Referral of patients from rural primary care clinics to telemedicine vendors for opioid use disorder treatment: A mixed-methods study

INTRODUCTION

Rural primary care clinics can expand their medication treatment for opioid use disorder (MOUD) capacity by coordinating care with external telemedicine (TM) vendors specializing in addiction medicine. This study used mixed methods to identify factors that influence patient referrals from rural primary care clinics to TM vendors for MOUD.

METHODS

Between July/August 2020 and January/February 2021, 582 patients with OUD were identified across six primary care sites; that included 68 referred to an external TM vendor to receive MOUD. Mixed effects logistic regression identified individual and site-level factors associated with being referred to the TM vendor. Clinic providers and staff participated in in-depth interviews and focus groups to discuss their considerations for referring patients to the TM vendor.

RESULTS

Patient referrals were positively associated with local household broadband coverage (OR = 2.55, p < 0.001) and negatively associated with local population density (OR = 0.01, p  =  0.003) and the number of buprenorphine prescribers in the county (OR = 0.85, p < 0.001). Clinic personnel expressed appreciation for psychiatric expertise and the flexibility to access MOUD brought by the TM vendor. Perceived concerns about TM referral included a lack of trust with external providers, uncertainty about TM service quality, workflow delays, and patients' technological and insurance challenges.

CONCLUSION

This study revealed several clinic-level factors that may potentially influence patient referral to TM vendor services for MOUD. To facilitate the referral process and utilization of TM vendors, efforts should be made to foster open communication and trust between clinic providers and TM vendors, streamline workflows, and improve Internet access for patients.

Identifying patients with opioid use disorder using International Classification of Diseases (ICD) codes: Challenges and opportunities

BACKGROUND AND AIMS

International Classification of Diseases (ICD) diagnosis codes are often used in research to identify patients with opioid use disorder (OUD), but their accuracy for this purpose is not fully evaluated. This study describes application of ICD-10 diagnosis codes for opioid use, dependence and abuse from an electronic health record (EHR) data extraction using data from the clinics' OUD patient registries and clinician/staff EHR entries.

DESIGN

Cross-sectional observational study.

SETTING

Four rural primary care clinics in Washington and Idaho, USA.

PARTICIPANTS

307 patients.

MEASUREMENTS

This study used three data sources from each clinic: (1) a limited dataset extracted from the EHR, (2) a clinic-based registry of patients with OUD and (3) the clinician/staff interface of the EHR (e.g. progress notes, problem list). Data source one included records with six commonly applied ICD-10 codes for opioid use, dependence and abuse: F11.10 (opioid abuse, uncomplicated), F11.20 (opioid dependence, uncomplicated), F11.21 (opioid dependence, in remission), F11.23 (opioid dependence with withdrawal), F11.90 (opioid use, unspecified, uncomplicated) and F11.99 (opioid use, unspecified with unspecified opioid-induced disorder). Care coordinators used data sources two and three to categorize each patient identified in data source one: (1) confirmed OUD diagnosis, (2) may have OUD but no confirmed OUD diagnosis, (3) chronic pain with no evidence of OUD and (4) no evidence for OUD or chronic pain.

FINDINGS

F11.10, F11.21 and F11.99 were applied most frequently to patients who had clinical diagnoses of OUD (64%, 89% and 79%, respectively). F11.20, F11.23 and F11.90 were applied to patients who had a diagnostic mix of OUD and chronic pain without OUD. The four clinics applied codes inconsistently.

CONCLUSIONS

Lack of uniform application of ICD diagnosis codes make it challenging to use diagnosis code data from EHR to identify a research population of persons with opioid use disorder.

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

INTRODUCTION

Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor.

METHODS

We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale.

RESULTS

Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff.

CONCLUSIONS

Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Perceptions of COVID-19 risk during the pandemic: perspectives from people seeking medication for opioid use disorder

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) pandemic has had devastating consequences for persons with opioid use disorder (OUD). Yet, little is known about how people seeking treatment for OUD perceive the risks of COVID-19 and how their perception interplays with their health behaviours.

METHODS

In-depth interviews were conducted from September 2021 to March 2022 with 32 patients seeking medication treatment for OUD (MOUD) in Southern California. All interviews were conducted virtually and lasted between one and two hours. Interviews were recorded and transcribed verbatim. Two qualitative researchers independently conducted a content analysis of the transcripts to identify themes.

