Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Telepharmacy Implementation to Support Pharmaceutical Care Services during the COVID-19 Pandemic: A Scoping Review

Background

Telepharmacy was effectively applied for remote pharmaceutical care during the COVID-19 pandemic.

Objectives

To determine the implementation of telepharmacy services to support pharmacists in providing pharmaceutical care during the pandemic.

Data Sources

Seven electronic databases were searched from inception to June 2021: PubMed, Ovid MEDLINE, Excerpta Medica database (Embase), Web of Science, Proquest, Scopus, and the Cochrane Database of Systematic Reviews.

Study Selection and Data Extraction

The review followed PRISMA guidelines and was registered with the PROSPERO registry of systematic reviews. Reports of original research investigating the implementation of telepharmacy during the COVID-19 pandemic were retrieved. Researchers screened the title and abstract of each article, and then evaluated the full text of eligible articles to identify studies that met the inclusion criteria. Pharmacists' responsibilities and actions were classified in relation to the International Pharmaceutical Federation guideline for managing the COVID-19 pandemic. Extracted data included study characteristics, pharmacists' interventions delivered through a telepharmacy system, and the benefits of telepharmacy implementation.

Data Synthesis

The database search yielded 1400 articles. After removal of duplicates and articles not meeting the specific inclusion criteria (n = 1381), a total of 19 relevant original research articles were reviewed. According to these studies, telepharmacy was used to perform remote medication review and optimization, assess medication adherence, dispense and deliver medications, educate and counsel patients, promote disease prevention, collaborate with health care providers, and monitor treatment outcomes.

Conclusions

This study highlighted the use of telepharmacy services to support pharmacists' activities during the COVID-19 pandemic. Randomized clinical trials are needed to investigate the long-term efficacy and cost-effectiveness of telepharmacy services.

Challenges Faced and Coping Strategies Adopted by Injecting Drug Users during COVID-19 Lockdown-A Qualitative Study

Background

The lockdown due to COVID-19 pandemic has adversely affected the lives of vulnerable population, including the injecting drug users (IDUs). The objective of the study was to document the coping mechanism adopted by IDUs and suggest measures to mitigate the adverse effects, if similar situation were to arise in future.

Materials and Methods

A qualitative study was conducted at the Targeted Intervention Non-Government Organizations catering to IDUs in Delhi and Ghaziabad district of Uttar Pradesh. Four focus group discussions among 41 IDUs and 7 key informant interviews of the NGO staff were conducted in the study. The Hindi recordings were coded and the data analysis was performed manually using grounded theory approach.

Results

We found that the lockdown affected the lives of most of the IDUs and they found it difficult to access the harm reduction services. To cope with this, many IDUs started following alternate methods to support the drug habits. There was an increase in reuse of needles and syringes.

Conclusion

The lockdown during COVID-19 and the resulting challenges negatively impacted the physical and mental health of the IDUs. We recommend that in any similar future scenario, travel pass may be issued to the IDUs and the TI-NGO personnel.

Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants

BACKGROUND

Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention.

OBJECTIVE

This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions.

METHODS

The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification.

RESULTS

The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement.

CONCLUSIONS

Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.

Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review

INTRODUCTION

The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD.

METHODS

The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles.

RESULTS

A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience.

CONCLUSIONS

Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.

Pandemic telehealth flexibilities for buprenorphine treatment: a synthesis of evidence and policy implications for expanding opioid use disorder care in the United States

Buprenorphine is a highly effective treatment for opioid use disorder (OUD) and a critical tool for addressing the worsening US overdose crisis. However, multiple barriers to treatment-including stringent federal regulations-have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 public health emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the public health emergency has been set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this narrative review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on the uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment, and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue nonrestricted use of telehealth for buprenorphine initiation.

While allied health students prefer face-to-face clinical placement, telehealth can support competency development: results from a mixed-methods study

Introduction

Student clinical placements are a mandatory requirement within most accredited health programs. During the COVID-19 pandemic, many health settings that had traditionally provided placements cancelled their offerings. Telehealth services however, increased and emerged as an alternative placement setting.

Aim

To compare the learning experiences for allied health students provided by telehealth and face-to-face accredited health placements.

