Perspectives of opioid use disorder treatment providers during COVID-19: Adapting to flexibilities and sustaining reforms

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland

BACKGROUND

Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs.

METHODS

People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services.

RESULTS

The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors).

CONCLUSIONS

Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Patient and Clinician Experiences with the Implementation of Telemedicine and Related Adaptations in Office-Based Buprenorphine Treatment During the COVID-19 Pandemic: A Qualitative Study

Background

Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, likely influencing patients' access to and retention in care. In response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. To date, relatively few prior studies have combined patient and clinician perspectives to examine the implementation of telemedicine and related care adaptations, particularly in safety-net settings.

Methods

Qualitative methods were used to explore clinician and patient experiences with telemedicine in an office-based buprenorphine treatment clinic affiliated with an urban safety-net hospital. From this clinic, we interviewed 25 patients and 16 clinicians (including prescribers and non-prescribers) to understand how telemedicine impacted treatment quality and engagement in care, as well as preferences for using telemedicine moving forward.

Results

Five themes regarding the implementation of telemedicine and other COVID-19-related care adaptations arose from patient and clinician perspectives: 1) telemedicine integration precipitated openness to more flexibility in care practices, 2) concerns regarding telemedicine-related adaptations centered around safety and accountability, 3) telemedicine encounters required rapport and trust between patients and clinicians to facilitate open communication, 4) safety-net patient populations experienced unique challenges when using telemedicine, particularly in terms of the technology required and the need for privacy, and 5) there is an important role for telemedicine in office-based buprenorphine treatment moving forward, primarily through its use in hybrid models of care.

Conclusions

Telemedicine implementation within office-based buprenorphine treatment has the potential to improve patients' engagement in care; however, our findings emphasize the need for tailored approaches to implementing telemedicine in office-based buprenorphine treatment, particularly within safety-net settings. Overall, this study supports the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency.

Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19

Introduction

This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona.

Methods

A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time.

Results

Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey).

Conclusions

Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

Rural and urban clinician views on COVID-19's impact on substance use treatment for individuals on community supervision in Kentucky

BACKGROUND

The COVID-19 pandemic produced system-level changes within the criminal legal system and community-based substance use disorder (SUD) treatment system with impacts on recovery efforts. This study examines rural and urban clinicians' perspectives of COVID-19 on SUD treatment delivery for people on community supervision.

METHODS

Virtual qualitative interviews were conducted between April and October 2020 with 25 community supervision clinicians employed by Kentucky's Department of Corrections (DOC), who conduct assessments and facilitate community-based treatment linkages for individuals on probation or parole. Transcripts were analyzed in NVivo using directed content analysis methods.

RESULTS

Clinicians were predominantly white (92%) and female (88%) with an average of over 9 years working in the SUD treatment field and 4.6 years in their current job. Four COVID-19 themes were identified by both rural and urban clinicians including: (1) telehealth increases the modes of communication, but (2) also creates paperwork and technological challenges, (3) telehealth requires more effort for inter/intra-agency collaboration, and (4) it limits client information (e.g., no urine drug screens). Two additional rural-specific themes emerged related to COVID-19: (5) increasing telehealth options removes SUD treatment transportation barriers and (6) requires flexibility with programmatic requirements for rural clients.

CONCLUSIONS

Findings indicate the need for community-based SUD treatment providers approved or contracted by DOC to support and train clients to access technology and improve information-sharing with community supervision officers. A positive lesson learned from COVID-19 transitions was a reduction in costly travel for rural clients, allowing for greater engagement and treatment adherence. Telehealth should continue to be included within the SUD continuum of care, especially to promote equitable services for individuals from rural areas.

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.

North Carolina Medicaid System Perspectives on Substance Use Disorder Treatment Policy Changes During the COVID-19 Pandemic

OBJECTIVE

This study aimed to describe perspectives from stakeholders involved in the Medicaid system in North Carolina regarding substance use disorder (SUD) treatment policy changes during the coronavirus disease 2019 pandemic.

METHODS

We conducted semistructured interviews in early 2022 with state agency representatives, Medicaid managed care organizations, and Medicaid providers (n = 22) as well as 3 focus groups of Medicaid beneficiaries with SUD (n = 14). Interviews and focus groups focused on 4 topics: policies, meeting needs during COVID, demand for SUD services, and staffing.

RESULTS

Overall, policy changes, such as telehealth and take-home methadone, were considered beneficial, with participants displaying substantial support for both policies. Shifting demand for services, staffing shortages, and technology barriers presented significant challenges. Innovative benefits and services were used to adapt to these challenges, including the provision of digital devices and data plans to improve access to telehealth.

CONCLUSIONS

Perspectives from Medicaid stakeholders, including state organizations to beneficiaries, support the continuation of SUD policy changes that occurred. Staffing shortages remain a substantial barrier. Based on the participants' positive responses to the SUD policy changes made during the coronavirus disease 2019 pandemic, such as take-home methadone and telehealth initiation of buprenorphine, these changes should be continued. Additional steps are needed to ensure payment parity for telehealth services.

