What can we learn from COVID-19 to improve opioid treatment? Expert providers respond

Abstract

Background:

The COVID-19 pandemic has had devasting effects on drug abuse treatment systems already stressed by the opioid crisis. Providers within opioid use disorder (OUD) outpatient treatment programs have had to adjust to rapid change and respond to new service delivery provisions such as telehealth and take-home medication. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, this study explores providers’ perspectives about strategies and policies that, if made permanent, can potentially improve access to and quality of OUD treatment.

Methods:

This qualitative study was conducted in Los Angeles County, which has one of the largest substance use disorder (SUD) treatment systems in the United States serving a diverse population, including communities impacted by the opioid crisis. We collected qualitative interview data from 30 high-performing programs (one manager/supervisor per program) where we based high performance on empirical measures of access, retention, and program completion outcomes. The study team completed data collection and analysis using constructivist grounded theory (CGT) to describe the social processes in which the participating managers engaged when faced with the pandemic and subsequent organizational changes. We developed 14 major codes and six minor codes with definitions. The interrater reliability tests showed pooled Cohen’s kappa statistic of 93 %.

Results:

Our results document the impacts of COVID-19 on SUD treatment systems, their programmatic responses, and the strategic innovations they developed to improve service delivery and quality and which managers plan to sustain within their organizations.

Conclusion:

Providers identified three primary areas for strategic innovation designed to improve access and quality: (1) designing better medication utilization, (2) increasing telemedicine capacity, and (3) improving reimbursement policies. These strategies for system transformation enable us to use lessons from the COVID-19 pandemic to direct policy and programmatic reform, such as expanding eligibility for take-home medication and enhancing access to telehealth services.

1. Introduction

The COVID-19 pandemic greatly challenged US addiction health services—a system that is already overburdened by limited treatment program capacity (Holliday et al., 2020; Jones et al., 2015; Guerrero et al., 2016) and a worsening opioid crisis (Blanco et al., 2020; Jones et al., 2015; Substance Abuse and Mental Health Services Administration, 2020a). The collision of the pandemic with the opioid crisis has had devastating effects on Los Angeles County in particular, where there was a 52 % increase in accidental drug overdose deaths attributed to the pandemic in the period March–December 2020 (County of Los Angeles Department of Public Health [LA DPH], 2021). These findings are corroborated by California substance use disorder (SUD) providers who witnessed increased relapse rates among their clients during the pandemic (Henretty et al., 2021; Lin et al., 2022). Yet we have a limited understanding of the current capacity of opioid use disorder (OUD) treatment programs to deliver necessary services to vulnerable populations.

Increases in Los Angeles drug overdose rates during the COVID-19 pandemic were especially high for racial and ethnic minority populations, with drug overdose rates increasing by 75.2 % among Asians, 68.5 % among African Americans, and 55.7 % among Latinos, compared to 42.2 % among whites (LA DPH, 2021). Furthermore, national reports have found greater odds of COVID-19 mortality among individuals with SUD compared to individuals without SUD, with even higher odds of COVID-19 mortality among Black and Latino individuals with SUD compared to white individuals with SUD (Gross et al., 2020; Wang, Kaelber, et al., 2021). Therefore, an examination of the impact of COVID on OUD treatment services for individuals from diverse racial and ethnic backgrounds in large urban settings like Los Angeles is warranted.

Early studies of providers on the front lines of SUD treatment indicated that some of the main challenges brought on by COVID-19 at the organizational level included the difficulty of maintaining programs’ financial health in a shifting regulatory and funding environment, and staff shortages in the context of pressure to implement new technologies to replace in-person treatment, as well as lower morale due to reduced in-person work (Cantor et al., 2020; Gonzales-Castaneda et al., 2021; Holliday et al., 2020; Krawczyk et al., 2021; Pagano et al., 2021). These challenges coexisted with changes in program operations to prevent the spread of COVID-19, such as providing staff and clients with personal protective equipment (PPE), increasing cleaning procedures, and enacting measures to prevent overcrowding (Holliday et al., 2020). Many SUD programs cut back on the range of services they offered as a result of these strains (Hunter et al., 2021; Samuels et al., 2020).

The regulatory and funding environment for OUD treatment programs changed rapidly, if temporarily, in response to the COVID-19 pandemic. For example, in March 2020 the Substance Abuse and Mental Health Services Administration (SAMHSA) issued an emergency regulation expanding eligibility for take-home dosing of methadone (SAMHSA, 2020a; Suen, Castellanos, et al., 2022; Suen, Nguyen, & Knight, 2022). Prior to these measures, clients were required to attend daily methadone clinics, often located in neighborhoods that have been economically/socially marginalized, to be observed taking their medication and to provide a urine sample. Relaxed take-home dosing regulations gave clinicians discretion to prescribe take-home doses of up to 28 days. Providers were able to make high-stakes judgments about, for example, whether a client was “unstable” and could be trusted with only a 14-day supply of take-home methadone or whether they were “stable” and could be trusted with a 28-day supply (Hunter et al., 2021; Suen, Nguyen, & Knight, 2022). These changes brought the prescribing regulations for this chronic disease more in line with that of other chronic diseases (Hatch-Maillette et al., 2021; Suen, Castellanos, et al., 2022; Suen, Nguyen, & Knight, 2022). Further, this relaxation did not result in increased misuse or diversion of medications as had been predicted by some (Amram et al., 2021).

