Substance Use Disorders and Telehealth in the COVID-19 Pandemic Era: A New Outlook

Opioid Maintenance Therapy: A Review of Methadone, Buprenorphine, and Naltrexone Treatments for Opioid Use Disorder

The rates of opioid use and opioid related deaths are escalating in the United States. Despite this, evidence-based treatments for Opioid Use Disorder are underutilized. There are three medications FDA approved for treatment of Opioid Use Disorder: Methadone, Buprenorphine, and Naltrexone. This article reviews the history, criteria, and mechanisms associated with Opioid Use Disorder. Pertinent pharmacology considerations, treatment strategies, efficacy, safety, and challenges of Methadone, Buprenorphine, and Naltrexone are outlined. Lastly, a practical decision making algorithm is discussed to address pertinent psychiatric and medical comorbidities when prescribing pharmacology for Opioid Use Disorder.

Considerations for Opioid Use Disorder Treatment From Policy Makers' Experiences With COVID-19 Policy Flexibilities

OBJECTIVE

This qualitative study aimed to examine how states implemented COVID-19 public health emergency-related federal policy flexibilities for opioid use disorder treatment from the perspective of state-level behavioral health policy makers. Recommendations are given for applying lessons learned to improve the long-term impact of these flexibilities on opioid use disorder treatment.

METHODS

Eleven semistructured interviews were conducted with 13 stakeholders from six state governments, and transcripts were qualitatively coded. Data were analyzed by grouping findings according to state-, institution-, and provider-level barriers and facilitators and were then compared to identify overarching themes.

RESULTS

Policy makers expressed positive opinions about the opioid use disorder treatment flexibilities and described benefits regarding treatment access, continuity of care, and quality of care. No interviewees reported evidence of increased adverse events associated with the relaxed medication protocols. Challenges to state-level implementation included gaps in the federal flexibilities, competing state policies, facility and provider liability concerns, and persistent systemic stigma.

CONCLUSIONS

As the federal government considers permanent adoption of COVID-19-related flexibilities regarding opioid use disorder treatment policies, the lessons learned from this study are crucial to consider in order to avoid continuing challenges with policy implementation and to effectively remove opioid use disorder treatment barriers.

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.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Walk-in mental health: Bridging barriers in a pandemic

'Single Session Therapy' (SST) is a service delivery model that seeks to provide an evidence-based, solution-focused, brief intervention within a single therapy session. The stand-alone session affords the opportunity to provide brief psychological interventions while clients await access to longer-term services. The COVID-19 pandemic has adversely impacted individuals' mental health. However, the majority of research has investigated patient mental health within hospital settings and community organizations that offer long-term services, whereas minimal research has focused on mental health concerns during COVID-19 within an SST model. The primary aim of the study was to measure client experiences of a brief mental health service. The nature of client mental health concerns who access such services at various points during a pandemic was also investigated. The current study utilized client feedback forms and the Computerized Adaptive Testing-Mental Health (CAT-MH) to measure client experiences and mental health concerns. Qualitative analysis of client feedback forms revealed themes of emotional (e.g., safe space) and informational support (e.g., referrals). Clients also reported reduced barriers to accessing services (e.g., no appointment necessary, no cost), as well as limitations (e.g., not enough sessions) of the Walk-in clinic. Profile analysis of the CAT-MH data indicated that clients had higher rates of depression before COVID-19 (M = 64.2, SD = 13.07) as compared to during the pandemic (M = 59.78, SD = 16.87). In contrast, higher rates of positive suicidality flags were reported during the pandemic (n = 54) as compared to before (n = 29). The lower reported rates of depression but higher rate of suicidality during the pandemic was an unanticipated finding that contradicted prior research, to which possible explanations are explored. Taken together, the results demonstrate the positive experiences of clients who access a single session therapy.

Transitioning Virtual-Only Group Therapy for Substance Use Disorder Patients to a Hybrid Model

Purpose

Telehealth is associated with a myriad of benefits; however, little is known regarding substance use disorder (SUD) treatment outcomes when participants join group therapy sessions in a combination in-person and virtual setting (hybrid model). We sought to determine if treatment completion rates differed.

Patients and Methods

Policy changes caused by the COVID-19 pandemic created a naturalistic, observational cohort study at seven intensive outpatient (IOP) programs in rural Minnesota. Virtual-only delivery occurred 6/1/2020-6/30/2021, while hybrid groups occurred 7/1/2021-7/31/2022. Data was evaluated retrospectively for participants who initiated and discharged treatment during the study period. Participants were IOP group members 18 years and older who had a SUD diagnosis that both entered and discharged treatment during the 26-month period. A consecutive sample of 1502 participants (181-255 per site) was available, with 644 removed: 576 discharged after the study conclusion, 49 were missing either enrollment or discharge data, 14 transferred sites during treatment, and 5 initiated treatment before the study initiation. Helmert contrasts evaluated the impact of hybrid group exposure.

Results

A total of 858 individuals were included. Data was not from the medical chart and was deidentified preventing specific demographics; however, the overall IOP sample for 2020-2022, from which the sample was derived, was 29.8% female, and 64.1% were 18-40 years of age. For completed treatment, hybrid group exposure relative to virtual-only had a univariate odds ratio of 1.88 (95% CI: 1.50-2.41, p < 0.001). No significant difference was seen across IOP sites.

Conclusion

These results describe a novel hybrid group approach to virtual care for SUDs with outcome data not previously documented in the literature. While virtual treatment delivery can increase access, these results suggest a benefit is derived from including an in-person option. Further research is needed to identify how an in-person component may change dynamics and if it can be replicated in virtual-only models.

