key: cord-0913745-bmrrpytg
authors: Collins, Alexandra B.; Beaudoin, Francesca L.; Samuels, Elizabeth A.; Wightman, Rachel; Baird, Janette
title: The Impact of COVID-19 on Service Provision for Emergency Department Patients Post-Opioid Overdose: A Field Report
date: 2020-11-16
journal: J Addict Med
DOI: 10.1097/adm.0000000000000779
sha: 653c225b42c1083a504d012be5c935da9db23ed7
doc_id: 913745
cord_uid: bmrrpytg

BACKGROUND: To minimize the spread of COVID-19, health and ancillary care providers altered service delivery patterns. These changes included an increase in reliance on telemedicine modalities, a reduction in services or hours of operation, and prohibiting guests and nonessential personnel from healthcare settings. We describe a rapid environmental assessment with senior emergency department (ED) practitioners in Rhode Island to understand how COVID-related procedural changes impact the provision of post-overdose care in ED. METHODS: Semi-structured interviews were conducted with 14 senior healthcare practitioners in EDs across Rhode Island from June to July 2020. Interviews were part of a larger, ongoing study examining the implementation and effectiveness of post-opioid overdose care in EDs and sought to understand how COVID-19 had impacted the provision of services for people who use drugs (PWUD). RESULTS: COVID-related policy changes challenged the provision of services to PWUD in the ED, and extended challenges in connecting people with OUD to services in the community. Specifically, challenges included transitions to telehealth modalities, required COVID tests for treatment services, and gaps in community resources. CONCLUSIONS: This study underscores opportunities to improve the delivery of services amid overlapping public health crises for PWUD, including bolstering the use of telemedicine in EDs and across the care continuum.

T he overlapping overdose crisis and coronavirus disease (COVID-19) pandemic have placed an increased strain on an already overwhelmed healthcare system. Public health efforts to minimize COVID-19 exposure have included interventions to reduce the spread during medical encounters, such as the introduction and expansion of telehealth modalities, social distancing policies (including stay-at-home orders), and reduced hours or temporary closure of support services (eg, harm reduction centers, housing services). Although necessary, the impact of such public health strategies disproportionately impacts people who use drugs (PWUD), a population that has historically faced barriers accessing traditional health systems. 1 Understanding the impacts of COVID-19 on the provision of care for PWUD is critical as jurisdictions across the US are reporting significant increases in fatal and nonfatal overdoses since the start of the COVID-19 pandemic. 2 Rhode Island has long been an epicenter of the overdose crisis and has experienced a significant spike in fatal overdoses since early 2020. 2, 3 In 2017, the Rhode Island Department of Health mandated Levels of Care for patients presenting to the emergency department (ED) after an opioid overdose or for PWUD seeking treatment for an opioid use disorder (OUD). These levels of care include naloxone distribution, peer recovery supports, and referrals to treatment. 4 Here, we describe how COVID-related changes impacted the effectiveness of hospital and ED treatment standards for ED patients after an opioid overdose in Rhode Island. Understanding how COVID-related public health transitions shape the provision of care for PWUD in the ED is critical to addressing overdose risk and iterating on existing programs and practices to better meet the needs of individuals within a second wave of the pandemic.

COVID-focused qualitative interviews were undertaken with 14 senior ED practitioners in Rhode Island EDs from June to July 2020. Participants were purposefully sampled to represent nursing and physician leadership, community and academic practices, and men and women. These interviews were part of a larger study evaluating the effectiveness of statewide policies for ED patients following an opioid overdose. This sub-study sought to explore how COVID-19 impacted the provision of post-overdose resources for ED patients. Interviews were conducted by 2 trained researchers and were facilitated using a semi-structured guide. Topics included: COVID-19 impacts on patient census; impact of COVID-19 on ED providers; adaptations to resources offered post-overdose; transitions to how services are provided (eg, telephone, telehealth resources); suggestions for improving ED resources during a pandemic and supports needed; community impacts on service accessibility; and site readiness for implementing changes to post-overdose care during COVID-19. All interviews were audio-recorded and transcribed verbatim. Participants received a $50 honorarium for their participation. All participants provided informed consent before the interview and ethical approval was received from the site Institutional Review Board.

Interview transcripts were analyzed thematically using NVivo, drawing loosely on the tenants from grounded theory. 5 A coding framework was developed collaboratively by the research team using themes emerging from the data. 5 Analysis involved multiple readings of transcripts by the study team with the coding structure applied to identify the main themes presented.

