Information from the Norwegian Centre for Addiction Research (SERAF), University of Oslo, Norway, about special measures for vulnerable groups with substance use disorders (SUD) during the Coronavirus epidemic
The Coronavirus is now spreading in most populations worldwide. Persons with SUD, both in and out of treatment, must be considered as extra vulnerable groups in this context.
Low standard living conditions and little access to good hygiene standards will increase the risk of getting infected.
People with SUD often also have other chronic diseases, such as diseases of the airways, liver, kidneys or cardiovascular disorders. People with other chronic diseases are at increased risk of having a serious course of coronavirus disease if infected.
Older persons are generally at increased risk of developing serious disease if they are infected with coronavirus. In Opioid Agonist Treatment (OAT) many are 50 years or older and most of them have other chronic conditions that further increase their risk of serious outcomes.
Guides produced by the Harm Reduction Coalition (pdf)
- Safer Drug Use During the COVID-19 Outbreak
- Syringe Services and Harm Reduction Provider Operations During the COVID-19 Outbreak
About the coronavirus and infection
The coronavirus seems to transmit easily from person to person both directly and indirectly. As the virus is new, no one has built up resistance (immunity) to this disease yet, so many who are infected will get the illness. Most of those infected will experience mild illness, similar to a common cold, but some (especially people with other chronic illness or vulnerabilities) will be at higher risk of getting serious illness in need of hospitalization. The greatest danger of this disease is the impact on the lungs and lung function.
As a general rule, the coronavirus infects through droplets from the mouth and nose, for example if an infected person nearby coughs or sneezes, but also if objects for drug intake that are taken in the mouth or nose are shared. Infection is also transmitted through hands and when touching yourself in the face (mouth, nose, eye).
The coronavirus can survive for quite a while on surfaces, such as handles, armrests, countertops and on drug user equipment. One can therefore be infected indirectly by touching objects that an infected person recently has touched, or from used drug user equipment.
Risk of overdose
Persons who have an ongoing illness may be at increased risk of overdose. This also applies to acute diseases and thus also to coronavirus infection. Multiple diseases at the same time will increase the risk of overdose. People with malnutrition are at increased risk of overdose. Coronavirus infection may reduce lung function and this will increase the risk of overdose.
People who inhale their drugs through smoking, vaping etc., may exacerbate the condition and disease progression in the airways if coronavirus infected. Alternative ingestion methods should be considered, where sniffing or oral ingestion is recommended as alternatives if a person is infected. It is not recommended to take drugs by injection, because of the high risk of overdose in general. In the case of coronavirus infection, less drugs (lower dose) than usual should be used.
Combinations of several central depressant drugs at the same time, such as opioids, benzodiazepines and alcohol, increases the risk of overdose. Older persons may generally have an increased risk of overdose caused by gradually decreasing tolerance to drug as they age.
General advice to drug users
There may be situations in the coming weeks and months where there is unusually low availability of the drugs you normally use. Make a plan to deal with this. Be careful when buying drugs from unknown or new dealers. Divide the dose into 4 and take them in turn, not all at once.
The most dangerous way to take drugs is by injection. Avoid this as long as possible. On a scale from most harmful to least harmful, the modes of drug use are as follows;
injection - inhalation (smoking or vaping) - sniffing - oral intake.
In case of coronavirus infection or other acute illness, divide the dose and take less than usual.
The health care system is preparing to supply stable access to OAT medicines and availability of clean user equipment and emergency health services, etc. for persons with substance use. But there may be changes in opening hours and routines, so keep an eye on the lookups and information from the service providers you attend.
In many regions, it is possible to start "Low Threshold OAT" for stabilization on a OAT medication (typically buprenorphine) with a fairly quick and easy initiation. The availability and schemes of such low-threshold OAT vary from one place to the other. Contact your health care provider or your family physician to discuss this if you consider starting OAT.
Try and avoid taking drugs while alone, at the same time keep more than usual distance to others.
Get a Naloxone nasal spray/kit as an overdose prevention if you don't have one already.
Advice for drug users to help avoid infection
Good hand hygiene is the single most important measure to avoid being infected by the coronavirus. In addition, general hygiene measures and enhanced cleaning are generally important and should be strengthened at this time.
Avoid hand-shaking and hugs, and be careful with hand hygiene before touching your face, eating with your hands, handling your drugs, etc.
Avoiding large gatherings and events is recommended. Keep distance to others, more than normal.
Avoiding public transport as far as possible is recommended.
Talk to your doctor about the need for seasonal flu vaccine and any other vaccines.