Patient Engagement in and Adaptations to Delivery of Outpatient Care for Opioid Use Disorder During the COVID-19 Pandemic

OBJECTIVE

The authors investigated adaptations to outpatient care delivery and changes in treatment demand and engagement among patients receiving medications for opioid use disorder (MOUD) in the months after the declaration of the COVID-19 public health emergency in 2020.

METHODS

Data were collected through an online survey (June-November 2020) of outpatient MOUD prescribers. The survey obtained information on outpatient practices' adaptations to MOUD treatment and urine drug screening (UDS) and elicited provider views on the effects of the COVID-19 pandemic on patient demand for, and engagement in, treatment. Multivariable regression analyses were used to examine associations among practice characteristics, patient engagement, and service adaptations.

RESULTS

Of 516 respondents, 74% reported adaptations to MOUD delivery during the pandemic. Most respondents implemented virtual visits for initial (67%) and follow-up (77%) contacts. Prescribers of buprenorphine were more likely than those who did not prescribe the medication to report MOUD adaptations. Among respondents reporting any MOUD adaptation, 77% made adaptations to their UDS practices. Among 513 respondents who answered COVID-19-related questions, 89% reported that the pandemic had affected the treatment and engagement of their patients. Of these respondents, 30% reported increased difficulty with patient engagement, and 45% reported that their patients preferred virtual visits during this period, whereas 18% endorsed patient preference for in-person visits.

CONCLUSIONS

Telehealth and federal regulatory easements in response to the COVID-19 pandemic enabled providers to continue treating patients for opioid use disorder in 2020. The results suggest that care adaptations and changes in patient demand and engagement were common in the practices surveyed.

Modality and terminology changes for behavioral health service delivery during the COVID-19 pandemic: a systematic review

Introduction

The COVID-19 pandemic prompted healthcare professionals to implement service delivery adaptations to remain in compliance with safety regulations. Though many adaptations in service delivery were reported throughout the literature, a wide variety of terminology and definitions were used.

Methods

To address this, we conducted a PRISMA review to identify service delivery adaptations across behavioral healthcare services in the United States from March 2020 to May 2022 and to identify variations in terminology used to describe these adaptations. We identified 445 initial articles for our review across eight databases using predetermined keywords. Using a two-round screening process, authors used a team approach to identify the most appropriate articles for this review.

Results

Our results suggested that a total of 14 different terms were used to describe service modality changes, with the most frequent term being telehealth (63%). Each term found in our review and the frequency of use across identified articles is described in detail.

Discussion

Implications of this review such as understanding modality changes during the COVID-19 pandemic and beyond are discussed. Our findings illustrate the importance of standardizing terminology to enhance communication and understanding among professionals.

Loss, liberation, and agency: Patient experiences of methadone treatment at opioid treatment programs during the COVID-19 pandemic

BACKGROUND

Despite its safety and effectiveness, methadone treatment for opioid use disorder (OUD) remains highly stigmatized, and stringent opioid treatment program (OTP) attendance requirements create barriers to retention for many patients. The COVID-19 pandemic prompted a shift in federal regulations governing methadone, including a blanket exemption permitting increased take-home doses of methadone. We studied the impact of these changes upon established patients' experiences of OTP care.

METHOD

We conducted semi-structured qualitative interviews with 18 OTP patients who met our criteria of having established OTP care (i.e., enrolled at the OTP for at least 12 weeks) and were administered methadone three to six days weekly prior to the March 2020 blanket exemption. Interviews centered on how COVID-19 had affected their experiences of receiving treatment at an OTP.

RESULTS

We identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic. Participants described mourning therapeutic OTP relationships and structure (1. loss), yet feeling more satisfaction with fewer in-person OTP visits (2. liberation), and appreciating more opportunities to self-direct their OUD care (3. agency).

DISCUSSION

Structural changes made to OTP care early in the COVID-19 pandemic resulted in loss of community and structure. Increasing the availability of take-home methadone also improved patient experience and sense of agency. Our findings join a diverse body of converging evidence in support of policy changes allowing for more flexible dosing and individualized OTP care.

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.

Opioid use disorder: current trends and potential treatments

Opioid use disorder (OUD) is a major public health threat, contributing to morbidity and mortality from addiction, overdose, and related medical conditions. Despite our increasing knowledge about the pathophysiology and existing medical treatments of OUD, it has remained a relapsing and remitting disorder for decades, with rising deaths from overdoses, rather than declining. The COVID-19 pandemic has accelerated the increase in overall substance use and interrupted access to treatment. If increased naloxone access, more buprenorphine prescribers, greater access to treatment, enhanced reimbursement, less stigma and various harm reduction strategies were effective for OUD, overdose deaths would not be at an all-time high. Different prevention and treatment approaches are needed to reverse the concerning trend in OUD. This article will review the recent trends and limitations on existing medications for OUD and briefly review novel approaches to treatment that have the potential to be more durable and effective than existing medications. The focus will be on promising interventional treatments, psychedelics, neuroimmune, neutraceutical, and electromagnetic therapies. At different phases of investigation and FDA approval, these novel approaches have the potential to not just reduce overdoses and deaths, but attenuate OUD, as well as address existing comorbid disorders.

