A qualitative exploration of the use of telehealth for opioid treatment: Implications for nurse-managed care

Abstract

Aim:

To characterize experiences with telehealth for Medications for Opioid Use Disorder services among patients, prescribers, nurses, and substance use counselors to inform future best practices.

Design:

We engaged a qualitative descriptive study design.

Methods:

Semi-structured interviews were conducted with prescribers (nurse practitioners and physicians, n=20), nurses and substance use counselors (n=7), and patients (n=20) between June-September 2021. Interviews were verbatim transcribed. Thematic analysis was conducted using a qualitative descriptive method.

Results:

Among both providers and patients, four themes were identified: 1) Difficulties with telehealth connection 2) Flexibility in follow-up and retention, 3) Policy changes that enabled expanded care, 4) Path forward with telehealth. Two additional findings emerged from provider interviews: 1) Expansion of nurse-managed office-based opioid treatment, and 2) Novel methods to engage patients.

Conclusions:

Patients and providers continued to view telehealth as an acceptable means for delivery and management of Medications for Opioid Use Disorder, particularly when utilized in a hybrid manner between in-person visits. Nurse-managed care for this service was evident as nurses extended the breadth of services offered and utilized novel methods such as text messages and management of “call-in” lines to engage patients.

Implications for the profession and/or patient care:

Use of telehealth for Medications for Opioid Use Disorder should be incorporated into practice settings to reach patients in a flexible manner. Nurses in particular can use this medium to extend office-based opioid treatment by conducting assessments and expanding capacity for other wrap-around services.

Impact:

We identify recommendations for best practices in the use of telehealth for opioid use disorder management and highlight the value of nurse-managed care.

Reporting method:

The Consolidated Criteria for Reporting Qualitative Research

Patient or Public Contribution:

Patients with opioid use disorder and prescribers with experience using telehealth were interviewed for this study.

1. Introduction

The United States is facing the impacts of what many have referred to as a collision of epidemics: the intersection of COVID-19 and the opioid crisis. In particular, many jurisdictions throughout the country show increases in overdose rates (Alter A, Yeager C., 2020). Additionally, people who use opioids have faced significant disruptions in crucial substance use treatment services as a result of the pandemic, which can lead to increases in relapse and overdose risk. A broad, cross-sectional survey conducted by the Addiction Policy Forum in 2020 found that over one third of respondents diagnosed with a substance use disorder experienced changes in their treatment or recovery support services as a result of the pandemic, with 14% reporting being unable to access these services at all (Hulsey J, Mellis A, Kelly B., 2020). In order to address this ongoing crisis, access to and retention in evidence-based treatment and harm reduction services are necessary.

2. Background

Medications for opioid use disorder (MOUD) have been recognized as a best practice in the treatment of individuals with opioid use disorder (OUD) (Larochelle et al., 2018). MOUD treatment is associated with multiple positive outcomes among people with OUD, including reductions in both all-cause and overdose mortality by up to one half, a decreased risk of relapse, reduction in risk behaviors associated with HIV and HCV transmission (Platt et al., 2017), increased treatment retention, and improved social functioning (Mancher et al., 2019). Despite the effectiveness of medications, people who use opioids faced significant treatment barriers prior to the COVID-19 pandemic, including stringent state and national policies which restricted MOUD prescribing including prohibiting initiation using telehealth, limiting the duration scripts, and requiring strict licensing for prescribers. However, in response to the limitations on in-person visits to mitigate COVID-19 risk, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance in March of 2020 encouraging states to allow individuals on methadone to receive 14–28 days of take-home medication at a time (Substance Abuse and Mental Health Services Administration, 2020), and the Drug Enforcement Administration (DEA) waived requirements that individuals starting on buprenorphine treatment must first present for an in-person visit (Drug Enforcement Administration, 2020).

Another way in which MOUD capacity expanded during the pandemic was through increasing engagement of nurses in the oversight and maintenance of OUD patients. In the US, the 2016 Comprehensive Addiction and Recovery Act enabled Nurse Practitioners to prescribe MOUD and studies indicate that engaging NPs to prescribe MOUD can significantly reduce barriers to MOUD access (Spetz et al., 2022). Additionally, nurses in several settings have been utilized as care managers to support team-based approaches to MOUD-delivery, providing screening, care coordination, medication support, and general patient advocacy (LaBelle et al., 2016). In general, the office-based opioid treatment (O-BOT) model highlights the important role of nurses in the evaluation, monitoring, and treatment of OUD patients (Campbell et al., 2021). Yet the role of nurses in the shifting OUD care environment caused by the pandemic remains poorly characterized. This is particularly relevant given findings that advanced practice nurses accounted for the greatest increase in capacity to prescribe buprenorphine treatment during the COVID-19 pandemic (Spetz et al., 2022).

