Telemedicine-delivered treatment for substance use disorder: A scoping review

Abstract

Introduction:

The COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a “new normal” policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM’s acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs.

Method:

We searched studies published in 2012–2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis.

Results:

A total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives.

Conclusions:

TM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

Introduction

Drug overdose fatalities have increased in the USA in recent years and worsened during the COVID-19 pandemic.¹ While evidence-based treatments for substance use disorders (SUDs) have been proven to reduce overdose and substance-related harms,^2–4 key treatment barriers often impede patients’ opportunity to receive care, especially in rural areas.^5–7 These barriers include stigma, cost, distance to treatment facilities, and lack of treatment service providers. As a result, access to SUD treatment has remained low, with only 1 in 10 individuals with SUD receiving any evidence-based treatment.⁸ Furthermore, about 35% of individuals with opioid use disorder (OUD) received any substance use treatment.⁹ Telemedicine (TM), defined as the utilization of telecommunications technology that allows healthcare providers to interact with patients remotely to diagnose conditions, prescribe treatments and medications, provide psychotherapy, and administer other healthcare services,^10,11 could be an important approach to address treatment barriers.

Previous studies and reviews have demonstrated promising aspects of TM for SUDs,^12–14 including its effectiveness as an alternative treatment model when in-person treatment is limited and its association with high levels of patient satisfaction.¹³ Still needed are more rigorously designed comparative effectiveness studies of TM versus in-person care, studies that assess acceptability and engagement among patients and providers, and studies that identify patient characteristics associated with success.¹³ A comprehensive review of TM acceptability in SUD treatment is crucial as it signifies the willingness of both providers and patients to embrace TM,¹⁵ while the understanding of TM service quality would promote sustained patient commitment and retention and inform clinical practice.^16,17 Exploring access and utilization of TM can facilitate the development of targeted strategies to enhance TM adoption,¹⁸ while understanding the cost implications is significant for comprehending provider incentives and patient burdens.¹⁹ These evaluation metrics collectively contribute to informing policy decisions regarding the implementation of TM in SUD treatment.

The COVID-19 pandemic triggered significant TM policy changes in the spring of 2020, including temporary waivers of the requirement for in-person evaluation prior to initiating controlled medications, such as buprenorphine for treatment of OUD.^20,21 There was a subsequent dramatic increase in the utilization of TM by many healthcare systems.²² Acting as a natural experiment, the pandemic allowed for the generation of new, real-world evidence that enhanced the understanding of various aspects of TM-delivered SUD treatment, including access to care, quality of service, effectiveness of treatment, and associated costs. As the USA transitions into the post-pandemic era, it is crucial to thoroughly compile and review the existing evidence related to TM-delivered SUD treatment in order to shape “new normal” healthcare policies and practices for the post-pandemic world.

We conducted a scoping review²³ of studies regarding TM along the SUD continuum of care²⁴ covering the period before and during the pandemic. The objectives are to examine the current body of evidence on the evaluation of TM in SUD treatment from provider and patient perspectives and to identify research gaps in this area. Findings will illuminate future clinical practices and policy decisions and highlight key areas for further research in the evaluation of TM for SUD treatment.

Methods

We utilized a scoping review approach, which is appropriate for conducting exploratory and practical investigations, to summarize key findings and evidence gaps on TM-delivered SUD treatment using pragmatic evaluation metrics.^23,25 We followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines (see Supplemental Table 2).²⁶ Research questions are as follows: (1) Based on the current literature, what is the evidence of TM in SUD treatment in terms of benefits and acceptability, service quality, effectiveness, access, and cost from the perspectives of providers and patients? (2) What are the research gaps in TM in SUD treatment that warrant further investigations?

