COVID-19 Treating People who are Homeless

COVID-19 - Treating People who are Homeless

Treating People Who Are Homeless

The ongoing COVID-19 pandemic is presenting significant challenges for continuing to provide quality addiction treatment while minimizing patient, staff, and community risk for COVID-19. These challenges are even greater for providers and organizations that serve patients who are experiencing homelessness. This resource is intended to provide guidance on the issues related to adaptations safety net systems may need to make to address individuals with addiction and lack of housing as they navigate the COVID-19 crisis.

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Updated: 6/30/20

Topics

Reopening

While many places across the country are starting to relax physical distancing restrictions, the COVID-19 pandemic is not over. Communities and treatment programs across the country remain at risk for increasing population prevalence over time.

People who have addiction and are experiencing homelessness are at high risk for COVID-19 infection. The prevention measures that are advocated for the general population are much more difficult to implement for this population. For instance, physical distancing is impossible in crowded shelters and on the street where people congregate for protection from violence and overdose. Hand hygiene measures are impractical due to lack of adequate access to bathrooms, sinks, and soap. And people who are impaired due to intoxication or withdrawal are less likely to adhere to the use of masks or covering their cough, even if they do have access to masks.1

Alcohol and drug use behaviors are also likely to independently increase the probability of contracting coronavirus through a number of mechanisms including sharing substances, inhalation of substances, direct and indirect immunosuppressing effects (particularly when used heavily and chronically), increased engagement in risky behaviors, poor hygiene, etc.

For these reasons COVID-19 infection is likely to spread rapidly among people experiencing homelessness, particularly among those who have addiction. In addition, homelessness and addiction are both likely to be independently associated with a more severe course of COVID-19. People with addiction, and those experiencing homelessness have high rates of chronic health conditions (e.g. respiratory disorders, cardiac disorders, chronic infections [HIV, HCV, infective endocarditis]) that confer risk, and many individuals experiencing homelessness are over age 502. A recent analysis suggested that individuals experiencing homelessness who are infected by COVID-19 would be twice as likely to be hospitalized, two to four times as likely to require critical care, and two to three times as likely to die than the general population.3

During this public health crisis, people without access to housing will have significant need for both general medical care and addiction treatment. However, it may be more difficult to access treatment during this time. Addressing this situation is both critical to providing adequate care to these individuals and for protecting public health.

The CDC has released guidance for Homeless Service Providers to Plan and Respond to COVID-19 and for people experiencing Unsheltered Homelessness. These guidance documents both highlight the need for continued linkages to “medical, mental health, syringe services, and substance use treatment, including provision of medication-assisted therapies (e.g., buprenorphine, methadone maintenance, etc.).”

Continuity of care is critical for patients during this time. The relationship with a supportive treatment provider may be one of the most stable relationships in the life of a person experiencing homelessness, and so disruption of this relationship can be especially difficult.

Increased regulatory flexibility during this public health emergency is supporting increased access to treatment for addiction, including medications, through telehealth and increased access to take home doses of methadone. However, individuals experiencing homelessness may not have access to a reliable phone (with minutes) or other technologies that would be needed to access telehealth services.