While the pandemic limited the capacity for providers to engage in office-based treatment models, the expansion of telehealth services enabled medical teams to increase their access to patients through a range of new platforms. Specifically, reductions in restrictions on MOUD prescribing practices among both medical doctors and nurse practitioners led to as much as a 143% increase in the use of telehealth, or health care delivered via a technology-based platform, as a means for providers to initiate and manage MOUD (Cantor et al., 2022). Telehealth has the potential to significantly reduce barriers to health care access by allowing individuals to meet with their providers without leaving their home, which proved to be particularly valuable in the context of the COVID-19 pandemic when many outpatient clinics were closed or significantly limited access (Mahmoud, H., Naal, H., Whaibeh, E., & Smith, A., 2022). Recognizing the importance of this treatment modality, the DEA has extended its COVID-19 era policies for use of telehealth to manage MOUD as it considers new permanent rules (Federal Register, 2023).While some telehealth methodologies were in use prior to the COVID-19 pandemic, most clinical practices relied upon in-person services for the majority of their care. Yet a systemic review including 38 meta-analyses on the use of telehealth across 10 medical disciplines between 2010 and 2019 found that across all disciplines, telehealth was seen as equally if not more effective compared with standard care (Snoswell et al., 2021). While this evidence exists, few studies have examined the use of telehealth specifically for MOUD treatment (tele-MOUD), particularly in the context of policy and practice changes, as well as the patient perspectives of this service medium (Mahmoud, H., Naal, H., Whaibeh, E., & Smith, A., 2022). Finally, while nurses and nurse practitioners play an important role in MOUD management, particularly in integrated care settings, there has been little guidance on the use of tele-MOUD in nurse-managed care (Cos et al., 2021).

3. Study Aim

The aim of this study was to understand experiences with using telehealth for MOUD services among patients, prescribers, nurses, and substance use counselors to inform use of telehealth in nurse-managed MOUD care.

4. Methods/Methodology

4.1. Study Design

We engaged a qualitative research design grounded in qualitative descriptive research methodology.

4.2. Theoretical Framework

The study’s methodological orientation was grounded in a qualitative descriptive research design, an approach designed to explore and understand a phenomenon and process based upon accounts from those involved in it (Bradshaw C, Atkinson S, Doody O., 2017). There are several key philosophical underpinnings inherent to this approach: 1) qualitative descriptive research is inductive, enabling researchers to remain flexible to changes in their understanding of a phenomena or experience; 2) knowledge is subjective, and meaning is created at an individual level, indicating that participants may hold distinct and perhaps opposing viewpoints or perspectives on a single phenomenon; and 3) researchers play an active part in the creation of meaning through the research process, particularly through the process of interpretation of findings. Decisions around the study’s methods, including data collection, analysis, interpretations, and the presentation of results, were made based upon the consistent application of qualitative descriptive research.

4.3. Study Setting and Recruitment

Between June-September 2021, we conducted semi-structured qualitative interviews with 20 prescribers (nurse practitioners and physicians), 7 substance use counselors and nurses, and 20 patients utilizing tele-MOUD working or receiving care in the greater Baltimore City area. In line with qualitative descriptive research methodology, we engaged purposive sampling to enable the selection of participants whose experiences were directly aligned with the goals of the study (Bradshaw C, Atkinson S, Doody O., 2017). We utilized purposive sampling from a variety of care venues, including academic affiliated outpatient clinics, community-based clinics, and low-barrier OUD treatment programs in Baltimore City and the surrounding counties to assess a variety of experiences and resources. MOUD prescribers with whom the senior author had an established, pre-existing professional relationship were initially contacted via email and received one follow-up outreach for recruitment. Nurses and substance use counselors from these same organizations were also initially contacted via email and received one follow-up for recruitment. Eligible participants reported active licensure or certification in their respective profession and use of tele-MOUD for visits with patients.

Following interviews, prescribers, nurses, and substance use counselors were given a study recruitment flyer and asked to distribute it to their MOUD patients. Physical copies of this flyer were also displayed at participating clinics. Interested patients contacted the study team for a screening call. Also informed by a qualitative descriptive approach, the research team did not predetermine a sample size but rather continued to collect data and discuss the findings until the team felt they had reached saturation, or a point at which interviews were not yielding new information (Bradshaw C, Atkinson S, Doody O., 2017). Throughout the course of recruitment, there were no individuals who refused to participate directly or dropped out of the study.

The interview guides were created to enable participants to share their first-hand accounts of engagement with tele-MOUD. Question categories and prompts were generated by the research team collectively and focused upon barriers, facilitators, and best practices for utilization of tele-MOUD. Additional patient questions probed about participants’ experience with utilizing telehealth, its impact on quality of care delivered/received, and future models for its continued use in practice. OH conducted three pilot interviews and then met with the team to discuss and refine the guide before subsequent interviews were conducted. The team met regularly to discuss emergent findings and adapt the guide as needed.

4.4. Inclusion and/or Exclusion Criteria

Prescribers were eligible for the study if they reported: having an active Drug Enforcement Agency (DEA) license to prescribe controlled substances, an active X-waiver, an additional requirement by the DEA at the time of these interviews to prescribe MOUD, and reporting use of tele-MOUD for care management within the past 6 months. Patients eligibility criteria included current prescription of MOUD and use of tele-MOUD at least once in the last 6 months for MOUD services.

