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

The Association Between COVID-fear with Psychological Distress and Substance Use: the Moderating Effect of Treatment Engagement

The purpose of this brief report was to examine the association between COVID-fear with psychiatric symptoms severity and substance use risk in an outpatient population with co-occurring substance use and mental health disorders and whether these associations were moderated by treatment engagement, especially after providers had shifted from an in-person care model to a telehealth format. A total of 136 patients receiving outpatient treatment for comorbid substance use and mental health disorders completed self-report questionnaires on their psychiatric symptoms, substance use, and treatment engagement (i.e., frequency, length, and helpfulness of phone and video sessions with a mental health counselor, psychiatrist, or primary care provider) in the past month between November 2020 and March 2021. Results showed that COVID-fear was significantly associated with psychiatric symptom severity, but not substance use risk. Additionally, perceived helpfulness of phone counseling sessions moderated the associations between COVID-fear and global psychiatric symptom severity, such that COVID-fear and global psychiatric symptom severity were positively associated when perceived helpfulness was low, and not associated if perceived helpfulness was high. The present results highlight the importance of directly addressing fears specific to a national emergency, as well as for providers to build strong rapport with their clients.

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

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

Mental Health Providers' Challenges and Solutions in Prescribing Over Telemedicine: Content Analysis of Semistructured Interviews

BACKGROUND

In response to the COVID-19 pandemic, the United States extended regulatory flexibilities to make telemedicine more accessible to providers and patients. Some of these flexibilities allowed providers to intake patients over telemedicine and prescribe certain scheduled medications without an in-person visit.

OBJECTIVE

We aim to understand providers' parameters for their comfort in prescribing over telemedicine and report on solutions providers have adopted in response to potential barriers and challenges in prescribing via telemedicine.

METHODS

As part of a larger mixed methods study between February and April 2024, we conducted 16 semistructured interviews with mental health providers who prescribe via telemedicine within the United States. We used the results of a web-based, cross-sectional survey to develop a codebook and support recruitment. We analyzed a subsection of the 16 interviews using content analysis to capture comfort, barriers, and workarounds in telemedicine prescribing. We reported codes by frequency and by provider.

RESULTS

Participants were typically male (11/16, 69%), provided care mostly or completely over telemedicine (11/16, 69%), and were psychiatrists (8/16, 50%) or other physician (3/16, 19%). Providers' primary states (10/16, 62%) of practice included Oregon, Texas, New York, and California. The content analysis yielded a total of 234 codes, with three main codes-comfort (98/234, 41.9%), barriers or challenges (85/234, 36.3%), and workarounds or solutions (27/234, 11.5%)-and two subcodes-uncomfortable prescribing (30/98, 31%) and comfortable prescribing (68/98, 69%) over telemedicine. Participants reported being comfortable prescribing over telemedicine as long as they could meet their main parameters of working within their expertise, having access to needed patient health information, and being compliant with rules and regulations. Participants reported frustrations with e-prescription workflows and miscommunications with pharmacies. Solutions to ease frustrations and alleviate discomforts in prescribing over telemedicine included developing workflows to help patients complete laboratory tests and physical examinations and directly communicating with pharmacies.

CONCLUSIONS

By applying content analysis to the semistructured provider interviews, we found that physicians are comfortable prescribing via telemedicine when they feel they are practicing within their personal parameters for safety. While many providers experience frustrations such as miscommunication with pharmacies, these barriers appear to not prevent them from telemedicine prescribing. With expected changes in 2024 and 2025 to the US laws and regulations for telemedicine prescribing, we may see changes in provider comfort in prescribing.

The first five years of implementing Missouri's medication first approach to opioid use disorder treatment: Plateaus, regressions, and underbellies of progress

INTRODUCTION

Missouri's Medication First ("MedFirst") approach promotes same-day and long-term low-threshold access to medications for opioid use disorder (MOUD). Since 2017, Missouri's SAMHSA-funded State Targeted and State Opioid Response (STR/SOR) grants have supported MedFirst services (both medical and psychosocial) for uninsured individuals with opioid use disorder at state-contracted treatment programs. Though MedFirst demonstrated early success, results - with attention to possible racial disparities - must be revisited after five years of implementation.

