In response to community transmission of COVID-19 Delta Variant in New South Wales (NSW), patients were admitted to Special Health Accommodation (SHA) with often complex psychosocial and medical needs including addiction. SHA functioned as a subacute hospital in repurposed apartment blocks and provided integrated health care to people with COVID-19 or close contacts, if otherwise unable to isolate [1]. We reviewed the outcomes of patients who received remote Addiction Medicine consultation, onsite clinical support and provision of alcohol during SHA admission, July–October 2021.

As illicit drugs were prohibited in SHA, drug withdrawal due to abrupt cessation risked death or hospitalisation. Identification of substance use occurred during nursing admission assessment with the question ‘Do you have any addiction to alcohol, drugs or tobacco?’.

An alcohol provision guideline was developed for SHA, informed by a harm reduction approach and an understanding of the challenges of isolation. Alcohol provision enabled access to a familiar coping strategy and prevented withdrawal without compromising staff or patient safety [2, 3]. Patients reporting >40 g alcohol/day (four Australian standard drinks) were flagged on admission with nurse unit managers and doctors. The alcohol policy was explained to patients who could place orders with their preferred retailers. Deliveries were provided to patients unless intoxicated, limited daily to 6 × 375 ml beers (5–8 standard drinks) or pre-mixed drinks (9–13 standard drinks), 750 ml wine or champagne (7–8 standard drinks) or 375 ml spirits (11 standard drinks), with a second delivery later in the day (excluding spirits) permitted based on nursing review and discretion. Further variations required escalation to co-directors of nursing, typically where usual consumption significantly exceeded the amounts provided, with medical review as required.

Opioid agonist treatment was provided according to NSW Clinical Guidelines [4, 5]. Pharmacological withdrawal management for substances other than alcohol and nicotine was in accordance with NSW Withdrawal Guidelines [6].

Onsite assessment and monitoring by nursing and allied health staff was supported by medical and other specialist health care from Royal Prince Alfred (RPA) Virtual Hospital. Addiction Medicine consultation was provided remotely by RPA Hospital Drug Health Services. RPA Pharmacy delivered prescribed withdrawal medication for nurses to administer.

SHA was an untested high-risk environment for withdrawal management, with reduced visual surveillance of patients in an apartment environment. Clinician experience was varied and most were not trained in Addiction Medicine.

We retrospectively collected data from electronic medical records. Severe withdrawal was defined as delirium, delirium tremens, seizure or psychosis attributable to alcohol and other drug (AOD) withdrawal. Sydney Local Health District (LHD) Human Research Ethics Committee (X21-0473) approved the study.

A total of 5810 patients were admitted to SHA from 1 July to 31 October 2021. Addiction Medicine consultation was provided to 58 (1.0%): median age 37 years, 23 female, 42 psychiatric co-morbidities, 39 non-Sydney LHD residents, nine homeless. This was a vulnerable patient group with high rates of comorbid mental illness, and the majority were non-Sydney LHD residents, living in social housing or boarding houses, or homeless. Close collaboration across Sydney LHD teams and other government and non-government agencies provided integrated health and social care. It is noteworthy that in the 4 months pre-Delta outbreak (March–June 2021) there were only two SHA Addiction Medicine consultations.

Most were COVID-19 positive on admission while nine were close contacts. Most were admitted from the community, but some transferred from hospital, airport or prison. Eight were detained under Section 62, Public Health Act 2010 (NSW) to mitigate risks to public health [7]. Section 62 allows authorised medical officers to make a public health order if a person with COVID-19, or someone exposed to and at risk of developing COVID-19, is behaving in a way that poses a risk to public health. The order allows detainment and treatment for up to 14 days, to reduce the likelihood that the person will spread COVID-19.

AOD issues were identified during nursing admission assessment in most and Addiction Medicine phone consultations occurred on median day two of SHA admission.

