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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers

BACKGROUND

Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk.

METHOD

Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model.

RESULTS

The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested.

CONCLUSIONS

Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Referral of patients from rural primary care clinics to telemedicine vendors for opioid use disorder treatment: A mixed-methods study

INTRODUCTION

Rural primary care clinics can expand their medication treatment for opioid use disorder (MOUD) capacity by coordinating care with external telemedicine (TM) vendors specializing in addiction medicine. This study used mixed methods to identify factors that influence patient referrals from rural primary care clinics to TM vendors for MOUD.

METHODS

Between July/August 2020 and January/February 2021, 582 patients with OUD were identified across six primary care sites; that included 68 referred to an external TM vendor to receive MOUD. Mixed effects logistic regression identified individual and site-level factors associated with being referred to the TM vendor. Clinic providers and staff participated in in-depth interviews and focus groups to discuss their considerations for referring patients to the TM vendor.

RESULTS

Patient referrals were positively associated with local household broadband coverage (OR = 2.55, p < 0.001) and negatively associated with local population density (OR = 0.01, p  =  0.003) and the number of buprenorphine prescribers in the county (OR = 0.85, p < 0.001). Clinic personnel expressed appreciation for psychiatric expertise and the flexibility to access MOUD brought by the TM vendor. Perceived concerns about TM referral included a lack of trust with external providers, uncertainty about TM service quality, workflow delays, and patients' technological and insurance challenges.

CONCLUSION

This study revealed several clinic-level factors that may potentially influence patient referral to TM vendor services for MOUD. To facilitate the referral process and utilization of TM vendors, efforts should be made to foster open communication and trust between clinic providers and TM vendors, streamline workflows, and improve Internet access for patients.

Missed Opportunities: Substance Use Hotline Operator Uncertainty of State Buprenorphine Prescribing via Telemedicine

OBJECTIVES

We examined substance use hotline operator certainty of each US state and Washington, DC's endorsement of buprenorphine (initiation and continuation) prescribing via telemedicine.

METHODS

Between March and May 2021, we called hotlines in 50 US states and Washington, DC, requesting information on whether practitioners in that state could initiate or continue buprenorphine treatment for opioid use disorder (OUD) via telephone or video conference. We compared operator responses to state implementation of buprenorphine telemedicine initiation. This study was designated as not human subjects research by the Boston University Institutional Review Board.

RESULTS

We spoke with operators in 47 states and Washington, DC. Operators could not be reached in Alaska, California, and Montana. Most operators were uncertain (don't know, probably yes, probably no) whether the state permitted buprenorphine initiation (81%, n = 39) or continuation (83%, n = 40) via telemedicine. Practitioners could initiate buprenorphine prescribing via telemedicine in 7 states (100%) where operators were certain practitioners could initiate buprenorphine, 1 state (100%) where the operator was certain practitioners could not, and 6 states (86%) where operators indicated practitioners probably could not.

CONCLUSIONS

Most US states and Washington, DC, expanded the role of telemedicine in OUD treatment. However, most operators expressed uncertainty and sometimes communicated inaccurate information regarding whether practitioners could initiate buprenorphine treatment via telemedicine. There is an urgent need for policy mandates institutionalizing the role of telemedicine, and of buprenorphine specifically, in OUD treatment and for resources to train and support substance use hotline operators in this evolving policy environment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Pilot trial of a telehealth-delivered behavioral economic intervention promoting cannabis-free activities among adults with cannabis use disorder

BACKGROUND

Cannabis is increasingly consumed and increasingly perceived as harmless. Among those whose use develops into a cannabis use disorder (CUD), <5% initiate and engage in treatment. Thus, novel options for low-barrier, appealing treatments are needed to foster engagement in care.

METHODS

We conducted an open trial of a telehealth-delivered multicomponent behavioral economic intervention for non-treatment-engaged adults with CUD. Participants with CUD were recruited from a health system and screened for eligibility. Participants completed behavioral economic indices (cannabis demand, proportionate cannabis-free reinforcement), measures of cannabis use and mental health symptoms, and provided open-ended feedback on the intervention experience.

RESULTS

Of the 20 participants who enrolled and engaged in the initial intervention session, 70% (14 out of 20) completed all intervention components. All participants were satisfied/very satisfied with the intervention and 85.7% reported the telehealth delivery made it at least slightly easier/more likely for them to receive substance use care. Baseline to immediate post-treatment, behavioral economic cannabis demand decreased (intensity: Hedges' g = 0.14, maximum total expenditure: Hedges' g = 0.53, maximum expenditure for a single hit: Hedges' g = 0.10) and proportionate cannabis-free reinforcement (Hedges' g = 0.12) increased. Past-month total cannabis use decreased by 8.9% from baseline to post-treatment (Hedges' g = 0.39), along with decreases in recent depression (Hedges' g = 0.50) and anxiety symptoms (Hedges' g = 0.29).

DISCUSSION

These preliminary findings suggest that this behavioral economic intervention was highly acceptable and feasible for adults with untreated CUD. Changes in potential mechanisms of behavior change (cannabis demand, proportionate cannabis-free reinforcement) were consistent with reduced frequency of cannabis use and improved mental health outcomes.

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.

Temporal association of pre-pandemic perceived social support with psychological resilience and mental well-being during the COVID-19 pandemic among people with a history of injection drug use

BACKGROUND

There are limited data on whether modifiable social factors foster psychological resilience and mental well-being among people who use drugs following Big Events. We examined the temporal association of pre-pandemic perceived social support with psychological resilience and negative mental health symptoms during the COVID-19 pandemic among people with a history of injection drug use.

METHODS

Between June and September 2020, we conducted a telephone survey among 545 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study: a community-based cohort of adults with a history of injection drug use. Leveraging data from study visits in 2018-early 2020, associations of pre-pandemic perceived social support with psychological resilience scores (range=1-5) and the probability of negative mental health symptoms during the pandemic were assessed using multivariable linear and modified Poisson regression models, respectively.

RESULTS

Participants' median age was 58 years, 38.2% were female, 83.3% identified as Black, and 30.3% were living with HIV. During the pandemic, 14.5% had low (<3) resilience scores, 36.1% experienced anxiety, and 35.8% reported increased loneliness. Compared to participants in the lowest tertile of pre-pandemic social support, participants in the highest tertile had higher mean resilience scores (β = 0.27 [95% CI = 0.12, 0.43]), a lower probability of anxiety (prevalence ratio [PR] = 0.71 [95% CI = 0.52, 0.96]), and a lower probability of increased loneliness (PR = 0.62 [95% CI = 0.45, 0.84]).

CONCLUSIONS

Pre-pandemic perceived social support was associated with greater psychological resilience and generally better mental well-being during the pandemic. Interventions that improve social support may foster psychological resilience and protect the mental well-being of people who use drugs, especially during periods of social disruption.