Telemedicine-delivered treatment interventions for substance use disorders: A systematic review

LGBTQIA+ Adapted Telehealth Intensive Outpatient Program for Youth and Young Adults: Subgroup Analysis of Acuity and Improvement Following Treatment (Preprint)

BACKGROUND

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized gender and sexual identities (LGBTQIA+) youth have disproportionately high levels of depression, self-harm, and suicidal thoughts and behaviors. In addition, LGBTQIA+ youth frequently report lower levels of satisfaction or comfort with their health care providers because of stigmatization, which may prevent continuation of care, yet there is a lack of mental health treatment and outcome research addressing these disparities. However, there is some indication that LGBTQIA+ individuals feel more comfortable with web-based formats, indicating that telehealth services may be beneficial for this population.

OBJECTIVE

This program evaluation explored the effectiveness of a remote intensive outpatient program with a curriculum tailored specifically to LGBTQIA+ youth with high-acuity depression, anxiety, and suicidality. This study sought to understand baseline acuity differences between LGBTQIA+ and non-LGBTQIA+ youth and young adult patients and to determine if there were differences in clinically significant improvement by subtypes within the LGBTQIA+ population following participation in LGBTQIA+-specific programming.

METHODS

Data were collected from intake and discharge outcome surveys measuring depression, suicidality, and nonsuicidal self-injury (NSSI) in 878 patients who attended at least six sessions of a remote intensive outpatient program for youth and young adults. Of these 878 clients, 551 (62.8%) were identified as having at least one LGBTQIA+ identity; they participated in an LGBTQIA+-adapted program of the general curriculum.

RESULTS

LGBTQIA+ patients had more clinically severe intake for depression, NSSI, and suicidal ideation. Nonbinary clients had greater NSSI within the LGBTQIA+ sample at intake than their binary counterparts, and transgender clients had significantly higher depressive scores at intake than their nontransgender counterparts. LGBTQIA+ patients demonstrated improvements in all outcomes from intake to discharge. The Patient Health Questionnaire for Adolescents depression scores improved from 18.15 at intake to 10.83 at discharge, representing a 41.5% reduction in depressive symptoms. Overall, 50.5% (149/295) of the LGBTQIA+ youth who endorsed passive suicidal ideation at intake no longer reported it at discharge, 72.1% (160/222) who endorsed active suicidal ideation at intake no longer reported it at discharge, and 55.1% (109/198) of patients who met the criteria for clinical NSSI no longer met the criteria at discharge. In the subgroup analysis, transgender patients were still 2 times more likely to report clinical NSSI at discharge.

CONCLUSIONS

This program evaluation found substantial differences in rates of depression, NSSI, and suicidal ideation between LGBTQIA+ clients compared with their non-LGBTQIA+ counterparts. In addition, this evaluation showed a considerable decrease in symptoms when clients attended LGBTQIA+-affirming care. The findings provide support for the role of LGBTQIA+-specific programming to meet the elevated mental health needs of these youth and that more research is needed to understand barriers that may negatively affect transgender clients, specifically.

Telemedicine as bridge to the offline world for person affected with problematic internet use or internet use disorder and concerned significant others

Introduction

Internet use disorder is a disorder of the digital age and presents a growing problem worldwide. It appears that due to structural and personal barriers, many persons affected (PA) and Concerned Significant Others (CSO) do not reach the health care system so far and thus a chronification of the pathology can proceed.

Methods

A telemedicine counseling service for PA and CSO of PA unwilling to enter treatment with two webcam-based sessions of 60 minutes for each group was created with the aim of reaching out to PA and CSO to provide a low-threshold support and refer the participants to the local health care system. Motivational interviewing for PA and CRAFT (Community Reinforcement and Family Training) for CSO were used as methods. Participants answered questions about their Internet use and sociodemographic data and six months after participation, participants were asked via email if they entered the local health care system. CSO answered the questions for themselves and in a third-party rating for PA unwilling to enter treatment.

Results

107 PA (34 years (SD = 13.64), 86% male) and 38 CSO (53 years (SD = 6.11), 28.9% male) participated in the two telemedicine sessions. After participation, 43.9% of the PA and 42.1% of the CSO reached the health care system. When there was consistency between the location of telemedicine consultation and treatment locally, over 90% of participants arrived (PA: 92.3%, CSO: 100%).

Conclusion

The results from this study reveal that telemedicine services could be a promising approach to address PA and CSO and build a bridge to the local health care system. Future studies should verify if these results can be replicated in randomized controlled trials.

Telepsychiatry: The future is already present

This review paper analyzes the state of knowledge on Telepsychiatry (TP) after the crisis caused by COVID and the resulting need to use new modalities of care. Six essential aspects of TP are addressed: patient's and mental health staff satisfaction, diagnostic reliability, effectiveness of TP interventions, cost-effectiveness in terms of opportunity cost (or efficiency), legal aspects inherent to confidentiality and privacy in particular and the attitude of professionals toward TP. Satisfaction with TP is acceptable among both patients and professionals, the latter being the most reluctant. Diagnostic reliability has been demonstrated, but requires further studies to confirm this reliability in different diagnoses and healthcare settings. The efficacy of TP treatments is not inferior to face-to-face care, as has been proven in specific psychotherapies. Finally, it should be noted that the attitude of the psychiatrist is the most decisive element that limits or facilitates the implementation of TP.

Effects of Telehealth on Dropout and Retention in Care among Treatment-Seeking Individuals with Substance Use Disorder: A Retrospective Cohort Study

Background: During the COVID-19 pandemic, telehealth became a widely used method of delivering treatment for substance use disorders (SUD), but its impact upon treatment engagement and dropout remains unknown. Methods: We conducted a retrospective analysis of adult SUD patients (n = 544) between October 2020 and June 2022 among a cohort of treatment-seeking patients at a nonprofit community behavioral health center in Southwestern Ohio. We estimated the likelihood of treatment dropout using survival curves and Cox proportional hazard models, comparing patients who used telehealth with video, telephone, or solely in-person services within the first 14 days of diagnosis. We also compared the likelihood of early treatment engagement. Results: Patients who received services through telehealth with video in the initial 14 days of diagnosis had a lower hazard of dropout, compared to patients receiving solely in-person services (0.64, 95% CI [0.46, 0.90]), while there was no difference in hazards of dropout between patients who received telephone and in-person services. Early use of telehealth, both via video (5.40, 95% CI [1.92, 15.20]) and telephone (2.12, 95% CI [1.05, 4.28]), was associated with greater odds of treatment engagement compared to in-person care. Conclusion: This study adds to the existing literature related to telehealth utilization and engagement in care and supports the inclusion of telehealth in SUD treatment programs for treatment-seeking individuals.

Key implementation factors in telemedicine-delivered medications for opioid use disorder: a scoping review informed by normalisation process theory

Telemedicine could improve access to medications for opioid use disorder (MOUD). Telemedicine-delivered MOUD (TMOUD) has expanded substantially in response to the restrictions imposed by the COVID-19 pandemic on in-person clinical contact, yet this expansion has not happened consistently across all health systems and countries. This Review aims to understand key factors in TMOUD implementation that might explain variations in uptake. We did a scoping review using three English language databases for articles reporting on the implementation of TMOUD services. 57 peer-reviewed articles were identified, subjected to open coding and thematic analysis, and further interpreted through normalisation process theory (NPT). NPT was originally used to evaluate telehealth innovations and has been applied extensively to describe, assess, and develop the implementation potential of a broad range of complex health-care interventions. By categorising our findings according to the four core NPT constructs of coherence, cognitive participation, collective action, and reflexive monitoring, we aim to rationalise the current evidence base to show the workability of TMOUD in practice. We find that variations in TMOUD models in practice depend on organisations' attitudes towards risk, clinicians' tensions around giving up control over standard practices, organisation-level support in overcoming operational and technological challenges, and evaluation methods that might neglect a potential widening of the digital divide.