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.

Impact of COVID-19-related methadone regulatory flexibilities: views of state opioid treatment authorities and program staff

BACKGROUND

During the COVID-19 pandemic, federal regulations in the USA for methadone treatment of opioid use disorder (OUD) were temporarily revised to reduce clinic crowding and promote access to treatment.

METHODS

As part of a study seeking to implement interim methadone without routine counseling to hasten treatment access in Opioid Treatment Programs with admission delays, semi-structured qualitative interviews were conducted via Zoom with participating staff (N = 11) in six OTPs and their State Opioid Treatment Authorities (SOTAs; N = 5) responsible for overseeing the OTPs' federal regulatory compliance. Participants discussed their views on the response of OTPs in their states to the pandemic and the impact of the COVID-related regulatory flexibilities on staff, established patients, and new program applicants. Interviews were audio recorded, transcribed, and a content analysis was conducted using ATLAS.ti.

RESULTS

All SOTAs requested the blanket take-home exemption and supported the use of telehealth for counseling. Participants noted that these changes were more beneficial for established patients than program applicants. Established patients were able to obtain a greater number of take-homes and attend individual counseling remotely. Patients with limited resources had greater difficulty or were unable to access remote counseling. The convenience of intake through telehealth did not extend to new program applicants because the admission physical exam requirement was not waived.

CONCLUSIONS

The experienced reflections of SOTAs and OTP providers on methadone practice changes during the COVID-19 pandemic offer insights on SAMHSA's proposed revisions to its OTP regulations. Trial registration Clinicaltrials.gov # NCT04188977.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids

Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID-19 pandemic permitted increased take-home doses beginning March 2020.Objectives: We assessed the impact of this exemption on opioid use.Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids.Results: In the pre- vs. post-COVID-19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID-19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses.Conclusions: Although take-home doses post-COVID-19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.

Trajectories of drug treatment and illicit opioid use in the AIDS Linked to the IntraVenous Experience cohort, 2014-2019

BACKGROUND

Medication for opioid use disorder (MOUD) is an effective intervention to combat opioid use disorder and overdose, yet there is limited understanding of engagement in treatment over time in the community, contextualized by ongoing substance use. We aimed to identify concurrent trajectories of methadone prescriptions, buprenorphine prescriptions, and illicit opioid use among older adults with a history of injection drug use.

METHODS

We used data on 887 participants from the AIDS Linked to the IntraVenous Experience cohort, who were engaged in the study in 2013 and attended ≥1 visit during follow-up (2014-2019). Outcomes were self-reported MOUD prescription and illicit opioid use in the last 6 months. To identify concurrent trajectories in all 3 outcomes, we used group-based multi-trajectory modeling. We examined participant characteristics, including sociodemographics, HIV status, and other substance use, overall and by cluster.

RESULTS

We identified 4 trajectory clusters: (1) no MOUD and no illicit opioid use (43%); (2) buprenorphine and some illicit opioid use (11%); (3) methadone and no illicit opioid use (28%); and (4) some methadone and illicit opioid use (18%). While prevalence of each outcome was stable across time, transitions on/off treatment or on/off illicit opioid use occurred, with the rate of transition varying by cluster. The rate of transition was highest in Cluster 3 (0.74/person-year) and lowest in Cluster 1 (0.18/person-year). We saw differences in participant characteristics by cluster, including that the buprenorphine cluster had the highest proportion of people with HIV and participants who identified as non-Hispanic Black.

CONCLUSIONS

Most participants had discontinued illicit opioid use and were also not accessing MOUD. Trajectories defined by engagement with buprenorphine or methadone had distinct sociodemographic and behavioral characteristics, indicating that tailored interventions to expand access to both types of treatment are likely needed to reduce harms associated with untreated opioid use disorder.

Pandemic telehealth flexibilities for buprenorphine treatment: a synthesis of evidence and policy implications for expanding opioid use disorder care in the United States

Buprenorphine is a highly effective treatment for opioid use disorder (OUD) and a critical tool for addressing the worsening US overdose crisis. However, multiple barriers to treatment-including stringent federal regulations-have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 public health emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the public health emergency has been set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this narrative review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on the uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment, and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue nonrestricted use of telehealth for buprenorphine initiation.

Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic necessitated changes in opioid use disorder care. Little is known about COVID-19's impact on general healthcare clinicians' experiences providing medication treatment for opioid use disorder (MOUD). This qualitative evaluation assessed clinicians' beliefs about and experiences delivering MOUD in general healthcare clinics during COVID-19.

METHODS

Individual semistructured interviews were conducted May through December 2020 with clinicians participating in a Department of Veterans Affairs initiative to implement MOUD in general healthcare clinics. Participants included 30 clinicians from 21 clinics (9 primary care, 10 pain, and 2 mental health). Interviews were analyzed using thematic analysis.

