Harm Reduction During the COVID-19 Pandemic: When to Go Above Our Comfort Zone?

Authored and presented by:

Elvis Espero, MD, Addiction Psychiatry Fellow, Boston Medical Center/Boston University School of Medicine; Larissa Mooney, MD, UCLA/ Department of Veteran’s Affairs; John Renner, MD, Professor of Psychiatry, Boston University School of Medicine, and Associate Chief of Psychiatry for the VA Boston Healthcare System; Kathleen Brady, MD, PhD, Professor and Vice President for Research, Medical University of South Carolina College of Medicine; Thomas Penders, MD, Affiliate Professor, Brody School of Medicine at East Carolina University

About this year’s case:

Chief Complaint: Decrease anxiety and maintain sobriety

HPI: Patient is a 36-year-old female, with a history of General Anxiety Disorder (GAD), Opioid Use Disorder in sustained remission on injectable naltrexone, stimulant use disorder in sustained remission, Attention Deficit Hyperactive Disorder (ADHD), and chronic back pain, was followed in the clinic for pharmacotherapy and individual therapy. Patient attended biweekly psychotherapy for GAD and was prescribed gabapentin 800 mg three times a day for anxiety, baclofen 10 mg twice a day to decrease cocaine cravings, tizanidine 4 mg twice a day for chronic back pain, mirtazapine 15 mg at bedtime for insomnia, lisdexamfetamine 60 mg daily for ADHD and monthly naltrexone injections for opioid use disorder. Her anxiety symptoms were exacerbated by stressors relating to her finances and family relationships. Despite these stressors, she remarried, remained motivated to return to college and she had taken steps towards becoming a peer recovery coach. She had asked her estranged mother of 25 years to move in with her to mend their relationship. She maintained family photos and videos on her phone to remind herself that maintaining sobriety was important.

Family History: Substance Use Disorder in multiple family members Past Psychiatric Treatment: Multiple trials of antidepressants, anxiolytics, mood stabilizers, benzodiazepines and antipsychotics for GAD. Multiple therapists in the past, multiple inpatient admissions, history of two suicide attempts while incarcerated.

Treatment Course: Stay at home precautions due to COVID-19 had started to increase the patient’s anxiety symptoms and she started experiencing debilitating panic attacks. Her overall support system became limited as she was unable to go to work or visit her daughter and father. Patient sought out different online group meetings, maintained her appointments, and deepened her relationships with her mother and husband to help her cope with her anxiety. The patient’s husband relapsed, and she found him deceased in their home after an unintentional overdose. The patient’s anxiety symptoms were significantly exacerbated due to his death. While grieving, she was additionally concerned about eviction without the additional financial support from her husband. She requested benzodiazepines for increasing anxiety and insomnia but declined other suggested medications. Patient agreed to weekly follow-up visits, but benzodiazepines were not prescribed due to previous history of benzodiazepine misuse. Patient did not attend her next appointment. She called in from a psychiatric inpatient facility and reported relapsing after 22 months of sobriety.

Follow Up: Upon discharge, patient called requesting a follow-up appointment and a lisdexamfetamine refill. She was upset that she needed to wait until her follow-up appointment to discuss medication refills. Patient did not attend her follow-up appointment and has been lost to contact despite multiple attempts to reach the patient. Discussion: This patient with worsening mood and anxiety, numerous stressors, and loss of social support in part due to COVID-19, was eventually lost to follow-up.

During high-risk or emergency situations, utilizing complimentary psychosocial interventions and emphasizing harm-reduction while still weighing risks and benefits of treatment and utilizing evidence-based practices may have helped retain this patient in care.

Educational Objectives:

  1. Describe a variety of approaches (including harm reduction) to engage and support patients with substance use disorders during a pandemic
  2. Review best practices for deciding whether or not to prescribe amphetamines to patients with a history of ADHD/stimulant use disorder and benzodiazepines to patients with a history of GAD/sedative use disorder
  3. Describe an approach to maintaining clinician wellness when working with patients who present with an overwhelming clinical picture and limited supports