Methods

Health students, from a university clinic between March to December 2020, delivering both face-to-face and telehealth consultations, were invited to complete a telephone survey with 3 demographic questions; and 10-items comparing their telehealth and face-to-face learning experiences. Pearson's chi-squared/Fisher's exact test was used to examine the association between each item and consultation setting. Qualitative survey data was thematically analysed using a descriptive approach.

Results

49 students from 2 universities and 5 disciplines completed the survey. Students rated their face-to-face experiences significantly higher than their telehealth experiences across all items (all p-values <0.01). Across 9 items students reported positive learning experiences in both settings. Students had greater opportunities to work in a multidisciplinary team in a face-to-face setting. Four themes were generated: (1) placements can vary in quality regardless of setting; (2) telehealth can provide valuable learning experiences and support competency development; (3) enablers for telehealth placements and (4) barriers for telehealth placements.

Conclusion

While telehealth can support student learning and competency development, in this study students preferred face-to-face experiences. To optimise telehealth placements consideration needs to be given to barriers and enablers such as technological issues and university curricula preparation.

The Evolution of Telepsychiatry for Substance Use Disorders During COVID-19: a Narrative Review

Purpose of Review

This article aims to review and synthesize the current research evidence regarding the efficacy of telepsychiatry-delivered substance use disorder treatment using a narrative review with a focus on the effects of remote healthcare delivery within the substance abuse treatment space.

Recent Findings

The COVID-19 pandemic exerted substantial pressures on all levels of society. Social isolation, loss of employment, stress, physical illness, overburdened health services, unmet medical needs, and rapidly changing pandemic restrictions had particularly severe consequences for people with mental health issues and substance use disorders. Since the start of the pandemic, addiction treatment (and medical treatment overall) using remote health platforms has significantly expanded to different platforms and delivery systems. The USA, in particular, reported transformational policy developments to enable the delivery of telehealth during the COVID-19 pandemic. However, systemic barriers such as a widespread lack of internet access and insufficient patient and provider digital skills remain.

Summary

Overall, telepsychiatry is a promising approach for the treatment of substance use disorders, but more randomized controlled trials are needed in the future to assess the evidence base of available interventions.

A Generation Ready for Change: Preparing for the Deregulation of Medications for Opioid Use Disorder in Undergraduate Medical Education

The U.S. Department of Health and Human Services recently released updated guidance that allows providers under standard licensure to treat 30 or fewer patients with buprenorphine, a partial opioid agonist shown to be safe and effective as an office-based treatment for opioid use disorder (OUD). Previously, physicians and advanced practice providers needed to complete specialized training and certification under the Drug Addiction Treatment Act (DATA) of 2000 before prescribing medications for OUD (MOUD). This deregulatory action comes as rates of opioid-involved overdose have accelerated during the COVID-19 pandemic. Given the limited success of stepwise efforts to legislate for expanded access to MOUD, providers, professional associations, and other advocates have called for the elimination of the DATA requirements for all practitioners. An understanding of the statutory and regulatory history of MOUD may prove critical as legislative and policy actions continue to reshape clinical practice. Incorporating MOUD training as a standard in undergraduate medical education represents a unique opportunity for the medical community to prepare trainees for future deregulation of MOUD. Indeed, medical schools already offering or requiring MOUD training have demonstrated success in improving MOUD knowledge, skills, and attitudes among medical students and graduates. Existing virtual and hybrid training tools designed to meet DATA standards represent an accessible means to ensure critical learning for future generations of physicians uniquely ready and willing and to provide quality, evidence-based care to patients with OUD.

Pandemic telehealth flexibilities for buprenorphine treatment: A synthesis of evidence and policy implications for expanding opioid use disorder care in the U.S

Buprenorphine is a highly effective treatment for opioid use disorder and a critical tool for addressing the worsening U.S. overdose crisis. However, multiple barriers to treatment - including stringent federal regulations - have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 Public Health Emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the Public Health Emergency is set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue non-restricted use of telehealth for buprenorphine initiation.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BACKGROUND

The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.

METHODS

The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.

