Responding to COVID-19: Emerging Practices in Addiction Medicine in 17 Countries

Florian Scheibein , M. J. Stowe , Sidharth Arya , Nirvana Morgan , Tomohiro Shirasaka , Paolo Grandinetti , Noha Ahmed Saad , Abhishek Ghosh , Ramyadarshni Vadivel , Woraphat Ratta-apha , Sagun Ballav Pant , Ramdas Ransing , Rodrigo Ramalho , Angelo Bruschi , Tanay Maiti , Anne Yee HA , Mirjana Delic , Shobhit Jain , Eric Peyron , Kristiana Siste , Joy Onoria , Saïd Boujraf , Lisa Dannatt , Arnt Schellekens 24 and Tanya Calvey *


INTRODUCTION
Following the classification of the Coronavirus disease (COVID-19) as a pandemic by the World Health Organization (WHO), countries were encouraged to implement urgent and aggressive actions to change the course of the disease spread while also protecting the physical and mental health and well-being of all people. The challenges and solutions of providing prevention, treatment, and care for those affected with issues related to substance use and addictive behaviors are still being discussed by the global community. Several international documents have been developed for service providers and public health professionals working in the field of addiction medicine in the context of the pandemic (1-3), however, less is known about country-level responses. In the current paper we, as individual members of the Network of Early Career Professionals working in Addiction Medicine (NECPAM), discuss emerging country-level guidelines developed in the 6 months following the outbreak.
We identified a number of pertinent, country-level documents in the 17 countries represented here and we summarized country-level briefing notes, practice documents, guidelines, discussion papers and other documents containing recommendations on prevention, harm reduction, treatment, and care for people who use drugs (PWUD). Documents were identified in 12 out of the 17 countries. These documents are summarized and charted in Table 1. Additionally, several documents were under development at the time of our exercise in the Netherlands, Slovenia, and Paraguay and have not been included in this work. No specific documents or intentions to develop any were identified in Egypt, Uganda, or South Africa. Below we provide a summary of the identified documents.
Documents published in India (23) and Thailand (24) addressed substance withdrawal. The Thai document included strategies for the management of alcohol withdrawal that may have occurred due to local restrictions on alcohol sales. In Japan (22), there were discussions regarding the potential increase in the use of the internet, gambling, gaming, and higher prevalence of drinking at home during the COVID-19 pandemic.
Guidelines, SOPs and recommendations in Nepal (6), Ireland (28,29), and France (21), respectively, have also advocated for increased access to harm reduction services. In New Zealand, guidelines addressed practices of adopting a health equity/social determinant lens, developing culturally and trauma informed approaches, awareness, and education efforts, development of self-help resources and the inclusion of people with lived experience of substance use and gambling into the evaluation of interventions (10,11).

DISCUSSION
A range of practices have been suggested at the country-level to deal with the challenges brought about by the ongoing pandemic. These include those around mitigating the spread of the corona virus, managing the risks associated with lockdown policies and changing trends in substance use and addictive behaviors.
In order to limit the spread of COVID-19, guidance has been drawn up to limit in-person meetings, physical support meetings, and contact time with physicians. Guidance suggests that this be operationalised through shifting services online, increased availability of TADs of OAMT, increased duration of TADs and increased availability of naloxone and injecting equipment allocations. Protocols have also been drawn up for the operation of clinics and outreach services for patients in isolation.
Several potential negative effects associated with the pandemic and resulting lockdown procedures have been identified which may require service adaptions. These include increased risks of substance withdrawal (30), access to service issues and potential changes in trends related to gambling, gaming, and internet related disorders. Several guidance documents discuss meeting these challenges through increased access to TADs, expedited access to OAMT and increased availability of onlinebased self-help groups and other services (11,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). The increased commitment to TADs, telemedicine and access to harm reduction supplies are likely to address several issues brought about by the pandemic for people who use opioids and/or inject drugs. However, few documents explicitly discuss the increased availability of harm reduction supplies (for example, naloxone and injecting equipment) and service adaptions for people who use non-opioid drugs and/or engage in addictive behaviors (such as gambling and gaming) continue to be neglected by most documents.
There are also concerns regarding the implementation of COVID-19-related policy documents as a recent global survey indicates that among 130 countries, 60% reported disruptions to mental health services for vulnerable people, 67% reported disruptions to counseling and psychotherapy, 35% reported disruptions to emergency interventions, and 30% reported disruptions to access for medications for mental, neurological, and substance use disorders (31). The combination of a reduction in the availability of services, increased reliance on telemedicine, physical distancing protocols, and travel restrictions may exasperate underlying health inequities in terms of access to addiction services (31)(32)(33)(34). This seems to disproportionately affect the most marginalized and socioeconomically disadvantaged patients (32) who may lack access to internet-enabled devices, sufficient internet, the necessary private spaces to engage in telemedicine and means of transport to services.
The lack of representation of country-level documents from the Americas, Eastern Europe, the Middle East, Africa, and other regions is a limitation of this paper. Future research should document emerging practices in additional regions and monitor and evaluate the implementation of country-level policies. Country-level documents may be useful as they may allow clinicians to adapt to their given local context. Such documents should consider best emerging practices as it relates  to issues surrounding a wide range of substances, addictive behaviors, harm reduction, and health inequities exasperated by the pandemic and restrictions.