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Scottish Drugs Forum
Scottish Drugs Forum, 2020
How can needle exchange services and opioid substitution therapy be safeguarded in the midst of a novel viral outbreak? Scottish Guidance considers potential disruptions to delivery, and suggests ways of ensuring continuity of services when best practice or ‘service as usual’ might be out of the question.
Summary The featured guidance was drafted by the Scottish Drugs Forum in March 2020 in collaboration with the Sexual Health and Blood Borne Virus Prevention Leads Network, and co-ordinated by the Scottish Health Protection Network. It represents their expert consensus about how to manage the COVID-19 outbreak within the substance use field – in particular, ensuring the continued provision of injecting equipment and opioid substitution therapy. The document was accurate at the point of publication on 19 March 2020. As this is a rapidly-changing situation, the guidance will need to be regularly reviewed and updated. For the most up-to-date information see the Scottish Drugs Forum website.
Cases of a “mysterious illness” were first reported in Wuhan (China) in December 2019. The virus was officially named by the World Health Organization on 11 February 2020 as COVID-19 (a shortened version of ‘coronavirus disease 2019’).
COVID-19 is a type of coronavirus – a group of viruses that usually cause mild illnesses but can result in more severe respiratory issues such as pneumonia or bronchitis.
On 11 March 2020, the World Health Organization declared that the outbreak had reached pandemic proportions, with multiple countries seeing sustained transmission between people, causing illness and death.
The guidance was designed for anyone working with people who use drugs, especially those working with people on opioid substitution therapy and people attending services to obtain injecting equipment. Its chief aim was to raise awareness of potential problems around service provision during the COVID-19 outbreak, and offer suggestions as to how these challenges might be mitigated.
Specific populations of service users may be at heightened risk of COVID-19-related illness or complications. This includes pregnant women, people over the age of 70, residents of a nursing home or other chronic-care facility, people who have chronic illnesses, and people who have compromised immune systems either through illness or medication.
In Scotland, over half of the 60,000 people with drug problems are over the age of 35 and have co-occurring illness and disease, including chronic inflammatory lung disease, which causes obstructed airflow from the lungs. This makes them a very vulnerable high-risk group in relation to COVID-19.
Interruption to the existing provision of opioid substitution therapy and associated clinical care as a result of COVID-19 will put people at increased risk of overdose and, in turn, drug-related death. It is also likely to result in people sourcing illicit drugs as an alternative and thus putting themselves at further increased risk from overdose, blood-borne viruses, related infections, and potentially increasing the risk of COVID-19 exposure or transmission.
In Scotland there are around 300 sites distributing injecting equipment, with over four million needles and syringes distributed and people attending around 300,000 times each year. Any reduction to the number of needle and syringe exchange sites, or restrictions on opening hours or operation, will reduce availability of new, sterile equipment for people who inject drugs. Shortages will increase the risk of people reusing equipment as well as sharing, which will increase the risk of skin and soft tissue infections, spore-forming bacterial infections, and blood-borne virus infections in a population with an already high rate of viral hepatitis and HIV compared to the general population.
Controlled drugs are medicines or drugs whose use is regulated by law “because they may cause serious problems like dependence (‘addiction’) and harm if they are not used properly”.
Naloxone has become the standard of care for the medical treatment of overdoses. Administered nasally or via injection, naloxone rapidly reverses the effects of opiate-type drugs, including the respiratory depression which causes overdose.
Self-isolation is described by the NHS as the process of an individual or a family isolating themselves within your the if they have symptoms of COVID-19, have a confirmed case of COVID-19, or have potentially been exposed to COVID-19. This is different to social-distancing, which as of March 2020 was recommended for everyone in the UK in order to reduce the number of opportunities across the population for people to contract and transmit the COVID-19 virus. Social distancing is about avoiding non-essential contact – for example, avoiding large gatherings, and only going out for necessary supplies or for exercise, and if doing so ensuring that a safe distance is maintained between yourself and other people.
Sharps containers are specially-designed hard plastic containers for the safe disposal of injecting equipment such as needles.
Medication supplies may be disrupted for a variety of reasons. Anyone in receipt of opioid substitution therapy should be informed about the potential for a disruption in medication supply as a result of COVID-19, and be encouraged to take home a supply of naloxone ( see glossary), even if they have previously received naloxone.
In the event of a stock shortage, consider:
• moving existing supplies within the community pharmacy network: medications, including controlled drugs ( see glossary), can be transferred between pharmacies within the same business organisation; multi-site pharmacy businesses should be encouraged to have contingency plans in place to move stock between premises to meet patient need;
• alternative opioid substitution therapy options: in the event of severe disruption to medication supplies there may be a need to use alternative medications or formulations.
It is important to note that controlled drug regulations require a written prescription stating the drug, formulation, and dose in order to be legal, and changes to one or more of these may require a new or amended prescription.
The worst case scenario would be if there is a complete breakdown of the supply chain and opioid substitution therapy supplies are exhausted. In the event of this happening, “symptomatic relief packs” should be provided. These would consist of a small quantity of opioid agonist (a medication which has similar psychoactive effects to the misused substance, for example methadone for heroin dependence) with guidance on how to reduce the dose over a few days, along with treatments to manage symptoms of withdrawal.
Community pharmacy closures or restricted opening hours are likely to occur at some point during the COVID-19 pandemic. In the event of closures, this will lead to disruption in the dispensing of opioid substitution therapy.
It is imperative that the Scottish Government and local health boards regard opioid substitution therapy and needle exchange services as core services which are to be maintained even if other pharmacy services cannot.
