Telemedicine Use and Quality of Opioid Use Disorder Treatment in the US During the COVID-19 Pandemic

Patient experiences with telehealth treatment for opioid use disorder in Alabama

INTRODUCTION

Telehealth-only provision of buprenorphine for the treatment of opioid use disorder (OUD) was first made possible during the COVID-19 pandemic. However, Alabama instituted a law in July 2022 that mandated an annual in-person visit in order to receive this treatment. In July 2023, our usually telehealth-only group established a temporary clinic in Birmingham to meet this requirement.

METHODS

The study administered a survey instrument to patients at the time of clinic check-in.

RESULTS

158 of 160 (98.8 %) patients completed the survey. Mean distance traveled was 86.4 (standard deviation (SD) 53.7) miles; time required for travel was mean 1.6 (SD 1.0) hours. Twenty-five patients (15.8 %) reported needing to find childcare to attend the visit and 40 patients (25.3 %) reported missing work to attend. Patients disagreed (median 2 on 1-5 Likert scale, interquartile range (IQR) <1-3>) that it is important to see their provider in-person, that seeing their provider in-person improves care or improves their ability to succeed in treatment, and that they have other OUD treatment resources in their community. Patients strongly agreed (median 5, IQR <5-5>) that OUD can be treated by telehealth without the need for an in-person visit.

CONCLUSIONS

An annual in-person visits requirement to receive telehealth OUD services imposed a significant burden on patients, was not desired by patients, and may be associated with harm.

Buprenorphine discontinuation in telehealth-only treatment for opioid use disorder: A longitudinal cohort analysis

INTRODUCTION

At the beginning of the COVID-19 pandemic, federal agencies permitted telehealth initiation of buprenorphine treatment for opioid use disorder (OUD) without in-person assessment. It remains unclear how telehealth-only buprenorphine treatment impacts time to discontinuation and patient reported treatment outcomes.

METHODS

A longitudinal observational cohort study conducted September 2021 through March, 2023 enrolled participants with OUD initiating buprenorphine (≤ 45 days) with internet and phone access in Oregon and Washington. The intervention was a fully telehealth-only (THO) app versus treatment as usual (TAU) in office-based settings with some telehealth. We assessed self-reported buprenorphine discontinuation at 4-,12-, and 24-weeks. Generalized estimating equations (GEE) calculated unadjusted and adjusted relative risk ratios (RR) for discontinuation averaged over the study period. Secondary outcomes included change in the Brief Addiction Monitor (BAM) and the visual analogue craving scale. Generalized linear models estimated average within-group and between-group differences over time.

RESULTS

Participants (n = 103 THO; n = 56 TAU) had a mean age of 37 years (SD = 9.8 years) and included 52 % women, 83 % with Medicaid insurance, 80 % identified as White, 65 % unemployed/student, and 19 % unhoused. There were differences in gender (THO = 54 % women vs. TAU = 44 %, p = .04), unemployed status (60 % vs 75 %, p = .02), and stable housing (84 % vs 73 %, p = .02). Rates of buprenorphine discontinuation were low in the THO (4 %) and TAU (13 %) groups across 24 weeks. In the adjusted analysis, the risk of discontinuation was 61 % lower in the THO group (aRR = 0.39, 95 % CI [0.17, 0.89], p = .026). Decreases occurred over time on the harms subscale of the BAM (within-group difference - 0.85, p = .0004 [THO], and - 0.68, p = .04 [TAU]) and cravings (within-group difference - 13.47, p = .0001 [THO] vs -7.65, p = .01 [TAU]).

CONCLUSIONS

A telehealth-only platform reduced the risk of buprenorphine discontinuation compared to office-based TAU. In-person evaluation to receive buprenorphine may not be necessary for treatment-seeking patients.

CLINICAL TRIALS IDENTIFIER

NCT03224858.

