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?