RESULTS

The following 4 themes were identified: overall impact of the pandemic on MOUD care and patient well-being, features of MOUD care impacted, MOUD care delivery, and continuance of telehealth for MOUD care. Clinicians reported a rapid shift to telehealth care, resulting in few changes to patient assessments, MOUD initiations, and access to and quality of care. Although technological challenges were noted, clinicians highlighted positive experiences, including treatment destigmatization, more timely visits, and insight into patients' environments. Such changes resulted in more relaxed clinical interactions and improved clinic efficiency. Clinicians reported a preference for in-person and telehealth hybrid care models.

CONCLUSIONS

After the quick shift to telehealth-based MOUD delivery, general healthcare clinicians reported few impacts on quality of care and highlighted several benefits that may address common barriers to MOUD care. Evaluations of in-person and telehealth hybrid care models, clinical outcomes, equity, and patient perspectives are needed to inform MOUD services moving forward.

Clinics Optimizing MEthadone Take-homes for opioid use disorder (COMET): Protocol for a stepped-wedge randomized trial to facilitate clinic level changes

INTRODUCTION

Regulatory changes made during the COVID-19 public health emergency (PHE) that relaxed criteria for take-home dosing (THD) of methadone offer an opportunity to improve quality of care with a lifesaving treatment. There is a pressing need for research to study the long-term effects of the new PHE THD rules and to test data-driven interventions to promote more effective adoption by opioid treatment programs (OTPs). We propose a two-phase project to develop and test a multidimensional intervention for OTPs that leverages information from large State administrative data.

METHODS AND ANALYSIS

We propose a two-phased project to develop then test a multidimensional OTP intervention to address clinical decision making, regulatory confusion, legal liability concerns, capacity for clinical practice change, and financial barriers to THD. The intervention will include OTP THD specific dashboards drawn from multiple State databases. The approach will be informed by the Health Equity Implementation Framework (HEIF). In phase 1, we will employ an explanatory sequential mixed methods design to combine analysis of large state administrative databases-Medicaid, treatment registry, THD reporting-with qualitative interviews to develop and refine the intervention. In phase 2, we will conduct a stepped-wedge trial over three years with 36 OTPs randomized to 6 cohorts of a six-month clinic-level intervention. The trial will test intervention effects on OTP-level implementation outcomes and patient outcomes (1) THD use; 2) retention in care; and 3) adverse healthcare events). We will specifically examine intervention effects for Black and Latinx clients. A concurrent triangulation mixed methods design will be used: quantitative and qualitative data collection will occur concurrently and results will be integrated after analysis of each. We will employ generalized linear mixed models (GLMMs) in the analysis of stepped-wedge trials. The primary outcome will be weekly or greater THD. The semi-structured interviews will be transcribed and analyzed with Dedoose to identify key facilitators, barriers, and experiences according to HEIF constructs using directed content analysis.

DISCUSSION

This multi-phase, embedded mixed methods project addresses a critical need to support long-term practice changes in methadone treatment for opioid use disorder following systemic changes emerging from the PHE-particularly for Black and Latinx individuals with opioid use disorder. By combining findings from analyses of large administrative data with lessons gleaned from qualitative interviews of OTPs that were flexible with THD and those that were not, we will build and test the intervention to coach clinics to increase flexibility with THD. The findings will inform policy at the local and national level.

Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access

Importance

Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization.

Objective

To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access.

Design, Setting, and Participants

This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021.

Exposure

Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence.

Main Outcomes and Measures

Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty.

Results

Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation.

Conclusions and Relevance

In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.

Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care

BACKGROUND

Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.

OBJECTIVES

To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity.

RESEARCH DESIGN

Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021).

SUBJECTS

Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633).

MEASURES

OUD medication continuity: months with any use, days of continuous use, and proportion of days covered.

RESULTS

5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35].

CONCLUSIONS

Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.

Pandemic telehealth flexibilities for buprenorphine treatment: A synthesis of evidence and policy implications for expanding opioid use disorder care in the U.S

Buprenorphine is a highly effective treatment for opioid use disorder and a critical tool for addressing the worsening U.S. overdose crisis. However, multiple barriers to treatment - including stringent federal regulations - have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 Public Health Emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the Public Health Emergency is set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue non-restricted use of telehealth for buprenorphine initiation.

Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey

BACKGROUND

During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19.

METHODS

From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020).

RESULTS

During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19.

CONCLUSIONS

During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.

Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy

As the USA faces a worsening overdose crisis, improving access to evidence-based treatment for opioid use disorder (OUD) remains a policy priority. Federal regulatory changes in response to the COVID-19 pandemic substantially expanded flexibilities on take-home doses for methadone treatment for OUD. These changes have fuelled questions about the effect of new regulations on OUD outcomes and the potential effect on health of permanently integrating these flexibilities into treatment policy going forward. To aide US policy makers as they consider implementing permanent methadone regulatory changes, we conducted a review synthesising peer-reviewed research on the effect of the flexibilities of methadone take-home policies introduced during COVID-19 on methadone programme operations, OUD patient and provider experiences, and patient health outcomes. We interpret the findings in the context of the federal rule-making process and discuss avenues by which these findings can be incorporated and implemented into US policies on substance use treatment going forward.