Associations Between Telemedicine Use Barriers, Organizational Factors, and Physician Perceptions of Care Quality

Introduction: Evaluating physician perceptions of telemedicine use and its impact on care quality among physician providers is critical to sustaining telemedicine programs, given the uncertainty of reimbursement policy, preferences, inadequate training, and technical difficulties. Physicians reported technical barriers to effectively practicing integrated medicine using telemedicine as patient volumes increased during the pandemic. The objective of this work was to examine whether perceived practice barriers and facilitators were associated with physician respondents' perceptions of telemedicine care quality compared with in-person care. Methods: This cross-sectional study analyzed the 2021 National Electronic Health Record Survey. The sample comprised 1,857 nonfederally employed physicians (weighted n = 403,013) delivering integrated patient care. Of those physicians, 1,630 (weighted n = 346,646) reported providing care through telemedicine. We reported frequencies and percentages of reported practice characteristics. Generalized ordinal logistic regressions examined relationships between practice factors and care quality for telemedicine care. Results: Most of the sample (n = 1,630) were male (66.1%), >50 years of age (66.1%), and worked in a single location (73.5%). A total of 70% of respondents reported that patients had difficulty using telemedicine platforms, and 64% reported limitations in patients' access to technology. Most respondents indicated having provided quality care to some extent (45%) and to a great extent (26%) during telemedicine visits compared to in-person visits. Associations between barriers, facilitators, and care quality perceptions were positive, underscoring resiliency in telemedicine programs among practices. Conclusion: Care modalities and the organizational, environmental, and personal facilitators drive quality perceptions among physicians. Perceived fit and usability determine perceptions of care quality for providers integrating telemedicine into their practice.

Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study

BACKGROUND

Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed.

OBJECTIVE

To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care.

DESIGN

Comparative case study, using video- and telephone-based semi-structured interviews.

PARTICIPANTS

Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system.

APPROACH

Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process.

KEY RESULTS

Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference.

CONCLUSIONS

Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

Digital health interventions to support women with opioid use disorder: A scoping review

BACKGROUND

Digital health interventions have the potential to address barriers to care for women. To design effective digital health interventions that meet the needs of this population, a full assessment of the existing literature is required.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. A total of four databases were searched: Medline (OVID), Embase, the Cumulative Index to Nursing and Allied Health Literature, and PsychInfo. Search terms were informed by a preliminary search and included synonyms for opioid use disorder, digital health, and women. Abstract screening and full text review was completed after reviewer calibration. Data extraction was carried out through data charting.

RESULTS

After removal of duplicates, 901 abstracts were screened; the full text of 26 manuscripts were reviewed. After full text review, 17 studies published between 2018 and 2023 were included in the scoping review. Types of digital health interventions and study designs varied widely, with a majority focused on the peripartum period (n=12). Of 11 studies focused on OUD treatment, only three reported outcomes related to MOUD utilization. Two studies described community engagement to inform the development or modification of interventions.

CONCLUSION

A variety of digital health interventions are currently being used to address OUD among women. Areas for future work include examining efficacy for MOUD utilization, incorporating community engagement into intervention development, providing support for OUD treatment and recovery in the late postpartum period and beyond, and the development of mobile health applications.

Medicare Payment for Opioid Treatment Programs

Importance

Medicare began paying for medications for opioid use disorder (MOUD) at opioid treatment programs (OTPs) that dispense methadone and other MOUD in January 2020. There has been little research describing the response to this payment change and whether it resulted in more patients receiving MOUD or just a shift in who pays for this care.

Objective

To describe how many and which Medicare beneficiaries receive care from OTPs and how this compares to those receiving MOUD in other settings.

Design, Setting, and Participants

This cross-sectional study included all patients receiving MOUD care identified in 2019-2022 100% US Medicare Parts B and D claims. Patients receiving care in an OTP who were dually insured with Medicare and Medicaid in the 2019-2020 Transformed Medicaid Statistical Information System were also included.

Exposure

Receiving MOUD care in an OTP.

Main Outcomes and Measures

Comparisons of 2022 beneficiaries treated in OTPs vs other non-OTP settings in 2022.

Results

The share of Medicare beneficiaries treated by OTPs rose steadily from 4 per 10 000 (14 160 beneficiaries) in January 2020 to 7 per 10 000 (25 596 beneficiaries) in August 2020, then plateaued through December 2022; of 38 870 patients (23% ≥66 years; 35% female) treated at an OTP in 2022, 96% received methadone. Patients in OTPs, compared to those receiving MOUD in other settings, were more likely be 65 years and younger (65% vs 62%; P < .001), less likely to be White (72% vs 82%; P < .001), and more likely to be an urban resident (86% vs 74%; P < .001). When Medicare OTP coverage began, there was no associated drop in the number of dually insured patients with Medicaid with an OTP claim. Of the 1854 OTPs, 1115 (60%) billed Medicare in 2022, with the share billing Medicare ranging from 13% to 100% across states.