Digital interventions for opioid use disorder treatment: A systematic review of randomized controlled trials

INTRODUCTION

Opioid use disorders are associated with a high burden of disease and treatment gap. Digital interventions can be used to provide psycho-social treatment for opioid use disorders, as an alternative to or together with face-to-face interventions. This review aimed to assess the application and effectiveness of digital interventions to treat opioid use disorder globally.

METHODS

The study team searched four electronic databases (PubMed, Psych INFO, Web of Science and Cochrane Central register of controlled trials). The inclusion criteria were: randomized controlled trials, assessment for opioid use before and at least once following intervention, and use of digital interventions. The primary outcomes were opioid use and/or retention in treatment, with data being summarized in tables and a narrative review presented.

RESULTS

The initial database search yielded 3542 articles, of which this review includes 20. Nineteen were conducted among adults in the United States. The digital interventions used included web-based, computer-based, telephone calls, video conferencing, automated self-management system, mobile applications and text messaging. They were based on therapeutic education systems, community reinforcement approaches, cognitive behavior therapy, relapse prevention, brief interventions, supportive counselling and motivational interviewing. The studies had mixed findings; of the 20 studies, 10 had statistically significant differences between the treatment groups for opioid abstinence, and four had significant differences for treatment retention. Comparisons were difficult due to varying methodologies. Participants rated the interventions as acceptable and reported high rates of satisfaction.

CONCLUSION

The use of digital interventions for opioid use disorder treatment was acceptable, with varying levels of effectiveness for improving outcomes, which is influenced by participant and intervention delivery factors. Further studies in different parts of the world should compare these findings, specifically in low- and middle-income countries.

Treatment utilization and modality preference among veterans receiving outpatient substance use disorder treatment during a pandemic

BACKGROUND AND OBJECTIVES

This study examines substance use disorder (SUD) treatment utilization patterns in response to a pandemic.

METHOD

Retrospective electronic medical record data were collected during three time periods (N = 390): "Pre-COVID-19" (12/02/2019-03/14/2020), "COVID-19" (03/15/2020-06/30/2020), and COVID-19 "Re-entry" (7/01/2020-10/01/2020). Number of visits in each time period, SUD diagnosis, treatment modality (video, telephone, none), demographic, and clinical variables were examined. One-way analyses of variance (ANOVA) and chi-square analyses tested the relationships between treatment modality, demographics, clinical variables, and psychiatric emergency room (PER) visits. Binary logistic regressions examined the effect of treatment modality on PER use during COVID-19 and Re-entry, controlling for alcohol, opioid, and cocaine use disorders, age, and past-year (pre-COVID-19) PER use.

RESULTS

Treatment modality was associated with SUD (alcohol, cocaine, opioids), age, and PER visits. Veterans who primarily attended telephone appointments were more likely to require PER services compared to those attending video appointments. In the full model, alcohol use disorder (AUD), past-year PER visits, and treatment modality (telephone visits) continued to be significantly associated with COVID-19 PER use, while past-year PER visits correlated with Re-entry PER use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

During COVID-19, veterans whose main treatment modality was telephone were more likely to require PER services than veterans who were seen by video, even after controlling for age, AUD, opioid use disorder, and past-year PER visits. This study is the first to have examined SUD treatment modality utilization patterns in response to COVID-19. Findings suggest that treatment modality during the initial phase of COVID-19 correlated with PER presentation.

A cohort study examining changes in treatment patterns for alcohol use disorder among commercially insured adults in the United States during the COVID-19 pandemic

INTRODUCTION

We know very little about how the pandemic impacted outpatient alcohol use disorder (AUD) care and the role of telemedicine.

METHODS

Using OptumLabs® Data Warehouse de-identified administrative claims, we identified AUD cohorts in 2018 (N = 23,204) and 2019 (N = 23,445) and examined outpatient visits the following year, focusing on week 12, corresponding to the March 2020 US COVID-19 emergency declaration, through week 52. Using multivariable logistic regression, we examined the association between patient demographic and clinical characteristics and receipt of any outpatient AUD visits in 2020 vs. 2019.

RESULTS

In 2020, weekly AUD visit utilization decreased maximally at the pandemic start (week 12) by 22.5 % (2019: 3.8 %, 2020: 3.0 %, percentage point change [95 % CI] = -0.86[-1.19, -0.05]) but was similar to 2019 utilization by mid-April 2020 (week 16). Telemedicine accounted for 50.1 % of AUD visits by early July 2020 (week 27). Individual therapy returned to 2019 levels within 1 week (i.e., week 13) whereas group therapy did not consistently do so until mid-August 2020 (week 31). Further, individual therapy exceeded 2019 levels by as much as 50 % starting mid-October 2020. The study found no substantial differences in visits by patient demographic or clinical characteristics.

CONCLUSIONS

Among patients with known AUD, initial outpatient care disruptions were relatively brief. However, substantial shifts occurred in care delivery-an embrace of telemedicine but also more pronounced, longer disruptions in group therapy vs. individual and an increase in individual therapy use. Further research needs to help us understand the implications of these findings for clinical outcomes.

Broadband access and telemedicine adoption for opioid use disorder treatment in the United States

PURPOSE

Buprenorphine utilization remains low in the United States. Telemedicine guidelines and flexibilities introduced during the COVID-19 pandemic provide an opportunity to increase patient access to buprenorphine. However, it is not known whether Americans without access to buprenorphine waivered provider, especially those residing in rural counties, have sufficient broadband internet access to support telemedicine.

METHODS

Administrative data from the Substance Abuse and Mental Health Services Administration's Buprenorphine Treatment Practitioner Locator Tool and the Fixed Broadband Deployment Data from the Federal Communications Commission are utilized to identify counties with low broadband penetration rate and the number of buprenorphine waivered providers with capacity to accept patients within a 30 miles radius.

FINDINGS

23.9% of the US population does not have access to any buprenorphine waivered provider with a capacity to accept new patients within a 30 miles radius. In counties with low broadband penetration rate, 78.9% of residents does not have access to any buprenorphine waivered provider with patient capacity. In rural counties with low broadband penetration rate, 82.3% of the residents does not have access to any buprenorphine waivered provider with patient capacity within a 30 miles radius.

CONCLUSIONS

Federal policy initiatives are expected to continue the COVID-19-related telehealth flexibilities and to increase the number of providers available to prescribe buprenorphine, but for that to translate into more patients utilizing treatment via telemedicine, high-speed internet access will be essential. This is particularly salient for residents in rural counties where access to both buprenorphine providers and high-speed internet access is limited.

Telemedicine in Thai-otorhinolaryngology patients in COVID-19 situation; primary surveys

Introduction

COVID-19 pandemic has put a strain on various aspects of hospital management due to high rates of infection and increased preventive measures around the world. Physicians and patients alike are susceptible to the ongoing virus causing concern leading to loss or postpone of follow up. Thailand has just start integration of digital solutions such as telemedicine which expected similar level of medical care and efficiency while reducing risk of exposure during the COVID-19 pandemic.

