SUBSTANCE USE TREATMENT inequities among rural populations are well documented and the COVID-19 pandemic has exacerbated these inequalities.1-3 When in-person services were curtailed, healthcare professionals who care for individuals with substance use disorder (SUD) had to be creative in the delivery of treatment. Systematic reviews on the use of telehealth to treat SUD conducted before the pandemic showed that telehealth interventions are promising alternatives to in-person services.4 This article examines the evidence supporting the use of telehealth in treating patients with SUD and explores other promising options that can help overcome both preexisting and pandemic-related barriers to treatment. The authors argue that adopting innovative ways to give patients access to treatment is fundamental to providing treatment continuity, preventing adverse events, and supporting patients' long-term recovery during the pandemic and beyond.
What the evidence shows
A systematic review of 50 studies with diverse participants, interventions, and designs found that telehealth is an acceptable alternative to in-person services and can be used to substitute or supplement traditional service provision for SUDs, including opioid use disorder (OUD).5 In fact, 61% of the studies reported positive SUD treatment outcomes and patient satisfaction. The most favorable results were found in studies that utilized shorter interventions, were initiated by patients, and were asynchronous (did not require everyone to participate at the same time, thereby providing more flexibility). In addition, one study evaluating a buprenorphine program in which services were provided via telehealth found 50% retention at the 3-month follow-up, further demonstrating utility of telehealth-delivered interventions for the treatment of OUD, particularly for those living in rural settings.6 This result is impressive because adherence to opioid agonist therapy (OAT) is a consistent challenge for clinicians and researchers, with adherence rates as low as 19% in some cases.7
Barriers to OUD treatment
Substance use treatment inequities in rural populations are well documented, and large-scale crises such as the COVID-19 pandemic exacerbate these existing inequalities, particularly among socially and economically vulnerable populations.8-11 The COVID-19 pandemic has created additional treatment disruptions that worsen poor treatment outcomes, mostly related to unemployment, social isolation, and intense psychological stressors; interrupted access to OAT; and interference with daily routines that provide the necessary structure for many people with SUD.12,13 This is especially true because financial instability, which can result from unemployment, is robustly associated with poor treatment outcomes such as relapse and suicidal ideation.14,15 Moreover, treatment disruption results in increased risk for relapse and even fatal overdoses, making substance use treatment access and continuity an urgent priority for healthcare and public health professionals.13
Although an estimated 1.4 million people in the US have a prescription drug OUD, only 22% of them receive treatment.16 Barriers to accessing SUD treatment for the almost 80% of individuals with OUD who did not seek treatment despite their need are significant and pervasive. Substance use related stigma, lack of healthcare coverage, treatment costs, lack of knowledge of available resources, and inability to cease drug use without medical intervention are all culprits in perpetuating treatment barriers, which significantly contribute to the ongoing opioid crisis.17 These are especially pronounced in rural areas of the US such as the Deep South.8
In response to the opioid epidemic, the US Department of Health and Human Services has identified improving access to treatment and recovery services an urgent priority in combating the opioid overdose crisis.18 Challenges, however, still exist in realizing this dream, particularly in the Deep South where access to treatment is further complicated by increased stigma and limited resources in the areas of prevention, treatment, and recovery.19,20 Indeed, OAT providers are more likely to be located in urban areas.21,22 Over 53% of rural counties do not have a single OAT provider, suggesting that innovative strategies are urgently needed to address not only preexisting inequities facing rural dwelling communities, but also the exacerbation of harms caused by COVID-19.23
Even under noncrisis circumstances, individuals with OUD have lower access to treatment, which places them at increased risk for adverse events. The COVID-19 pandemic created additional challenges, heightening treatment barriers and forcing substance use providers nationwide to be creative in the delivery of treatment.