METHODS

Using state behavioral health claims, we examined four outcomes: (1) MOUD utilization, (2) time-to-medication, (3) psychosocial service volume, and (4) substance use disorder (SUD) treatment retention. Models compared four groups: (a) individuals in MedFirst during the first and fifth year of implementation (2018 vs. 2022), (b) individuals in MedFirst compared to non-MedFirst, (c) individuals prior to MedFirst (2017) compared to individuals during MedFirst's fifth year (2022), and (d) White compared to Black individuals within and outside MedFirst.

RESULTS

Overall, MedFirst outcomes were superior to non-MedFirst outcomes. Among individuals in MedFirst, however, outcomes were generally poorer in 2022 than in 2018, and Black individuals had shorter treatment episodes and were less likely to receive MOUD than White individuals. Overall, Missourians had only slightly better outcomes in 2022 than prior to STR/SOR initiation.

CONCLUSIONS

Since Missouri's initial implementation of STR/SOR-funded MedFirst, select overall treatment outcomes have improved. Within MedFirst programs, however, outcomes worsened over time, and racial disparities were evident. Though fentanyl's dominance of the drug supply alongside the COVID-19 pandemic contributed to these results, fidelity drift, particularly due to financial implications of MedFirst, likely also negatively impacted sustainability.

Peer-assisted telemedicine hepatitis-C treatment for people who use drugs in rural communities: a mixed methods study

BACKGROUND

The increase in opioid use disorder among young, nonurban people has fueled sharp rises in hepatitis C virus (HCV) infections. Innovative treatment models are needed that circumvent healthcare system barriers for people who use drugs (PWUD), particularly in rural areas. The Oregon HOPE TeleHCV study randomized PWUD living with HCV in rural Oregon to peer-facilitated and streamlined telemedicine HCV treatment (Peer TeleHCV) versus enhanced usual care (EUC) and assessed sustained virologic response at 12 weeks post treatment (SVR12). Peer Support Specialists (peers) conducted HCV screening in the community, facilitated pretreatment evaluation and linkage to telemedicine HCV treatment clinicians, and supported Peer TeleHCV study participants in HCV medication adherence. A qualitative investigation queried telemedicine clinicians and peers about their experiences with the implementation of the model and key drivers of implementation effectiveness.

METHODS

Two remote audio/video recorded focus groups were conducted, one with the study's clinicians and one with the peers. Participants were asked their views of key elements for successful implementation and outcomes of the Peer TeleHCV model. Group interviews lasted one hour. Recordings were professionally transcribed for thematic analysis with a mixed deductive and inductive framework, using Atlas.ti. Patients were surveyed about their interactions and satisfaction with peers.

RESULTS

Quantitative data (n = 78) indicated patients had high levels of satisfaction with and support from the peers. Three themes were identified from the qualitative data (n = 12) including. (1) Key peer-level elements such as providing support during potentially difficult lab draws, creating a peer-facilitated "bubble of trust" between patients and clinicians, enabling technology access, conducting outreach to maintain contact and support treatment retention, and facilitating stabilizing wrap-around services (e.g., housing vouchers) (2) Key clinician-level factors such as capacity for unscheduled peer-facilitated appointments, having dedicated time for case consults with peers, and clinicians trained in working with PWUD and skilled in identifying related clinical concerns (3) Key systems-level elements such as standing lab orders, challenges related to specialty pharmacies and Medicaid managed care organizations, and streamlined communication strategies between peers and clinicians.

CONCLUSION

All participants reported that the Peer TeleHCV model built trust and eased barriers for PWUD initiating and remaining in HCV treatment. This low-barrier model makes space for PWUD to receive HCV treatment, regardless of drug use. Implementing support from peer specialists, telemedicine technology, and streamlined testing and treatment strategies may connect more rural PWUD living with HCV with the cure.

Acceptance and adoption determinants of telemedicine in public healthcare institutions

BACKGROUND

 One of the challenges facing the usage of telemedicine technology in South Africa, particularly in the North West province (NWP), is lack of user acceptance by health care professionals which prevents piloted project to produce the desired outcomes.

OBJECTIVES

 The purpose of this study was to investigate the influential factors for the adoption of telemedicine by health care professionals from three selected hospitals (Bophelong, Taung and Klerksdorp) in the NWP.

METHOD

 The study adopted a case study approach and gathered data through questionnaires, which were distributed to the health care professionals of the three selected hospitals. In order to ensure that the instrument was accurate, a pilot study was carried out prior to the main investigation. Both the alpha and power values were set at 0.05 for the statistical analysis. The statistical tool used for the data analysis was SPSS v. 23.0.