Objective

Evaluation the willingness to accept telemedicine in otorhinolaryngology patients during the peak COVID-19 outbreaks in our institution.

Methods

Collected data from all patients who had a schedule follow up for otorhinolaryngology department between the months of June to August, 2021 at out-patient Center.

Results

Total of 299 otorhinolaryngology patients included, 213 patients (71.2%) denied a virtual medical visit whereas 86 patients (28.8%) accepted. The obstructive sleep apnea (OSA) was the only group to have more acceptance of telemedicine, 79.5% than denying 20.5% with statistical significance (p < 0.01). Age difference between the accepting and declining group also showed statistical significance, 48.5 years and 56 years respectively (p < 0.01). Main Reasons for their decision, 48% of patients accepted due to experiencing clinical improvement and stability. The main reason for not accepting telemedicine was 80% of patients preferred a special otorhinolaryngologic examination on follow up.

Conclusions

This primary surveys among Thai otorhinolaryngology patients about telemedicine. The greater number of patients not interested in telemedicine due to requirement of otorhinolaryngologic examination. Which OSA follow-up patients have more attention in telemedicine.

A pilot study comparing in-person and remote outpatient substance use treatment services on quality-of-life outcomes

Background

The widespread shift from in-person to Telehealth services during the Covid-19 pandemic irreversibly shifted the landscape of outpatient substance use treatment. This shift was necessitated by health, rather than data-driven, reasons. As we reflect on whether to continue providing Telehealth services moving forward, we require empirical support on the effectiveness of Telehealth services (compared to in-person services) in terms of patient outcomes, such as Quality of Life (QOL), to support this decision.

Objective

To present data from a pilot project comparing changes in QOL across patients receiving outpatient in-person versus Telehealth substance use treatment in five clinics across New York State.

Method

To retrospectively compare total self-reported QOL scores from admission to 3-months later utilizing the Quality-of-Life Enjoyment and Satisfaction scale during in-person (pre-pandemic, n = 298) and Telehealth (pandemic, n = 316) services with a mixed repeated measures ANOVA.

Results

Self-reported QOL scores significantly improved across the first three months, regardless of treatment modality.

Conclusion

Telehealth and in-person treatment appear comparable on QOL outcomes over the first 3 months of outpatient treatment. Both modalities are associated with improved QOL scores.

Scientific significance

These preliminary findings provide evidence that Telehealth services are associated with positive patient outcomes and appear comparable to QOL outcomes among patients receiving in-person services. Future directions include further assessment of additional clinical outcomes and investigation into causal mechanisms.

Implications for a System of Care in Hawai'i: Primary Care Integration of Substance Use Disorder Treatment

Primary care physicians (PCPs) in Hawai'i face many challenges in treating patients with substance use disorders (SUD) who tend to have higher medical complexity and thus require more resources. PCPs play a vital role in identifying early misuse, integrating and coordinating care for patients with SUD including office-based interventions like medication-assisted treatment, and connecting patients to community treatment programs. In addition to enormous burdens to care for and increasingly complex patient panels, the challenges include lack of education on addiction medicine, insufficient resources and SUD treatment programs in the office and community, low reimbursement for the complexity of care provided, and an overall physician shortage which drives higher patient volume and less time for any given physician. This article suggests responses to address these challenges such as providing more training and continuing education in SUD for PCPs and trainees, enhancing team-based care to better support PCPs, and funding more SUD treatment programs. More funding should widen accessibility to treatment and reduce the overall burden on the health care system by preventing or treating the disease early, which is a core principle of primary care. Additionally, incentives to practice in Hawai'i in primary care, and especially to treat patients with SUD, need to be improved. Such steps must be taken to address the overall physician shortage that limits patients' access to SUD treatment. A collaborative care model between PCPs, care managers, and addiction specialists is an example of an integrated care system that may address many of these challenges in the short term. To truly improve care for all in Hawai'i, however, system wide interventions are essential to increase the incentive for PCPs to remain and practice in Hawai'i to take care of its unique population, including those dealing with SUD.

A Latent Class Analysis of Perceived Barriers to Help-seeking Among People with Alcohol Use Problems Presenting for Telephone-delivered Treatment

AIMS

Despite the magnitude of alcohol use problems globally, treatment uptake remains low. This study sought to determine the proportion of people presenting to telephone-delivered alcohol treatment who are first-time help-seekers, and explored perceived barriers to help-seeking to understand the barriers this format of treatment may help to address.

METHODS

Secondary analysis of baseline data from a randomized controlled trial of a telephone-delivered intervention for alcohol use problems. Latent class analysis (LCA) identified participant profiles according to self-reported barriers to alcohol treatment.

RESULTS

Participants' (344) mean age was 39.86 years (SD = 11.36, 18-73 years); 51.45% were male. Despite high alcohol problem severity (Alcohol Use Disorder Identification Test: mean = 21.54, SD = 6.30; 63.37% probable dependence), multiple barriers to accessing treatment were endorsed (mean = 5.64, SD = 2.41), and fewer than one-third (29.36%) had previously accessed treatment. LCA revealed a two-class model: a 'low problem recognition' class (43.32%) endorsed readiness-for-change and attitudinal barriers; a 'complex barriers' class (56.68%) endorsed stigma, structural, attitudinal and readiness-to-change barriers, with complex barrier class membership predicted by female sex (adjusted OR = 0.45, 95% CI 0.28, 0.72) and higher psychological distress (adjusted OR = 1.13, 95% CI 1.08, 1.18).

CONCLUSION

The majority of people accessing this telephone-delivered intervention were new to treatment, yet had high alcohol problem severity. Two distinct profiles emerged, for which telephone interventions may overcome barriers to care and tailored approaches should be explored (e.g. increasing problem awareness, reducing psychological distress). Public health strategies to address stigma, and raise awareness about the low levels of drinking that constitute problem alcohol use, are needed to increase help-seeking.

Telehealth interventions for substance use disorders in low- and- middle income countries: A scoping review

The increasing prevalence and magnitude of harmful effects of substance use disorders (SUDs) in low- and middle-income countries (LMICs) make it imperative to embrace interventions which are acceptable, feasible, and effective in reducing this burden. Globally, the use of telehealth interventions is increasingly being explored as possible effective approaches in the management of SUDs. Using a scoping review of literature, this article summarizes and evaluates evidence for the acceptability, feasibility, and effectiveness of telehealth interventions for SUDs in LMICs. Searches were conducted in five bibliographic databases: PubMed, Psych INFO, Web of Science, Cumulative Index of Nursing and Allied Professionals and the Cochrane database of systematic review. Studies from LMICs which described a telehealth modality, identified at least one psychoactive substance use among participants, and methods that either compared outcomes using pre- and post-intervention data, treatment versus comparison groups, post-intervention data, behavioral or health outcome, and outcome of either acceptability, feasibility, and/or effectiveness were included. Data is presented in a narrative summary using charts, graphs, and tables. The search produced 39 articles across 14 countries which fulfilled our eligibility criteria over a period of 10 years (2010 to 2020). Research on this topic increased remarkably in the latter five years with the highest number of studies in 2019. The identified studies were heterogeneous in their methods and various telecommunication modalities were used to evaluate substance use disorder, with cigarette smoking as the most assessed. Most studies used quantitative methods. The highest number of included studies were from China and Brazil, and only two studies from Africa assessed telehealth interventions for SUDs. There has been an increasingly significant body of literature which evaluates telehealth interventions for SUDs in LMICs. Overall, telehealth interventions showed promising acceptability, feasibility, and effectiveness for SUDs. This article identifies gaps and strengths and suggests directions for future research.