Telehealth comes of age
Telehealth services were once largely viewed as optional--either as a luxury for people with the ability to access care from the comfort of their homes, or as a means to increase access to care in areas where treatment accessibility is scarce.24,25 During the pandemic, telehealth moved front and center. Stringent Drug Enforcement Administration (DEA) guidelines that govern OUD treatment were somewhat loosened in order to mitigate the negative effects of the pandemic on the opioid epidemic.26 These changes increased the number of patients eligible for take-home methadone and allowed prescribing and therapy sessions to be conducted via telehealth.27
Challenges and barriers
Although telehealth is a promising strategy for increasing treatment accessibility for patients with OUD, particularly those in underserved areas, significant challenges exist in the effective implementation and expansion of telehealth in rural areas. On the provider side, technology costs, access and training, DEA regulations, and Medicare/Medicaid limitations (such as varying levels of OAT Medicaid coverage from state to state) stymie expansion of telehealth.28
On the patient side, lack of internet access or cell phone service for individuals who live in rural areas is a primary concern.29 This is especially problematic because only 24% of rural-dwelling adults in the US have access to high-speed internet.30 Additionally, challenges related to insurance and coverage of telehealth services that extend beyond the current pandemic may be a barrier, especially for many rural-dwelling individuals who are underemployed and unable to afford insurance coverage.31
COVID-19 has permanently altered the way healthcare providers treat patients with mental, physical, and behavioral health needs. Consequently, society as a whole may consider embracing the changes in healthcare delivery as “the new normal” to make treatment more accessible, convenient, and affordable. Researchers and clinicians alike need to rethink substance use treatment and service delivery by adopting creative strategies that address disparities and inequalities for people living in the rural south. Some examples of strategies currently in use include:
- making maintenance medications such as methadone or buprenorphine available to individuals via personal door-to-door delivery.32
- allowing maintenance medications to be administered by registered pharmacists, particularly in rural counties where transportation and provider access are serious barriers to care.33
- decreasing the frequency of urine drug screens for those on OAT.34
These innovative solutions also require advocacy to influence healthcare policy and remove regulatory restrictions that govern OUD treatment.
Another way to overcome some of these challenges is the use of a TeleECHO program.35 This revolutionary, innovative, and timely guided practice model was developed by the ECHO Institute at the University of New Mexico. An acronym for Extension for Community Healthcare Outcomes, ECHO is designed to reduce inequities in socioeconomically disadvantaged communities that are plagued by healthcare disparities, particularly in remote areas such as those found in the Deep South.
The teleECHO model utilizes a tele-mentoring approach through a hub-and-spoke knowledge-sharing framework. It focuses on improving patient outcomes, increasing provider expertise, and maximizing providers' ability to deliver evidence-based, state-of-the-science care to underserved populations. The adoption of this model in many rural clinics promises to lower many of the barriers identified above and can in fact mitigate the negative consequences of provider shortages in rural areas in the Deep South.
From innovation to standard practice
These changes should not be considered only a stop-gap response to pandemic-related barriers; rather, they should be incorporated into standard practice going forward. To achieve this, all relevant stakeholders are implored to propose policy changes that take into account inherent healthcare inequalities. Such strategies also have the potential to reduce the stigma associated with treatment, which often prevents individuals from accessing the care they need; for example, telehealth has been shown to reduce the stigma of SUD.36,37
Finally, securing community partnerships, particularly with faith-based organizations, and creating programs to address the risk of overdose can save lives. An example is establishing mobile naloxone distribution in areas where overdose deaths are high or in communities where people are at most risk of overdose.
Individuals with OUD have been disproportionately affected by COVID-19 pandemic because of social distancing restrictions, further jeopardizing the social support networks that people in recovery urgently need to mitigate effects of social isolation.33,38 Moving forward, promoting innovative ways to provide treatment continuity is foundational to preventing adverse events and supporting patients' long-term recovery, especially among financially and geographically disadvantaged populations.10,32 This requires urgent attention to the need for expanding Medicaid, strengthening community partnerships, addressing stigma, and renewing a commitment to providing inclusive, accessible, and affordable treatment for populations that have experienced both historical and ongoing social and economic marginalization.
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