Program Director Reports of COVID-19 Lockdown-Driven Service Changes in Community-Based STI Clinics and Syringe Services Programs in the Southeastern U.S

The COVID-19 pandemic strained the U.S. health care system, posing logistical challenges for community-based programs. This study surveyed 11 program directors in sexually transmitted infection (STI) clinics and syringe services programs (SSPs) that served people who use substances and are at risk for HIV in five southeastern U.S. states. Brief survey questions asked about programs' use of in-person and telehealth services. Results indicated widespread reduction of in-person services and concomitant adoption of telehealth services. In STI clinics, telehealth replaced in-person visits for all but urgent treatment of active symptoms. In SSPs, in-person contact continued or increased from pre-pandemic volumes. In both programs, the most salient telehealth use barrier was limited device or internet access and limited technological ease. Services were sustained through innovative adaptations. This snapshot of response to the early COVID-19 lockdown phase offers actionable guidance about service preparedness for future public health catastrophes in community-based programs serving vulnerable populations.

Assessing Feasibility and Barriers to Implementing a Family-Based Intervention in Opioid Treatment Programs

Families Facing the Future (FFF) is an intervention designed specifically for families with a parent in methadone treatment. FFF is unique because it addresses prevention for children and recovery for parents in a single intervention. The primary goals of the program are to prevent parents' relapse, help them cope with relapse if it occurs, and teach parenting skills in order to reduce the likelihood of substance use among their children. FFF has been implemented as an adjunct to treatment in several Opioid Treatment Programs, but has not been widely adopted due to various implementation barriers. The aims of this study, therefore, were to (1) assess the perceived feasibility of implementing FFF and (2) identify/describe barriers to implementing FFF. An online survey was used to assess implementation feasibility, while individual qualitative interviews were conducted to explore specific barriers to implementation. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two Opioid Treatment Programs in Florida. Analyses revealed high feasibility scores, indicating that FFF was viewed by both patients and providers as a practical intervention to implement. Despite strong perceived feasibility of the intervention, qualitative findings identified several implementation barriers with respect to difficulty attending parent training sessions, aversion to in-home visits, and lack of funding (inability to provide patient incentives/bill insurance). This study provides evidence that while patients and providers view FFF as having high feasibility, significant implementation barriers exist. This paper fills a void in the literature by informing if and which modifications might be necessary to facilitate wider adoption of FFF in real-world Opioid Treatment Program settings.

Architecture and Development Framework for a Web-Based Risk Assessment and Management Platform Developed on WordPress to Address Opioid Overdose

The number of overdose-related fatalities continues to reach historic levels across Canada, despite ongoing efforts by authorities. To reduce mortality, a clinical trajectory ranging from preventative measures to crisis intervention, skill training to treatment, and risk assessment to risk management needs to be supported. The web-based Risk Assessment and Management Platform (RAMP) was developed to realize this concept and to empower people who use drugs through an integrated tool that allows them to better understand and manage their risk of overdose. This paper outlines the architecture and development of RAMP, which is built on the WordPress platform. WordPress components are mapped onto a 3-tier architecture that consists of presentation, application, and database layers. The architecture facilitates the development of a modular software that includes several features that are independent in functionality but interact with each other in an integrated platform. The relatively low coupling and high coherence of the features may reduce the cost of maintenance and increase flexibility of future developments. RAMP's architecture comprises a user interface, conceptual framework, and backend layers. The RAMP front end effectively uses some of the WordPress' features such as HTML5, CSS, and JavaScript to create a mobile, friendly, and scalable user interface. The RAMP backend uses several standard and custom WordPress plug-ins to support risk assessment and monitoring, with the goal of mitigating the impacts and eliminating risks together. A rule-based decision support system has been hard-coded to suggest relevant modules and goals to complement each user's lifestyle and goals based on their risk assessment. Finally, the backend uses the MySQL database management system and communicates with the RAMP framework layer via the data access layer to facilitate a timely and secure handling of information. Overall, RAMP is a modular system developed to identify and manage the risk of opioid overdose in the population of people who use drugs. Its modular design uses the WordPress architecture to efficiently communicate between layers and provide a base for external plug-ins. There is potential for the current system to adopt and address other related fields such as suicide, anxiety, and trauma. Broader implementation will support this concept and lead to the next level of functionality.

Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Application of trauma-focused cognitive behavioral therapy among children and adolescents with childhood household dysfunction

Childhood household dysfunction (CHD) is a common adverse childhood experience, which brings the heavy physical and mental afflictions to children and adolescents. Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy that helps children and adolescents who have experienced childhood trauma with traumatic memories. It aims to enhance the coping abilities of CHD children and adolescents, thereby improving the negative effects caused by trauma and effectively reducing psychological burden. TF-CBT can effectively improve post-traumatic stress disorder, emotional and behavioral problems, and family function in children and adolescents with CHD. It is recommended to conduct high-quality original research in the future, develop targeted TF-CBT intervention plans based on potential predictive factors, adopt a combination of online and offline methods, and construct TF-CBT interventions suitable for the Chinese CHD population to meet the mental health service needs of CHD children and adolescents.

Virtual agents among participants with methamphetamine use disorders: Acceptability and usability study

INTRODUCTION

While the potential future role of virtual agents (VAs) in treating addiction is promising, participants' attitudes toward the use of VAs in psychotherapy remain insufficiently investigated. This lack of investigation could pose barriers to the adoption of VA-led psychotherapy for people with substance use disorders (SUD). This research aims to explore the acceptability and usability of VAs for people with methamphetamine use disorder.

METHODS

Following a single session of psychotherapy led by VAs through the Echo-app, a group of 49 individuals actively seeking treatment for current DSM-V substance dependence (with a mean age of 39.06 ± 8.02) completed self-administered questionnaires and participated in focus group interviews. These questionnaires aimed to investigate participants' preference regarding the type of psychotherapy and their willingness to engage in VA-led psychotherapy, taking into account their diverse psychological needs.

RESULTS

Quantitative data were subjected to analysis through both descriptive and inferential statistical methods. Interestingly, participants exhibited a significantly higher acceptability for traditional face-to-face psychotherapy compared to email-based psychotherapy (p = 0.042), but there was no statistically significant difference between their acceptance of traditional psychotherapy and VA-led psychotherapy (p = 0.059). The questionnaire outcomes indicated participants' willingness to engage in VA-led psychotherapy for purposes such as relapse prevention intervention, addressing emotional issues, managing somatic experiences, and facilitating social and family functional recovery. Furthermore, the participants' attitudes toward VA-led psychotherapy were predicted by factors including the need for anxiety-focused psychotherapy (p = 0.027; OR [95%CI] = 0.14[0.03,0.80]), the presence of chronic somatic diseases (p = 0.017; OR [95%CI] = 13.58[1.59,116.03]), and marital status (p = 0.031; OR [95%CI] = 5.02[1.16,21.79]).

