As the COVID-19 wave crested upon Boston, Boston Medical Center swiftly transitioned its operations to become a dedi­cated COVID hospital. In order for BMC to care for some of the city’s sickest patients, ambulatory care was moved to a primarily virtual setting. For providers of BMC’s Grayken Center for Addiction, they worked around the clock to find their footing in this new telehealth landscape. Bolstered by innovative solutions and quick-thinking, clinical teams developed new ways of staying connected to patients with substance use disorder (SUD) and preserving high-touch care comparable to in-person visits.

A RAPIDLY EVOLVING SITUATION

Seemingly overnight, red tape was cut away at the state and federal policy level, creating several positive developments in providers’ plans. In an effort to reduce barriers and facilitate access to medical services, the Department of Health and Human Services announced a transition to telehealth with reimbursement opportunities comparable to office visits, regardless of sites’ ability to meet HIPAA compliance regulations. Additionally, the Drug Enforcement Administration (DEA) relaxed several guidelines around prescribing treatment to those with opioid use disorder (OUD), to mitigate interruptions in caring for new and existing patients. With more options to link with patients and expanded medication access, the concept of “meeting patients where they are” took on an entirely new meaning.

While the changes were inherently positive, they were made—in rapid fashion—against a backdrop of growing concerns, including rising overdose deaths and an HIV outbreak among unstably housed people who inject drugs. Mandates against large gatherings contra­dicted typical SUD safety guidance to have a buddy system, to “never use substances alone” and to find support in walk-in recovery centers and meetings. Furthermore, people could be turning to substances to cope with the stress of a global pandemic and the economic instability it rendered.

Given the groundswell of risks to those struggling with SUD, the Grayken team sprang into action.

COMMUNICATION: A VITAL BRIDGE

In keeping with the resourceful nature of the time, Colleen LaBelle, MSN, RN-BC, CARN, director of BMC’s Office-Based Addiction Treatment (OBAT) program, found herself rushing to a cell phone store as soon as plans to change outpatient clinic operations were announced.

“Our immediate concern was how we would continue to communi­cate with patients. We needed to keep them as plugged in as possibleto care, so to speak,” says LaBelle. “While we were concerned for all of our patients, we were most worried about those who were difficult to reach, whether it was because they didn’t have phones, ran out of minutes or simply didn’t answer phone calls. These are the patients who just walk into the clinic and we see them. We were able to give phones to our highest-risk patients so they could have a direct line of communication to the nurses.”

OBAT treats patients with OUD through evidence-based medications known as buprenorphine (also known as Suboxone) and injectable naltrexone (also known as Vivitrol). The medications are life-saving—without access to them, patients are at risk for recurrent use and overdose. “Buprenorphine restores the brain changes of substance use and allows the person to feel normal without the need to use illicit substances,” LaBelle explains.

Due to the evolving situation around the pandemic, patients were understandably fearful they wouldn’t be able to obtain their medication.

“We needed a way to communicate with patients and to assure them we would get them their medication and update them on the status of prescriptions, pharmacy access and refills,” LaBelle says. “The ability to communicate with patients directly by cell phone and text lifted a huge weight off their shoulders. It was one less thing they had to worry about.”

Moreover, changes to prescribing guidelines meant LaBelle and her team could adjust prescriptions to lengthen them and add refills. For example, if transportation to a pharmacy was a concern, they could receive a 28-day supply instead of a typical one-week supply. If patients were concerned their medication would get stolen, the team would add more refills.

For the providers, keeping in touch with patients meant they could continue to monitor their progress and be a source of sup­port. LaBelle points out communicating via cell phone—especially through text messages—has helped patients cope with mental health comorbidities that have increased due to the pandemic. It has even been life-saving at times.

“We’re finding patients are more comfortable broaching certain sub­jects [over cell phone],” she explains. “Feelings of suicide and depression have come up. We even had a patient express her life was in danger. If we didn’t have the ability to communicate with her in real time [during lockdown], I don’t know what would have happened.”

“MANY OPTED TO STAY ON THE STREETS”

Mobile phones were also invaluable in helping patients not actively nor consistently engaged in care. Typically, these patients are seen at Project TRUST, BMC’s drop-in center offering testing, case management and basic primary care. However, the small space proved challenging in light of social distancing guidelines so the center doubled down on its street outreach throughout the city to connect with those who were homeless and using substances.

“The people we see are notoriously disenfranchised from care,” explains Glory Ruiz, director of Public Health Programs. “Many opted to stay on the streets instead of going to shelters because they feared that by getting tested [for COVID], they would be required to stay off the streets. We have experience responding to communicable diseases of public health significance and we were familiar to a lot of people.”

One objective was to provide harm reduction services, COVID education and hand out essentials like masks and hand sanitizer. Additionally, the DEA’s relaxed guidelines meant they could use those moments of undivided attention to conduct on-the-spot medication-assisted treatment (MAT) prescribing—normally, laws require an in-person visit first.

“Using iPhones and iPads, the team would call the providers at Faster Paths to Treatment [BMC’s substance use disorder bridge clinic] for a telemedicine MAT consultation right there on the street,” says Ruiz. “We know if we treat the cravings for drugs, we’re setting up the patients for success. Then, they will be more willing to engage in clinical care, like going to BMC’s COVID Respite Unit (CRU) or getting tested for HIV. It’s a crisis response that should remain because it’s an incredibly important tool.”

The team also set up a tent outside of Project TRUST, in the matter of a day, complete with snacks, a hand washing station and items like sleeping bags. It would “open” in the late afternoon, after shelter beds were filled, so those without a place to sleep could collect what they needed for a night outdoors. The keen awareness of what was most important to visitors—essentially, survival—was not lost on the team. In fact, it was a concerted effort in cultural competency.