Polysubstance use was common, with a mean of three substances used in the past month: 40 were daily nicotine smokers, 28 methamphetamine users, 25 cannabis smokers, 18 heroin users, 18 on opioid agonist treatment, 14 daily alcohol drinkers, 11 illicit benzodiazepine users, 9 gamma-hydroxybutyrate (GHB) users and 1 cocaine user.

Forty daily smokers reported a mean of 14 cigarettes/day. Smoking of self-funded cigarettes on SHA balconies was permitted (unless locked, if self-harm risk), which likely contributed to lower rates of problematic nicotine withdrawal than in hospital. Free nicotine replacement therapy was provided, although only one-quarter of daily smokers utilised this.

Of the 58 persons who received Addiction Medicine consultation, 14 reported daily alcohol drinking, often of substantial quantities: their median consumption was 18 standard drinks per day. Therefore, many were drinking considerably less while in SHA due to the alcohol limits imposed. Three had a history of alcohol withdrawal seizures. At SHA, eight utilised benzodiazepines to manage withdrawal, four continued drinking and two had already completed alcohol withdrawal during recent hospitalisation. Alcohol withdrawal scales were completed by on-site nurses to monitor patients and guide administration of benzodiazepines where prescribed. There were no referrals for severe alcohol withdrawal, suggesting that early identification of at-risk patients, early Addiction Medicine consultation and provision of benzodiazepines and alcohol were effective.

Opioid agonist treatment was continued in 18 and initiated in 11 patients. Two patients were transferred to SHA to maintain daily dosing of methadone, unavailable in other COVID-19 accommodation, and as they were unsuitable for takeaway doses despite increased access during COVID-19 [8].

In the preceding month, 28/58 used methamphetamine and 25/58 smoked cannabis: 16/28 and 9/25 respectively required pharmacological withdrawal management with olanzapine and/or diazepam. 11/58 used illicit benzodiazepines and 8/11 were managed with a tapering regimen. We identified a high frequency of GHB users (9/58 in past month, 7 daily users of 10–100 ml) reflecting the high prevalence of GHB use in polysubstance users (23%) [9]. None had complicated withdrawal and all were managed with tapering diazepam, plus one with baclofen.

Challenging patient behaviours were seen due to the impact of isolation particularly for those with psychiatric illness, trauma and forensic history. Deteriorating patients were transferred to tertiary hospital by ambulance as needed. Six hospital transfers for AOD issues occurred but all were transferred back to SHA following ED review or brief admission. No severe incidents related to AOD intoxication, withdrawal or deaths occurred. Some continued to use substances by arranging delivery of heroin or other drugs.

Limited alcohol provision appeared safe and may have future applications such as in housing complex lockdowns or quarantine [10]. Alcohol has been made available to patients in other supervised care settings such as managed alcohol programmes [11].

Only 5/58 were available for follow-up via telephone (routine, to offer support and service linkage) at a median of 45 days post discharge. Four out of the five experienced illicit substance withdrawal managed with pharmacotherapy prescribed in SHA, expressed appreciation for support for unplanned withdrawal, and reported reduced substance use since discharge. Low follow-up rates likely introduced selection bias, as those unavailable were likely to have ongoing substance use. Review of medical records demonstrated that 26/58 presented to hospital with AOD issues <90 days post discharge, indicating that ongoing substance use was more extensive than our follow-up suggested.

This observational cohort data suggests that some patients traditionally considered high risk and requiring hospitalisation for AOD withdrawal management might be managed with remote Addiction Medicine support or shared care arrangements with general practitioners. Virtual health appears to be a feasible modality to deliver generalist care with specialist support with clearly defined protocols, at geographical or physical distance, such as in isolation. Accordingly, this approach seems suitable for continuing evaluation in larger cohorts.