DISCUSSION

Through the interviews, the study uncovered the factors that either supported or hindered participants' experiences with VA-led psychotherapy, while also gathering suggestions for future improvements. This research highlights the willingness and practicality of individuals with SUD in embracing VA-led psychotherapy. The findings are anticipated to contribute to the refinement of VA-led tools to better align with the preferences and needs of the users.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

APPROACH

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

KEY RESULTS

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

CONCLUSIONS

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

The impact of the COVID-19 pandemic on the rate of primary care visits for substance use among patients in Ontario, Canada

The COVID-19 pandemic has led to an increase in the prevalence of substance use presentations. This study aims to assess the impact of the COVID-19 pandemic on the rate of primary care visits for substance use including tobacco, alcohol, and other drug use among primary care patients in Ontario, Canada. Diagnostic and service fee code data were collected from a longitudinal cohort of family medicine patients during pre-pandemic (March 14, 2019-March 13, 2020) and pandemic periods (March 14, 2020-March 13, 2021). Generalized linear models were used to compare the rate of substance-use related visits pre-pandemic and during the pandemic. The effects of demographic characteristics including age, sex, and income quintile were also assessed. Relative to the pre-pandemic period, patients were less likely to have a primary care visit during the pandemic for tobacco-use related reasons (OR = 0.288, 95% CI [0.270-0.308]), and for alcohol-use related reasons (OR = 0.851, 95% CI [0.780-0.929]). In contrast, patients were more likely to have a primary care visit for other drug-use related reasons (OR = 1.150, 95% CI [1.080-1.225]). In the face of a known increase in substance use during the COVID-19 pandemic, a decrease in substance use-related primary care visits likely represents an unmet need for this patient population. This study highlights the importance of continued research in the field of substance use, especially in periods of heightened vulnerability such as during the COVID-19 pandemic.

Association Between Clinician-Level Factors and Patient Outcomes in Virtual and In-Person Outpatient Treatment for Substance Use Disorders: Multilevel Analysis

BACKGROUND

The use of virtual treatment services increased dramatically during the COVID-19 pandemic. Unfortunately, large-scale research on virtual treatment for substance use disorder (SUD), including factors that may influence outcomes, has not advanced with the rapidly changing landscape.

OBJECTIVE

This study aims to evaluate the link between clinician-level factors and patient outcomes in populations receiving virtual and in-person intensive outpatient services.

METHODS

Data came from patients (n=1410) treated in a virtual intensive outpatient program (VIOP) and an in-person intensive outpatient program (IOP), who were discharged between January 2020 and March 2021 from a national treatment organization. Patient data were nested by treatment providers (n=58) examining associations with no-shows and discharge with staff approval. Empathy, comfort with technology, perceived stress, resistance to change, and demographic covariates were examined at the clinician level.

RESULTS

The VIOP (β=-5.71; P=.03) and the personal distress subscale measure (β=-6.31; P=.003) were negatively associated with the percentage of no-shows. The VIOP was positively associated with discharges with staff approval (odds ratio [OR] 2.38, 95% CI 1.50-3.76). Clinician scores on perspective taking (β=-9.22; P=.02), personal distress (β=-9.44; P=.02), and male clinician gender (β=-6.43; P=.04) were negatively associated with in-person no-shows. Patient load was positively associated with discharge with staff approval (OR 1.04, 95% CI 1.02-1.06).

CONCLUSIONS

Overall, patients in the VIOP had fewer no-shows and a higher rate of successful discharge. Few clinician-level characteristics were significantly associated with patient outcomes. Further research is necessary to understand the relationships among factors such as clinician gender, patient load, personal distress, and patient retention.

Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants

BACKGROUND

Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention.

OBJECTIVE

This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions.

METHODS

The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification.

RESULTS

The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement.

CONCLUSIONS

Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.

The benefits and challenges of virtual SMART recovery mutual-help groups: Participant and facilitator perspectives

BACKGROUND

COVID-19 prompted widespread transition of face-to-face mutual-help groups to virtual delivery. Current understanding of the experience of virtual mutual-help groups is limited to 12-step approaches or asynchronous groups (e.g., forums). This paper explores participant and facilitator perspectives regarding the benefits and challenges of accessing SMART Recovery mutual-help groups virtually via videoconference.

METHODS

A self-selected convenience sample of participants (n = 29) and facilitators (n = 15) from SMART Recovery mutual-help groups in Australia were enrolled. Participants and facilitators were sampled to reflect experience of virtual groups delivered via videoconference ('online'), face-to-face groups ('face-to-face') or both types of groups ('both'). Telephone qualitative interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analysed using iterative categorisation.

RESULTS

Participant and facilitators discussed their experience across eight interconnected themes benefits were typically discussed with regard to the (1) availability, (2) ease of access and (3) value add of the chat feature in online groups. Challenges largely pertained to (1) in-group engagement, (2) group size, (3) non-verbal cues, (4) social interaction and (5) technology problems. The impact of these challenges on participant and facilitator experience varied, and neither modality was consistently identified as superior.

CONCLUSIONS

SMART Recovery mutual-help groups provided participants with another option for accessing mutual-help and appealed to different people under different circumstances. Depending on the needs and preferences of the individual, online SMART Recovery mutual-help groups may help to mitigate a range of barriers to help seeking and may also engage people otherwise unable or reluctant to engage in treatment. To inform training, practice and policy, improved understanding of the individual and contextual factors that enhance participant engagement, experience and outcomes is needed.

