When the coronavirus pandemic arrived in the U.S., life changed dramatically.
Some states carried on with business as usual, but for a majority of communities, local public health guidelines led to significant changes in everything from how residents worked and went to school to how they shopped for essentials, socialized, and accessed essential services such as medical care.
When the federal government declared COVID-19 a public health emergency on March 16th, 2020, and announced 15 Days to Slow the Spread, the changes became official. The Centers for Disease Control (CDC) advised everyone to:
- Wear masks
- Maintain social distance
- Make only essential trips for food, healthcare, work, or emergencies
That’s a drastic oversimplification, but since we all lived through it – and don’t really want to revisit it again in detail – we’re safe leaving it at that:
Our daily lives changed in major ways.
We all remember it well: the scene in New York City as residents cheered healthcare workers at the end of their shifts, the nail-biting wait for vaccines, and the gradual reopening and a return to a new, near-normal.
We all remember it because it impacted all of us. People who lived in states with fewer restrictions felt it because our states and communities aren’t sequestered or cut off from one another. Though travel was discouraged, travel restrictions were suggestions, not new, enforceable laws. Therefore, individuals, communities, and businesses everywhere felt the pandemic effect.
One area that faced significant challenges was healthcare. Since healthcare is essential, ongoing, and unpredictable – meaning people may need care at any time of the day or night for any reason – the healthcare system itself had to adapt literally overnight.
This article will focus on one specific component of healthcare – medication-assisted treatment (MAT) for opioid use disorder – and discuss how the coronavirus pandemic impacted both treatment providers and treatment recipients.
How Treatment for Opioid Use Disorder Changed During the Pandemic
A meta-analysis published in the journal Current Psychiatry Reports in July 2022 called “Telehealth-Based Delivery of Medication-Assisted Treatment for Opioid Use Disorder: A Critical Review of Recent Developments” evaluated the delivery of medication-assisted treatment (MAT) via telephone or videoconference – i.e. telehealth platforms – to individuals diagnosed with opioid use disorder.
Researchers identified the need for a review of the effectiveness of MAT via telehealth due to the increases in use driven by the coronavirus pandemic, as identified above. Before we get into the details of the report, let’s define the terms we’ll use throughout this article: telebehavioral health (TBH), medication-assisted treatment (MAT), and opioid use disorder (OUD).
Telebehavioral Health (TBH)
- TBH is defined as behavioral health treatment delivered via video or audio communication technology. It’s distinct from text-based interventions or other treatment methods that do not used video or audio.
- Within various video or audio formats, TBH treatment can be delivered in one of two ways:
- Synchronously: This refers to live, simultaneous, real-time interaction between treatment recipient and treatment provide. Phone calls or video conferences/meetings are examples of synchronous
- Asynchronously: This refers to treatment wherein the provider and treatment recipient can exchange information – i.e. engage in a treatment session – independent of time. A video or audio message and a video or audio reply – a therapeutic exchange – between treatment recipient and provider is an example of asynchronous treatment.
Medication-Assisted Treatment (MAT)
- MAT is an evidence-based therapeutic approach used for opioid use disorder (OUD) and/or alcohol use disorder (AUD) that includes the prescription of Food and Drug Administration (FDA) approved medication – buprenorphine, methadone, or naltrexone – in combination with therapy, counseling, lifestyle changes, and social support.
- Benefits of MAT include:
- Reduced withdrawal symptoms
- Reduced cravings
- Decreased euphoric/sedative effect of opioids
- Reduced overdose rate
- Reduced relapse rate
- Decreased infectious disease transmission
- Increased time-in-treatment
Opioid Use Disorder (OUD)
- The Diagnostic and Statistical Manual of Mental Disorders, Volume 5 (DSM-5), defines OUD as a substance use disorder with the substance or substances of disordered use specified as an opioid or opioids.
For the rest of this article, we’ll refer to MAT delivered via telehealth as tele-MOUD, where MOUD is an acronym for medication for opioid use disorder.
Those are the terms we’ll use. Now, before we get to the study, let’s outline the scope of the problem that tele-MOUD can help us address.
The Opioid Crisis: Where We Are Now
The current problem in the U.S. is known by more than one name. Most people refer to it as the opioid crisis, the opioid epidemic, or the overdose crisis. Whatever name we use, the fact is that close to a million people have died of drug overdose since 1999.
The trend is not improving. It’s something we need to change.
Here are additional important facts about opioid and drug overdose in the U.S.:
- In 2021, over 107,000 people died of drug overdose – 28.5% increase over 2020
- The pandemic caused an increase comorbidity, or the presence of co-occurring disorders. When an individual receives a diagnosis for a substance use disorder and mental health disorder at the same time, they receive a dual diagnosis and have co-occurring disorders.