DISCUSSION

The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

Key implementation factors in telemedicine-delivered medications for opioid use disorder: a scoping review informed by normalisation process theory

Telemedicine could improve access to medications for opioid use disorder (MOUD). Telemedicine-delivered MOUD (TMOUD) has expanded substantially in response to the restrictions imposed by the COVID-19 pandemic on in-person clinical contact, yet this expansion has not happened consistently across all health systems and countries. This Review aims to understand key factors in TMOUD implementation that might explain variations in uptake. We did a scoping review using three English language databases for articles reporting on the implementation of TMOUD services. 57 peer-reviewed articles were identified, subjected to open coding and thematic analysis, and further interpreted through normalisation process theory (NPT). NPT was originally used to evaluate telehealth innovations and has been applied extensively to describe, assess, and develop the implementation potential of a broad range of complex health-care interventions. By categorising our findings according to the four core NPT constructs of coherence, cognitive participation, collective action, and reflexive monitoring, we aim to rationalise the current evidence base to show the workability of TMOUD in practice. We find that variations in TMOUD models in practice depend on organisations' attitudes towards risk, clinicians' tensions around giving up control over standard practices, organisation-level support in overcoming operational and technological challenges, and evaluation methods that might neglect a potential widening of the digital divide.

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

BACKGROUND

The COVID-19 pandemic has changed the landscape of healthcare service delivery. This review aims to describe telemedicine-delivered substance use disorder (SUD) treatments and services along the cascade of care in the U.S. after the start of the COVID-19 pandemic.

METHODS

A literature review was conducted on PubMed, Embase, Web of Science, and Cochrane Library (Wiley). English-language articles that describe any healthcare services for patients with SUDs using telemedicine in the U.S. since the onset of the COVID-19 pandemic were identified (N = 33). We narratively summarized telemedicine-based service provision along the cascade of SUD care, such as screening/assessment, prescription, monitoring, recovery support, and other services.

RESULTS

Soon after the onset of COVID-19 and mandated restrictions, cadres of healthcare providers from different specialties mobilized to ramp up video- and audio-based services to remotely treat patients with SUDs. Medication prescription (48.5%) and individual counseling (39.4%) were the most frequently reported services delivered via telemedicine. Other steps of SUD care delivered by telemedicine characterized in our review included SUD screening and assessment (30.3%), induction (21.2%), medication management (27.3%), monitoring (27.3%), recovery support (15.2%), and referral (24.2%). Feasibility issues and challenges to implementing telemedicine included patients' lack of access to technology and health insurance coverage, providers' capacity limits and concerns, and clinics' financial and office-space constraints.

CONCLUSION

The COVID-19 pandemic has offered a window of opportunity to advance telemedicine expertise by formalizing clinical guidance and routinizing provider in-service training in virtual SUD treatment. Findings suggest enhanced efforts to reduce disparities in telemedicine-based services.

A COVID-19 self-isolation monitoring module for FMUI undergraduate medical students: Linking learning and service needs during the pandemic surge in Indonesia

To ensure that students continued receiving adequate yet safe clinical exposure during the COVID-19 pandemic, the Faculty of Medicine at Universitas Indonesia (FMUI) created the Module of COVID-19 Self-Isolation Monitoring which aims to equip students with the knowledge and skill to monitor confirmed and close contact cases of COVID-19. Module development, divided into four phases: preparation, orientation, implementation, and evaluation phase, started as soon as the delta wave of COVID-19 cases forced medical students to halt their offline clinical rotations. A quantitative secondary data were obtained from student and patient satisfaction questionnaires and on students' performance and reflection. We analyzed the distribution of module evaluation, the student's discussion score during the module, the students' interest in participating as Covid-19 volunteers before and after the module's deployment, and the correlation between learning outcomes and satisfaction. A total of 372 patients were monitored by 208 students during the 4-week module. The response rates were above 80%, with the majority agreeing that students found this module well-organized and fulfilled their expectations. There was a significant increase in discussion scores from weeks 1 to 4, a significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion as well as a significant low correlation between the patient's monitoring score sheet and the reflection essay towards the patient's satisfaction. We should still improve tutors' time management, tutors' provision of triggering questions for critical thinking skills, and tutors' feedback for students. The module met patient expectations and is expected to assist tutors in providing feedback and examples of doctor-patient communication, thus accelerating students' competence in patient interaction. Further evaluation is needed regarding knowledge transfer, the impact on community health, and the faculty development program, especially regarding how tutors fulfill their roles as medical educators.

Factors associated with self-reported avoidance of harm reduction services during the COVID-19 pandemic by people who use drugs in five cities in the United States and Canada

BACKGROUND

This study examines individual-level factors associated with avoiding two important health services for people who use drugs-medications for treatment of opioid use disorder and syringe service programs-during the first year of the COVID-19 pandemic.