Telehealth and In-Person Behavioral Health Services in Rural Communities Before and During the COVID-19 Pandemic: Multisite Prospective Cohort Study

BACKGROUND

The COVID-19 pandemic triggered widespread adjustments across the US health care system. Telehealth use showed a substantial increase in mental health conditions and services due to acute public health emergency (PHE) behavioral health needs on top of long-standing gaps in access to behavioral health services. How health systems that were already providing behavioral telehealth services adjusted services and staffing during this period has not been well documented, particularly in rural areas with chronic shortages of behavioral health providers and services.

OBJECTIVE

This study investigates patient and treatment characteristic changes from before the COVID-19 PHE to during the PHE within both telehealth and in-person behavioral health services provided in 95 rural communities across the United States.

METHODS

We used a nonrandomized, prospective, multisite research design involving 2 active treatment groups. The telehealth cohort included all patients who initiated telehealth treatment regimens during the data collection period. A comparison group included a cohort of patients who initiated in-person treatment regimen. Patient enrollment occurred on a rolling basis, and data collection was extended for 3 months after treatment initiation for each patient. Chi-square tests compared changes from pre-PHE to PHE time periods within telehealth and in-person treatment cohorts. The dependent measures included patient diagnosis, clinicians providing treatment services, and type of treatment services provided at each encounter. The 4780 patients in the telehealth cohort and the 6457 patients in the in-person cohort had an average of 3.5 encounters during the 3-month follow-up period.

RESULTS

The encounters involving anxiety, dissociative, and stress-related disorders in the telehealth cohort increased from 30% (698/2352) in the pre-PHE period to 35% (4632/12,853) in the PHE period (P<.001), and encounters involving substance use disorders in the in-person cohort increased from 11% (468/4249) in the pre-PHE period to 18% (3048/17,047) in the PHE period (P<.001). The encounters involving treatment service codes for alcohol, drug, and medication-assisted therapy in the telehealth cohort increased from 1% (22/2352) in the pre-PHE period to 11% (1470/13,387) in the PHE period (P<.001); likewise, encounters for this type of service in the in-person cohort increased from 0% (0/4249) in the pre-PHE period to 16% (2687/17,047) in the PHE period (P<.001). From the pre-PHE to the PHE period, encounters involving 60-minute psychotherapy in the telehealth cohort increased from 8% (190/2352) to 14% (1802/13,387; P<.001), while encounters involving group therapy in the in-person cohort decreased from 12% (502/4249) to 4% (739/17,047; P<.001).

CONCLUSIONS

The COVID-19 pandemic challenged health service providers, and they adjusted the way both telehealth and in-person behavioral therapy services were delivered. Looking forward, future research is needed to explicate the interaction of patient, provider, setting, and intervention factors that influenced the patterns observed as a result of the COVID-19 pandemic.

Validity and reliability of in-person and remote oral fluids drug testing compared to urine drug testing

BACKGROUND

Increased telehealth use has led to greater interest in remote drug testing. The speed, acceptability, and ability to observe oral fluids testing makes it the best candidate for remote drug testing, but its validity and reliability compared to gold-standard urine drug testing have not been established.

METHODS

Veterans (N = 99) recruited from mental health clinics completed in-person and remote oral fluids testing and in-person urine drug testing. The validity of oral fluids versus urine drug testing and reliability of in-person versus remote oral fluids testing were evaluated.

RESULTS

Validity of oral fluids testing was similar for samples collected in-person and virtually. Oral fluids testing had good specificity (0.93-1.00) and negative predictive value (0.85-1.00), but lower sensitivity and positive predictive value. Sensitivity (0.21-0.93) was highest for methadone and oxycodone, followed by cocaine and then amphetamine and opiates. Positive predictive value (0.14-1.00) was highest for cocaine, opiates, and methadone, followed by oxycodone and then amphetamine. Validity for cannabis was low, likely because of differences in detection windows for oral fluids versus urine drug screens. Reliability of remote oral fluids testing was adequate for opiates, cocaine, and methadone, but not oxycodone, amphetamine, or cannabis.

CONCLUSIONS

Oral fluids testing identifies most negative, but not most positive, drug test results. While oral fluids testing is appropriate in some circumstances, its limitations should be acknowledged. Remote drug testing addresses many barriers, but also generates new barriers related to self-administration and remote interpretation. Limitations include a small sample and low base rates for some drugs.

Adherence to SARS-CoV-2 Vaccination Recommendations among Patients with Substance Use Disorders: A Cross-Sectional Study in Rome, Italy

Adherence to vaccination recommendations is a challenge for national immunization programs. We quantified adherence to COVID-19 vaccination recommendations in people with substance use disorders (SUDs) attending an outpatient addiction center in Rome, Italy; we investigated the determinants of adherence, and also analyzed patient risk perception and compliance with preventive measures. A multivariable logistic regression model identified predictors of adherence to vaccination recommendations, with statistical validity tested by estimating adjusted odds ratios (aORs) and 95% confidence intervals (CIs). From December 2021 to January 2022, 200 SUD patients completed a questionnaire, 80% of whom reported being vaccinated against SARS-CoV-2 (minimum one dose). Negative predictors of vaccine uptake included being non-Italian (aOR: 0.36, 95% CI: 0.13-0.97), having coexisting comorbidities (aOR: 0.35, 95% CI: 0.13-0.95), and previous use of heroin (aOR: 0.24, 95% CI: 0.08-0.71). No difference was found for cocaine use, demographic characteristics, previous COVID-19 infection, methadone therapy, or compliance with preventive measures. Major reasons for non-adherence to vaccination recommendations were fear of side effects, insufficient recognition of the importance of vaccination, bureaucratic issues, and lack of trust in the authorities. Given their vulnerability, additional efforts are needed to facilitate access to vaccination for people with SUDs, and to limit disinformation around vaccines..