A comparison of telehealth versus in-person group therapy: Results from a DBT-based dual diagnosis IOP

OBJECTIVE

The effectiveness of remotely delivered group interventions and treatments for individuals with more complex psychiatric presentations is understudied. Nevertheless, the emergence of the COVID-19 pandemic shifted such treatments from in-person to remote service delivery without the establishment of comparable effectiveness between in-person and remote delivery. The current study presents the results of a private practice's transition from in-person treatment delivery to a videoconference-delivered Dialectical Behavior Therapy (DBT)-based intensive outpatient program (IOP) for individuals with comorbid mental health and substance use disorder diagnoses in response to the pandemic.

METHODS

Change in symptoms of depression, anxiety, and stress following completion of the IOP was compared between the in-person and videoconference groups.

RESULTS

Large reductions in symptoms were found following completion of the IOP for both the in-person and videoconference groups. Furthermore, no significant differences in symptom reduction were found between the groups.

CONCLUSION

Although large-scale replication is needed, these results suggest that IOPs and other intensive group therapies delivered via videoconference may be as effective as in-person therapies, even among individuals with more complex psychiatric presentations. Providers who have transitioned group therapies to videoconference formats or are considering creating remote groups can be more confident that they are not sacrificing treatment efficacy.

Effectiveness of a Stand-alone Telephone-Delivered Intervention for Reducing Problem Alcohol Use: A Randomized Clinical Trial

Importance

Despite the magnitude of alcohol use problems globally, treatment uptake remains low. Telephone-delivered interventions have potential to overcome many structural and individual barriers to help seeking, yet their effectiveness as a stand-alone treatment for problem alcohol use has not been established.

Objective

To examine the effectiveness of the Ready2Change telephone-delivered intervention in reducing alcohol problem severity up to 3 months among a general population sample.

Design, Setting, and Participants

This double-blind, randomized clinical trial recruited participants with an Alcohol Use Disorders Identification Test (AUDIT) score of greater than 6 (for female participants) and 7 (for male participants) from across Australia during the period of May 25, 2018, to October 2, 2019. Telephone assessments occurred at baseline and 3 months after baseline (84.9% retention). Data collection was finalized September 2020.

Interventions

The telephone-based cognitive and behavioral intervention comprised 4 to 6 telephone sessions with a psychologist. The active control condition comprised four 5-minute telephone check-ins from a researcher and alcohol and stress management pamphlets.

Main Outcomes and Measures

The primary outcome was change in alcohol problem severity, measured with the AUDIT total score. Drinking patterns were measured with the Timeline Followback (TLFB) instrument.

Results

This study included a total of 344 participants (mean [SD] age, 39.9 [11.4] years; range, 18-73 years; 177 male participants [51.5%]); 173 participants (50.3%) composed the intervention group, and 171 participants (49.7%) composed the active control group. Less than one-third of participants (101 [29.4%]) had previously sought alcohol treatment, despite a high mean (SD) baseline AUDIT score of 21.5 (6.3) and 218 (63.4%) scoring in the probable dependence range. For the primary intention-to-treat analyses, there was a significant decrease in AUDIT total score from baseline to 3 months in both groups (intervention group decrease, 8.22; 95% CI, 7.11-9.32; P < .001; control group decrease, 7.13; 95% CI, 6.10-8.17; P < .001), but change over time was not different between groups (difference, 1.08; 95% CI, -0.43 to 2.59; P = .16). In secondary analyses, the intervention group showed a significantly greater reduction in the AUDIT hazardous use domain relative to the control group at 3 months (difference, 0.58; 95% CI, 0.02-1.14; P = .04). A greater reduction in AUDIT total score was observed for the intervention group relative to the control group when adjusting for exposure to 2 or more sessions (difference, 3.40; 95% CI, 0.36-6.44; P = .03) but not 1 or more sessions (per-protocol analysis).

Conclusions and Relevance

Based on the primary outcome, AUDIT total score, this randomized clinical trial did not find superior effectiveness of this telephone-based cognitive and behavioral intervention compared with active control. However, the intervention was effective in reducing hazardous alcohol use and reduced alcohol problem severity when 2 or more sessions were delivered. Trial outcomes demonstrate the potential benefits of this highly scalable and accessible model of alcohol treatment.

Trial Registration

ANZCTR Identifier: ACTRN12618000828224.

Struggling With Recovery From Opioids: Who Is at Risk During COVID-19?

OBJECTIVES

Individuals in recovery from opioid use disorder (OUD) are vulnerable to the impacts of the COVID-19 pandemic. Recent findings suggest increased relapse risk and overdose linked to COVID-19-related stressors. We aimed to identify individual-level factors associated with COVID-19-related impacts on recovery.

METHODS

This observational study (NCT04577144) enrolled 216 participants who previously partook in long-acting buprenorphine subcutaneous injection clinical trials (2015-2017) for OUD. Participants indicated how COVID-19 affected their recovery from substance use. A machine learning approach Classification and Regression Tree analysis examined the association of 28 variables with the impact of COVID-19 on recovery, including demographics, substance use, and psychosocial factors. Tenfold cross-validation was used to minimize overfitting.

RESULTS

Twenty-six percent of the sample reported that COVID-19 had made recovery somewhat or much harder. Past-month opioid use was higher among those who reported that recovery was harder compared with those who did not (51% vs 24%, respectively; P < 0.001). The final classification tree (overall accuracy, 80%) identified the Beck Depression Inventory (BDI-II) as the strongest independent risk factor associated with reporting COVID-19 impact. Individuals with a BDI-II score ≥10 had 6.45 times greater odds of negative impact (95% confidence interval, 3.29-13.30) relative to those who scored <10. Among individuals with higher BDI-II scores, less progress in managing substance use and treatment of OUD within the past 2 to 3 years were also associated with negative impacts.

CONCLUSIONS

These findings underscore the importance of monitoring depressive symptoms and perceived progress in managing substance use among those in recovery from OUD, particularly during large-magnitude crises.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework

The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.

Practical Technology for Expanding and Improving Substance Use Disorder Treatment: Telehealth, Remote Monitoring, and Digital Health Interventions

The US opioid crisis and the COVID-19 pandemic have sparked innovation in substance use disorder (SUD) treatment such that telehealth, remote monitoring, and digital health interventions are increasingly feasible and effective. These technologies can increase SUD treatment access and acceptability, even for nontreatment seeking, remote, and underserved populations, and can be used to reduce health disparities. Overall, digital tools will likely overcome many barriers to delivery of evidence-based behavioral treatments such as cognitive behavioral therapy and contingency management, that, along with appropriate medications, constitute the foundation of treatment of SUDs.

Feasibility of a Novel COVID-19 Telehealth Care Management Program Among Individuals Receiving Treatment for Opioid Use Disorder: Analysis of a Pilot Program

Background

The emergence of COVID-19 exacerbated the existing epidemic of opioid use disorder (OUD) across the United States due to the disruption of in-person treatment and support services. Increased use of technology including telehealth and the development of new partnerships may facilitate coordinated treatment interventions that comprehensively address the health and well-being of individuals with OUD.

Objective

The analysis of this pilot program aimed to determine the feasibility of delivering a COVID-19 telehealth care management program using SMS text messages for patients receiving OUD treatment.