Examination of methadone involved overdoses during the COVID-19 pandemic

BACKGROUND

The US opioid overdose epidemic continues to escalate. The restrictions on methadone availability including take-home dosing were loosened during the COVID-19 pandemic although there have been concerns about the high street value of diverted methadone. This report examined how fatal overdoses involving methadone have changed over the past two-decades including during the pandemic.

METHODS

The CDC's Wide-ranging Online Data for Epidemiologic Research (WONDER) was used to find the unintentional methadone related overdose death rate from 1999 to 2020. Unintentional methadone deaths were defined using the ICD X40-44 codes with only data for methadone (T40.3). Data from the DEA's Automation of Reports and Consolidated Orders System (ARCOS) on methadone overall use, opioid treatment programs use, and pain management use was gathered for all states for 2020 and corrected for population.

RESULTS

There have been dynamic changes over the past two-decades in methadone overdoses. Overdoses increased from 1999 (0.9/million) to 2007 (15.9) and declined until 2019 (6.5). Overdoses in 2020 (9.6) were 48.1% higher than in 2019 (t(50) = 3.05, p < .005). The state level correlations between overall methadone use (r(49) = +0.75, p < .001), and opioid treatment program use (r(49) = +0.77, p < .001) with overdoses were positive, strong, and statistically significant. However, methadone use for pain treatment was not associated with methadone overdoses (r(49) = -0.08).

CONCLUSIONS

Overdoses involving methadone significantly increased by 48.1% in 2020 relative to 2019. Policy changes that were implemented following the COVID-19 pandemic involving methadone take-homes may warrant further study before they are made permanent.

Patient experiences of COVID-19-induced changes to methadone treatment in a large community-based opioid treatment program in Baltimore

INTRODUCTION

Following the March 2020 federal declaration of a COVID-19 public health emergency, in line with recommendations for social distancing and decreased congregation, federal agencies issued sweeping regulation changes to facilitate access to medications for opioid use disorder (MOUD) treatment. These changes allowed patients new to treatment to receive multiple days of take-home medications (THM) and to use remote technology for treatment encounters-allowances that previously had been reserved exclusively for "stable" patients who met minimum adherence and time-in-treatment criteria. The impact of these changes on low-income, minoritized patients (frequently the largest recipients of opioid treatment program [OTP]-based addiction care), however, is not well characterized. We aimed to explore the experiences of patients who were enrolled in treatment prior to COVID-19 OTP regulation changes, with the goal of understanding patients' perceptions of the impact of these changes on treatment.

METHODS

This study included semistructured, qualitative interviews with 28 patients. We used a purposeful sampling method to recruit individuals who were active in treatment just before COVID-19-related policy changes went into effect, and who were still in treatment several months later. To ensure a diverse array of perspectives, we interviewed individuals who either had or had not experienced challenges with methadone medication adherence from 3/24/21 to 6/8/21, approximately 12-15 months following the onset of COVID-19. Interviews were transcribed and coded using thematic analysis.

RESULTS

Participants were majority male (57 %), Black/African American (57 %), with a mean age of 50.1 (SD = 9.3). Fifty percent received THM prior to COVID-19, which increased to 93 % during the pandemic. COVID-19 program changes had mixed effects on treatment and recovery experiences. Themes identified convenience, safety, and employment as reasons for preferring THM. Challenges included difficulty with managing/storing medications, experiencing isolation, and concern about relapse. Furthermore, some participants reported that telebehavioral health encounters felt less personal.

CONCLUSIONS

Policymakers should consider patients' perspectives to foster a more patient-centered approach to methadone dosing that is safe, flexible, and accommodating to a diverse array of patients' needs. Additionally, technical support should be provided to OTPs to ensure interpersonal connections are maintained in the patient-provider relationship beyond the pandemic.

The development and validation of the pandemic medication-assisted treatment questionnaire for the assessment of pandemic crises impact on medication management and administration for patients with opioid use disorders

Pandemic and the globally applied restriction measures mainly affect vulnerable population groups, such as patients with opioid use disorders. Towards inhibiting SARS-Cov-2 spread, the medication-assisted treatment (MAT) programs follow strategies targeting the reduction of in-person psychosocial interventions and an increase of take-home doses. However, there is no available instrument to examine the impact of such modifications on diverse health aspects of patients under MAT. The aim of this study was to develop and validate the PANdemic Medication-Assisted Treatment Questionnaire (PANMAT/Q) to address the pandemic effect on the management and administration of MAT. In total, 463 patients under ΜΑΤ participated. Our findings indicate that PANMAT/Q has been successfully validated exerting reliability and validity. It can be completed within approximately 5 min, and its implementation in research settings is advocated. PANMAT/Q could serve as a useful tool to identify the needs of patients under MAT being at high risk of relapse and overdose.

