key: cord-0684111-a1sw0eyt
authors: Melamed, Osnat C.; deRuiter, Wayne K.; Buckley, Leslie; Selby, Peter
title: COVID-19 and the impact on substance use disorder treatments
date: 2021-11-12
journal: Psychiatr Clin North Am
DOI: 10.1016/j.psc.2021.11.006
sha: e0a2d0d47450a9832734b348377f5e820551ba3b
doc_id: 684111
cord_uid: a1sw0eyt

COVID-19 related stressors and restrictions, in the absence of social and institutional support, has led many individuals to either increase their substance consumption or relapse. Consequently, treatment programs for substance use disorders (SUDs) made a transition from in-person to remote care delivery. This review will discuss the following evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs: 1) reduction in availability of care, 2) increase in demand for care, 3) transition to telemedicine use, 4) telemedicine for the treatment of opioid use disorders and 5) considerations for the use of telemedicine in treating SUDs.

The COVID-19 pandemic and the resulting societal response to limit its spread poses a threat to vulnerable groups such as those with substance use disorders (SUDs). The need for social distancing to limit the spread of the infection disrupted the delivery of care in most specialized SUDs treatment programs as well as community-based mutual-aid support groups (e.g.

Alcoholics Anonymous (AA)). Reduction in access to SUDs treatment in general medical settings was further exacerbated by furloughed staff, reduced work hours, and redeployment of primary care and emergency medicine teams to deal with acute COVID infections.

Consequently, the treatment gap found among individuals with SUDs prior to the pandemic was further widened.

Concurrently, the stressors brought about by the pandemic including social isolation, loss of employment, financial concerns and fear of falling ill with COVID have disproportionally affected individuals with SUDs. An abundance of stressors in the absence of social and institutional support led many individuals to increase their substance consumption as a means of coping with these challenges and may have caused many individuals in recovery to relapse.

Many treatment programs for SUDs made a swift transition from in-person to remote care delivery (i.e. telemedicine visits) in order to keep patients and providers safe from COVID infection. Relaxing of regulatory restrictions on the provision of controlled substances (e.g. opioid agonist therapy) and payors' coverage of telemedicine visits facilitated the adoption of remote care in the treatment of SUDs during the pandemic. This transition necessitated a considerable organizational effort and ongoing activities are underway to restore the full breadth of treatment services that were available prior to the pandemic.

The transition to telemedicine presents both advantages and disadvantages for patients and providers alike and emerging data acknowledges factors that facilitate or hinder treatment engagement and retention.

This special article used a selective literature review to synthesize emerging evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs. We will discuss the 1) reduction in availability of care, 2) increase in demand for care, 3) transition to telemedicine use, 4) telemedicine for the treatment of opioid use disorders and 5) considerations for the use of telemedicine in treating SUDs and implications for practice. Reduction in availability of treatment for SUD during the pandemic Traditionally, in-person care has been the mainstay of treatment for SUDs. In specialized addiction treatment settings, many face-to-face individual and group-based therapies were halted due to reduced hours or partial closures of treatment facilities. In many residential substance rehabilitation programs, patients often sleep, dine, and receive treatment in congregate conditions 1 as part of the recovery milieu. Lack of trained staff in IPAC, limited funding and space limitations made implementing infection control measures a challenge. Specifically critical J o u r n a l P r e -p r o o f activities were affected such as screening for COVID symptoms, access to PPE, quarantine rooms and the installation of physical barriers. 2 Treatment programs have reported a 20 to 60% reduction in attendance. Consequently, SUDs treatment programs have experienced delays in initiating treatment, a reduction in service options, less frequent services, and the prohibition of family visitations. 2 Similarly, public health regulations banned gatherings which prevented individuals from attending meetings of mutual-aid groups within their communities (e.g. AA, SMART recovery). This eliminated much-needed venues of ongoing recovery support.

