Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives

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.

A qualitative study exploring the impact of the COVID-19 pandemic on People Who Inject Drugs (PWID) and drug service provision in the UK: PWID and service provider perspectives

“…These were mostly related to difficulties assessing client health and wellbeing virtually and perceived reductions in levels of support provided. This is in line with earlier research reporting a lack of provider comfort and willingness in using such methods ( Aronowitz et al., 2021 ; Goldsamt, Rosenblum, Appel, Paris, & Nazia, 2021 ), and disrupted support routines among clients ( Kesten et al., 2021 ). PWID also face disparities in accessing telehealth services, and although innovations – including onsite, private rooms with sanitized telephones ( Quiñones et al., 2021 ) and the distribution of donated mobile phones ( Komaromy et al., 2021 ) – have proved successful in offsetting some of these issues, there remains a need to ensure access to telehealth services is more evenly distributed among PWID.…”

“…PWID also face disparities in accessing telehealth services, and although innovations – including onsite, private rooms with sanitized telephones ( Quiñones et al., 2021 ) and the distribution of donated mobile phones ( Komaromy et al., 2021 ) – have proved successful in offsetting some of these issues, there remains a need to ensure access to telehealth services is more evenly distributed among PWID. Similarly, providers must be equipped and comfortable with using telehealth methods as their use becomes increasingly integrated in treatment frameworks and routine health care ( Aronowitz et al., 2021 ). The development of an improved telehealth infrastructure, including dedicated and tailored telehealth training curricula for health and social care workers, has been recommended ( Fisk, Livingstone, & Pit, 2020 ; Thomas et al., 2020 ), and may have similar utility for those working in drug services.…”

“…Further measures - including the home delivery of harm reduction equipment (e.g. naloxone, injecting equipment), mobile outreach and expanded telephonic and telehealth services - were also established in attempts to increase treatment access in the context of reduced service availability ( Aronowitz et al., 2021 ; Courser & Raffle, 2021 ; Mehtani et al., 2021 ; Nordeck, Buresh, Krawczyk, Fingerhood, & Agus, 2021 ). Given how treatment engagement and retention is often compromised by inaccessibility and – in the case of OST - the daily burden of supervised consumption ( Frank, 2021 ; Frank et al., 2021 ; Hall, Le, Majmudar, & Mihalopoulos, 2021 ), the pandemic presents a context in which these particular issues could be addressed and improved, at least temporarily.…”

Nothing really changed: Arizona patient experience of methadone and buprenorphine access during COVID

“…Assessing the impact of sweeping regulatory changes to MOUD treatment during a pandemic is daunting. Evidence is emerging about implementation, views about the federal policy recommendations, and experiences of them throughout the country [ 33 , 34 ]. However, a full picture of peer-reviewed evidence has yet to emerge.…”

Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review

“…The time-saving benefits of remote consultations were also reported as facilitating factors, primarily in relation to reducing time spent travelling to appointments ( Goetter et al, 2022 ; Moo et al, 2020 ; Schubert et al, 2019 ). In addition, patients also reported that remote consultations improved their access to care by removing some of the logistical barriers, including requiring less time off work ( Aronowitz et al, 2021 ), reducing expenses ( Das et al, 2020 ), removing childcare barriers ( Lockard et al, 2022 ), and reducing waiting times ( Tuijt et al, 2021 ). In the context of the COVID-19 pandemic, patients also remarked that remote consultations reduced their likelihood of contracting COVID-19 ( Severe et al, 2020 ).…”