Requirements for minimizing physical contact to reduce transmission of severe acute respiratory syndrome coronavirus 2 have led to shifts in treatment and research on psychiatric disorders,1,2 including substance use disorders (SUDs). Notable have been increases in use of telehealth, changes to reimbursement for remote services, shifts in rules and regulations, impacts on vulnerable populations, and difficulties with data collection. These shifts provide an opportunity to evaluate which changes should remain after coronavirus disease 2019 (COVID-19), which should be reserved for crises, and which ones are deleterious.
In clinical practice, the most notable change has been the expansion of telehealth, especially by videoconference.2 However, internet access can be challenging in certain geographical areas or for individuals less comfortable with technology or who cannot pay for it. Provision of treatment by telephone may be an alternative, but there is insufficient information on differences in efficacy and acceptability of telephone vs videoconference visits. Furthermore, management of some patients, such as those with suicidal ideation, may be harder to conduct in a telehealth visit regardless of modality, and certain assessments, such as urine toxicology screens, may not be possible.
To our knowledge, no study to date has examined changes in treatment patterns of individuals with SUDs or other psychiatric disorders. Whether there were changes in visit frequency, access to or retention in treatment, or risk of relapse is unknown. Because telehealth and other digital modalities will remain common after physical distancing rules are relaxed, it is important to evaluate for which patients these delivery modalities are equal to or better than in-person delivery and which result in long-term treatment retention. The role of mobile outreach and low barrier care to facilitate treatment and avoid unnecessary visits to emergency departments should also be investigated.
Temporary waivers of licensure requirements have facilitated expansion of services.3 This has helped to maintain continuity of care for patients and improved access for individuals entering treatment by increasing the availability and diversity of clinicians. Documenting the benefits and adverse consequences of expanded licensing privileges could inform future licensing policies.
Regulatory changes have also increased flexibility for treatment with opioid agonists.4 Although initiation of methadone maintenance treatment still requires in-person visits, take-home privileges have been expanded, potentially increasing the ability of patients to work or engage in other productive activities. By contrast, buprenorphine induction can now be conducted via telehealth. Given that 40% of US counties lack a physician authorized to prescribe buprenorphine,5 greater flexibility in induction procedures combined with expanded medical licensing privileges could vastly expand availability of buprenorphine treatment. Monitoring the outcomes will help guide future interventions. It is also crucial to investigate the potential for negative consequences, such as increased diversion and nonadherence to treatment.
Reimbursement and Coverage
Regulatory changes can be severely constrained in the absence of reimbursement. The Centers for Medicare & Medicaid Services have allowed for reimbursement of telehealth services at levels similar to in-person visits.6 Many private insurance plans have followed suit. Information to support the expansion of coverage will be key to supporting changes in service provision.
Because many individuals involved with the justice system have SUDs, improving treatment and prevention in correctional settings is a high clinical and research priority. For example, as part of the Healing Addiction Long-Term Initiative, the National Institute on Drug Abuse funded the Justice Community Opioid Innovation Network, which will award close to $150 million throughout 5 years to support research on quality addiction treatment for opioid use disorder in justice settings nationwide.7 The increased risk of COVID-19 transmission in jails and prisons has led to the release of individuals incarcerated for nonviolent offenses, including many incarcerated for substance-related crimes. Research on health outcomes, including substance-related outcomes, and justice outcomes (eg, recidivism) of those individuals could inform discussions between justice and health care systems. Further, the expansion of telehealth into jails and prisons has opened new opportunities for enhancing the capacity to provide treatment for SUDs and comorbid psychiatric disorders. Importantly, the deployment alternative models to incarceration for those with SUDs may help address some of the worse racial disparities that have led to disproportionate incarceration of African American individuals.
Effects on Clinical and General Populations
COVID-19 has led to broad societal changes that will not be fully reversed after the pandemic subsides. Those changes include less frequent physical contact, fewer opportunities for informal interactions, increased telework, and new ways of interacting online. Maintaining existing personal and professional relationships and developing new ones may become more challenging, leading to decreased social support for many. More time at home may lead to increased interpersonal conflict and violence. The economic consequences of COVID-19 will also be significant. In the short-term, those consequences are likely to be felt more strongly by vulnerable populations, such as those with lower educational attainment, lower income, and underserved marginalized individuals. In the long term, there may be changes in demand for certain jobs and workforce composition. The effects of those changes on patterns of substance use and SUD are unknown.
Delays in the implementation of mitigation approaches to COVID-19 and reliance on simulation models to make policy decisions have highlighted the need for faster data collection. At present, most nationally representative surveys of SUDs and related behaviors, such as the National Survey on Drug Use and Health and Monitoring the Future, are collected on a yearly basis. Their results are available only several months after data collection and the surveys often cannot reach populations, such as homeless individuals, that are at increased risk for substance use and psychopathology. Similarly, information on fatal and nonfatal overdoses relies mostly on state-dependent systems with long delays in data processing. These lags in information hamper the ability to allocate resources in optimal ways to address changes in patterns of substance use or overdoses. There is an urgent need to develop new approaches to data collection that can provide more timely information and cover hard-to-reach populations.
Implementation and Need for Learning Systems of Care
The changes in service delivery triggered by COVID-19 have led to questioning of our existing health care system. Most evident has been the prominence by which COVID-19 has unveiled the racial disparities in access to health care. As awareness about the importance of social determinants of health continues to grow, the system should evolve toward addressing not only the medical needs of patients but also needs that are key for sustained remission, such as housing and access to food.8 Improvements to our treatment and prevention systems will require ongoing dialogue between research, policy, and practice (ie, a learning health care system or, more broadly, a learning system of care). Studies of implementation and de-implementation strategies and contextually adapted evidence-based interventions to promote equity could play a key role in developing these systems of care. Use of simulations, including agent-based models, could provide empirical bases for scaling up proven but adapted interventions.9,10
As the pandemic continues to expand and evolve, there is a need to evaluate the efficacy and safety of the changes triggered by COVID-19 and to assess patient preferences to ensure that care is equitable, precise, evidence-based, accessible, and person-centered. Research is urgently needed to learn which of the COVID-19–mediated changes provide benefit to patients and public health and, thus, should be maintained long term and which should be retired. The COVID-19 crisis gives us an opportunity to evaluate new strategies and policies for improving the treatment of SUD and for reducing the racial inequalities that link drug use with justice settings.
Corresponding Author: Carlos Blanco, MD, PhD, Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, 6001 Executive Blvd, Bethesda, MD 20852 (firstname.lastname@example.org).
Published Online: September 1, 2020. doi:10.1001/jamapsychiatry.2020.3177
Conflict of Interest Disclosures: Dr Compton reports long-term stock holdings from General Electric, 3M Company, and Pfizer outside the submitted work. No other disclosures were reported.
Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of the National Institute on Drug Abuse, the National Institutes of Health, or any US government agency.
CA. Geographic disparities affect access to buprenorphine services for opioid use disorder. US Department of Health and Human Services Office of Inspector General. Published January 2020. Accessed June 14, 2020. https://oig.hhs.gov/oei/reports/oei-12-17-00240.pdf