Initiating Opioid Use Disorder Medication via Telemedicine During COVID-19: Implications for Proposed Reforms to the Ryan Haight Act

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.

Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review

BACKGROUND

Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs.

METHOD

This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021.

REVIEW FINDINGS AND CONCLUSIONS

Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.

Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022

Importance

The COVID-19 pandemic reportedly increased behavioral health needs and impacted treatment access.

Objective

To assess changes in incident prescriptions dispensed for medications commonly used to treat depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), and opioid use disorder (OUD), before and during the COVID-19 pandemic.

Design, Setting, and Participants

This was a cross-sectional study using comprehensive, population-level, nationally projected data from IQVIA National Prescription Audit on incident prescriptions (prescriptions dispensed to patients with no prior dispensing from the same drug class in the previous 12 months) dispensed for antidepressants, benzodiazepines, Schedule II (C-II) stimulants, nonstimulant medications for ADHD, and buprenorphine-containing medication for OUD (MOUD), from US outpatient pharmacies. Data were analyzed from April 2018 to March 2022.

Exposure

Incident prescriptions by drug class (by prescriber specialty, patient age, and sex) and drug.

Main Outcomes and Measures

Interrupted time-series analysis to compare changes in trends in the monthly incident prescriptions dispensed by drug class and percentage changes in aggregate incident prescriptions dispensed between April 2018 and March 2022.

Results

Incident prescriptions dispensed for the 5 drug classes changed from 51 500 321 before the COVID-19 pandemic to 54 000 169 during the pandemic. The largest unadjusted percentage increase in incident prescriptions by prescriber specialty was among nurse practitioners across all drug classes ranging from 7% (from 1 811 376 to 1 944 852; benzodiazepines) to 78% (from 157 578 to 280 925; buprenorphine MOUD), whereas for patient age and sex, the largest increases were within C-II stimulants and nonstimulant ADHD drugs among patients aged 20 to 39 years (30% [from 1 887 017 to 2 455 706] and 81% [from 255 053 to 461 017], respectively) and female patients (25% [from 2 352 095 to 2 942 604] and 59% [from 395 678 to 630 678], respectively). Trends for C-II stimulants and nonstimulant ADHD drugs (slope change: 4007 prescriptions per month; 95% CI, 1592-6422 and 1120 prescriptions per month; 95% CI, 706-1533, respectively) significantly changed during the pandemic, exceeding prepandemic trends after an initial drop at the onset of the pandemic (level changes: -50 044 prescriptions; 95% CI, -80 202 to -19 886 and -12 876 prescriptions; 95% CI, -17 756 to -7996, respectively). Although buprenorphine MOUD dropped significantly (level change: -2915 prescriptions; 95% CI, -5513 to -318), trends did not significantly change for buprenorphine MOUD, antidepressants, or benzodiazepines.

Conclusions and Relevance

Incident use of many behavioral health medications remained relatively stable during the COVID-19 pandemic in the US, whereas ADHD medications, notably C-II stimulants, sharply increased. Additional research is needed to differentiate increases due to unmet need vs overprescribing, highlighting the need for further ADHD guideline development to define treatment appropriateness.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Primary Care Providers' Experiences Treating Opioid Use Disorder Using Telehealth in the Height of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic catalyzed a rapid shift in healthcare delivery towards telehealth services, impacting patient care, including opioid use disorder (OUD) treatment. Regulatory changes eliminated the in-person evaluation requirement for buprenorphine treatment, encouraging adoption of telehealth. This study focused on understanding experiences of primary care providers in predominantly rural areas who used telehealth for OUD treatment during the pandemic.

METHODS

Semi-structured interviews were conducted with 22 primary care providers. Participants practiced in 13 rural and 9 urban counties in Kentucky and Arkansas. Data were analyzed using conventional content analysis.