  • Treatment providers should work with their state and community leaders to identify strategies for supporting access to addiction treatment services during COVID-19. For example:
    • Providing phones (with minutes) to support engagement in telehealth
    • Working with street outreach teams, harm reduction service providers, and other homeless service providers to connect patients with addiction who are experiencing homelessness to treatment, including low barrier initiation of buprenorphine or methadone for those with opioid use disorder.
  • If a patient is in need of care but does not have access to the technology needed to engage in telehealth the treating provider should either provide in person care or can have the patient come to the facility and provide care through room-to-room telehealth (where the patient is placed in a room with a computer for a telehealth encounter with a provider who is in a different room in the facility) to minimize risks to both patient and staff.
  • In areas of community spread, addiction treatment providers should assume that patients who are unhoused or residing in shelters have been exposed to the novel coronavirus.
    • Symptom screening may be of limited utility because the virus has a long incubation period and can be transmitted by asymptomatic individuals. Identification of symptomatic individuals for the purpose of helping them access needed medical care, however, is still recommended.
    • If testing with sufficient sensitivity to be used in asymptomatic individuals is available, it can be used to cohort shelter residents, keeping those who test COVID-19 positive away from those who test negative in order to reduce exposures.
  • Work closely with isolation and quarantine facilities to provide addiction treatment to patients with, and those suspected of having, COVID-19.
    • Isolation and quarantine can be very stressful for people with addiction. Treating providers may consider short term interventions to help patients tolerate staying in isolation and quarantine facilities, such as maintaining patients on benzodiazepines, whether they were receiving these medications by prescription or on the street, in order to prevent withdrawal. Likewise, providers may consider treating patients who have stimulant use disorders with prescribed stimulants. Even though such treatment has not been shown conclusively to improve the course of stimulant use disorder, the goal during this public health crisis is different, namely to help patients to tolerate staying in isolation and quarantine facilities for the limited period of time necessary to protect the patient and the broader community.
  • Hospitals and emergency departments should continue to screen for substance use disorder and withdrawal risk, and should assess housing status before discharging patients with or suspected of having COVID-19.
  • Residential or inpatient treatment programs should assess housing status before discharging patients.
    • When discharging patients who lack stable access to housing and have COVID-19, the treatment program should work with their local public health department to identify an isolation site where they can access the ongoing care that they need for both addiction and COVID-19.
    • When discharging patients who lack stable access to housing and are suspected of having COVID-19, the treatment program should work with their local public health department to have the patient tested and identify an alternative care site where they can access the ongoing care that they need for addiction while they await the test results.
    • When discharging patients who lack stable access to housing and are not suspected of having COVID-19, the treatment program should:
      • Work with treatment providers in the community to ensure that the patient is effectively engaged in the appropriate level of outpatient care.
      • Work with the community housing services, as well as local recovery homes, to identify housing and other recovery support services available to the patient.
      • Make sure the patient has a mask.
  • Opioid treatment providers should work with shelters and alternative care sites to explore options for take home doses of methadone and telehealth-based appointments.
    • Opioid treatment providers should coordinate with shelter managers and staff at alternative care sites to ensure medication continuity for patients treated for OUD.
    • Opioid treatment programs should be prepared to deliver doses of methadone to established patients in shelters and alternative care sites, utilizing alternative medication delivery systems if those are available (e.g. mobile dispensing units, OTP staff or law enforcement-based delivery systems).
    • Local practitioners able to start buprenorphine for patients with untreated OUD should make themselves known and available to shelters and alternative care sites through locally developed systems of care.
  • Detachment from treatment and recovery support groups can be particularly difficult for people experiencing homelessness, as they may be less likely to have the ability to access online support groups. Treatment providers should consider options for supporting access to support groups.
    • On site groups that maintaining physical distancing.
    • Provide technology for virtual support groups.
  • Treatment providers should counsel their patients about strategies to minimize their risk of transmission including physical distancing; hand hygiene when possible; not sharing cups, bottles, utensils, etc.; not sharing cigarettes, e-cigarettes, joints, etc.; and not sharing other drug use equipment (e.g. syringes, cookers, cottons).
  • Patients should also be advised on where to seek care if they develop COVID-19 symptoms, as well as where to seek care if they experience withdrawal or other potentially serious health issues related to their substance use.
  • In areas of significant community spread, advise patients that emergency services may be slower to respond.
    • Emphasize importance of access to naloxone and having someone who can check in on them.
    • Work with community naloxone distribution programs to keep naloxone available to distribute to patients and community members.
    • Also consider partnering with local pharmacies to ensure they have naloxone on hand so patient prescriptions can be filled if direct distribution is not available. (However, note that many patients may not be able to afford the co-pay for naloxone)
  • There may be more interest in treatment if drug supplies are disrupted or if individuals experience withdrawal.
    • Be ready to engage.
    • Work with outreach workers, emergency departments, harm reduction service providers, etc. to identify people and engage them in care.
  • Ensure patients have consistent access to their addiction treatment medications.