In general hospital settings, fewer resources were available to treat patients with SUD because of redeployment of clinical staff towards COVID care and preparedness. 3 In particular, the capacity for substance use treatment by emergency medicine staff providers was reduced due to the overwhelming workload created by patients infected by COVID. 4 Furthermore, individuals with SUDs may have been reluctant to approach general hospital care due to fear of infection.

However, the percent of hospitalized patients with acute alcohol withdrawal using a CIWA cut off of 8 or more was about 34% higher in 2020 compared to the same time in 2019. The peak was at the end of the stay home orders but continued to be elevated during the reopening phase. 5 Primary care is another major source of support for individuals with SUDs, providing screening, brief interventions and medication-assisted therapies. 6 Primary care facilities reported a 21.8% reduction in visit volume during the early days of the COVID pandemic. 7 Many primary care services had reported a decreased capacity for in-person care during the pandemic. Shorter opening hours, staff redeployment and complete closures were all factors which contributed to a reduction in the availability and accessibility for SUDs treatment.

Increase in demand for treatment of SUDs during and post pandemic J o u r n a l P r e -p r o o f In the US, while evidence suggests that over 20 million individuals are in need of treatment for SUDs, only one in ten have access to care. 8 Accounting for this treatment gap are lack of skilled providers which creates long wait times, a lack of integration of SUDs treatment within general medical settings, stigma, and living in non-urban communities. 9 Concurrently, with the reduction in the availability of treatment for SUDs, the societal response to the pandemic was associated with an increase in the demand for treatment of SUDs. For example, a study looking at medical visits to a large Health Maintenance Organization found a 42% increase in the number of visits for addiction conditions during the first few months of the pandemic when compared with prepandemic volume visit 10 and a similar increase was also observed in another study conducted in primary care. 11 Specifically, during the pandemic, non-Hispanic Whites reported an increase of 10.5% in MH/SUD visits. 11 This increased demand for SUD treatment could be attributed to a decline in emotional and psychological well-being of the population. The far-reaching societal responses to limit the spread of COVID-19 led to closures of workplaces, educational institutions, places of worship and recreational/entertainment community venues. In conjunction with guidance to limit one's interaction to only household members, social isolation, loneliness and depressive symptoms have been higher than ever. 12, 13 Declines in psychological well-being manifested by anxiety or depressive symptoms as well as heightened SU patterns to cope with such symptoms have been reported by 40% of individuals. 13 While infection control measures are necessary to protect the public from the COVID virus, the negative effects are disproportionally borne by vulnerable groups such as people with SUDs, who tend to have low social capital. Vulnerable groups are also overrepresented in minimumwage jobs which saw a greater loss of employment compared to those working other positions (38% vs. 13%) during the first months of the pandemic. 14 Financial stressors and social isolation, J o u r n a l P r e -p r o o f especially in the absence of traditional sources of formal and informal addiction support, creates the "perfect storm" which drove many to increase their substance use patterns. 13 Pandemic-related distress can negatively affect individuals who are in different stages of their SUDs illness. Stress is a well-established factor that is involved in relapse to substance use. 15 Stress can induce cravings and pre-occupation with substance use that eventually culminates in substance consumption. 16 For example, those who are working towards stabilization of excess substance consumption or those in early remission usually require intensive in-person support, characterized by high frequency of visits (1-2 times per week). The reduction of in-person professional and peer (mutual aid groups) support concomitantly with an increase in pandemicrelated concerns (e.g. loss of employment) and stressors (e.g., loneliness) can potentially trigger a relapse to previous substance use patterns. Moreover, individuals who are in remission from their SUD, could experience a relapse due to a new stressor (e.g., loneliness) brought about by the pandemic, in the absence of traditional support such as mutual-aid groups (e.g., AA meetings). Individuals without SUDs or with sub-threshold substance use patterns such as at-risk drinking, may develop a de novo SUD in response to the changes brought about by the pandemic. Individuals who drank heavily in post work hours may have a greater opportunity to consume alcohol during their work day when transitioned to work-from-home. Others may have greater motivation to consume substances to cope with added stressors such as combining work from home with homeschooling children. Population-based surveys found that approximately 13% or more of individuals either started or increased their use of alcohol to cope with stress related to the pandemic. 13, 17, 18 It is highly likely that the general increase in alcohol consumption during the pandemic might not return to baseline levels of consumption in the new normal state. The disproportionate J o u r n a l P r e -p r o o f increase in drinking especially binge drinking patterns by women, portend a future increase in alcohol related harms including use disorders in women. The demand for services might increase once people realize they might have developed a problem and cannot stop on their own. It will be important for primary care providers to increase their screening of all their patients and provide effective treatment geared to the severity of use disorder detected.