Search strategy

We searched PubMed, Embase, Web of Science, and Cochrane Library for articles from January 2012 to April 2022 covering periods before and during COVID-19. We also identified articles using Google Scholar and a manual search of reference lists of included articles and previous reviews. Search terms are combinations of sets of medical subject headings (MeSH) and keywords including TM, substance use, SUD continuum of care, and evaluation metrics (Supplemental Table 1). Our search strategy was based on an SUD continuum of care model²⁴ and the incorporation of key pragmatic evaluation metrics. We assessed TM in SUD treatment in terms of perceived benefits and acceptability, service quality, effectiveness, access, and cost.^15–19 To cover all possible aspects of each evaluation metric, we pre-defined components of each metric. For example, perceived benefits and acceptability include factors such as convenience, ease of use, level of support, privacy protection, and long-term commitment (see Figure 1).

Figure 1.

SUD continuum of care and evaluation metrics.

Study selection

Inclusion criteria included peer-reviewed articles published in English between 2012 and 2022 that (1) utilized TM or telehealth (using either video or audio platforms), (2) applied SUD treatment (including medication treatment such as buprenorphine, as well as behavioral treatments), and (3) reported at least one evaluation metric. We excluded studies that were tobacco focused, not original research (e.g. commentary), not SUD treatment or TM focused, and insufficiently rigorous in that they did not conduct statistical tests in quantitative studies or had too small sample sizes (less than 10) in qualitative studies. We used Rayyan, a web-based tool that aimed to expedite the review process and facilitate teamwork, to apply inclusion and exclusion criteria.²⁷ Each article underwent review by a minimum of two reviewers, and any disagreements were resolved through consensus discussions.

Data extraction and analysis

We applied thematic synthesis analysis, which has been used in literature reviews.^15,28,29 Microsoft Excel was used to summarize paper characteristics in terms of the context of the paper and aims, method components, evaluation metrics, method limitations, and suggestions for future studies on TM in SUD treatment and related policies. We categorized the final papers into the five evaluation metrics and synthesized them in terms of subpopulations, time of data collection, and study designs (cross-sectional, cohort, interventional, qualitative, and mixed-methods). As we included both quantitative and qualitative studies in the review, we synthesized the results from the included papers narratively and qualitatively using the framework synthesis approach and reported according to the “enhancing transparency in reporting synthesis of qualitative” research (ENTREQ) statement (see Supplemental Table 3).³⁰

Results

Figure 2 shows the PRISMA-ScR study flow chart providing details of the identification, screening, eligibility, and included steps. Among the 856 unique articles identified, 42 papers were included in the final list. Table 1 presents the characteristics of the included articles. Most studies focused on TM access/use, followed by perceived benefits and acceptability, effectiveness, cost, and then service quality. We present key findings accompanied by study designs for each measure (e.g. perceived benefits and acceptability) by provider and patient perspectives and by pre-COVID-19 and during COVID-19 periods across the measures (Tables 2 and 3).

Figure 2.

The PRISMA-ScR flow diagram for the scoping review with details database searches, title, and abstract screening, and the number of full text articles included in the review.

Table 1.

Telemedicine (TM) article characteristics.

	Total (n = 42)	Prior to COVID-19a (n = 18)	During COVID-19a (n = 24)	Providers (n = 12)	Patients (n = 30)
By data collection time
Prior to COVID-19	18	N/A	N/A	3 (17%)	15 (83%)
During COVID-19	24	N/A	N/A	9 (38%)	15 (62%)
By study designs
Interventional studies	4	4 (100%)	0 (0%)	0 (0%)	4 (100%)
Cohort studies	9	6 (67%)	3 (33%)	0 (0%)	9 (100%)
Cross-sectional studies	19	4 (21%)	15 (79%)	6 (32%)	13 (68%)
Qualitative studies	7	2 (29%)	5 (71%)	4 (57%)	3 (43%)
Mixed-methods studies	3	2 (67%)	1 (33%)	2 (67%)	1 (33%)
By providers/patients
Providers	12	3 (25%)	9 (75%)	N/A	N/A
Patients	30	15 (50%)	15 (50%)	N/A	N/A
By evaluation metrics b
Perceived benefits and acceptability	23	10 (43%)	13 (57%)	10 (43%)	13 (57%)
Service quality	5	1 (20%)	4 (80%)	3 (60%)	2 (40%)
Effectiveness	18	11 (61%)	7 (39%)	3 (17%)	15 (83%)
Access	25	7 (28%)	18 (72%)	9 (36%)	16 (64%)
Cost	8	3 (38%)	5 (63%)	4 (50%)	4 (50%)

The percents in the table are row percents.

