[Skip to Content]
[Skip to Content Landing]

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Among Veterans Health Administration patients receiving buprenorphine for opioid use disorder in the year following implementation of COVID-19–related telehealth policies, did patient characteristics and retention differ across treatment modalities?

Findings  In this cross-sectional study of 17 182 patients, patients who were younger, male, Black, unknown race, Hispanic, non–service connected, or with certain comorbidities were significantly less likely to receive telehealth; those who were older, male, Black, non–service connected, or experiencing homelessness and/or housing instability were significantly less likely to receive video compared with telephone-only telehealth. Telehealth was positively associated with retention.

Meaning  These findings suggest that discontinuing or reducing telephone-only access may disrupt treatment for groups with access disparities and that telehealth-delivered buprenorphine may support retention.

Abstract

Importance  The coronavirus disease 2019 (COVID-19) pandemic prompted policy changes to allow increased telehealth delivery of buprenorphine, a potentially lifesaving medication for opioid use disorder (OUD). It is unclear how characteristics of patients who access different treatment modalities (in-person vs telehealth, video vs telephone) vary, and whether modality is associated with retention—a key indicator of care quality.

Objectives  To compare patient characteristics across receipt of different treatment modalities and to assess whether modality was associated with retention during the year following COVID-19–related policy changes.

Design, Setting, and Participants  This cross-sectional study was conducted in the national Veterans Health Administration. Participants included patients who received buprenorphine for OUD during March 23, 2020, to March 22, 2021. Analyses examining retention were stratified by buprenorphine initiation time (year following COVID-19–related changes; prior to COVID-19–related changes).

Exposures  Patient characteristics; treatment modality (at least 1 video visit, at least 1 telephone visit but no video, only in-person).

Main Outcomes and Measures  Treatment modality; 90-day retention.

Results  Among 17 182 patients, 7094 (41.3%) were aged 30 to 44 years and 6251 (36.4%) were aged 45 to 64 years; 15 835 (92.2%) were male, 14 085 (82.0%) were White, and 16 292 (94.8%) were non-Hispanic; 6547 (38.1%) had at least 1 video visit, 8524 (49.6%) had at least 1 telephone visit but no video visit, and 2111 (12.3%) had only in-person visits. Patients who were younger, male, Black, unknown race, Hispanic, non–service connected, or had specific mental health/substance use comorbidities were less likely to receive any telehealth. Among patients who received telehealth, those who were older, male, Black, non–service connected, or experiencing homelessness and/or housing instability were less likely to have video visits. Retention was significantly higher for patients with telehealth compared with only in-person visits regardless of initiation time (for initiated in year following COVID-19–related changes: adjusted odds ratio [aOR], 1.31; 95% CI, 1.12-1.53; for initiated prior to COVID-19–related changes: aOR, 1.23; 95% CI, 1.08-1.39). Among patients with telehealth, higher retention was observed in those with video visits compared with only telephone for patients who initiated in the year following COVID-19 (aOR, 1.47; 95% CI, 1.26-1.71).

Conclusions and Relevance  In this cross-sectional study, many patients accessed buprenorphine via telephone and some were less likely to have any video visits. These findings suggest that discontinuing or reducing telephone access may disrupt treatment for many patients, particularly groups with access disparities such as Black patients and those experiencing homelessness. Telehealth was associated with increased retention for both new and continuing patients.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 27, 2022.

Published: October 12, 2022. doi:10.1001/jamanetworkopen.2022.36298

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Frost MC et al. JAMA Network Open.

Corresponding Author: Lewei (Allison) Lin, MD, MS, Department of Psychiatry, University of Michigan, Bldg 16, 2nd Floor, 2800 Plymouth Rd, Ann Arbor, MI 48109 (leweil@med.umich.edu).

Author Contributions: Dr Lin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Frost, Lin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Frost.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Zhang, Kim.

Obtained funding: Lin.

Administrative, technical, or material support: Lin.

Supervision: Lin.

Conflict of Interest Disclosures: Dr. Lin reported receiving personal fees for consults on telehealth for substance use disorder treatment for Providers Clinical Support System with funding from the Substance Abuse and Mental Health Services Administration, and for National Center for Quality Assurance with funding from Alkermes. No other disclosures were reported.