Pharmacies are independent contractors who are responsible for their own business continuity plans. Copies of these plans should be submitted to local health boards, including plans for pharmacies with multiple locations or with a chain of businesses to share stock internally in the event of closures.
Pharmacies should liaise with local health boards and drug treatment services throughout the pandemic. When pharmacy sites are closed staff should ensure that controlled drug registers, active prescriptions, and necessary stock are transferred to the new site. There will be limited capacity for single-site businesses to mitigate the impacts in the same manner as larger multiple businesses.
In the event of pharmacy closures, consider the following steps:
• providing replacement prescriptions to another pharmacy;
• exploring alternative models of dispensing and delivery.
The closure of pharmacies has the potential to be hugely challenging. Home deliveries may be an option in some areas and businesses depending on current capacity and support. In general, deliveries do not form part of the NHS contracted service and pharmacy companies provide this according to their own business needs. Some capacity may be achieved through existing delivery arrangements within the pharmacies. Nominated representatives (such as family members, friends etc.) can already collect dispensed medication, including controlled drugs, with the patient’s written consent. This could be extended to health service staff, police etc. Only the patient (not the prescriber) can authorise someone to collect on their behalf. No amendment is required to the prescription.
Community pharmacies play an important role in the provision of injecting equipment in many areas, and if they had to close or restrict access as a result of the COVID-19 outbreak this may disrupt needle and syringe provision.
All injecting equipment services should have an additional one month’s supply of injecting equipment and naloxone. They should order this without delay. Stock should be monitored locally to identify any unusual patterns of provision that may risk stock being exhausted in any given outlet. All areas should keep an additional contingency supply of injecting equipment at a local location for immediate re-stocking or delivery.
Other methods for supplying injecting equipment should be considered in the event of site closures, for example mobile vehicles, outreach on foot, and postal delivery. Some of these methods may require the collection of personal information (ie, name and address) to allow them to operate. The client should be aware of this and told exactly how this information will be used. An urgent audit should be undertaken so that needle and syringe services can contact service users if supplies are interrupted or services are going to close.
The provision of enough new needles to meet the number of planned injections should be paramount. Clients should be asked to take away enough injecting equipment to last 14 days and return at 14-day intervals thereafter, though this may not be realistic for many.
Naloxone should be offered and promoted with every needle exchange, with the exception of people using image and performance enhancing drugs. Staff should also communicate the higher mortality risk related to a drug-related overdose if airways are compromised due to the person contracting the COVID-19 virus.
Large 30-litre sharps containers ( see glossary) should be provided for service users to safely dispose of their injecting equipment at home. These should be returned to the injecting equipment programme when full.
All clients should receive advice on how to clean/re-use injecting equipment in the event that they are not able to access new, sterile injecting equipment.
All injecting equipment programmes should have hand sanitiser available and each client should be offered this on entry to the premises.
Staff should promote ways to avoid transmitting and contracting COVID-19 in all injecting equipment programmes. Staff should also communicate the increased risk of transmission if the client is sharing smoking/inhalation equipment.
There should be strategic discussions with local police regarding the need for people who use drugs to carry extra injecting equipment with them.
In the best-case scenarios, staff shortages will occur due to illness, self-isolation ( see glossary), or carer and childcare responsibilities. In the worst-case scenarios, staff shortages will be the result of staff being re-deployed within the NHS to care for patients with COVID-19. The latter will inevitably impact on the ability of services to operate a full-service model and activities will need to be prioritised.
If the situation deteriorates to the extent that there are severe restrictions on treatment services and pharmacy staffing, it may be necessary to seek temporary local or national amendments to legal requirements in order to ensure continuity of prescribing and dispensing.
For each patient, staff should consider relaxing arrangements for dispensing opioid substitutes. The aim should be to reduce pharmacy visits where possible, in order to reduce the number of opportunities for the COVID-19 virus to be transmitted. For some patients there will be a greater risk of overdose as a result of these changes. It is therefore essential to offer naloxone – even if this has been previously supplied – and for clinicians to conduct risk assessments, which would consider safe storage of medication and any children at home where the medication would be stored and consumed.
Supervision is not a legal requirement and pharmacists can exercise professional judgment when relaxing dispensing arrangements. However, this should be done in consultation with the prescribing clinician. For patients advised to stay at home by the government because they are an at-risk group, an immediate relaxation of drug-supervision arrangements should be considered.
Patients may need a full 14 days of take-home medications to comply with self-isolation dependent on symptoms. This supply may need to be collected by family members or a designated other. Ideally the pharmacist should receive and retain a signed letter from the patient authorising someone to collect on their behalf. However, verbal consent would be acceptable.
commentary The featured guidance was published by the Scottish Drugs Forum, a membership-based policy and information organisation, which works to improve Scotland’s response to problem drug use.
At the time of writing, COVID-19 was a relatively new virus, so all the field could be sure about was that this would be a rapidly-changing situation that would present significant challenges for the substance use field. The guidance was, as the authors said, “accurate at the point of publication and will be reviewed regularly and updates issued as and when required”. Pre-empting problems with service provision and aiming to provide direction, experts offered advice on the basis of consensus about what could ensure continuity of services for people who use drugs when best practice or ‘service as usual’ might be out the question.
For the most up-to-date policy on COVID-19 in the UK, key sources would include the websites of Public Health England and the UK Government. For more information on the evidence base around the interventions featured in the guidance, search the Effectiveness Bank for opioid substitution therapy and needle and syringe exchange programmes.
A range of Effectiveness Bank hot topics intersect with the issues raised in the guidance, including those on prescribing opiate-type drugs, overdose deaths, take-home naloxone provision, and harm reduction.
Last revised 19 March 2020. First uploaded 19 March 2020
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