ACEP COVID-19 Field Guide

Table of Contents

Patients With Substance Use Disorders

Special Populations

Author: Evan S. Schwarz, MD, FACEP, Assistant Professor, Emergency Medicine; Section Chief, Medical Toxicology; Director, Medical Toxicology and Addiction Medicine Clinic, Washington University School of Medicine

The current pandemic is changing both how health care is delivered and how patients receive it. For patients with substance use disorders (SUDs), including opioid use disorder (OUD) and alcohol use disorder (AUD), social distancing and other necessary public policies that are meant to save lives can also make it harder for patients with SUDs to receive their typical care. They may have less access to treatment centers, outpatient care, psychologists, support groups, social resources, recovery coaches, and medication. They also may be at increased risk of experiencing withdrawal. In addition, they are dealing with the same stress, fear, isolation, and possible depression that the rest of us are experiencing. As such, they are at an elevated risk of both overdose and relapse. The following are suggestions, resources, and tools to assist in treating patients with SUDs during these difficult times.

  • If you have an X-waiver, consider writing longer prescriptions, including up to 30 days if you are comfortable doing so. It may be difficult for patients to get to follow-up appointments, get a new prescription, or get to the pharmacy. Pharmacies in your area may offer home delivery as well. For more information, refer to the California Bridge Model’s “COVID-19 National Emergency Response” and the San Francisco Department of Public Health Population Health Division’s “Interim Guidance for Providers: Addressing Needs of People Who Use Alcohol, Tobacco, or Other Drugs Who are Sheltering in Place or Require Isolation or Quarantine Related to COVID-19.”
  • For assistance with prescribing buprenorphine, use ACEP’s Buprenorphine tool. The app also includes guidance for treating both acute and chronic pain in the emergency department. Additionally, home induction is an option to minimize the time the patient spends in the emergency department and is a standard part of many addiction medicine practices. For additional information, review the California Bridge Model’s “Starting Buprenorphine Outside of Hospitals/Clinics” resource. 
  • Give patients with SUDs accurate information about what COVID-19 is, identifying symptoms of COVID-19 and how to stay safe during the pandemic. This includes harm-reduction strategies, such as not sharing supplies during continued substance use. 
  • The DEA is allowing physicians to prescribe controlled substances (eg, buprenorphine) without having an in-person appointment. This may potentially allow the hospital to develop a virtual bridge clinic to assist patients until they can get to a treatment center. For more information, review “How to Prescribe Controlled Substances to Patients During the COVID-19 Public Health Emergency” and the “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 
  • The initial evaluation of patients with OUD, including the prescription of buprenorphine, can be done either via telehealth (ie, via an audio and video device) or over the telephone, if an in-person evaluation is impractical. Review “How to Prescribe Controlled Substances to Patients During the COVID-19 Public Health Emergency” and the American Society of Addiction Medicine’s “COVID-19 - Supporting Access to Telehealth” resource.
  • The Substance Abuse and Mental Health Services Administration is becoming more liberal about enforcing 42 CFR Part 2. This makes it easier to communicate with patients and other health care providers and better allows for telehealth and phone consultations with patients (see the “COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance.” 
  • It may be difficult for patients to access take-home naloxone due to closings, limited hours of centers that distributed naloxone, or less access to recovery coaches. Without these resources, it can be difficult for patients in some areas to find naloxone (see “Naloxone Deserts in NJ Cities: Sociodemographic Factors Which May Impact Retail Pharmacy Naloxone Availability.” If possible, consider distributing naloxone from the emergency department or assisting patients in finding resources for free naloxone.
  • Patients may benefit from recovery support apps, podcasts, and online groups. These resources may not only help with social isolation but also substitute for therapy that patients may no longer be able to access (see the American Society of Addiction Medicine’s “COVID-19 - Promoting Support Group Attendance” resource).
  • For emergency medical services, naloxone, including intransasal naloxone, should still be administered to patients with opioid induced respiratory depression or failure. First responders should use this with the proper PPE both for potential aerosolization concerns as well as because patients may still need to be bagged. Intramuscular preparations are also an option. More guidance can be found in SAMHSA’s Guidance For Law Enforcement And First Responders Administering Naloxone.

Apps include:

More resources are available from national organizations dedicated to the treatment of patients with SUDs, including the:

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