^aIndicating data collection time, not published time. Prior to COVID-19 = Prior to April 2020.

^bSome articles focused on two or more evaluation metrics.

Table 2.

TM evaluation papers prior to COVID-19.

			Evaluation metrics
Authors	Study design	Study population (sample size)	Perceived benefit and acceptability	Quality	Effectiveness	Access	Cost
Uscher-Pines et al., 2020 (a)	Cross-sectional	12,334 licensed SUD treatment facilities				Associated with rural areas and multiple treatment settings, offering pharmacotherapy
Brunet et al., 2020	Mixed-methods	19 primary providers in rural community-based outpatient clinics	Barriers included inadequate and insufficient staff and general reservation of TM in SUD		Treatment discontinuation related to side effects and a required higher level of care
Uscher et al., 2020 (b)	Qualitative	22 SAMHSA health center leaders from 14 states	The most common service provided via video was medication management for OUD			Tele-OUD allows patients to remain in their local community rather than travel long distances for treatment	Health center representatives chose not to implement tele-OUD services because group visits were not reimbursable
Weintraub, 2018	Cohort	177 buprenorphine patients in rural areas	Implementing TM in rural sites was feasible		By the end of 3 months of treatment, 57.4% remained engaged in treatment; 86.1% of patients were opiate negative	Increased access to MOUD for patients in rural Maryland
LaBelle et al., 2018	Cohort	9077 patients with OUD and mental disorders in Canada	TM is a key solution for increasing access, particularly for those patients living in isolated regions			Patients with concurrent disorders receive psychiatric services via OTN more often than patients who do not have OUD	The mean cost per patient via TM has increased during this period
Eibl et al., 2017	Cohort	3733 OAT patients in Canada	Benefits: convenience, reduced time spent traveling to and from clinics		Patients treated via TM or hybrid (vs in person) were more likely to be retained in therapy
Lin et al., 2022	Cohort	2718 buprenorphine patients via TM and 30,898 in-person buprenorphine patients			The median days supplied of buprenorphine treatment was 722 among the tele-buprenorphine patients compared to 295 in-person patients	Tele-buprenorphine patients were less likely to be male or Black and more likely to be treated in community-based outpatient clinics (vs large medical centers) and to live in rural areas (vs urban areas)
Vakkalanka et al., 2021	Cohort	28,791 veteran buprenorphine patients			The risk of discontinuation among those with TM was 0.69 times that of in-person SUD encounters
Weintraub et al., 2021	Cohort	468 MOUD patients including buprenorphine (N=443) or naltrexone (N=25)			By the end of the third month of treatment, 48% of treated individuals were engaged in treatment. Most engaged patients maintained an opioid-negative status (more than 80%)
Creedon et al., 2020	Cross-sectional	1,603,066 claims from 2012–2017 from the IBM MarketScan Multi-State Medicaid Database				TM receipt was associated with receipt of more in-person outpatient services, being rural Medicaid beneficiaries (at 0.6 percentage points)
Huskamp et al., 2019	Cross-sectional	2,550,047 Medicare Advantage enrollees				Associated with living in rural areas with a median household income in the upper two quartiles than non-tele-SUD users
Zheng et al., 2017	Cross-sectional	100 patients in a comprehensive Opioid Addiction Treatment program			No statistically significant difference in substance use and retention between telepsychiatry buprenorphine and in person
Mitchell et al., 2020	Interventional	77 patients used TM AUD treatment via a smartphone application	Access to treatment known to reduce the harms of continued drug use in pregnancy and reduction in maternal mortality		Treatment retention at 90 days was 55%. Substantial decrease (50%) in alcohol use among patients with TM	Depending on patient access to technology and willingness to pay	Cost for the app is $99 per month
Staton-Tindall et al., 2014	Interventional/RCT	127 rural at-risk alcohol users (81% male) located in four Kentucky counties designated as Appalachian	62% successfully engaged in the intervention by completing a minimum of one or two sessions		ME Telemedicine significantly reduced the likelihood of any alcohol use during the 3-month follow-up period by 72%
King et al., 2014	Interventional/RCT	85 OTP patients	Overall treatment satisfaction remained high for both TM and in person		Participants exposed to TM had similar rates of counseling attendance and drug-positive urinalysis results
Guille et al., 2020	Interventional/non-RCT	98 women receiving perinatal OUD treatment by TM or in person			TM produced similar maternal and newborn outcomes compared with in-person care
Tarp et al., 2017	Mixed-methods	71 outpatient AUD treatment patients in Denmark	Patients with video-based conferencing treatment were satisfied with the treatment compared with in person	Patients were happy with the video quality but were less satisfied with the sound quality
Rakita et al., 2016	Qualitative	30 patients obtaining methadone maintenance therapy	Patients preferred TM and rated their experience and perception of services better compared to in-person consultation