4.5. Data collection

Participation in this study consisted of completion of a one-time in-depth interview: no follow-up interviews were conducted. All interviews were conducted over either Zoom or an audio-only phone call per each participant’s preference. Interviews were conducted by OH, AW, and SP and lasted from 30–75 minutes. Only the individual participant and the interviewer were present during each interview. All interviews were audio recorded and transcribed verbatim. Transcripts were not provided to participants for comment or correction: after completion of the one-time interview, they were informed that they had fulfilled all study requirements.

At the start of each interview, interviewers introduced themselves, providing a brief overview of their role in the project and the study’s overall goals. Each participant was then provided with a consent form which the interviewer reviewed, then given the chance to ask questions or raise any concerns before the start of the interview. Once informed consent was obtained, the interview was conducted. Healthcare providers received $20.00 and patients $30.00 for interview completion. The Consolidated Criteria For Reporting Qualitative Research were utilized to maximize quality and trustworthiness (COREQ: Tong et al., 2007).

4.6. Data analysis

A qualitative descriptive analysis was applied, focusing on participants’ perspectives of using tele-MOUD services (Bradshaw C, Atkinson S, Doody O., 2017). An initial a priori codebook was developed based upon the first author’s clinical experience. Emergent themes were added to the codebook iteratively as transcripts were reviewed and new thematic categories were identified. The finalized codebook was comprised of 17 parent codes, each with one or more sub-codes. Each parent and subcode was clearly defined to ensure its standardized application. Subcode examples included “Telehealth_Facilitators,” “Telehealth_Barriers,” and “Telehealth_Quality.”

Four research team members each individually coded the first transcript using the original codebook, updating it with new codes based upon emergent themes. The study team then jointly reviewed this transcript, discussing new themes and revising the codebook. This process continued with subsequent transcripts until no new thematic categories were identified. The research team then independently coded several healthcare provider and patient transcripts and met to review coding decisions. Inconsistencies in coding were reviewed by the research team and the code definitions were revised until a sufficient inter-coder agreement was reached. All coding was conducted in Atlas.ti version 9.0 (ATLAS.Ti Scientific Software Development GmbH, 2022). Member checking with study participants was not conducted.

4.7. Ethical Considerations

The study procedures were approved by the Institutional Review Board.

4.8. Rigor and Reflexivity

The interviewers for this study were one male (post-doctoral fellow) and two females (PhD students with master’s degrees in public health). An additional female master’s student joined the team for coding and thematic analysis. All authors had extensive experience conducting qualitative research with healthcare providers and people who use drugs from other studies, community outreach, and/or clinical practice. Additionally, the first author is a nurse practitioner with experience providing opioid treatment and harm reduction services in the primary care and low barrier settings. The research team members kept notes during interviews to ensure that no context was lost when analyzing interview data. During data collection, the interview team met to discuss impressions of interviews, practice reflexivity, and discuss any issues with bias during data collection, analysis, and interpretation. These discussions informed saturation, and recruitment continued until no new categories arose from interviews.

5. Findings

5.1. Participant characteristics

47 individuals were interviewed for this study. Participants were recruited from Baltimore city and four surrounding counties, an area characterized by majority urban or sub-urban. Approximately 20% of participants were recruited from an Opioid Treatment Program where methadone was managed and dispensed; all sites prescribed buprenorphine. The majority of patient participants (65%) received their MOUD from a care site which also provided primary care services. Detailed and stratified descriptions of provider and patient characteristics are presented in Tables 1 and 2.

Table 1.

Demographic of n=27 prescribers, nurses, and substance use counselors who utilized tele-MOUD for MOUD care visits.

	n	%
Participants
Female	17	63%
Race/Ethnicity
Black or African American	6	22%
White	17	63%
Other	4	15%
Profession
Nurse practitioner	9	33%
Physician	11	41%
Nurse	3	11%
Substance use counselor	4	15%
Clinic/practice
Setting (Some providers had multiple affiliations)
Community medical or mental health clinic	17	63%
Hospital-based or affiliated health clinic	9	33%
Low-threshold MOUD	9	33%
MOUD prescribed or managed
Methadone	6	22%
Buprenorphine or Buprenorphine/naloxone	27	100%

Table 2.

Demographic of n=20 participants who utilized tele-MOUD for MOUD care visits.

	n	%
Mean Age (std. dev)	55.0	11.3
Gender
Male	9	45%
Female	11	55%
Race
Black	13	65%
White	7	35%
MOUD
Buprenorphine	17	85%
Methadone	3	15%
MOUD setting
Outpatient Care at Academic Center	3	15%
Community Health Center (Health Department/FQHC)	10	50%
Behavioral Health Clinic/Opioid Treatment Program	3	15%
Low threshold MOUD	4	20%
Drug use in the last 6 months
Yes	3	15%
No	17	85%

5.2. Results

Thematic analysis from MOUD prescribers, nurses, and patients highlighted the following themes: 1) Difficulties with telehealth connection 2) Flexibility in follow-up and retention, 3) Policy changes that enabled expanded care, and 4) Path forward with telehealth. Two additional emergent findings were identified based upon prescriber data only: 1) Recommendations for the expansion of nurse-managed office-based addiction treatment, and 2) Novel methods to engage tele-MOUD patients.