Conclusions and Relevance

This study showed that since the initiation of Medicare OTP coverage in 2020, there has been a rapid increase in the number of Medicare beneficiaries with claims for OTP services for MOUD, and most OTPs have begun billing Medicare. Patients in OTPs were more likely to be urban residents and members of racial or ethnic minority groups than the patients receiving other forms of MOUD.

Trends in Use of Telemedicine for Stimulant Initiation Among Children and Adults

OBJECTIVE

The authors sought to examine trends in stimulant initiation and follow-up care for attention-deficit hyperactivity disorder (ADHD) via telemedicine.

METHODS

This retrospective longitudinal study used national, deidentified commercial health insurance outpatient claims among children (ages 2-17 years; N=535,629) and adults (ages 18-64 years; N=2,116,160) from January 2019 through April 2022. Regression analyses were used to examine risk for stimulant initiation, whether initiation occurred via telemedicine or in-person care, and receipt of a follow-up visit.

RESULTS

The mean monthly adjusted number of stimulant initiations per 100,000 enrollees was similar for children before and during the COVID-19 pandemic (prepandemic, 57 initiations; during pandemic, 56 initiations) but increased for adults (prepandemic, 27 initiations; during pandemic, 33 initiations). Initiations via telemedicine peaked at 53%-57% in April 2020 and dropped to about 14% among children and 28% among adults in April 2022. Telemedicine initiations were significantly more common among psychiatrists than among other prescribers (OR=3.70, 95% CI=3.38-4.06 [children]; OR=3.02, 95% CI=2.87-3.17 [adults]) and less common for rural residents (OR=0.57, 95% CI=0.40-0.82 [children]; OR=0.75, 95% CI=0.61-0.92 [adults]). Follow-up care was significantly more common among individuals whose care was initiated via telemedicine than among those receiving in-person care (OR=1.09, 95% CI=1.00-1.19 [children]; OR=1.61, 95% CI=1.53-1.69 [adults]).

CONCLUSIONS

Many stimulant treatments were initiated via telemedicine. Proposed rules to prohibit controlled substance prescribing without an in-person evaluation would require significant changes in current practice, potentially limiting access to stimulant medications for ADHD.

Federal Impacts on Buprenorphine Prescribing in Washington State, 2012 to 2022

Objectives. To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022. Methods. We conducted an interrupted time series analysis comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes. Results. Physician prescribing increased by 1.63% (95% confidence interval [CI] = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic. Conclusions. CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (Am J Public Health. 2024;114(7):696-704. https://doi.org/10.2105/AJPH.2024.307649).

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021

Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.

Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Racial and Ethnic Disparities in Geographic Availability of Buprenorphine

OBJECTIVES

Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups.

METHODS

Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes' racial and ethnic minority composition and rurality with t tests.

RESULTS

Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = -4.9 to -2.7) and 2.6 in rural ZIP codes (95% confidence interval = -3.0 to -2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude.

CONCLUSIONS

Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.

Telehealth in opioid use disorder treatment: policy considerations for expanding access to care

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was intended to address the online diversion of controlled substances. However, it inadvertently limited access to care for patients seeking medications for opioid use disorder (MOUD). During the COVID-19 pandemic, temporary flexibility in telemedicine prescriptions for MOUD were implemented. Now, with the conclusion of the public health emergency, policymakers need to develop strategies to maintain some of the lifted restrictions in order to maintain increased access to care for patients with opioid use disorder (OUD). One potential solution to address these issues is the implementation of a hybrid model combining outpatient clinics and telemedicine. This model offers the opportunity to maintain the benefits of telemedicine while ensuring comprehensive and safe care for OUD patients.

Association of licensure and relationship requirement waivers with out-of-state tele-mental health care, 2019-2021

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental health care utilization of patients diagnosed with COVID-19. Using claims from January 2019 until December 2021 of 2 037 977 commercially insured individuals in 3 metropolitan statistical areas (MSAs) straddling Midwestern state borders, we found increased out-of-state telehealth utilization as a share of out-of-state mental health care by 0.1411 and 0.0575 visits per month or 1679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental health care. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state health care online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental health care than emergency waivers.

