Today we will discuss how we can help homeless people in a pandemic, especially when they are an addict. The ongoing COVID-19 pandemic presents substantial challenges for giving good addiction treatment while decreasing staff, patient, and community risk for COVID-19. These challenges are even bigger for clinicians and organizations and programs that serve patients experiencing homelessness.
This resource offers guidance for how safety net systems might have to adapt to encourage support for those struggling with substance use disorders and unstable housing during the COVID-19 crisis.
I. Caring For Patients with Addiction and Having Homelessness
Individuals who have substance use disorders and have homelessness are at high risk for COVID-19 disease due to their inability to effectively implement preventative measures advocated for the overall population. For example, physical distancing is hopeless in crowded shelters and on the road where people congregate to protect against overdose and violence.
Hand hygiene measures are hard to follow because of insufficient access to baths, sinks, and soap. Individuals that are impaired because of intoxication or withdrawal are not as likely to adhere to the use of masks or covering their cough, even if they do have access to masks.
Alcohol and Drug use behaviors are also prone to independently raise the possibility of contracting coronavirus through various ways, including sharing materials, inhalation of substances, and indirect and direct immunosuppressing effects (especially when used heavily and chronically), and increased involvement in risky behaviors. The lack of access to decent consistent sanitation facilities and hygiene supplies, along with limited access to health care, are all factors that may increase the chance of spread and transmission of COVID-19 among sheltered inhabitants.
Additionally, homelessness and addiction are both likely to be independently associated with a more severe course of COVID-19. People with addiction and people experiencing homelessness have higher rates of chronic health diseases (e.g., cardiac disorders, respiratory disorders, chronic infections [HCV, HIV, infective endocarditis]) that confer people’s risk homelessness are over age 50.
A recent analysis suggested that people experiencing homelessness infected by COVID-19 are twice as likely to be hospitalized, two to four times as likely to need critical care, and two to three times more possible to die than the general population.
During this public health crisis, people with no access to a home will have a significant need for general medical care and addiction treatment. Improving access to treatment in this period is equally critical to providing adequate care to such people and protecting public health. The CDC has approved Homeless Service Clinicians and Programs to Plan and Respond to COVID-19 and individuals in Unsheltered Homelessness.
These guidance reports both stress the need for and continued linkages into “medical, psychological health, syringe services, and substance use treatment, such as the provision of medication-assisted treatments (e.g., methadone maintenance, buprenorphine, etc.).” Continuity of care is crucial for patients at this time.
The connection with a supportive treatment clinician/ app might be among the most solid relationships in the life span of an individual experiencing homelessness, so disruption of the relationship can be particularly tough. Increased regulatory flexibility in this public health crisis encourages increased access to addiction treatment, including medications, through telehealth and enhanced accessibility to take-home doses of methadone.
However, individuals undergoing homelessness might not have access to a trusted telephone, minutes, data plan, net, or other technology that would be necessary to get telehealth services. Additionally, they may be unable to safely store and handle a substantially increased variety of take-home methadone doses.
Treatment Program and Clinician Partnerships to Support Patients Through COVID-19
A. Treatment programs and clinicians should work with outreach workers, emergency departments, harm reduction service programs to identify individuals and engage them in care.
- Be ready to participate as individuals may be experiencing withdrawal at a greater frequency when their drug supply was disrupted.
B. Treatment programs and clinicians should work with their state and community leaders to determine strategies for supporting access to addiction treatment services during COVID-19. For example:
- Giving away phones (with minutes) to help engagement in telehealth
- Partnering with harm reduction service programs, street outreach teams, jails and prisons, and other homeless service programs and clinicians to connect patients with addiction who are homeless to treatment, such as methadone or very low barrier initiation buprenorphine for anyone who has opioid use disorder.
- Ensuring continuous access to harm reduction services such as Syringe providers and naloxone.
C. Treatment programs and clinicians should work closely with isolation and quarantine facilities to give addiction treatment to individuals with and people vulnerable to COVID-19.
- Quarantine and isolation can be very stressful for individuals with addiction. Treating programs and clinicians may consider short term interventions to help patients continue staying in quarantine and isolation facilities.
- For patients reliant on benzodiazepines, either prescribed or through illicit usage, consider offering medications by prescription to prevent withdrawal.
