Case study: Re-orienting the Opioid Treatment Program to meet the challenges of COVID-19

The NSW Opioid Treatment Program (OTP) aims to reduce the social, economic and health harms associated with opioid use by delivering pharmacotherapy and associated services to opioid-dependent patients in NSW. Prior to COVID-19, OTP clients travelled to clinics and pharmacies to receive their daily medication. This method of service delivery was identified as likely to increase the transmission of COVID-19 during the pandemic as in-person treatment would expose clients to other individuals who may be COVID-19 positive. As a result of their history of opioid dependence, people on the OTP are also at increased risk of coexisting health conditions that make them more vulnerable to complications from COVID-19. In addition, with opioid withdrawal symptoms similar to COVID-19 symptoms, OTP clients may not be aware if they have COVID-19 and need to isolate, inadvertently exposing other clients to infection when collecting their medication each day.

Therefore, the Centre for Alcohol and Other Drugs, NSW Ministry of Health, put in place several strategies to ensure the almost 23,000 OTP patients in NSW could safely continue their treatment during COVID-19. These strategies aimed to reduce the number of times clients attended the clinic or pharmacy to collect their medication or the extent of social contact they encountered during treatment, and included:

• conducting case management appointments by phone where appropriate
• increasing the number of takeaway doses prescribed to reduce the number of in-person collections (this included the provision of take home naloxone to treat inadvertent overdoses)
• permitting medication (and naloxone) to be collected by a nominated friend or family member if the individual was in isolation
• rapidly rolling out depot buprenorphine, an OTP medication that is administered weekly or monthly, to help reduce the number of medical appointments required by clients
• moving treatment access points from a clinic to community pharmacy sites to reduce congregation around a single collection point.

A particular challenge was managing attendance at clinic locations, which OTP clients regularly attended prior to COVID-19. The number of clients visiting clinics was reduced, both to promote physical distancing and to manage staffing capacity. In general, fewer staff were available due to isolation/quarantine requirements or redeployment to support the COVID-19 response. More pharmacies were therefore engaged to take on the role of clinics. There were several advantages to this approach, including:

• pharmacies had longer opening hours and therefore were able to include more patient appointments over a longer period, ensuring physical distancing could be maintained
• more pharmacies existed than clinics, providing more options if closures were necessary and reducing the distance travelled by some clients to access medication
• pharmacies could efficiently make up takeaway doses so waiting times to receive medication were reduced.

The prescription of depot buprenorphine was a significant success story of the pandemic. Prior to the emergence of COVID-19 there was an 18-month plan in place to deliver in-person training to clinicians across the state to administer this new medication. The pandemic made online training courses more acceptable to service providers. As a result, the number of clients on the formulation increased from approximately 80 at the end of 2019, to over 1700 in 2020, and over 4500 in 2021.

OTP 'take-aways' were generally very well taken up. A survey completed by one local health district indicated clients managed the cost of dosing at pharmacies and there were low instances of negative outcomes.