Access to Medications for Opioid Use Disorder During COVID-19: Retrospective Study of Commercially Insured Patients from 2019-2022

INTRODUCTION

This study assesses disparities in medications for opioid use disorder in adults with opioid use disorder and examines the associations between state-level COVID-19 lockdown and telehealth policies and medications for opioid use disorder utilization rates during the COVID-19 pandemic.

METHODS

This retrospective cohort study of 396,872 adults with opioid use disorder analyzed monthly medications for opioid use disorder utilization rates between January 2019 and June 2022 using data from Clinformatics Data Mart Database. Primary outcome measure was monthly medications for opioid use disorder utilization rates. Variables of interest were patients' demographics and state-level characteristics (telehealth policies for controlled substance prescribing, COVID-19 lockdown policy, and registered buprenorphine providers/100,000). In multivariable analyses, time trend was grouped into four time periods: before COVID-19, early COVID-19, early vaccine, and Omicron-related COVID-19 surge and thereafter.

RESULTS

Medications for opioid use disorder rates increased from a 1.2% change in slope monthly on a log scale to 2% monthly from February 2021 to October 2021, after which the utilization rate increased to a lesser degree. Women had 28% lower odds of receiving medications for opioid use disorder than men; Hispanic, Black, and Asian patients had 40%, 34%, and 32% lower odds of receiving medications for opioid use disorder than White patients, respectively. These sex and racial disparities persisted throughout the pandemic. Regional medications for opioid use disorder rate differences, mediated by buprenorphine providers/100,000 state population, decreased during the pandemic. States with telehealth policies for controlled substance prescribing had greater percentages of patients on medications for opioid use disorder (11.7%) than states without such policies (10.4%).

CONCLUSIONS

Monthly medications for opioid use disorder rates increased during the pandemic, with higher rates in men, White individuals, and residents of the Northeast region. States with policies permitting telehealth prescribing of controlled substances also had higher medications for opioid use disorder rates, supporting a future expansion of medications for opioid use disorder-related telehealth to improve access to care.

A qualitative study to determine perspectives of clinicians providing telehealth opioid use disorder treatment

BACKGROUND

Telehealth-only medication for opioid use disorder (teleMOUD) treatment with buprenorphine was first made possible in the United States during the COVID-19 Public Health Emergency. As a result, several large provider groups now treat opioid use disorder (OUD) patients in nearly every state using telehealth. This study evaluates the perceptions and experiences of providers working almost exclusively in a teleMOUD program.

METHODS

Qualitative interviews were conducted with 18 providers (physicians, physician assistants and nurse practitioners) using a semi-structured interview guide. Interviews were recorded, transcribed and reviewed. After reviewing the transcripts, a codebook was developed, interviews were coded, and coded excerpts were analyzed for key themes.

RESULTS

Inductive codes were used to organize provider responses and included patient-level codes, provider-level codes, and telehealth environment codes. For providers, there are benefits of a flexible and less stressful working environment, which contribute to a higher quality of life. Providers also expressed mixed feelings regarding professional identity and focusing specifically on OUD, differences in relationships with colleagues, and challenges related to policy changes and ambiguities. For patients, providers perceived greater access, less stigma, more convenience, and a unique provider-patient relationship compared to in-person treatment. These themes affect providers and patients on multiple levels of the social-ecological model.

CONCLUSIONS

Multiple themes emerged in this study. This work is amongst the first to describe perspectives of providers working in the nascent teleMOUD setting, and can inform initiatives to improve provider wellness, provider retention, and quality of care for patients treated in the setting.

