COVID-19 Guidance for Colorado Opioid Treatment Programs

The following information supports the opioid treatment program (OTP) agency and medical directors in responding to the spread of novel coronavirus (COVID-19) in Colorado. This interim guidance contains recommendations and resources as we await further guidance from our federal partners.

If you have additional questions, please email them to Amy Cooper at amy.cooper@state.co.us. We will update this blog post as needed and post updated versions on our OTP webpage.

Guidance from Substance and Mental Health Services Administration (SAMHSA) 

SAMHSA recognizes the evolving issues surrounding COVID-19 and the emerging needs OTPs continue to face. SAMHSA affirms its commitment to supporting OTPs in any way possible during this time. As such, we are expanding our previous guidance to provide increased flexibility.

For states that have declared a state of emergency (including Colorado) 

The state may request blanket exceptions for all stable patients in an OTP to receive 28 days of Take-Home doses of the patient’s medication for opioid use disorder. The state may request up to 14 days of Take-Home medication for those patients who are less stable but who the OTP believes can safely handle this level of Take-Home medication.

Guidance from the Office of Behavioral Health 

Prevention

The Centers for Disease Control and Prevention has provided interim infection prevention and control recommendations in health care settings.

  • Encourage programs to communicate to patients that they should immediately report any cough, fever, or flu-like symptoms. 

  • Anyone with a respiratory illness (e.g., cough, runny nose) should be given a mask before entering the space.

  • Provide hand sanitizer at the front desk and at each dosing window.

  • Clean all surfaces and knobs several times each day with EPA-approved sanitizers.

Isolation/Containment

OBH encourages programs to develop procedures for OTP staff to take clients who present at the OTP with respiratory illness symptoms, such as fever and cough, to a location other than the general dispensary and/or lobby to dose clients in closed rooms as needed.

OTP staff should follow interim infection prevention and control recommendations in health care settings published by the Centers for Disease Control and Prevention.

Guidance from Colorado and SAMHSA to provide clients with take-home dosing 

For individual client cases, please continue to submit exceptions through the SAMHSA OTP extranet website. Consider informing clients through phone, email, and signage onsite that they should let the OTP know they are sick before coming onsite. This way, OTP staff can prepare take-home approval in advance for dispensing.

For large-scale, agency-wide policies to provide take-homes, please submit a blanket exception request for your OTP through the SAMHSA OTP extranet website. For any blanket exception requests, OTP medical directors must also please include details about agencies policies and procedures during this time period. See the list of limitations to what programs can request under Course of Action just below.

Course of Action for Colorado OTPs

  • As per SAMHSA’s Division of Pharmacologic Therapies and the State Opioid Treatment Authority of Colorado, here are the following approved courses of action for which a Colorado OTP may consider applying for via the SAMHSA OTP extranet website.

  • Blanket take-home medication exceptions for patients with lab confirmed COVID-19 disease: As described above, patients with symptoms of a respiratory viral illness, with or without confirmation via COVID-19 viral testing, present an immediate risk to the rest of the population.

  • For patients endorsing symptoms of a respiratory infection (to include cough and fever): These patients will be isolated and evaluated by a medical provider, who will determine a safe number of take-home doses, considering the patient’s stability in treatment and ability to safely store and protect medication. This is not to exceed two weeks of medication.

  • For patients who have already earned one additional take home: These patients have meaningfully fulfilled the eight take-home criteria and have done so for a period sufficiently long enough to suggest likely ongoing compliance. In the setting of a public health emergency of this scale, these patients have demonstrated enough clinical stability to warrant limiting their in-person dosing with Monday and Friday clinic schedule for a total of five take-home doses per week (e.g.,attend clinics for dosing on Monday and Friday and receive take-homes on the alternate days and weekend).

  • For patients with significant medical comorbidities: Particularly those patients over the age of 60 with conditions such as co-morbid chronic and severe pulmonary, cardiac, renal or liver disease, immunosuppression, can be eligible for take-homes up to one to two weeks at the discretion of medical provider.

  • For patients with only one take home (unearned), determined by the medical provider to vbe appropriate: A staggered take-home schedule should be adopted whereby half the OTP’s patients present will present on Mondays, Wednesdays and Fridays, and the other half of OTP patient’s present on Tuesday, Thursday, Saturdays. The remaining doses of the week should be provided as a take-home as appropriate. Patients should receive no more than two consecutive take-homes at a time. This reduces the clinic’s daily census in half and has a tolerable risk profile, as patients are still evaluated frequently and do not receive more than two days of take-home medication at any one time.

  • For patients on buprenorphine: Based on the more favorable safety profile of buprenorphine, outpatient dosing on buprenorphine for new clients will be extended to one per week clinic visits with take-homes (no CSAT exemption required). Stable patients should already have earned at least a two-week clinic attendance schedule on average.