METHODS

Data come from two subsamples of people who use drugs who were active participants in one of nine cohort studies in Vancouver, British Columbia; Baltimore, Maryland; Los Angeles, California; Chicago, Illinois; and Miami, Florida. Participants were interviewed remotely about COVID-19-associated disruptions to healthcare. We estimated the association of demographic, social, and health factors with each outcome using logistic regression among 702 participants (medication analysis) and 304 participants (syringe service analysis.) Analyses were repeated, stratified by city of residence, to examine geographic variation in risk.

RESULTS

There were large differences between cities in the prevalence of avoiding picking up medications for opioid use disorder, with almost no avoidance in Vancouver (3%) and nearly universal avoidance in Los Angeles, Chicago, and Miami (>90%). After accounting for between-city differences, no individual factors were associated with avoiding picking up medications. The only factor significantly associated with avoiding syringe service programs was higher levels of self-reported worry about COVID-19.

CONCLUSION

During the first year of the COVID-19 pandemic, geographic differences in service and policy contexts likely influenced avoidance of health and harm reduction services by people who use drugs in the United States and Canada more than individual differences between people.

Synthesis of the Evidence on What Works for Whom in Telemental Health: Rapid Realist Review

BACKGROUND

Telemental health (delivering mental health care via video calls, telephone calls, or SMS text messages) is becoming increasingly widespread. Telemental health appears to be useful and effective in providing care to some service users in some settings, especially during an emergency restricting face-to-face contact, such as the COVID-19 pandemic. However, important limitations have been reported, and telemental health implementation risks the reinforcement of pre-existing inequalities in service provision. If it is to be widely incorporated into routine care, a clear understanding is needed of when and for whom it is an acceptable and effective approach and when face-to-face care is needed.

OBJECTIVE

This rapid realist review aims to develop a theory about which telemental health approaches work (or do not work), for whom, in which contexts, and through what mechanisms.

METHODS

Rapid realist reviewing involves synthesizing relevant evidence and stakeholder expertise to allow timely development of context-mechanism-outcome (CMO) configurations in areas where evidence is urgently needed to inform policy and practice. The CMO configurations encapsulate theories about what works for whom and by what mechanisms. Sources included eligible papers from 2 previous systematic reviews conducted by our team on telemental health; an updated search using the strategy from these reviews; a call for relevant evidence, including "gray literature," to the public and key experts; and website searches of relevant voluntary and statutory organizations. CMO configurations formulated from these sources were iteratively refined, including through discussions with an expert reference group, including researchers with relevant lived experience and frontline clinicians, and consultation with experts focused on three priority groups: children and young people, users of inpatient and crisis care services, and digitally excluded groups.

RESULTS

A total of 108 scientific and gray literature sources were included. From our initial CMO configurations, we derived 30 overarching CMO configurations within four domains: connecting effectively; flexibility and personalization; safety, privacy, and confidentiality; and therapeutic quality and relationship. Reports and stakeholder input emphasized the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care. The review also identified particular service users likely to be disadvantaged by telemental health implementation and a need to ensure that face-to-face care of equivalent timeliness remains available. Mechanisms underlying the successful and unsuccessful application of telemental health are discussed.

CONCLUSIONS

Service user choice, privacy and safety, the ability to connect effectively, and fostering strong therapeutic relationships need to be prioritized in delivering telemental health care. Guidelines and strategies coproduced with service users and frontline staff are needed to optimize telemental health implementation in real-world settings.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO); CRD42021260910; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021260910.

Buprenorphine implementation at syringe service programs following waiver of the Ryan Haight Act in the United States

INTRODUCTION

Among people with an opioid use disorder in the United States, only 10% receive buprenorphine treatment. The Ryan Haight Act is a federal law that has regulated buprenorphine delivery, requiring an in-person examination between a patient and provider before initiating treatment. At the beginning of the COVID-19 pandemic, federal agencies waived in-person examination requirements for buprenorphine treatment initiation. We examined whether Ryan Haight Act waiver improved implementation of telehealth buprenorphine within syringe service programs (SSPs) - organizations that serve people with historically low access to treatment.