Ethical Dilemmas Facing Substance Use Counselors During the COVID-19 Pandemic

Introduction

During the COVID-19 pandemic, substance use disorder (SUD) treatment settings experienced several abrupt changes, including decreased admissions, reduction in services, and modified requirements for medication for substance use disorder. While these changes were implemented to facilitate the maintenance of important treatment options, the ethical consequences of such changes remained unknown. The current study aimed to explore ethical issues related to COVID-19-related changes reported by counselors in SUD treatment facilities.

Method

From May to August 2020, we conducted 60 to 90 minutes in-depth interviews with 18 front-line staff in 1 residential and 1 outpatient treatment program, exploring issues drawn from the ethical principles of the national organization representing SUD counselors. Counselors volunteered to participate via phone or email, and participation was confidential. Interviews were conducted via videoconferencing. Topics included day-to-day experiences of ethical dilemmas in the workplace, particularly during the COVID-19 era. Interviews were recorded, transcribed, and checked for accuracy and a trained team of analysts then coded transcripts using thematic analysis.

Results

As a result of the COVID-19 pandemic, SUD treatment programs quickly modified procedures to adhere to public health mandates while also continuing to offer care to clients. SUD counselors reported several ways their programs adapted new and creative procedures to reduce the risk of COVID-19 transmission. SUD counselors also identified several novel ethical dilemmas that occurred during the COVID-19 pandemic, often resulting from the counselor balancing the needs for responding to public health mandates with providing services to clients. There were several ways that COVID-19 related changes resulted in therapeutic challenges for some clients, and the SUD counselors highlighted ways that changes resulted in more flexible services for other clients.

Conclusions

This study highlights the quick response to COVID-19 that occurred within SUD treatment. While these changes resulted in novel ethical dilemmas, they also offered more flexible and client-centered approaches to treatment.

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.

Nutzen und zukünftige Relevanz der Corona-bedingt befristeten Änderungen in der Substitution in Deutschland

Ziel der Studie Die COVID-19-Pandmie hat die Substitutionsbehandlung vor große Herausforderungen gestellt. An der oft als restriktiv angesehenen Rechtsgrundlage (BtM-VV) wurden befristete Änderungen vorgenommen, um Behandler:innen mehr Spielraum bei der Gestaltung der Therapien zu gewährleisten. Weitreichende Flexibilisierungen wurden in den Bereichen Take-Home-Verschreibungen, konsiliarische Behandlung und Delegation vorgenommen. Zusätzlich wurden neue Vergütungsmöglichkeiten im Einheitlichen Bewertungsmaßstab (EBM) geschaffen. Durch leitfadengestützte Interviews mit substituierenden Ärzt:innen wurde eine Evaluation der befristeten BtM-VV- und EBM- Änderungen vorgenommen.

Methodik Im Jahr 2021 wurden 16 qualitative Interviews mit substituierenden Ärzt:innen aus zehn verschiedenen Bundesländern in Deutschland geführt. Die Interviewten wurden zu ihren Erfahrungen mit den Corona-bedingt befristeten BtM-VV- und EBM-Änderungen befragt. Im Fokus stand dabei, ob die temporären Flexibilitäten dauerhaft in die post-pandemische Praxis übernommen werden sollten. Der Interviewleitfaden enthielt zusätzlich Fragen zu strukturellen Barrieren, Nachwuchsmangel und Stigmatisierung.

Ergebnisse Zur Kontaktreduzierung verlängerte die Mehrheit der Ärzt:innen Take-Home-Rezepte. In Folge machte nur eine befragte Person ausschließlich negative Erfahrungen. Insgesamt berichteten die Ärzt:innen über keine und/oder positive Veränderungen im Therapieverlauf. Behandler:innen nutzten die meisten der befristeten Rechts- und Vergütungsänderungen in der Behandlungsgestaltung. Sie sprachen sich überwiegend für eine Übernahme der befristeten Regelungen in den post-pandemisch Regelbetrieb aus. Kontrovers wurden die Änderungen bezüglich der Aufhebung der Kapazitätsgrenze bei der Konsiliarregelung und der erweiterten Delegation diskutiert.

Schlussfolgerung Die Ergebnisse sprechen für die Übernahme der befristeten BtM-VV- und EBM-Änderungen in den post-pandemischen Regelbetrieb. Die Flexibilisierungen erleichtern die Anpassung der Therapie an individuelle Umstände der Behandler:innen und Patient:innen. Dies könnte dazu beitragen, die derzeitigen Versorgungsengpässe zu entschärfen und mehr Menschen mit Opioid-Abhängigkeit eine qualitativ hochwertige Substitutionstherapie anbieten zu können. Eine Untersuchung und Beseitigung struktureller Barrieren darf bei der Ein- bzw. Fortführung erweiterter Handlungsspielräume nicht vergessen werden. Da gesetzliche Flexibilisierungen zwangsläufig mehr Verantwortung auf die einzelnen Ärzt:innen übertragen, sollte eine verstärkte Unterstützung durch Schulungen und Vernetzung angeboten werden.