The table for articles prior to the pandemic was ordered by subpopulations (providers/patients) and then by study designs.

AUD: alcohol use disorder; MOUD: medications for opioid use disorder; OAT: opioid agonist therapy; OTN: Ontario Telemedicine Network; OTP: opioid treatment program; OUD: opioid use disorder; RCT: randomized controlled trial; SUD: substance use disorder; TM: telemedicine.

Table 3.

TM evaluation papers during COVID-19.

			Evaluation metrics
Authors	Study design	Study population (sample size)	Perceived benefit and acceptability	Quality	Effectiveness	Access	Cost
Molfenter et al., 2021	Cross-sectional	ATTCs from 43 states	Intent to use telephone-based services was significantly greater for health systems than for specialty treatment sites			Most patients have access to telephone counseling	Telephone counseling is affordable to patients
Cantor and Laurito, 2021	Cross-sectional	377 OTP facilities in the USA				Outpatient-only facilities were more likely to offer telehealth
Jones et al., 2021	Cross-sectional	10,238 DATA-waivered clinicians	Difficulty with tele-buprenorphine initiation was withdrawal symptoms			Predictors of tele-buprenorphine prescribing included a large number of patients and previous experience
Riedel et al., 2021	Cross-sectional	602 OUD primary care practitioners on WebMD/Medscape	The vast majority reported being comfortable using video for patients who were clinically stable		60% of respondents agreed that TM was effective as in person and were comfortable to use video for clinically stable patients	The most common barrier to implement video visits was a lack of patient readiness	80% would offer TM if reimbursement is the same as in person
Huskamp et al., 2021	Cross-sectional	602 clinicians	Clinicians with more OUD patients were more likely to report being comfortable
Martin et al., 2021	Mixed-methods	42 counselors for OUD in Rhode Island	Overall satisfaction with telephone counseling	Greater comfort, convenience, safety, flexibility, increased patient engagement		Improved access to services and EHR	Reduced travel cost
Aronowitz et al., 2021	Qualitative	22 OUD prescribers	Preference for TM related to flexibility and benefits whereas preference for in-person care related to ability to better engage with patients	Patients did not understand the nature of care delivered by TM; substantial variability in patients’ comfort and ability to use different TM formats		Challenges for marginalized patients with unreliable access to technologies
Uscher-Pines et al., 2020 (c)	Qualitative	18 clinicians from 10 states	Benefits included reducing travel-related anxiety and risk of COVID in the waiting room and understanding of patients’ homes and home life	Concerns about the impact of TM on the quality of their interactions with patients, particularly over the long term	Concern included reduced access to other behavioral health services	Patients no longer had to travel to appointments so increased access
Mattocks et al., 2022	Qualitative	23 VA clinicians	Clinicians had a better understanding of patients’ living conditions and placed more trust in their patients. Clinicians could not rely on urine toxicology screens or in-person interactions during the pandemic
Hughes et al., 2021	Cohort	242 OBOT patients in rural areas of North Carolina				Expanded access to patients farther from the clinics and patients from rural zip codes
Cunningham et al., 2022	Cohort	107 patients including 72 patients before COVID and 35 during COVID (TM based) in New York			Buprenorphine patients referred during the pandemic were more likely to be retained in treatment at 90 days	Patients referred during the pandemic were more likely to have private insurance and from acute care settings	Patients referred during the pandemic were more likely to have private insurance
