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

Abstract

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.

Adaptations to Opioid Use Disorder Care During the COVID-19 Pandemic: A National Survey of Prescribers

“…22 Prescribers working in nonrural and academic medical centers may have been supportive as they likely had had more reliable technology and the staffing to accommodate new clinic workflows. 23 While prescribers who treated a moderate versus small number of patients preferred to continue virtual visits to initiate MOUD perhaps due to better access to resources such as virtual technology, prescribers who treated a larger number of patients did not demonstrate a significant preference. The reason for this finding warrants further exploration.…”

Patients' perceptions of telehealth services for outpatient treatment of substance use disorders during the COVID‐19 pandemic

“…Insurance coverage of telehealth will also likely influence patient preferences for its use. Pre‐pandemic, insurance coverage for telehealth was more limited 2 , 24 and the future state of insurance coverage for telehealth is an active and unsettled area of health policy. Future research should examine the role of insurance status and type in preferences for telehealth care.…”

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities

“…Our study findings suggest that access to treatment might be particularly challenging for people living in rural communities that have fewer methadone programs, 14 buprenorphine providers, 15 and behavioral health services, 13 an essential component of methamphetamine use disorder treatment, for which no medications have been approved, than urban areas. Interventions to expand substance use treatment access in rural communities, such as mobile methadone delivery models 34 and telemedicine buprenorphine interventions, 35 should integrate evidence-based methamphetamine use disorder treatments such as contingency management. 36 Participants with concomitant opioid and methamphetamine use were younger and more commonly reported American Indian or Alaskan Native race.…”