Virtual Training Is More Cost-Effective Than In-Person Training for Preparing Staff to Implement Contingency Management

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities’ relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (n = 26) from eight OTPs attended in-person training, and a subsequent cohort (n = 31) from ten OTPs attended virtual training. Common training elements were the facilitator, learning objectives, and educational strategies/activities. All clinicians submitted a post-training role-play, independently scored with a validated fidelity instrument for which performances were compared against benchmarks representing initial readiness and advanced proficiency. To examine the utility and expense of in-person and virtual trainings, cohort-specific rates for benchmark attainment were computed, and per-clinician expenses were estimated. Adjusted between-cohort differences were estimated via ordinary least squares, and an incremental cost effectiveness ratio (ICER) was calculated. Readiness and proficiency benchmarks were attained at rates 12–14% higher among clinicians attending virtual training, for which aggregated costs indicated a $399 per-clinician savings relative to in-person training. Accordingly, the ICER identified virtual training as the dominant strategy, reflecting greater cost-effectiveness across willingness-to-pay values. Study findings document greater utility, lesser expense, and cost-effectiveness of virtual training, which may inform post-pandemic dissemination of CM and other therapies.

Behavioral healthcare organizations' experiences related to use of telehealth as a result of the COVID-19 pandemic: an exploratory study.

BACKGROUND: Due to the COVID-19 pandemic, healthcare providers were forced to shift many services quickly from in-person to virtual, including substance use disorder (SUD) and mental health (MH) treatment services. This led to a sharp increase in telehealth services, with health systems seeing patients virtually at hundreds of times the rate as before the onset of the COVID-19 pandemic. By analyzing qualitative data about SUD and MH care organizations' experiences using telehealth, this study aims to elucidate emergent themes related to telehealth use by the front-line behavioral health workforce. METHODS: This study uses qualitative data from large-scale web surveys distributed to SUD and MH organizations between May and August 2020. At the end of these surveys, the following question was posed in free-response form: "Is there anything else you would like to say about use of telehealth during or after the COVID-19 pandemic?" Respondents were asked to answer on behalf of their organizations. The 391 responses to this question were analyzed for emergent themes using a conventional approach to content analysis. RESULTS: Three major themes emerged: COVID-specific experiences with telehealth, general experiences with telehealth, and recommendations to continue telehealth delivery. Convenience, access to new populations, and lack of commute were frequently cited advantages of telehealth, while perceived ineffectiveness of and limited access to technology were frequently cited disadvantages. Also commonly mentioned was the relaxation of reimbursement regulations. Respondents supported continuation of relaxed regulations, increased institutional support, and using a combination of telehealth and in-person care in their practices. CONCLUSIONS: This study advanced our knowledge of how the behavioral health workforce experiences telehealth delivery. Further longitudinal research comparing treatment outcomes of those receiving in-person and virtual services will be necessary to undergird organizations' financial support, and perhaps also legislative support, for virtual SUD and MH services.

Persons from racial and ethnic minority groups receiving medication for opioid use disorder experienced increased difficulty accessing harm reduction services during COVID-19.

INTRODUCTION: The COVID-19 pandemic collided with the opioid epidemic and longstanding health inequities to exacerbate the disproportionate harms experienced by persons with opioid use disorder (OUD) who self-identify as from racial and ethnic minority groups. Disrupted access to harm reduction services (e.g., naloxone, sterile syringes, recovery support) is one pathway whereby COVID-19 might exacerbate health disparities. We tested the hypothesis that persons receiving medication for opioid use disorder (MOUD) who self-identify as from racial/ethnic minority groups would experience more disruptions in access to harm reduction services than persons identifying as non-Hispanic White, even when controlling for severity of opioid use and sociodemographics (e.g., education, income, biological sex, age). METHODS: Analyses used data from a cluster randomized trial that had enrolled 188 patients, all of whom had provided baseline data on sociodemographics and severity of opioid use, across eight opioid treatment programs. Data collectors re-contacted participants between May and June 2020 and 133 (71% response rate) agreed to complete a survey about access to harm reduction services. RESULTS: Twenty-six respondents (20%) identified as from racial/ethnic minority groups (predominantly Black, Hispanic, and/or biracial). Between 7% and 27% of respondents reported disrupted access to harm reduction services. Logistic regressions indicated that persons identifying as from racial/ethnic minority groups were 8-10 times more likely than persons identifying as non-Hispanic White to report reduced access to naloxone and sterile syringes (p < .01), even when accounting for potential confounding variables. CONCLUSIONS: This report concludes with a discussion of potential outreach strategies and policies to advance more equitable access to essential harm reduction services.

Impacts of the COVID-19 pandemic on healthcare access among patients receiving medication for opioid use disorder.