5.2.1. Difficulties with telehealth connection

Patients and healthcare providers reported comfort with various forms of telehealth. Providers and patients reported connecting through a myriad of applications, including video systems embedded in the electronic medical record, utilizing a third-party application, or via telephone for an audio-only visit. However, a common barrier reported by both providers and patients centered around coordination of care and communication leading up to and following telehealth visits. Providers in general reported difficulties with staff capacity to coordinate telehealth appointments and communicate with patients regarding their type of appointment. Said one provider:

“…[it] is wrought with so many issues that even when a poor person has a scheduled telehealth visit with me, they will still show up to the clinic because they didn’t know there was a telehealth visit. So logistically there are so many hoops a person has to go through to just get to me to be taken care of. Whether it’s through a telephone or an in person visit.” (Participant 12, Nurse Practitioner)

Patients echoed similar concerns regarding difficulty in communication with providers and healthcare teams regarding their appointments, and how to connect for their visits. One patient highlighted, “I had an issue because they had scheduled me for a phone visit on my appointments list…and I got no phone call. I called them and unfortunately, it’s the call center that is very ineffective and non-communicative.”

For assessments, healthcare providers were most concerned about their ability to fully assess their patients’ safety when the telehealth connection was unreliable or when engaging in audio-only visits. Poor phone reception and unreliable call-back numbers were top concerns listed. One provider highlighted this, stating:

“If I’m sitting in a room with a person I can pretty quickly tell if they’re distracted and I can pretty quickly tell if they’re falling asleep or not. But over the phone it’s actually very hard to tell. And sometimes…that has left me in a situation where I didn’t know if the person was safe. Like I’ve had people fall asleep on the phone and I’m yelling into the phone, ‘Hello. Wake up. Are you there? Can you hear me?’ and I don’t know if they just overdose.” (Participant 14, Physician)

The same provider continued, sharing a sentiment held by several other healthcare providers regarding the lack of overall preparation to conduct comprehensive visits using telehealth: “But those are situations that I have never been trained in because I never learned how to do—nobody taught me how to do telehealth.”

5.2.2. Flexibility in follow-up and retention

Providers were positive regarding the flexibility telehealth gave their patients. When visits were in person exclusively prior to the COVID-19 pandemic (almost all providers and patients started using telehealth during the COVID-19 pandemic for MOUD care), they reported clinic structures that were not conducive to their patients’ lifestyle or accommodating to their work or home responsibilities. Providers appreciated the ability to follow up with their patients in a flexible manner via telehealth, connecting with them at a time during the day that worked with their schedule and often removing barriers associated with in-person clinical visits. These barriers included needing to take time off work; finding child and/or elder care; transportation to and from the appointment, which was often via public transportation; and the costs associated with these barriers. Said one provider:

“I do know particularly for my patients who are doing well and working 40 hours a week, telehealth is great because otherwise an appointment with me took three hours, they had to get there, they had to wait, see me and then get back to where they were going. Now they can say I get off work at 4:00 and I’ll go sit in my car and I’ll say fine, I’ll see you at 4:05 and we’ll do a 20-minute visit, and it took 20 minutes of their day but it didn’t disrupt their work. It didn’t disrupt anything. So it has huge bonuses I think.” (Participant 17, Physician)

Patients echoed similar appreciation for the flexibility that telehealth provided. One patient whose provider has since changed back to exclusively seeing patients in person remarked,

“It’s easier overall, for somebody that’s, I guess, doing what I’m doing, because I didn’t want to use [drugs] anymore. I didn’t want to go through that ritual of going to the place and seeing everybody and sitting around in the lobby, waiting to get seen, every week or every month. I’d still do it, but I wish it was all tele appointments.” (Participant 27, Tele-MOUD Patient)

The same patient also addressed the cost associated with in-person appointments due to a day lost at work after factoring in travel to and from the clinic and time spent for the appointment: “It took the whole day away on a Saturday. I couldn’t work because the appointment, say, was at 10 o’clock. The day’s shot.”

In discussing the transportation difficulties, one patient remarked on the benefit of telehealth in improving access to MOUD:

“The hardest part would be with people that live in rural areas that don’t have transportation. Their addiction has brought them down to their knees, and they’ve lost their transportation. They’re stuck in a rut, and there’s no programs that they can walk to, or they’re not on a bus. That’s when it becomes hard to get in a Suboxone program.” (Participant 27, Tele-MOUD Patient)

Providers also viewed telehealth visits as a means for additional points of contact with patients, enabling them to gain a new perspective on their lives. Many remarked on the ability to see and learn about their patients outside the walls of the clinics, including opportunities to be introduced to friends and family members of the patient who were nearby during telehealth visits. Providers saw the benefit in learning more contextually about their patients and could use this information to develop a better patient-provider relationship with their patients:

“I would say that I have different conversations with some patients in person rather than over the phone or on a video chat. I think the topics of conversation are a little bit different. I think the conversations add context to some issues. I’m able to talk a little bit more about home life when I’m literally seeing their home. That’s a nice thing…So that kind of stuff is actually good. If I had more time on my visits for some of these video chats in their home, I would be talking a lot more about what’s in their home.” (Participant 1, Nurse Practitioner)

Finally, in discussing the benefits of telehealth in providing flexible care to patients, one provider with knowledge of their clinic’s retention of MOUD patients remarked:

“So in essence, our no show rate—pre-pandemic, our no show rate was—I’m not the office manager, but I’m pretty much involved in the operations of the place. Our no show rate was less than 20% pre-pandemic. With telemedicine, telephone, and all the type of access that we’re able to reach these patients, our no show rate is down to below 5%. Transportation to the appointment is a big factor. (Participant 7, Nurse Practitioner)

One minor theme, or sub-theme that emerged regarding flexibility in providing MOUD services centered around initiation of buprenorphine. While providers reported generally counseling patients during their intake visit on best practices surrounding initiation and providing handouts with information when and how to take their MOUD during induction, many saw telehealth as a means for increasing access for individuals who could not attend intake visits, and for rapid follow up during the week individuals initiated on MOUD. Said one provider, “With inductions there’s a way to have kind of an on-call service for people who are starting, to be able to touch base if they’re, for example, struggling with a dose or struggling with induction. And I feel that is a benefit. I think that would be the best application of some of the things that we’ve been doing in telehealth.” (Participant 16, Nurse Practitioner)

5.2.3. Policy changes that enabled expanded care

Providers remarked on the easing of restrictions as a facilitator in allowing for flexibility in management of MOUD and personalizing care. There were many policy changes and government programs mentioned by providers. Methadone providers described the lifting of restrictions on take-home doses for patients as a helpful way to reduce exposure to COVID-19 in the clinic and appreciated being able to conduct follow-up assessments and check-ins with patients through a telehealth visit. Said one provider, “We were able to early on get down to like 100, 125 patients a day at our dispensing window from 400 people a day, kind of thing…So we really pushed the numbers to give people more take-homes…that was super consequential for us.” (Participant 2, Physician)

The most frequently mentioned policy changes were provisions concerning billing for telehealth visits, particularly if the visit was audio-only. Many providers were supportive of this as a means of reaching patients but worried that without permanent policy changes, insurance companies would prohibit, limit, or not reimburse for audio-only visits. One provider captured the many barriers in place for patients receiving MOUD, and worried that these barriers would soon recur if there were not lasting policy guidance regarding flexible telehealth visits:

“It just strikes me as totally arbitrary a lot of the barriers that we’ve erected and hopefully we’ll be able to hold onto this telemedicine because people have had such a good experience with it that there will remain a billing and service infrastructure to support it so that those barriers don’t just go flying right back up. Because there’s so many barriers, anyway…It’s been really eye-opening the low barrier care which has been great for us here.” (Participant 14, Physician)

Others worried that if policy only allowed for telehealth to continue without audio-only visits, their patient population would suffer given the difficulties with connecting via video visits due to unreliable connections and limited access to smartphones with video capabilities among some patients:

It is really important that we maintain – there’s a fear that the ability to use just audio would go away, but it appears just audio is going to stay, and that’s really important. For patients that have government issued phones that have limited capabilities, it’s pretty important to have audio as a possibility. (Participant 15, Physician)

Finally, many providers reported that their panel of patients living with OUD increased during the COVID-19 pandemic. However, providers were capped due to X-waiver limits on prescribing buprenorphine and could not accommodate the demand: “But at a certain point — it didn’t last very long before we also capped out at how many patients [we] could take on.” (Participant 9, Nurse Practitioner)

5.2.4. Path forward with telehealth

Providers and patients agreed that tele-MOUD should continue in conjunction with in-person visits. Patients described their in-person visits as a means of accountability and relationship-building with their healthcare provider and team. One patient discussed this preference for some in-person visits for primary care, where he also receives his MOUD:

“I like mix. Yeah, I like mix because sometimes it’s not just about the Suboxone. By him being the primary care it’s different other things that he talk to me about or he might check. So at one point I like – I love over the phone. I do. But I like it mixed so I can, you know, talk to him or he can actually see me too.” (Participant 23, Tele-MOUD Patient)

Another patient echoed this sentiment as some struggled with building enough rapport with providers to share health-related concerns, particularly when related to their mental health. Said one patient regarding their preference to have in-person visits:

“Sometimes I don’t like to talk over the phone. Sometimes I might have some- I have mental health issues, too. Sometimes I just want to be able to get something of my chest, and I can really express myself in person, more than I can over the phone.” (Participant 25, Tele-MOUD Patient)

Providers and nurses proposed many ways to incorporate the flexibility of telehealth both for their own and their patients’ busy schedules. Most frequently, providers discussed incorporating a hybrid model where patients were seen over telehealth between in-person visits. These visits were not as formal as their in-person visits, but provided both the provider and patient an opportunity to connect regarding their MOUD, discuss harm reduction, and assess other primary care and preventive healthcare needs. Regarding incorporating telehealth into their practice as a means for long-term retention in care, one nurse remarked:

It’s so wonderful to be able to offer the telehealth service and to let people know we don’t have to see you in person…the most important thing to us is your safety, and your safety means getting the medication- part of your safety is getting the medication into your hands.” (Participant 45, Nurse)

In deciding which patients received telehealth services, providers broadly agreed that the decision should be made with patients and personalized to their needs and goals of care. Additionally, as one individual described, providers should use telehealth broadly in this hybrid model and not reserve it for those who are deemed most stable in their care:

“Well, I’m hoping to keep telehealth. I think it is very useful. Particularly for stable patients. Also very useable to some degree for unstable patients. For stable patients you’re seeing every couple of weeks, it’s a very low threshold to see them because they just have to pick up their phone. For unstable patients, it’s an easy way for me to touch base with them and if their lives have gotten chaotic and they aren’t showing up for an appointment, I don’t have to assume the worst and I can connect with them for a telehealth session and kind of get the information as to well, why didn’t you show up? What’s going on? So I hope to be able to keep both, because I think they both have a role and it isn’t a particular kind of patient for which it has a role, it’s more circumstances.” (Participant 17, Physician)

5.2.5. Expansion of nurse-managed office-based opioid treatment

The nurses interviewed for this study discussed applications of the office-based opioid treatment (OBOT) model to tele-MOUD. While specific protocols differed by site, nurses reported utilizing tele-MOUD to assist patients prior to and during induction, conduct follow-up assessments, and in collaboration with a prescriber, make changes to patients’ MOUD regimen. Said one nurse:

“It was a nurse-led program, so nurses were doing most of the [buprenorphine] counselling…a typical nurse visit would be a follow-up visit for someone who had just been inducted. They would talk to the nurse the next week, as close to seven days as possible. And if it was someone who had been receiving services for a while and they just needed a periodic provider because of a change of status, or something wasn’t going well, or maybe they had been lost to service and they were coming back on board, generally the nurses would speak to people I’d say one to four times before a provider would then speak to them again, just to make sure everything was going OK. (Participant 47, Nurse)

Nurses also described engaging tele-MOUD to assess and address other patient needs, including primary care concerns and general case management services. Said one nurse about tele-MOUD visits, “I always like to take a bit of a step back and understand what else is going on with them. They might bring up a primary care concern, in which case I will offer to help.” (Participant 45, Nurse). Providers also appreciated the role nurses played in expansion of OBOT services through tele-MOUD. One provider described how care coordination with nurses improved and was streamlined with the addition of tele-MOUD:

So when I’m with the client and I’m doing an intake and there’s a need, I will just chat [the nurse] who I want to talk to and say, “Hey, are you available to jump on the call with this client?” And we can do a three-way conversation…So more real time consultations, I think, happened when we were all on [tele-MOUD]. That was really helpful. (Participant 2, Physician)

5.2.6. Novel methods to engage tele-MOUD patients

Nurses and substance use counselors described multiple new services to retain and engage their patients through tele-MOUD. These services allowed them to remain in contact with patients, particularly though long stretches during the COVID-19 pandemic when in-person care was not an option. One means through which providers reported engaging with patients during this time was through text messages, which served as a valuable way of connecting to patients, particularly when they had limited video capacity. This enabled expanded access between patients and their care-team members. Sending patients texts through a centralized system managed by all nurses and counselors allowed an “on call” team member to address any emerging needs of their patient population during and after normal business hours. Nurses also described utilizing this service to follow up with patients during the initial stages of the treatment to maintain contact,, assess their tolerance of a new MOUD regimen, and provide harm reduction counseling. As an extension of this service, some nurses and counselors managed “call in” lines for their patients. This service was more common at low-barrier facilities to accommodate patients with limited access to cell phones for their tele-MOUD visits. From “call in” lines, nurses were able to triage patient needs and conduct nursing assessments. They described assessing the patients’ cravings and withdrawal symptoms, verifying their MOUD dose and timing of their next prescription, and coordinating next steps for the patient to continue to receive their medication without delays with prescribers. This process allowed the nurses to practice to the full extent of their license and allowed prescribers to efficiently see scheduled and add-on patients; said one nurse:

“I got a lot of their [the patient’s] information on the phone, and then I had that information to give to the providers, so that they already knew a lot of stuff when they came in. And the patients could – the new patients could get in and out more quickly than had we not done that.” (Participant 41, Substance Use Counselor)

6. Discussion

6.1. Implications for Policy and Practice

This study details the experiences of healthcare providers, nurses, substance use counselors and patients utilizing tele-MOUD services. It is one of the first to our knowledge to characterize the impact of the use of tele-MOUD a full year into the pandemic. Further, it uniquely offers perspectives from a diverse assortment of providers as well as patients, providing nuance and depth to an issue often explored solely from the side of those delivering care. Emergent themes from this study included ongoing difficulties with telehealth connections, flexibility for home-based induction of buprenorphine, follow-up visits and retention in care, the importance of policy changes that enabled this expanded modality of care delivery, novel methods to engage this population in OUD care, and the valuable role of nurses in telehealth-based MOUD management. Specifically, nurses described how engaging in tele-MOUD enabled them to expand Office-Based Opioid Treatment (OBOT) and case management roles. All participants contributed their perspective on a path forward for MOUD services which includes a hybrid of in-person and flexible telehealth visits.