- For patients with stimulant use disorders, clinicians may think about treating patients with prescribed stimulants. Though such treatment hasn’t been shown conclusively to improve the plan of a stimulant use disorder, the aim in this public health crisis differs, namely to assist patients to continue staying in quarantine and isolation facilities for the limited period required to protect the patient and the wider community.
D. Treatment programs and clinicians should work with local jails and prisons, many of which are expediting discharge for low-level crimes, to make sure that individuals with substance use disorders also experiencing homelessness are related to addiction treatment and home services.
Treatment Program and Clinician Adjustments to Clinical Services Throughout COVID-19
A. Treatment programs and clinicians should do everything they can to ensure patients have consistent access to their dependence treatment medications.
B. If a patient needs care but doesn’t have access to the technologies required to participate in telehealth, the healing clinician/program should provide personal care or facilitate alleviate onsite telehealth. Patients can access a telephone or computer in practice or through a partnering organization while linking to a clinician in another room or company to minimize risks to both staff and patient.
C. In areas of community spread, addiction treatment programs and clinicians should assume that all patients accessing the facility might have been subjected to COVID-19.
D. Symptom screening, while essential, will be of limited utility in identifying asymptomatic people or pre-symptomatic patients because of the long incubation period of the virus. However, the identification of symptomatic individuals to help them access needed medical care is still suggested.
- If rapid testing is available, it may be used to cohort residents residing in congregate settings, maintaining people who test COVID-19 positive away from individuals who test negative to be able to reduce exposures.
E. For individuals with confirmed or suspected COVID-19, residential or inpatient treatment programs should use their community public health department to get patients tested and decide on an isolation site where they can get the continuing care they need for both addiction and COVID-19 if the residential treatment program is not able to provide adequate isolation/ quarantine space.
- When discharging patients who lack safe accessibility to home and aren’t suspected of having COVID-19, the treatment program should:
- Work with treatment programs and clinicians in the area to ensure that the patient is effectively engaged in the appropriate amount of outpatient care.
- Work with the community home services and local recovery houses to determine housing and other recovery support services available to the individual.
- Make sure the individual is wearing a mask.
- Ensure patients who are at risk for opioid overdose have naloxone.
F. Opioid treatment programs and clinicians should work with shelters and other care sites to research options for take-home methadone doses and telehealth-based appointments.
- Opioid treatment programs and clinicians should coordinate with shelter managers and personnel at different care sites to ensure medication continuation for patients treated for OUD.
- Opioid treatment plans should be prepared to deliver doses of methadone to established patients in shelters and other care sites, using alternative medication delivery systems if those are available (e.g., mobile dispensing units, OTP personnel, or legislation enforcement-based delivery systems).
G. DATA-waived health experts can prescribe buprenorphine for individuals with untreated OUD must make themselves available to shelters and other care sites via locally developed systems of care.
H. Impartiality from treatment and recovery support groups can be especially tricky for people experiencing homelessness because they might be less inclined to find online support groups. Treatment clinicians and applications should consider options for encouraging access to support groups:
- Onsite classes that maintain physical distancing.
- Provide technology for virtual support groups.
Patient Guidance during COVID-19
A. Health clinicians should advise patients with addiction about approaches to lessen their risk of transmission such as physical distancing; hand washing when possible; not sharing cups, utensils, bottles, etc.; not sharing smokes, e-cigarettes, joints, etc.; rather than discussing other drug use equipment (e.g., syringes, cookers, cotton).
B. Patients should also be recommended to seek care if they found COVID-19 symptoms and seek care if they undergo withdrawal or other potentially severe health problems associated with their substance use.
C. In regions of significant community spread, direct patients that emergency services could be slower to react.
- Emphasize the importance of accessibility to naloxone and having somebody check in on them when using substances and alcohol.
- Keep a check if patients have access to overdose education and Naloxone kits- either through your organization, through community naloxone distribution programs, or pharmacy dispensing.
Hospitals and emergency departments must continue to screen for substance use disorder and withdrawal risk and assess housing status before releasing patients suspected of having COVID-19.
When possible, emergency departments and hospitals providing care to patients with opioid use disorder should:
- Provide initiation of buprenorphine (or methadone for inpatient services) before discharge and ensure linkage to community-based treatment supplier.
- Provide naloxone kits (or, if not possible, naloxone prescription) to anybody who might be at risk for opioid overdose.
