a naloxone kit
• Ten delivery teams consisting of one volunteer driver and one volunteer courier– Regulations prohibit individuals with a history of substance use disorder
from being couriers
Safety• Protocols to ensure staff safety
– Personal protective equipment provided
– Cleaning supplies and regular cleaning of vehicles
– Cohorting shifts so people maintain the same contacts
– Electronic signatures so no paper involved in delivery
– Maintaining distance from sick patients
– Security or staff escorts when delivery methadone
– Curbside home delivery
CHALLENGES AND LESSONS
LEARNED
Challenges: Creating MDS
• Delivery protocol had to account for a
number of priorities, including:
– Preventing treatment disruption among
patients
– Obtaining delivery requests with ample time to
plan deliveries
– Abiding by DEA and SAMHSA regulations
– Ensuring safety and health of delivery staff
Challenges: Implementing MDS
• Low initial utilization of Methadone
Delivery System
– In response: DOHMH expanded
recommended eligibility and emphasized that
OTP Medical Directors should exercise their
discretion in referring individuals for delivery
Lessons learned
• Stigma surrounding the provision of
methadone treatment is prevalent at many
levels:
– Institutional
– Individual
• Buy-in among stakeholders at all levels is
critical to ensure that system is utilized
METHADONE DELIVERIES TO
DATE AND NEXT STEPS
Expansion of MDS into other
settings
• New York City Health and Hospitals Isolation Hotels
– Individuals who have COVID or COVID-like illness
• New York City Emergency Management Isolation Hotels
– Individuals who have COVID or COVID-like illness
• Mayor’s Office of Criminal Justice Reentry Hotels:
– Asymptomatic individuals released from correctional facilities
Implications of Methadone
Delivery System
• Due to COVID-19, DEA and SAMHSA relaxed federal regulations surrounding methadone provision
• Potentially provide avenue for advocating for fewer methadone treatment regulations
• Methadone Delivery System will be evaluated to influence future policy
QUESTIONS?