Methods

Eligible individuals were identified from a statewide opioid treatment program (OTP) network. Those who screened positive for COVID-19 symptoms were invited to connect to care management through a secure SMS text message that was compliant with Health Insurance Portability and Accountability Act standards. Care management monitoring for COVID-19 was provided for a period of up to 14 days. Monitoring services consisted of daily SMS text messages from the care manager inquiring about the participant’s physical health in relation to COVID-19 symptoms by confirming their temperature, if the participant was feeling worse since the prior day, and if the participant was experiencing symptoms such as coughing or shortness of breath. If COVID-19 symptoms worsened during this observation period, the care manager was instructed to refer participants to the hospital for acute care services. The feasibility of the telehealth care management intervention was assessed by the rates of adoption in terms of program enrollment, engagement as measured by the number of SMS text message responses per participant, and retention in terms of the number of days participants remained in the program.

Results

Between January and April 2021, OTP staff members referred 21 patients with COVID-19 symptoms, and 18 (82%) agreed to be contacted by a care manager. Participants ranged in age from 27 to 65 years and primarily identified as female (n=12, 67%) and White (n=15, 83%). The majority of participants were Medicaid recipients (n=14, 78%). There were no statistically significant differences in the demographic characteristics between those enrolled and not enrolled in the program. A total of 12 (67%) patients were enrolled in the program, with 2 (11%) opting out of SMS text message communication and choosing instead to speak with a care manager verbally by telephone. The remaining 10 participants answered a median of 7 (IQR 4-10) SMS text messages and were enrolled in the program for a median of 9 (IQR 7.5-12) days. No participants were referred for acute care services or hospitalized during program enrollment.

Conclusions

These results demonstrate the feasibility of a novel telehealth intervention to monitor COVID-19 symptoms among OTP patients in treatment for OUD. Further research is needed to determine the applicability of this intervention to monitor patients with comorbid chronic conditions in addition to the acceptability among patients and providers using the SMS text messaging modality.

Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study

BACKGROUND

Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology.

METHODS

Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus.

RESULTS

Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions.

CONCLUSIONS

A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.

Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic

INTRODUCTION

Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care.

METHODS

We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine.

RESULTS

Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust.

CONCLUSIONS

The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.

Virtual opioid agonist treatment: Alberta's virtual opioid dependency program and outcomes

Background

Virtually delivered healthcare (telehealth, telemedicine) has the potential to reduce gaps in access to opioid agonist therapy (OAT). Barriers to accessing OAT such as lack of transportation, in-person induction requirements, employment demands and limited childcare options reduce treatment opportunities for clients. A completely virtual model of care has been developed in Alberta, Canada. This paper introduces the unique virtual clinic model and describes outcomes from that model.

Methods

A retrospective chart review was conducted using datasets within existing electronic health records and databases from Alberta’s Virtual Opioid Dependency Program (VODP). Outcome data were extracted at admission to ongoing care by Case Management within the VODP and at 3, 6 and 12 months for the duration of treatment. Utilization trends over three years were analyzed, including admissions, discharges and active client information. Data regarding clinical outcomes for clients engaged in ongoing care with the VODP were aggregated for analysis over four time periods, including treatment retention rates at 6 and 12 months.

Results

A total of 440 client records were included in the study sample. Descriptive analysis showed rapid growth in utilization over three fiscal years. Despite rapid growth in utilization, median wait days for treatment decreased from 6 to 0 days with the initiation of a Same Day Start service to support low barrier immediate access to treatment. Treatment retention rates for clients in ongoing care were comparable to published reports, with 90% of the study sample remaining in treatment over 6 months, and 58% showing retention over 12 months. Clients reported high levels of satisfaction (90%) and outcomes reflected reductions in drug use and overdose as well as improved social functioning.

Conclusions

The VODP model demonstrated high levels of client satisfaction, rapid growth in utilization and positive preliminary clinical outcomes. Entirely virtual delivery of opioid agonist therapy is a promising option to facilitate access to evidence based treatment for opioid use disorder (OUD) in the context of a fentanyl overdose crisis, particularly for individuals living in rural or underserved areas.

Perspectives of Patients Receiving Telemedicine Services for Opioid Use Disorder Treatment: A Qualitative Analysis of User Experiences

OBJECTIVE

Telemedicine for opioid use disorder (tele-OUD) has the potential to increase access to medications for OUD (MOUD). Fully virtual tele-OUD services, in which all care is provided via telemedicine, are increasingly common, yet few studies document the experiences of patients who use such services. Understanding patient perspectives is one of multiple considerations to inform the regulation and reimbursement of tele-OUD services.

METHODS

We conducted semi-structured interviews with 20 adults receiving care from one fully virtual tele-OUD service who had received 3 to 5 weeks of treatment. Analyses were conducted using an inductive and deductive approach informed by the modified Unified Theory of Acceptance and Use of Technology model.

RESULTS

Over three quarters of patients with past experience receiving in-person MOUD treatment described tele-OUD as more advantageous with its key strength being more patient centered. Over three quarters of patients said they felt tele-OUD helped to ameliorate social barriers to seeking treatment, and nearly all said they appreciated the speed at which they were able to initiate MOUD treatment via tele-OUD. Surprisingly, the pandemic was not among the factors that influenced patient interest in tele-OUD.

CONCLUSIONS

Patients engaged in one fully virtual tele-OUD service described unique advantages of tele-OUD. More research is needed to determine the appropriateness of tele-OUD for people in various stages of recovery, and data on long-term treatment outcomes are needed to inform decisions regarding the regulation and reimbursement of fully virtual and hybrid care models for OUD.

Improving equity and access to buprenorphine treatment through telemedicine at syringe services programs

Background and aims

In the United States, access to buprenorphine remains low and disparities regarding who receives treatment have emerged. Federal laws have regulated buprenorphine delivery, ultimately limiting its implementation more broadly. At the onset of the COVID-19 pandemic, federal agencies acted quickly to remove a legal barrier, effectively allowing people with opioid used disorder (OUD) to initiate buprenorphine treatment via telemedicine. Leveraging this policy shift, a low barrier buprenorphine treatment initiative via telemedicine was started at syringe service programs in California. We assessed early findings from participants reached by this model of treatment.

Methods

In May 2020, buprenorphine treatment was offered through a virtual platform to SSP participants in California. SSP staff connected interested participants to virtual appointments with medical providers in a private location. During these visits, clinicians conducted clinical assessments for diagnosing participants with OUD and developed an unsupervised home induction plan for individuals who were eligible. Participants were prescribed a 7-day supply of up to 16 mg daily buprenorphine or 16 mg buprenorphine-2 mg naloxone and asked to return the following week if interested in continuing treatment.

Results

From May 2020 to March 2021, the SSP-buprenorphine virtual care initiative inducted 115 participants onto treatment with 87% of participants inducted on the same day as their referral. Of those inducted, 58% were between the ages of 30 and 49 and 28% were cisgender female. Regarding participants’ method of payment to reimburse buprenorphine costs, 92% of participants were covered by Medicare/Medicaid. Overall, 64% of participants returned for a second buprenorphine prescription refill.

Conclusions

These early findings suggest that this could be a promising approach to improve equity and access to buprenorphine treatment. We encourage policymakers to continue allowing buprenorphine delivery via telemedicine and researchers to study whether this approach improves equity and access to treatment throughout the United States.

