The Covid-19 pandemic presents particular challenges for people who are using drugs and for those providing services to vulnerable populations. In April 2020, the Drug Policy Unit at the Department of Health (DOH) established a rapid assessment group to look at the impact of the pandemic in Ireland. As part of this rapid assessment, DOH asked the Health Research Board (HRB) to prepare an evidence brief examining the situation in a number of comparable jurisdictions. This rapid evidence brief will help DOH put the Irish response to the Covid-19 crisis in an international context. The findings will enable a comparison with the situation in other countries and assist in identifying initiatives that may be relevant to the drugs situation in Ireland.
The primary research question for the evidence brief is what approaches have been taken in Scotland; New South Wales (NSW), Australia; New York State (NYS); and British Columbia (BC), Canada to deal with the impact of the Covid-19 pandemic on people who use drug treatment and harm reduction services and other people who use drugs.
There are four sub-questions:
1 How has Covid-19 impacted on people who use drugs?
2 How has Covid-19 impacted on the demand for drug and alcohol services?
3 What guidelines and supports have been provided for drug and alcohol services in light of Covid-19?
4 How are drugs and alcohol services being restructured to meet clients’ needs in light of Covid-19, especially clients with complex needs and who are most vulnerable?
The evidence brief applied the four research questions to the situation in Scotland, NSW, NYS, and BC. These were chosen because they are developed economies and have been disrupted by the Covid-19 pandemic and because official documentation is available in English. They also have patterns of problem drug use similar to Ireland and provide a comparable range of treatment and harm reduction responses. The evidence brief also presents a summary of information available in Ireland and in other European Union (EU) countries to provide a context beside which findings from the four research jurisdictions can be read.
Question 1: How has Covid-19 impacted on people who use drugs?
When this research was being carried out, there was very little evidence available regarding the impact of the Covid-19 pandemic. In early March 2020, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) began an investigative rapid assessment to monitor the impact of Covid-19 on the drugs situation in Europe and the responses to it. This assessment included a mini-web survey of people who use drugs but might not be accessing services. The first report from the EMCDDA study was published in May 20201 and some report findings from that and from an EMCDDA report on drug markets are presented in the evidence brief. Information on the situation in the four research jurisdictions was mainly anecdotal, apart from one survey undertaken in Scotland.
Ireland and European context
Data from the EMCDDA mini-web survey indicate that respondents in Ireland who used cannabis or cocaine more frequently (daily or almost daily) in the 30 days prior to the introduction of restrictions were much more likely to use drugs more frequently or to use greater amounts in one session than they had before. In answer to the question ‘In general, would you say you have used more or less illicit drugs, since the start of the Covid-19 epidemic in your country?’, 209 (33%) respondents replied less, 142 (22%) replied more, and 90 (14%) replied the same amount.
An EMCDDA study on drug markets2 found that disruptions to the supply chain were most evident at the distribution level, resulting in increased violence in some jurisdictions. Bulk movement of drugs through shipping has not been interrupted. Domestic production of cannabis has been disrupted and prices have increased. Alternative means of both acquisition, for instance, through online sources, and distribution, through the postal service and drops, have been reported.
New York State
The Drug Enforcement Administration (DEA), a federal body and lead agency for domestic enforcement of the Controlled Substances Act, reports that the price of street drugs has increased as distribution costs have risen. Since March, cannabis prices increased by 55%, cocaine prices by 12%, and heroin prices by 7%.
The Scottish Drug Deaths Taskforce has received feedback from services and communities which suggests that service-level provision of harm reduction services is being scaled back in some areas. Responses to the Crew survey3 in April suggest that there have been product shortages, less variety, poorer quality, and some price increases. Some respondents report an increase in unintended withdrawal symptoms as a result of reduced availability.
Question 2: How has Covid-19 impacted on the demand for drug and alcohol services?
There was little concrete information available to answer this question when the research was being conducted. The European context is described below with information from one of the research jurisdictions.
Ireland and European context
Many EU jurisdictions saw an initial decline in treatment demand attributed to restrictions on movements, reduced capacity in treatment services, and fewer referrals from the criminal justice system. Harm reduction services have reported an increase in demand for social support and increases in alcohol and benzodiazepine use as a result of higher levels of anxiety among service users. Generally, much of the increased demand for treatment services has come from people’s inability to access heroin.
There is anecdotal evidence that more stimulant users are coming into contact with services due to a reduced ability to source these drugs or due to changes to daily routine enforced by lockdown, leading to the realisation that their substance use is problematic. This includes more vulnerable stimulant users who may not have been previously visible to services.