METHODS

We surveyed all known SSPs operating in the US in 2021 (N = 421) of which 77% responded (n = 325). We calculated the prevalence and accompanying 95% confidence intervals (CI) for implementation of telehealth buprenorphine inductions at SSPs in 2020. Multivariable logistic regression was used to assess differences in implementing telehealth buprenorphine inductions by organizational characteristics.

RESULTS

In 2020, the prevalence of implementing buprenorphine inductions via telehealth was 24% (95% CI:19-30%). Non-governmental SSPs had a higher odds of telehealth buprenorphine inductions (adjusted odds ratio (aOR)= 2.92; 95% CI:1.22-7.00; p = 0.016), compared to governmental SSPs. Furthermore, the larger the organization's annual budget, the higher the odds of telehealth buprenorphine implementation (aOR=2.00 per quartile (95% CI:1.33-2.99; p = 0.001). SSPs located in states with higher opioid overdose mortality rates did not have significantly higher likelihood of telehealth buprenorphine implementation.

CONCLUSION

A substantial number of SSPs implemented telehealth buprenorphine after waiver of the Ryan Haight Act. Permanent adoption of this waiver will be critical and providing financial resources to SSPs is vital to support implementation of new innovations.

Coronavirus Disease 2019 and the Impact on Substance Use Disorder Treatments

Coronavirus disease 2019 (COVID-19)-related stressors and restrictions, in the absence of social and institutional support, have led many individuals to either increase their substance consumption or relapse. Consequently, treatment programs for substance use disorders (SUDs) made a transition from in-person to remote care delivery. This review discusses the following evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs: (1) reduction in availability of care, (2) increase in demand for care, (3) transition to telemedicine use, (4) telemedicine for treatment of opioid use disorders, and (5) considerations for use of telemedicine in treating SUDs.

Telehealth for people who inject drugs: An acceptable method of treatment but challenging to access

BACKGROUND

While telemedicine is seen as an emerging practice that will outlast the COVID-19 pandemic, it can reduce health services for those with limited internet and technological devices access or sufficient literacy.

OBJECTIVE(S)

The aim of this study was to explore the feasibility of using telehealth with people who inject drugs (PWID).

METHODS

A survey on availability and accessibility of different methods of communication was administered to a sample of PWID from an ongoing longitudinal cohort in Montréal, Canada.

RESULTS

Among the 96 respondents, phone calls were generally considered acceptable (89.6%) although availability was low (50%). Acceptability and availability of social media were 26% and 41.7%, respectively. Internet-based communication applications were considered acceptable to use for telehealth in 28.1% of participants, even if not frequently available (8.3%).

CONCLUSIONS

Telehealth is an acceptable form of treatment for PWID, but may be challenging due to low availability of phone or internet access.

AÇÕES DE PROMOÇÃO DA SAÚDE NAS UNIVERSIDADES EM FACE DA PANDEMIA DO COVID-19: SCOPING REVIEW

RESUMO Objetivo: mapear na literatura as ações e estratégias de promoção da saúde das universidades no contexto da pandemia do novo coronavírus (COVID-19). Metodo: Scoping Review, baseado nos procedimentos recomendados pelo Instituto Joanna Briggs. Com base nestas perspectivas, ficou estabelecida a pergunta norteadora: quais ações e estratégias de promoção da saúde foram realizadas em universidades com a comunidade interna e seu entorno na pandemia do COVID-19? As buscas foram realizadas em março de 2021 nas bases de dados de portais de informação públicos, restritos e de literatura cinzenta. Resultados: foram selecionados 38 estudos e com base nesses foram construídas três categorias: 1) Ações e estratégias de enfrentamento do COVID-19 nas universidades 2) Ações e estratégias inclusivas e de Proteção social a grupos vulneráveis ao COVID-19 nas universidades 3) Ações e estratégias de Educação em saúde e bem-estar em face do COVID-19 nas universidades. Conclusões: o estudo evidenciou que ações e estratégias de promoção da saúde nas Universidades acontecem quando a proposta encontra apoio institucional, mobilização inter e transdisciplinar, integração com setores governamentais e iniciativa privada, além do engajamento da população acadêmica. Observaram-se diversas ações em diferentes cenários, demonstrando comprometimento social e posicionamento crítico em face do COVID-19, visando uma sociedade mais justa e sustentável pela via do conhecimento.