Addiction and COVID: Issues, Challenges, and New Telehealth Approaches

In recent decades, the United States has seen a substantial increase in the number of people diagnosed with substance use disorder (SUD). Both SUDs and COVID-19 separately have had, and continue to have, a widespread impact on our society. While they are two distinct entities, they are intricately related and have been shown to influence one another. Lockdown mandates intended to enhance public safety produced unintended consequences for people with SUDs by decreasing access to treatment and disrupting their current care. Telehealth could offer a solution to this disruption as its utilization expands the provider’s reach and increases access to treatment in underserved populations, including those with SUDs. The use of telemedicine seems to result in higher rates of patient satisfaction, compliance, and treatment retention rates while maintaining the need for social distancing. Even when pandemic restrictions resolve, telehealth can continue to provide invaluable benefits to individuals with addiction, particularly those in rural America. In summary, ongoing research regarding telehealth delivery and the expansion of telehealth is a byproduct of the pandemic and can advance the American healthcare system beyond the days of COVID-19. This manuscript will review studies regarding the use of telehealth in SUD with the hope that further research within and beyond the COVID-19 pandemic will lead to the increased use of telehealth by those involved in and those receiving care for SUDs.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Addressing the needs of older adults receiving alcohol treatment during the COVID-19 pandemic: a qualitative study

OBJECTIVES

The COVID-19 global pandemic resulted in major changes to the provision of alcohol treatment in the UK, these changes coincided with increases in the use of alcohol. This study sought to understand the impact of the pandemic on older adults in alcohol treatment, and to explore how changes in the provision of alcohol treatment were experienced.

METHOD

Semi-structured interviews were completed with older adults (aged 55+) in alcohol treatment, as well as alcohol practitioners providing support to older adults. Data were analysed using thematic analysis. Alcohol use was assessed using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C).

RESULTS

Thirty older adults in alcohol treatment and fifteen alcohol practitioners were recruited. The COVID-19 pandemic was found to result in both increases and decreases in alcohol use; changes in alcohol use depended on a number of factors, such as living arrangements, family support, physical and mental health. Many alcohol treatment services moved to a model of remote support during the pandemic. However, face-to-face service provision was considered to be essential by both older adults in alcohol treatment and alcohol practitioners. Engagement with online support was low, with older adults facing barriers in using online technology.

CONCLUSION

The study highlights the importance of face-to-face treatment and intervention for older adults in alcohol treatment. Addiction services may see increased demand for treatment as a result of the pandemic; it is important that services consider the needs of older adults, many of whom may be marginalised by a remote model of service provision.

Virtual Care in an Outpatient Subspecialty Substance Use Disorder Treatment Program

OBJECTIVES

This article reports on the experience of an outpatient adolescent substance use disorder treatment program transitioning to virtual care during the COVID-19 pandemic. We describe the processes used to make the transition, including development of a safety protocol for patients seen virtually, present clinical volume data before and after the transition, and we describe a range of patient experiences through 3 clinical vignettes.

METHODS

Using data from the electronic health record, we generated counts of the total number of scheduled and completed appointments between December 2019 and June 2020. We used simple proportions to calculate the completed visit rate.

RESULTS

Both the absolute number of scheduled appointment and the percent of appointments completed increased with the initiation of virtual care, supporting the acceptability of this modality. Several patients experienced clinical improvements in conjunction with greater engagement, though challenges were also noted.

CONCLUSIONS

Virtual visits are a practical mode of treatment for adolescent substance use disorders, and more evidence is needed to understand the risks and benefits of this treatment modality.

Coronavirus Disease 2019 and the Impact on Substance Use Disorder Treatments

Coronavirus disease 2019 (COVID-19)-related stressors and restrictions, in the absence of social and institutional support, have led many individuals to either increase their substance consumption or relapse. Consequently, treatment programs for substance use disorders (SUDs) made a transition from in-person to remote care delivery. This review discusses the following evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs: (1) reduction in availability of care, (2) increase in demand for care, (3) transition to telemedicine use, (4) telemedicine for treatment of opioid use disorders, and (5) considerations for use of telemedicine in treating SUDs.

Comparing telemedicine to in-person buprenorphine treatment in U.S. veterans with opioid use disorder

BACKGROUND

Telemedicine-delivered buprenorphine (tele-buprenorphine) can potentially increase access to buprenorphine for patients with opioid use disorder (OUD), especially during the COVID-19 pandemic, but we know little about use in clinical care.

METHODS

This study was a retrospective national cohort study of veterans diagnosed with opioid use disorder (OUD) receiving buprenorphine treatment from the Veterans Health Administration (VHA) in fiscal years 2012-2019. The study examined trends in use of tele-buprenorphine and compared demographic and clinical characteristics in patients who received tele-buprenorphine versus those who received in-person treatment only.

RESULTS

Utilization of tele-buprenorphine increased from 2.29% of buprenorphine patients in FY2012 (n = 187) to 7.96% (n = 1352) in FY2019 in VHA veterans nationally. Compared to patients receiving only in-person care, tele-buprenorphine patients were less likely to be male (AOR = 0.85, 95% CI: 0.73-0.98) or Black (AOR = 0.54, 95% CI: 0.45-0.65). Tele-buprenorphine patients were more likely to be treated in community-based outpatient clinics rather than large medical centers (AOR = 2.91, 95% CI: 2.67-3.17) and to live in rural areas (AOR = 2.12, 95% CI:1.92-2.35). The median days supplied of buprenorphine treatment was 722 (interquartile range: 322-1459) among the tele-buprenorphine patients compared to 295 (interquartile range: 67-854) among patients who received treatment in-person.

CONCLUSIONS

Use of telemedicine to deliver buprenorphine treatment in VHA increased 3.5-fold between 2012 and 2019, though overall use remained low prior to COVID-19. Tele-buprenorphine is a promising modality especially when treatment access is limited. However, we must continue to understand how practitioners and patient are using telemedicine and how these patients' outcomes compare to those using in-person care.

Connecting Medical Personnel to Dentists via Teledentistry in a Children's Hospital System: A Pilot Study

Investigators evaluated feasibility, acceptability, and sustainability of a teledentistry pilot program within a children's hospital network between March, 2018, and April, 2019. The program connected dentists to medical personnel and patients being treated in urgent care clinics, a primary care clinic, and a freestanding emergency department via synchronous video consultation. Three separate but parallel questionnaires evaluated caregiver, medical personnel, and dentist perspectives on the experience. Utilization of teledentistry was very low (2%, 14/826 opportunities), but attitudes regarding this service were largely positive among all groups involved and across all survey domains. Uptake of new technology has barriers but teledentistry may be an acceptable service, especially in the case of dental trauma.

Transition to telehealth: Challenges and benefits of conducting group-based smoking and alcohol treatment virtually

In the midst of the COVID-19 pandemic, many research and clinical teams have transitioned their projects to a remote-based format, weighing the pros and cons of making such a potentially disruptive decision. One key aspect of this decision is related to the patient population, with underserved populations possibly benefiting from the increased reach of telehealth, while also encountering technology barriers that may limit accessibility. Early in the pandemic, our team shifted a group-based, smoking cessation and alcohol modification treatment trial to a remote-based format. Our population included individuals who concurrently wanted to quit smoking and modify their alcohol use. This paper describes technical and logistical considerations of transitioning from in-person to remote-based delivery for group-based treatment, including the impact upon study staff, group facilitators, participants, and the institution. Remotely-delivered group treatment may be valuable not only in response to pandemic-related restrictions, but it may also offer an alternative treatment-delivery modality with independent benefits in terms of population reach, costs, and pragmatics for clients, staff, and institutions.

Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States

OBJECTIVE

The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period.

METHODS

Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics.

RESULTS

Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits.