RESULTS

The pandemic significantly impacted healthcare delivery. While telehealth was integrated for behavioral health counseling, in-person visits remained crucial, especially for urine drug screenings. Telehealth experiences varied, with some facing technology issues, while others found it efficient. Telehealth proved valuable for behavioral health counseling and sustaining relationships with established patients. Patients with OUD faced unique challenges, including housing, internet, transportation, and counseling needs. Stigma surrounding OUD affected clinical relationships. Building strong patient-provider relationships emerged as a central theme, emphasizing the value of face-to-face interactions. Regarding buprenorphine training, most found waiver training helpful but lacked formal education.

CONCLUSION

This research offers vital guidance for improving OUD treatment services, especially in rural areas during crises like the COVID-19 pandemic. It highlights telehealth's value as a tool while acknowledging its limitations. The study underscores the significance of strong patient-provider relationships, the importance of reducing stigma, and the potential for training programs to elevate quality of care in OUD treatment.

How are state telehealth policies associated with services offered by substance use disorder treatment facilities? Evidence from 2019 to 2022

BACKGROUND

The COVID-19 pandemic led several states to adopt policies permitting the delivery of substance use disorder treatment (SUDT) by telehealth. We assess the impact of state-level telehealth policies in 2020 that specifically permitted audio or audiovisual forms of telehealth offerings among SUDT facilities.

PROCEDURE

Cross-sectional analysis of secondary data from between 2019 and 2022. Pre-pandemic, federal law permitted states to allow audiovisual telehealth modes for SUDT to a limited extent. 2020 laws permitted states to allow audio-only modes for the first time and strengthened ability to offer audiovisual modes. We compared national SUDT facility self-reported telehealth offerings in 2020 and beyond to 2019, in states that in 2020 had policies permitting audiovisual and audio only, compared to other states.

MAIN FINDINGS

Among outpatient SUDT facilities (n = 5227) present in all four years of our data, the proportion offering telehealth increased from 18% (n = 921) in 2019-26% in 2020, 60% in 2021, and 79% in 2022. We estimate an audiovisual and audio only policy in 2020 was associated with an increase in telehealth offering rates in 2022 of +16.5% points (pp) (95% CI [+10.4,+22.6]) compared to the rates in states with no such listed policy. There was little evidence of an influence on telehealth offering in 2020 (-2.9 pp, CI [-9.0,+3.2]) and 2021 (+0.6 pp, CI [-5.5,+6.7]).

CONCLUSIONS

The enactment of state-level telehealth policies that allow audio and audiovisual modalities may have increased SUDT facilities' likelihood of offering telehealth services two years after enactment.

Treatment of poppy seed tea misuse with buprenorphine in a telehealth practice: a case series

BACKGROUND

Poppy seed tea (PST) is a legally obtainable source of opiates made from the seeds of the opium poppy. Our large telehealth opioid use disorder (OUD) provider group has treated several patients with PST misuse.

METHODS

We retrospectively identified patients with primary PST use disorder treated with buprenorphine in a telehealth-only practice with first visits between January 2021 and December 2022. Patients were identified by having the word "poppy" in their enrollment note, and then charts were reviewed to determine which patients had primary PST misuse. Demographics, buprenorphine doses, and retention in treatment were recorded.

RESULTS

We identified 18 patients treated for PST use disorder. Fifteen (83.3%) identified as male, mean age was 40.4 (standard deviation 8.8) years, and patients resided in 10 different U.S. states. Median starting buprenorphine dose was 2 mg (interquartile range (IQR) 2-2.5 mg). Median stabilizing dose of buprenorphine was 16 mg daily (IQR 15-20.5 mg). As of June 2023, 5 patients (27.8%) were still in active treatment. Two patients (11.1%) had completed a planned, elective taper. Ten patients (55.6%) had unplanned discontinuation from treatment, and 3 patients (16.7%) discontinued for other reasons.

CONCLUSIONS

To our knowledge, this is the largest case series describing PST misuse in the U.S., and the first to demonstrate its treatment in the telehealth setting. PST use disorder is treatable with buprenorphine with doses similar to treatment of other opioid use disorders. Clinicians who treat patients with OUD should be aware of PST use disorder and its treatment.