Weintraub et al., 2021	Cohort	94 outpatient patients who entered the treatment with TM-based medication			More than half of patients retained by 3 months. Opioid use was reduced by more than 30% compared with baseline
Yang et al., 2020	Cross-sectional	52,907 (in 2018), 62,756 (in 2019), and 73,184 (in 2020) patients in outpatient programs in Massachusetts				TM enabled a rapid, system-wide ability to maintain and early on increase access to MH care
Chang et al., 2022	Cross-sectional	795 patients (4557 TM visits for MOUD)				Older patients had a higher likelihood of using telephone versus video. Patients with more than a high school education and with overdose and new patients were significantly less likely to rely on telephones
Patton et al., 2021	Cross-sectional	90 patients from integrated SUD and prenatal care clinics	Benefits included the convenience of not needing transportation and childcare, avoiding stigma relating to clinical settings or neighborhoods			Comparing pre-COVID to during COVID-19, no-show rates fell from 34% of visits to 10% of visits, respectively
Cance and Doyle, 2020	Cross-sectional	30,013 patients before COVID-19 and 36,225 patients during COVID-19				Electronic prescribing significantly increased from 38.56% to 46.49%
Barsky et al., 2022	Cross-sectional	377 TM patients and 2325 in-person patients from commercial and Medicare Advantage claims data from the OptumLabs Data Warehouse				Patients 70 years or older (vs 30–49) living in a county with a higher quartile of median household income were less likely to have a TM induction
Mellis et al., 2021	Cross-sectional	1148 participants (1094 completed) from the Addiction Policy Forum				Polysubstance users were more likely to report both use of telehealth services and difficulties accessing needed services
Tofighi et al., 2022	Cross-sectional	78 buprenorphine–naloxone patients (252 visits) in New York City			Among the initial cohort of patients followed at 8 weeks, 42 patients remained in the OBOT program (53.8%)	The clinic population was mostly male and enrolled in Medicaid
Sugarman et al., 2021	Cross-sectional	58 outpatient patients engaged telehealth from McLean Hospital, Massachusetts	Most participants liked accessing treatment from home (90%) and that they did not need to dedicate time to traveling to appointments (83%)	The majority of participants (86.2%) reported that they were “very satisfied” or “satisfied” with the quality of telehealth care	Only 58% of participants who received group therapy were “very satisfied” with receiving this service via telehealth.	Very few participants (n=2, 3.5%) reported having difficulty logging into the telehealth platform
Yeo et al., 2021	Cross-sectional	227 patients enrolled in the MAT clinic			In-person retention rates (94%) were substantially higher than low-threshold audio-only telehealth retention rates (68%)
Kang et al., 2022	Cross-sectional	264 OTP outpatients in Rhode Island had used telephone counseling services	Barriers to telephone counseling included lack of privacy, unstable phone service, or their preference for using traditional office visits
Zhen-Duan et al., 2022	Qualitative	20 Medicaid outpatient patients in New York City	Buprenorphine was more accessible. Participants preferred individual counseling than group counseling
Moore et al., 2021	Qualitative	15 buprenorphine patients who were currently receiving buprenorphine from the TM clinic	Psychological safety was a benefit of telehealth visits. Patients liked the individualized care they received			TM access improved	Program costs are covered in self-pay, private insurance or through SAMHSA

Note: The table for articles during the pandemic was ordered by subpopulations (providers/patients) and then by study designs.