Advice for drug users in case of suspected coronavirus infection
In the case of new-onset signs that may be coronavirus disease; (fever, headache, cough, body pain) take the needed considerations and try as far as possible to avoid infecting others. Stay in the home quarantine for at least 14 days if you suspect you have mild coronavirus disease.
If you feel anxious or the symptoms worsen, do not hesitate to contact your health care providers, first by phone, then follow the advice and guidance you receive.
It is advised to keep a lower threshold to contact the doctor / health service for those who are particularly vulnerable during this time.
If you suffer from coronavirus disease and experience deterioration of health and more severe signs of respiratory illness such as breathing difficulties or growing cough; contact the health service and ask to be examined.
In a typical coronavirus disease with an exacerbating course, an infected person may experience worsening from days 4-7 in the course of the disease. Worsening can be in terms of: more cough, increased fever, more feeling of sickness and breathing difficulties. This is absolutely serious and one must contact the health care system in such a situation. The above described may also occur in other forms and at times other than from days 4-7+, so do not limit your contact with the health care system to the above-mentioned conditions, these are just some examples.
The health services will facilitate for different delivery arrangements for persons undergoing OAT who are coronavirus infected. Talk to your health care provider.
Change your drug use to a safer method and preferably oral intake. Reduce the dose of drugs consumed.
For people who are undergoing OAT
Buprenorphine has a slightly lower risk of overdose than methadone. Applying long-acting buprenorphine preparations (1- or 4-weeks depot treatments) may be a good treatment choice. Discuss with your treatment provider if this is appropriate for you.
Talk to your OAT practitioner about medication routines and urine tests, emergency schedules etc., and make a plan for the next few weeks where different risk situations are discussed. Topics you should discuss are; how often should the OAT medication be obtained, where should the drug delivery (OAT clinic or pharmacy) take place, or is there a need for delivery with home service if possible? In this context, make a plan for how to reduce the need to attend larger gatherings of people (i.e. outside medication dispensing units) and reduce the use of public transport etc.
Agree with your OAT care provider on how to maintain contact with the OAT health service in the future; is it at regular clinical meetings, by phone or other forms of communication and how often should this be done?
Have an emergency plan and an emergency phone number you can call in case of emergency.
Advice to treatment services that offer OAT
In a normal situation, substance use treatment is demanding and often consists of many dilemmas. In the current situation it is crucial to consider how to stabilize and maintain good drug treatment. At the same time paying extra attention to worsening of chronic diseases as a risk factor while planning and managing the risk of coronavirus infection and acute respiratory disease is necessary. It is, and will be challenging, but all treatment providers must do these assessments and make adequate plans for dealing with them for the coming weeks and months.
Assess the health of patients on OAT more carefully these days. If chronic and / or acute illnesses are suspected, overdose risk should be specifically assessed and preventive measures taken.
Have a particular focus on whether patients have respiratory symptoms. In that case, take appropriate measures both to look after the patient's health and to reduce the risk of transmission of the virus.
Have available hand disinfection and also consider facemasks for patients who come to get OAT medication.
Consider the dosage of OAT medication in the event of an acute infection. If a patient develops symptoms of lung infection and / or coronavirus disease, reducing the dose of OAT medication may be considered / attempted in agreement with the patient.
Make a plan for whether the OAT medication should be taken at the OAT care centres or delivered differently to patients with coronavirus infection and how to reduce the risk of spread to other patients and the staff, including home care services.
Make a plan for the provision of medication to OAT patients who develop severe coronavirus disease and whom will need hospitalization.
Consider whether there is a need and feasibility with longer take-home intervals and with fewer appointments for patients who obtain medication for several days, when this is appropriate.
Consider whether there is a need for outpatient consultations during this period, for example the need to regular urine tests or physical attendance for consultations.
Balance the need for patient’s travel to collect medication and the efforts to reduce risk of disease transmission with the patient’s need for contact, follow-up and monitoring.
In a crisis some patients may need more not less attention and follow-up, and some may feel increased loneliness and a sense of crisis during these circumstances.
Consider whether there will be stable and predictable opening hours and delivery routines for those who receive OAT drug daily / regularly at your clinic. Reassure patients, within what is realistic, that there will be stable availability of OAT medication even during a time of crisis for health care services/ staff.
Prepare the service delivery so that delivery of OAT medication does not result in large assembly of patients at the same time. Increase hygiene measures at the delivery points.
Ensure that sufficient OAT medication is available, and consider ordering stock for a longer period of time than usual order intervals.
Consider sufficiently available capacity and opportunity for low-threshold OAT inclusion.
Consider and prepare for appropriate measures to keep your staff at low-risk of virus exposure.
People who use illegal drugs regularly may experience instability in access to the drugs they usually use. Discuss with patients how they plan for such a situation and contribute where it is possible to avoid the related risks.