Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study

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.

A Qualitative Evidence Synthesis of Patient and Provider Attitudes Toward Audio-Only Telemental Health Care

Background: Audio-only (phone) telemental health care can increase access to care, but its lack of nonverbal information may negatively impact care quality as compared to video or in-person visits. The objective of this work was to understand patient and provider attitudes toward phone care via a review of qualitative research. Methods: A qualitative evidence synthesis was conducted of peer-reviewed qualitative research published between 2013 and 2023. Studies were required to include qualitative data regarding patient and/or provider attitudes toward audio-only telemental health care. Results pertinent to phone care were extracted and underwent coding followed by theme identification. Results: We identified 2,065 abstracts and 29 articles were ultimately included in the synthesis; 27 of these studies were conducted during the COVID-19 pandemic. Five themes described benefits of phone care, nine described drawbacks, and three themes were neutral. Phone care was seen as easy to use, particularly for briefer check-ins or as a back-up option if video calls failed, and some patients preferred the privacy of not being seen. However, the loss of visual information during phone visits was considered particularly challenging in the treatment of more complex or severe patients; providers questioned whether they were able to provide high quality care, and patients reported feeling less supported and understood by their providers. Conclusions: The relative benefits and drawbacks of audio-only telemental health care must be carefully weighed against the options of video or in-person treatment based on patient needs and severity. Future work should continue to examine patient and provider attitudes toward phone care as the mental health landscape evolves postpandemic.

Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study

BACKGROUND

Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed.

OBJECTIVE

To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care.

DESIGN

Comparative case study, using video- and telephone-based semi-structured interviews.

PARTICIPANTS

Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system.

APPROACH

Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process.

KEY RESULTS

Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference.

CONCLUSIONS

Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

Internet-based, continuously available Narcotics Anonymous meetings: a new resource for access to Twelve Step support for abstinence

Background: A Zoom-based website was developed in 2020 that offers continuous access to online Narcotics Anonymous (NA) meetings for the first time. This website provides immediate access for persons with substance use disorder to support abstinence from substance-related addictive disorders.Objectives: This study is designed to characterize attendees employing this online format; to evaluate their experiences for gaining support to maintain abstinence; and to compare the 24/7 experience to face-to-face (FF) meetings they attend.Methods: An anonymous 33-item survey was made available on the 24/7 NA website that links to the 24/7 meetings. Persons accessing the site could choose to fill out the survey.Results: 530 respondents completed the survey (64.9% female/35.1% male). Most had stable prior involvement in NA. They had attended more 24/7 meetings (14.9, SD 19.7) than FF meetings (4.6, SD 7.8) in the previous month. 86% had previously attended FF meetings, 48% had served as sponsors, and 92% reported that the 24/7 meetings were more comfortable for them than the FF meetings (p < .001, Cohen's d = 0.65) and more supportive of abstinence (p < .001, Cohen's d = 0.91). Of the respondents, 8% were still using drugs, of whom 52% had previously completed some of the Twelve Steps.Conclusions: The 24/7 format provides a new and easily accessible way for NA members to gain support for abstinence and is positively rated by attendees seeking support for recovery from substance use disorders. It may serve as a valuable adjunct to the traditional FF format.

Identifying Factors Associated With Variation in Telemental Health Delivery at Federally Qualified Health Centers

BACKGROUND

COVID-19 accelerated federally qualified health centers' use of telemental health. However, factors associated with telemental health service delivery remain unclear. We examined telemental health delivery by clinician type and mental health workforce composition across the U.S. to understand how staffing and other organizational characteristics are related to telemental health delivery at health centers.

METHODS

Using data from the 2021 Uniform Data System, we characterized the proportion of mental health care delivered via elemental (i.e., virtual visits) at health centers in the U.S. that received HRSA grant funding (n = 1,270) overall and by state and clinician type. Then, we conducted multivariate beta regression analyses to assess the proportion of mental health visits delivered via telemental health at health centers as a function of mental health workforce composition, while adjusting for health center size, patient mix, and state.

RESULTS

In 2021, health centers delivered 43% of their mental health visits via telemental health, with significant variation by state and clinician type. On average, the proportion of mental health visits delivered via telemental health was greater among psychiatrists (61%, P < .001) than psychologists (49%) and clinical social workers (45%). Factors significantly associated with the increased proportion of telemental health delivered by health centers included a higher supply of psychiatrists per patient, more grant dollars per patient, and a greater proportion of Asian patients served.

CONCLUSIONS

Access to telemental health varies by state and across health centers based on mental health workforce composition. Future work is needed to examine funding and workforce strategies to increase telemental health service availability.