COVID-19 and substance use disorders: a review of international guidelines for frontline healthcare workers of addiction services

Abstract

Background

People with substance use disorders may be at a greater risk of contracting COVID-19 infection and developing medical complications. Several institutional and governmental health agencies across the world developed ad hoc guidance for substance use disorder services and care of individuals misusing substances. We aimed to synthesise the best available recommendations on management and care of people with or at risk of substance use disorders during the COVID-19 pandemic from existing guidelines published in UK, USA, Australia, Canada, New Zealand, and Singapore.

Methods

We systematically searched existing guidelines and websites from 28 international institutions and governmental bodies in the context of the COVID-19 pandemic (May 4^th 2021). We summarized the extracted data as answers to specific clinical questions.

Results

We organised the available recommendations from 19 sources in three sections. First, we focused on general advice and recommendations for people who misuse alcohol or drugs during the COVID-19 pandemic, the design of contingency plans, safeguarding issues for children and families of service users and advice to the public, patients, and carers. Then, we summarised specific guidelines for people who use illicit drugs and related services, such as opioid substitution treatment and needle and syringe programmes. Finally, we provided a synthesis on specific recommendations for services supporting people who misuse alcohol and key topics in the field, such as management of alcohol detoxification and safe transition between supervised and unsupervised consumption.

Conclusions

Available guidance reflected different approaches, ranging from being extremely cautious in providing recommendations other than generic statements to proposing adaptation of previously available guidelines to confront the challenges of the COVID-19 pandemic. After the early phase, guidance focused on reduction of infection transmission and service delivery. Guidance did not provide advice on infection prevention via vaccination programmes and service access strategies tailored to individuals with substance use disorders.

Background

The worldwide prevalence of substance use disorders (SUD) is estimated to be around 100 million for alcohol use disorders and between 27–41 million for people who are opioid dependent [1, 2]. Drug and alcohol use disorders are ranked 16^th and 20^th, respectively, as leading causes of global burden of disease in adults aged 25 to 49 years old [3]. The coronavirus disease 2019 (COVID-19) pandemic presents significant challenges for people with SUD, magnifying social and economic inequalities further, especially for groups at higher overall risk such as immigrants and ethnic minorities [4,5,6,7].

People with SUD may be more susceptible to developing COVID-19. They may have a higher burden of comorbid medical and mental health conditions, be less likely to be tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), and live in social conditions which make it difficult to comply with home isolation (e.g. homeless, living in shelters) [8,9,10]. People with SUD may also face increased barriers to accessing health services for substance misuse [4, 5]. In addition, treatment providers may struggle to maintain adequate levels of continuity of care while protecting both patients and healthcare workers from COVID-19 [5].

Governmental health agencies across the world have rapidly developed additional guidance on treatment services, with adaptations to national legislation and policies, to try and meet the specific needs of patients with SUD during the COVID-19 pandemic [5]. However, the landscape of evidence-based clinical guidance is fragmented, and it is not easy for mental health professionals to find the information they need in a timely fashion.

To aid the busy clinicians in rapidly accessing reliable sources of existing guidelines in this area, we systematically searched and synthesised the best available guidance of both governmental and non-governmental agencies in the UK, USA, Australia, Canada, New Zealand, and Singapore, focusing on treatment of SUD during the COVID-19 pandemic and its aftermath.

Methods

A multidisciplinary team (including mental health clinicians, researchers, methodologists, and a pharmacist) within the Oxford Precision Psychiatry Lab [11] systematically searched English language websites of organisations 1) defined as governmental institutions, professional bodies, health technologies agencies, international agencies, and scientific societies, 2) either international or from a list of English-speaking countries (i.e. United Kingdom, the United States, Australia, New Zealand, Canada, and Singapore), and 3) publishing guidelines or guidance on the management of substance and alcohol misuse and SUD in the context of the current COVID-19 pandemic and afterwards. We defined “substance” and “alcohol” as any substance or alcohol with abuse potential or whose use might cause dependence, or it is usually considered of interest for services dedicated to addiction. We used an a priori defined approach (further details can be found online), [12] already validated in synthesising guidelines on several topics [13,14,15]. At least two researchers (EGO, JSWH, OM, KS, and CZ) searched independently across the following sources in English until May 4^th 2021:

