During the COVID-19 pandemic, opioid treatment programs (OTPs) have been given some flexibility in dispensing methadone and using telemedicine and other patient services, such as audio-only telephone visits for individual counseling. Favorable outcomes and better patient care were seen in a Bronx OTP study, covered separately in these pages, but a study of views and responses of clinicians at 20 OTPs in 13 states found less-favorable outcomes.
The latter study, from the RAND Drug Policy Research Center, cited clinicians’ concerns: sustainability issues and a possible decline in access and quality of care. The study was published in May of this year in the Journal of Substance Abuse Treatment.
The Rand study was based on telephone interviews conducted from May 14 to June 19, 2020. Interviewed were 20 clinicians approved to dispense methadone in OTPs: physicians, physician assistants, or nurse practitioners. The clinicians were asked about how changes in care patterns affected access and quality of care. Authors of the study used rapid thematic analysis to summarize clinicians’ views.
We describe the Rand study findings below.
Changes in clinical practice
Methadone dispensing procedures changed at 72% of OTPs; some OTPs considered patient risk or stability when deciding on increases in take-home doses
New doses ranged from a weekend supply for unstable patients to a four-week supply for stable patients. To explain why 28% of OTPs hadn’t changed their distributed doses, one clinician cited concerns about liability related to medication abuse.
Urine toxicology screening procedures varied markedly
About one-third of OTPs reported no change in toxicology screening procedures; about one-fourth discussed performing screenings less often and basing them on patient risk; and another one-fourth had temporarily stopped screening.
Some clinicians were concerned that screening less often could increase patient risk.
Said one, “… we’re flying more blindly. Luckily though we haven’t had any reported overdoses…”
Most psychosocial services were transitioned to telemedicine
Some OTPs stopped administering group therapy or offered sessions far less frequently; one OTP increased frequency, because it was convenient to serve patients in their own home.
Telemedicine During the Pandemic
Most OTPs surveyed—85%—offered telemedicine for medication management, psychosocial services, or both
Telemedicine was a new experience for 44% of the clinicians.
Said one, “They’ve been trying to push it for a while…there was so much resistance from the patients, from the staff… Covid kind of pushed us into having to do it.”
About 25% said that insufficient reimbursement had held back widespread use of telemedicine before COVID-19.
Patient and clinician factors determined whether phone or video was chosen for telemedicine
Many clinicians preferred video, but 20% to 90% of visits were by phone instead. Reasons cited by the clinicians were patients’ limited digital literacy or their lack of technology tools, such as smart phones and Internet access.
“There have been some patients who are just not so savvy with their computers…”
At first, telemedicine presented logistical challenges to OTPs
Challenges mentioned included clinic capacity, platforms available (HIPPA compliance was an issue), and stability and reliability of the options. Another concern was the time staff spent helping patients with technology.
Telemedicine “requires extra staff time to coordinate visits and do tech support … Normally we’re done at least by 5:00. The other day… we were still calling clients at 8:00 at night.”
Patients’ response to telemedicine
Most clinicians—82%—said patients had a positive response to telemedicine
Clinicians reporting a favorable response said telemedicine saves time, reduces transportation problems, is more flexible, and lowers risk of COVID-19. Clinicians who believed patients’ response had been unfavorable said patients had technical problems, felt isolated, or viewed telemedicine as impersonal.
Referring to telemedicine, a clinician remarked that patients in their mid-30s and up “just don’t like this.”
Implications for quality
Most clinicians—75%—thought increased use of telemedicine and the other changes had negatively impacted quality of care. Many mentioned they were unable to adequately assess patient status.
“You need to see the patients…touch the skin…look at the arms…look at the eye. How can you do this with telemedicine?”
“…especially for the telephone visits, it makes it harder to build rapport with them.”
Despite perceiving negative impacts on quality, some clinicians believed changes in service delivery had been beneficial
Patients are “in their own safe space… they can kind of open up more.”
“If I have to put my money in stock, I will put it in telemedicine, because it’s going to be the future of medicine eventually. It’s been very good for patients.”
Future service-delivery plans
Most clinicians (63%) considered telemedicine and other service delivery changes “desired and sustainable,” and wanted to continue using telemedicine, but believed it was necessary to expand reimbursement. Those who didn’t want to continue with the changes—21%—were either concerned about the quality of care or felt that patients preferred in-person care. Those who were undecided mentioned concerns about patient needs and access. Also mentioned: patient risk and liability issues.
Summary
The clinicians indicated that in their OTPs, COVID-19 had resulted in more take-home doses of methadone, greater use of telemedicine for managing psychosocial services and medication, less use of urine toxicology screening, and fewer new patients being accepted in their program. Some clinicians supported increased dosing flexibility and greater use of telemedicine; others were concerned that doing so might increase the risk of medication diversion and overdose.
Maintaining telemedicine services, clinicians said, would require continued reimbursement.
Conclusions
The clinicians said the pandemic had “dramatically altered the delivery of methadone treatment in the U.S.” They also said that their findings suggest OTPs may have reduced methadone treatment in the early months, “and that the flexibilities offered by policy changes may not have resulted in changes in care delivery for all patients.” The authors also brought up sustainability issues and suggested that “quality of care as well as access may have declined.”
The authors said in closing: “Future research should examine how these changes in methadone services and telemedicine impact treatment access and outcomes, including retention, diversion, overdose, and deaths.”
Reference
Hunter SB, Dopp AR, Ober AJ, Uscher-Pines L. Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study. J Subst Abuse Treat. 2021 (May);124:108288. doi:10.1016/j.jsat.2021.108288