Evaluation of urine drug screen falsification of results among patients with opioid use disorder receiving treatment in a telehealth model of care

INTRODUCTION

As telehealth models for treatment of opioid use disorder (OUD) are expanding, the field does not know the reliability of urine drug screening (UDS) in this setting. The objective of this study is to determine the rate of falsification of UDS testing among patients with OUD in active treatment with buprenorphine via a telehealth provider.

METHODS

This is a prospective cohort study of 899 randomly selected eligible patients, of which 392 participated in the final cohort that the study team used for analysis. The study mailed patients a UDS cup and asked them to return the sample by mail. After the UDS sample was received, a buccal swab was mailed, and the study asked patients to schedule a virtual meeting in which consent was sought and an observed buccal swab was obtained. We evaluated urine for evidence of falsification, and used buccal swabs to genetically match individuals to urine samples.

RESULTS

After exclusion criteria, 395 (52.3 %) of 755 patients who received a UDS kit returned it for analysis prior to knowledge of the study. Of that, 392 samples had sufficient quantity for testing. We determined 383 (97.7 %) to be human urine containing buprenorphine without indication of exogenous buprenorphine addition and with evidence of compliance. A total of 374 patients received a buccal swab kit and 139 (37.2 %) attended the consent/observed buccal swab session. One hundred and thirty-two patients consented and completed the swab under video observation, and 120 successfully sent the swab back to the external laboratory. Of the 120 buccal swabs received, 109 (90.8 %) were a genetic match, 10 (8.3 %) were indeterminate, and 1 (0.8 %) was a genetic mismatch.

CONCLUSIONS

This study of patients treated by a telehealth OUD provider demonstrated a low rate of urine test falsification.

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.

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.

Long-Term Prospects for Telemedicine in Opioid Use Disorder (OUD) Treatment: Results from a Longitudinal Survey of OUD Clinicians

BACKGROUND

During the pandemic, there was a dramatic shift to telemedicine for opioid use disorder (OUD) treatment. Little is known about how clinician attitudes about telemedicine use for OUD treatment are evolving or their preferences for future use.

OBJECTIVE

To understand OUD clinician views of and preferences regarding telemedicine.

DESIGN

Longitudinal survey (wave 1, December 2020; wave 2, March 2022).

SUBJECTS

National sample of 425 clinicians who treat OUD.

MAIN MEASURES

Self-reported proportion of OUD visits delivered via telemedicine (actual vs. preferred), comfort in using video visits for OUD, impact of telemedicine on work-related well-being.

KEY RESULTS

The mean reported percentage of OUD visits delivered via telemedicine (vs. in person) dropped from 56.9% in December 2020 to 41.5% in March 2022; the mean preferred post-pandemic percentage of OUD visits delivered via telemedicine was 34.8%. Responses about comfort in using video visits for different types of OUD patients remained similar over time despite clinicians having substantially more experience with telemedicine by spring 2022 (e.g., 35.8% vs. 36.0% report being comfortable using video visits for new patients). Almost three-quarters (70.9%) reported that most of their patients preferred to have the majority of their visits via telemedicine, and 76.7% agreed that the option to do video visits helped their patients remain in treatment longer. The majority (58.7%) reported that telemedicine had a positive impact on their work-related well-being, with higher rates of a positive impact among those who completed training more recently (68.5% of those with < 10 years, 62.1% with 10-19 years, and 45.8% with 20 + years, p < 0.001).

CONCLUSIONS

While many surveyed OUD clinicians were not comfortable using telemedicine for all types of patients, most wanted telemedicine to account for a substantial fraction of OUD visits, and most believed telemedicine has had positive impacts for themselves and their patients.

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.

Many Clinicians Implement Digital Equity Strategies To Treat Opioid Use Disorder

Drawing upon a longitudinal survey of clinicians who treat patients with opioid use disorder (OUD), we report changes over time in telemedicine use, clinicians' attitudes, and digital equity strategies. Clinicians reported less use of telemedicine (both video and audio-only) in 2022 than in 2020. In March 2022, 77.0 percent of clinician respondents reported implementing digital equity strategies to help patients overcome barriers to video visits.

