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

Digital geographies of care: Telehealth landscapes of addiction treatment during the COVID-19 pandemic

The COVID-19 pandemic has created new digital health care landscapes for the management of substance use and misuse. While telehealth was prohibited for addiction treatment prior to the pandemic, the severity of COVID-19 precipitated telehealth expansion for the delivery of individual and group-based treatment. Research has highlighted benefits and challenges of telehealth; however, little is known about the impacts of telehealth on the quality, use, and effectiveness of treatment. Fewer studies examine how these emerging digital geographies of care transform the spaces and landscapes of substance misuse. This article examines how telehealth affects landscapes of opioid use disorder care in Pennsylvania, West Virginia, and Kentucky during the COVID-19 pandemic. Our findings reveal that while telehealth extends access to treatment for opioid use disorder (OUD), it also creates new care inequities within and between providers and clientele that can undermine effective care and recovery.

It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health.

METHODS

The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline.

RESULTS

About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms.

CONCLUSIONS

Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.

Growing importance of high-volume buprenorphine prescribers in OUD treatment: 2009-2018

BACKGROUND

We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018.

METHODS

In this observational cohort study, IQVIA Real World retail pharmacy claims data were used to characterize trends in high-volume buprenorphine prescribers (clinicians with a mean of 30 or more active patients in every month that they were an active prescriber) during 2009-2018. Very high-volume prescribing (mean of 100+ patients per month) was also examined.

RESULTS

Overall, 94,491 clinicians prescribed buprenorphine dispensed during 2009-2018. The proportion of active prescribers meeting high-volume criteria increased from 7.4 % in 2009 to 16.7 % in 2018. High-volume prescribers accounted for 80 % of dispensed buprenorphine prescriptions during 2009-2018; very high-volume prescribers accounted for 26 %. Adult primary care physicians consistently comprised the majority of high-volume prescribers. Addiction specialists were much more likely to be high-volume prescribers compared to other specialties, including psychiatrists and pain specialists. By 2018, the proportion of prescriptions from high-volume prescribers paid by Medicaid had doubled to 40 %, accompanied by a decline in both self-pay and commercial insurance. High-volume prescribers were overwhelmingly concentrated in urban counties with the highest fatal overdose rates. In 2018, the highest density of high-volume prescribers was in New England and the mid-Atlantic region.

CONCLUSIONS

Growth in high-volume prescribers outpaced the overall growth in buprenorphine prescribers across 2009-2018. High-volume prescribers play an increasingly central role in providing medication for OUD in the U.S., yet results indicate key regional variation in the availability of high-volume buprenorphine prescribers.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Telemedicine-delivered treatment for substance use disorder: A scoping review

INTRODUCTION

The COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a "new normal" policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM's acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs.

METHOD

We searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis.

RESULTS

A total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives.

CONCLUSIONS

TM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

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.

Service users' perception and attitude toward telemedicine-based treatment for substance use disorders: A qualitative study from India

Aim

We aimed to assess the service user's acceptability, feasibility, and attitude toward telemedicine practice and compare it with in-person consultation in substance use disorder (SUD).

Materials and Methods

We recruited 15 adult patients with SUD who accessed both telemedicine and in-person care. We conducted in-depth interviews on awareness and access, facilitators and barriers, treatment satisfaction, and therapeutic relationship in the telemedicine context. We performed a conventional content analysis of the interview excerpts and used inductive and deductive coding. We assumed that social, personal, and logistic contexts influence patients' perceptions and experiences with telemedicine-based addiction care (TAC).

Results

Most participants were middle-aged men (40.5 years, 86.7%), dependent on two or more substances (86.7%), and had a history of chronic, heavy substance use (use ~16 years, dependence ~11.5 years). Patients' perspectives on TAC could broadly be divided into three phases: pre-consultation, consultation, and post-consultation. Patients felt that TAC improved treatment access with adequate autonomy and control; however, there were technical challenges. Patients expressed privacy concerns and feared experiencing stigma during teleconsultation. They reported missing the elaborate inquiry, physical examination, and ritual of visiting their doctors in person. Additionally, personal comfort and technical difficulties determine the satisfaction level with TAC. Overall perception and suitability of TAC and the decision to continue it developed in the post-consultation phase.

Conclusion

Our study provides an in-depth insight into the barriers and facilitators of telemedicine-based SUD treatment access, use, and retention; it also helps to understand better the choices and preferences for telehealth care vis-à-vis standard in-person care for SUDs.

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.

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

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

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.

"You'll come in and dose even in a global pandemic": A qualitative study of adaptive opioid agonist treatment provision during the COVID-19 pandemic

BACKGROUND

Opioid agonist treatment (OAT) improves multiple health and social outcomes, yet requirements to attend for supervised dosing can be burdensome and stigmatising. The COVID-19 pandemic and associated restrictions threatened continuity of care and the wellbeing of people receiving OAT, risking a parallel health crisis. This study sought to understand how adaptations in the complex system of OAT provision impacted and responded to risk environments of people receiving OAT during the COVID-19 pandemic.

METHODS

The analysis draws on semi-structured interviews with 40 people receiving and 29 people providing OAT located across Australia. The study considered the risk environments that produce COVID-19 transmission, treatment (non-)adherence, and adverse events for people receiving OAT. Drawing on theories of risk environments and complex adaptive systems, data were coded and analysed to understand how adaptations to the typically rigid system of OAT provision impacted and responded to risk environments during the COVID-19 pandemic.

RESULTS

During COVID-19, the complex system of OAT provision demonstrated possibilities for responsive adaptation to the entangled features of risk environments of people receiving OAT. Structural stigma was evident in the services which stayed rigid during the pandemic, requiring people to attend for daily supervised dosing and risking fracturing therapeutic relationships. In parallel, there were several examples of services developing enabling environments by offering flexible care through increased takeaways, treatment subsidies, and home delivery.

CONCLUSIONS

Rigidity in the delivery of OAT has been an impediment to achieving health and wellbeing over past decades. To sustain health-promoting environments for people receiving OAT, the wider impacts of the complex system should be acknowledged beyond narrowly defined outcomes relating solely to the medication. Centring people receiving OAT in their own care plans will ensure adaptations in the complex system of OAT provision are responsive to the individual's risk environment.

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

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

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.