Medication for Opioid Use Disorder Service Provision and Telephone Counseling: A Concurrent Mixed-Methods Approach

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.

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.

Old tech but not low tech: telephone-based treatment provision for substance use

The future of telemedicine for substance use treatment hangs by a thread, as the United States awaits approval of proposed regulations and laws to increase care access in light of the 2022 Centers for Medicare and Medicaid Services revisions allowing for audio-only care. Telemedicine improves patient care access and outcomes. Audio-only telemedicine can be an effective and viable modality for individuals without technology resources (devices, internet services, and literacy), those with reduced telehealth service utilization (Black individuals or those with unstable housing, who are older, with low income, or with low education), and those living in rural locations. Studies suggest that telephone visits for buprenorphine treatment are well-accepted by patients and providers, making telephone visits essential in care access to reduce disparities. Telephone counseling for patients in substance use treatment is convenient, flexible, and empowering and can augment therapeutic alliances and treatment goals. Both providers and patients advocate for patient-centered hybrid care to include telephone-only treatment, which enhances service productivity and care access; reduces no-show rates, costs, and stigma; and is sustainable. Numerous solutions can expand technology access, proficiency, assimilation, and trust. Despite being "old" technology, the telephone remains an essential resource for substance use treatment.

"And Then COVID Hits": A Qualitative Study of How Jails Adapted Services to Treat Opioid Use Disorder During COVID-19

Background: Jails in Massachusetts are among the first nationwide to provide correctional populations with medications to treat opioid use disorder (MOUD). The COVID-19 pandemic caused jails to pivot and adapt MOUD programming. We aimed to identify adaptations and barriers to MOUD access that COVID-19 exacerbated or created, and document new elements that staff wish to sustain as COVID-19 recedes. Methods: We conducted semi-structured in-depth interviews and focus groups in 2020-2021 with 29 jail staff who implement MOUD programming in two Massachusetts jails. We conducted qualitative data analysis in Atlas.ti 8 using an inductive approach. Results: Participants shared that access to MOUD among correctional populations is understood by jail staff to be an essential health service. Thus, to facilitate continued access to MOUD, both during incarceration and also at community reentry, jail staff quickly implemented changes in MOUD regulations and dosing protocols and established telehealth capacity. Despite these program adaptations, participants identified how COVID-19 increased health and social needs among correctional populations, reduced availability of community-based healthcare and recovery-supportive services, and introduced new factors that could undermine recovery. Innovations that participants wished to sustain as COVID-19 receded included telehealth capacity, smaller-sized therapeutic groups, and application of a public health approach to treat opioid use disorder among correctional populations. Conclusions: During disruptive events, jails can adapt MOUD programming to ensure access for people living in jail and upon release. Findings identify factors for understanding the outcomes of jail-based MOUD programming during COVID-19 and highlight opportunities to improve service delivery after COVID-19.

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.

"We figured it out as we went along": Staff perspectives of COVID-19 response efforts at a large North American syringe services programme

Syringe services programmes face operational challenges to provide life-sustaining services to people who use substances and those who have substance use disorders. COVID-19 has disrupted operations at these programmes and is a threat to people with substance use disorder because of severe poverty, de-prioritisation of COVID-19 safety and high prevalence of comorbidities. This phenomenological qualitative study describes 16 in-depth interviews with staff of one of the largest syringe services programme in North America-Prevention Point Philadelphia, located in the Kensington neighbourhood of Philadelphia, Pennsylvania. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and coded to develop a thematic framework. Participants were mostly white (71.4%) and female (68.8%) with a median age of 31.5. Three main and four sub-themes related to the impact of COVID-19 on the syringe services programme were identified: (1) COVID-19 altered services provision (sub-theme: select service changes should be retained); (2) unclear or absent COVID-19 response guidance which compromised mitigation (sub-themes: COVID-19 messaging was difficult to translate to practice, learn-as-we-go); and (3) staff and clients experienced elevated mental anguish during the pandemic (sub-theme: already limited resources were further strained). COVID-19 presented complex challenges to an organisation normally strained in pre-pandemic times. A staff culture of resourcefulness and resiliency aided the syringe services programme to balance client needs and staff safety. However, staff experienced a serious psychological impact, largely attributable to being unable to find reprieve from the stressors of COVID-19 and the difficulties associated with navigating and acting-on contradictory public health messaging. Staff also shared a belief that the relaxing of some pre-pandemic barriers allowed staff to link clients more readily with services. Syringe services programmes should embrace the potential for lasting changes to health services delivery brought about by wide-scale changes in service provisions because of COVID-19.

Impact of COVID-19 among people who use drugs: A qualitative study with harm reduction workers and people who use drugs

Background

Fatal drug overdoses in the USA hit historical records during the COVID-19 pandemic. Throughout the pandemic, people who used drugs had greater odds of contracting COVID-19, increased drug use due to COVID-related stress, and heightened levels of anxiety and depression. This qualitative study examined the specific ways the pandemic negatively impacted people who use drugs.

Methods

Qualitative interviews with 24 people who use drugs and 20 substance use harm reduction workers were conducted. Data from the qualitative interviews were analyzed using applied thematic analysis to identify emergent themes based on the a priori research goals.

Results

Thematic analysis identified several common experiences during the pandemic among people who use drugs. These included mental distress due to financial strain and social isolation; increased drug use; increased risky drug-seeking and use behaviors due to changes in the drug markets; and reduced access to harm reduction, treatment, and recovery support services.

Conclusions

Our study highlighted critical systemic failures that contributed to the rise in overdose deaths during the COVID-19 pandemic. Addressing these challenges through policy reform and improved funding models will ensure the sustainability of harm reduction services and increase access to substance use treatment among highly vulnerable people who use drugs.