HEALTH PROMOTION ACTIONS IN UNIVERSITIES IN THE FACE OF THE COVID-19 PANDEMIC: A SCOPING REVIEW

ABSTRACT Objective: to map in the literature the universities' health promotion actions and strategies in the context of the new coronavirus (COVID-19) pandemic. Method: a Scoping Review, based on the procedures recommended by the Joanna Briggs Institute. Based on these perspectives, the following guiding question was established: which health promotion actions and strategies were implemented in universities with the internal community and its surroundings in the COVID-19 pandemic? The searches were carried out in March 2021 in the databases of public, restricted and gray literature information portals. Results: a total of 38 studies were selected and three categories were elaborated based on them, namely: 1) Actions and strategies for coping with COVID-19 in universities; 2) Inclusive and Social protection actions and strategies for groups vulnerable to COVID-19 in universities; and 3) Health and Well-being Education actions and strategies in the face of COVID-19 in universities. Conclusions: the study evidenced that health promotion actions and strategies in universities become a reality when the proposals find institutional support, inter- and transdisciplinary mobilization and integration with governmental sectors and private initiative, in addition to engagement of the academic population. Several actions were observed in different scenarios, showing social commitment and a critical stance in the face of COVID-19, aiming at a fairer and more sustainable society through knowledge.

Acceptability, feasibility, and pilot results of the tele-harm reduction intervention for rapid initiation of antiretrovirals among people who inject drugs

BACKGROUND

People who inject drugs (PWID) have been a marginalized and a stigmatized population since the beginning of the AIDS epidemic and have not experienced the same life-changing benefits of antiretroviral therapy as others. Tele-Harm Reduction (THR) is a telehealth-enhanced, harm reduction intervention, delivered within a trusted SSP venue. It aims to facilitate initiation of care and achieve rapid HIV viral suppression among PWID living with HIV.

METHODS

In this mixed-methods study, we employed the Practical, Robust, Implementation and Sustainability Model (PRISM) implementation science framework to identify multilevel barriers and facilitators to implementing the THR intervention. Focus groups (n = 2, 16 participants), stakeholder interviews (n = 7) and in-depth interviews were conducted with PWID living with HIV (n = 25). In addition, to assess feasibility and acceptability, we pilot tested the THR intervention and reported viral suppression at 6 months.

RESULTS

Focus groups and stakeholder interviews revealed system and organizational level barriers to implementation including requirements for identification and in person visits, waiting times, stigma, case management inexperience, multiple electronic health records, and billing. A potential facilitator was using telehealth for case management and initial provider visit. In the in depth interviews conducted with PWID living with HIV, participants expressed that the SSP creates a convenient, comfortable, confidential environment for delivering multiple, non-stigmatizing PWID-specific services. 35 PWID living with HIV were enrolled in the pilot study, 35 initiated antiretroviral therapy, and 25 (78.1%) were virally suppressed at six months.

CONCLUSION

Rooted in harm reduction, the THR intervention shows promise in being an acceptable and feasible intervention that may facilitate engagement in HIV care and viral suppression among PWID.

Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives

BACKGROUND

The majority of individuals with opioid use disorder (OUD) face access barriers to evidence-based treatment, and the COVID-19 pandemic has exacerbated the United States (US) opioid overdose crisis. However, the pandemic has also ushered in rapid transitions to telehealth in the USA, including for substance use disorder treatment with buprenorphine. These changes have the potential to mitigate barriers to care or to exacerbate pre-existing treatment inequities. The objective of this study was to qualitatively explore Philadelphia-based low-barrier, harm-reduction oriented, opioid use disorder (OUD) treatment provider perspectives about and experiences with telehealth during the COVID-19 pandemic, and to assess their desire to offer telehealth to patients at their programs in the future.

METHODS

We interviewed 22 OUD treatment prescribers and staff working outpatient programs offering OUD treatment with buprenorphine in Philadelphia during July and August 2020. All participants worked at low-barrier treatment programs that provide buprenorphine using a harm reduction-oriented approach and without mandating counseling or other requirements as a condition of treatment. We analyzed the data using thematic content analysis.

RESULTS

Our analysis yielded three themes: 1/ Easier access for some: telehealth facilitates care for many patients who have difficulty attending in-person appointments due to logistical and psychological barriers; 2/ A layered digital divide: engagement with telehealth can be seriously limited by patients' access to and comfort with technology; and 3/ Clinician control: despite some clinic staff beliefs that patients should have the freedom to choose their treatment modality, patients' access to treatment via telehealth may hinge on clinician perceptions of patient "stability" rather than patient preferences.