Treatment providers should also consider new strategies for getting medications to patients, including those in isolation or quarantine, while minimizing the risk to patients, staff, and public health. This will likely involve close coordination with community safety net providers and isolation and quarantine sites. Some communities are currently exploring the use of mobile dispensing units to deliver buprenorphine, methadone, and other medications to patients that cannot or should not come to an in-patient visit.4

The DEA released guidance related to alternative medication delivery systems for methadone on March 16, 2020 during the COVID-19 pandemic. The guidance allows for “door-step” delivery of controlled medications, specifically methadone, from OTPs to patients in need of isolation or quarantine. This delivery method requires that either an OTP staff member, a law enforcement officer, or a member of the National Guard deliver a duly ordered and dispensed amount of methadone to a patient in a locked box or container while maintaining appropriate physical distancing. Practically, this guidance means that the person delivering the medication must witness the patient or an approved member of the household retrieve the locked box/container from the doorstep. Deliveries of medication to patients unable to present in-person to an OTP can also be done through established chain-of-custody protocols with a responsible adult.

The CDC recommends that, “For street medicine or other healthcare staff who are providing medical care to clients with suspected or confirmed COVID-19 and close contact (within 6 feet) cannot be avoided, staff should at a minimum, wear eye protection (goggles or face shield), an N95 or higher level respirator (or a facemask if respirators are not available or staff are not fit tested), disposable gown, and disposable gloves. Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated. Healthcare providers should follow infection control guidelines.

Also see ASAM’s COVID-19 Guidance on Infection Mitigation in Outpatient Settings.

People experiencing homelessness are unable to quarantine or isolate at home. Communities are taking varying approaches to providing facilities for this purpose, including use of convention centers, dormitories, hotel rooms, etc. with varying levels of staffing and medical capacity. However, individuals with addiction are sometimes prevented from accessing these facilities or are evicted because of addiction related behaviors. CDC guidance recommends that these sites “Arrange for continuity of and surge support for mental health, substance use treatment services, and general medical care.”

Patients who are admitted to an isolation or quarantine facility are typically not seeking treatment for SUDs. To protect both individual and public health, it is important to create an environment in which the person feels welcomed and able to stay during the required period of isolation. This may involve tolerating ongoing substance use and supporting the provision of harm reduction services including safe injection equipment and overdose-prevention interventions. The National Health Care for the Homeless Council notes that “Failure to accommodate substance use disorders will likely mean increases in fatal overdoses/dangerous withdrawals, higher rates of vulnerable people leaving I&Q against medical advice, and compromised individual and public health.”

Resources

Interagency Council on Homelessness webinar series on Seattle Isolation and Quarantine facility; LA County hotels for I/Q; Boston COVID Recuperation Unit (https://www.bostonglobe.com/2020/04/26/metro/when-covid-19-patients-need-recuperate-home-have-no-home/)

An estimated 50% of people who are homeless have a substance use disorder.5 Isolation and quarantine facilities should be prepared to address the needs of individuals with addiction by:

  • Screening for substance use disorder and assessing both overdose and withdrawal risk as individuals enter the facility.
  • Working with community addiction treatment providers to develop protocols to triage and address risks related to substance use and addiction.
    • Establish protocols for addressing risk for withdrawal from alcohol, opioids, and benzodiazepines.
    • Establish protocols for reducing harms and discomfort associated with withdrawal from nicotine.
    • Develop protocols to proactively offer and encourage participation in substance use disorder treatment services.
  • Supporting the provision of addiction treatment services to residents through telehealth.
    • Explore options for providing access to technologies for telehealth (e.g. phones and minutes, computers, private space for these visits).
  • Ensuring patients have continued access to medications for the treatment of substance use disorders, especially medications for opioid use disorder since discontinuation can put patients at significant risk for relapse and overdose.
    • Coordinate with local OTPs to ensure medication continuity patients who are receiving methadone or buprenorphine through the OTP.
    • Coordinate with local buprenorphine waivered clinicians to enable both initiation and continuation of buprenorphine treatment.
  • Support the delivery of harm reduction services.
    • Maintain a sufficient supply of naloxone for both residents and staff.
    • When possible, ensure that patients being discharged have access to naloxone (through direct distribution, a prescription, or linkage to community-based naloxone distribution).
    • Train staff in the use of naloxone.
    • Coordinate access to syringe service programs.
  • Do not deny services to individuals on the basis of their addiction and do not evict people because of substance use.
  • Acknowledge that some residents may obtain and use substances while in isolation and quarantine. Be ready to ensure the safety of these, and other patients, and staff.
    • This is less likely when appropriate medical services are provided to screen for and treat withdrawal symptoms.
  • Train staff on how to manage residents who are intoxicated.
    • Encourage use of non-judgmental, trauma informed approaches.
    • Consider engaging peer support specialists who have experience working with individuals with addiction.
    • Directly address the biases that may lead to de-prioritization of care for these patients (particularly COVID care).
  • Consider options for supporting access to support groups.
    • On site groups that maintain physical distancing
    • Provide technology for virtual support groups.