Re-Engineering Medication Delivery
Treatment programs and clinicians should consider new approaches for getting drugs to patients, such as those in quarantine or isolation while minimizing the risk for patients, employees, and people’s health. This will probably involve close coordination with neighborhood safety net clinicians and programs and isolation and quarantine sites.
Some communities are now researching the use of mobile dispensing units to provide buprenorphine, methadone, along with other medications to patients who can’t or shouldn’t come to an inpatient visit. The DEA released guidance associated with alternate medication delivery systems for methadone on March 16, 2020, during the COVID-19 pandemic.
The guidance allows for “doorstep” delivery of controlled drugs, specifically methadone, from OTPs to patients in need of isolation or quarantine. This delivery method requires that an OTP staff member, a law enforcement officer or a member of the National Guard provide a properly managed and dispensed amount of methadone to a patient in a container or locked box while maintaining proper physical distancing.
Practically, this advice means that the individual delivering the drug must witness the individual or an approved member of the family retrieve the locked box/container on the doorstep. Deliveries of medication to patients unable to introduce in-person to an OTP may also be achieved through established chain-of-custody protocols with a responsible adult.
Infection Mitigation and Control when Telehealth Isn’t an Option
The CDC encourages that for street medication or other health care staff that are providing medical services to clients with suspected or confirmed COVID-19 and close contact (within 6 feet) can’t be avoided, employees should at a minimum, wear eye protection (face shield or goggles), an N95 or higher level respirator (or a facemask if respirators aren’t available or staff aren’t fit testing), disposable apparel, and disposable gloves.
Cloth face covers aren’t PPE and shouldn’t be used when a facemask or respirator is indicated. Healthcare programs and clinicians should follow infection control guidelines.
II. Considerations for Isolation and Quarantine
People experiencing homelessness aren’t able to quarantine or isolate at home. Communities are taking varying approaches to provide facilities for this purpose, including conference centers, dormitories, hotel rooms, etc. offering different levels of medical and staffing capacity.
Yet, individuals with addiction are sometimes prevented from accessing these centers or are discharged due to addiction-related behaviors. CDC guidance recommends these sites “Organize for continuity of and surge support for mental health, substance use treatment services, and general healthcare.”
Patients who are admitted to a quarantine or isolation facility might not be seeking treatment for SUDs. To protect both individual and public health, harm reduction programs should be employed to create an environment where the individual feels welcomed and can stay during the necessary period of isolation.
This may entail tolerating continuing substance use and supporting safer injection and inhalation equipment and overdose-prevention interventions such as naloxone availability. The National Health Care for the Homeless Council notes, “Failure to adapt substance use disorders will probably mean increases in fatal overdoses/ hazardous withdrawals, higher rates of vulnerable people leaving I&Q [quarantine and isolation ] against medical advice and endangered public and individual health.”
An estimated 50 percent of homeless people have a substance use disorder. Quarantine and isolation facilities should be prepared to address the needs of people with dependence by:
A. Testing for substance use disorders and identifying both overdose and withdrawal threat as individuals enter the center.
B. Training facility staff on symptoms and signs of withdrawal, protocols for a response, and if symptoms are recognized, linkage to medical clinicians and treatment programs as necessary.
C. Working with community addiction therapy clinicians to develop protocols to triage and address substance use and addiction risks.
- Establish protocols to effectively assess and address withdrawal from alcohol, opioids, and benzodiazepines.
- Establish protocols for reducing injuries and distress associated with withdrawal from nicotine.
- Develop Protocols to proactively provide substance use disorder treatment services.
D. Supporting the supply of addiction treatment services to residents through telehealth.
- Explore options for providing access to telehealth technology (e.g., telephones and moments, computers, personal space for these visits).
E. Ensuring patients have continued access to drugs for treating substance use disorders, especially drugs for opioid use disorder, as discontinuation can put patients at higher risk for overdose and relapse, along with increased risk for patients leaving early.
- Engage with local OTPs to ensure medication continuation for patients receiving buprenorphine or methadone through the OTP.
- Coordinate with local buprenorphine waivered clinicians to empower both initiation and continuation of buprenorphine therapy.
- Offer Nicotine replacement treatment for patients using tobacco products.
- Offer drugs and withdrawal control for alcohol use disorder for interested individuals
- Offer the ability to initiate counseling services through telehealth when possible.