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

BACKGROUND

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

METHODS

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

RESULTS

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

CONCLUSION

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

Nothing really changed: Arizona patient experience of methadone and buprenorphine access during COVID

Objective

To understand patient experience of federal regulatory changes governing methadone and buprenorphine (MOUD) access in Arizona during the COVID-19 pandemic.

Methods

This community-based participatory and action research study involved one-hour, audio-recorded field interviews conducted with 131 people who used methadone and/or buprenorphine to address opioid use disorder at some point during COVID (January 1, 2020- March 31, 2021) in Arizona. Transcribed data were analyzed using a priori codes focused on federally recommended flexibilities governing MOUD access. Data were quantitated to investigate associations with COVID risk and services access.

Results

Telehealth was reported by 71.0% of participants, but the majority were required to come to the clinic to attend video appointments with an offsite provider. Risk for severe COVID outcomes was reported by 40.5% of the sample. Thirty-eight percent of the sample and 39.7% of methadone patients were required to be at the clinic daily to get medication and 47.6% were at high risk for COVID severe outcomes. About half (54.2%) of methadone patients indicated that some form of multi-day take home dosing was offered at their clinic, and 45.8% were offered an extra day or two of multi-day doses; but no participants received the federally allowed 14- or 28-day methadone take-home doses for unstable and stable patients respectively. All participants expressed that daily clinic visits interrupted their work and home lives and desired more take-home dosing and home delivery options.

Conclusions

MOUD patients in Arizona were not offered many of the federally allowed flexibilities for access that were designed to reduce their need to be at the clinic. To understand the impact of these recommended treatment changes in Arizona, and other states where they were not well implemented, federal and state regulators must mandate these changes and support MOUD providers to implement them.

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic prompted policy changes to allow increased telehealth delivery of buprenorphine, a potentially lifesaving medication for opioid use disorder (OUD). It is unclear how characteristics of patients who access different treatment modalities (in-person vs telehealth, video vs telephone) vary, and whether modality is associated with retention-a key indicator of care quality.

OBJECTIVES

To compare patient characteristics across receipt of different treatment modalities and to assess whether modality was associated with retention during the year following COVID-19-related policy changes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted in the national Veterans Health Administration. Participants included patients who received buprenorphine for OUD during March 23, 2020, to March 22, 2021. Analyses examining retention were stratified by buprenorphine initiation time (year following COVID-19-related changes; prior to COVID-19-related changes).

EXPOSURES

Patient characteristics; treatment modality (at least 1 video visit, at least 1 telephone visit but no video, only in-person).

MAIN OUTCOMES AND MEASURES

Treatment modality; 90-day retention.

RESULTS

Among 17 182 patients, 7094 (41.3%) were aged 30 to 44 years and 6251 (36.4%) were aged 45 to 64 years; 15 835 (92.2%) were male, 14 085 (82.0%) were White, and 16 292 (94.8%) were non-Hispanic; 6547 (38.1%) had at least 1 video visit, 8524 (49.6%) had at least 1 telephone visit but no video visit, and 2111 (12.3%) had only in-person visits. Patients who were younger, male, Black, unknown race, Hispanic, non-service connected, or had specific mental health/substance use comorbidities were less likely to receive any telehealth. Among patients who received telehealth, those who were older, male, Black, non-service connected, or experiencing homelessness and/or housing instability were less likely to have video visits. Retention was significantly higher for patients with telehealth compared with only in-person visits regardless of initiation time (for initiated in year following COVID-19-related changes: adjusted odds ratio [aOR], 1.31; 95% CI, 1.12-1.53; for initiated prior to COVID-19-related changes: aOR, 1.23; 95% CI, 1.08-1.39). Among patients with telehealth, higher retention was observed in those with video visits compared with only telephone for patients who initiated in the year following COVID-19 (aOR, 1.47; 95% CI, 1.26-1.71).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, many patients accessed buprenorphine via telephone and some were less likely to have any video visits. These findings suggest that discontinuing or reducing telephone access may disrupt treatment for many patients, particularly groups with access disparities such as Black patients and those experiencing homelessness. Telehealth was associated with increased retention for both new and continuing patients.

Opioid Use Disorder and COVID-19: Treatment and Recovery Factors among Vulnerable Populations at the Intersection of Two U.S. Epidemics

Social inequities made some sociodemographic groups - including those of older age, minoritized race/ethnicity, and low socioeconomic status - disproportionately vulnerable to morbidity and mortality associated with the opioid epidemic and COVID-19 pandemic. Given shared vulnerability to these public health crises, it is critical to understand how COVID-19 impacts substance use disorder (SUD) treatment and recovery among people with these characteristics. The current study examined COVID-19's perceived impact on treatment factors and psychosocial outcomes by sociodemographic vulnerability. Patients receiving SUD treatment with a history of opioid misuse were recruited. Participants completed self-report questionnaires regarding the impact of COVID-19 on treatment indicators and mood and substance use symptoms. Most participants reported that COVID-19 decreased their treatment access and quality. There were no sociodemographic differences in treatment factors. Those with high sociodemographic vulnerability reported greater pandemic-related increases in depression and demonstrated greater mood symptoms. Post-hoc analyses demonstrated that unmet basic needs were significantly associated with lower treatment access and quality, greater mood symptoms, and higher substance use. Findings suggest pandemic-related stressors and barriers affected those across the sociodemographic spectrum. Treatment systems must address socioeconomic barriers to care exacerbated by the pandemic and bolster integrated treatment options for opioid use and mood disorders.