Funding/Support: Dr Lin is supported by a Career Development Award (CDA 18-008) from the US Department of Veterans Affairs Health Services Research & Development Service and Centers for Disease Control and Prevention grant R49 CE003085. Dr Frost was supported by a predoctoral training award from the Veterans Affairs Puget Sound Research and Development Service at the time this work was conducted.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed in this work are the authors’ and do not necessarily reflect those of the institutions, funders, the Centers for Disease Control and Prevention, the Department of Veterans Affairs, or the United States Government.

Meeting Presentation: Preliminary findings from this study were presented at the 2021 Addiction Health Services Research Conference; October 13 to 15, 2021; virtual.

References
1.
Lin  LA , Fernandez  AC , Bonar  EE .  Telehealth for substance-using populations in the age of coronavirus disease 2019: recommendations to enhance adoption.   JAMA Psychiatry. 2020;77(12):1209-1210. doi:10.1001/jamapsychiatry.2020.1698PubMedGoogle ScholarCrossref
2.
Volkow  ND , Jones  EB , Einstein  EB , Wargo  EM .  Prevention and treatment of opioid misuse and addiction: a review.   JAMA Psychiatry. 2019;76(2):208-216. doi:10.1001/jamapsychiatry.2018.3126PubMedGoogle ScholarCrossref
3.
Wakeman  SE , Larochelle  MR , Ameli  O ,  et al.  Comparative effectiveness of different treatment pathways for opioid use disorder.   JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622PubMedGoogle ScholarCrossref
5.
U.S. Department of Justice Drug Enforcement Administration. DEA qualifying practitioners, DEA qualifying other practitioners. Published 2020. Accessed December 10, 2021. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%20+Esign.pdf
6.
117th Congress. S.987 - CARA 3.0 Act of 2021. Accessed March 17, 2022. https://www.congress.gov/bill/117th-congress/senate-bill/987/text
7.
Huskamp  HA , Busch  AB , Uscher-Pines  L , Barnett  ML , Riedel  L , Mehrotra  A .  Treatment of opioid use disorder among commercially insured patients in the context of the COVID-19 pandemic.   JAMA. 2020;324(23):2440-2442. doi:10.1001/jama.2020.21512PubMedGoogle ScholarCrossref
8.
Nguyen  TD , Gupta  S , Ziedan  E ,  et al.  Assessment of filled buprenorphine prescriptions for opioid use disorder during the coronavirus disease 2019 pandemic.   JAMA Intern Med. 2021;181(4):562-565. doi:10.1001/jamainternmed.2020.7497PubMedGoogle ScholarCrossref
9.
Currie  JM , Schnell  MK , Schwandt  H , Zhang  J .  Prescribing of opioid analgesics and buprenorphine for opioid use disorder during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(4):e216147. doi:10.1001/jamanetworkopen.2021.6147PubMedGoogle ScholarCrossref
10.
Jones  CM , Guy  GP  Jr , Board  A .  Comparing actual and forecasted numbers of unique patients dispensed select medications for opioid use disorder, opioid overdose reversal, and mental health, during the COVID-19 pandemic, United States, January 2019 to May 2020.   Drug Alcohol Depend. 2021;219:108486. doi:10.1016/j.drugalcdep.2020.108486PubMedGoogle ScholarCrossref
11.
Lin  LA , Bohnert  ASB , Blow  FC ,  et al.  Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration.   Addiction. 2021;116(1):96-104. doi:10.1111/add.15116PubMedGoogle ScholarCrossref
12.
Manhapra  A , Stefanovics  E , Rosenheck  R .  Initiating opioid agonist treatment for opioid use disorder nationally in the Veterans Health Administration: who gets what?   Subst Abus. 2020;41(1):110-120. doi:10.1080/08897077.2019.1640831PubMedGoogle ScholarCrossref
13.