Question 3: What guidelines and supports have been provided for drug and alcohol services in light of Covid-19?
This was the research question for which there was most evidence available. All of the health services in the areas covered responded very quickly to the situation with clear recommendations and generally a high degree of flexibility. The need to maintain access to opioid substitution treatment (OST) or opioid agonist therapy (OAT) for existing clients is a common theme and ensuring this has required a great deal of coordination and the development of innovative service and policy approaches. Variations in responses are somewhat determined by historical factors, the degree of autonomy accorded to local administrators of health services, and the degree to which a harm reduction ethos has been embedded. For instance, NYS followed guidelines issued by DEA, and the degree of independence, or willingness to innovate, at the state and city level seems to be less than in Vancouver or BC. Separate but compatible guidelines for OAT have been published by Vancouver Coastal Health,4 a regional health authority, and the British Columbia Centre on Substance Use (BCCSU)5 addiction. Health Canada provides the overarching direction for policy and health service delivery at the federal level.
Ireland and European context
In Ireland, guidelines on contingency planning from the Health Service Executive (HSE)6 recommend several actions, in particular for people who are unable to access services either through their own isolation or because services are not currently available. The process by which a clinical review for OST clients can be undertaken remotely (with video link or smartphone) is spelled out in detail in guidance documents. A number of options are available for a person in treatment who is isolating at home, including provision of sufficient doses for the duration of the self-isolation and provision of medication to family members or a driver or key worker. The guidelines provide advice regarding the secure storage of doses, general safety, medicines management policy, remote consultation, and record keeping.
OST treatment services in Ireland have continued. The use of eConsultation software and the delivery of medication have ensured people in isolation can continue their treatment. Clinics have implemented social distancing measures and provided people with letters stating the date and time of their appointment to ensure permission to travel during the period of restricted movement. Recovery groups are now provided online in several areas.
The wait for methadone treatment has been reduced from 12 weeks to three days. Benzodiazepine prescriptions have increased to enable easier stabilisation of drug use during isolation. Resources have been provided to support cocooning and isolation of vulnerable homeless people. Outreach services have been active in providing information on Covid-19 to clients when delivering needle and syringe exchange services.
Temporary amendments to the Medicinal Products and Misuse of Drugs legislation are designed to ensure that patients can continue to access their ongoing treatment and ‘regular’ medicines during the ongoing emergency and to assist in easing the additional burdens on prescribers and pharmacists arising from the pandemic. The amendments allow for the electronic transfer of prescriptions between doctors and pharmacies and remove the need for a paper equivalent. The legislation also extends the validity of prescriptions from six to nine months and enables pharmacists to make additional supplies of prescription-only medicines to patients from an existing prescription. This additional authority to pharmacists must only be used where, in the pharmacist’s professional judgement, continued treatment is required, and it is safe and appropriate to make an additional supply.
Several international organisations have produced guidelines for drug services and these have been adapted or added to by services in many countries. Most guidelines include advice on take-home doses, moving from supervised consumption of substitution medication, prescription delivery, remote counselling, and initiation of treatment. German guidelines7 point out that OST patient must be visited by a doctor when a prescription for self-administration is being delivered.
While these guidelines are welcome, many jurisdictions have reported challenges in starting treatment for new clients. Detoxification has been discontinued or significantly curtailed in most jurisdictions. The need to maintain access to OST for existing clients is a common theme and ensuring this has required a great deal of coordination and the development of innovative service and policy approaches. There is concern around the greater danger of overdose as some services prescribe larger take-home packs of OST. The effort to accommodate those entering or seeking to maintain OST may have the effect of making less resources available for those who use other drugs. Telemedicine, by phone or video, has largely replaced face-to-face contacts. There are obvious benefits to using these technologies as contacts with clients can be maintained and counselling sessions continued. However, there have been difficulties in persuading clients to engage with remote technologies and the inability of service users to access the devices needed to use them.
New York State
At the federal level, DEA has partnered with the Substance Abuse and Mental Health Services Administration (SAMHSA) to ensure authorised practitioners may admit and treat new patients with opioid use disorder. DEA states that practitioners may prescribe controlled substances to patients using telemedicine without first conducting an in-person evaluation during this public health emergency. Patients presenting with respiratory symptoms should be evaluated by a medical provider who will decide on a safe number of take-home doses, up to 28 days of medication, taking into consideration the patient’s stability in treatment and ability to safely store and protect the medication.