CONCLUSIONS

Telehealth may address many access issues, however, barriers to implementation remain, including patient ability and desire to attend healthcare appointments virtually. In addition, the potential for telehealth models to extend OUD care to patients currently underserved by in-person models may partially depend on clinician comfort treating patients deemed "unstable" via this modality. The ability of telehealth to expand access to OUD care for individuals who have previously struggled to engage with in-person care will likely be limited if these patients are not given the opportunity to receive treatment via telehealth.

Strategies Adopted by Addiction Facilities during the Coronavirus Pandemic to Support Treatment for Individuals in Recovery or Struggling with a Substance Use Disorder: A Scoping Review

This review aimed to identify and synthesize strategies and actions adopted by addiction facilities to support and maintain treatment during the coronavirus disease 2019 (COVID-19) pandemic. A scoping review was conducted using the following information sources: Virtual Health Library, SCOPUS, Web of Science, PubMed, CINAHL, and Latin American and Caribbean Health Science Literature. From a total of 971 articles, 28 studies were included. The strategies to maintain the care offer were telehealth/telemedicine, counselling/screening, 24-h telephone, webinars, conducting group therapy and support among users, adaptation for electronic health records, increased methadone/naloxone dispensing, restriction in the number of medication dispensing/day, and electronic prescription and home delivery medications. These strategies can be used to support health professionals in addressing the impact of the pandemic on the treatment of those in recovery or struggling with a substance use disorder when in-person treatment is not possible.

Early innovations in opioid use disorder treatment and harm reduction during the COVID-19 pandemic: a scoping review

BACKGROUND

The COVID-19 pandemic has exerted a significant toll on the lives of people who use opioids (PWUOs). At the same time, more flexible regulations around provision of opioid use disorder (OUD) services have led to new opportunities for facilitating access to services for PWUOs. In the current scoping review, we describe new services and service modifications implemented by treatment and harm reduction programs serving PWUO, and discuss implications for policy and practice.

METHODS

Literature searches were conducted within PubMed, LitCovid, Embase, and PsycInfo for English-language studies published in 2020 that describe a particular program, service, or intervention aimed at facilitating access to OUD treatment and/or harm reduction services during the COVID-19 pandemic. Abstracts were independently screened by two reviewers. Relevant studies were reviewed in full and those that met inclusion criteria underwent final data extraction and synthesis (n = 25). We used a narrative synthesis approach to identify major themes around key service modifications and innovations implemented across programs serving PWUO.

RESULTS

Reviewed OUD treatment and harm reduction services spanned five continents and a range of settings from substance use treatment to street outreach programs. Innovative service modifications to adapt to COVID-19 circumstances primarily involved expanded use of telehealth services (e.g., telemedicine visits for buprenorphine, virtual individual or group therapy sessions, provision of donated or publicly available phones), increased take-home medication allowances for methadone and buprenorphine, expanded uptake of long-acting opioid medications (e.g. extended-release buprenorphine and naltrexone), home delivery of services (e.g. MOUD, naloxone and urine drug screening), outreach and makeshift services for delivering MOUD and naloxone, and provision of a safe supply of opioids.

CONCLUSIONS

The COVID-19 pandemic has posed multiple challenges for PWUOs, while simultaneously accelerating innovations in policies, care models, and technologies to lower thresholds for life-saving treatment and harm reduction services. Such innovations highlight novel patient-centered and feasible approaches to mitigating OUD related harms. Further studies are needed to assess the long-term impact of these approaches and inform policies that improve access to care for PWUOs.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Utilization of Telehealth Solutions for Patients with Opioid Use Disorder Using Buprenorphine: A Scoping Review