ATTCs: Addiction Technology Transfer Centers; DATA: Drug Addiction Treatment Act; EHR: electronic health records; MAT: medication-assisted treatment; MH: mental health; OBOT: office based opioid treatment; OUD: opioid use disorder; SUD: substance use disorder; TM: telemedicine; VA: veterans affairs.

Perceived benefits and acceptability

Provider perspectives.

Before the onset of COVID-19, two studies were conducted. One qualitative study identified key barriers including insufficient nursing staff and a preference for in-person care rather than TM.³¹ The second study used a mixed-methods approach and indicated that medication management was the predominant service delivered via video in 8 out of 22 SAMHSA health centers.³²

During the pandemic, eight studies were conducted. One cross-sectional study indicated that the intent to use telephone-based services was significantly greater for general healthcare systems than SUD specialty settings.³³ Another cross-sectional study showed that a majority of primary care practitioners reported being comfortable with TM for stable patients.³⁴ Factors associated with TM comfort included having a greater volume of patients with OUD and using TM in the treatment of pre-existing patients rather than new patients.³⁵ In two qualitative studies, providers perceived that TM helped reduce travel-related anxiety, reduced risk of COVID-19 in the waiting room, and enhanced clinician–patient interaction.^36,37 Providers’ preference for TM continuation was reported in one qualitative study related to TM flexibility,³⁸ although some providers indicated TM shortcomings in lack of face-to-face interactions³⁴ and difficulty managing patients’ opioid withdrawal symptoms during TM-based induction onto buprenorphine treatment of OUD.³⁹

Patient perspectives.

In eight studies before the pandemic, patients rated their experience and satisfaction with TM as similar to in-person care in one interventional study⁴⁰ and one mixed-methods study⁴¹ and even greater than in-person care in one qualitative study.⁴² Implementing TM healthcare models in rural areas was indicated to be feasible in one interventional study⁴³ and two cohort studies.^44,45 Patient-perceived TM benefits included convenience, reduced time traveling in one cohort study,⁴⁶ and reduced substance use in one interventional study.⁴⁷

Five studies were conducted during the pandemic. Most patients (>80%) liked TM and indicated that TM advantages included not needing transportation and childcare in one cross-sectional survey,⁴⁸ avoiding stigma relating to clinical settings or neighborhoods in one cross-sectional study,⁴⁹ and psychological safety and individualized care in one qualitative study.⁵⁰ Problems with telephone-based TM included face-to-face preference and unstable phone service.⁵¹ A qualitative study reported that patients preferred TM-based individual counseling more than group counseling because providers were more accessible and TM allowed frequent check-ins, which helped with stress coping and reduced substance use risk.⁵²

Perceived quality

Provider perspectives.

There were no published studies evaluating TM service quality from provider perspectives prior to COVID-19. Three studies were conducted during the pandemic. Providers perceived that TM increased patient engagement and valued TM’s safety and flexibility.⁵³ Qualitative studies reported that providers had concerns about service quality at times during interactions with their patients³⁷ and about patient engagement.³⁸

Patient perspectives.

Only one study using mixed-methods was conducted prior to the pandemic and indicated that most patients had good TM connectivity, whereas some patients experienced technical problems.⁴¹ One cross-sectional study during the pandemic reported that more than 80% of the patients were satisfied with the quality of telehealth and patients rated the quality highest for TM-based individual therapy, followed by medication management and then group therapy.⁴⁸

Efficacy and effectiveness

Provider perspectives.

One mixed-methods study prior to the pandemic indicated that TM was perceived to be efficacious among veterans with OUD in rural areas.³¹ A cross-sectional, national online survey during the pandemic reported that about 60% of 602 OUD primary care practitioners agreed that TM was as effective as in-person care.³⁴ In contrast, a qualitative study indicated that clinicians were concerned about the effectiveness of TM in SUD treatment in general due to reduced access to other behavioral health services during the pandemic.³⁷

Patient outcomes.