RESULTS

Three primary themes were identified: (1) perceptions and beliefs about COVID-19 susceptibility and severity; (2) perceptions of COVID-19 risk compared to substance use behaviours; and (3) vaccine hesitancy. Participants were mixed in their beliefs of susceptibility to contracting COVID-19 and the severity of the disease if contracted. Some participants reported taking precautions to mitigate their chances of acquiring COVID-19, and other participants reported that COVID was not a big concern as substance use took priority. For many of the participants, COVID-19 concerns were overshadowed by the risk of overdosing on substances and other risky substance use behaviour. Most of the participants (n = 23; 72%) had received at least one COVID-19 vaccine by the time of the interview, but over half (n = 19; 59%) expressed vaccine hesitancy. Vaccine hesitancy was driven by concerns about the unknown long-term side effects and potential interactions of the vaccine with MOUD.

CONCLUSIONS

Our study provides insight into COVID-19 prevention measures as well as vaccination perceptions and hesitancy among people who received treatment for OUD.Key messagesParticipants expressed diverse perceptions of the seriousness of COVID-19, with some taking precautions to mitigate their chances of acquiring COVID-19 and others perceiving that the risk of contracting COVID-19 was less than the risk of overdosing.Substance use, social isolation, vaccine hesitancy and COVID-19 risk behaviours should be studied as co-occurring phenomena that have potentially overlapping relationships that can influence behaviours that impact health and well-being.

Patient brokering in for-profit substance use disorder treatment: a qualitative study with people with opioid use disorder and professionals in the field

BACKGROUND

Opioid use and opioid overdose deaths are at an all-time high and evidence-based treatments for people with opioid use disorder (OUD) are underutilized. Therefore, we sought to understand experiences and perceptions of abuses in the for-profit substance use disorder treatment industry that could potentially put people with OUD at an increased risk for an overdose.

METHODS

One-on-one semi-structured interviews were conducted from November 2018 to May 2019 in Southern California with 20 people with OUD and 20 professionals who work in the substance use disorder (SUD) treatment field. A grounded theory approach was conducted to discover emerging patterns from the data.

RESULTS

Three major themes emerged:1) financial and material enticements, 2) encouraging substance use in the for-profit treatment sector, and 3) contributors to overdose risk. Participants reported that patient brokers would pay for plane tickets and offer financial incentives (e.g., money) to attract individuals to SUD treatment, capitalizing on insurance profits despite initial expenses. Participants reported being encouraged to use drugs before treatment to meet insurance conditions, thus jeopardizing genuine recovery efforts and adding to the temptation of drug use. Many participants linked patient brokering to increased overdose deaths, emphasizing the dangerous practices of brokers providing drugs, promoting relapse, and creating a revolving door of treatment, which compounds the overdose risk after periods of abstinence.

CONCLUSIONS

Patient brokering and unethical abuses in the for-profit treatment industry have caused some people with OUD to seek treatment for money and housing instead of seeking treatment to stop opioid use. The harmful treatment environment was seen as a barrier to care and an unwanted obstacle to overcome on the path to recovery.

Detoxification, 12-step meeting attendance, and non-fatal opioid overdoses among a suburban/exurban population with opioid use disorder

BACKGROUND

Drug overdoses are the leading cause of injury death in the United States with an estimated 105,752 individuals dying from an overdose in the United States in a 12-month period ending October 2021. Given that people who have opioid use disorder (OUD) are at an increased risk of death, it is crucial to assess risk factors associated with opioid overdose to improve interventions.

OBJECTIVES

We examine factors associated with non-fatal overdose among a suburban/exurban population with OUD in Southern California.

METHODS

Participants were recruited by convenience sampling (n = 355) and were interviewed between November 2017 to August 2018. Participants were eligible for the study if they had a history of pharmaceutical opioid use.

RESULTS

A total of 198 (55.8%) participants reported at least one overdose in their lifetime. A total of 229 participants identified as male, 124 identified as female, and 2 identified as non-binary. When controlling for demographic factors, non-oral opioid administration at first opioid use (AOR 2.82, 95% CI 1.52-5.22), having a history of methadone detoxification, (AOR 2.23, 95% CI 1.27-3.91), history of buprenorphine detoxification (AOR 1.77, 95% CI 1.02-3.07), and history of 12 step attendance (AOR 1.89, 95% CI 1.12-3.20) were found to be independently and positively associated with lifetime opioid overdose.

CONCLUSIONS

Detoxification with buprenorphine and methadone was found to be associated with having a non-fatal opioid overdose. Buprenorphine and methadone should not be prescribed as a detoxification medication as long-term use of medication for OUD results in better outcomes than medication that is used short-term.