Legislation passed in April 2020 waived the 2008 Ryan Haight Act’s requirement that patients be evaluated in-person before being prescribed a controlled substance, including buprenorphine, for the treatment of opioid use disorder, allowing physicians to prescribe buprenorphine after an initial telephone or audio-visual communication (Wang, Weiss, et al., 2021). Individual states vary in their Medicaid reimbursement policies, but during the pandemic some made dramatic changes in funding for methadone clinics. For example, with permission from the Centers for Medicare and Medicaid Services, New York began delivering reimbursement in a weekly bundled rate (Andraka-Christou et al., 2021; COVID OTP Billing Guidance, 2021).

Additionally, early in the pandemic, Health and Human Services (HHS) loosened HIPPA requirements to allow the use of telehealth on free platforms such as Face Time and Google Hangout (U.S. Department of Health and Human Services, 2021). Although Medicaid funding for telehealth varies by state for use in OUD treatment, Medicaid funding for telehealth was increasing in many states prior to the pandemic, and increased further during the pandemic (Dunlap et al., 2018; Hughto et al., 2021).

The overall impact of changes in OUD treatment regulation and funding was greater flexibility in service delivery designed to improve access to quality services (Suen et al., 2022; Hatch-Maillette et al., 2021; Lin et al., 2022; Treitler et al., 2022; Volkow & Blanco, 2021). These changes included (a) greater autonomy for methadone patients: expanded access to long-acting forms of medication for opioid use disorder (MOUD), and waivers for urine-testing requirements (Krawczyk et al., 2021); (b) expanded access to buprenorphine prescriptions as a result of allowances for telehealth induction (Wang, Kaelber, et al., 2021; Wang, Weiss, et al., 2021); and (c) increased reimbursement for telehealth through Medicaid leading to increased use (Chu et al., 2021).

Responding to challenges to program access and quality posed by COVID-19 in a rapidly changing funding and regulatory environment was viewed by some service providers as an opportunity to develop practice innovations (Treitler et al., 2022). Examples of innovation across a broad spectrum of OTP programs include providers who gave clients phones (Hughto et al., 2021; Krawczyk et al., 2021; Wang, Weiss, et al., 2021); providers who created a phone hotline to connect patients seeking treatment for opioid use with telehealth buprenorphine prescribers (Samuels et al., 2020); providers who created temporary services for home-delivery and curb-side dosing of MOUD (Krawczyk et al., 2021; Lin et al., 2022); implementing COVID-19 screening and testing protocols (Lin et al., 2022); creating crisis management teams (Holliday et al., 2020); and finding ways to provide food and other social services to clients (Holliday et al., 2020).

1.1. Expert service providers

This study, approved by The University of Chicago’s Institutional Review Board, focuses on the perspectives of expert service providers, defining expertise in terms of program outcomes. That is, expert service providers are those leaders, managers, and/or supervisors whose programs demonstrate high scores on outcome measures of client access, retention, and program completion. Sampling of these experts was guided by the theories of expertise (Ericsson, 1996; Fook et al., 1997). Within cognitive psychology and social work, expertise is characterized by the ability to handle complexities, quickly rank relevant factors to understand how to act, and attentiveness to constraints and resources (Fook et al., 1996; Fook et al., 1997). Theories of expertise assume that experts adapt to their specific environment, using knowledge and skills derived from accumulated years of “on-the-ground” training and practice to best respond to the service needs of clients (Nilsson et al., 2007).

SUD treatment is a field that has been historically criticized due to great variability in the professionalization, quality, and outcomes of programs (Glasner-Edwards & Rawson, 2010; Kerwin et al., 2006). We expect expert treatment providers to rely on policies and evidence-based practices to provide the best possible outcomes. Learning from those providers is critical because they must evaluate their local realities often to respond effectively. Their responses can inform lower-performing treatment providers how to employ better strategies for coping with policy changes, particularly in times of regional or national crisis. The field has a need for a deeper understanding of how expert treatment providers address problems, the type of knowledge used, and how knowledge is structured and prioritized within OUD treatment in the context of the COVID-19 pandemic.