Ethics of Technology Practice: Beliefs and Behaviors of Certified Rehabilitation Counselors During the COVID-19 Pandemic

The coronavirus (COVID-19) pandemic represented a critical moment for technology use within rehabilitation counseling. This study explored trends in the beliefs and behaviors of certified rehabilitation counselors (CRCs) regarding the ethical use of technology before and during the pandemic. Specifically, this study compared two groups of CRCs regarding the degree to which they engaged in 59 technology behaviors and whether they viewed each behavior to be ethical. Overall, group comparisons suggested an increased use of telephone, videoconferencing, and email to deliver counseling, assessment, and supervision services during the pandemic. Furthermore, supervision via videoconferencing and email in the pandemic were rated as more ethically appropriate than before the pandemic. As a general trend, synchronous modes of communication such as the telephone and video conferencing were rated as more ethically appropriate than asynchronous modes such as social networking and text messaging. Indicating a high degree of congruence between beliefs and behaviors, the technology practices viewed as most ethical were used the most often. Implications address the revisions to the Code of Professional Ethics for Rehabilitation Counselors regarding the ethical use of technology in rehabilitation counseling.

Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic

BACKGROUND

Telehealth has the potential to improve health care access for patients but it has been underused and understudied for examining patients with substance use disorders (SUD). VA began distributing video-enabled tablets to veterans with access barriers in 2016 to facilitate participation in home-based telehealth and expanded this program in 2020 due to the coronavirus COVID-19 pandemic.

OBJECTIVE

Examine the impact of VA's video-enabled telehealth tablets on mental health services for patients diagnosed with SUD.

METHODS

This study included VA patients who had ≥1 mental health visit in the calendar year 2019 and a documented diagnosis of SUD. Using difference-in-differences and event study designs, we compared outcomes for SUD-diagnosed patients who received a video-enabled tablet from VA between March 15th, 2020 and December 31st, 2021 and SUD-diagnosed patients who never received VA tablets, 10 months before and after tablet-issuance. Outcomes included monthly frequency of SUD psychotherapy visits, SUD specialty group therapy visits and SUD specialty individual outpatient visits. We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person). Regression models adjusted for several covariates such as age, sex, rurality, race, ethnicity, physical and mental health chronic conditions, and broadband coverage in patients' residential zip-code.

RESULTS

The cohort included 21,684 SUD-diagnosed tablet-recipients and 267,873 SUD-diagnosed non-recipients. VA's video-enabled tablets were associated with increases in video visits for SUD psychotherapy (+3.5 visits/year), SUD group therapy (+2.1 visits/year) and SUD individual outpatient visits (+1 visit/year), translating to increases in visits across all modalities (in-person, phone and video): increase of 18 % for SUD psychotherapy (+1.9 visits/year), 10 % for SUD specialty group therapy (+0.5 visit/year), and 4 % for SUD specialty individual outpatient treatment (+0.5 visit/year).

CONCLUSIONS

VA's distribution of video-enabled tablets during the COVID-19 pandemic were associated with higher engagement with video-based services for SUD care among patients diagnosed with SUD, translating to modest increases in total visits across in-person, phone and video modalities. Distribution of video-enabled devices can offer patients critical continuity of SUD therapy, particularly in scenarios where they have heightened barriers to in-person care.

Demographic differences in services utilization across in-person (2019), telehealth (2020), and hybrid (2021) outpatient substance use services in New York

OBJECTIVES

Many outpatient substance use programs have experienced in-person, remote/telehealth, and hybrid models of care since the 2020 Covid-19 Pandemic. Changes in treatment models naturally affect service utilization and may affect treatment trajectories. Currently, limited research examines the implications of different health care models on service utilization and patient outcomes in substance use treatment. Here, we reflect on the implications of each model from a patient-centered care approach and review the implications on service utilization and outcomes.

METHODS

We employed a retrospective, observational, longitudinal, cohort design to explore differences in demographic characteristics and service utilization among patients receiving in-person, remote, or hybrid services across five substance use clinics in New York. We reviewed admission (N = 2238) and discharge (N = 2044) data from four outpatient SUD clinics within the same health care system across three cohorts (2019, in-person; 2020, remote; 2021, hybrid).

RESULTS

Patients discharged in 2021 (hybrid) had significantly more median total treatment visits (M = 26, p ≤ 0.0005), a longer course of treatment (M = 154.5 days, p ≤ 0.0001), and more individual counseling sessions (M = 9, p ≤ 0.0001) compared to the other two cohorts. Demographic analyses indicate more ethnoracial diversity (p = 0.0006) among patients admitted in 2021, compared to the other two cohorts. Over time, the proportion of individuals being admitted with a co-existing psychiatric disorder (2019, 49 %; 2020; 55.4 %, 2021, 54.9 %) and no prior mental health treatment (2019, 49.4 %; 2020, 46.0 %; 2021, 69.3 %) increased (p = 0.0001). Admissions in 2021 were more likely to be self-referred (32.5 %, p < 0.0001), employed full-time (39.5 %, p = 0.01), and have higher educational attainment (p = 0.0008).

CONCLUSION

During hybrid treatment in 2021, patients from a wider range of ethnoracial backgrounds were admitted and retained in care, patients with higher socioeconomic status (who were previously less likely to enter treatment) were admitted, and fewer individuals left against clinical advice (compared to the remote 2020 cohort). More patients successfully completed treatment in 2021. Service utilization, demographic, and outcome trends support a hybrid model of care.

The Evolution of Telepsychiatry for Substance Use Disorders During COVID-19: a Narrative Review

Purpose of Review

This article aims to review and synthesize the current research evidence regarding the efficacy of telepsychiatry-delivered substance use disorder treatment using a narrative review with a focus on the effects of remote healthcare delivery within the substance abuse treatment space.

Recent Findings

The COVID-19 pandemic exerted substantial pressures on all levels of society. Social isolation, loss of employment, stress, physical illness, overburdened health services, unmet medical needs, and rapidly changing pandemic restrictions had particularly severe consequences for people with mental health issues and substance use disorders. Since the start of the pandemic, addiction treatment (and medical treatment overall) using remote health platforms has significantly expanded to different platforms and delivery systems. The USA, in particular, reported transformational policy developments to enable the delivery of telehealth during the COVID-19 pandemic. However, systemic barriers such as a widespread lack of internet access and insufficient patient and provider digital skills remain.