Telemedicine for SUDsgeneral considerations For many SUD treatment programs, the increased demand for SUD treatment in addition to a reduction in the availability of in-person care during the pandemic led to an adoption of innovative service delivery models, most of which include the use of telemedicine. Recently, the use of telemedicine has been on the rise as practitioners attempt to improve their reach and accessibility to care for patients, particularly those in for rural populations. 19 The use of telemedicine provides a solution for healthcare continuity while keeping patients and providers safe by facilitating stay and home and preserving limited PPE for only those encounters requiring face to face visits. 20 By definition, telemedicine includes the use of telecommunications technology to deliver healthcare services across a distance. 19 The technologies most commonly used are telephone (audio only) and video/web-conferencing (VC, audio and visual).

Telemedicine can provide care that is similar to in-person delivery with numerous advantages for both the patients and providers. Patients will likely experience a reduction in time and travel commitments for care, increased convenience, a decline in wait time, and reduced stigma. 21, 22 Consequently, compared to in-person care, the use of telemedicine suggests greater attendance and a decline in the number of cancelled mental health appointments 23 as well as a lower noshow rate (8.3 vs 25.9%) in attendance for treatment of opioid use disorders. 6 Despite these J o u r n a l P r e -p r o o f advantages, telemedicine has not been widely adopted in the area of SUD treatment before the pandemic. 24 The most notable barriers among telemedicine providers pertain to regulations imposed by governing bodies and payors. These regulations include a requirement for an inperson assessment for prescribing of controlled substances and a lack of re-imbursement for remote visits. The majority of these barriers have been removed early in the course of the pandemic which facilitated a rapid increase in the use of telemedicine in the treatment for SUDs. 25 The patient level barriers included lack of privacy, access to advanced telecommunication equipment such as smart phones, laptops, poor internet connections, lack of privacy in their settings and low levels of digital literacy. 22 Transition of SUDs treatment programs to telemedicine during the COVID pandemic At the onset of the pandemic, 43% of mental health treatment facilities in the US and only 27% of SUD treatment facilities had telehealth capabilities. 26, 27 With COVID-19 restrictions preventing in-person care, the number of visits rapidly declined from March 2020, reaching a reduction of 48% by July of 2020 as compared with the previous year. 28 This reduction was more than two-fold greater than the 21.8% loss of visit volume reported in primary care settings. 7 Primary care settings appeared to demonstrate a greater preparedness and a willingness to adopt remote visits via telemedicine early during the pandemic which may have limited the number of lost visits.

Both clinicians and patients report encouraging experiences regarding the acceptability of telemedicine. Most providers used a combination of telephone and VC visits. Telephone visits were helpful for patients who lacked digital literacy or computer/ internet access. 22 Most providers felt that telemedicine could provide SUDs treatment that was comparable to in-person J o u r n a l P r e -p r o o f care. 22 Many practitioners acknowledged the benefits of VC compared to telephone with regards to accurately assessing the patient's condition and learning about the patient's home environment. 29 Other practitioners recognized the need to continue to have in-person visits for new patients or those experiencing substance relapse. 30 Mutual-aid support groups such as Alcoholics Anonymous, Narcotics Anonymous, and SMART recovery are traditionally delivered in-person. 32, 33 However, in the context of COVID-19, attendance of mutual support programs via online platforms have flourished. 34 In part, the selfdirected nature of mutual aid, likely permitted adoption of existing web-conferencing platforms which are low cost or free. Given the global community adoption of mutual aid, online support is essentially available 24/7 across the world. This ease of access partially compensated for the deficits in the availability of SUD treatment programs. 33 Telemedicine in the treatment of Opioid Use Disorders