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

IMPORTANCE

Little is known about the potential implications of the rapid transition to telehealth during the COVID-19 pandemic for treatment of opioid use disorder (OUD).

OBJECTIVE

To examine the association between telemedicine adoption during the COVID-19 pandemic and indicators of OUD treatment quality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed deidentified administrative claims data from OptumLabs Data Warehouse. Claims for telemedicine visits were included for both the prepandemic period (March 14, 2019, to March 13, 2020) and pandemic period (March 14, 2020, to March 13, 2021). Patients with OUD and continuous enrollment in either commercial insurance or Medicare Advantage plans were included. Clinicians who provided office-based OUD care were included and categorized into low, medium, or high telemedicine use groups. Patients were attributed to the clinician (and corresponding telemedicine use group) from whom they received a plurality of OUD visits.

MAIN OUTCOMES AND MEASURES

The 4 outcomes were all outpatient visits, OUD visits (in person vs telemedicine) within 90 days of an index visit, medications for OUD (MOUD) prescribing, and OUD-related clinical events (including drug overdose, inpatient detoxification and rehabilitation center stay, or injection drug use-related infections).

RESULTS

The analysis included 11 801 patients (mean [SD] age, 53.9 [15.7] years; 5902 males [50.0%]) who were treated by 1768 clinicians. Clinicians with low vs high telemedicine use conducted a mean (SD) of 2.1% (2.5%) vs 69.5% (18.6%) of their office visits virtually in the pandemic period. While telemedicine use for OUD increased significantly from the prepandemic to pandemic periods, total OUD visit volume (in person plus telemedicine) per patient episode remained stable among both high (2.6 to 2.7 visits per patient episode) and low (3.1 to 3.3 visits per patient episode) telemedicine use groups. In adjusted analyses comparing the prepandemic with pandemic periods, there was no differential change in MOUD initiation (adjusted odds ratio [OR], 1.00; 95% CI, 0.84-1.19), MOUD days' supply (differential change in days' supply, -0.27; 95% CI, -1.84 to 1.30), or OUD-related clinical events (adjusted OR, 1.01; 95% CI, 0.73-1.24) among patients who were treated by clinicians in low vs high telemedicine use groups.

CONCLUSIONS AND RELEVANCE

Results of this study revealed that clinical outcomes were similar among patients who were treated by clinicians with high and low telemedicine use during the COVID-19 pandemic, suggesting that telemedicine is a comparable alternative to in-person OUD care. There was no evidence that telemedicine was associated with increased access to or improved quality of OUD 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.

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.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

Opioid usage and COVID-19 prognosis: A systematic review and meta-analysis

The COVID-19 pandemic continues to have profound health, social, psychological, and economic ramifications. Infection by COVID-19 has been of concern in people who use opioids, as opioid use has been known to mediate immunosuppression and is associated with respiratory depression and end-organ damage. With differing modalities of opioid usage, the association between opioids and COVID-19 outcomes is not well understood. We performed a comprehensive systematic search of seven health science databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data, up to December 15, 2021. We identified a total of five related articles, which were included in this study. The meta-analysis showed that opioids have a significant association with ICU admission for COVID-19 patients (OR = 5.41, 95%CI: 1.85 to 15.79, P = 0.002). Use of opioids was also associated with higher mortality among patients with COVID-19 compared to non-users (OR = 2.74, 95%CI: 1.34 to 5.62, P = 0.034), while use of opioids was not significantly associated with need for mechanical ventilation (OR = 3.68, 95%CI: 0.85 to 15.90, P = 0.081). Furthermore, the adjusted analysis indicated that COVID-19 patients with a history of opioid use were more likely to be admitted to the ICU (OR = 3.57, 95%CI: 3.05 to 4.17, P<0.001) and have higher mortality rates (OR = 1.72, 95%CI: 1.09 to 2.72, P = 0.02), while there was no significant association with need for mechanical ventilation (OR = 2.09, 95%CI: 0.77 to 5.64, P = 0.146). Significant heterogeneity existed across the included studies. Patients using opioids with COVID-19 were at higher risk of ICU admission and mortality. Prospective studies are required to confirm these findings.