Summary

Overall, telepsychiatry is a promising approach for the treatment of substance use disorders, but more randomized controlled trials are needed in the future to assess the evidence base of available interventions.

The adoption and sustainability of digital therapeutics in justice systems: A pilot feasibility study

BACKGROUND

This study explored whether participants with substance use disorder (SUD) would adopt and use a smart-phone app with a cognitive behavioral therapy program, weekly Brief Addiction Monitor (BAM) assessments, daily check-ins, tools to track sobriety and treatment, and other patient-centered resources. In addition, participants with SUD could access a social worker and peer support specialists.

METHODS

The study sought participants from two groups: those referred by a justice-related agency and participants who responded to outreach from the Addiction Policy Forum (APF). The Connections smart-phone app was offered to both groups. The study examined use of the app and social worker/peer recovery support services by participants who downloaded and used the app; those referred by a justice-related agency and those who self-referred through APF. The app provided primary data, including socio-demographics, referral status, dates of use, activities completed, and BAM scores.

RESULTS

The app was offered to 1973 participants, 40% of whom downloaded it. Three groups emerged from among the 350 who used the app: those who used only the cognitive behavioral aspects of the app, those who used only the recovery support services offered, and those who used both the app and recovery support services. Looking at the two referral groups, the justice-referred group preferred telehealth recovery support services with the social worker; the self-referred group used the app and the app plus the recovery support services equally. Scores on the BAM improved across time. Justice-referred participants' protective behaviors improved more than those of the self-referred participants while self-referred participants' risk behaviors improved more than those of justice-referred participants. Older participants were more likely to use the app, and to report fewer risky behaviors, as measured by the BAM.

CONCLUSIONS

Use of a digital therapeutic appears to support recovery of participants with SUD although many clients need and want the integration of social worker-driven recovery support services. Basically, the app can be an extension to personal services, but many people with SUD (particularly during COVID-19) crave human interaction. It also appears that those who seek assistance on their own, rather than being referred by a justice-related agency, may be more likely to benefit from digital therapeutics such as the Connections app.

Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic's mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

The Efficacy of Telepsychiatry in Addiction Patients: A Systematic Review

Psychiatry is one of the many medical subspecialties that have benefited from the advent of telemedicine. Substance abuse treatment via telepsychiatry expeditiously increased with the start of the pandemic and has brought changes to its rules and regulations. In this study, we focused on the prognosis of substance abuse patients treated with telepsychiatry, the various changes that occurred during the pandemic, and the difficulties faced by clinicians using telepsychiatry. PubMed and Google Scholar were searched for relevant articles between January 2010 and July 2022 using both broad and narrow keywords in addition to the MeSH (Medical Subject Heading) approach. The total number of records found was 765. Strict criteria for inclusion and exclusion ensured that only relevant information was collected. After removing duplicates, irrelevant studies, and research that did not meet the inclusion criteria, we were left with 373 studies from both electronic databases. From those, we ultimately retrieved 35 studies, which were subjected to a thorough content search and quality evaluation with the help of specialized instruments, and a total of 19 papers were included in our systematic review. We concluded that telepsychiatry use for substance abuse patients increased during the pandemic, and the prognosis of these patients treated with telepsychiatry was similar to that of in-person treatment. However, a combination of telepsychiatry with in-person sessions showed much better results.

Supporting people affected by problematic alcohol, substance use and other behaviours under pandemic conditions: A pragmatic evaluation of how SMART recovery Australia responded to COVID-19

BACKGROUND

The COVID-19 pandemic prompted rapid, reflexive transition from face-to-face to online healthcare. For group-based addiction services, evidence for the impact on service delivery and participant experience is limited.

METHODS

A 12-month (plus 2-month follow-up) pragmatic evaluation of the upscaling of online mutual-help groups by SMART Recovery Australia (SRAU) was conducted using The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Data captured by SRAU between 1st July 2020 and 31st August 2021 included participant questionnaires, Zoom Data Analytics and administrative logs.

RESULTS

Reach: The number of online groups increased from just 6 pre-COVID-19 to 132. These groups were delivered on 2786 (M = 232.16, SD = 42.34 per month) occasions, to 41,752 (M = 3479.33, SD = 576.34) attendees.

EFFECTIVENESS

Participants (n = 1052) reported finding the online group meetings highly engaging and a positive, recovery supportive experience. 91 % of people with experience of face-to-face group meetings rated their online experience as equivalent or better. Adoption: Eleven services (including SRAU) and five volunteers delivered group meetings for the entire 12-months.

IMPLEMENTATION

SRAU surpassed their goal of establishing 100 groups. Maintenance: The average number of meetings delivered [t(11.14) = -1.45, p = 0.1737] and attendees [t(1.95) = -3.28, p = 0.1880] per month were maintained across a two-month follow-up period.

CONCLUSIONS

SRAU scaled-up the delivery of online mutual-help groups in response to the COVID-19 pandemic. Findings support the accessibility, acceptability and sustainability of delivering SMART Recovery mutual-help groups online. Not only are these findings important in light of the global pandemic and public safety, but they demonstrate the potential for reaching and supporting difficult and under-served populations.

Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone

INTRODUCTION

Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey.

METHODS

We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic.

RESULTS

Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant.

CONCLUSIONS

Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.

Opioid overdose prevention education in Texas during the COVID-19 pandemic

BACKGROUND

Distribution of naloxone and training on its proper use are evidence-based strategies for preventing opioid overdose deaths. In-person naloxone training was conducted in major metropolitan areas and urban centers across Texas as part of a state-wide targeted opioid response program. The training program transitioned to a live, virtual format during the COVID-19 public health emergency declaration. This manuscript describes the impact of this transition through analyses of the characteristics of communities reached using the new virtual training format.

CASE PRESENTATION

Training participant addresses were compared to county rates of opioid overdose deaths and broadband internet access, and census block comparison to health services shortages, rural designation, and race/ethnicity community characteristics.