Federal law requires a complete physical evaluation before admission to an opioid treatment programme (OTP). Under exemptions to the Controlled Substances Act, practitioners may prescribe controlled substances to patients using telemedicine without first conducting an in-person evaluation. New patients treated with buprenorphine can be assessed using telehealth systems, but this exemption does not apply to methadone patients, who are not permitted to receive escalating doses for induction as take-home medication.
Patients who only have access to one take-home medication or do not use this service should be considered for a staggered take-home schedule. Patients can still be evaluated frequently and do not receive more than two days of take-home medication at any one time. Based on the more favourable safety profile of buprenorphine, programmes should seek to maximise the ability of patients to take their buprenorphine at home during the Covid-19 crisis.
As there are no time-in-treatment take-home regulatory requirements for patients being dispensed buprenorphine, patients should be evaluated for flexible take-home doses as clinically warranted. An OTP can provide delivery of medication to an individual patient’s home or to another controlled treatment environment. A responsible adult can serve as a designated other or surrogate to pick up an OTP patient’s medication.
SAMHSA urges providers to consider utilising benzodiazepines for individuals with alcohol use disorder where they believe there would not be a benefit from administration of anticonvulsant medications. Medications such as gabapentin, topiramate, or carbamazepine are useful in preventing seizures related to alcohol or benzodiazepine withdrawal. These medications also possess a much lower abuse potential. Limited doses of benzodiazepines might be considered for specific symptom relief for a short duration (several days).
Specialised substance use services, including withdrawal management services, are delivered primarily through five regional health authorities, the First Nations Health Authority, and the Provincial Health Services Authority. Canada’s Controlled Drugs and Substances Act 1996 has been amended to permit pharmacists to extend, renew, and transfer prescriptions and verbally prescribe controlled substances, which can be delivered by pharmacy technicians to a private address, not necessarily that of the patient receiving the prescription. Changes of pharmacy regulation allow emergency supplies to patients with expired prescriptions and the provision of carries to reduce exposure to Covid-19.
BCCSU general prescribing guidance advises general practitioners to send OAT prescriptions to pharmacies with the capacity to deliver, or deliver medications directly to patients, weekly if necessary, with advice on storage. In order to reduce the risk of withdrawal, exposure to Covid-19, and exposure to a limited and toxic drug supply, BCCSU recommended replacing illicit and licit products with prescribed or regulated substances. For patients who use opioids, BCCSU recommended offering OAT or increasing doses or providing carries for existing current patients. Co-prescription of oral morphine will help to reduce withdrawal symptoms.
For patients using street opioids in addition to their OAT or who decline OAT, prescriptions should be made according to current use and patient preference as well as clinical judgement to select appropriate medications and dosage. Dose and medication will depend on whether or not patients are being co-prescribed OAT and patterns of substance use. The dose can be adjusted over time, with the goal of the person being comfortable and not needing to access the illicit drug market. Witness ingestion is not required and the prescription of up to seven days’ supply of carries, preferably in blister packages, can be considered where clinically appropriate. Similar guidelines apply to the prescription of buprenorphine/naloxone and patients can receive longer duration carries because of the reduced risk of overdose. Micro-induction may be considered for individuals transitioning from another OAT medication to buprenorphine/naloxone, to avoid the need for a washout period and moderate withdrawal to be reached prior to induction.
Similar guidelines are provided for prescribing sustained-release oral morphine and methadone, and guidance on injectable OAT (hydromorphone and diacetylmorphine) is forthcoming. As with other OAT medication, prescribing will depend on patient stability and their capacity to store. In all cases, clear communication with pharmacies is essential. Risk of overdose, diversion, or risks to household members must be carefully considered when deliveries or extended carries are being considered. Telehealth is especially recommended for use when dealing with patients accessing OAT.
For those at risk of severe withdrawal from alcohol, BCCSU recommended inpatient withdrawal management, which may include prescribing benzodiazepines. For those declining this treatment, advice on withdrawal, including safely reducing alcohol and accessing alcohol, should be given. If the patient is at low risk of complicated withdrawal, prescribers should consider gabapentin and/or clonidine and/or carbamazepine. BCCSU recommended psychostimulants, such as Dexedrine and methylphenidate, as part of replacement therapy for those with stimulant use disorder. The prescription must come with advice regarding possible worsening of symptoms and side-effects of medication. For users of illicit benzodiazepines, BCCSU recommended relatively low doses of clonazepam or diazepam with up-titration as needed.
A Health Canada class exemption enables a flexible approach to supervised consumption services that may include drug checking and virtual supervision of drug consumption. The British Columbia Centre for Disease Control (BCCDC) has published an overdose prevention protocol in the context of Covid-19, taking account of the change in regulations and making recommendations on safer injecting, take-home naloxone kits, and observation of consumption in any health or social service sector environment.