“We meet patients where they are and while we don’t miss an opportunity to educate them about COVID, that might not be their priority,” she notes. “It might be the abscess on someone’s hand because they’ve been preparing an injection site with dirty water. We need to take care of all the other things in someone’s life, too, because it leads back to keeping them safe.”

The second objective for Ruiz and her colleagues was establishing a harm reduction team at BMC’s CRU, where asymptomatic COVID-positive people experiencing homelessness recovered. “There’s a large proportion of unstably housed individuals with co-occurring SUD and mental health issues,” Ruiz shares. “We wanted to make sure we were offering support to patients for the duration of their quarantine.” In addition to harm reduction education groups and using outdoor breaks as an opportunity to talk to patients about SUD treatment, the team led naloxone (an overdose reversal drug) trainings with CRU staff.

REACHING NEW POPULATIONS

A study published in the JAMA Network Open found Massachusetts jails and prisons were reporting higher rates of COVID—infection rates were 2.91 times higher than the state’s population and 4.8 times higher than the United States’ population. To reduce the census in correctional facilities and therefore decrease the spread of COVID, the Massachusetts Supreme Judicial Court granted the early release of non-violent offenders. However, the well-intentioned motion came with a significant danger: opiate-naïve individuals are 120 times more likely to overdose following release.

To curb those odds, LaBelle and her team worked alongside the Police Assisted Addiction and Recovery Initiative to prepare “survival kits” consisting of items like naloxone as well as a number to BMC’s hotline. “Through that call, we would assess individuals and they would talk to a provider,” notes LaBelle. “Then, we’d send the prescription to the pharmacy so they can begin buprenorphine.”

LaBelle and BMC’s pharmacy set up a system where individuals without insurance would still be able to receive medications. Simply, the pharmacy would send an invoice to LaBelle, and it would be pro­cessed using funds supplied by the Prevention Unit at the Department of Public Health’s Bureau of Substance Addiction Services.

“That bridge is so critical, we couldn’t let insurance status or anything else stand in the way,” says LaBelle. “By getting people on medication right away, we are literally changing outcomes. Since March, we’ve started more than 300 people on treatment who were coming out of incarceration in urgent need.”

STRIKING THE RIGHT BALANCE

Of course, new approaches to care cannot cover everything traditional, in-person care can. Experts note it’s a matter of striking the right bal­ance. Amy Yule, MD, explains a key benefit of seeing patients in clinic is the ability to engage and establish a rapport with them—something that is especially valuable in her experience with the adolescent and young adult (AYA) population.

“It’s hard to meet a young patient for the first time over the phone or video,” she says. “In person, you can read their body language and if they’re shutting down, you can address it. If they don’t want to engage on the phone, they can just disconnect the call.”

Yule adds care coordination and warm hand-offs are more efficient when colleagues are together in the clinical space. It was especially helpful when transitioning young parents from the SOFAR clinic (BMC’s medical home for parents in recovery and their children) to the CATALYST clinic (BMC’s multidisciplinary clinic for AYA struggling with or at risk for SUD). “It was much easier to make sure mom and baby seamlessly moved between teams while maintaining the same level of care and support,” Yule states. “A practitioner could just walk a few hallways over to say hi and introduce themselves.” Yule mentions that prior to COVID there was an institutional push toward integrating behavioral health in addiction care, speaking to yet another example of how in-person visits would be best for coordinating multiple disciplines.

On the other side, Yule has found virtual visits to be ideal for maintaining care in between visits, noting it as a convenient way for patients to see providers without having to make time in their busy schedules to travel to and from the hospital—especially while juggling school and work. Moreover, she sees telemedicine as facilitating expansion of BMC’s addiction care well beyond Greater Boston in order to reach patients in areas that might not offer AYA SUD care.

She and her colleagues Sarah Bagley, MD, director of the CATALYST clinic and Scott Hadland, MD, MPH, MSc, shared their takeaways from adapting AYA care under COVID guidelines in a recent article published in the Journal of Substance Abuse Treatment. Overall, the authors advise measuring effectiveness of new practices to determine the best path forward, noting, “although COVID-19 has forced the health care system to provide care in new and innovative ways, we must not lose the opportunity to evaluate the impact of those changes so that we can determine what changes should be sustained.”

“THERE ARE SILVER LININGS AND WE HAVE TO TAKE THEM”

Despite the immense challenges and tragedy brought on by the pandemic, it has shown barriers can be broken to improve patient outcomes, especially those with SUD. “COVID is terrible,” remarks LaBelle. “But there are silver linings and we have to take them.”

Among the most critical is the center’s advocacy efforts to make relaxed prescribing guidelines and expansion of access permanent. Doing so would not only benefit existing patients, but would also allow the center to widen its reach because patients living farther away would not need to come to the clinic as often. Additionally, telemedicine is now a billable service—something that LaBelle says would have taken years to implement if it weren’t for the pandemic. Experts expanded on these takeaways in a recent Journal of Addiction Medicine article, highlighting how making SUD care more flexible and accessible will benefit patient initiation and retention.

COVID-19 has also revealed key insights about BMC’s SUD patient population, informing a path forward centered on building stronger relationships and support systems.

“We always thought the carrot on the stick—the incentive to keep patients coming back into the clinic—was the one-week prescriptions,” LaBelle concludes. “But, we gave longer scripts and we’re still hearing from them. In fact, our visit volume has increased by 60 percent. Turns out the carrot is the personal connection. It’s a provider who cares and wants to give someone their life back. It’s the empathy that people deserve and need, especially in the midst of a pandemic.”