1.2. The current study

Early research on the impact of the COVID-19 pandemic on the delivery of OUD treatment presents a picture of the immediate programmatic and policy responses of programs across the country. We know less about providers’ perspectives about the strategies and policies that, if made permanent, have the potential to improve access to and quality of OUD treatment. To date, researchers have interviewed providers regardless of their experience or expertise in the provision of high-quality SUD services in racial and ethnically diverse urban communities. In this study, we seek to narrow the gap in our understanding by obtaining the perspectives of expert service providers in a diverse, urban community especially hard-hit by the COVID-19 pandemic. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, our specific research questions include: What are the programmatic and policy responses to the COVID-19 pandemic that expert providers would make permanent in efforts to improve and transform the substance abuse treatment system? More specifically, what was the impact of COVID-19 on OUD outpatient treatment programs? What were the changes to treatment delivery strategies to manage the COVID-19 impacts? What were the developments in integrating and sustaining practice innovations in response to COVID-19?

2. Methods

2.1. Setting and context

We conducted this qualitative study in Los Angeles County, which has one of the largest SUD treatment systems in the United States, serving a diverse population, including communities heavily impacted by the opioid crisis. Though Los Angeles County is the largest metropolitan area in the United States, with more than 10 million residents, the county has more than 4000 mile² of rural and high desert areas where treatment locations may be located. In 2019, the county provided treatment to more than 40,000 individuals, with opioids the leading drug of choice (LA DPH, 2022). OUD treatment within Los Angeles is largely publicly funded and ranges from sizable, medicalized treatment programs and smaller storefront programs primarily serving racial and ethnic minority groups. In Los Angeles County, young people ages 18–25 are most impacted by opioid use. Although the rates of opioids distributed at pharmacies have decreased in Los Angeles County since 2014, drug overdose deaths reached an all-time high in 2020, with 64 % of drug overdose deaths involving opioids (Los Angeles County Department of Public Health, 2022). Not incidentally, 2020 also marked the beginning of the COVID-19 pandemic, resulting in lockdowns, lack of access to treatment, and isolation of any clients eligible for treatment (Chiappini et al., 2020).

2.2. Participant recruitment

Drawing from the relationships developed to collect four prior waves of program data (Guerrero, Padwa et al., 2015; Guerrero et al., 2016), the research team coordinated emails and calls to a subset (n = 30) of administrators and program managers/supervisors from the highest performing programs in the original sample (n = 70) to gain consent to participate in the study. After program managers agreed to participate, a research team member gained consent via phone from each participant. As an incentive, participants received a $50 gift card for participation.

2.3. Sampling and inclusion criteria

The study defined expert treatment providers as directors, managers, and supervisors of administrators of top performing outpatient treatment programs in the 2017 wave of quantitative data collection (Marsh et al., 2021). To select this sample of experts, the researchers relied on the most current data from the parent grant (Marsh et al., 2021). For each program in the 2017 wave of data collection, the study team created a performance index.

We defined the performance index as below:

$$\text{Index}=\frac{{\overline{x}}_{wait}-min\left({\overline{x}}_{wait}\right)}{\text{range}\left({\overline{x}}_{wait}\right)}+\frac{{\overline{x}}_{duration}-min\left({\overline{x}}_{duration}\right)}{\text{range}\left({\overline{x}}_{duration}\right)}+\frac{{\overline{x}}_{completion}-min\left({\overline{x}}_{completion}\right)}{\text{range}\left({\overline{x}}_{completion}\right)}$$

where ${\overline{x}}_{wait}$, ${\overline{x}}_{duration}$, and ${\overline{x}}_{completion}$ denote the average wait time, average treatment duration, and average treatment completion rate by program.

Based on the distribution of these data, the team then selected 30 OUD treatment programs with the highest performance indicator data, i. e., the lowest rates of wait time, highest rates of retention, and highest rates of treatment plan completion. It should be noted that although we aimed to recruit directors, managers, and supervisors, due to workforce shortages during the pandemic, managers often played different roles within their organizations. For example, managers would often supervise counselors while providing direct services. However, participants responded to interview questions within the context of their role as directors, managers, and supervisors for this study.

2.4. Sample-size determination

Based on previous studies with similar populations (Guerrero, Harris et al., 2015, 2016), we determined that a sample of 30 or fewer would be adequate to achieve saturation. The study continued participant recruitment and interviews until reaching theoretical saturation per grounded theory methodology (Charmaz, 2014).

2.5. Interview guide development

The research team developed the interview guide to assess (a) respondents’ descriptions of adherence to standards of care and best practices in their programs, (b) their perceptions of changes in service delivery in response to the COVID-19 pandemic, and (c) their perceptions of the changes they would make permanent in efforts to increase access and quality of care. The study team finalized the draft interview guide using two pilot interviews with providers who did not appear in the randomly selected sample of implementation experts. The final interviews were conducted by LMH and VS, qualitative researchers who have conducted studies within Los Angeles County’s SUD treatment system for more than ten years. See Appendix A for the interview guide questions used in this study.

