Unprecedented need and recommendations for harnessing data to guide future policy and practice for opioid use disorder treatment following COVID-19

Changes in opioid treatment programs and harm reduction provider services during the COVID-19 pandemic: Findings from 10 states

Harm reduction and opioid treatment programs (OTPs) modified service delivery based on rapid changes to state and federal regulations during the COVID-19 pandemic. There is little evidence on how these regulations changed the delivery of medication for opioid use disorder and harm reduction services and whether certain regulations should be made permanent. This study explores how harm reduction OTPs across the United States leveraged changes in regulations and responded to impacts of COVID-19 to continue providing services and perspectives on future legislation that regulates their practice and practice sites. The COVID Harm Reduction and Treatment programs Survey study administered a survey that included closed-ended and free-response questions to 22 sites between August 2020 and January 2021. Program demographics and responses to survey items pertaining to site and service modifications were tabulated and proportions reported. A qualitative descriptive method was used to analyze free-response questions. All (100%) surveyed providers reported the need to modify their services. The majority (68%) reported an increase or no change in client volume; 68% reported increases in naloxone services and 77% reported increases in syringe services programs. Qualitative themes included (a) flexibility in reaching clients due to regulatory changes, (b) benefits and drawbacks of telehealth, and (c) increased vulnerabilities of their clients during the pandemic. Despite difficulties during the COVID-19 pandemic, harm reduction and OTP sites found that regulatory changes provided flexibility in service delivery and that they were better able to serve their clients. Future policies should bolster these sites to continue to provide low-barrier and high-quality services. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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.

State guidance and system changes related to COVID-19: Impact on opioid treatment programs

INTRODUCTION

In the United States, methadone treatment may only be provided through opioid treatment programs (OTPs), which operate under a complex system of federal and state regulations. During the pandemic, federal regulators relaxed several longstanding restrictions for OTPs by permitting expanded eligibility for take-home medication and allowing counseling and medication management through telehealth. The purpose of this study was to assess the guidance provided by states regarding the revised guidelines and efforts to protect staff and patients in response to the pandemic.

METHODS

Between September and October of 2020, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Friends Research Institute, fielded a web-based qualitative survey of state opioid treatment authorities (SOTAs) across the United States, the District of Columbia, and Puerto Rico. The study conducted the survey prior to the availability of the COVID vaccines. It queried 42 SOTAs concerning state guidance provided to OTPs on treatment operations and practices for existing patients and new admissions; actions to protect staff and patients; changes in treatment need and operational capacity; and administrative practices regarding treatment. This study examines the responses of 42 SOTAs (65 %) who completed the survey.

RESULTS

Using content analysis, responses to the survey indicate that most states provided guidance to OTPs in response to the revised federal regulations and the need to protect staff and patients. All respondents reported that their states permitted increased number of take-homes doses for existing patients (100 %) and most reported doing so for new admissions (69 %; N=29). Ninety-eight percent (98 %; N=41) reported permitting remote counseling for existing patients and 90 % (N=38) permitting this for new admissions. SOTAs reported providing guidance on staff safety, operational procedures, oversight, and reforming billing practices to align with new models of service delivery.

CONCLUSIONS

SOTAs generally reported that federal guidance increased patient access, engagement, and retention. Increased take-home flexibilities were viewed as important for expanding access and continuity of treatment, with the majority of SOTAs stating that the revised treatment practices (e.g., expansion of telehealth, flexible medication dispensing practices) were beneficial. These regulatory flexibilities, many believe, promoted the continuation of treatment and successful patient outcomes during the pandemic.

Gender differences in receipt of telehealth versus in person behavioral therapy, medication for opioid use disorder (MOUD), and 90-day MOUD retention during the pandemic: A retrospective veteran cohort study

BACKGROUND

COVID-19 significantly negatively impacted access to care among patients with opioid use disorder (OUD). The Veterans Health Administration (VHA) enacted policies to expand telehealth and medication for OUD (MOUD) during the public health emergency, which offset risk of treatment disruption. In this study, we evaluated gender differences in utilization of behavioral therapy in person and via telehealth, MOUD utilization, and achieving 90-day MOUD retention pre-post pandemic onset, given known gender differences in treatment utilization between men and women. Secondarily, we examined MOUD receipt and retention as a function of in-person vs. telehealth behavioral therapy received over time.