CONCLUSIONS

The virtual training format reached more learners than the in-person events. Training reached nearly half of the counties in Texas, including all with recent opioid overdose deaths. Most participants lived in communities with a shortage of health service providers, and training reached rural areas, those with limited broadband internet availability, and majority Hispanic communities. In the context of restrictions on in-person gathering, the training program successfully shifted to a live, online format. This transition increased participation above rates observed pre-pandemic and reached communities with the need for equipping those most likely to witness an opioid overdose with the proper use of naloxone.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities

OBJECTIVE

To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas.

METHODS

Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic.

RESULTS

The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began.

CONCLUSIONS

This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Public policy for healthy living: How COVID-19 has changed the landscape

The coronavirus disease 2019 (COVID-19) pandemic had a transformational impact on public policy as governments played a leading role, working alongside and coordinating with business/industry, healthcare, public health, education, transportation, researchers, non-governmental organizations, philanthropy, and media/communications. This paper summarizes the impact of the pandemic on different areas of public policy affecting healthy living and cardiovascular health including prevention (i.e., nutrition, physical activity, air quality, tobacco use), risk factors for chronic disease (hypertension, diabetes, obesity, substance abuse), access to health care, care delivery and payment reform, telehealth and digital health, research, and employment policy. The paper underscores where public policy is evolving and where there are needs for future evidence base to inform policy development, and the intersections between the public and private sectors across the policy continuum. There is a continued need for global multi-sector coordination to optimize population health.

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.

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.

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.

Telemedicine along the cascade of care for substance use disorders during the COVID-19 pandemic in the United States

BACKGROUND

The COVID-19 pandemic has changed the landscape of healthcare service delivery. This review aims to describe telemedicine-delivered substance use disorder (SUD) treatments and services along the cascade of care in the U.S. after the start of the COVID-19 pandemic.

METHODS

A literature review was conducted on PubMed, Embase, Web of Science, and Cochrane Library (Wiley). English-language articles that describe any healthcare services for patients with SUDs using telemedicine in the U.S. since the onset of the COVID-19 pandemic were identified (N = 33). We narratively summarized telemedicine-based service provision along the cascade of SUD care, such as screening/assessment, prescription, monitoring, recovery support, and other services.

RESULTS

Soon after the onset of COVID-19 and mandated restrictions, cadres of healthcare providers from different specialties mobilized to ramp up video- and audio-based services to remotely treat patients with SUDs. Medication prescription (48.5%) and individual counseling (39.4%) were the most frequently reported services delivered via telemedicine. Other steps of SUD care delivered by telemedicine characterized in our review included SUD screening and assessment (30.3%), induction (21.2%), medication management (27.3%), monitoring (27.3%), recovery support (15.2%), and referral (24.2%). Feasibility issues and challenges to implementing telemedicine included patients' lack of access to technology and health insurance coverage, providers' capacity limits and concerns, and clinics' financial and office-space constraints.

CONCLUSION

The COVID-19 pandemic has offered a window of opportunity to advance telemedicine expertise by formalizing clinical guidance and routinizing provider in-service training in virtual SUD treatment. Findings suggest enhanced efforts to reduce disparities in telemedicine-based services.

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

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

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Depressive and anxious symptoms among young adults in the COVID-19 pandemic: Results from monitoring the future

PURPOSE

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is associated with worsening mental health among young adults, but further research is necessary to quantify the associations with depression and anxiety.

METHODS

Using Monitoring the Future data (N = 1244 young adults, modal age: 19, Fall 2020 supplement), we examined internalizing symptoms (Patient Health Questionnaire-8 and Generalized Anxiety Disorder Scale-7 separately), dividing the sample into those without clinically significant scores, significant scores but minimal pandemic-attributed symptoms, and significant scores with substantial pandemic-attributed symptoms. Logistic regression analyses linked demographic factors, pandemic-related experiences, and coping methods to symptom groups.

RESULTS

Internalizing symptoms were highly prevalent, with many occurring among a majority at least several days over the past 2 weeks. Major changes in education, employment, and resource availability predicted elevated symptom risk (e.g., lacking a place to sleep or money for rent, gas, or food led to 4.43 [95% confidence interval: 2.59-7.55] times the risk of high depressive symptoms significantly attributed to the pandemic). High internalizing symptoms were linked to underutilization of healthy coping behaviors, substance use overutilization, and dietary changes. High depressive and anxious symptoms attributed to the pandemic were marked by high levels of taking breaks from the news/social media and contacting healthcare providers.

CONCLUSIONS

The pandemic's associations with young adults' depressive and anxious symptoms warrants urgent attention through improved mental health treatment infrastructure and stronger structural support.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coronavirus disease 2019 and the liver

PURPOSE OF REVIEW

The objective of this review is to examine the epidemiology and pathogenesis of liver injury in coronavirus disease 2019 (COVID-19) and the impact of COVID-19 on patients with chronic liver disease (CLD) and liver transplant recipients.

RECENT FINDINGS

Abnormal liver chemistries occur in up to 60% of COVID-19 patients and are typically mild. COVID-19- associated liver injury may be because of direct viral cytopathic effect, immune-mediated damage, hypoxia, drug-induced liver injury (DILI), or exacerbation of CLD. COVID-19 patients with CLD and who are liver transplant recipients are at risk for severe disease and mortality. COVID-19 precipitated hepatic decompensation in 20-46% of cirrhotic patients. Alcohol consumption and cases of acute alcohol- associated hepatitis increased during the COVID-19 pandemic. Corticosteroids and calcineurin inhibitors are well tolerated to use during COVID-19 but immunomodulators have been associated with mortality. Less than 50% of transplant recipients produce adequate antibody titers after COVID-19 vaccination.

SUMMARY

COVID-19 patients with CLD should be monitored for liver injury and hepatic decompensation. Patients with CLD and liver transplant recipients should be considered for targeted COVID-19 pharmacotherapeutics and advised vaccination against COVID-19, including a third booster dose. CLD treatments and immunosuppression in liver transplant recipients could generally continue without interruption during COVID-19 infection, with the possible exception of immunomodulators.