2.6. Data collection

The study completed all 30 interviews via phone or video conference call, depending on the participant’s request. The researchers made appointments two weeks in advance to give participants enough time to manage their schedules and devote 45 to 90 min to the interview. The study audio recorded all interviews and had them professionally transcribed, with all identifiers removed before the analysis.

2.7. Data analysis

Interviews were transcribed by a professional service (REV.com), and the research team removed all identifying information before the analysis process. The study team completed data collection and analysis using a constructivist grounded theory (CGT) approach (Charmaz, 2014), meaning that our goal was not to generate a theory but to employ CGT techniques throughout our coding and data analysis process to describe the lived experiences of the participating managers.

Following the completion of the interviews, two authors (LMH and VS) coded half of the transcripts line by line. Initial codes were clustered by topic to develop focused codes. The team used the most frequent and significant focused codes to construct a codebook that consisted of 14 major codes and six minor codes with definitions. We used Dedoose^™ (Version 9.0.17, 2021), a web-based qualitative data analysis platform, to facilitate data organization and coding (SocioCultural Research Consultants, 2021). The codebook was uploaded into Dedoose software, and the study used Dedoose’s coding functions to code 50 % of the interview transcripts. The finalized codebook was based on iterative discussions of interview transcripts (Hsieh & Shannon, 2005; Joffe & Yardley, 2004).

Next, we performed interrater reliability tests, comparing the two researchers’ coded transcripts to ensure agreement. After obtaining a pooled Cohen’s kappa statistic of 93 % (Cohen, 1960), LMH and VS met as a team to discuss and adjudicate on each excerpt about which the researchers did not initially agree. Cohen’s kappa statistic is a widely used measure to evaluate intercoder agreement compared to the rate of agreement expected by chance. According to Landis and Koch (1977), the Kappa statistic achieved by the researchers is considered excellent agreement. After the adjudication process was complete and reached 100 % agreement, the remaining interview transcripts were coded. Next, we conducted a thematic analysis on the coded transcripts, iteratively refining themes until reaching a consensus. The authors maintained memos related to analytic decisions, consulted with other team members, and discussed the relationships among codes that emerged from the data (Charmaz, 2014; Strauss & Corbin, 2015).

3. Results

As Table 1‘s quantitative data show, the high performing programs treated a diverse client population. Forty to 100 % of the clientele served by the study subsample were males. At least 60 % of clients served in these programs spoke Spanish, and 10 % spoke Tagalog, Armenian, or Farsi. Three percent of clients served spoke Korean, and 6 % identified a variety of other languages. Service characteristics (e.g., prescribing MOUD, providing counseling, and receiving Medi-Cal funding) of high performing programs indicate they are operating according to accepted standards of care (Blanco & Volkow, 2015). Ninety percent of the organizations offered medication as a treatment for opioid addiction, 97 % offered behavioral therapy services, and 70 % required behavioral therapy or counseling as a part of treatment. Eighty percent of the organizations offered treatment through in-person and online formats.

Table 1.

Client and program characteristics of high performing programs.

Gender identity of client population
Proportion of clients who identify as male	40–100 %
Proportion of clients who identify as female	0–60 %
Proportion of clients who identify as non-binary or transgender	0–10 %
Racial and/or ethnic makeup of client population
Asian	0–10 %
Black	0–45 %
Hispanic/Latinx	0–90 %
Non-Hispanic White	5–80 %
Other—Native American, Persian, Middle Eastern, mixed-race (identified by providers)	0–31 %
Preferred language of clients
English	60–100 %
Other languages	0–40 %
Number of organizations serving clients who speak languages other than English
Spanish	60 % (n = 18)
Tagalog	10 % (n = 3)
Korean	3 % (n = 1)
Armenian	10 % (n = 3)
Farsi	10 % (n = 3)
Other	6 % (n = 28)
Does the program offer medication as a treatment for opioid addiction?
Yes	90 % (n = 27)
No	10 % (n = 3)
Offer counseling or behavioral therapy services, e.g., domestic violence or anger management counseling
Yes	97 % (n = 29)
No	3 % (n = 1)
Counseling or behavioral therapy required or optional
Required	70 % (n = 21)
Optional	27 % (n = 8)
Not available	3 % (n = 1)
Counseling or therapy provided in person, using telehealth, or both
In person	6 % (n = 28)
Telehealth	10 % (n = 3)
Both	80 % (n = 24)
Not available	3 % (n = 1)

The qualitative data indicate that providers underwent a process of managing the impacts of the COVID-19 pandemic. First participants described the impacts of COVID-19 on their programs; then they described how they responded with strategic innovations to maintain access to quality programming. Finally, they reflected on strategies they thought would be important to continue to maintain access to and quality of OUD treatment. Fig. 1 elucidates the three stages of this process—assessing the impact of the pandemic on providing treatment, crafting organizational responses, and implementing strategic innovations—as well as the various social processes embedded within each stage.

Fig. 1.