Navigating addiction treatment during COVID-19: policy insights from state health leaders

To mitigate pandemic-related disruptions to addiction treatment, US federal and state governments made significant changes to policies regulating treatment delivery. State health agencies played a key role in implementing these policies, giving agency leaders a distinct vantage point on the feasibility and implications of post-pandemic policy sustainment. We interviewed 46 state health agency and other leaders responsible for implementing COVID-19 addiction treatment policies across 8 states with the highest COVID-19 death rate in their census region. Semi-structured interviews were conducted from April through October 2022. Transcripts were analyzed using summative content analysis to characterize policies that interviewees perceived would, if sustained, benefit addiction treatment delivery long-term. State policies were then characterized through legal database queries, internet searches, and analysis of existing policy databases. State leaders viewed multiple pandemic-era policies as useful for expanding addiction treatment access post-pandemic, including relaxing restrictions for telehealth, particularly for buprenorphine induction and audio-only treatment; take-home methadone allowances; mobile methadone clinics; and out-of-state licensing flexibilities. All states adopted at least 1 of these policies during the pandemic. Future research should evaluate these policies outside of the acute COVID-19 pandemic context.

Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic

OBJECTIVE

The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic.

METHODS

The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022).

RESULTS

From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth.

CONCLUSIONS

Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.

An Assessment of the One-Month Effectiveness of Telehealth Treatment for Opioid Use Disorder Using the Brief Addiction Monitor

OBJECTIVES

Telehealth treatment with medication for opioid use disorder (teleMOUD) was made possible with regulations following the COVID-19 pandemic that permitted prescribing buprenorphine without an in-person visit. This study evaluates the self-reported outcomes of patients treated by teleMOUD using the Brief Addiction Monitor (BAM), a 17-question tool that assesses drug use, cravings, physical and psychological health, and psychosocial factors to produce 3 subset scores: substance use, risk factors, and protective factors.

METHODS

Patients treated by a teleMOUD provider group operating in >30 states were asked to complete an app-based version of BAM at enrollment and at 1 month. Patients who completed both assessments between June 2022 and March 2023 were included.

RESULTS

A total of 2556 patients completed an enrollment BAM and 1447 completed both assessments. Mean number of days from baseline BAM to follow-up was 26.7 days. Changes were significantly different across most questions. The substance use subscale decreased from mean 2.6 to 0.8 (P < .001), the risk factors subscale decreased from mean 10.3 to 7.5 (P < .001), and the protective factors subscale increased from mean 14.3 to 15.0. (P < .001). Substance use and risk factor subscale changes were significant across all sex and age groups, while protective factors subscale did not improve for those <25 and >54 years. Patient reports of at least 1 day of illegal use or misuse decreased, including marijuana (28.1% vs 9.0%), cocaine/crack (3.9% vs 2.6%), and opioids (49.8% vs 10.5%).

CONCLUSIONS

Among patients treated by teleMOUD who completed assessments at enrollment and 1 month, there was improvement in drug use, risk factor, and protective factor scores.

Utilization and disparities in medication treatment for opioid use disorder among patients with comorbid opioid use disorder and chronic pain during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear.

METHODS

We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity.

RESULTS

Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001]).

CONCLUSIONS

Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups.

Responding to the US opioid crisis: leveraging analytics to support decision making

The US is experiencing a severe opioid epidemic with more than 80,000 opioid overdose deaths occurring in 2022. Beyond the tragic loss of life, opioid use disorder (OUD) has emerged as a major contributor to morbidity, lost productivity, mounting criminal justice system costs, and significant social disruption. This Current Opinion article highlights opportunities for analytics in supporting policy making for effective response to this crisis. We describe modeling opportunities in the following areas: understanding the opioid epidemic (e.g., the prevalence and incidence of OUD in different geographic regions, demographics of individuals with OUD, rates of overdose and overdose death, patterns of drug use and associated disease outbreaks, and access to and use of treatment for OUD); assessing policies for preventing and treating OUD, including mitigation of social conditions that increase the risk of OUD; and evaluating potential regulatory and criminal justice system reforms.

What can we learn from COVID-19 to improve opioid treatment? Expert providers respond

BACKGROUND

The COVID-19 pandemic has had devasting effects on drug abuse treatment systems already stressed by the opioid crisis. Providers within opioid use disorder (OUD) outpatient treatment programs have had to adjust to rapid change and respond to new service delivery provisions such as telehealth and take-home medication. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, this study explores providers' perspectives about strategies and policies that, if made permanent, can potentially improve access to and quality of OUD treatment.

