Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics

"The people who depended on us became expendable": Experiences of frontline workers with lived and living expertise of drug use during the COVID-19 pandemic

BACKGROUND

This paper explores the perspectives of a group of people with lived and living expertise of unregulated drug use who worked as frontline harm reduction service providers and activists in Canada during the dual public health emergencies of COVID-19 and the toxic drug crisis. Specifically, this paper explores their initial experiences at the onset of the COVID-19 pandemic, their reflections on how these experiences varied one year into the pandemic, and their perspectives on how shifting public health measures and policies shaped their work.

METHODS

Drawing on collaborative research methods, this project was developed with a national working group of people with lived and living expertise of substance use. Three rounds of roundtable discussions along with two sets of semi-structured interviews were conducted with working group members from May 2020 to June 2021. A thematic analysis was co-developed by academic facilitators and the working group through deductive and indictive group coding and reflexive analysis.

RESULTS

Four themes emerged from the interviews and roundtable sessions: (1) initial negative impacts of COVID-19-related public health measures; (2) societal abandonment, collective anger and grief; (3) navigating constantly shifting public health emergencies over time; and (4) leveraging lived expertise to create positive change.

CONCLUSIONS

The COVID-19 pandemic, in concert with the toxic drug crisis, presented many challenges for working group members on the frontlines to continue their work providing essential services to people who use unregulated drugs in Canada. The experiences shared by this unique group demonstrate these challenges, as well as how the immediate and long-term impacts of these dual public health emergencies provided opportunities for innovating and advocating for sustainable policy changes.

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.