OUD treatment programs’ process of managing the impacts of COVID-19.

3.1. The impact of COVID-19 on OUD treatment programs

Managers experienced the impact of COVID 19 across six domains: lack of staff, relapse and retention, medication for addiction therapy (MAT) services, trauma and disconnection, productivity issues, and problems with technology and internet access.

3.1.1. Lack of staff

Managers described the devasting impact of losing their staff due to COVID-19 exposure and competing caregiving needs. In addition, some staff were unwilling to enter the agency for fear of contracting the virus, particularly staff who were older or had pre-existing medical conditions. One manager summarized the effect of the lack of staff, saying, “We had lack of staff because some of the staff had COVID, some of them had exposure, some had children at home that needed to be cared for without any school being available, some were older and they didn’t want to be exposed, and on and on and on and on.” The lack of staffing required managers to float to various roles within the organization to maintain treatment for clients. One manager shared, “I manage the outpatient, so I’m in charge of that and all the responsibilities that go with that. But I’m currently understaffed, so I’m also a counselor.”

3.1.2. Relapse and retention

At the same time, managers were overburdened due to surges in relapse rates. As one manager stated, “The relapse cases went through the roof.” Another manager spoke about the increase in synthetic opioid use during the pandemic, stating, “The majority went to amphetamines or methamphetamine, and mixing it with opiates, and also that new thing that is killing all of them...Fentanyl. Fentanyl is taking over the [other] opiates.” Relapse and retention were complicated by understaffing and clients dropping out of the program. Asked about who was retained in the program during the height of the pandemic, one manager replied, “Myself, one case manager, and one part-time DUI clerk.”

3.1.3. Medication for addiction therapy services

The pandemic led to disruptions in access to MAT services by clients who depended on them for recovery. Distribution of MAT services was altered, and many counseling programs halted or were delayed in attempts to pivot to online platforms. One manager described how the pandemic impacted the SUD care cascade and MAT in a negative way:

Well, pre-pandemic we were licensed for outpatient, residential, and detox treatment, and we still are, but once the pandemic hit and because of the requirements of the pandemic, it’s a requirement that all new patients being brought in had to be quarantined in a space for 14 days. Because of space constraints, the space that we had been using for our detox program we had to convert to a quarantine facility. We stopped providing detox.

3.1.4. Trauma and disconnection

Managers coped with employees and clients who experienced trauma related to the pandemic: “Some people are really afraid…. There’s a lot of PTSD going on behind this COVID thing, and we get that. So, we do offer telehealth services, but it’s going to be like at this location it’s individual casting, right.” Employees experienced disconnection to their clients due to a lack of “physical energy in the room.” Another manager commented about the lack of popularity of the online counseling or group sessions: “They were just not feeling connected via this telehealth platform.”

3.1.5. Productivity issues

The pandemic lowered typical rates of productivity due to competing life events, illness, caregiving needs, and distance requirements. As one manager stated, “There were productivity issues.” Another manager described how productivity issues increased her workload and forced her to get back into the field and work directly with clients: “I’m doing intakes. I step up and do the groups that the counselor is out…I definitely do interventions. If needed, I answer phones. You name it, I do it. I assist the doctor…I do everything here.”

3.1.6. Issues with technology and internet access

When employees and clients were sent home due to shelter-in-place orders, managers were confronted with problems related to technology and internet access. “There were issues with technology. [Clients] didn’t really know how to use the technology, and we didn’t know how to really use the technology. There were so many people using technology that sometimes we had internet services, sometimes we didn’t. It just changed everything.” Telehealth platforms also made it hard for providers to perceive whether their clients were using substances:

So it has changed dramatically. With face to face, you can actually be in the session with the patient and observe their behavior more so than over the phone. It’s a different dynamic where you kind of have to listen, because if they’re using drugs, then you [need] to listen for slurred speech or the conversation rate of speech, pitch and tone. Whereas in person you can actually see that, as well—you can look at them and see. See the pupils of their eyes and if they seem flushed.

3.2. Organizational responses

To respond to the crisis of the COVID-19 pandemic, managers led organizational responses, which involved changes to telehealth, increasing take-home medication prescriptions, building trust and technology literacy, implementing COVID-19 safety protocols, and ensuring privacy protection in billing and health insurance communications.

3.2.1. Telehealth

Managers responded to the pandemic by putting in place online mechanisms for consent for treatment, intake, assessments, group work, and counseling. One manager reflected on all elements of the organizational response to telehealth implementation, explaining:

We did learn how to make it [telehealth] effective with the client. So, we had to learn new things, like how to present videos over the telehealth, [how] to incorporate worksheets, and [how to make] clients able to participate in the groups. We had to figure out the whole telehealth intake and what that looks like with them signing the consent for treatments.