During the COVID pandemic, a considerable change occurred in the delivery of treatment for individuals with opioid use disorders (OUD). 27, 35 Traditionally, initiation of opioid agonist therapy (OAT) such as methadone or buprenorphine for OUD required an in-person assessment as well as frequent follow-up visits until stabilization of SU patterns and medication dose had been reached. During stabilization visits, a urine drug screen would be performed to verify the presence or absence of misused opioids concurrently with optimization of the OAT dosing. Inperson care during the stabilization phase of OUD is considered advantageous due to its ability to provide structured support, close monitoring for OAT side effects, and prevention of diversion of medication, during dose titration (e.g. overdose and sedation). Regulators define OAT dose titration schedules, urine drug screen frequency and the gradual transition process to take-home doses of medication once the individual has stabilized and ceased illicit opioid use.

With the onset of the pandemic, most jurisdictions began to allow for telemedicine visits for the assessment and treatment of OUD, reduced frequency of urine drug screening, and an expedited schedule for take-home doses. In one study of primary care settings, 91.2% of facilities modified their OUD treatment practices, specifically the implementation of medication and behavioural health/counselling visits. 36 Approximately half of the initial and follow-up behavioural health/consulting visits were conducted remotely. 36 This compared to 23.1% and 40.4% of initial and follow-up medication evaluations, respectively, that were conducted virtually. 36 This allowed patients to receive care for OUD while mitigating the risk of contracting or spreading COVID. In some cases, in-person visits were reserved for new patients, patients who relapsed, patients who did not adhere to prescribed medication, patients who lacked proper technology, patients who were homeless, patients requiring injections, and patients who needed a physical exam or testing. 22 To mitigate the risk of COVID, programs may have chosen to offer OAT drop J o u r n a l P r e -p r o o f off at the patient's home or allowing for a family member to pick up their medication in the case the patient was in quarantine. 35, 37 The relaxing of regulations led to fewer disruptions in the delivery of care brought about by the pandemic, and in some cases, provided an opportunity for OUD treatments to have a greater reach than previously occurred. 38, 39 In many cases, OUD treatment programs can successfully transition to the telemedicine platform by using existing provider resources. 29 In one example of an urban center, telemedicine was used to provide comprehensive care for patients including initiation and maintenance of OAT, behavioural counselling and peer-support recovery groups. 29 These remote services reported a greater uptake by patients compared with in-person care. To ensure equity, some programs reported on their efforts to close the "digital divide", when patients could not access telemedicine due to low digital literacy or lack of computer/internet access. For example, pregnant and postpartum women with SUD were provided with borrowed smartphones and pre-paid internet data which enabled them to access telemedicine. 40 Technology was not only used for the delivery of telemedicine visits but also for sending patients pre-visit mental health and substance use screeners for the purpose of informing care. 40 Given the excess number of deadly opioid overdoses that was observed during the COVID pandemic, certain programs aimed to increase access to OUD treatment. 41 In New England, the availability of OAT via phone visits prompted the use of a treatment "hotline" which provided patients with an opportunity to access buprenorphine treatment while simulanteously removing many of the barriers associated with the initiating such treatment. 42 Similarly, in Florida, people attending a needle-exchange site were invited to participate in a telemedicine visit for the J o u r n a l P r e -p r o o f initiation of OAT. The latter program was co-facilitated by medical students, which has an added value of reducing stigma against SUDs among future healthcare providers. 43 It appears that relaxing regulations to allow for remote OUD treatment and greater flexibility in take-home doses can have a number of advantages. It improves access to care and it is more convenient and less disruptive to patients' lives. Furthermore, based on pre-pandemic data, a majority of patients reported high levels of satisfaction, simplicity, and comfort with using telemedicine and believed the quality of virtual care received from practitioners was similar to in-person care. 44 However, these benefits need to be balanced with the risk of accidental overdose, misuse, or diversion of OAT, especially during early stabilization periods. Similarly, telemedicine may not provide the structured support that is beneficial to individuals with unstable OUD. In this case, in-person settings could be advantageous.