The CDC suggests a “whole community” approach to planning and responding to COVID-19 among people experiencing homelessness. They recommend that: A community coalition centered on COVID-19 preparation and response should include:
- State and local health departments
- Street medicine clinicians and programs and outreach teams
- Homeless Service programs and clinicians and continuum of Care direction
- Emergency management
- Law enforcement
- Healthcare clinicians and programs
- Housing authorities
- Local government direction https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html
F. Support the delivery of harm reduction services.
- Train staff on overdose recognition, naloxone administration, and response protocol.
- Maintain an adequate supply of naloxone for both staff and residents.
- When possible, check that patients being discharged have access to naloxone (through a prescription, direct distribution, or linkage to community-based naloxone supply).
- Coordinate access to syringe services.
- Ensure access to sharps containers for the safety of all individuals living at the center and personnel.
G. Do not deny services to people based on addiction and don’t discharge people due to substance use.
H. Acknowledge that some residents may acquire and use substances while in isolation and quarantine. Prepare yourself to ensure the safety of these and other patients and personnel.
- This is less likely to happen when appropriate medical services to screen for and treat withdrawal symptoms on time are supplied.
I. Train staff on the best way best to support and monitor residents that are intoxicated.
- Encourage the use of noninvasive, trauma-informed approaches.
- Consider communicating with peer support specialists who have experience working with people with addiction.
- Directly deal with the biases that may lead to the de-prioritization of care for these patients (especially COVID care).
J. Consider options for encouraging access to support groups.
- Onsite groups that maintain physical distancing.
- Provide technology for virtual support groups.
III. Significance of Community Coordination For Supporting People With Alcoholism Experiencing Homelessness
The CDC Urges a “whole community” approach to planning and reacting to COVID-19 among homeless individuals. They urge that: A community coalition centered on COVID-19 preparation and response should include:
- Local and state health departments
- Outreach teams and street medicine programs and clinicians
- Homeless Service programs and clinicians and Continuum of Care direction
- Emergency management
- Law enforcement
- Healthcare clinicians and programs
- Housing authorities
- Local government leadership
- Other support services such as case management, emergency food programs, syringe service applications, and behavioral health care
- Individuals with lived experiences of homelessness.
Alcoholism treatment clinicians and programs are crucial partners in this work as most quarantine and isolation facilities and other care sites won’t have the essential expertise or staff to address people’s complex addiction needs. There are many alternatives for community partnerships that could help address people with addiction who lack a home. By way of instance, alternative care sites can connect with therapy clinicians and programs to provide telehealth services.
In Chicago, community federally qualified health centers (FQHCs) are partnering with other care sites to supply telehealth solutions for addiction treatment, including drugs for opioid use disorder. In another case from Boston, a substance use disorder bridge clinic is collaborating with a drop-in health clinic, a community syringe service, and injury reduction program, and other clinicians and programs who serve those that are homeless, utilizing street-based outreach workers from such applications to initiate discussions about addiction treatment and connect interested individuals to care with their phones.
The regulatory flexibility for providing telehealth services in this public health crisis enables treatment clinicians and programs to charge for these services. This may promote the expansion of innovative ways of expanding access to quality care for dependence.
The COVID-19 pandemic is increasing the risk of injuries associated with substance use in several ways:
A. Increased stress linked to uncertainty and risks because of COVID-19 and increased isolation can cause individuals with substance use disorders in remission to resume use or individuals with active substance use disorder to have a worsening of symptoms.
B. Physical distancing measures and other constraints have limited access to harm reduction services such as naloxone supply and syringe service applications, which may put people at risk for an overdose in addition to infectious diseases.
C. People may be more inclined to use alone to increase the risk of overdose death.
D. Changes in the medication supply lead people to new substances and new sources that increase risks.
- Disrupted Drug supply chains might mean people are buying drugs from various sources or changing medicines that could place them at risk for overdose.
E. Communities must forge partnerships focused on engaging individuals with substance use disorders experiencing homelessness with SUD treatment and withdrawal and harm reduction services.
- Identify opportunities for outreach teams and programs and clinicians that serve those experiencing homelessness to associate with outpatient addiction treatment programs and clinicians to give treatment for SUD, such as drugs for opioid use disorder.
Given the high risk of coronavirus transmission inside all congregate living settings (residential centers, shelters, recovery houses ), communities should prioritize these sites for greater access to surveillance testing.