Manhapra  A , Quinones  L , Rosenheck  R .  Characteristics of veterans receiving buprenorphine vs. methadone for opioid use disorder nationally in the Veterans Health Administration.   Drug Alcohol Depend. 2016;160:82-89. doi:10.1016/j.drugalcdep.2015.12.035PubMedGoogle ScholarCrossref
14.
Pierce  M , Bird  SM , Hickman  M ,  et al.  Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England.   Addiction. 2016;111(2):298-308. doi:10.1111/add.13193PubMedGoogle ScholarCrossref
15.
Krawczyk  N , Mojtabai  R , Stuart  EA ,  et al.  Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services.   Addiction. 2020;115(9):1683-1694. doi:10.1111/add.14991PubMedGoogle ScholarCrossref
16.
Barsky  BA , Busch  AB , Patel  SY , Mehrotra  A , Huskamp  HA .  Use of telemedicine for buprenorphine inductions in patients with commercial insurance or Medicare Advantage.   JAMA Netw Open. 2022;5(1):e2142531. doi:10.1001/jamanetworkopen.2021.42531PubMedGoogle ScholarCrossref
17.
Patel  SY , Ortiz  EG , Barsky  BA , Huskamp  HA , Busch  AB , Mehrotra  A .  Patient and clinician characteristics associated with use of telemedicine for buprenorphine induction among Medicare beneficiaries.   J Gen Intern Med. 2022;1-4. doi:10.1007/s11606-022-07633-yPubMedGoogle ScholarCrossref
18.
Chang  JE , Lindenfeld  Z , Thomas  T , Waldman  J , Griffin  J .  Patient characteristics associated with phone versus video telemedicine visits for substance use treatment during COVID-19.   J Addict Med. Published online February 22, 2022. doi:10.1097/ADM.0000000000000985PubMedGoogle ScholarCrossref
19.
Cunningham  CO , Khalid  L , Deng  Y ,  et al.  A comparison of office-based buprenorphine treatment outcomes in Bronx community clinics before versus during the COVID-19 pandemic.   J Subst Abuse Treat. 2022;135:108641. doi:10.1016/j.jsat.2021.108641PubMedGoogle ScholarCrossref
20.
Harris  R , Rosecrans  A , Zoltick  M ,  et al.  Utilizing telemedicine during COVID-19 pandemic for a low-threshold, street-based buprenorphine program.   Drug Alcohol Depend. 2022;230:109187. doi:10.1016/j.drugalcdep.2021.109187PubMedGoogle ScholarCrossref
21.
Yeo  EJ , Kralles  H , Sternberg  D ,  et al.  Implementing a low-threshold audio-only telehealth model for medication-assisted treatment of opioid use disorder at a community-based non-profit organization in Washington, D.C.   Harm Reduct J. 2021;18(1):127. doi:10.1186/s12954-021-00578-1PubMedGoogle ScholarCrossref
22.
Kaur  J , Mania  I , Tirupathi  R , Polavarapu  L .  Impact of telemedicine on retention in Medications for Opioid Use Disorder (MOUD) treatment with buprenorphine in the times of COVID-19 pandemic: a retrospective chart review.   Rural Mental Health. 2022;46(2):75-81. doi:10.1037/rmh0000206Google ScholarCrossref
23.
Ward  KM , Scheim  A , Wang  J , Cocchiaro  B , Singley  K , Roth  AM .  Impact of reduced restrictions on buprenorphine prescribing during COVID-19 among patients in a community-based treatment program.   Drug Alcohol Depend Rep. 2022;3:100055. doi:10.1016/j.dadr.2022.100055PubMedGoogle ScholarCrossref
24.
Wyse  JJ , Gordon  AJ , Dobscha  SK ,  et al.  Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: historical perspective, lessons learned, and next steps.   Subst Abus. 2018;39(2):139-144. doi:10.1080/08897077.2018.1452327PubMedGoogle ScholarCrossref
25.
Connolly  SL , Stolzmann  KL , Heyworth  L , Weaver  KR , Bauer  MS , Miller  CJ .  Rapid increase in telemental health within the Department of Veterans Affairs during the COVID-19 pandemic.   Telemed J E Health. 2021;27(4):454-458. doi:10.1089/tmj.2020.0233PubMedGoogle ScholarCrossref
26.
