番茄社区

For 46-year-old Jocelyn Tavarez, maintaining access to medication-assisted treatment (MAT) during the pandemic meant going from "The Flintstones" to "The Jetsons" in a matter of days, she told 番茄社区.

Tavarez has been receiving MAT and other services at CODAC Behavioral Healthcare -- the largest non-profit, outpatient provider for opioid treatment in Rhode Island -- for about two years. MAT is the standard of care for opioid-use disorder, and involves medications, such as buprenorphine and methadone, in combination with counseling. Since early in the pandemic, MAT patient Tavarez has been receiving her counseling telephonically.

Initially, the transition from in-person to virtual care was daunting, the self-described "people-person" said. Tavarez wasn't sure using technology to receive the essential services she looked forward to each week -- including counseling, yoga, and a women's support group -- would be navigable or beneficial.

But CODAC provided Tavarez a cell phone to ease the process. And once she warmed up to the technology and connecting with her care team and peers in a different way, she hasn't looked back. Maintaining the routine and connection -- albeit virtually -- has been essential to her ongoing success, she said.

Tavarez isn't alone.

CODAC partnered with Brown University to study how well patients and providers feel telephone counseling for MAT has been working during the pandemic. The results have proved promising in a potential bright spot for the addiction treatment sector, grappling with how best to protect vulnerable patients from potential exposure to COVID-19, serve new ones as overdoses spike during the pandemic, and get reimbursed for their efforts.

Unpublished data show that the majority of 247 patients and 41 counselors who participated in a survey between August and October of last year believed telephone counseling improved the therapeutic relationship, Linda Hurley, president and CEO of CODAC, told 番茄社区. These data also show that the majority of patients and counselors were satisfied with the telephone counseling experience, found it convenient, and wanted to continue it after the pandemic, she said.

The overall satisfaction with telephone counseling was 92.3%, according to Hurley. Some 70.9% of individuals said that telephone counseling helped the same with substance use as prior in-person services, and 16.4% said it helped more. Some 69.1% of individuals said that telephone counseling helped the same with recovery as in-person services, and 19.3% said it helped more.

"The counseling was helping [patients] to meet their treatment goals at a higher rate," Hurley said, noting that CODAC and Brown are planning to next study why that has been.

However, in addition to the positive feedback, patients and counselors highlighted some potential problems with telephone counseling, including a lack of privacy during sessions at home and the potential for impersonal experiences, according to Hurley. Counselors also felt that telephone counseling made their workflow more tedious.

To date, CODAC has invested more than $1 million in its transition to telehealth services during the pandemic. And the training for staff is ongoing.

Gathering data on virtual care during the pandemic is important because many patients being treated for opioid-use disorder have multiple comorbidities that can make them more vulnerable in terms of access to care and their overall health during a coinciding crisis, Hurley said. Focusing on that population when tackling public health issues is essential, she said.

Additionally, data are important for reimbursement for telephone counseling and other virtual care by third-party payers.

Focus on Take-Home Doses

Another closely linked issue that CODAC and Brown have studied during the pandemic is the distribution of more take-home doses of MAT medications. Federal and state regulations on MAT were loosened in the early days of the pandemic to help minimize potential exposure to COVID-19 in crowded clinics and maintain access to essential care.

That included expanding take-home doses of methadone, though new patients are still being initiated in person and obtaining daily doses in person.

Early in the pandemic, CODAC and Brown examined 160,000 bottles of methadone provided by CODAC to be administered outside of the clinic. The results were that less than 1% of the medication was not managed well, according to CODAC.

The organization's telephone counseling survey included patients prescribed methadone who were receiving two-week and 28-day supplies of their medication, as well as patients prescribed other MAT medications, Hurley said.

Some patients were being checked in on once a day, while others were being monitored and counseled once a week or less frequently, she said.

"There was a full range of acuity," Hurley said.

Outside of Rhode Island, Allegra Schorr, president of the Coalition of Medication Assisted Treatment Providers and Advocates of New York State, noted the connection between telehealth and loosened regulations to safely maintain access to care during the pandemic.

"You could certainly make the statement that telehealth visits have supported the use of take-homes," Schorr said.

The association has stressed the importance of limiting potential exposure to COVID-19 when possible. Going forward, more data will be important in determining how to proceed once the pandemic subsides, Schorr said.

For instance, though the overdose rate has spiked during the pandemic, the synthetic opioid fentanyl seems to be the driver, Schorr said. Methadone doesn't initially appear to be a driver.

The goal is to make MAT as convenient for patients as possible, "but we have to balance the safety issue," Schorr said.

It shouldn't be hard for patients to be stable methadone patients, she said. It's the harder-to-treat and less stable cases that should be looked at carefully.

One thing that could help prior to making any sweeping policy changes is undertaking small pilot programs, Schorr said.

"I do think it's important to try to make the system flexible and meet the needs of the patient, but it's also [important] to maintain that balance," she said.

Jonathan Samuels, MD, director of addiction medicine at SBH Health System in the Bronx in New York City, concurred.

The benefits of take-home doses have to be balanced with how well specific patients are doing, and whether they are stable enough in terms of their drug use.

Samuels noted that he has enjoyed video as well as telephone visits during the pandemic, but that there is nothing like interacting with patients face-to-face.

Benefits of In-Person Care & the Future

Virtual care for medication-assisted treatment patients has helped fill a void for patients and staff, especially as the Bronx was hit hard by COVID-19 in the early days of the pandemic, Samuels noted. But, he added, "Our census has decreased."

SBH typically has about 600 patients receiving medication-assisted treatment, according to Samuels. But that number has dropped to about 550 in recent months

Samuels says he believes there is something about coming in for care regularly that reinforces staying in treatment.

For people who are sick or who are working, for example, telehealth has made their lives a lot easier, he said. "But for people who are floundering, this is the one stable thing in their life."

Whether new measures remain after the pandemic, he said, will be up to regulatory bodies.

Christopher Garrett, senior media adviser for the Substance Abuse and Mental Health Services Administration, noted in an email that the agency "granted state opioid treatment authorities the ability to provide 'blanket' program-wide, take-home exceptions to opioid treatment programs directly during the pandemic."

Garrett said that the actions are being tracked at the state level and that SAMHSA doesn't currently have data on tele-counseling in opioid treatment programs (OTP). "However," he added, "it is a viable option OTPs are utilizing to increase access to care."

"The emergency flexibilities will remain throughout the duration of the emergency," he said. "Afterward, SAMHSA will review the regulatory adjustments under its domain individually."

Ultimately, Hurley of CODAC said she wants more patients to be able to provide feedback on how telephone counseling and other new measures have been working for them during the pandemic.

"We really need their voice," Hurley said.

CODAC patient Tavarez said that she can't overstate the importance of the telephone counseling she's received during the pandemic.

Asked if she wants to go back to in-person services anytime soon, she said she remains worried about potential exposure to COVID-19, especially as new variants emerge.

About telephone counseling, she said, "It's gotten me through."

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