- Co-occurring disorders that increased during COVID-19 include:
- Opioid use disorder (OUD) is associated with intravenous (IV) drug use, which is associated with high rates of infectious disease such as:
- OUD is associated with an increase in additional health problems, including:
- Chronic pain
- Liver disease
- Experts place the financial liability related to OUD, nationwide, at an estimated 78 billion dollars per year.
Addiction treatment experts agree that MAT is the gold-standard treatment for OUD, and the statistics above show we need all the help we can get in mitigating the harm caused by the opioid crisis. Nevertheless – despite the high demonstrated need for MAT for OUD – the following facts remain:
- 71% of counties in the U.S. lack available MAT prescribers/providers
- 60% of counties in the U.S. lack physicians with buprenorphine waivers
- Physicians report training and Drug Enforcement Agency (DEA) waivers and regulations for practice are restrictive and unnecessarily burdensome
- Many physicians with buprenorphine waivers treat very few patients with OUD
In addition to those facts, common barriers to the gold-standard care of OUD include:
We’ve offered the important facts and outlined the scope of the OUD/overdose/MAT access problem in the U.S., which means we now have everything we need to discuss the details of the study.
Lets’ take a look.
Tele-MOUD for People With OUD: Can It Help?
Here’s how the authors of the study introduce their work:
“Telehealth-delivered medication-assisted treatment for opioid use disorder (tele-MOUD) has received increased attention, with the intersection of the opioid epidemic and COVID-19 pandemic, but research on recent developments is scattered.”
To rectify the situation and bring a level of consistency and reliability to the fragmented, “scattered” nature of the existing data on tele-MOUD, the research team searched for any and all peer-reviewed journal articles on the topics “MAT,” “OUD,” and “telehealth.” They identified over 900 possible titles and found 30 that met their criteria for inclusion in the study.
Of the 30 studies that met their criteria, they evaluated tele-MOUD across four categories:
- Clinical effectiveness, as measured by rates of treatment retention and abstinence.
- Non-clinical effectiveness, as measured by non-clinical criteria such as access to care and practical implementation for both treatment providers and treatment recipients.
- Perceptions, as reported by treatment providers and treatment recipients.
- Regulations, as reported by treatment providers and insurance providers.
We’ll now share what they found, one category at a time, in the order we list above.
Reminder: researchers defined the metrics for clinical effectiveness as treatment retention rates and abstinence rates.
The majority of studies reviewed showed:
- Improved retention rates
- Improved abstinence rates
- Comparable rates for pregnant women with OUD as measured by:
- Improved treatment retention
- Decreased rates of neonatal abstinence syndrome (NAS)
Reminder: researchers defined the metrics for non-clinical effectiveness as access to care and practical implementation for both treatment providers and treatment recipients.
- Improved access to care for:
- Recipients in rural areas
- Recipients with mobility challenges
- Disadvantaged demographics
- Reduced wait times
- Treatment recipients reported tele-MOUD helped mitigate challenges caused by:
- Treatment providers reported tele-MOUD improved treatment in the following areas:
- Increased capacity
- Reduced need for outgoing referrals
- Continuity of integrated care
- Consistency in record-keeping
- Treatment providers also reported:
- Increased patient demand for treatment
- Increased duration of buprenorphine prescriptions
- Improved ease in retaining patients
Researchers collected data on perceptions from treatment providers and treatment recipients through online and in-person surveys. Researchers received most of the perception data via personal anecdotes conveyed by providers and recipients.
Surveys and anecdotes indicated the following:
- Clinician perceptions:
- Clinicians reported tele-MOUD was more effective than other telemedicine therapies, including remote psychotherapy
- Many clinicians reported a need for access to affordable technology that complies with standards established by the Health Insurance Portability and Accountability Act (HIPAA).
- Many clinicians prefer patients to also have access to in-person, local therapist/counselor, in addition to a tele-MOUD provider
- Clinicians identified a need for solutions with regard to urine screens:
- Screening for substances of misuse is part of MAT, but requiring a patient to travel to a site for screening recapitulates the challenges that led to the need for tele-MOUD
- 62% of physicians surveyed across studies indicated willingness to provide tele-MOUD, but only 38% provided tele-MOUD
- 82% of physicians reported satisfaction with tele-MOUD
- Treatment recipient perceptions:
- Recipients reported satisfaction with:
- Ease of access
- Scheduling flexibility
- The feeling of a less “formal or medicalized” treatment context
- Recipients reported dissatisfaction with:
- Technical glitches
- Lack of face-to-face contact
- Lack of group counseling session
- Compared to in-person MAT, recipients reported:
- Feeling safer
- Feeling less stigmatized
- Satisfaction with access to 24/7 hotlines related to tele-MOUD
- Recipients reported satisfaction with:
Researchers studied the impact of regulations on tele-MOUD by noting the policy changes around MAT directly related to the pandemic, and by collecting data from the Center for Medicare and Medicaid Services (CMS).
