On March 17, 2020, BC declared a public health emergency due to a novel coronavirus, which causes COVID-19. In order to help prevent the spread of the virus, the province has implemented directives to encourage physical distancing for everyone and self-isolation for those with symptoms.

This public health emergency compounds the harms and challenges of the opioid overdose emergency, declared in April 2016, in response to escalating opioid overdoses and related deaths. Although we have seen some promising decreases in the number of overdose deaths in BC over the last several months, we are still seeing consistently high numbers of non-fatal overdoses, indicating that the street drug supply remains toxic. Together, these two crises increase a number of risks for people who use drugs or alcohol, including the ongoing risk for overdose and other harms related to the toxic illicit drug supply, the risk of infection and spread of infection among those with underlying health conditions and who face social marginalization, and risks due to withdrawal for those who must self-isolate or quarantine to prevent the spread of COVID-19.

Innovative approaches are needed to support people who use drugs and alcohol to stay safe and prevent the spread of COVID-19.

The document provides clinical guidance that supports health care providers in efforts to reduce the risk of overdose and withdrawal among people who use drugs and alcohol in the context of COVID-19. In response to the COVID-19 pandemic, the government has made changes which lower the barriers for patients to receive evidence-based addiction care. In cases where patients’ risk cannot be lowered with standard evidence-based approaches, the document provides guidance for prescribing substances to support self-isolation or physical distancing. These recommendations are not intended to treat substance use disorders, but to reduce risks for those that would go into withdrawal without access to drugs or alcohol.

Offering prescribed medications may reduce several risks. These include:

• Overdose and other harms related to an increasingly toxic illicit drug supply
• COVID-19 infection risk and spreading the infection from going outside multiple times per day to acquire drugs or alcohol
• Withdrawal that may occur with physical distancing or self-isolation

Physical distancing and self-isolation are public health directives aimed at preventing the spread of COVID-19. By maintaining at least 6 feet separation from others and staying home/indoors when unwell, there will be fewer opportunities to transmit the virus between people, resulting in fewer people becoming sick and less pressure on the health care system. People who use drugs or alcohol face challenges in exercising these precautions, as buying drugs or alcohol and getting the money to purchase substances often requires multiple in-person transactions. Many people who use drugs also face additional barriers including homelessness or unstable housing, poverty, and chronic physical or mental illness, which make it much harder to follow public health directives and safely access services.

Prescribed medications may not be suitable for everyone who uses drugs or alcohol. The clinical guidance gives prescribers (i.e. physicians and nurse practitioners) more options to help reduce risk and keep people safe.

At present, everyone is at risk for COVID-19 infection. For people who actively use substances and are at risk of withdrawal, overdose, craving, or other harms from drug or alcohol use, receiving prescribed medications may be an option.

These individuals should talk to their primary care provider (doctor or nurse practitioner) about their options. For those who don’t have a primary care provider, see Regional Contacts and Services, below for other options.

A medical assessment is required and includes questions about current and past substance use, including any medications or other treatments that have been tried, any symptoms of withdrawal, and individual goals. As with any medical decision—where possible—a plan should be made in collaboration with the patient and prescriber and take into consideration the individual’s goals, health status, risks, and benefits.

A number of options for pandemic prescribing may help keep people safe during COVID-19:

• Treatment with medication may be best for people diagnosed with a substance use disorder (for example, Suboxone for opioid use disorder or naltrexone for alcohol use disorder)
  • For individuals already taking medication, their prescriber may offer carries or a longer prescription duration to help reduce their risk of COVID-19 exposure
  • For people who are currently—or were recently—on medication but continue to experience cravings or withdrawal symptoms, their prescriber may discuss different options. This could include changing medication (for example, switching from Methadose to Metadol-D or Kadian), increasing doses, or splitting doses
  • For people who have tried treatment in the past and it hasn’t worked, other medications, as outlined in the new clinical guidance, may be trialled (for example, hydromorphone, M-Eslon). These medications can be used in addition to an individual’s baseline opioid agonist treatment
• Other medications (for example, opioids, benzos, stimulants) may be prescribed for people who use illicit drugs
• Connecting with other resources (for example, a managed alcohol program)
• Creating a plan to avoid withdrawal (for example, self-managing alcohol intake)

As with any health issue, treatment decisions should be made by the patient and their prescriber (i.e. doctor or nurse practitioner) together.

Individuals should be aware that the prescribing outlined in the interim clinical guidance sits outside of current standard practice and may not be provided by all community prescribers. However, prescribers may refer patients for an addiction assessment at a different clinic and support them during the COVID-19 pandemic.

Decisions to prescribe must be made considering a number of factors, and not everyone may be eligible for a particular medication or treatment option.

If a person’s care provider is unable to support them to reduce the risk of withdrawal, there are other options available. See Regional Contacts below for additional supports available in each area.

For people who have an alcohol use disorder or who drink a large amount of alcohol regularly, quitting drinking “cold turkey” can cause dangerous withdrawal symptoms, including seizures or even death.

Liquor stores have been classified as “essential services” in BC, meaning that most will stay open. Smaller stores or those in smaller communities may close or have more limited hours of operation. This means that some individuals may not be able to access alcohol as usual and could experience alcohol withdrawal without health care support.

There are medications that can help a person safely manage withdrawal (“detox”) or help a person to safely reduce or stop drinking. For individuals who are not ready to stop drinking, there may be local services that can help a person with severe alcohol use disorder to access alcohol (called managed alcohol programs). Individuals should speak with a health care provider or prescriber to learn more about resources in their area.

For individuals who do not already have a primary care provider, rapid access addiction clinics (RAACs) in Vancouver, Victoria, Surrey, and Kamloops may be an option for substance use care. RAACs may also be able to offer telehealth for follow up appointments.

Vancouver Coastal Health

Vancouver Rapid Access Addiction Clinic
St. Paul’s Mental Health Wellness Clinic
1081 Burrard Street, Second Floor
Vancouver, BC
Phone: 604-806-8867

Overdose Outreach Team (OOT)
Phone: 604-360-2874
(8:00 am to 8:00 pm)

Fraser Health

Creekside Rapid Access Addiction Clinic
13740 94A Avenue
Surrey, BC
Phone: 604-587-3755

Northern Health

Substance Use Resource Nurse
Call Shawn at: 250-565-5435
If no answer, leave a message and someone will return your call

Interior Health

Kamloops Rapid Access Addiction Clinic
103-220 3rd Ave
Kamloops, BC V2C 3M3
Phone: 250-374-2345

Kelowna OAT Clinic
505 Doyle Ave
Kelowna, BC
Canada V1Y 6V8
Phone: 250-801-2589

Island Health

Victoria Rapid Access Addiction Clinic
1119 Pembroke St
Victoria, BC
Phone: 250-381-3222
Monday to Friday: 9 am to 12:00 pm

If a person thinks they have COVID-19:

• Access the Ministry of Health self-assessment tool here.
• Call 811 to talk to someone about symptoms or get medical advice. They will provide further information and instructions on what to do next.

For non-medical information about COVID-19:

• Call 1-888-COVID19 (1-888-268-4319) or text 604-630-0300 from 7:00 am to 8:30 pm every day to get information about physical distancing and what kinds of support, resources, and assistance are available from the provincial and federal governments.
• Access general information about COVID-19 including symptoms and prevention strategies here.

The BC Centre for Disease Control has information for people who use substances here.