The advent of monthly injections of buprenorphine as a treatment option in North America also offers a potential solution. By label, the patient had to be on a stable dose of SL buprenorphine above 8mg for at least a week. However, novel models with earlier administration of the injection in emergency rooms after tolerable test doses of SL buprenorphine are being trialed.

The monthly in person visits combined with telemedicine could be a good compromise in providing safe and effective pharmacotherapy and counselling especially during early recovery.

Moreover, patients on stable doses of 8mg or less of buprenorphine could be transitioned to subcutaneous 6 monthly implants to minimize clinic visits.

Although not permitted in the US, in Canada, SROM has gained acceptance as a suitable form of OAT. 45 In some provinces, supervised injection facilities and iOAT are also becoming more common place. For those patients in quarantine in COVID shelters or hotels, delivery of OAT and/or SIS were permitted. Regardless, given the toxic drug supply especially admixture of J o u r n a l P r e -p r o o f highly potent illegal benzodiazepines such as etizolam with designer fentanyls including carfentanyl has led to an increase in opioid related poisonings and deaths. In British Columbia and Ontario, programs of safe supply have been initiated with access to high potency prescription opioids such as hydromorphone.

The COVID-19 pandemic and the societal response to limit its spread led to regulatory and policy changes that greatly affected the delivery of SUD treatment. SUD treatment programs can now deliver comprehensive care via remote visits which includes screening, initiation of medication, behavioural counselling and peer-support groups. This has been a paradigm shift for most SUD treatment facilities that traditionally relied on in-person care. While this shift was necessary to maintain continuity of care during the pandemic, it may not be suitable for all. Therefore, additional information is needed to characterize which patient populations are likely to benefit from remote care. This can allow practitioners to dedicate more time and resources, such as frequent in-person care, towards those patients who are more vulnerable.

The COVID-19 pandemic provided us with valuable insight regarding the potential advantages and disadvantages of telemedicine use in the treatment of SUDs. Emerging evidence suggests healthcare providers find telemedicine to be a venue for care delivery that is comparable with inperson care but also identify that remote support may not be enough for patients with severe SUDs, who are struggling. 22, 30 J o u r n a l P r e -p r o o f

In the early stages of transitioning to remote care, it can become evident that certain groups of the population will derive fewer benefits. Studies indicated that older adults (ages 60+) find the use of telemedicine for SUD treatment challenging. For example, a qualitative study of older adults with alcohol use disorder and their providers found that both patients and providers felt the quality of remote support was inferior to in-person care. 46 This finding could partially explain the low rates of engagement within remote programs. Similarly, others reported that older adults were disproportionally affected by social isolation during the pandemic. Consequently, for many older adults, remote care may not provide sufficient social support. 47 It was also agreed that many older adults have low digital literacy and limited computer/internet access that precluded participation.

Studies found that patients with severe SUDs or concurrent psychiatric conditions may also be challenged by remote care leading to poor engagement and retention. Patients who report polysubstance vs. single substance use concerns experienced greater disruptions to their care as well as greater difficulty in accessing remote treatment for SUDs. 48 It is likely that remote care does not provide the same level of support that in-person care provides. Similarly, women with OUDs who are pregnant reported a substantial reduction in attending group-based therapy when it was offered remotely. 31 While this could be attributed to low digital literacy and low digital access (e.g. lack of computer, internet) among vulnerable groups, it also suggests that in-person care is a critical component of care for many individuals.