Responsibility for the National Health Service (NHS) in Scotland is a devolved matter and rests with the Scottish Government. The Scottish Drugs Forum works with policymakers, service planners and commissioners, service managers and staff as well as people who use or have used services to ensure service quality and evidence-based policy and practice. The forum has published comprehensive guidance to help treatment services plan, manage, and deliver services for people who use drugs during the Covid-19 pandemic.
Supervision of self-isolating OST patients can be relaxed, and 14 days of take-home medication can be provided where needed, and arrangements made for home delivery. The patient can nominate a representative to collect and deliver medication, including controlled drugs. Provision should be made to ensure medication is still available should a pharmacy be closed.
Take-home supplies of safe injecting equipment for up to 14 days should be encouraged. Take-home supplies have largely replaced daily supervised dispensing and there is guidance around managing home delivery. Priority should be given to those seeking treatment as a result of the supply reduction of heroin. Doorstep titrations – of methadone or buprenorphine, depending on the patient’s circumstances – using existing protocols are used by some services, and guidelines on this approach are provided.
Serious shortage protocols legislation may be enacted to allow pharmacists to supply branded products and different preparation strengths, and methadone tables not currently licensed may be used if an oral solution is not available. Conversion to various formulations of buprenorphine is possible with caution of the risk of precipitated withdrawal and micro-dosing to support a slower transition. Injectable buprenorphine and modified-release preparations may be considered.
For those with alcohol use disorders, the priority should be to avoid the abrupt changes in alcohol consumption patterns that might trigger serious withdrawal symptoms. Relapse prevention medications, such as acamprosate, disulfiram (Antabuse), naltrexone, and baclofen, can be crucial to recovery, and prescriptions should be maintained. It has been reported that more vulnerable stimulant users are seeking treatment. While psychosocial interventions are typical for problematic stimulant use, the guidelines note the harm reduction approach being pursued in Canada. Scotland has decided to allow the prescribing of benzodiazepines to those at risk of harm, while acknowledging the absence of peer-reviewed and established evidence-based guidance on benzodiazepine prescribing. While it is not possible to estimate tolerance when illicitly produced benzodiazepines are being used, estimated equivalents of prescribed drugs serve as a guideline.
New South Wales
The federal minister for health administers Australia’s national health policy, and state and territory governments administer elements of healthcare within their jurisdictions. State governments have responsibility for funding and managing community and mental health services, which include drug and alcohol services. A national guidance document suggests sublingual buprenorphine, with transfer to depot buprenorphine, as it requires less clinical monitoring and a shorter period of supervised dosing. Patients should be categorised into high, moderate, or low risk groups, which will determine the dosing regimen. Guidance is provided on collection and delivery of medication for those in isolation, including the selection of the agent responsible. Prescribers should advise all OAT patients to obtain take-home naloxone as a safety precaution.
Question 4: How are drugs and alcohol services being restructured to meet clients’ needs in light of Covid-19, especially clients with complex needs and who are most vulnerable?
New York State
The Office of Addiction Services and Supports (OASAS) states that an inability to keep take-home doses of medication safe due to a chaotic living situation (e.g. certain types of homelessness) would be grounds for patients being deemed ineligible for an emergency, take-home exemption. For these patients who, for safety reasons, need to continue daily dosing, every precaution should be made to limit exposure to patients possibly symptomatic for Covid-19, as well as to older and/or medically fragile patients. However, OASAS do not provide any further guidance in relation to this.
Vancouver Coastal Health published comprehensive guidance for implementing and operating Covid-19 facilities for homeless and under-housed residents who are unable to self-isolate. They identify that long-term substance users are at high risk from complications of Covid-19 and that their needs should be addressed.
In February 2020, some 26% of the prison population were receiving a daily OST, which is difficult to sustain under Covid-19 due to efforts to comply with social distancing and elevated rates of staff absence. The Scottish Government guidance recommended transferring appropriate patients receiving daily OST via oral methadone or solid dose buprenorphine to monthly injections of slow-release buprenorphine (Buvidal). It is essential that those leaving prison at risk of overdose are provided with naloxone on release. In addition to the existing intramuscular products already provided, work is underway to pilot the provision of intranasal naloxone to increase the numbers of people with naloxone in their possession on release. It was anticipated that 350–400 people under the scheme would be released from prison by the end of May 2020.
Guidance from Pathway, the leading homeless healthcare charity in the United Kingdom (UK), has been developed in a UK/English legal context, but is of use to those planning and delivering services in Scotland. The guidance states that patients with alcohol, drug, or nicotine addiction should be able to access a variety of approaches to prevent withdrawal, with input from specialist addiction services to minimise their need to leave isolation.