为应对新南威尔士州 (NSW) 的 COVID-19 Delta Variant 社区传播，患者入住特殊健康住宿 (SHA)，通常具有复杂的心理社会和医疗需求，包括成瘾。SHA 在改造后的公寓楼中充当亚急性医院，并在无法隔离的情况下为 COVID-19 患者或密切接触者提供综合医疗保健 [ 1 ]。我们回顾了 2021 年 7 月至 10 月 SHA 入院期间接受远程成瘾医学咨询、现场临床支持和提供酒精的患者的结果。

由于 SHA 禁止使用违禁药物，因突然停药而停药可能会导致死亡或住院。在护士入院评估过程中发现物质使用情况，问题是“您对酒精、药物或烟草有任何成瘾吗？”。

为 SHA 制定了酒精供应指南，以减少危害的方法和对隔离挑战的理解为依据。酒精供应使人们能够获得熟悉的应对策略并防止戒断，而不会影响工作人员或患者的安全 [ 2, 3]。报告 > 40 g 酒精/天（四种澳大利亚标准饮料）的患者在入院时被护士单位经理和医生标记。向可以向首选零售商下订单的患者解释了酒精政策。除非醉酒，否则为患者提供送货服务，每天限制为 6 × 375 毫升啤酒（5-8 标准饮料）或预混合饮料（9-13 标准饮料）、750 毫升葡萄酒或香槟（7-8 标准饮料）或 375毫升烈酒（11 标准饮料），根据护理审查和酌情权，允许在当天晚些时候进行第二次交付（不包括烈酒）。进一步的变化需要升级到护理的联合主管，通常是在通常的消费量大大超过提供的量的情况下，并根据需要进行医疗审查。

根据 NSW 临床指南 [ 4, 5 ] 提供阿片受体激动剂治疗。酒精和尼古丁以外物质的药理学戒断管理符合新南威尔士州戒断指南 [ 6 ]。

皇家阿尔弗雷德王子 (RPA) 虚拟医院的医疗和其他专业医疗保健支持护理和专职医疗人员进行现场评估和监测。成瘾药物咨询由 RPA 医院药物健康服务远程提供。RPA 药房为护士提供处方戒断药物。

SHA 是一个未经测试的戒断管理高风险环境，在公寓环境中对患者的视觉监控减少。临床医生的经验多种多样，大多数人没有接受过成瘾医学方面的培训。

我们回顾性地从电子病历中收集数据。严重戒断定义为酒精和其他药物（AOD）戒断引起的谵妄、震颤谵妄、癫痫发作或精神病。悉尼地方卫生区 (LHD) 人类研究伦理委员会 (X21-0473) 批准了这项研究。

2021 年 7 月 1 日至 10 月 31 日，共有 5810 名患者被 SHA 收治。为 58 名（1.0%）提供了成瘾医学咨询：中位年龄 37 岁，23 名女性，42 名精神病合并症，39 名非悉尼 LHD 居民，九无家可归。这是一个易患精神疾病的弱势患者群体，大多数是非悉尼 LHD 居民，住在社会住房或寄宿公寓，或无家可归。悉尼 LHD 团队以及其他政府和非政府机构之间的密切合作提供了综合健康和社会护理。值得注意的是，在三角洲爆发前的 4 个月（2021 年 3 月至 6 月）中，只有两次 SHA 成瘾医学咨询。

大多数人在入院时 COVID-19 呈阳性，而九人是密切接触者。大多数是从社区入院的，但也有一些是从医院、机场或监狱转移过来的。八人根据2010 年公共卫生法（新南威尔士州）第 62 条被拘留，以减轻公共卫生风险 [ 7 ]。如果 COVID-19 患者或暴露于 COVID-19 并有患上 COVID-19 风险的人的行为对公众健康构成风险，第 62 条允许授权医务人员发布公共卫生令。该命令允许拘留和治疗长达 14 天，以减少此人传播 COVID-19 的可能性。