• Governmental institutions: Public Health England (PHE), Centers for Disease Control and Prevention (CDC), US Department of Labor, Singapore Ministry of Health (SMH), Health Canada (Government department), Australian Government Department of Health, Substance Abuse and Mental Health Services Administration (SAMHSA), and Canadian Society of Addiction Medicine (CSAM).

• Professional bodies: Royal College of Psychiatrists (RCPsych), Royal College of Nursing (RCN), Royal College of Physicians (RCP), American Psychiatric Association (APA), Singapore Psychiatric Association (SPA), Singapore Medical Association (SMA), Canadian Psychiatric Association (CPA), Royal Australian and New Zealand College of Psychiatrists (RANZCP).

• Health Technology Agencies (HTA): The National Institute for Health and Care Excellence (NICE), Healthcare Improvement Scotland.

• International agencies: World Health Organization (WHO), Inter-Agency Standing Committee (IASC), UNICEF, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).

• Scientific societies: The National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU), RCPsych with British Geriatric Society and European Delirium Association, Massachusetts General Hospital Psychiatry, World Psychiatry Association (WPA), British Association of Psychopharmacology (BAP), Scottish Health Action on Alcohol Problems (SHAAP).

Further sources were hand-searched from the references of each website. Given that summarising data from primary studies was beyond our scope, we did not search reference databases (e.g. PubMed, EMBASE). Nonetheless, should we come across a particularly relevant publication, either supporting or in disagreement with available recommendations, we included it to better outline the context of a specific question. A search on Google was also completed using keywords relevant to COVID-19 (e.g. COVID-19, coronavirus, SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2]), substance and alcohol use disorders and related treatments (e.g. opioid, buprenorphine), and guidelines (e.g. guideline, guidance, recommendation). Queries or disagreements were resolved by discussion with a third researcher (AC), and the team collaborated with international experts in the field (ARLH, MJO) to keep the guidance global, focused, and comprehensive. We incorporated the feedback of clinicians and mental health professionals, and the final synthesis of guidelines was grouped in a questions and answers format for ease of consultation, with key sentences highlighted in bold. The recommendations were classified as “General advice and recommendations”, when applicable to the whole population potentially accessing healthcare services due to substance or alcohol misuse, or “specific guidelines” when tailored to distinct sub-groups of service users. Finally, we appraised the identified recommendations according to type of source organisations and institutions (i.e. governmental institutions, professional bodies, healthcare technology assessment (HTA), international agencies, scientific societies).

Results

We collected recommendations from 19 sources, [16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34] of which the majority (n = 11, 58%%) were from governmental institutions (please check Additional file 1 for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist). The other identified sources were international agencies (n = 3), healthcare technology agencies (n = 2), professional bodies (n = 2), and scientific societies (n = 1). The identified sources focused on promoting telepsychiatry in routine care, providing detailed recommendations on how to deliver digital assessments to abide by the social distancing requirements. Moreover, available guidance emphasised the potential benefits of digital services, such as an increased level of anonymity for consultancy services, though inevitably some services require face-to-face interaction. A blended or mixed approach was thus recommended, such as in-person assessments delivered for people with a moderate level of dependence. Where possible, an increased level of flexibility was prompted in the provision of take-home treatments.

The full guidance is reported in Table 1. Section 1 of the table is about general advice on issues such as particular risks for people who misuse alcohol or drugs during the COVID-19 pandemic (including those who are not on treatment), the design of contingency plans, safeguarding issues for children and families of service users and advice to the public, patients, and carers. Section 2 of the table provides specific advice for services supporting people who use illicit drugs, with an added focus also on the available recommendations for needle and syringe programmes. The third and final section summarises specific advice for services supporting people who misuse alcohol, the management of alcohol detoxification, Wernicke’s encephalopathy, and the co-morbidity of alcohol use disorder and other mental illness.