CONCLUSIONS

In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

Alcohol use disorder in the COVID-19 era: Position paper of the Italian Society on Alcohol (SIA)

Coronavirus disease 2019 (COVID-19) first emerged in China in November 2019. Most governments have responded to the COVID-19 pandemic by imposing a lockdown. Some evidence suggests that a period of isolation might have led to a spike in alcohol misuse, and in the case of patients with alcohol use disorder (AUD), social isolation can favour lapse and relapse. The aim of our position paper is to provide specialists in the alcohol addiction field, in psychopharmacology, gastroenterology and in internal medicine, with appropriate tools to better manage patients with AUD and COVID-19,considering some important topics: (a) the susceptibility of AUD patients to infection; (b) the pharmacological interaction between medications used to treat AUD and to treat COVID-19; (c) the reorganization of the Centre for Alcohol Addiction Treatment for the management of AUD patients in the COVID-19 era (group activities, telemedicine, outpatients treatment, alcohol-related liver disease and liver transplantation, collecting samples); (d) AUD and SARS-CoV-2 vaccination. Telemedicine/telehealth will undoubtedly be useful/practical tools even though it remains at an elementary level; the contribution of the family and of caregivers in the management of AUD patients will play a significant role; the multidisciplinary intervention involving experts in the treatment of AUD with specialists in the treatment of COVID-19 disease will need implementation. Thus, the COVID-19 pandemic is rapidly leading addiction specialists towards a new governance scenario of AUD, which necessarily needs an in-depth reconsideration, focusing attention on a safe approach in combination with the efficacy of treatment.

Acceptability, feasibility, and pilot results of the tele-harm reduction intervention for rapid initiation of antiretrovirals among people who inject drugs

BACKGROUND

People who inject drugs (PWID) have been a marginalized and a stigmatized population since the beginning of the AIDS epidemic and have not experienced the same life-changing benefits of antiretroviral therapy as others. Tele-Harm Reduction (THR) is a telehealth-enhanced, harm reduction intervention, delivered within a trusted SSP venue. It aims to facilitate initiation of care and achieve rapid HIV viral suppression among PWID living with HIV.

METHODS

In this mixed-methods study, we employed the Practical, Robust, Implementation and Sustainability Model (PRISM) implementation science framework to identify multilevel barriers and facilitators to implementing the THR intervention. Focus groups (n = 2, 16 participants), stakeholder interviews (n = 7) and in-depth interviews were conducted with PWID living with HIV (n = 25). In addition, to assess feasibility and acceptability, we pilot tested the THR intervention and reported viral suppression at 6 months.

RESULTS

Focus groups and stakeholder interviews revealed system and organizational level barriers to implementation including requirements for identification and in person visits, waiting times, stigma, case management inexperience, multiple electronic health records, and billing. A potential facilitator was using telehealth for case management and initial provider visit. In the in depth interviews conducted with PWID living with HIV, participants expressed that the SSP creates a convenient, comfortable, confidential environment for delivering multiple, non-stigmatizing PWID-specific services. 35 PWID living with HIV were enrolled in the pilot study, 35 initiated antiretroviral therapy, and 25 (78.1%) were virally suppressed at six months.

CONCLUSION

Rooted in harm reduction, the THR intervention shows promise in being an acceptable and feasible intervention that may facilitate engagement in HIV care and viral suppression among PWID.

Identifying barriers to emergency department-initiated buprenorphine: A spatial analysis of treatment facility access in Michigan

STUDY OBJECTIVES

Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access.

METHODS

Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers.

RESULTS

Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress.

CONCLUSION

Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.

Early innovations in opioid use disorder treatment and harm reduction during the COVID-19 pandemic: a scoping review

BACKGROUND

The COVID-19 pandemic has exerted a significant toll on the lives of people who use opioids (PWUOs). At the same time, more flexible regulations around provision of opioid use disorder (OUD) services have led to new opportunities for facilitating access to services for PWUOs. In the current scoping review, we describe new services and service modifications implemented by treatment and harm reduction programs serving PWUO, and discuss implications for policy and practice.

METHODS

Literature searches were conducted within PubMed, LitCovid, Embase, and PsycInfo for English-language studies published in 2020 that describe a particular program, service, or intervention aimed at facilitating access to OUD treatment and/or harm reduction services during the COVID-19 pandemic. Abstracts were independently screened by two reviewers. Relevant studies were reviewed in full and those that met inclusion criteria underwent final data extraction and synthesis (n = 25). We used a narrative synthesis approach to identify major themes around key service modifications and innovations implemented across programs serving PWUO.

RESULTS

Reviewed OUD treatment and harm reduction services spanned five continents and a range of settings from substance use treatment to street outreach programs. Innovative service modifications to adapt to COVID-19 circumstances primarily involved expanded use of telehealth services (e.g., telemedicine visits for buprenorphine, virtual individual or group therapy sessions, provision of donated or publicly available phones), increased take-home medication allowances for methadone and buprenorphine, expanded uptake of long-acting opioid medications (e.g. extended-release buprenorphine and naltrexone), home delivery of services (e.g. MOUD, naloxone and urine drug screening), outreach and makeshift services for delivering MOUD and naloxone, and provision of a safe supply of opioids.

CONCLUSIONS

The COVID-19 pandemic has posed multiple challenges for PWUOs, while simultaneously accelerating innovations in policies, care models, and technologies to lower thresholds for life-saving treatment and harm reduction services. Such innovations highlight novel patient-centered and feasible approaches to mitigating OUD related harms. Further studies are needed to assess the long-term impact of these approaches and inform policies that improve access to care for PWUOs.

A qualitative examination of substance use service needs among people who use drugs (PWUD) with treatment and service experience in Ontario, Canada

BACKGROUND

People who use drugs (PWUD) often have complex health and social support needs related to substance use, yet face numerous barriers to service access, resulting in unmet treatment needs and a corresponding gap in treatment. While initiatives to scale up substance use services for PWUD in Canada - and Ontario - have been undertaken, these have excluded PWUD' perspectives, and their needs have largely been defined by other actors. As end-users of services, PWUD' perspectives are vital to understanding what services are required, and whether existent services are adequate, appropriate and effective. Thus, the present study aimed to elicit in-depth knowledge from PWUD with lived experience of accessing services to better understand their unmet treatment and service needs, towards closing the service and treatment gap in Ontario.

METHODS

This qualitative study included one-on-one interviews conducted with a cohort of n = 45 adult PWUD with substance use and treatment experience in Ontario, Canada. Participants were recruited from substance use services based on ConnexOntario's directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants' experiences and perspectives on substance use services towards understanding their service needs. Data underwent an inductive thematic analysis based on key themes that emerged.

RESULTS

Participants commonly engaged in polysubstance use, and identified a number of unmet substance use service needs including complex factors within the current service system that influenced access to available programs. Specifically, participants suggested the need to address stigmatization and system fragmentation, increase service provision and capacity, and scale up specific services and related supports such as harm reduction, counseling, treatment, and housing.

CONCLUSIONS

This study identified PWUD' needs in relation to substance use service provision in Ontario, Canada, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated service delivery and referral models that include PWUD as collaborators and program facilitators to ensure that services are as accessible, effective, and cohesive as possible. Results from this study can be used to enhance provincial substance use treatment and service provision.

Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond

IMPORTANCE

Federal and state governments implemented temporary strategies for providing access to opioid use disorder (OUD) treatment during the COVID-19 pandemic. Advocates hope many of these policies become permanent because of their potential to expand access to care.