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between men and women veterans, pre- to post-pandemic onset (January 2019-February 2020 vs. March 2020-April 2021). Primary outcomes included receipt of behavioral therapy (in person or telehealth), number of appointments attended, any MOUD, and whether patients achieved 90-day MOUD retention post-induction.

RESULTS

Veterans with OUD were less likely to receive behavioral therapy post-pandemic onset, which was driven by marked decreases in in-person care; these effects were strongest among women. The odds of receiving MOUD also decreased pre- to post-pandemic onset, particularly among men. Receipt of or achieving 90-day MOUD retention was differentially related to receipt of behavioral therapy via in person vs. telehealth; telehealth was more strongly associated with these utilization indicators post-pandemic onset-an effect that was more pronounced for men.

CONCLUSION

The likelihood of receiving behavioral therapy and MOUD were lower during COVID-19 and varied by gender, with men being less likely to receive MOUD over time and women being less likely to receive in-person behavioral therapy. Behavioral therapy received via telehealth was generally associated with improved MOUD utilization compared to in-person behavioral therapy, but this was less true for women than for men regarding utilization of or achieving 90-day MOUD retention. In addition to the need for further telehealth expansion for veterans with OUD, more research should explore how to better engage men in MOUD treatment and improve adherence to MOUD among women engaged in behavioral therapy.

Substance Use Disorder Treatment Programs during a Health Crisis: Response to the COVID-19 Pandemic and Future Implications

Background: The COVID-19 pandemic rapidly changed how substance use disorder (SUD) treatment services are delivered. In this qualitative study, we examined what changes SUD treatment programs in Arkansas implemented in response to the pandemic, what factors influenced their ability to implement these changes, and their reflections, outlook, and future recommendations. Methods: Between May and August 2020, we conducted semi-structured phone interviews with 29 leaders at 21 SUD programs throughout Arkansas. Interview questions focused on what changes programs implemented in response to the pandemic, barriers and facilitators to implementation, and future outlook. Interviews were thematically analyzed. Results: Programs implemented similar infection control practices, including COVID-19 screening at entry, masks, hand hygiene, and social distancing. Residential programs discontinued outside visitations and capped admissions, and outpatient programs implemented telehealth services. Clients generally responded well to the changes, however many experienced difficulties (e.g., anxiety, lack of access to telehealth). While programs welcomed additional financial support (e.g., CARES act) and looser regulatory restrictions (e.g., telehealth use), many struggled economically due to lower demand and insufficient reimbursement. Programs varied in leadership and staff responses to the pandemic, and in their capacity to implement the changes (e.g., facilities, staffing). Finally, interviewees acknowledged they were unprepared for the pandemic and were uncertain about the future. Conclusions: The insights from the COVID-19 pandemic and SUD programs' responses helps researchers, policymakers and practitioners understand what has happened during the pandemic, how to prepare for future crises, and how to build more resilient SUD and public health systems.

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study

BACKGROUND

In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD).

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year.

RESULTS

Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics.

CONCLUSION

Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

The introduction of a novel formulation of buprenorphine into organized health systems

Background

Effective medications for opioid use disorder (MOUD) are underutilized. This exploratory study used real-world data to analyze US distribution patterns of buprenorphine extended-release (BUP-XR) within organized health systems (OHS), including the Veterans Health Administration (VHA), Indian Health Service (IHS), criminal justice system (CJS), and integrated delivery networks (IDNs).

Methods

National BUP-XR distribution data within each OHS were available from WNS Global Services and were evaluated from July 2019 through July 2020. BUP-XR distribution data by OHS subtype (VHA, IHS, CJS, IDN) and state were aggregated and reported.

Results

The total distribution of BUP-XR increased from 6,721 units in the second half of 2019 (H2'19) to 12,925 in the first half of 2020 (H1'20). OHS distribution increased from H2'19 to H1'20 in every subtype but was primarily driven by IDN distribution growth. IDNs accounted for 73% of total units in H2'19 and continued to grow in H1'20. In H1'20, IDNs accounted for 78%, VHA for 12%, CJS for 6%, and IHS for 4%. IDN distribution for BUP-XR increased from 4,911 to 10,100 units, showing the highest growth rate of 106% within all OHS subtypes. The states with the highest total BUP-XR distribution over the 12-month period were Massachusetts (4,534), Pennsylvania (3,773), and California (1,866).