Telemedicine-delivered treatment for substance use disorder: A scoping review

INTRODUCTION

The 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.

METHOD

We searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis.

RESULTS

A 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.

CONCLUSIONS

TM 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.

Psychosis among individuals with methamphetamine use disorder is associated with elevated rates of hospitalizations and emergency department visits across an academic health care system

INTRODUCTION

Methamphetamine (MA) is increasingly available in the United States and manufactured with increasing potency. Although psychosis is a known harm related to MA use, we know little about the clinical outcomes and prognosis of individuals who use MA and experience psychosis. Some evidence exists that psychosis among people who use methamphetamine leads to a high utilization of emergency and acute inpatient services, but the extent of this use is unclear.

METHODS

Using an electronic health record (EHR) database, this study assessed acute care visits of individuals receiving diagnostic codes of the following disorders: methamphetamine use disorder with undifferentiated psychosis (MUDp), schizophrenia (MUDs) and no history of psychosis (MUD) in addition to individuals without MUD diagnosis but with diagnoses of either undifferentiated psychosis (Psy) or schizophrenia (Scz) from 2006 to 2019. The study explored potential clinical risk factors associated with rate of acute care visits.

RESULTS

Receiving diagnoses of psychotic disorders and MUD were both associated with high rates of acute care utilization. The incidence rate ratio (IRR) was highest in the MUDp group 6.30 (95 % CI: 5.73, 6.93) followed by the MUDs group 4.03 (95 % CI: 3.87, 4.20), the Psy group 3.77 (95 % CI: 3.45, 4.11), the Scz group 3.11 (95 % CI: 2.99, 3.23), and the MUD group 2.17 (95 % CI: 2.09, 2.25). Receiving another SUD diagnosis was identified as a risk factor for acute care visits in the MUDp group, and mood and anxiety disorder diagnoses were a risk factor in the MUDs group.

CONCLUSIONS

In a general health care system, individuals receiving diagnoses of MUD and co-occurring psychotic disorders were observed to have particularly high rates of acute care service utilization, suggesting a high degree of disease burden and the need for development of targeted treatment interventions with both MUD and psychosis.

Disparities in digital access among American rural and urban households and implications for telemedicine-based services

PURPOSE

To examine characteristics associated with disparities in digital access (i.e., access to high-speed Internet via a computer or smartphone) in American rural and urban households given that digital access has a direct impact on access to telemedicine-based services.

METHODS

Using the 2019 American Community Survey, we analyzed the proportions of geographic area, race/ethnicity, and socioeconomic status according to device and high-speed Internet access. Maximum likelihood logit estimators estimated how these factors influenced device and high-speed Internet access.

FINDINGS

Of 105,312,959 households, 32.29% were without a desktop or laptop computer with high-speed Internet (WDW), 21.51% were without a smartphone with a data plan for wireless Internet (WSW), and 14.02% were without any digital access (WDA). Nonmetropolitan households were significantly more likely to be WDA than metropolitan households (odds ratio [OR] = 1.87; 95% confidence interval [CI]: 1.83-1.91). Relative to non-Hispanic Whites, non-Hispanic Blacks (OR = 1.60; 95% CI: 1.56-1.64), American Indian or Alaska natives (OR = 2.00; 95% CI: 1.82-2.19), or Hispanics (OR = 1.70; 95% CI: 1.66-1.74) were significantly more likely to be WDA. When compared to households with private health insurance coverage, households WDA were significantly more likely to have no insurance (OR = 2.44; 95% CI: 2.36-2.53) or public insurance coverage (OR = 3.78; 95% CI: 3.70-3.86). Households with any digital access reported higher income and more family members living at home. Using the same predictors, similar findings were reported for households WDW or WSW.

CONCLUSIONS

Significant disparities in digital access exist among nonmetropolitan households, racial/ethnic minority households, and lower-income households. The lack of digital access has implications for the accessibility of health care services via telemedicine and thus could exacerbate health disparities.

The impact of COVID-19 on substance use disorder treatment in California: Service providers' perspectives

Background

The COVID-19 pandemic has had a profound impact on the U.S. health care system, including addiction treatment. The objective of this study is to describe the impact of COVID on the delivery of treatment for substance use disorders (SUDs) from the perspectives of service providers.

Methods

Between May and September 2020, 61 service providers from 16 SUD treatment sites in California participated in virtual focus groups that lasted about an hour. We recorded the discussions and transcribed them verbatim. Two qualitative analysts independently conducted content analysis to identify themes from the transcripts.