METHODS

This qualitative study was conducted in Los Angeles County, which has one of the largest substance use disorder (SUD) treatment systems in the United States serving a diverse population, including communities impacted by the opioid crisis. We collected qualitative interview data from 30 high-performing programs (one manager/supervisor per program) where we based high performance on empirical measures of access, retention, and program completion outcomes. The study team completed data collection and analysis using constructivist grounded theory (CGT) to describe the social processes in which the participating managers engaged when faced with the pandemic and subsequent organizational changes. We developed 14 major codes and six minor codes with definitions. The interrater reliability tests showed pooled Cohen's kappa statistic of 93 %.

RESULTS

Our results document the impacts of COVID-19 on SUD treatment systems, their programmatic responses, and the strategic innovations they developed to improve service delivery and quality and which managers plan to sustain within their organizations.

CONCLUSION

Providers identified three primary areas for strategic innovation designed to improve access and quality: (1) designing better medication utilization, (2) increasing telemedicine capacity, and (3) improving reimbursement policies. These strategies for system transformation enable us to use lessons from the COVID-19 pandemic to direct policy and programmatic reform, such as expanding eligibility for take-home medication and enhancing access to telehealth services.

Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review

INTRODUCTION

The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD.

METHODS

The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles.

RESULTS

A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience.

CONCLUSIONS

Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.

Trends in Opioid Medication Adherence During the COVID-19 Pandemic: Retrospective Cohort Study

BACKGROUND

The recent pandemic had the potential to worsen the opioid crisis through multiple effects on patients' lives, such as the disruption of care. In particular, good levels of adherence with respect to medication for opioid use disorder (MOUD), recognized as being important for positive outcomes, may be disrupted.

OBJECTIVE

This study aimed to investigate whether patients on MOUD experienced a drop in medication adherence during the recent COVID-19 pandemic.

METHODS

This retrospective cohort study used Medicaid claims data from 6 US states from 2018 until the start of 2021. We compared medication adherence for people on MOUD before and after the beginning of the COVID-19 pandemic in March 2020. Our main measure was the proportion of days covered (PDC), a score that measures patients' adherence to their MOUD. We carried out a breakpoint analysis on PDC, followed by a patient-level beta regression analysis with PDC as the dependent variable while controlling for a set of covariates.

RESULTS

A total of 79,991 PDC scores were calculated for 37,604 patients (age: mean 37.6, SD 9.8 years; sex: n=17,825, 47.4% female) between 2018 and 2021. The coefficient for the effect of COVID-19 on PDC score was -0.076 and was statistically significant (odds ratio 0.925, 95% CI 0.90-0.94).

CONCLUSIONS

The COVID-19 pandemic was negatively associated with patients' adherence to their medication, which had declined since the beginning of the pandemic.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study

PURPOSE

The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings.

METHODS

The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records.

FINDINGS

All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period.

CONCLUSIONS

To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study

Background: The COVID-19 pandemic resulted in a marked increase in telehealth for the provision of primary care-based opioid use disorder (OUD) treatment. This mixed methods study examines characteristics associated with having the majority of OUD-related visits via telehealth versus in-person, and changes in mode of delivery (in-person, telephone, video) over time. Methods: Logistic regression was performed using electronic health record data from patients with ≥1 visit with an OUD diagnosis to ≥1 of the two study clinics (Rural Health Clinic; urban Federally Qualified Health Center) and ≥1 OUD medication ordered from 3/8/2020-9/1/2021, with >50% of OUD visits via telehealth (vs. >50% in-person) as the dependent variable and patient characteristics as independent variables. Changes in visit type over time were also examined. Inductive coding was used to analyze data from interviews with clinical team members (n = 10) who provide OUD care to understand decision-making around visit type. Results: New patients (vs. returning; OR = 0.47;95%CI:0.27-0.83), those with ≥1 psychiatric diagnosis (vs. none; OR = 0.49,95%CI:0.29-0.82), and rural clinic patients (vs. urban; OR = 0.05; 95%CI:0.03-0.08) had lower odds of having the majority of visits via telehealth than in-person. Patterns of visit type varied over time by clinic, with the majority of telehealth visits delivered via telephone. Team members described flexibility for patients as a key telehealth benefit, but described in-person visits as more conducive to building rapport with new patients and those with increased psychological burden. Conclusion: Understanding how and why telehealth is used for OUD treatment is critical for ensuring access to care and informing OUD-related policy decisions.