Improving methadone access for rural communities in the USA: lessons learned from COVID-19 adaptations and international models of care.

CONTEXT: The COVID-19 pandemic led to several changes to methadone treatment protocols at federal opioid treatment programs in the USA. ISSUE: Protocol changes were designed to reduce transmission of COVID-19 while allowing for continuity of care, but those changes also demonstrated that many policies surrounding opioid use disorder care in the USA cause unnecessary burdens to patients. In this commentary, we describe how current policies create and maintain fatal barriers to methadone treatment for people in rural communities who have opioid use disorder, and highlight how COVID-19 adaptations and more flexible methadone models in other countries can better allow for effective and accessible care. Reasons and ways to address these issues to create lasting solutions for rural communities are discussed. LESSONS LEARNED: We focus on three lessons: (1) methadone dispensing and take-home schedules during COVID-19, (2) telehealth services during COVID-19, and (3) international models in use prior to COVID-19. We then outline recommendations for each lesson to improve access to methadone treatment long term for rural communities in the USA. There is an urgent need to implement recommendations that maintain flexible approaches and address methadone treatment barriers in the rural USA. To achieve lasting health policy change and combat stigma about addiction and methadone treatment, there is a need for advocacy efforts that give voice to rural residents impacted by inequitable access to methadone treatment and rural-tailored educational initiatives that promote the evidence base for methadone. We hope opioid treatment program directors, regulatory authorities, and health policymakers consider our recommendations.

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.

Access to OUD Treatment and Maintenance of Sobriety amid the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic changed the way that healthcare is delivered, with non-urgent care becoming almost entirely virtual. Underserved communities already battling the opioid epidemic had new challenges in accessing medication assisted treatment (MAT). The investigators sought to determine if patients were retaining access to their opioid use disorder (OUD) treatment and maintaining sobriety during the pandemic, with the intention of using this information to improve subsequent patient care while the pandemic continues. METHODS: In the assessment, seventy-five patient Epic EMR (electronic medical record) charts were reviewed to collect information on demographics, socioeconomic factors, healthcare access and sobriety during the pandemic period between March 1st, 2020 and June 15th, 2020. Patient charts were selected based on those receiving office-based opioid treatment (OBOT) for OUD at an urban healthcare center. RESULTS: 98.7% of patients accessed the healthcare center in some form since March 1st, 2020. The most common form of communication was through telemedicine with 94.6% of calls over audio. Out of the 21 toxicology screens performed during the pandemic period, 16 (76%) patients were found to be adhering to their buprenorphine treatment. Only 78.7% had documented they had Narcan at their disposal. Among all patients, 11 (14.6%) reoccurrences in opioid use were documented during the pandemic period. Few patients (76%) were adhering to their prescribed buprenorphine treatment, revealing that patients may not be receiving needed MAT support amid the pandemic. CONCLUSION: This assessment reveals short-comings of patient education in managing craving and the maintenance of support systems amid social-isolating conditions.

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.

Impact of COVID-19 Related Policy Changes on Buprenorphine Dispensing in Texas.

OBJECTIVES: To measure the change in the daily number of patients receiving buprenorphine and buprenorphine prescribers during the early phase of the COVID-19 (SARS-CoV-2) pandemic in Texas. METHODS: Counts of the number of patients filling and number of providers prescribing buprenorphine were calculated for each weekday between November 4, 2019 and May 12, 2020. The change in daily patients and prescribers between March 2, 2020 and May 12, 2020, was modeled as a change in slope compared to the baseline period using autoregressive, interrupted time series regression. RESULTS: The rate of change of daily buprenorphine prescriptions (ß = -1.75, 95% CI = -5.8-2.34) and prescribers (ß = -0.32, 95% CI = -1.47-0.82) declined insignificantly during the COVID-19 period compared to the baseline. CONCLUSIONS: Despite a 57% decline in ambulatory care utilization in the south-central US during March and April of 2020, health services utilization related to buprenorphine in Texas remained robust. Protecting access to buprenorphine as the COVID-19 pandemic continues to unfold will require intensive efforts from clinicians and policy makers alike. While the presented results are promising, researchers must continue monitoring and exploring the clinical and humanistic impact of COVID-19 on the treatment of substance use disorders.

Response to coronavirus 2019 in Veterans Health Administration facilities participating in an implementation initiative to enhance access to medication for opioid use disorder.

The actions needed to mitigate the spread of the coronavirus 2019 (COVID-19) have forged rapid paradigm shifts across healthcare delivery. In a time of crisis, continued access to and delivery of medication for opioid use disorder (M-OUD) is essential to save lives. However, prior to COVID-19, large variability in M-OUD adoption existed across the Veteran Health Administration (VHA) and it is unknown whether the COVID-19 pandemic exacerbated this divide. For the past two years, our team worked with eight VHA facilities to enhance adoption of M-OUD through a multi-component implementation intervention. This commentary explores these providers' responses to COVID-19 and the subsequent impact on their progress toward increasing adoption of M-OUD. Briefly, the loosening of regulatory restrictions fostered accelerated adoption of M-OUD, rapid support for telehealth offered a mechanism to increase M-OUD access, and reevaluation of current practices surrounding M-OUD strengthened adoption. Overall, during the COVID-19 crisis, facilities and providers responded positively to the call for increased access to M-OUD and appropriate care of patients with OUD. The VHA providers' responses and continued progress in enhancing M-OUD amidst a crisis may, in part, be attributable to their participation in an implementation effort prior to COVID-19 that established resources, expert support, and a community of practice. We anticipate the themes presented are generalizable to other healthcare systems grappling to deliver care to patients with OUD during a crisis. We propose areas of future research and quality improvement to continue to provide access and high quality, life-saving care to patients with OUD.

Treatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine.

OBJECTIVE: The COVID-19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about the experiences of front-line clinicians in the transition to telemedicine. This study described how, in the context of the early stages of the pandemic, clinicians used telemedicine for OUD in conjunction with in-person care, barriers encountered, and implications for quality of care. METHODS: In April 2020, we conducted semistructured interviews with clinicians waivered to prescribe buprenorphine. We used maximum variation sampling. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches, to identify and characterize themes. RESULTS: Eighteen clinicians representing 10 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID-19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological challenges, and shorter visits. CONCLUSIONS: In the context of the pandemic, buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns, including the quality and safety of widespread use of telemedicine for OUD treatment.