Results

At the beginning of the pandemic, service providers observed a slight decrease in patient admissions, followed by an uptick in patient flow due to increased mental health issues, alcohol use, and relapse. Many of the clinics adopted flexible service delivery modes, such as curbside dosing and extended take-home medication, to enable social distancing in clinic settings. Approximately half of the clinic encounters offered telemedicime, and a considerable proportion of patients preferred to use telephone-based services rather than video-based services. Internet instability and technical difficulties limited the use of telemedicine among their patients.

Conclusion

COVID has been challenging for SUD treatment, but health care systems rapidly reacted with adjustments that may result in long-term changes in SUD service delivery. Telemedicine-based services have played a major role in ensuring uninterrupted patient care. Providers need organizational, technical, and logistical support to improve and sustain telemedicine services that increase access to quality care for their patients.

Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial

Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.

Survival Sex Trading in Los Angeles County, California, USA

Most studies on survival sex, defined as sex trading for money, drugs, or other needs, have limited their focus to adolescents. The current study reports about the relationships between survival sex trading (SST) and high-risk behaviors in a sample of adults. Bivariate analysis shows that HIV-positive status, use of cocaine, ketamine, methamphetamine, heroin, having received drug treatment, and having received medical services are associated with SST. SST are more likely to not use condoms with partners other than their main partner, to have partners who inject drugs and are more likely to use drugs with sex. A logistic regression model included unwanted sexual touching, partner abuse, identifying as bisexual, African American, higher age, gender (women more likely), homelessness, a higher number of sexual partners, having anal sex, injection drug use, HIV seropositivity, crack use, and the likelihood of injecting drugs. The model was retested on independently collected Risk Behavior Assessment (RBA) data and showed significant relationships between survival sex and crack use, gender (women more likely), HIV positivity, identifying as bisexual, having anal sex, African American, and a higher number of sex partners. These findings make it imperative to integrate victimization counseling and HIV education into substance abuse treatment programs.

Drug-Avoidance Self-Efficacy Among Exclusive Cannabis Users vs. Other Drug Users Visiting the Emergency Department

BACKGROUND

Medical care in the emergency department (ED) is a growing and complex area of outpatient care, with about 256 visits made to EDs every minute in 2013. Studies report that, compared to people who do not use drugs, people who use illicit drugs are more likely to use the ED for their medical care. Self-efficacy has been shown to be a predictor of abstinence or reduced use among drug-using individuals.

OBJECTIVES

The current study describes drug avoidance self-efficacy among exclusive cannabis-using individuals and other drug-using individuals who use the ED for any reason.

METHODS

Participants were 693 adult patients visiting the trauma units and EDs of two large urban "safety net" hospitals (i.e., providing care to low-income, uninsured, and vulnerable population) in Southern California who reported using illicit drugs in the past 30 days.

RESULTS

For people who use only cannabis, higher drug-avoidance self-efficacy was associated with older age, lower drug involvement scores, lower drug severity scores, and higher readiness to change use. For people who use other drugs, higher drug avoidance self-efficacy scores was associated with lower drug severity scores, lower psychiatric severity scores, higher medical severity scores, and higher readiness to change use.

CONCLUSION

This study identified several factors (some common, some unique) related to higher drug-avoidance self-efficacy for both groups. Results may be important when designing intervention protocols for use in the ED.

Impulsiveness, and trait displaced aggression among drug using female sex traders

OBJECTIVE

This study compared women who sex trade for drugs, money, or both compared to neither (did not sex trade), and introduced the concept of trait displaced aggression to the literature on sex trading.

METHODS

Female participants (n=1055) were recruited from a low-income area of southern California. Measures included: the Risk Behavior Assessment (RBA), Barratt Impulsivity Scale (BIS), Eysenck Impulsiveness Scale (EIS), and the Displaced Aggression Questionnaire (DAQ).

RESULTS

Women who traded sex for both drugs and money used crack cocaine, powder cocaine, and alcohol significantly more, scored higher on the BIS, and the EIS, and were significantly older. Those who only sex traded for drugs used more amphetamine, heroin, and injected drugs more days. They were also higher on the DAQ and all of the DAQ subscales. Those who traded for money only used marijuana more and were more likely to use marijuana before sex.

CONCLUSIONS

This study may help address specific issues unique to those who sex trade for different commodities in that the drugs used are different and the underlying personality characteristics are different.