Another manager discussed the impact of telehealth on the lives of workers and the organizational structure: “So we had to dislocate from a central location (that could be a clinic in this case), to dislocate some of the workforce, so they would be working from home.” One manager spoke about the necessity of connection for her clients and how telehealth enabled clients to stay engaged in care during the pandemic: “We didn’t want the patients to feel isolated, and a lot of our patients don’t have anybody…and now all of a sudden, we have to change things to doing…mostly telephonic in order to protect them and protect our staff.”

3.2.2. Increasing take-home medication prescriptions

Managers implemented new organizational policies to respond to SAMHSA’s emergency regulation expanding eligibility for take-home dosing of MAT. Managers responded in several ways, including spreading the word about which take home medications could be administered via telehealth. One manager shared, “When it came for medication, between methadone and buprenorphine, buprenorphine they can do over the phone. Versus with methadone, the doctors have to see them in-person. So they try to make it a little easier for some patients, and for safety of the facility and the doctors, letting them know that buprenorphine can be over the phone.”

Another manager reinforced the need for daily dosing despite more flexible regulations around take-home MAT: “There are patients that are doing very well to where they can accumulate take home privilege…and they don’t have to come into the clinic, but they have to dose every day.” Another manager described the use of take-home MAT to be the most significant change that occurred during the pandemic because clients “don’t have to come in every day. They don’t have to risk too much exposure by coming in on a much more frequent basis.”

3.2.3. Building trust and technology literacy

Managers shared that they were tasked with building both clients’ and workers’ trust in telehealth as a pathway to treatment and sobriety. One strategy that they used was counseling time to onboard patients to telehealth platforms. One manager reflected on the work involved:

God, we had much to do. We had … It was just a lot of retraining. And lot of our staff … It was more our staff not wanting to … not believing in telehealth. Trying to change the mindset of staff and to let them see, one, we had no choice because they shut everything down. LA County closed down in-person groups and in-person everything.

3.2.4. Implementing COVID-19 safety protocols

In addition to building literacy with technology, managers were tasked with implementing safety protocols for clients who were unable to stay at home. They also needed to educate employees about PPE and social distancing. This process involved considerations for populations with increased vulnerability, such as clients who were unhoused during the pandemic. One manager shared, “For those folks who were unable to access telehealth because they were homeless or don’t have the technical equipment to do that we still offered in patient services where we could, as long as you were abiding by all the COVID managing guidelines.”

Managers also had to navigate enrolling patients in treatment and trying to increase engagement in care while offering protection to clients and staff against COVID. One manager explained,

We also have an intake process where we have to do… The patient has to be in clinic. And so the two people that do the intake is myself and our lead counselor, and the lead counselor preferred to have the patient in one room on the phone while she’s in another room because of social distancing. I prefer to have the patient in my office. My office is big enough to where we wear our masks and do social distancing. That’s what I prefer. And so as far as the counseling, it’s done 100 % telehealth with the counselors, but in the clinic, it’s a different dynamic.

3.3. Strategic innovations

Our findings indicate that the COVID-19 pandemic shifted protocols and gave way to strategic innovations for OUD treatment. Managers stated that these innovations made treatment more accessible, thus reducing health disparities. The pandemic kick-started practices that many agencies intend to continue after the pandemic subsides. These included becoming a testing and vaccination site, maintaining and improving telehealth, having flexible work options for employees, and capitalizing on looser regulations and funding requirements to offer clients increased flexibility in managing their treatment.

3.3.1. Becoming a testing and vaccination site

Managers were able to integrate COVID-19 testing and vaccination within their existing system of care. One manager described how their clinic supported vaccination and testing efforts in the county, and how vaccination and testing allowed clients to reengage in face-to-face counseling: “We even have a vaccination site onsite here at my facility… We have the home test; we have the rapid test. So, we make it so that our clients can have access to the things that they need to feel safe to show up.”

3.3.2. Maintaining and improving telehealth

After years of wondering whether telehealth might be a viable option for care, managers were now able to lean into innovation and change. One manager said, “A significant accomplishment is the fact that telehealth all of a sudden became possible. I’ve been in … decades of meetings with people who were talking about, ‘Is telehealth possible? And confidentiality and reimbursement?’…But all that stuff became quickly resolved.”

Managers reported that telehealth was a positive development in treatment. One stated, “We have shifted to tele-counseling, which was something that we did not readily offer before. But now it seems to be an integral part of making sure that patients continue to get the care that they need, so that’s the biggest shift.”

Another manager found the shift to online counseling increased engagement in care. Some clients work during clinic hours, and telehealth makes it possible for them “to schedule 10 minutes where they can jump on their computer or jump on the phone…where before, it was a big stressor to have to take the entire day off to get here to see our doctor. So, I think that telehealth, yes, is here to stay.”

