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.

Sustainment of Contingency Management within Opioid Treatment Programs: COVID-Related Barriers and Innovative Workflow Adaptations.

Introduction: Contingency Management (CM) is one of the most effective interventions for persons with opioid use disorder, but one of the least available interventions in community settings, including opioid treatment programs. Project MIMIC is a NIDA-funded cluster randomized trial that is measuring CM implementation and sustainment across 30 opioid treatment programs in the New England region of the United States. The advent of the COVID-19 pandemic occurred in the midst of Project MIMIC's first cohort of eight opioid treatment programs, presenting a natural opportunity to document and analyze novel challenges to CM sustainment. Utilizing both quantitative and qualitative data collection, we aimed to identify both COVID-related barriers to CM sustainment and innovative workflow strategies to mitigate these barriers. Methods: Quantitative analysis was conducted using data collected from a study-specific CM tracker tool on various CM implementation metrics over three distinct, successive time intervals: prior to COVID-19 social distancing orders with active support; during COVID-19 social distancing orders with active support; and during COVID-19 social distancing orders after removal of support. Semi-structured qualitative interviews were conducted with a representative from each of the eight opioid treatment programs. Using a reflexive team approach, transcripts were coded by independent raters to identify both COVID-related barriers to sustainment and innovative workflow adaptations. Results: Quantitative data revealed a substantial decrease in the number of CM encounters following social distancing orders from 31.8 encounters weekly across eight programs to 6.9 encounters weekly across five programs. A further decline to 1.8 weekly encounters across three programs was observed after implementation support was removed. Four COVID-related barriers were identified via thematic analysis: fear of contagion; difficulty engaging patients remotely; challenges re-defining the CM attendance target due to changing regulations; and staff shortages. Potential adjustments discussed to help address one or more of these barriers included an electronic prize generator; use of technology to promote engagement; brief individual remote check-ins; and expansion of training to non-counseling staff. Conclusion: Although CM implementation challenges emerged during the pandemic, associated workflow adaptations also emerged. The feedback solicited in this study will inform multi-level strategies to aid with CM sustainment post-pandemic.

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.