Conclusions

Overall distribution of BUP-XR, as a treatment option for OUD, is increasing; however, access to MOUD varies greatly across OHS subtypes and geography. Identifying and overcoming barriers to appropriate MOUD use is critical in addressing the opioid crisis.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

"The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment

Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.

Telehealth-Based Delivery of Medication-Assisted Treatment for Opioid Use Disorder: a Critical Review of Recent Developments

PURPOSE OF REVIEW

Telehealth-delivered medication-assisted treatment for opioid use disorder (tele-MOUD) has received increased attention, with the intersection of the opioid epidemic and COVID-19 pandemic, but research on recent developments is scattered. We critically review recent literature on tele-MOUD and synthesize studies reporting primary data under four themes: clinical effectiveness, non-clinical effectiveness, perceptions, and regulatory considerations.

RECENT FINDINGS

Despite increasing publications, most failed to include long-term comprehensive assessments. Findings indicate favorable outcomes such as improvements in retention and abstinence rates, positive experiences, and improved feasibility with the relaxation of regulatory measures. With increased adoption, clinician and patient perceptions appeared largely positive. Negative findings, albeit minor, were primarily associated with workflow adaptation difficulties and limited access of underserved populations to technology and internet connection. Additional financial, logistical, outreach, and training support for clinicians, patients, and support staff is recommended, in addition to permanent evidence-based regulatory reforms, to scale and optimize tele-MOUD services. Comprehensive recommendations to overcome limitations are expanded therein.

Did drug use increase following COVID-19 relaxation of methadone take-out regulations? 2020 was a complicated year

Background

Relaxation of federal regulations for methadone take-out dosing during the COVID-19 pandemic is unprecedented. The impact of this change on drug use is unknown. This study explores the impact of the federal take-out variance on drug use in one urban opioid treatment program as measured by drug testing.

Methods

This study collected drug test results from 613 patients receiving methadone from July 2020, following COVID-19-related take-out dose adjustments, and July 2019 for comparison. Using a generalized linear mixed model, we computed the average estimated probability of a positive drug test for each year for each take-out phase. To isolate the effect of changing take-out, we removed the main effect of year, while retaining the main effect of take-out phase and the interaction between year and phase.

Results

The percent of drug tests positive for opiates, benzodiazepines, and methamphetamine was greater in July 2020 than in July 2019 (p < 0.001 for each), while the percent of tests negative for methadone increased (p < 0.001). Oxycodone, barbiturate, and cocaine positive tests remained stable. In a separate analysis of opioid and non-opioid test results, take-out phase was associated with both opioid and non-opioid positive results (p < 0.001, each outcome). The association of take-out phase with opioid and non-opioid positive results differed in the two years (year-by-phase interaction p < 0.025, each outcome). After removing the year main effect, the rate of positive tests was lower in 2020 for the smallest number of take-out doses, higher for a moderate number of take-out doses, and about the same for the highest number of take-out doses.

Conclusions

Positive opioid and non-opioid drug tests increased following the federal variance allowing more methadone take-out doses, but these findings cannot fully be attributed to alterations in the take-out schedule.

Medication for Opioid Use Disorder Service Provision and Telephone Counseling: A Concurrent Mixed-Methods Approach

Using quantitative and qualitative evidence, this study triangulates counselors' perspectives on the use of telemedicine in the context of Opioid Use Disorder (OUD) treatment. A concurrent mixed-methods design examined counselors' experiences with telephone counseling during the COVID-19 pandemic. N = 42 counselors who provided OUD counseling services completed a close-ended, quantitative survey examining their experiences in addressing clients' anxiety, depression, anger, substance use, therapeutic relationship, and substance use recovery using telephone counseling. The survey also assessed comfort, convenience, and satisfaction with telephone counseling. Counselors also completed open-ended responses examining satisfaction, convenience, relationship with patients, substance use, and general feedback with telephone counseling. The synthesis of quantitative and qualitative evidence indicated that a majority of counselors had positive experiences with using telephone counseling to provide services to clients undergoing OUD treatment. Convenience, greater access to clients, and flexibility were among the reasons cited for their positive experience. However, counselors also expressed that the telephone counseling was impersonal, and that some clients may have difficulties accessing appropriate technology for telehealth adoption. Findings suggest that further research with counselors is needed to identify the key elements of an effective integration of telephone counseling with traditional in-person treatment approaches in the post-pandemic era.

Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond

Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management. The learning objectives for this conference proceedings were: Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.