Written by: Briana Harris-Mills

Health centers have quickly adapted in the wake of the pandemic and social distancing regulations, offering care to their medications for addiction treatment (MAT) patients primarily via phone and telehealth.

We spoke with Heather Couch, a family nurse practitioner at Santa Cruz County Health Services Agency, to learn more about how Santa Cruz is managing care for their patients during COVID-19.

CCI: What are the two biggest concerns you’ve heard about initiating MAT via telephone? And how would you address those concerns?

Heather Couch: I am most concerned about co-occurring alcohol use disorder (AUD). I haven’t heard any concerns from others. I would guess there would be concerns over liver function, active Hepatitis C, and polysubstance use.

On CCI’s “Problem Solving Around COVID-19 and MAT” webinar on April 15, Dr. Joe Sepulveda, of Family Health Centers of San Diego discussed how to address prescribing MAT to patients with co-occurring diagnoses. Dr. Sepulveda explained that the most important thing to understand is that by prescribing Suboxone or buprenorphine, you significantly reduce the rate of use, relapse, infectious disease transmission, and mortality even in those with co-occurring disorders. If you encounter a new patient using stimulants, benzodiazepines, or alcohol, you can still start them on Suboxone. If your patient is already on Suboxone and using multiple substances, you should continue to prescribe Suboxone.

When prescribing to new patients who have a significant alcohol history and polysubstance use, Dr. Sepulveda explained you should take caution and check in with the patient often because alcohol withdrawal, in combination with opioid withdrawal, can be life threatening. If your clinic is allowing for in-person medication initiation and your patient is having complications, you may want to have the patient come in and see them in person.

Regarding Hepatitis C, Dr. Sepulveda noted that his clinic suspended taking baseline labs for patients who were being started on MAT, to limit foot traffic in the clinic. The current guidelines do not require providers get labs before starting medications. Providers should use their clinical decision making to determine whether that patient needs to have labs run now or if it can wait until recommendations around physical distancing change.

CCI: One clinic shared their strategy of using seasoned prescribers to initiate medications for new patients by telephone or telemedicine and using newer prescribers for refills. Is this something your clinic has considered? Do you have other recommendations for increasing the comfort level of newer prescribers?

Heather Couch: Our current protocol at Santa Cruz is to initiate MAT via telephone. When I am squeamish about prescribing, I remind myself that clients have been using on the streets, many for years, surviving overdoses, and that Suboxone is a much safer alternative when compared to full agonists combined with polysubstance use, alcohol, and/or benzos.

CCI: In thinking about care beyond medications — behavioral health support, substance use disorder (SUD) counseling, and case management — what are the most significant changes you’ve had to make to support the behavioral health needs of your patients in light of COVID-19?

Heather Couch: At Santa Cruz, our SUD counselors or case managers have telephone or telemedicine visits with our patients. We provide whole person care by assessing our patient’s needs and providing resources, such as providing housing needs or motel vouchers to our patients who are experiencing homelessness. We have check-ins based on tiers and individual’s needs.

On our “Problem Solving Around COVID-19 and MAT” webinar on April 8, Danny Contreras, a health services manager at Santa Cruz, discussed how they adapted their phases of care for patients in response to COVID-19. They developed a patient-facing COVID-19 flyer that outlines their treatment tiers and weekly follow-up procedure.

If you were unable to attend our Addiction Treatment Starts Here “Problem Solving Around COVID-19 and MAT” webinar series, you can access the slides and webinar recordings below.