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.

CYP2D6 phenotypes and opioid metabolism: the path to personalized analgesia

INTRODUCTION

Opioids play a fundamental role in chronic pain, especially considering when 1 of 5 Europeans adults, even more in older females, suffer from it. However, half of them do not reach an adequate pain relief. Could pharmacogenomics help to choose the most appropriate analgesic drug?

AREAS COVERED

The objective of the present narrative review was to assess the influence of cytochrome P450 2D6 (CYP2D6) phenotypes on pain relief, analgesic tolerability, and potential opioid misuse. Until December 2021, a literature search was conducted through the MEDLINE, PubMed database, including papers from the last 10 years. CYP2D6 plays a major role in metabolism that directly impacts on opioid (tramadol, codeine, or oxycodone) concentration with differences between sexes, with a female trend toward poorer pain control. In fact, CYP2D6 gene variants are the most actionable to be translated into clinical practice according to regulatory drug agencies and international guidelines.

EXPERT OPINION

CYP2D6 genotype can influence opioids' pharmacokinetics, effectiveness, side effects, and average opioid dose. This knowledge needs to be incorporated in pain management. Environmental factors, psychological together with genetic factors, under a sex perspective, must be considered when you are selecting the most personalized pain therapy for your patients.

Attitudes toward Medication for Opioid Use Disorder among Substance Use Treatment Providers

Background: Provider attitudes can be a powerful reinforcer of stigma toward medication for opioid use disorder (MOUD). This study examines attitudes toward MOUD among substance use treatment providers and identifies personal and professional characteristics associated with more positive attitudes. Methods: Treatment providers (N = 570) working at publicly-funded substance use programs in Michigan self-administered a web-based survey (November 2020 through July 2021), reporting their socio-demographics, professional experience, and attitudes toward MOUD. Linear regression was used to identify factors associated with general attitudes toward MOUD and three logistic regression models were calculated to identify factors associated with perceptions of each medication. Results: Half of providers considered methadone an effective treatment (53.0%); 62.9% considered buprenorphine effective, and 70.3% considered naltrexone effective. Receipt of training (B = 1.433, p = .009) and serving pregnant women or women with children (B = 1.662, p < .001) were associated with more positive attitudes toward MOUD. Providers with advanced degrees were more likely to consider methadone (OR = 2.264, p = .006), buprenorphine (OR = 2.192, p = .009), and naltrexone (OR = 2.310, p = .011) effective. Rural providers were more likely to consider naltrexone effective (OR = 2.708, p = .003). Providers working with criminal legal populations were more likely to consider buprenorphine (OR = 2.948, p = .041) and naltrexone (OR = 4.108, p = .010) effective, but not methadone. Conclusion: Treatment providers' attitudes remain poorly aligned with the evidence base. Increased efforts are needed to address attitudes toward MOUD among the specialized treatment workforce.

The impact of COVID-19 on people who inject drugs in New York City: increased risk and decreased access to services

Background

While people who inject drugs (PWID) are vulnerable to the adverse outcomes of events like COVID-19, little is known regarding the impact of the current pandemic on PWID. We examine how COVID-19 has affected PWID in New York City across four domains: substance use, risk behaviors, mental health, and service utilization.

Methods

As part of a randomized trial to improve access to HCV treatment for PWID, we recruited 165 participants. Eligibility criteria included detectable HCV RNA and recent drug injection. The present cross-sectional analysis is based on a subsample of 106 participants. We compared responses between two separate samples: 60 participants interviewed prior to the pandemic (pre-COVID-19 sample) and 46 participants interviewed during the pandemic (COVID-19 sample). We also assessed differences by study group [accessible care (AC) and usual care (UC)].

Results

Compared to the pre-COVID-19 sample, those interviewed during COVID-19 reported higher levels of mental health issues, syringe reuse, and alcohol consumption and greater reductions in syringe-service programs and buprenorphine utilization. In the analysis conducted by study group, the UC group reported significantly higher injection risk behaviors and lower access to buprenorphine treatment during COVID-19, while during the same period, the AC group reported lower levels of substance use and injection risk behaviors.

Conclusion

The current study provides insight on how COVID-19 has negatively affected PWID. Placing dispensing machines of harm-reduction supplies in communities where PWID live and increasing secondary exchange, mobile services, and mail delivery of supplies may help maintain access to lifesaving supplies during big events, such as COVID-19.

Trial registration ClinicalTrials.gov NCT03214679. Registered July 11 2017. https://clinicaltrials.gov/ct2/show/NCT03214679.