ABSTRACT
Medications for opioid use disorder (OUD) such as buprenorphine are the gold standard for treatment of OUD, but patients face many barriers accessing these medications. To address this gap, a team at Penn Medicine leveraged new regulatory flexibilities during the Covid-19 pandemic that allow for virtual prescribing of buprenorphine. Their goal in establishing the model, called CareConnect, was to provide same-day, high-quality, short-term buprenorphine treatment as well as linkage to longitudinal care. CareConnect includes trained clinicians who provide OUD care integrated into a broader virtual urgent care practice. The program is enhanced by a substance use navigator team that assesses patients, supports patients and clinicians throughout a patient's care journey, and links patients to longitudinal OUD care programs based in primary care or specialty behavioral health. In this article, the authors describe the development and implementation of this novel program to treat OUD embedded within an existing telehealth urgent care program. Penn Medicine's work shows that buprenorphine telehealth prescribing can be adopted by generalist clinicians. The substance use navigator support is a critical element to fill gaps and overcome barriers to care in the community and health system.
ABSTRACT
The COVID-19 pandemic and ensuing service delivery interruptions had serious impacts on people who use drugs (PWUD) and people experiencing homelessness, including instability in the drug supply, decreased access to substance use disorder (SUD) treatment and harm reduction supplies, increased substance use and relapse due to stress and isolation, inability to properly isolate and quarantine without stable housing, and risk of COVID-19 spread in congregate living spaces. At the same time, many have noted a potential opportunity for rapid change in health, housing, and drug policy despite previous stagnation-referred to as a "punctuated equilibrium" by Baumgartner and Jones-in response to the pandemic. The pandemic forced some important policy interventions in the United States at both national and local levels, including eviction moratoriums and loosening of drug policy related to substance use treatment. However, to what extent some of these changes will be sustained past the current COVID-19 crisis is still unclear, as is how drug and housing related policy shifts have impacted the work of frontline overdose prevention, substance use treatment, and homelessness advocacy workers. In this qualitative study, we used semi-structured interviews to assess how Philadelphia's harm reduction advocates, community organizers, and SUD treatment clinicians have responded to the overdose and homelessness crises during COVID-19, and how they predict the pandemic and ensuing policy changes will impact the future of overdose prevention, harm reduction efforts, and homelessness advocacy. We interviewed 30 eligible participants during July and August 2020. The analysis of these data yielded three themes: 1/"None of it should be new to anybody": COVID-era issues impacting PWUD and people experiencing homelessness are extensions of existing problems; 2/"An opportunity to actually benefit in some way from this crisis": Possibility for innovation and improved care for PWUD and people experiencing homelessness; and 3/"Nothing we've tried has worked, so we have to be uncomfortable and creative": The uncertain path forward. Despite the many barriers that participants faced to promoting the health and well-being of marginalized communities during the pandemic, they also believed that the pandemic presented an important opportunity for positive policy change that has the potential to promote drug user health into the future, including a continuation of loosened federal restrictions on substance use disorder treatment, legalization of safe consumption spaces, safe supply of substances, and progressive, creative housing solutions.
ABSTRACT
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.