BACKGROUND: The COVID-19 pandemic significantly altered treatment delivery for opioid treatment programs (OTPs) dispensing medications for opioid use disorder (MOUD). We aimed to identify patterns of substance use among MOUD patients and examine whether COVID-19-related impacts on access to healthcare varied across subgroups. METHODS: This analysis was embedded within a type 3 hybrid trial that enrolled patients across eight OTPs at the start of the pandemic. Enrolled patients reported on past-30 day use of multiple substances during their baseline assessment. Participants re-contacted in May-July 2020 completed a survey about COVID-19-related impacts on various life domains. Using latent class analysis we identified patient subgroups, and then examined group differences on a set of negative and positive COVID-19 impacts related to healthcare access. RESULTS: Of the 188 trial participants, 135 (72 %) completed the survey. Latent class analysis identified three MOUD patient subgroups: minimal use (class probability: 0.25); opioid use (class probability: 0.34); and polysubstance use (class probability: 0.41). Compared to the minimal use group, the polysubstance use group reported increased substance use and difficulty accessing sterile needles, naloxone, and preferred substance. The opioid use group reported increased substance use and difficulty accessing their preferred substance. There were no significant group differences related to accessing routine or specialized healthcare or medication; or paying attention to their health. CONCLUSIONS: During COVID-19, many MOUD patients reported challenges accessing care, particularly harm reduction services for patients with polysubstance use. Additional efforts, like providing wraparound support, may be necessary to serve the needs of MOUD patients.

Use of Telehealth in Substance Use Disorder Services During and After COVID-19: Online Survey Study.

BACKGROUND: Social distancing guidelines for COVID-19 have caused a rapid transition to telephone and video technologies for delivering treatment for substance use disorders (SUDs). OBJECTIVE: This study examined the adoption of these technologies across the SUD service continuum, acceptance of these technologies among service providers, and intent of providers to use these technologies after the pandemic. Additional analysis using the validated technology acceptance model (TAM) was performed to test the potential applications of these technologies after the pandemic. The study objectives were as follows: (1) to assess the use of telehealth (telephone and video technologies) for different SUD services during COVID-19 in May-June 2020, (2) to assess the intended applications of telehealth for SUD services beyond COVID-19, (3) to evaluate the perceived ease of use and value of telehealth for delivering SUD services, and (4) to assess organizational readiness for the sustained use of telehealth services. METHODS: An online survey on the use of telephonic and video services was distributed between May and August 2020 to measure the current use of these services, perceived organizational readiness to use these services, and the intent to use these services after COVID-19. In total, 8 of 10 regional Addiction Technology Transfer Centers representing 43 states distributed the survey. Individual organizations were the unit of analysis. RESULTS: In total, 457 organizations responded to the survey. Overall, the technology was widely used; >70% (n>335) of organizations reported using telephone or video platforms for most services. The odds of the intent of organizations to use these technologies to deliver services post COVID-19 were significantly greater for all but two services (ie, telephonic residential counseling and buprenorphine therapy; mean odds ratio 3.79, range 1.87-6.98). Clinical users preferred video technologies to telephone technologies for virtually all services. Readiness to use telephone and video technologies was high across numerous factors, though telephonic services were considered more accessible. Consistent with the TAM, perceived usefulness and ease of use influenced the intent to use both telephone and video technologies. CONCLUSIONS: The overall perceived ease of use and usefulness of telephonic and video services suggest promising post-COVID-19 applications of these services. Survey participants consistently preferred video services to telephonic services; however, the availability of telephonic services to those lacking easy access to video technology is an important characteristic of these services. Future studies should review the acceptance of telehealth services and their comparative impact on SUD care outcomes.

Is necessity also the mother of implementation? COVID-19 and the implementation of evidence-based treatments for opioid use disorders.

Opioid-related overdoses and the coronavirus disease 2019 (COVID-19) represent two of the deadliest crises in United States' history and together constitute a syndemic. The intersecting risks of this syndemic underscore the urgent need to implement effective opioid use disorder (OUD) treatments that are sustainable amid COVID-19 mitigation strategies. In response to new federal guidance released during the pandemic, opioid treatment programs (OTPs) have quickly innovated to implement new systems of medication delivery. OTPs rapid implementation of new medication delivery models defies conventional wisdom about the pace of research transfer. As part of an ongoing cluster-randomized type 3 hybrid trial evaluating strategies to implement contingency management (CM), select staff of eight OTPs had been trained to deliver CM and were in the midst of receiving ongoing implementation support. As COVID-19 emerged, all eight OTPs mirrored trends in the addiction field and effectively adapted to federal/state demands to implement new methods of medication delivery. However, over the past few months, necessity has arguably been the mother of implementation. We have observed greater variance among these OTPs' success with the additional implementation of adjunctive CM. The speed and variability of innovation raises novel questions about drivers of implementation. We argue that the mother of the next innovation should be a public call for a progressive, thoughtful set of public health policies and other external setting levers to address the needs of those with OUD and the OTPs that serve them.