This section presents key findings from studies of the impact of TM on patient outcomes. Ten studies were conducted prior to the pandemic. TM demonstrated similar outcomes in terms of reduced substance use in three interventional studies,^40,43,54 two cohort studies,^45,55 and one retrospective analysis on medical records.⁵⁶ In addition, TM was associated with high treatment retention in one interventional study with 55% retained at the 3-month follow-up⁴⁷ and also in three cohort studies.^45,46,55

During the pandemic, five studies were conducted. More than half of patients in TM were retained in treatment in one retrospective cohort study⁵⁷ and one retrospective analysis chart review.⁵⁸ A cohort study showed that patients who initiated buprenorphine during the pandemic were more likely to remain in treatment than those referred before the pandemic.⁵⁹ Another cross-sectional study found that the retention rates for patients in TM-based care at 90 days (68%) were comparable to other findings on OUD retention rates.⁶⁰

Access

Provider perspectives.

One cross-sectional study was conducted prior to the pandemic and indicated that greater adoption of TM was associated with centers being in a rural area, having multiple treatment settings, and serving a variety of patients.⁶¹ During the pandemic, seven studies were conducted on access. Findings from the cross-sectional studies show that outpatient-only treatment settings (vs not) were associated with greater delivery of TM services.⁶² Predictors of TM-delivered buprenorphine for OUD included greater numbers of patients and previous TM experience of clinicians.³⁹ TM helped with increasing patient access in a mixed-methods study and two qualitative studies,^38,53 whereas barriers to TM access, including unreliable technology, were reported in a qualitative study.⁶³

Patient perspectives.

Five studies on TM access were conducted prior to the pandemic. TM usage was positively associated with living in rural areas in two cohort studies^45,64 and two cross-sectional studies^65,66 and was associated with community-based outpatient clinics in one cohort study.⁶⁴ TM usage was negatively associated with being male and Black in one cohort study.⁶⁴ Creedon et al.⁶⁶ used 2012–2017 claims data from Medicaid and found a difference of about 0.6 percentage points higher in rural areas than in urban areas in access to TM in SUD treatment.

Eleven studies were conducted during the pandemic. Improved access to care via TM was indicated in one cohort study⁶⁷ and two cross-sectional studies.^49,68 Factors associated with different TM platforms varied, with older age being positively associated with audio-based TM care for SUDs and higher education, prior overdose, and new patients being positively associated with video-based SUD care in a cross-sectional study.⁶⁹

Cost

Provider perspectives.

One qualitative study conducted prior to the pandemic showed that concerns about reimbursement were a barrier to implementing TM.³² During the pandemic, three studies were conducted. One cross-sectional study indicated that telephone counseling was perceived to be affordable to patients.³³ The other cross-sectional study indicated that 80% of providers would offer TM if reimbursement was the same as for in-person services.³⁴ The mixed-methods study involving counselors of patients with OUD indicated that TM helped with reduced travel cost.⁵³

Patient perspectives.

One cohort study of patients with OUD and mental disorders prior to the pandemic showed that the mean cost per patient receiving TM-delivered services increased over time; however, the authors did not include costs avoided by the provision of TM relative to transportation costs for face-to-face encounters.⁴⁴ During the pandemic, a cohort study showed that private insurance was positively associated with receipt of TM.⁵⁹

Discussion

This review of TM for SUD treatment synthesized study findings of TM evaluation regarding its acceptability, service quality, effectiveness, access, and cost from the perspectives of providers and patients prior to and during the COVID-19 pandemic. TM-based SUD was generally perceived to be beneficial and acceptable by providers and patients. Acceptability and access of different TM platforms varied, warranting future studies that examine these different TM platforms. TM treatment was as effective as in-person care in terms of reduced substance use and improved treatment retention, but more rigorous designs are needed. Additional investigation is needed into TM service quality and related costs.