Zulman  DM , Wong  EP , Slightam  C ,  et al.  Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans.   JAMIA Open. 2019;2(3):323-329. doi:10.1093/jamiaopen/ooz024PubMedGoogle ScholarCrossref
27.
Ferguson  JM , Jacobs  J , Yefimova  M , Greene  L , Heyworth  L , Zulman  DM .  Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization.   J Am Med Inform Assoc. 2021;28(3):453-462. doi:10.1093/jamia/ocaa284PubMedGoogle ScholarCrossref
28.
Lin  LA , Zhang  L , Kim  HM , Frost  MC .  Impact of COVID-19 telehealth policy changes on buprenorphine treatment for opioid use disorder.   Am J Psychiatry. Published online July 28, 2022. doi:10.1176/appi.ajp.21111141PubMedGoogle ScholarCrossref
29.
Souden  M . Overview of VA data, information systems, national databases and research uses. Published 2017. Accessed July 26, 2019. https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2376-notes.pdf
30.
Department of Veterans Affairs. Memorandum: COVID-19: controlled substance prescribing through telehealth during the COVID-19 public health emergency. 2020.
31.
Lin  LA , Fortney  JC , Bohnert  ASB , Coughlin  LN , Zhang  L , Piette  JD .  Comparing telemedicine to in-person buprenorphine treatment in U.S. veterans with opioid use disorder.   J Subst Abuse Treat. 2022;133:108492. doi:10.1016/j.jsat.2021.108492PubMedGoogle ScholarCrossref
32.
Economic Research Service.  Documentation: 2010 Rural-Urban Commuting Area (RUCA) Codes. United States Department of Agriculture; 2016.
33.
Blosnich  JR , Montgomery  AE , Dichter  ME ,  et al.  Social determinants and military veterans’ suicide ideation and attempt: a cross-sectional analysis of electronic health record data.   J Gen Intern Med. 2020;35(6):1759-1767. doi:10.1007/s11606-019-05447-zPubMedGoogle ScholarCrossref
34.
van Walraven  C , Austin  PC , Jennings  A , Quan  H , Forster  AJ .  A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data.   Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5PubMedGoogle ScholarCrossref
35.
Maynard  C , Nelson  K .  Compensation for veterans with service connected disabilities: current findings and future implications.   J Disabil Policy Stud. 2020;31(1):57-62. doi:10.1177/1044207319875070Google ScholarCrossref
36.
Young  BA , Maynard  C , Boyko  EJ .  Racial differences in diabetic nephropathy, cardiovascular disease, and mortality in a national population of veterans.   Diabetes Care. 2003;26(8):2392-2399. doi:10.2337/diacare.26.8.2392PubMedGoogle ScholarCrossref
37.
Hawkins  EJ , Malte  CA , Gordon  AJ ,  et al.  Accessibility to medication for opioid use disorder after interventions to improve prescribing among nonaddiction clinics in the US Veterans Health Care System.   JAMA Netw Open. 2021;4(12):e2137238. doi:10.1001/jamanetworkopen.2021.37238PubMedGoogle ScholarCrossref
38.
Zeger  SL , Liang  KY .  Longitudinal data analysis for discrete and continuous outcomes.   Biometrics. 1986;42(1):121-130. doi:10.2307/2531248PubMedGoogle ScholarCrossref
39.
Hanley  JA , Negassa  A , Edwardes  MD , Forrester  JE .  Statistical analysis of correlated data using generalized estimating equations: an orientation.   Am J Epidemiol. 2003;157(4):364-375. doi:10.1093/aje/kwf215PubMedGoogle ScholarCrossref
40.
SAS Enterprise Guide Software.  Version 7.1. Copyright. SAS Institute Inc; 2014.
41.
von Elm  E , Altman  DG , Egger  M , Pocock  SJ , Gøtzsche  PC , Vandenbroucke  JP ; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Ann Intern Med. 2007;147(8):573-577. doi:10.7326/0003-4819-147-8-200710160-00010PubMedGoogle ScholarCrossref
42.
Kunins  HV .  Structural racism and the opioid overdose epidemic: the need for antiracist public health practice.   J Public Health Manag Pract. 2020;26(3):201-205. doi:10.1097/PHH.0000000000001168PubMedGoogle ScholarCrossref