Here’s what they found:
- Before the federal government declared COVID-19 a public health emergency (PHE), clinicians and patients identified the following regulatory barriers to care:
- Restrictions related prescribing and dispensing methadone, buprenorphine, and naltrexone
- Restrictions related to reimbursement from public and private insurers
- Significant variation in regulations and implementation of regulations from state to state
- After the declaration of COVID-19 as a PHE, the Drug Enforcement Agency (DEA) lifted restrictions related to:
- Initiating buprenorphine-based MAT: initiating buprenorphine-based MAT via telehealth allowed during the PHE
- Continuing buprenorphine-based MAT: ongoing buprenorphine-based MAT via telehealth allowed during the PHE
- Take home doses of buprenorphine: allowed increases in take-home doses
- The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS):
- Allowed reimbursement for tele-MOUD
- Relaxed HIPPA requirements for tele-MOUD sessions
- Increased number of MAT patients for providers
- Regulatory easing resulted in:
- Increase in telehealth visits for Medicare recipients:
- 1% of behavioral health visits in 2019
- 38% of behavioral health visits in 2020
- By the end of 2020, 50% of behavioral health visits for Medicare recipients occurred via telehealth
- For recipients with OUD, CMS reports:
- 2% participation in telehealth in 2019
- 39% participation in telehealth in 2020
- Increase in telehealth visits for Medicare recipients:
That’s the data – and it’s a mixed bag.
Tele-MOUD is Effective and Feasible, But Providers and Patients See Room for Improvement
The results of this study tell us that tele-MOUD has distinct advantages over traditional MAT in specific categories related to treatment delivery and effectiveness. With the easing of regulations during COVID-19, tele-MOUD removed barriers to care and improved access for individuals in rural areas and in economically disadvantaged areas. It helped people on MAT manage transportation issues, work schedules, and childcare coverage without interrupting or preventing access to care. When these barriers fall, treatment retention increase, and treatment outcomes improve.
Clinicians reported increases in treatment capacity, increase in demand for treatment, increase in patient retention, and an increased ability to maintain continuity of care and deliver integrated treatment in a person-first, holistic manner. Improvements in all these areas translate to improvements in treatment outcomes for people with OUD.
Researchers identified disadvantages, too:
- Some treatment recipients preferred in-person treatment, in order to reduce feelings of isolation and loneliness
- Some treatment recipients reported missing group counseling sessions and contact with recovery peers
- Treatment providers identified the need for affordable, HIPPA-compliant technology
- Some treatment providers preferred their patients to have access to an in=person counselor, in addition to a tele-MOUD provider
In light of the advantages and disadvantages, the study authors compiled a list of ways to improve and expand “this effective method for delivering MAT for OUD.” Here’s the list of improvements they offer, based on the data collected in the study.
Tele-MOUD Needs Moving Forward
- Funding Increases
- Tele-MOUD works, but needs comprehensive funding to implement at the national scale
- Solutions to Logistical Challenges
- Providers need HIPPA-compliant technology that’s easy to acquire and implement
- Providers need solutions to the problem of urine screens for tele-MOUD recipients
- Programs to Identify Appropriate Patients
- Funding should include outreach efforts to find and initiate treatment for patients in need, particularly patients in rural areas with limited infrastructure
- Programs to Expand Awareness and Reduce Stigma
- Funding should include education campaigns in schools and communities, particularly in rural areas
- Expand Training for Clinicians and Staff at Treatment Centers
- All treatment center staff need expanded education and training to implement tele- MOUD in a manner that’s safe, private, and practical
- Expand Telehealth Infrastructure
- Funding should include expanding internet infrastructure in rural areas
- Funding should help providers expand office infrastructure to enable tele-MOUD
- Regulatory Reforms
- The changes in regulations implemented during COVID-19 should be made permanent, if evidence indicates they reduce harm
There’s something we need to say about these recommendations: they’re in process. And that’s very good news for people with OUD and for the treatment providers who support them.
The current and previous administrations – meaning the Biden White House and the Trump White House – both recommended funding items in the federal budget that would expand MAT generally, and improve access and infrastructure for tele-MOUD.
To learn more about those budget policies, please read this article on our blog:
Has the Treatment Gap for Opioid Use Disorder Improved?
We work to close the treatment gap every day. With this data – and the funding allocated by local, state, and federal public health agencies – we can reduce the ongoing harm caused by the opioid crisis, and improve the lives of our patients with OUD on MAT. When we add another component to our treatment options, such as tele-MOUD, we can only see it helping us achieve our overall mission, which is to provide the best evidence-based addiction treatment available to anyone and everyone who needs it.