Due to staffing shortages, clinics hired online counselors to fill in for sick or quarantined employees using telehealth platforms, and managers continue to take advantage of this resource. As one manager explained, if a clinic counselor needs to be absent, “we can reach out to our regional directors and see if they can have the tele counselors assist us for some time. Whereas before, that wasn’t something that we had, we would just have to find coverage within our own clinic.” Another manager spoke about the pandemic leading to hiring a new remote workforce: “We now have tele-counselors, which was not something that we had before. Just counselors that actually don’t live in LA County but are working for us. That’s a new implementation.”

3.3.3. Flexible work options for employees

Managers learned that they could increase retention and well-being among employees by maintaining flexible work options. One manager spoke about the benefits of new flexible working conditions: “If we have an outbreak of COVID, we go back to telephone and virtual. Yeah. At least now we have the ability to fluctuate.” Another manager discussed the improvements made to protocol and practices during COVID, saying:

[Maintaining the] health and safety of our employees and patients … are some of these lessons that we learned…, whether it’s this virus or another virus. I think some of these changes that we have been implementing, as we have maintained it over two years now, we probably will continue. And I think it certainly is good, positive change.

3.3.4. Increasing flexibility for clients

Managers learned that they could increase client engagement through offering more flexible clinic hours, service delivery methods, and take-home MAT options. One manager described the positive outcomes they are seeing with clients who are accessing take-home MAT since the pandemic:

As SAMHSA approved the blanket exemption, we were able to accommodate a lot of our patients with take-homes. And the interesting thing with that is that those patients that received these blanket exemptions did well in treatment. And a lot of them actually were able to achieve more stability in treatment. They were not using drugs anymore. Their urinalyses were coming back negative for illicit drugs. And some of those patients were actually able to be switched from these exemptions to regular and permanent takehomes. We saw some good came out of all this crazy time.

Some clinics began delivering MAT to clients’ homes. As one provider explained that when a client called in with proof of COVID, “we did a chain of custody and a counselor, and a nurse would get a doctor’s order [for take-home MAT] … and actually go deliver the medication to the home.” Another manager discussed increasing flexibility for clients in relation to regulatory flexibility and assumed risk: “If a patient was testing positive for any illicit substances, but they were deemed to have a higher risk of contracting COVID, we would provide them with medication to take home, whereas before COVID, that was not protocol.”

Telehealth resolved long-standing barriers to care posed by transportation difficulties and time constraints. For rural clinics within Los Angeles County, increasing access through telehealth services solved staffing issues. One manager stated, “Since the pandemic started...it was about just growing MAT services and the ability to utilize our providers that are not here in [rural area]. It’s kind of difficult to find providers in [our city]. We’re a rural area; not a lot of professional staff want to work here. So that’s a great option for us.”

Managers regarded the innovations developed during the pandemic as enabling them to reach more vulnerable populations with less access to treatment. One said:

I hope that we can continue to [offer] telehealth, because we serve, demographically, a much older population in this facility…So accommodating them with telehealth or more take-home is probably going to be increasing accessibility and reducing barriers to treatment. So, I’m hoping that some of these changes we have made remain with us.

4. Discussion

The converging of the COVID-19 pandemic and the opioid crisis provided a unique opportunity to examine the responses of Los Angeles County providers working with diverse, urban populations that are often stigmatized and are highly vulnerable to overdose-related death. Our findings show that providers identified three strategic innovations that improve access to and quality of OUD treatment. The first is the use of telemedicine: providers increased training for both employees and clients, expanded their capacity for online appointments, and developed hybrid service models incorporating both remote and in-person visits. Second, reimbursement for services allowed these hybrid models. Finally, more flexibility in prescribing protocols led to better medication use, especially of methadone.

Leaders in behavioral health are now deciding whether to return to policies that restrict MAT, thus decreasing flexibility granted in the COVID pandemic era (Wakeman et al., 2020). However, studies show promises of increased flexibility benefiting populations that have historically faced disproportionate access to treatment, resulting in unequal MAT access. In a study of patients’ experiences of SUD treatment during the pandemic, Saloner et al. (2022) found that despite reductions in in-person treatment across ten states, patients were satisfied with their treatment during the pandemic. Our provider-focused study supports this finding in that providers reported greater uptake of take-home medication and use of telehealth.

In addition to changing practices and policies with OUD treatment, our study’s findings contribute to the potential for stigma reduction within MAT. A potential longer-term consequence of this evolving treatment landscape could be reduced MAT-related stigma for patients and providers, particularly those who engage in methadone maintenance. Some leaders are positing that telemedicine is a viable alternative for OUD care in a post-COVID pandemic, now endemic, environment. A recent study suggests that telehealth through video supports patient retention and that ceasing video telehealth efforts could disproportionately impact patients, particularly from the Black community and unhoused persons (Frost et al., 2022). A recent study (Hailu et al., 2023) examined the impact of telemedicine on access to and quality of OUD care and found that patient treatment outcomes were comparable to face-to-face OUD treatment. Additionally, these findings may discredit long-held assumptions that telemedicine was risky or overutilized.

