Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis.

Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.

A qualitative study of patient experiences with telemedicine opioid use disorder treatment during COVID-19.

Background: The drug-related overdose crisis worsened during the COVID-19 pandemic. Recent drug policy changes to increase access to medications for opioid use disorder (MOUD) during COVID-19 shifted some outpatient MOUD treatment into virtual settings to reduce the demand for in-person care. The objective of this study was to qualitatively explore what is gained and lost in virtual patient encounters for patients with opioid use disorder at a low-threshold, addiction treatment clinic that offers buprenorphine and harm reduction services. Methods: Patients were included in this study if they received care at the Harm Reduction and BRidges to Care (HRBR) clinic and utilized virtual visits between November 2019 and March 2021. The study was conceptualized using a health care access framework and prior studies of telemedicine acceptability. Semi-structured interviews were completed between March and April 2021. Interviews were dual-coded and analyzed using directed content analysis. Results: Nineteen interviews were conducted. The sample was predominantly White (84%) and stably housed (79%) with comparable gender (male, 53%) and employment status (employed, 42%). The majority (63%) of patients preferred virtual visits compared to in-person visits (16%) or a combination of access to both (21%). Two overarching tandem domains emerged: availability-accommodation and acceptability-appropriateness. Availability-accommodation reflected participants' desires for immediate services and reduced transportation and work or caregiving scheduling barriers, which was facilitated by virtual visits. The acceptable-appropriate domain articulated how participants felt connected to their providers, whether through in-person interactions or the mutual trust experienced during virtual visits. Conclusions: Virtual visits were perceived by participants as a valuable and critical option for accessing treatment for OUD. While many participants preferred virtual visits, some favored face-to-face visits due to relational and physical interactions with providers. Participants desired flexibility and the ability to have a choice of treatment modality depending on their needs.

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.

Reduction in Oregon's Medication Dosing Visits After the SARS-CoV-2 Relaxation of Restrictions on Take-home Medication.

To slow the spread of SARS-CoV-2 in opioid treatment programs (OTPs), SAMHSA notified State Opioid Treatment Authorities that stable patients could receive up to 27 days of take-homes, less stable patients could receive up to 13 days with fewer take-homes for other patients. An analysis assessed how the relaxed standards affected the number of patient dosing visits and the amount of take-home medications dispensed in Oregon's 20 public, nonprofit, and for-profit OTPs. OTPs reported the number of patients receiving take homes pre and post federal policy change at 3 time points: pre SARS-CoV-2 (February or first half of March), post 1 SARS-CoV-2 (March, April, or May), and post 2 SARS-CoV-2 (April, May, or June). The patients receiving each quantity of take-homes were counted and means calculated for visits and take-homes per patient per month. A negative binomial mixed-effects regression model assessed change in mean dosing visits per patient. During the pre SARS-CoV-2 period, OTPs served 7792 patients monthly with 120,513 medication visits and dispensed 44,883 take-home doses. Mean patient visits per month were 15.5 with 5.8 take-homes per patient per month. Following the policy change, medication visits declined 33% and take-home medication increased 97% with 10.4 mean visits per patient and 11.3 mean take-homes per patient. The negative binomial mixed-effects regression model estimated a 54% reduction in mean visits per patient. The policy change had the intended effect. More research is needed to assess unintended consequences associated with increased access to take-home medication.

Addressing a rapidly changing service landscape during the COVID-19 pandemic: Creation of the Oregon substance use disorder resource collaborative.

Following the rising crisis of COVID-19 and the Oregon governor's stay-at-home orders, members of the Oregon Health and Science University (OHSU) inpatient addiction consult service recognized that local addiction treatment and recovery organizations were operating at limited capacity. As a result, discharge planning, patient access to local community-based treatment, and safety-net programming were affected. Given structural and intersectional risk vulnerabilities of people with substance use disorders (SUDs), the OHSU members felt that COVID-19 would disproportionately impact chronically marginalized members of our community. These inequities inspired the formation of the Oregon substance use disorder resources collaborative (ORSUD) led by four medical students. ORSUD's mission is to support the efforts of local safety-net organizations that and front-line providers who serve chronically marginalized community members in the midst of the global pandemic. We operationalized our mission through: 1) collecting and disseminating operational and capacity changes in local addiction and harm reduction services to the broader treatment community, and 2) identifying and addressing immediate resource needs for local safety-net programs. Our program uses a real-time public-facing document to collate local programmatic updates and general community resources. COVID-19 disproportionately burdens people with SUDs; thus, ORSUD exists to support programs serving people with SUDs and will continue to evolve to meet their needs and the needs of those who serve them.