New South Wales
The NSW Department of Communities and Justice has developed guidance for providers that are delivering services for people experiencing homelessness during Covid-19. It advises that consideration should be made in relation to assisting clients in accessing ‘take-away’ supplies of replacement drug therapies (i.e. methadone and buprenorphine) in consultation with the local health network/methadone clinic.
There was limited information on the impact of the Covid-19 pandemic on people who use drugs or on the demand for treatment services. The guidance for treating new patients entering OTPs differed by region. NYS recommended treating with buprenorphine where possible, as it can be prescribed by telemedicine without first conducting an in-person evaluation. However, this does not apply to patients starting methadone. Buprenorphine was also recommended by NSW, followed by transfer to depot buprenorphine after one week. Scotland stated that either buprenorphine or methadone may be used but titration onto methadone is often safer when the medication can be provided on a daily supervised dispensing regime from a pharmacy. BC recommended considering buprenorphine but also provided comprehensive guidance for all other potentially suitable medications. The reasons cited for using buprenorphine include its superior safety profile and reduced risk of overdose and diversion.
In response to the Covid-19 pandemic, each region has introduced changes to their protocols on providing take-away doses (TADs) to patients and on delivering medications. This has led to patients being allowed to receive an increased number of TADs. While NYS and NSW are prescriptive in their guidance around TADs, provision of TADs in BC and Scotland appear to be at the discretion of the prescriber and based on the individual patient. In circumstances where patients cannot access their medications, in each region it is now permissible for pharmacies and treatment programmes to deliver medication, or, alternatively, nominated persons are allowed to collect medication on the patient’s behalf. Given the relaxation of the rules around prescribing controlled medications, the risk of overdose was cited, with BC, Scotland, and NSW all recommending that patients be provided with take-home naloxone. Scotland recommended offering naloxone with injecting equipment provision transactions, while BC has allowed the establishment of temporary spaces that comply with physical distancing within supervised consumption services.
Regarding other substance use, BC has published the most comprehensive guidance. It recommends replacing illicit and licit products with prescribed or regulated substances. It has also published a detailed pharmacotherapy protocol for opiates, alcohol, benzodiazepines, and stimulants. In relation to alcohol use, NYS, BC, and Scotland provide guidance on managing outpatient withdrawal and on the use of medication to do this. BC is the only area that has guidance on how to provide a managed alcohol programme and on how to ensure that patients have access to an adequate alcohol supply to prevent severe withdrawal complications. For benzodiazepine use, NYS, BC, and Scotland recommend prescribing benzodiazepines, with BC providing more detailed guidance on how to manage these clients. Just BC and Scotland provide guidance for stimulant use, which in fact differs: BC recommends prescribing Dexedrine or methylphenidate for stimulant users, while the Scottish guidance does not recommend the use of these off-licence drugs.
There was some guidance in BC, Scotland, and NSW in relation to vulnerable people or those with complex needs. BC and NSW provided guidance for services dealing with people who are homeless; this guidance mainly related to ensuring they could access and store medications. Scotland was the only region to provide guidance in relation to prisons. It recommended transitioning those receiving daily supervised OST to Buvidal, which is a long-acting buprenorphine depot injection, for people serving six months or longer. This was to achieve a rapid reduction in the need for daily contact with NHS front-line and prison staff. It also recommended that those leaving prison be provided with naloxone.
Brian Galvin and Deirdre Mongan
1 European Monitoring Centre for Drugs and Drug Addiction (2020) European Trendspotter series. Impact of COVID-19 on drug services and help-seeking in Europe. Lisbon: EMCDDA.
2 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol (2020) EU drug markets: impact of COVID-19. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/32100/
3 Crew (2020) Covid-19 drug markets survey summary:
month 2 – May 2020. Edinburgh: Crew.
4 Vancouver Coastal Health (2020) Prescriber guidelines for risk mitigation in the context of dual public health emergencies. Vancouver: Vancouver Coastal Health.
5 British Columbia Centre on Substance Use (2020) COVID-19: information for opioid agonist treatment prescribers and pharmacists. Vancouver: British Columbia Centre on Substance Use.
6 HSE National Social Inclusion Office (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: Health Service Executive.
7 Conference of the Chairmen of Quality Assurance Commissions of the Associations of Statutory Health Insurance Physicians in Germany (2020) Information on opioid substitution and Sars-CoV-2/Covid-19: advice for physicians. Gernsheim/Hamburg: Forum Substitutionspraxis.