Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

Background: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD). Case Presentation: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later. Conclusion(s): COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

Expanding Access to Opioid Use Disorder Treatment Via Telehealth in Lewis County, Washington

Purpose of Study Lewis County is in southwest Washington state. With a population per square mile of 31.4, Lewis County is more rural than the rest of the state (101.2 per square mile). Citizens of the county, as well as health care workers at Chehalis Family Medicine (located in Lewis County), report concerns over rates of opioid use disorder. While Lewis County's age adjusted rate per 100,000 of deaths due to opioid overdose from 2014-2017 was lower than that of Washington state (7.6 vs 9.3), its rate of opioid related hospitalizations was significantly higher (110.7 vs 81.5). Methods Used An asset-based approach was used to learn how Lewis County has been addressing opioid use disorder amongst its citizens. Interviews with health care providers, patients at Chehalis Family Medicine, and the pastor of a local church were performed. These conversations revealed a lack of access to public transportation creates a major barrier to receiving opioid use disorder treatment. A literature review of interventions implemented in rural areas to deliver medically assisted opioid use disorder treatment was performed. Summary of Results The recent use of telemedicine to deliver suboxone treatment at Chehalis Family Medicine has increased access to medically assisted treatment of opioid use disorder. Telemedicine has become more prevalent with some loosening of governmental regulations due to the COVID-19 pandemic. Based upon articles by Guille et al and Weintraub et al, administration of medically assisted opioid use disorder treatment via telehealth offers a means to expand access to care in rural communities. They demonstrated no significant differences in patient outcomes. Implementation of telemedicine at other suboxone clinics in Lewis County would improve access to suboxone treatment. Conclusions A strength-based framework allows the existing assets in Lewis County to be appraised so future work can build upon what has already proved effective for the community. Regarding opioid use disorder treatment, Lewis county has several low barrier suboxone clinics which could increase access for rural patients through implementation of telemedicine. Chehalis Family Medicine's recent success with telemedicine in suboxone treatment could serve as a template for how to do so effectively.

BLUE FINGERS, EOSINOPHILIC LUNGS: ACUTE EOSINOPHILIC PNEUMONIA FOLLOWING COVID-19 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal

PROVIDING LOW-BARRIER MEDICATIONS FOR ADDICTION TREATMENT VIA A TELEMEDICINE CALL LINE TO PEOPLE EXPERIENCING HOMELESSNESS IN LOS ANGELES, COUNTY

BACKGROUND: Los Angeles County Department of Health Services (LAC DHS) provides medical care for the safety net population of Los Angeles County, including a large population of people experiencing homelessness (PEH). To enhance patients' access to medications for addiction treatment during the COVID19 pandemic, LAC DHS established a telemedicine call line in March 2020 to support patients' access low-barrier medications for addiction treatment. To operationalize the call line, LAC DHS partnered with community organizations already working with PEH to facilitate timely access to medications for addiction treatment on demand. One of the largest community partners partnered with LAC DHS during this time was Community Health Project Los Angeles (CHPLA). Little was previously published regarding the patients who accessed care via CHPLA and how many of these patients remained engaged in medical treatment. We aimed to quantify and characterize the cohort of PEH treated and retained in care during the first 20 months of the operation of the telemedicine call line. METHODS: The telemedicine addiction medications call line was established in March 2020 and was accessible by any DHS affiliated outreach providers to call when they identified a patient interested in receiving a medication for addiction treatment. After each telemedicine visit was completed, CHPLA social workers logged patient information into a secure registry. Registry information was collected from March 2020 to August 2021 including patient demographics and the reason for visit. Information on addiction medications prescribed by the call line providers was also collected. Descriptive statistics were obtained and resulted below. RESULTS: During our study period, 111 of CHPLA's clients experiencing homelessness were served by the LAC DHS telemedicine call line (mean age 39 years, 74% male (N=82), 23% Latinx (N=26), 11% Black (N=10, 60% White (N=67). All PEH were prescribed buprenorphine-naloxone (bup-nx) for opioid use disorder. Insurance covered 87% (N=97) of prescriptions for bupnx. Of the 111 PEH who were prescribed bup-nx, 78% (N=87) obtained their initial prescription. Additional services provided to PEH by CHPLA included referral for case management (N=4), specialty addiction treatment (N=8), and women's health services (N=2). Of the 87 patients that received their initial prescription for bup-nx, 21% (N=18) were interested in and referred to and 6% (N=5) established care with a continuity clinic offering maintenance medications for addiction treatment. CONCLUSIONS: A telemedicine call line can be feasible and effective way to initiate low-barrier medications for addiction treatment to PEH during the COVID-19 pandemic, but low threshold initiation of medications for addiction treatment is itself insufficient to address the patient readiness, the many social determinates of health, and the systemic barriers to continuity clinical services for PEH with substance use disorders.

Real-World Dispensing of Buprenorphine and Methadone from MAR 2019 to MAR 2021 in California

Objectives: The US is amid a national opioid crisis before and during the COVID-19 pandemic. The Food and Drug Administration has approved methadone, buprenorphine, and naltrexone as medications for opioid use disorder (MOUD). This study examined the real-world dispensing of MOUD. Methods: All dispensing pharmacies, clinics, or other dispensers of Schedule II-V controlled substances in California report to the Controlled Substance Utilization Review and Evaluation System (CURES) on the day of prescriptions refills. Leveraging the data of buprenorphine (schedule III) and methadone (Schedule II) prescriptions from Mar 2019-Mar 2021 employing California’s deidentified CURES database, this study examined real-world dispensing of methadone and buprenorphine before (03/19/2019-03/18/2020) and during the pandemic (03/19/2020-03/18/2021). We did not review naltrexone dispensing, which is not a controlled substance. Results: In Mar 2019-Mar 2021, 182,367 patients≥18 in California obtained 875,051 buprenorphine and methadone prescriptions: Before the pandemic, there were 482,965 MOUD prescriptions dispensed to 116,644 patients;since the pandemic, 97,887 patients received 392,086 prescriptions, of which 32,164 patients(as “non-naïve” patients) started their MOUD before Mar 2020. On average, patients refilled their prescriptions 4.1 times/year before the pandemic and 4.0 times/year since the pandemic. The MOUD non-naïve patients (n=32,164) received 8.1 prescriptions/year before Mar 2020 and 7.4 refills/year afterward. The MOUD medications most widely prescribed in Mar 2019-Mar 2021 were buprenorphine (473,206 (98.0%) and 383,297 (97.8%), respectively, before and after the pandemic), which included 802,936 counts of buprenorphine alone and 53,567 combination medications of buprenorphine and naloxone. The number of methadone prescriptions declined from 9,759 before Mar 2020 to 8,789 during the pandemic. Conclusions: Buprenorphine is the leading MOUD prescribed for patients in California. The decline in MOUD dispensing for non-naïve patients may indicate restricted access to medication-assisted treatment under the pandemic. Policymakers should maintain or modify the policy strategies to help support medication access.