RESULTS

 Attitude towards the use of telemedicine technology (ATUTT), perceived usefulness (PU) and acceptance of telemedicine technology (ATT) were considered to be the influential factors in the adoption of telemedicine technology. The association between perceived ease of use (PEOU) and perceived usefulness (PU) (0.150, p = 0.034), PEOU and Attitude towards the use of telemedicine technology (ATUTT) (0.211, p = 0.002), PEOU and Acceptance of telemedicine technology (ATT) (0.245, p = 0.000), PU and (ATT) (0.212, p = 0.002), ATUTT and (ATT) (0.189, p = 0.005). However, PEOU was found to have an insignificant relationship with (0.048, p = 0.093). Hypotheses 1, 3, 4, 5, and 6 are supported while H2 was not supported.

CONCLUSION

 The study aims to fill the knowledge vacuum identified, helping poor countries effectively implement telemedicine technology to modernise the health care sector. In addition, results from this study shed insight on the varied impacts of individual, technical, clinical and multidimensional social influence variables on health care providers' decisions to use telemedicine.Contribution: This study contributes to the body of knowledge by investigating the success factors for telemedicine technology adoption in South African public hospitals. These results have important implications for the public health care system in South Africa, both for the direction of future research and for the methods used to promote the use of telemedicine.

Impact of COVID-19 on Substance Use Disorder Treatment: Examining the Influence of In-Person and Telehealth Intervention on Outcomes Using Real-World Data

Background: The COVID-19 health crisis challenged healthcare systems around the world, leading to restrictions in access to face-to-face healthcare services, and forcing rapid adaptation to telehealth services. At present, there is a gap in the functioning of this adaptation in drug-dependence centres. The present study analyses, over four years, care indicators on the care modality (face-to-face vs. hybrid), the patient profile and the impact on retention in treatment. Methods: Retrospective observational study with data collected between 14 March 2019 and 21 June 2023. The electronic health records of 44,930 patients were analysed according to different moments and selected based on the different health measures imposed by the COVID-19 pandemic. Patients were classified according to whether they received an in-person or hybrid intervention. Bivariate statistics and logistic regression analysis were applied. Results: The trend over time shows an increase in the number of patients seen in addiction centres. However, no notable changes within the in-person care modality and a modest increase in telehealth services are observed. Telehealth is primarily used among patients with opiate addiction, as well as with those with comorbid mental disorders. Logistic regression analysis shows that patients in a hybrid modality are more likely to remain in treatment. Conclusions: Results show that hybrid care is associated with higher patient retention rates. Despite this, different profiles are mostly treated with in-person interventions rather than hybrid modalities. Future studies should explore how to generalise personalised hybrid care among SUD patients considering factors such as patients' educational level, employment status or accessibility to mental health services.

[Ethical challenges of telepsychiatry]

Telepsychiatry is shifting the focus of psychiatry and psychotherapy from personal interaction and relationship building to communication with technological mediators in the form of telecommunication, virtual reality (VR), social robots or artificial intelligence (AI). This article discusses the opportunities and risks of new technologies in psychiatric treatment, taking into account the principles of medical ethics. Telepsychiatric treatments can promote self-determination in the home environment as opposed to institutionalisation but carry the risk of uncontrolled data sharing. They harbour risks of potential harm such as social isolation, negative effects on the doctor-patient relationship and long-term changes in patient behaviour through, for example, VR. In terms of justice, demographic and psychopathological factors could result in unequal access to telepsychiatry, with questionable sustainability effects. The anonymity of telepsychiatry threatens alienation, while moral considerations cannot be replaced by AI for the time being. It is obligatory to carefully weigh up the benefits and risks of telepsychiatry, but especially in rural areas they could optimise care.Precisely because of ethical concerns, further intensive research is necessary to weigh up the risks and benefits. The development of telepsychiatric systems requires transdisciplinary co-operation. At a societal level, the significance of technologies as a supplement or replacement for the doctor-patient relationship needs to be discussed.

Impact of COVID-19 on MOUD retention in a sample of rural primary care patients: A secondary analysis of electronic health records

Introduction

There is limited research examining factors impacting MOUD retention in rural settings, especially within the context of the COVID-19 pandemic. Using electronic health records data collected as part of a NIDA Clinical Trials Network study (CTN-0102), this study explored how the onset of the COVID-19 pandemic may have impacted MOUD retention in a sample of 563 rural primary care patients.