43.
Nguemeni Tiako  MJ .  Addressing racial & socioeconomic disparities in access to medications for opioid use disorder amid COVID-19.   J Subst Abuse Treat. 2021;122:108214. doi:10.1016/j.jsat.2020.108214PubMedGoogle ScholarCrossref
44.
Wakeman  SE , Lambert  E , Kung  S ,  et al.  Trends in buprenorphine treatment disparities during the COVID pandemic in Massachusetts.   Subst Abus. 2022;43(1):1317-1321. doi:10.1080/08897077.2022.2095077PubMedGoogle ScholarCrossref
45.
Nguyen  T , Ziedan  E , Simon  K ,  et al.  Racial and ethnic disparities in buprenorphine and extended-release naltrexone filled prescriptions during the COVID-19 pandemic.   JAMA Netw Open. 2022;5(6):e2214765. doi:10.1001/jamanetworkopen.2022.14765PubMedGoogle ScholarCrossref
46.
Department of Veterans Affairs. Connecting Veterans to Telehealth Care. Published 2021. Accessed January 31, 2022. https://connectedcare.va.gov/sites/default/files/telehealth-digital-divide-fact-sheet.pdf
47.
Ali  MM , Ghertner  R .  Broadband access and telemedicine adoption for opioid use disorder treatment in the United States.   J Rural Health. 2022. doi:10.1111/jrh.12699PubMedGoogle ScholarCrossref
48.
Schmitt  SK , Phibbs  CS , Piette  JD .  The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment.   Addict Behav. 2003;28(6):1183-1192. doi:10.1016/S0306-4603(02)00218-6PubMedGoogle ScholarCrossref
49.
Aronowitz  SV , Engel-Rebitzer  E , Dolan  A ,  et al.  Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives.   Harm Reduct J. 2021;18(1):119. doi:10.1186/s12954-021-00572-7PubMedGoogle ScholarCrossref
50.
Treitler  PC , Bowden  CF , Lloyd  J , Enich  M , Nyaku  AN , Crystal  S .  Perspectives of opioid use disorder treatment providers during COVID-19: adapting to flexibilities and sustaining reforms.   J Subst Abuse Treat. 2022;132:108514. doi:10.1016/j.jsat.2021.108514PubMedGoogle ScholarCrossref
51.
Riedel  L , Uscher-Pines  L , Mehrotra  A ,  et al.  Use of telemedicine for opioid use disorder treatment—perceptions and experiences of opioid use disorder clinicians.   Drug Alcohol Depend. 2021;228:108999. doi:10.1016/j.drugalcdep.2021.108999PubMedGoogle ScholarCrossref
52.
Huskamp  HA , Riedel  L , Uscher-Pines  L ,  et al.  Initiating opioid use disorder medication via telemedicine during COVID-19: implications for proposed reforms to the Ryan Haight Act.   J Gen Intern Med. 2022;37(1):162-167. doi:10.1007/s11606-021-07174-wPubMedGoogle ScholarCrossref
53.
Mattocks  KM , Moore  DT , Wischik  DL , Lazar  CM , Rosen  MI .  Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic.   J Subst Abuse Treat. 2022;139:108777. doi:10.1016/j.jsat.2022.108777PubMedGoogle ScholarCrossref
54.
Moore  DJ , Goyal  D , Rodriguez  L .  Experiences of opioid use disorder patients receiving buprenorphine through a telehealth program.   J Addict Nurs. 2021;32(3):205-210. doi:10.1097/JAN.0000000000000419PubMedGoogle ScholarCrossref
55.
Walters  SM , Perlman  DC , Guarino  H , Mateu-Gelabert  P , Frank  D .  Lessons from the first wave of COVID-19 for improved medications for opioid use disorder (MOUD) treatment: benefits of easier access, extended take homes, and new delivery modalities.   Subst Use Misuse. 2022;57(7):1144-1153. doi:10.1080/10826084.2022.2064509PubMedGoogle ScholarCrossref
56.
Lockard  R , Priest  KC , Gregg  J , Buchheit  BM .  A qualitative study of patient experiences with telemedicine opioid use disorder treatment during COVID-19.   Subst Abus. 2022;43(1):1150-1157. doi:10.1080/08897077.2022.2060447PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close