The CDC recommends a “whole community” approach to planning and responding to COVID-19 among people experiencing homelessness. They recommend that:

A community coalition focused on COVID-19 planning and response should include:

  • Local and state health departments
  • Outreach teams and street medicine providers
  • Homeless service providers and Continuum of Care leadership
  • Emergency management
  • Law enforcement
  • Healthcare providers
  • Housing authorities
  • Local government leadership
  • Other support services like case management, emergency food programs, syringe service programs, and behavioral health support
  • People with lived experiences of homelessness

https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html

Addiction treatment providers are a critical partner in this work as most isolation and quarantine facilities, and alternative care sites will not have the necessary staff or expertise to address the complex needs of individuals with addiction. If these facilities cannot address the needs of these people they will likely end up on the street, undermining the purpose of these facilities and posing a risk to public health.

There are many options for community partnerships that can help address the needs of individuals with addiction who lack housing. For example, alternative care sites can partner with treatment providers to deliver telehealth services. In Chicago, local federally qualified health centers (FQHCs) are partnering with alternative care sites to offer telemedicine services for addiction treatment, including medications for opioid use disorder. In another example in Boston, a substance use disorder bridge clinic is partnering with a drop-in health clinic, a local syringe service and harm reduction program, and other providers who serve people who are homeless, using street-based outreach workers from these programs to initiate conversations about addiction treatment and connect interested people to care using their phones. https://www.bmc.org/healthcity/population-health/relaxed-federal-policies-enable-street-outreach-substance-use

The regulatory flexibility for providing telehealth services during this public health crisis is allowing treatment providers to bill for these services. This may promote expansion of creative ways of expanding access to quality care for addiction.

  • Communities should forge partnerships focused on engaging people with substance use disorders who are homeless with treatment for SUD and withdrawal, as well as harm reduction services.
    • Identify opportunities for outreach teams and providers who serve people who are homeless to partner with outpatient addiction treatment providers to provide treatment for SUD, including medications for opioid use disorder.
  • Given the high risk of coronavirus transmission within all congregate living settings prioritized (shelters, residential facilities, recovery homes), communities should prioritize these sites for broader testing. https://www-ncbi-nlm-nih-gov.ezproxy.bu.edu/pubmed/32338732

The COVID-19 crisis may be increasing the risk for harms associated with substance use in a number of ways:

  • Physical distancing measures and stay at home orders have limited access to harm reduction services including naloxone distribution and syringe service programs, which can put people at risk for overdose as well as infectious diseases.
  • People may be more likely to use alone during this time which can increase risk of overdose death.
  • • People who are experiencing medical issues are reluctant to seek help from the emergency department due to fear of coronavirus transmission.
  • Changes in the drug supply lead people to new substances and new sources which increases risks.
  • New unemployment and economic recession may make it difficult for people to be able to purchase substances which can put them at risk for withdrawal.
  • Treatment providers, isolation and quarantine sites, and harm reduction service providers should work together to develop strategies to provide harm reduction services, especially naloxone distribution and syringe services, to individuals in need.
  • Hospitals and emergency departments should continue to screen for substance use disorder and withdrawal risk and ensure that patients are engaged in appropriate care.
  • Outreach workers should be prepared to connect individuals in need of addiction treatment or withdrawal management services to treatment providers in their communities.