Methods

Cox regression model was applied to examine if COVID-19 was related to treatment retention, controlling for demographics, clinic, insurance type, and other diagnoses. The independent variable was the number of days between the patient's first MOUD prescription date during the pre-COVID observation period (10/1/2019-3/13/2020) and the start of the COVID-19 pandemic. The dependent variable was retention on MOUD, defined as the time from the first MOUD prescription documented during the pre-COVID observation period to the first break in consecutive MOUD prescriptions (right censored at 180 days).

Results

The findings demonstrated that there was a reduced risk of a prescription break for every 10-day increase in the time from the first documented MOUD prescription to the onset of the COVID-19 pandemic (HR = 0.96, 95 % CI = 0.92-0.99; p = 0.011).

Conclusions

While the data did not include complete treatment histories to determine who was new to MOUD treatment, the findings suggest that patients whose first documented MOUD prescription in the dataset was closer to the onset of the pandemic had a greater likelihood of experiencing retention challenges. This underscores the importance for clinics to establish comprehensive contingency plans for future emergencies to ensure uninterrupted MOUD treatment and support, particularly for individuals in the early stabilization phase of their recovery.

Comparison of Use Rates of Telehealth Services for Substance Use Disorder During and Following COVID-19 Safety Distancing Recommendations: Two Cross-Sectional Surveys

Background

The COVID-19 social distancing guidelines resulted in a dramatic transition to telephone and video technologies to deliver substance use disorder (SUD) treatment. Before COVID-19, the question was "Will telehealth ever take hold for SUD services?" Now that social distancing guidelines have been lifted, the question is "Will telehealth remain a commonly used care modality?"

Objective

The principal purpose of this investigation was to examine the extent to which telehealth use in SUD service settings persisted following the lifting of COVID-19 safety distancing recommendations. Additionally, the study aimed to explore practitioners' perceptions of telehealth convenience and value after its regular implementation during the pandemic. Specifically, the goal of this study was to compare telehealth activity between time intervals: May-August 2020 (during peak COVID-19 safety distancing recommendations) and October-December 2022 (following discontinuation of distancing recommendations). Specifically, we compared (1) telehealth technologies and services, (2) perceived usefulness of telehealth, (3) ease of use of telephone- and video-based telehealth services, and (4) organizational readiness to use telehealth.

Methods

An online cross-sectional survey consisting of 108 items was conducted to measure the use of telehealth technologies for delivering a specific set of SUD services in the United States and to explore the perceived readiness for use and satisfaction with telephonic and video services. The survey took approximately 25-35 minutes to complete and used the same 3 sets of questions and 2 theory-driven scales as in a previous cross-sectional survey conducted in 2020. Six of 10 Regional Addiction Technology Transfer Centers funded by the Substance Abuse and Mental Health Services Administration distributed the survey in their respective regions, collectively spanning 37 states. Responses of administrators and clinicians (hereafter referred to as staff) from this 2022 survey were compared to those obtained in the 2020 survey. Responses in 2020 and 2022 were anonymous and comprised two separate samples; therefore, an accurate longitudinal model could not be analyzed.

Results

A total of 375 staff responded to the 2022 survey (vs 457 in 2020). Baseline organizational characteristics of the 2022 sample were similar to those of the 2020 sample. Phone and video telehealth utilization rates remained greater than 50% in 2022 for screening and assessment, case management, peer recovery support services, and regular outpatient services. The perceived usefulness of phone-based telehealth was higher in 2022 than in 2020 (mean difference [MD] -0.23; P=.002), but not for video-based telehealth (MD -0.12; P=.13). Ease of use of video-based telehealth was perceived as higher in 2022 than in 2020 (MD-0.35; P<.001), but no difference was found for phone-based telehealth (MD -0.12; P=.11). From the staff's perspective, patients had greater readiness for using telehealth via phone than video, but the staff perceived their personal and organizational readiness for using telehealth as greater for video-based than for phone-based telehealth.

Conclusions

Despite lower telephone and video use in 2022 for telehealth services than in 2020, both modalities continue to be perceived positively. Future research may further determine the relative cost and clinical effectiveness of video-based services and thereby help to address some sources of the noted challenges to implementation by SUD organizations.

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.

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.