  • For unstable patients: Patients in any of the population categories above who are determined unstable or unsafe to manage take-home doses should continue daily dosing in the clinic. Inability to safely take unsupervised medication due to a cognitive or psychiatric condition, or inability to keep a take-home dose of medication safe due to an unstable living situation, would be grounds for patients being deemed ineligible for this emergency take-home exemption. For these unstable patients who, for safety reasons, need to continue daily dosing, every precaution should be made to limit exposures from symptomatic patients to medically fragile patients (No CSAT exemption required).

  • All patients must have a lockable take-home container and written instructions on protecting their medication from theft and exposure to children or animals. The clinic should remain open during regular business hours to field calls from patients who are receiving take homes. The efficacy and safety of this take-home strategy should be continually assessed. All medical exceptions should provide appropriate and complete documentation.

Please send any supporting documentation to State Opioid Treatment Authority, Amy Cooper, in addition to your OTP’s submission on the SAMHSA OTP extranet website. Our federal partners may want additional information to approve large-scale blanket exceptions.

Delivery of medication to our clients 

Federal law does not prohibit delivery of medication for appropriate populations, such as those who cannot leave their home or another controlled environment; however, resources to offer this level of service may vary by program. For information on how to attain approval for take home dosing, please see previous courses of action.. 

Where can I refer clients if they have a question about testing for COVID-19?

More information about assessing is available at the Colorado Department of Public Health and Environment (CDPHE) website. Additionally, CDPHE has established a call center to address questions from members of the public available at 1-877-462-2911.

Shutdown of an OTP

You must consult with both your local public health jurisdiction and Colorado State Opioid Treatment Authority, Amy Cooper, before making decisions about operations.

OTPs are considered essential public facilities under Colorado statute and should make plans to stay open in most emergency scenarios and be able to induct new clients. No OTP can hold new client admission groups at this time and will need to complete orientation with new clients on an individual basis.  

Supporting clients and staff during this time

Hearing the frequent news about COVID-19 can cause people to feel anxious and show signs of stress, which is a normal reaction. SAMSHA has published guides called Coping with stress during infectious disease outbreaks and Taking Care of Your Behavioral Health that includes useful information and suggestions. You could adapt messaging from this document for the people you serve or print this document for clients. 

There are also steps people should take to reduce their risk of getting and spreading any viral respiratory infection that have been outlined by the CDC. Steps include washing your hands often with soap and water for at least 20 seconds; covering your mouth and nose with your elbow when you cough or sneeze; and staying home and away from others if you are sick.

Medication shortages and/or disruption of a medication supply 

At this time, there has been no reported concern from any state or federal partner about a potential for disruption in the medication supply for methadone and/or any buprenorphine containing product.

Any future updates or changes to this guidance will come from the State Opioid Treatment Authority. Please contact the State Opioid Treatment Authority if your program has any specific concerns.

Other preparations for OTPs in response to concerns about COVID-19

  • Ensure you have up-to-date emergency contacts for your employees and your clients.

  • Ensure your program leadership has the contact information of the State Opioid Treatment Authority, Amy Cooper: 

  • Discuss with your clients whether they have or want to determine a designated other person who may be able to pick up their medications if they are unable to do so.

  • Develop and send procedures to the State Opioid Treatment Authority: 

    • Procedures for OTP staff to take clients who present at the OTP with respiratory illness symptoms, such as fever and coughing, to a location other than the general dispensary and/or lobby to dose clients in closed rooms as needed.

    • Protocols for provision of take-home medication if a client presents with respiratory illness such as fever and coughing

    • Communications strategy and protocol to notify clients who are diagnosed with or exposed to COVID-19, and/or clients who are experiencing respiratory illness symptoms, such as fever and coughing. Whenever possible, the client should call ahead to notify OTP staff of their condition. This way OTP staff can meet them upon their arrival at an OTP with pre-prepared medications and dispense in a location away from the general lobby and/or dispensing areas.

    • Plan for possible alternative staffing/dosing scheduling in case you experience staffing shortages due to staff illness. Develop a plan for criteria for staff members who may need to stay home when ill and/or return to the workforce when well.

  • OTPs may want to ensure they have enough medication inventory onsite for every client to have access to two weeks of take-home medication, or more. 

  • Current guidelines recommend trying to maintain six feet between clients onsite in any primary care setting as best as possible. We realize in an OTP setting that this guidance may be difficult to achieve;’however, OTPs should strive to meet these guidelines while considering the space and patient flow within the  OTP’s physical location. OTP may want to consider expanding dosing hours to help space out service hours, which can help mitigate the potential for individual clients queuing in large numbers in waiting rooms and dosing areas.

Report the death of any OTP client death within 24 hours to the State Opioid Treatment Authority Amy Cooper: