Telehealth for opioid use disorder: retention as a function of demographics and rurality

Association between different modalities of opioid use disorder-related care delivery and opioid use disorder-related patient outcomes: A retrospective cohort study

Objective

This study assessed the impact of different modalities of delivery of opioid use disorder (OUD)-related care on several patient outcomes.

Methods

This study was conducted among patients newly diagnosed with OUD and receiving OUD-related care between March 2020 and March 2022, using data from Epic Cosmos. We examined the association between the most common modality of OUD-related care delivery (audio-only vs. audiovisual vs. in-person) and the number of emergency department (ED) visits for any overdose and opioid-specific overdose and receipt of medication treatment for OUD (MOUD; primary). We also examined the association between the most common modality of OUD-related care delivery and all-cause ED visits, hospitalizations, and psychiatric-related hospitalizations (secondary outcomes). We estimated logistic regression for receipt of MOUD and negative binomial for all other outcomes.

Results

Most patients primarily received OUD-related care in person (87.6 %, n = 159,351), followed by audiovisual visits (11.3 %, n = 20,629) and audio-only visits (1.1 %, n = 1,869). The mean (SD) ages for these groups were 51.7 (15.9), 47.1 (15.0), and 51.1 (15.8) years, respectively. Compared to receiving OUD-related care primarily in-person, receiving care predominantly through audio-only or audiovisual visits was associated with a modest decrease in number of all-cause ED visits. Receiving OUD-related care primarily through audiovisual visits, compared to in-person care, was associated with a slight increase in the odds of receiving MOUD. No statistically significant differences were found between the care delivery modalities and the other outcomes we examined.

Conclusion

Telehealth, delivered via audio-only or audiovisual methods, appears to provide care of similar quality to in-person OUD care and may modestly reduce OUD-related ED visits while slightly increasing MOUD receipt. These findings support continued delivery of OUD-related care through telehealth and continuation of COVID-19-related policies.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative outpatient clinic data

QUESTION

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders (OUD), from large samples in the community.

GOAL

To determine sex disparities in non-medical opioid use (NMOU) at the end of treatment with medications for opioid use disorder (MOUD), using national data.

DESIGN

Observational study of outpatient MOUD programs in the "Treatment episode data set-discharges" (TEDS-D) for 2019.

PARTICIPANTS

Persons aged ≥ 18 in their first treatment episode, in outpatient MOUD-based therapy for heroin or other opioids (N = 10,065). The binary outcome was presence/absence of NMOU in the month prior to discharge.

RESULTS

In univariate analyses, males had higher odds of NMOU compared to females (odds ratio=1.22; p = 6.84 ×10-5 after Bonferroni correction). A multivariable logistic regression detected a relatively small male>female odds ratio of 1.14 (p = 0.0039), surviving adjustment for demographic variables and social determinants of health. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., if they were in the white racial category, and were not of hispanic ethnicity). Also, using by smoking, inhalation or injection routes (versus oral) was associated with greater odds of NMOU, irrespective of sex.

CONCLUSIONS

This national community sample shows that males overall have greater odds of NMOU in their first treatment episode with MOUD, a potential indicator of more unfavorable outcomes. Further analyses should examine the underpinnings of this disparity, including clinical severity features.

Patient and provider experiences with opioid use disorder care delivered via telehealth: A systematic mixed-studies review

INTRODUCTION

Since the onset of the COVID-19 pandemic and loosening of some opioid use disorder (OUD) treatment regulations in the U.S. and Canada, there has been a rapid rise in the use of telehealth for buprenorphine induction, maintenance, and counseling (tele-bupe). Previous reviews highlight that tele-bupe can expand access to OUD care and improve treatment retention, but none to date have synthesized patient and clinician experiences with and perceptions of this care.

OBJECTIVE

This review synthesized findings from quantitative, qualitative, and mixed-methods studies that examined patient and provider experiences with tele-bupe. We assessed the perceived effectiveness and acceptability of this treatment modality.

METHODS

Our systematic review followed PRISMA 2020 guidelines. In July 2023, we searched six databases using keywords 'telehealth AND opioid use disorder' (and related terms) for papers published in English. Papers were eligible for inclusion if they reported findings about patient or provider experiences. Two reviewers screened studies for inclusion; 40 studies were included. We used a data-based convergent synthesis design to extract and synthesize findings, and the Mixed-Methods Appraisal Tool to appraise studies.

RESULTS

Patients and providers hold generally positive views of tele-bupe and most support its continued use in some form, citing multiple benefits, including accessibility and convenience. Most studies also identified barriers to tele-bupe, including technological challenges. Patients and providers differed in how they thought telehealth affects the clinical relationship, with providers expressing more concern about rapport-building and patients stating that being in their own environments during visits facilitated comfort and openness. The findings also suggest that providers are conflicted about when and for whom tele-bupe is appropriate.

CONCLUSION

Overall, both patients and providers view tele-bupe favorably; however, providers are conflicted about the patients and situations for which it is appropriate, which may lead to inequities in who is offered this form of care.

Patient experiences with telehealth treatment for opioid use disorder in Alabama

INTRODUCTION

Telehealth-only provision of buprenorphine for the treatment of opioid use disorder (OUD) was first made possible during the COVID-19 pandemic. However, Alabama instituted a law in July 2022 that mandated an annual in-person visit in order to receive this treatment. In July 2023, our usually telehealth-only group established a temporary clinic in Birmingham to meet this requirement.

METHODS

The study administered a survey instrument to patients at the time of clinic check-in.

RESULTS

158 of 160 (98.8 %) patients completed the survey. Mean distance traveled was 86.4 (standard deviation (SD) 53.7) miles; time required for travel was mean 1.6 (SD 1.0) hours. Twenty-five patients (15.8 %) reported needing to find childcare to attend the visit and 40 patients (25.3 %) reported missing work to attend. Patients disagreed (median 2 on 1-5 Likert scale, interquartile range (IQR) <1-3>) that it is important to see their provider in-person, that seeing their provider in-person improves care or improves their ability to succeed in treatment, and that they have other OUD treatment resources in their community. Patients strongly agreed (median 5, IQR <5-5>) that OUD can be treated by telehealth without the need for an in-person visit.

CONCLUSIONS

An annual in-person visits requirement to receive telehealth OUD services imposed a significant burden on patients, was not desired by patients, and may be associated with harm.

Policies, adaptations, and ongoing challenges to naloxone, buprenorphine and nonprescription syringe access across four-states: Findings from an environmental scan and key informant interviews

Background

As the US opioid-involved morbidity and mortality increase, uptake and implementation of evidence-based interventions remain key policy responses. Respond to Prevent was a multi-component, randomized trial implemented in four states and two large pharmacy chains with the aim of improving the pharmacy's capacity to provide naloxone, dispense buprenorphine, and sell nonprescription syringes (NPS). We sought to provide context and assess how policies and organizational practices affect communities and pharmacies across the study states.

Methods

Using a multi-method approach we: 1) conducted an environmental scan of published literature and online materials spanning January 2015 to June 2021, 2) created timelines of key events pertaining to those policies and practices and 3) conducted semi-structured interviews with stakeholders (key informants) at the state and local levels (N=36) to provide further context for the policies and practices we discovered.

Results

Key informants discussed state policies, pharmacy policies and local practices that facilitated access to naloxone, buprenorphine and NPSs. Interviewees from all states spoke about the impact of naloxone standing orders, active partnerships with community-based harm reduction organizations, and some federal and state policies like Medicaid coverage for naloxone and buprenorphine, and buprenorphine telehealth permissions as key facilitators. They also discussed patient stigma, access in rural settings, and high cost of medications as barriers.

Conclusion

Findings underscore the important role harm reduction-related policies play in boosting and institutionalizing interventions in communities and pharmacies while also identifying structural barriers where more focused state and local attention is needed.

Use of in-network insurance benefits is critical for improving retention in telehealth-based buprenorphine treatment

An empiric evidence base is lacking regarding the relationship between insurance status, payment source, and outcomes among patients with opioid use disorder (OUD) on telehealth platforms. Such information gaps may lead to unintended impacts of policy changes. Following the phase-out of the COVID-19 Public Health Emergency, states were allowed to redetermine Medicaid eligibility and disenroll individuals. Yet, financial barriers remain a common and significant hurdle for patients with OUD and are associated with worse outcomes. We studied 3842 patients entering care in 2022 at Ophelia Health, one of the nation's largest OUD telehealth companies, to assess associations between insurance status and 6-month retention. In multivariable analyses, in-network patients who could use insurance benefits were more likely to be retained compared with cash-pay patients (adjusted risk ratio [aRR]: 1.50; 95% CI: 1.40-1.62; P < .001). Among a subsample of 882 patients for whom more detailed insurance data were available (due to phased-in electronic health record updates), in-network patients were also more likely to be retained at 6 months compared with insured, yet out-of-network patients (aRR: 1.86; 95% CI: 1.54-2.23; P < .001). Findings show that insurance status, and specifically the use of in-network benefits, is associated with superior retention and suggest that Medicaid disenrollment and insurance plan hesitation to engage with telehealth providers may undermine the nation's response to the opioid crisis.

A qualitative study to determine perspectives of clinicians providing telehealth opioid use disorder treatment

BACKGROUND

Telehealth-only medication for opioid use disorder (teleMOUD) treatment with buprenorphine was first made possible in the United States during the COVID-19 Public Health Emergency. As a result, several large provider groups now treat opioid use disorder (OUD) patients in nearly every state using telehealth. This study evaluates the perceptions and experiences of providers working almost exclusively in a teleMOUD program.

METHODS

Qualitative interviews were conducted with 18 providers (physicians, physician assistants and nurse practitioners) using a semi-structured interview guide. Interviews were recorded, transcribed and reviewed. After reviewing the transcripts, a codebook was developed, interviews were coded, and coded excerpts were analyzed for key themes.

RESULTS

Inductive codes were used to organize provider responses and included patient-level codes, provider-level codes, and telehealth environment codes. For providers, there are benefits of a flexible and less stressful working environment, which contribute to a higher quality of life. Providers also expressed mixed feelings regarding professional identity and focusing specifically on OUD, differences in relationships with colleagues, and challenges related to policy changes and ambiguities. For patients, providers perceived greater access, less stigma, more convenience, and a unique provider-patient relationship compared to in-person treatment. These themes affect providers and patients on multiple levels of the social-ecological model.

CONCLUSIONS

Multiple themes emerged in this study. This work is amongst the first to describe perspectives of providers working in the nascent teleMOUD setting, and can inform initiatives to improve provider wellness, provider retention, and quality of care for patients treated in the setting.

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.

The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices

The opioid epidemic is a significant public health crisis that has caused extensive harm and devastation in the United States. This literature review aimed to identify the contributing factors and negative consequences of the epidemic, as well as best practices for healthcare providers in managing the epidemic. Overprescribing opiates and opioids, lack of education and opportunity, and being unmarried or divorced were some of the identified contributing factors to dependence on opioids. The epidemic's negative consequences are substantial, leading to increased access to opioids for vulnerable populations, which consequently cause accidental death among men and the degradation of rural community health services. As part of the literature review, we also analyzed the best practices for healthcare providers, including implementing prescription drug monitoring programs (PDMPs). However, we found that while PDMPs resulted in a decrease in opioid overprescription and an increase in provider confidence when prescribing medication, the evidence for their effectiveness in improving rural community health services or reducing opioid overdoses and opioid-related deaths was inconclusive. Our review highlights that the greatest challenge to overcome is a lack of legal mandates and proper education for healthcare providers on best practices for addressing the epidemic. To regulate and control opioids effectively, tracking and standardizing prescription models by federal agencies and medical institutions is necessary but not enough. Legal action is vital for the successful containment of the opioid crisis.