Nurses have long played a key role in the containment and response to disease outbreaks on a global scale (Guilamo-Ramos et al., 2021). Nurse-managed care models have been highly effective in the face of the global HIV/AIDS pandemic, tuberculosis (Farley et al., 2014), as well as the Zika and Ebola virus outbreaks in the Americas and West Africa, respectively (Seidman & Atun, 2017). While the opioid epidemic has been particularly severe within the US, it has caused harm throughout the world: in 2019, 500,000 deaths due to drugs were reported globally, and 70% of these were opioid-related (World Health Organization, 2021). A recent scoping review highlights that nurse-managed OUD care is both safe and effective, serving to increase MOUD access among rural and other “hard to reach” communities. Engaging nurses in the prescribing and management of OUD care has occurred outside of the US (Bateman, Gilvarry, Tziggili, Crome, Mirza, McArdle, 2014). However, on a global scale as well as within the US, a range of legislative constraints and lack of education serve as barriers to the scaling up of nurse-managed OUD treatment. This study highlights telehealth as a valuable means through which nurses could continue to increase their role as providers of OUD treatment.

Flexibility emerged as a prominent theme among care team providers and patients. Home-based induction protocols have been in place for over a decade (Lee et al., 2009). However, with flexibility from regulatory changes, providers discussed protocols which enabled them to assess patients, provide education, and oversee the induction process within in the context of patients’ own homes. The provider, nurse, or substance use counselor could subsequently follow up over the next week to assess the patient, prepare their visit with the provider, and provide additional wrap-around services through telehealth, call-in lines, and text messages. Texting, in particular, has been shown as an acceptable intervention medium for OUD counseling with peer coaches (Ranjit et al., 2023). This flexibility transferred to follow-up visits, which facilitated retention in care. It has been well documented that technological barriers can limit many patients’ access to telehealth, particularly among lower socioeconomic status individuals (Mahmoud, H., Naal, H., Whaibeh, E., & Smith, A., 2022). Those who do not have access to smartphones or video capacity have traditionally been excluded from telehealth. The expansion of tele-MOUD to include both voice calls and text messaging represents a meaningful solution to this technology barrier, broadening access to a larger population of patients. However, access does remain a barrier for patients without their own cell phones. All of the patients included in this study did have a cell phone of their own and were not provided with either devices or cell phone data. However, we were not able to assess the number of patients who may have been excluded from tele-MOUD access during this time due to a lack of cell phones. This demonstrates the need to expand programs that do provide technology such as cell phones to individuals at low cost or free. During the pandemic, the state of Maryland maintained its Maryland Lifeline and Affordable Connectivity Programs, both of which offer government assisted wireless services to low-income families. Programs include subsidized service plans and some free cell phones, depending upon participants’ eligibility criteria (Life Wireless, 2023)

These findings support those of other qualitative and electronic health record studies examining the impact of tele-MOUD (Mahmoud, H., Naal, H., Whaibeh, E., & Smith, A., 2022). Shared decision-making principles can guide decisions for follow-up and are further supported by this flexibility. Studies in other medical specialties examining decisions for virtual versus in-person follow up visits have shown shared decision-making principles to be effective in improving patient and provider satisfaction (Barsom et al., 2021). The patient-provider dyad can decide together the goals of treatment with MOUD, markers of success, the length of the prescription and whether follow-up will be in-person or with telehealth. Given that many patients with OUD expressed competing priorities which often introduced barriers to healthcare access, this flexibility also allowed clinicians to reach patients when situations prevented an in-person visit; both patients and provider teams discussed this as a point of satisfaction with tele-MOUD because it allowed for continued prescription of MOUD even if patients had changes in their schedule. Given that visits for MOUD are generally more frequent, prescription lengths are shorter than those for other chronic diseases, and the transportation and other barriers associated with in-person visits, this flexibility was a source of satisfaction with care teams and providers to ensure delivery of essential MOUD services.

Changes in state and federal regulations enabled practitioners to utilize tele-MOUD to reach their patients for ongoing care. Methadone and its prescribing regulations through opioid treatment programs have the strictest regulations. During the COVID-19 emergency declaration, SAMHSA allowed for longer take-home doses of methadone and for prescribing following evaluation through tele-MOUD (SAMHSA, 2020). While initiation of methadone requires an in-person visit, this restriction does not apply to buprenorphine and buprenorphine/naloxone MOUD (DEA, 2020b). Providers in this study felt these policy changes enabled them to reduce the number of patients seen in-office daily, which allowed them to meet the increased demand in MOUD and served as a mitigation strategy to reduce COVID-19 risk. While SAMHSA and the DEA have allowed for these changes to continue past the end of the COVID-19 emergency declaration as they consider permanent rules (SAMHSA, 2023), draft regulations from the DEA roll back some regulations which providers, nurses, and patients expressed a desire to continue. In particular, one rule from the DEA would require providers to examine buprenorphine patients with an in-person exam and limits the length of prescriptions through telehealth (Federal Register, 2023). Provider advocacy groups echo the flexibility desired by providers and nurses in this study, encouraging the DEA to allow the prescribing rules from the COVID-19 pandemic to continue without additional restrictions (D’arrigo, T., 2023). Practitioners were able to expand their practices and retain patients who were satisfied with their tele-MOUD in this study. As healthcare providers and health systems attempt to standardize tele-MOUD practice, policy regulations should consider the impact of tele-MOUD on connecting and retaining patients in care, an important provision in preventing future overdose and drug related morbidity and mortality.