Our review on perceived benefits and acceptability indicated that TM allowed for greater flexibility, reduced travel time, and less anxiety, which are consistent with previous reviews.^13,14 Studies during the pandemic increased the understanding of TM acceptability for different TM platforms, with health systems more willing to use telephone-based TM than SUD specialty clinics, whereas no differences were seen in the intent to use video-based TM.³³ This could be due to organizational readiness for TM technology in SUD treatment settings,⁷⁰ particularly in the beginning of the pandemic. In addition, telephone-based TM was seen as simpler and more affordable but video services were valued more highly in terms of reimbursement and patient satisfaction.³³ Notably, some providers perceived that TM helped with enhancing provider–patient connection, which is a positive factor in treatment retention and outcomes.⁷¹

We find that patients generally reported positive experiences with TM in SUD treatment. Noticeably, TM-based individual counseling has been found to reduce stress and substance use risk,⁵² which has significant implications for treatment engagement and retention. This is particularly crucial considering that individuals with SUDs frequently engage in polysubstance use and often experience co-occurring mental disorders, which can impact their ability to stay engaged in treatment.^72,73 Additional research is needed to explore different treatment services delivered via TM, including TM-based individual versus group counseling, as acceptance and implementation of these services may improve with providers’ and patients’ familiarity with TM technology. Future studies should assess TM over longer periods using objective and subjective measures, as well as evaluating acceptability at different stages of treatment and recovery.^15,74

This review shows that TM was effective in terms of substance use reduction and high treatment retention across different study designs. However, follow-up periods in interventional and cohort studies were generally short at 3 months or less, which could potentially affect the reliability of outcome assessment and limit information on the long-term effects.⁷⁵ Other limitations include the lack of a rigorous study design that could help with inferring TM efficacy, as well as limited generalizability due to small sample sizes and single sites. Additional studies are necessary to investigate substance use patterns, relapse rates, and overdose occurrences related to various TM models, as well as the impact of clinical complexities on TM outcomes such as polysubstance use and psychiatric comorbidity.

Studies on TM access showed that variations in different TM platforms were associated with age, education, level of income areas, and prior overdose. Recognizing that diverse populations may possess distinct preferences enables the implementation of tailored approaches to enhance TM adoption and promote equitable access. Further studies should address barriers and challenges faced by specific demographic groups in accessing various TM modalities, which would aid in addressing disparities and ensuring inclusivity in TM implementation.

We also found that cost-related studies varied according to research questions and methodology. Some studies indicated that TM was affordable to patients; however, they were conducted from provider perspectives,³³ and there is still a lack of studies on affordability from patient perspectives. Furthermore, the existing literature suggests providers would be more willing to offer TM if reimbursement were increased.³⁴ However, it is essential to investigate whether comparable reimbursement would be justifiable from the payor’s perspective, highlighting the need for further exploration in this area. Studies focusing on patient perspectives also revealed that private insurance was associated with a higher likelihood of using TM in SUD treatment.⁵⁹ This finding aligns with the earlier observation³⁴ that providers exhibit greater willingness to offer TM service when reimbursement is more favorable.

Several limitations should be noted. First, although we regularly consulted with librarians in developing keywords and indexing terms for different databases, relevant papers might have been omitted due to the lack of comprehensiveness of the search terms used. Second, defining papers using evaluation metrics might be subjective and might lead to mis-categorizing relevant papers. We minimized this issue by building a codebook with the definition of each code while at least two researchers coded and summarized each paper. Finally, it is important to carefully consider the newly published articles that could provide new insights and perspectives on TM topics, which are necessary for improving the understanding of research, practice, and policy regarding TM care for SUDs.

In conclusion, TM-based SUD treatment shows overall benefits and acceptability but varies by different TM platforms. TM-based SUD was generally perceived to be beneficial and acceptable by providers and patients. Perspectives varied on the acceptability and access of different TM platforms, warranting future studies that address the different TM platforms. TM treatment was as effective as in-person care in terms of reduced substance use and improved treatment retention, but more rigorous designs are needed. Additional investigation is needed on service quality and on TM-related costs to provide evidence for supporting clinical decisions and policymaking for TM in SUD treatment.

Data availability statement

Data sharing not applicable to this article as no data sets were generated or analyzed during the current study.