It is likely that the majority of SUD treatment programs will be able to meet the needs of their patients by allowing for a hybrid model of care that includes a combination of in-person and remote visits. 22 We recognize that in-person and remote care are complementary and one cannot fully replace the other. The optimal composition of care (remote vs. in person) should be tailored J o u r n a l P r e -p r o o f to the needs of the individual and agreed upon by patients and providers by shared decision making.

Implications: How will these changes affect future delivery of SUD treatments?

During the pandemic, the use of telemedicine by SUD treatment programs substantially increased and may have partially helped to enhance accessibility and availability of treatment services. As the pandemic evolves, a growing number of SUD treatment programs will continue to acquire telemedicine capacity. Yet, even at this time, a year and a half into the pandemic, the ability of programs to deliver the full breadth of services via remote means is diminished.

SUD programs are now tasked with service planning for years to come with many embracing the use of telemedicine as an integral part of future services. The sustainability of telemedicine postpandemic will be determined by numerous factors. Integrating comprehensive care for SUDs including medication management, behavioural counselling, group-based therapy and lowintensity care for long-term relapse prevention (i.e. aftercare) will be essential. At the same time, the use of telemedicine needs to be balanced with an existing capacity for in-person care for a number of patient sub-groups that are likely to face challenges in engagement and retention via telemedicine care. Investments in infrastructure to expand the reach of telemedicine among practitioners and patients will be necessary, particularly in rural areas. 49 Furthermore, SUD treatment programs will need to train their providers to be proficient in best practices of telemedicine use and provide organizational support for both modalities of care. 49 Programs should offer patients training to improve digital literacy and ensure they have access to computer/smartphone and internet. 49 In order to sustain and grow telemedicine use in the postpandemic era, it will be necessary to extend those policies that allowed for telemedicine visits to J o u r n a l P r e -p r o o f occur during the pandemic. Such policies would allow for continued reimbursement to providers for in-person as well as remote care and allow for the provision of care, especially for OUD, without the need for an in-person assessment.

Telemedicine opens up a number of opportunities to revolutionize SUD treatment through integrating care into general medical settings, 6 offering low access entry to treatment by using phone "hotlines", 42 using remote screening tools and measurement based-care to inform SUD treatment and integrating digital health technologies as an adjunct to care delivered by providers. 40, [50] [51] [52] Summary The COVID-19 pandemic is an unprecedented force that has drastically changed our lives. In particular, the pandemic had a negative effect on vulnerable groups such as individuals with SUDs. The societal response to limit the spread of the virus reduced access to in-person care for SUDs but concurrently boosted the adaption of telemedicine for care delivery. Emerging evidence supports its acceptability by patients and providers alike but also highlights the need for it to be complemented by in-person care for those with the greatest need. Nevertheless, most agree that gains made in the area of telemedicine for the treatment of SUDs should not be receded post-pandemic. Therefore, there is a pressing need for evaluation and participatory research (with patients, families and healthcare providers) to effectively characterize individuals who are likely to engage and retain in remote care and conversely, those who require in-person care. This information is crucial to inform organizational change in specialized SUD treatment programs and in treatment programs that are integrated into general medical settings.  Telemedicine opens up a number of opportunities to revolutionize SUD treatment by:

integrating care into general medical settings, 6 offering low access entry to treatment by using phone "hotlines", 42 using remote screening tools and measurement based-care to inform SUD treatment and integrating digital health technologies as an adjunct to care delivered by providers. 40, [50] [51] [52]  The use of telemedicine needs to be balanced with an existing capacity for in-person care for a number of patient sub-groups that are likely to face challenges in engagement and retention via telemedicine care; older adults (ages 60+), people with polysubstance use, and pregnant women with OUD.

 In-person and remote care for the treatment of SUDs are complementary and a hybrid model of care that includes a combination of both is likely to meet the needs of those seeking care.

 In order to sustain and grow telemedicine use in the post-pandemic era, it will be necessary to extend those policies that allowed for telemedicine visits to occur during the pandemic.

 Need higher capacity to treat AUD and increase options for treatment of OUD.

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