Table 1 Guidance and information governance on substance use disorder and misuse of alcohol and drug. We used colour coding to highlight the different sources of information (see bottom of the table for details). Legend. AUDIT = Alcohol Use Disorders Identification Test. CDC = Centers for Disease Control and prevention. CG = Clinical Guideline. CO2 = Carbon Dioxide. COPD = Chronic obstructive pulmonary disease. COVID-19 = Coronavirus virus disease 2019. IM = Intra-Muscular. NIAAA = National Institute on Alcohol Abuse and Alcoholism. NHS = National Health Service. NICE = National Institute for Health and Care Excellence. NSP = Needle and syringe programme. OST = Opioid substitution therapy. PHE = Public Health England. PPE = Personal Protective Equipment. RCPsych = Royal College of Psychiatry. SAMHSA = Substance Abuse and Mental Health Services Administration. SHAAP = Scottish Health Action on Alcohol Problems. UK = United Kingdom. USA = United States of America. Sources of evidence: GI = Governmental Institutions. HTA = Healthcare Technology Assessment. IA = International Agencies. PB = Professional Bodies. SS = Scientific Societies

Discussion

We have summarised the available guidelines published in English-speaking countries on several key topics relevant to the management of people with substance or alcohol use disorders and misuse of drugs or alcohol during the COVID-19 pandemic. Identified sources were primarily from governmental institutions. Available guidance reflected several changes to standard practice and care that occurred due to the impact of the COVID-19 pandemic on substance and alcohol use disorders treatment services. Key changes in recommendations focused on the role of telepsychiatry and increased flexibility in dispensing take-home treatments.

Identified guidelines widely promoted the use of digital consultations and telepsychiatry to maintain social distancing when delivering substance and alcohol use services whilst minimising perceived social isolation. The social distancing restrictions in several countries prompted a rapid implementation of telehealth and the dissemination of digital mental health practices at an unprecedented pace [13]. Telehealth services have the potential to overcome some limitations and restrictions of the traditional in-person approach [36]. For instance, digital peer-to-peer recovery support services allowed individuals to access 24/7 support, whilst leveraging the potential benefit of greater anonymity [37].

In the early phase of the COVID-19 pandemic, detoxification services needed to adapt the management and delivery processes of their activities. However, these changes to usual practice came with some drawbacks. Service disruptions and unmet support needs have been recorded as a direct result of the impact of the COVID-19 pandemic [36, 38, 39]. Such initial lack of adequate provision of care is not exclusive to the substance and alcohol misuse field, with early reports from mental health patients in China experiencing difficulties accessing general mental health services and support [40]. These instances highlight underlying inequities in health service access and gaps which are being worsened by the pandemic. Early reports suggested that young individuals and ethnic minorities could be amongst those facing greater challenges in benefitting from healthcare services [35, 38, 41]. Available guidance prompted services to prevent and address this issue, failing however to offer healthcare workers with tangible solutions or pragmatic action points.

In some cases, the initial adaptation of policies and recommendations to the COVID-19 pandemic significantly deviated from usual care. For instance, in the UK requirements for opioid substitution therapy prescription were relaxed. Drug testing was suspended as a requirement for buprenorphine prescription and, in the case of methadone, limited to individuals without a clear history of opioid use and tolerance and known patients with evidence that opioids have been used in the previous 24 h [17]. In-person attendance was formerly required for procedures such as urine drug screening to ensure safe treatment with methadone and buprenorphine. [42]. A potential risk of increased use of opioid substitution therapy cannot be excluded. Indeed, the most recent recommendations from PHE now advise the collection of confirmatory evidence of intake when assessing patients [16, 17].