In discussing a path forward for use of tele-MOUD, both patients and their care teams were in favor of a hybrid approach which combined both in-person and tele-MOUD visits. Patients valued the therapeutic relationship with their providers and felt it was strongest with in-person visits. However, the rigid structures of frequent in-person visits for MOUD were commonly listed by patients as a reason for dissatisfaction with their care and cited by providers as a means for poor retention in MOUD. Hybrid visits provide an opportunity to continue care connections through tele-MOUD between visits. Nurse-based models for MOUD are also a potential means of expanding this desirably modality. Within this model, trained nurses conduct intake visits, facilitate connections with providers, and follow up with patients between in-person visits to monitor medication tolerance and recovery through tele-MOUD (Campbell et al., 2021). This hybrid approach has been echoed in other studies and found feasible in one (Mahmoud, Naal, Whaibeh & Smith, 2022), but requires further implementation and evaluation at a larger scale, including with the use of a toolkit to guide providers through best practices of tele-MOUD (Mahmoud, Naal, Whaibeh & Smith, 2022). These clinical touch points led by nurses can be a means to improve MOUD access and retention outside the previous rigid structures of MOUD visits that required in-person visits only. Additionally, uptake of tele-MOUD as a component of care can be strengthened with formal training. Some clinicians in this study described their lack of preparation or education for using tele-MOUD to assess patients and deliver high quality services. As medical, nursing, and physician associate schools add telehealth to their curricula, state legislation, similar to a recent bill in the state of Washington (Inslee, J., 2020), can expand legislation requiring healthcare providers to complete continuing education which specifies regulatory and clinical practice implications of using telehealth for delivering healthcare services.

6.2. Strengths and Limitations

Strengths of these findings include identifying themes from a robust number of patients and providers interviewed and venues from which they seek or provide care, Additionally, these interviews were conducted over one year after regulations were loosened to allow tele-MOUD and provider and patients had grown accustomed to tele-MOUD, capturing established practices and experiences. These findings and their implications are not without limitations. These interviews are limited to the contextual experiences of tele-MOUD and are not generalizable to all tele-MOUD. This study included nurse practitioners who prescribed MOUD in the state of Maryland where they have full practice authority, which is not the case in all U.S. states. Finally, these interview do not capture longitudinal experiences with tele-MOUD. One systematic review noted that while most studies of tele-MOUD showed favorable short-term outcomes of retention and positive experiences, there is not robust evidence of long-term outcomes using tele-MOUD (Mahmoud, Naal, Whaibeh & Smith, 2022).

6.3. Recommendations for Future Research

Future studies should utilize long-term clinical data and in particular mixed-methodologies to examine quantitative measures of retention when using a patient-centered and hybrid approach as well as capture qualitative measures to provide contextual evidence of successful care delivery and areas that require improvement and further study. These studies additionally should further test the impact of nurse-managed care with practice protocols.

7. Conclusions

In conclusion, this study provides contextual experiences of healthcare providers and patients using tele-MOUD one year after regulators as a result of the COVID-19 pandemic loosened regulations concerning MOUD prescription and management. While there were ongoing difficulties with telehealth connectivity and formal preparation to conduct visits over telehealth, both providers and patients found tele-MOUD to be not only an acceptable means for MOUD care delivery, but a desired approach for future use. Both groups expressed the flexibility this medium afforded them and felt it strengthened patient, provider, and care team relationships. Additionally, nurses played an important role in engaging patients with novel methods such as sending patients text messages and managing “call-in” lines to reach patients. Additionally, both prescribers and nurses described the ability to expand on nurse managed MOUD care through tele-MOUD. Clinicians and care teams should consider a hybrid approach supported by patient and providers in this study, utilizing in-person visits to build a therapeutic patient-provider relationship and tele-MOUD visits as a means to reach patients and promote retention in care.

What does this paper contribute to the wider global clinical community?

• Nurse and nurse practitioners play an important role in prescribing and managing medication for opioid use disorder treatment.

• Telehealth for delivery of these services allows for flexibility in follow-up and retention, particularly when delivered in a hybrid manner between in-person visits.

• Nurses championed novel methods to assess and maintain contact with this priority population, particularly through engaging patients through text messages and managing “call in” lines for patients with inconsistent access to telephones.

Trial and Protocol Registration: NA