The Impact of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Substance Use in the United States

The SARS-CoV-2 pandemic has been associated with dramatic increases in substance use, as marked by increased alcohol, nicotine, and cannabis sales. Lethal opioid overdoses also increased dramatically, especially during the initial phases of the epidemic when lockdowns and social isolation combined with increasing fentanyl contamination of the illicit drug supply resulted in more overdoses and fewer opportunities for rescue. Substance use, and especially inhalational drug use, increases the likelihood of both transmission and severe infection. Youth are especially vulnerable to substance use and have increased risk of long-term problems. These outcomes highlight the need for greater access to substance use treatment. Virtual treatment, which emerged as a promising format during the pandemic, may reduce access barriers. This article reviews trends in substance use during the pandemic, explores root causes of increased use and overdose, and examines the potential to increase treatment through virtual care, especially during future periods of disruption.

Reducing tobacco use in substance use treatment: An intervention to promote tobacco-free grounds

BACKGROUND

People in substance use disorder (SUD) treatment experience disproportionate rates of tobacco use. California has prioritized smoking cessation among these individuals through the Tobacco-Free for Recovery Initiative, which includes an intervention aimed at supporting programs in implementing tobacco-free grounds. The current study examined changes in client smoking prevalence, tobacco use behaviors, and receipt of cessation services among the first seven programs participating in the initiative.

METHODS

Residential treatment program clients completed cross-sectional surveys at the start of the intervention (baseline: n = 249), at an interim timepoint post-baseline (interim: n = 275), and at the end of the intervention 15 months later (post-intervention: n = 219). All participants reported smoking status. Current smokers reported tobacco use behaviors, and both current smokers and those who quit in treatment reported receipt of cessation services. Univariate analyses explored differences across the three timepoints and multivariate logistic regression assessed change from baseline to interim and baseline to post-intervention.

RESULTS

Client smoking prevalence decreased from 54.2% at pre- to 26.6% at post-intervention (Adjusted Odds Ratio [AOR] = 0.25, 95% CI = 0.13, 0.45). Current smokers and those who quit while in treatment reported an increase in NRT/pharmacotherapy (11.9% vs. 25.2%; AOR = 3.02, CI = 1.24, 7.35). When comparing baseline to the interim timepoint (a timepoint before the COVID-19 pandemic), data analyses also demonstrated a significant decrease in smoking prevalence (54.2% vs. 41.8%; AOR = 0.62, CI = 0.42, 0.92) and increase in NRT/pharmacotherapy (11.9% vs. 24.5%; AOR = 3.68, CI = 1.11, 12.19).

CONCLUSION

An intervention to promote tobacco-free grounds implemented in residential SUD treatment programs was associated with a significant reduction in client smoking and an increase in NRT/pharmacotherapy. These associations were observed both before the COVID-19 pandemic and in the early stages of the pandemic, suggesting that they may be due to the intervention rather than to the pandemic.

Effects of brief substance use interventions delivered in general medical settings: a systematic review and meta-analysis

AIMS

To estimate effects of brief substance use interventions delivered in general medical settings.

METHODS

A systematic review and meta-analysis of randomized trials conducted since 1990 of brief substance use interventions in patients of any age or severity level recruited in general medical settings. Primary outcomes were any measure of substance use or substance-related consequences (indexed with Hedges' g and risk ratios). Mixed-effects meta-regressions were used to estimate overall effects and predictors of effect variability. Analyses were conducted separately by brief intervention (BI) target substance: alcohol only or drugs.

FINDINGS

A total of 116 trials (64 439 participants) were identified; 111 (62 263 participants) provided effect size data and were included in the meta-analysis. Drug-targeted BIs yielded significant small improvements in multiple drug/mixed substance use (Hedges' g (g¯ ) = 0.08; 95% CI = 0.002, 0.15), but after adjusting for multiple comparisons, they did not produce significant effects on cannabis use ( g¯ = 0.06; 95% CI = 0.001, 0.12), alcohol use ( g¯ = 0.08; 95% CI = -0.0003, 0.17), or consequences ( g¯ = 0.05; 95% CI = 0.01, 0.10). Drug-targeted BIs yielded larger improvements in multiple drug/mixed substance use when delivered by a general practitioner ( g¯ = 0.19; 95% CI = 0.187, 0.193). Alcohol-targeted BIs yielded small beneficial effects on alcohol use ( g¯ = 0.12; 95% CI 0.08, 0.16), but no evidence of an effect on consequences ( g¯ = 0.05; 95% CI = -0.04, 0.13). However, alcohol-targeted BIs only had beneficial effects on alcohol use when delivered in general medical settings (g¯ = 0.17; 95% CI = 0.10, 0.24); the findings were inconclusive for those delivered in emergency department/trauma centers ( g¯ = 0.05; 95% CI = 0.00, 0.10).

CONCLUSIONS

When delivered in general medical settings, alcohol-targeted brief interventions may produce small beneficial reductions in drinking (equivalent to a reduction in 1 drinking day per month). There is limited evidence regarding the effects of drug-targeted brief interventions on drug use.

Telemedicine and visit completion among people with HIV during the coronavirus disease 2019 pandemic compared with prepandemic

OBJECTIVES

Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of PWH engaged in care prior to and during the COVID-19 pandemic.

DESIGN AND METHODS

We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The prepandemic period included 2010 people with at least one visit scheduled between 1 September 2019 and 15 March 2020. The pandemic period included 1929 people with at least one visit scheduled between 16 March 2020 and 30 September 2020. We determined the proportion of patients completing at least one of their scheduled visits during each period.

RESULTS

Visit completion increased significantly from 88% prepandemic to 91% during the pandemic (P = 0.008). Visit completion improved significantly for patients age 20-39 (82 to 92%, P < 0.001), women (86 to 93%, P < 0.001), Black patients (88 to 91%, P = 0.002) and patients with detectable viremia (77 to 85%, P = 0.06) during the pandemic. Only 29% of people who completed at least one telemedicine visit during the pandemic did so as a video (versus telephone) visit.

CONCLUSION

During the pandemic when care was widely delivered via telemedicine, visit completion improved among groups with lower prepandemic engagement but most were limited to telephone visits.