在大多数情况下，在护士入院评估期间发现了 AOD 问题，成瘾医学电话咨询发生在 SHA 入院的中间第二天。

多种物质的使用很常见，过去一个月平均使用了三种物质：40 人每天吸食尼古丁，28 人吸食甲基苯丙胺，25 人吸食大麻，18 人吸食海洛因，18 人接受阿片受体激动剂治疗，14 人每天饮酒，11 人非法吸食苯二氮卓类药物, 9 名 γ-羟基丁酸盐 (GHB) 用户和 1 名可卡因用户。

每天有 40 名吸烟者报告平均每天吸 14 支香烟。允许在 SHA 阳台上吸食自费香烟（除非上锁，如果有自残风险），这可能导致有问题的尼古丁戒断率低于医院。提供了免费的尼古丁替代疗法，尽管只有四分之一的每日吸烟者使用这种疗法。

在接受成瘾医学咨询的 58 人中，有 14 人报告称每天饮酒，而且数量通常很大：他们的平均饮酒量为每天 18 标准酒。因此，由于施加的酒精限制，许多人在 SHA 期间饮酒量大大减少。三人有酒精戒断癫痫病史。在 SHA，8 人使用苯二氮卓类药物来控制戒断，4 人继续饮酒，2 人在最近住院期间已经完成戒酒。现场护士完成酒精戒断量表，以监测患者并指导处方苯二氮卓类药物的给药。没有严重戒酒的转诊，这表明早期识别高危患者、早期成瘾药物咨询和提供苯二氮卓类药物和酒精是有效的。

18 名患者继续使用阿片受体激动剂治疗，11 名患者开始使用。两名患者被转移到 SHA 以维持美沙酮的每日剂量，这在其他 COVID-19 住宿中不可用，并且尽管在 COVID-19 期间增加了访问 [ 8 ] ，但他们不适合外卖剂量。

在上个月，28/58 使用甲基苯丙胺和 25/58 吸食大麻：16/28 和 9/25 分别需要使用奥氮平和/或地西泮进行药物戒断管理。11/58 使用了非法苯二氮卓类药物，8/11 使用逐渐减少的方案进行管理。我们发现 GHB 使用者的频率很高（过去一个月 9/58，每天 7 位使用者 10-100 毫升），这反映了多种物质使用者中 GHB 使用的高流行率（23%）[ 9 ]。没有人出现复杂的戒断，所有的人都用逐渐减少的地西泮治疗，再加上一个用巴氯芬治疗。

由于隔离的影响，特别是对于那些有精神疾病、创伤和法医病史的人，人们看到了具有挑战性的患者行为。病情恶化的患者根据需要由救护车转移到三级医院。发生了六次因 AOD 问题而转院，但在 ED 审查或短暂入院后全部转回 SHA。没有发生与 AOD 中毒、戒断或死亡相关的严重事件。一些人通过安排运送海洛因或其他毒品继续使用物质。

有限的酒精供应似乎是安全的，并且可能在未来的应用中得到应用，例如住宅区的封锁或隔离 [ 10 ]。在其他受监督的护理环境中，例如管理酒精计划 [ 11 ] ，已向患者提供酒精。

在出院后 45 天的中位时间，只有 5/58 可通过电话（常规，提供支持和服务联系）进行随访。在 SHA 规定的药物治疗中，五分之四的人经历过非法药物戒断，他们对支持计划外戒断表示感谢，并报告出院后药物使用减少。低随访率可能会引入选择偏倚，因为那些无法获得的人可能会持续使用药物。对医疗记录的审查表明，26/58 的患者在出院后 90 天内出现 AOD 问题，这表明持续的物质使用比我们的后续建议更广泛。

该观察性队列数据表明，一些传统上被认为具有高风险并需要住院以进行 AOD 戒断管理的患者可以通过远程成瘾药物支持或与全科医生的共享护理安排进行管理。虚拟健康似乎是一种可行的方式，可以在地理或物理距离上（例如隔离）提供具有明确定义协议的专家支持的全科护理。因此，这种方法似乎适合在更大的队列中继续评估。