OBJECTIVE

To consider the multitude of ways access to and utilization of treatment for individuals with OUD might have been expanded by state and federal policy so researchers can do a better job evaluating the effectiveness of specific policy approaches, which will depend on the interaction with other state policies.

EVIDENCE REVIEW

We summarize state-level policy data reported by government and nonprofit agencies that track health care regulations, specifically the Kaiser Family Foundation, Federation of State Medical Boards, American Association of Nurse Practitioners, American Academy of Physician Assistants, and the National Safety Council. Data were collected by these sources from September 2020 through January 2021. We examine heterogeneity in policy elements adopted across states during the COVID-19 pandemic in 4 key areas: telehealth, privacy, licensing, and medication for opioid use disorder. The analysis was conducted from March 2020 through January 2021.

FINDINGS

This cross-sectional study found that federal and state governments have taken important steps to ensure OUD treatment availability during the COVID-19 pandemic, but few states are comprehensive in their approach. Although all states and Washington, DC have adopted at least 1 telehealth policy, only 17 states have adopted telehealth policies that improve access to OUD treatment for new patients. Furthermore, only 9 states relaxed privacy laws, which influence the ability to use particular technology for telehealth visits. Similarly, all states have adopted at least 1 policy related to health care professional licensing permissions, but only 35 expanded the scope of practice laws for both physician assistants and nurse practitioners. Forty-four states expanded access to initiation and delivery of medication for OUD treatment. Together, no state has implemented all of these policies to comprehensively expand access to OUD treatment during the COVID-19 pandemic.

CONCLUSIONS AND RELEVANCE

With considerable policy changes potentially affecting access to treatment and treatment retention for patients with OUD during the pandemic, evaluations must account for the variation in state approaches in related policy areas because the interactions between policies may limit the potential effectiveness of any single policy approach.

The intertwined expansion of telehealth and buprenorphine access from a prescriber hub

In this manuscript, we describe how efforts to increase access to buprenorphine for Opioid Use Disorder (OUD) through a telemedicine hub before and since the COVID-19 pandemic have played out in the Veterans Healthcare Administration (VHA) in New England. We look at how the COVID-19 pandemic and subsequent spike in opioid overdoses tilted the risk: benefit calculation for tele-prescribing a controlled substance such as buprenorphine toward expanding access to tele-buprenorphine. We conclude that there is a need for tele-buprenorphine hubs that can fill gaps in geographically dispersed healthcare systems.

The Impact of the Covid-19-Related Transition to Telehealth on Visit Adherence in Mental Health Care: An Interrupted Time Series Study

Covid-19 has led to an unprecedented shift to telemental health (TMH) in mental healthcare. This study examines the impact of this transition on visit adherence for mental health services in an integrated behavioral health department. Monthly visit data for 12,245 patients from January, 2019 to January, 2021 was extracted from the electronic medical record. Interrupted time series (ITS) analysis examined the impact of the Covid-19 transition to TMH on immediate level and trend changes in the percentage of cancelled visits and no shows in the 10 months following the transition. ITS also compared changes across the three largest services types: adult, pediatric, and substance use. Following the TMH-transition, completed visits increased by 10% amounting to an additional 3644 visits. In April, 2020, immediately following the TMH-transition, no shows increased by 1.4%, (95% CI 0.1, 2.7, p < 0.05) and cancellations fell by 13.5% (95% CI − 17.9, − 9.0, p < 0.001). Across the 10-month post-TMH period, 18.2% of visits were cancelled, compared to 28.3% across the 14-month pre-TMH period. The proportion of no-shows remained the same. The pattern was similar for pediatric and adult sub-clinics, but no significant changes in cancellations or no shows were observed in the substance use sub-clinic. TMH during the Covid-19 pandemic is associated with improved visit adherence over time and may be a promising model for improving the efficiency of mental health care delivery once it is safe to resume in person care.

Utilization of Telehealth Solutions for Patients with Opioid Use Disorder Using Buprenorphine: A Scoping Review

Background: A scoping review was conducted to examine the breadth of evidence related to telehealth innovations being utilized in the treatment of opioid use disorder (OUD) with buprenorphine and its effect on patient outcomes and health care delivery. Materials and Methods: The authors systematically searched seven databases and websites for peer-reviewed and gray literature related to telehealth solutions for buprenorphine treatment published between 2008 and March 18, 2021. Two reviewers screened titles and abstracts for articles that met the inclusion criteria, according to the scoping review study protocol. The authors included studies if they specifically examined telehealth interventions aimed at improving access to and usage of buprenorphine for OUD. Results: After screening 371 records, the authors selected 69 for full review. These studies examined the effect of telehealth on patient satisfaction, treatment retention rates, and buprenorphine accessibility and adherence. Conclusion: According to the reviewed literature, incorporation of telehealth technology with medication-assisted treatment for OUD is associated with higher patient satisfaction, comparable rates of retention, an overall reduction in health care costs, and an increase in both access to and usage of buprenorphine. This has been made possible through the expansion of telehealth technologies and a substantial push toward relaxed federal guidelines, both of which were quickly escalated in response to the COVID-19 pandemic. Future research is needed to fully quantify the effect of these factors; however, the results appear promising thus far and should urge policymakers to consider making these temporary policy changes permanent.

Methamphetamine use and technology-mediated psychosocial interventions: A mini-review

Engagement with face-to-face psychosocial interventions is often compromised in people using methamphetamine (MA), in the context of high rates of polysubstance use, mental health disorders, cognitive impairment and geographic isolation. Technology-mediated interventions offer flexible ways of engaging with treatment and are readily accessible. This mini-review evaluates evidence from eight studies for the effectiveness of telephone, mHealth (text-messaging and apps) and computer-based interventions for MA use. Two papers from one telephone counselling study showed a small improvement in MA-related outcomes, particularly for individuals in active use. However, a directive counselling style was associated with a higher likelihood of MA use during recovery for those higher in resistance to authority. Text-messaging interventions generally showed small but significant reductions in MA use in non-treatment seekers. When compared, there was no significant difference in level of MA use reduction between interactive, automated and self-monitoring text messages. Studies in other modalities (smartphone app, one trial; computer-based interventions, two trials) did not confer statistically significant reductions in MA use, though were likely impacted by app design and participant characteristics. Preliminary findings hint at the potential effectiveness of telephone counselling in aftercare and the capacity for text-messaging to reach those who are not in treatment. Given the small amount of existing literature, this review discusses the potential value of emerging interventions, the importance of adapting interventions to the characteristics of people who use MA and suggests specific directions for research in each technology modality.

Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities

This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis

BACKGROUND

The prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in access to good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable.

METHODS

We conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants' experiences and views regarding telemental health during the pandemic were identified and extracted. Data collection and analysis used a participatory, coproduction approach where researchers with relevant lived experience, contributed to all stages of data collection, analysis and interpretation of findings alongside clinical and academic researchers.

FINDINGS

The experiences and preferences regarding telemental health care of the forty-four participants were dynamic and varied across time and settings, as well as between individuals. Participants' preferences were shaped by reasons for contacting services, their relationship with care providers, and both parties' access to technology and their individual preferences. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important challenges related to safety and privacy in online settings, and gave examples of good remote care strategies they had experienced, including services scheduling regular phone calls and developing guidelines about how to access remote care tools.

DISCUSSION

Participants in our study have highlighted advantages of telemental health care, as well as significant limitations that risk hindering mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and of supporting staff in making effective and collaborative use of relevant technologies.