As cities adjust to post-pandemic life, providers have called for policies that support the continued improvements in treatment access and experience (Suen, Nguyen, & Knight, 2022). For example, many providers—including the expert providers in our subsample—are in favor of policies that enable hybrid models of OUD treatment involving both remote and in-person services, including expanded telehealth reimbursement legislation, financial assistance to build capacity for new technologies, and evidence-based guidance on effective protocols for using telehealth to treat OUD (Hughto et al., 2021; Hunter et al., 2021; Krawczyk et al., 2021; Nguemeni Tiako, 2021; Wang, Weiss, et al., 2021). In addition to policy changes, providers recommend that resilience may be improved through information-sharing, cross-collaboration (Holliday et al., 2020), and self-care practices (Dombrowski, 2020).

Despite the generally positive assessment of the greater flexibility in treating substance use disorders, some providers worry that increasing take-home medication may decrease those clients’ overall use of health care (Walley et al., 2012). A larger concern is that even the current pandemic-era policies may perpetuate pre-pandemic patterns of inequitable access to MOUD within racial/ethnic minority communities (Hatch-Maillette et al., 2021; Holliday et al., 2020; Suen, Castellanos, et al., 2022) by allowing telehealth initiation for buprenorphine but not for methadone (Nguemeni Tiako, 2021) and by creating situations in which provider bias might adversely affect client access to take-home methadone (Hatch-Maillette et al., 2021). In deciding whether a client is eligible for take-home doses, providers might be swayed by subjective assumptions about clients’ “deservingness” and of their commitment to sobriety (Handler & Hasenfeld, 1991). Therefore, such assessments are susceptible to provider-level racism, classism, and homophobia. Recent studies have shown that African Americans and Latinos are less likely than white clients to receive take-home doses of methadone (D’Aunno & Pollack, 2002; Pollack & D’Aunno, 2008).

5. Conclusion

Our study joins the ranks of other regional studies on perspectives OUD treatment providers’ perspectives on changes to service delivery during the COVID-19 pandemic (Madden et al., 2021; Suen, Castellanos, et al., 2022). To our knowledge, ours is the first study to focus specifically on the perspectives of expert OUD treatment providers managing high-performing programs in the Los Angeles area. Our findings illustrate how providers in one of the largest and most diverse counties in the United States responded to the crisis of the COVID-19 pandemic within the context of an existing opioid epidemic. Rather than failing to care for their clients, providers used the crisis as an opportunity to implement changes that improved access to and quality of services. Additionally, study findings document these providers’ hopes and plans not just to maintain these practice innovations but to expand clients’ eligibility for take-home medication and access to telehealth services.

Appendix A.

Interview guide questions

1. I will use the term OUD to refer to opioid use disorder throughout the interview. To begin, could you briefly describe your role and responsibilities at this OUD treatment program?

Now, I have a few questions about the size and composition of your service population.

2. In recent years, roughly how many clients per year has your OUD treatment program served?

____per year

3. About what proportion of your OUD clients are men, and what proportion women?

What about non-binary or trans-gender people?

__% female

__% male

__% non-binary or transgender

4. What about the approximate racial/ethnic make-up of your OUD clients?

__% Asian

__% Black

__% Latinx/Hispanic

__% Non-Hispanic White

__ % Other _________________

5. About what proportion of your OUD clients are native English speakers and about what proportion communicate best in other languages?

__% Native English speakers

__% Communicate best in other languages ➔ 5A. [IF MORE THAN 1 %] What are the primary languages in which your non-native English-speaking clients best communicate?

□ Spanish

□ Chinese

□ Tagalog/Filipino

□ Korean

□ Armenian

□ Persian

□ Other, please list ___________________

6. Please briefly describe the primary ways in which your OUD services or service delivery strategies changed due to the COVID-19 pandemic.

7. I would like to ask you about the OUD services and service delivery strategies offered in your program as they currently exist. This includes any changes resulting from the COVID-19 pandemic.

8. Does your program offer medication as a treatment for opioid addiction?

9. (If medication not offered) What is the primary reason you do not offer medication as a treatment for opioid addiction?

10. In your experience, are there any drawbacks to medication as a treatment for opioid addiction?

11. What are the main barriers or challenges to delivering culturally responsive opioid addiction treatment services?

12. From your experience, please talk about the elements or qualities of the client-provider relationship that are critical to successful treatment of opioid addiction.

13. Given opioid users’ high risk of drop out more generally, what strategies does your organization use to keep OUD patients engaged?

14. Briefly, how, if at all, has the expansion of Medicaid affected your ability to provide OUD treatment services?

I’d like to wrap up by asking three last questions.

15. First, what about your program are you most proud of?

16. Second, what would you most like to change if you could wave a magic wand and change one thing about your program?

17. Finally, what advice would you have for other providers committed to providing high quality OUD treatment programs?