Background: A scoping review was conducted to examine the breadth of evidence related to telehealth innovations being utilized in the treatment of opioid use disorder (OUD) with buprenorphine and its effect on patient outcomes and health care delivery. Materials and Methods: The authors systematically searched seven databases and websites for peer-reviewed and gray literature related to telehealth solutions for buprenorphine treatment published between 2008 and March 18, 2021. Two reviewers screened titles and abstracts for articles that met the inclusion criteria, according to the scoping review study protocol. The authors included studies if they specifically examined telehealth interventions aimed at improving access to and usage of buprenorphine for OUD. Results: After screening 371 records, the authors selected 69 for full review. These studies examined the effect of telehealth on patient satisfaction, treatment retention rates, and buprenorphine accessibility and adherence. Conclusion: According to the reviewed literature, incorporation of telehealth technology with medication-assisted treatment for OUD is associated with higher patient satisfaction, comparable rates of retention, an overall reduction in health care costs, and an increase in both access to and usage of buprenorphine. This has been made possible through the expansion of telehealth technologies and a substantial push toward relaxed federal guidelines, both of which were quickly escalated in response to the COVID-19 pandemic. Future research is needed to fully quantify the effect of these factors; however, the results appear promising thus far and should urge policymakers to consider making these temporary policy changes permanent.

Opioid treatment programs, telemedicine and COVID-19: A scoping review

Background: Methadone and buprenorphine are effective medications for opioid use disorder (MOUD) that are highly regulated in the United States. The on-going opioid crisis, and more recently COVID-19, has prompted reconsideration of these restrictions in order to sustain and improve treatment access, with renewed interest in telemedicine. We reviewed the evidence on use of telemedicine interventions and applicability to MOUD policy changes in the post-COVID-19 treatment landscape. Methods: Ovid MEDLINE and the Cochrane Database of Systematic Reviews databases were searched from inception to April 2021 and reference lists were reviewed to identify additional studies. Studies were eligible if they examined telemedicine interventions and reported outcomes (e.g. treatment initiation, retention in care). Randomized trials and controlled observational studies were prioritized; other studies were included when stronger evidence was unavailable. One investigator abstracted key information and a second investigator verified data. We described the results qualitatively. Results: We identified nine studies: three controlled trials (two randomized), and six observational studies. Three studies evaluated patients treated with methadone and six studies with buprenorphine, including one study of pregnant women with OUD. All studies showed telemedicine approaches associated with similar outcomes (treatment retention, positive urine toxicology) compared to treatment as usual. Trials were limited by small samples sizes, lack of reporting harms, and most were conducted prior to the COVID-19 pandemic; observational studies were limited by failure to control for confounding. Conclusions: Limited evidence suggests that telemedicine may enhance access to MOUD with similar effectiveness compared with face-to-face treatment. Few studies have been published since COVID-19, and it is unclear the potential impact of these interventions on the existing racial/ethnic disparities in treatment. The COVID-19 pandemic and need for social distancing led to temporary policy changes for prescribing of MOUD that could inform additional research in this area to support comprehensive policy reforms.

Care Facilitation Advances Movement Along the Hepatitis C Care Continuum for Persons With Human Immunodeficiency Virus, Hepatitis C, and Substance Use: A Randomized Clinical Trial (CTN-0064)

Background

Direct-acting antivirals can cure hepatitis C virus (HCV). Persons with HCV/HIV and living with substance use are disadvantaged in benefiting from advances in HCV treatment.

Methods

In this randomized controlled trial, participants with HCV/HIV were randomized between February 2016 and January 2017 to either care facilitation or control. Twelve-month follow-up assessments were completed in January 2018.

Care facilitation group participants received motivation and strengths-based case management addressing retrieval of HCV viral load results, engagement in HCV/HIV care, and medication adherence. Control group participants received referral to HCV evaluation and an offer of assistance in making care appointments. Primary outcome was number of steps achieved along a series of 8 clinical steps (eg, receiving HCV results, initiating treatment, sustained virologic response [SVR]) of the HCV/HIV care continuum over 12 months postrandomization.

Results

Three hundred eighty-one individuals were screened and 113 randomized. Median age was 51 years; 58.4% of participants were male and 72.6% were Black/African American. Median HIV-1 viral load was 27 209 copies/mL, with 69% having a detectable viral load. Mean number of steps completed was statistically significantly higher in the intervention group vs controls (2.44 vs 1.68 steps; χ ² [1] = 7.36, P = .0067). Men in the intervention group completed a statistically significantly higher number of steps than controls. Eleven participants achieved SVR with no difference by treatment group.

Conclusions

The care facilitation intervention increased progress along the HCV/HIV care continuum, as observed for men and not women. Study findings also highlight continued challenges to achieve individual-patient SVR and population-level HCV elimination.

Clinical Trials Registration

NCT02641158.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

BACKGROUND

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

METHODS

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

RESULTS

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

CONCLUSIONS

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.