Participants reported on the time period between March and June 2020, the peak period for the COVID-19 outbreak in Rhode Island. All participants reported a substantial decrease in overall patient ED visits, and markedly greater reduction in patients presenting after an opioid overdose. Our analysis revealed 3 major themes that impacted post-overdose ED care provision: (1) transitions to telehealth; (2) COVID-test requirements for inpatient treatment services (eg, detox); and (3) barriers to community resources for post-ED care.

Many health and ancillary services in Rhode Island transitioned to telehealth (eg, telephone consultations, video calls) during COVID-19. Although participants underscored the potential benefits of telehealth for specific resources (eg, outpatient follow-up, specialty consultation), they also described barriers in using this approach, including limited access to telehealth modalities (eg, phone, video-enabled phone, computer) for patients who use drugs. Furthermore, participants felt that telehealth limited the ability to build relationships with patients compared to an in-person interaction.

Additionally, hospital policies limited access to nonpatients or nonhospital staff during COVID-19. Participants noted that this impacted in-person access to Certified Peer Recovery Support Specialists -or peer recovery coacheswho would typically be available to ED patients post-overdose. To reduce COVID-19 exposure, peer recovery coaches transitioned to phone consultations beginning in March. Participants felt that this transition limited the effectiveness of peer recovery coaches and described patients as less likely to accept phone consultations in the ED when offered. Importantly, some participants suggested that a transition from phone to video consultations may improve patient uptake of peer recovery coach services.

It was reported that COVID-19 exacerbated existing challenges hospitals faced in transferring patients to inpatient treatment facilities. Before COVID-19, participants highlighted how a dearth of local treatment beds already challenged their ability to connect patients to care. Although referral to inpatient treatment services was still occurring during COVID-19, the need for a negative COVID test before treatment admission was perceived as an added barrier. Specifically, several participants described how prolonged turnaround times for COVID tests led to delays in referrals to treatment or transfer to treatment facilities.

Participants noted several barriers to connecting patients to community resources, including: reduced hours and temporary closures, negative COVID test requirements, and limited telehealth options in service settings. Notably, these changes in community services were reported as impacting ED providers' willingness to prescribe medication for opioid use disorder (MOUD) as they were unsure if patients could be connected with an outpatient MOUD provider.

Importantly, participants felt that telehealth could be leveraged to improve the prescribing of MOUD and provider education through consultations with MOUD content experts. However, participants stressed that community service providers also needed to be equipped with telehealth infrastructure to increase accessibility for patients.

This rapid environmental assessment reveals the adverse consequences of COVID-related policy and service provision changes on the delivery of services in the ED to patients presenting after an opioid overdose. Although this work draws attention to how COVID-19 exacerbated barriers to services for PWUD, it also illustrates areas where modifications may better facilitate service access and uptake. Notably, telehealth is a promising approach to service engagement for PWUD, including peer-led services and MOUD prescribing. [6] [7] [8] Efforts should be undertaken to bolster telehealth capacity across community resources, including outpatient treatment facilities and within EDs. Expanding telehealth infrastructure for PWUD may be critical for reaching populations who face barriers accessing traditional health systems and can improve health equity for these populations.

Furthermore, this analysis demonstrates how delays in rapid COVID testing impacted PWUD, including those who experienced an opioid overdose, as it limited accessibility of inpatient treatment facilities. Expanding access to rapid COVID tests across EDs and health services is imperative to improving access to needed resources for PWUD, particularly amid an overdose crisis.

This work highlights how the ED may be an effective setting in which to fill gaps that exist across community resources. Scaling up ED services (eg telehealth buprenorphine treatment) 8 to improve buprenorphine induction may be an important step in increasing access to MOUD for PWUD. This is particularly critical amid overlapping public health crises in which patients experienced reduced access to health and ancillary services.

As fatal overdoses across the US continue to rise, there is a pressing need to implement and support timely harm reduction programs within the ED and across the care continuum that minimize overdose risk and increase access to care for PWUD. Doing so is critical to addressing compounding public health crises and ensuring better access to treatment and support services for these populations.

Stigma discrimination and the health of illicit drug users

Issue brief: reports of increases in opioidrelated overdose and other concerns during COVID pandemic

Overdose deaths involving opioids, cocaine, and psychostimulants -United States

Department of Behavioral Healthcare and Hospitals Developmental Disabilities. Levels of care for Rhode Island emergency departments and hospitals for treating overdose and opioid use

Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory

Low barrier tele-buprenorphine in the time of COVID-19: a case report

The effectiveness of telemedicinedelivered opioid agonist therapy in a supervised clinical setting

Innovation during COVID-19: improving addiction treatment access