As the pandemic has progressed, focus has shifted from immediate management and reduction of transmission to prevention via licensed COVID-19 vaccines. A key area of concern is vaccine hesitancy, in those with mental health difficulties more generally, [15] and specifically in those with SUD. Individuals with SUD have a greater risk of contracting a COVID-19 infection, [35] but are less likely to access preventative interventions such as vaccines [43]. Addressing equitable access to vaccines, as well as systemic and individual risk factors will be key to increasing uptake in this vulnerable group [44]. There is currently no specific formal guidance in addressing vaccine hesitancy in those with mental health difficulties or SUD. However, strategies aimed at increasing uptake in people with severe mental illness may be equally relevant in people with SUD. These include vaccination programmes within support services, alignment with other preventative health strategies including influenza vaccination, focused outreach, and monitoring uptake of vaccines [45].

Our work has some potential limitations. The search process was restricted to English language sources to synthesise available guidance from a list of English-speaking countries. The recommended resources in this paper are primarily limited to the UK and USA, whilst laws and policies regarding the treatment of and resources for people with SUD may differ between countries. For instance, this is indeed the case with regards to the treatment of opioid use disorder. Nonetheless, given the global nature of the COVID-19 pandemic, international collaborators have produced translations of our synthesis of guidance in several foreign languages and adapted it for local use [11, 13]. Since our aim was to synthesise guidelines and recommendations, our search strategy and data extraction processes were implicitly different in terms of replicability when compared to a systematic review of records from a database. To address this limitation, we adopted a comprehensive search and contacted experts in the field. We structured our work on the PRISMA checklist, adapting it where needed, to ensure the process was as systematic and rigorous as possible. For instance, results of our search strategy to locate additional potentially relevant international/national agencies are rapidly evolving and reflect the ongoing status of the COVID-19 pandemic. Nonetheless, our scope was to identify all the relevant governmental and non-governmental agencies, as opposed to systematic reviews relying on the number of records as the unit of analysis. We repeated a search for each country and checked all the links to other websites. We maximised transparency by listing all the identified sources searched and linking extracted information to the related website or document. Finally, we could not appraise the certainty of the evidence supporting the identified recommendations. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system allows evaluation of structured guidelines with defined methodologies and their evidence. However, GRADE discourages any modification to the current approach [46] and its application was not possible due to the nature of our aims and how quickly organisations and institutions responded to the COVID-19 pandemic. New approaches are needed to reliably appraise the confidence in recommendations when time is essential (e.g. disasters and emergencies).

Conclusions

Substance and alcohol misuse services had to rapidly and profoundly change to limit disruptions for service users and, where possible, continue the treatments previously in place. At the same time, the demand for services increased. More than 8 million adults in the UK are drinking at high risk, and a surge in the number of people addicted to opiates seeking help have been recorded [47]. Mental health care workers and researchers should use experience gained during the COVID-19 pandemic to address existing issues as well as to expand and improve the quality of the services offered. This will require a careful balance between the need to enhance flexibility while ensuring continuity of service delivery, and the need to maintain high standards of care [48]. When considering the available recommendations, clinicians should carefully weigh up potential risks and benefits on a case-by-case basis, especially when inconsistencies between newer recommendations and usual practice arise.

In the initial phase of the COVID-19 pandemic, regulatory agencies and professional bodies quickly provided guidance to address urgent issues. This rapid response was inherently based on limited evidence and resulted in several different approaches. Some sources of guidance were more conservative and limited to generic recommendations, whilst others suggested temporary amendments of pre-COVID-19 guidelines. Since then, a vast volume of scientific literature has been published on COVID-19, which present the opposite challenge of quickly synthesising available evidence. Future guidance should shift focus from acute restrictions to longer term management, such as the implementation of a comprehensive vaccination programme with equitable access and managing the mental health consequences of COVID-19. To do so, guidelines should source their recommendations from the growing body of literature by leveraging newly developed frameworks to provide up-to-date syntheses of the available evidence [49].