Abstract
Background:
Telemedicine-assisted buprenorphine (BNX) induction (TABI) has the potential to reduce the treatment gap for opioid use disorder.
Aim:
This study investigated the acceptability and feasibility of TABI in India. This was a retrospective study from a specialized addiction treatment center in a teaching hospital.
Methods:
TABI was introduced in November 2022; patients enrolled till May 2023 were included in the analysis. Feasibility was assessed by the proportion of patients who completed the TABI program, continued treatment for at least 3 months, and self-reported nonprescription opioid use during and after TABI. Acceptability was measured by patient satisfaction with TABI.
Results:
Sixty patients were enrolled: Fifty-three patients (88.3%) were retained during the TABI program, and 50 patients (83.3%) remained in treatment at the 3-month follow-up. Thirty-five patients (58.3%) reported using nonprescription opioids during TABI, and 28 patients (46.7%) reported such use after completing the program. Thirty-five (58.3%) were satisfied with the program, and 15 (25%) said they would recommend it to others. Patients who missed scheduled in-person appointments (P < .001) at 1 week, did not return unused BNX-naloxone (P < .001), and were not satisfied (P = .004) were more likely to report nonprescription opioid use. Those who attended the in-person follow-up at 1 week (P = .004) and were satisfied (P = .01) and did not use nonprescription opioids either during (P = .003) or after (P < .001) TABI were more likely to be retained in treatment at 3 months.
Conclusion:
The study shows TABI’s acceptability and feasibility in a specialized addiction treatment setting; further research is needed for broader applicability.
Keywords: Buprenorphine, India, opioid use disorder, telemedicine
INTRODUCTION
Telemedicine has rapidly expanded, especially in the postpandemic period. It has also shown promise in the treatment of opioid use disorder (OUD).[1] Buprenorphine (± naloxone-BNX), a medication-assisted treatment (MAT), has proven effective in managing OUD.[2] However, globally, 16% of people who inject opioids receive MAT; even in high-income countries like USA, only one-third receive treatment for OUD.[3,4] Fear and stigma due to the criminalization of drug use, along with logistical and regulatory challenges, pose barriers to accessing BNX treatment.[5] Telemedicine provides a level of anonymity that can reduce the stigma. Patients can engage with healthcare professionals from their homes, fostering a more confidential and supportive environment. The flexibility allows patients to undergo buprenorphine induction without the need for extensive travel or time away from work and family commitments. Therefore, telemedicine for BNX induction offers a novel approach to expand access to treatment. Moreover, this convenience can enhance patient engagement and adherence to the treatment plan. Telemedicine-assisted BNX induction (TABI) is associated with better treatment retention, more prescription refilling, and a lower likelihood of overdose.[6,7]
However, healthcare providers must navigate legal frameworks to ensure compliance while delivering effective and safe care.[8] Moreover, addressing potential technological barriers, such as limited digital literacy or inadequate equipment, is crucial to the success of telemedicine-based BNX induction.[9] Finally, telemedicine requires additional efforts to establish trust and connection as it lacks the in-person interactions that traditional healthcare settings offer.[9]
Therefore, the regulatory requirements, care delivery, Internet access, digital literacy, and patients’ or treatment providers’ comfort with telemedicine vary across countries. Although there is published research on BNX induction from the global north, research is lacking from the global south. India is one of the few Southeast Asian countries with robust telemedicine guidelines.[10] Nearly half of the Indians have Internet access, and nearly 70% have smartphone access.[11] Therefore, telemedicine is logistically feasible in the country. However, BNX is a controlled substance, and drug use in India is criminalized, creating regulatory hurdles for TABI. Alongside stigma and limited awareness, the high OUD treatment gap of 75% is contributed by the unavailability of evidence-based and low-threshold treatment.[12] Telemedicine-assisted BNX treatment could potentially reduce the treatment gap. This retrospective data analysis reviews the implementation and outcomes of TABI to assess its acceptability and feasibility in a clinical setting.
METHODS
Study design
This was a retrospective observational chart review from a specialized addiction treatment center in a teaching hospital in northern India. The center caters to the six neighboring states. Some of these are the states with the highest prevalence of OUD.
We started the TABI program in November 2022. This paper presents data on patients who received TABI as part of routine clinical care up until May 2023.
The ethics approval was obtained from the Institute’s intramural ethics committee (IEC-XXX2023/Study-1355).
Sample selection
Patients (18–65 years) with moderate to severe OUD were offered the TABI program as part of their treatment plan. Patients with severe mental illness, severe alcohol and benzodiazepine use disorders, and severe medical comorbidities (e.g., uncompensated cirrhosis, cardiac disease, infected skin ulcerations) and those who were uncomfortable with telemedicine or lacked access to a smartphone were not considered for the TABI program due to clinical considerations.
TABI process
Before the initiation of the TABI program in November 2022, the center provided MAT for OUD using in-person visits. The introduction of the TABI program aimed to expand access to treatment by integrating telemedicine into existing MAT practices. TABI was conceived as a distinct program to systematically integrate telemedicine with MAT for OUD, aimed at addressing specific barriers such as logistical constraints and stigma associated with in-person visits. This structured approach allowed for a controlled evaluation of telemedicine’s feasibility and acceptability in MAT, rather than an unplanned shift in clinical practice.
The program was developed in consultation with experts, clinicians, and pharmacists to comply with national regulations regarding telemedicine guidelines for controlled substances. The standard operating procedures (SOPs) were finalized following a series of consultations with stakeholders. The program was funded by an internal grant from the teaching hospital, which supported the procurement of necessary telehealth equipment, including secure communication platforms. The hospital’s IT department helped to set up the telemedicine infrastructure, and staff were trained on the new telemedicine guidelines and technologies. In compliance with national telemedicine guidelines, the initial assessment and BNX initiation were conducted in person, with urine drug screening and informed consent. Informed consent was obtained for the initiation of BNX treatment and the telemedicine consultation process. Those not willing for TABI received the standard in-person MAT. A psychiatrist did a comprehensive assessment for eligibility for the TABI program. The assessment included a medical history, OUD severity, and readiness for TABI. The withdrawal symptoms were assessed by the subjective opioid withdrawal scale (SOWS). Patients were explained how to use it, and copies were provided for self-assessment at home. Patients and their care providers were educated about the medication, its potential side effects, and the importance of follow-up care. Six days’ takeaway doses were dispensed on day 1. We provided extra doses of BNX for any potential dose adjustments during the telemedicine-based induction phase. The extra doses provided were calculated based on the patient’s initial response and were intended to cover minor adjustments that could be required due to individual variability in drug metabolism and response. We did not provide more than five extra doses of BNX (2/0.5 mg) to an individual patient. Patients were asked to return the unused medications on their follow-up. We tried to ensure the presence of a responsible adult family member to supervise patients’ medication use. Regular telehealth visits were scheduled for the first 3 days to monitor progress (withdrawal assessment, cravings, nonprescription opioid use, side effects) and adjust medication dosages. Dose adjustments were made based on the patient’s response and clinical needs during subsequent teleconsultations, but always within the prescribed limits and under strict monitoring. After the first 3 days, the frequency of telemedicine visits varied based on patient needs. In-person follow-up was done on the seventh day. Subsequently, patients were continued on weekly follow-ups from the routine BNX treatment program.
The BNX guidelines in India recommend three daily in-person visits during the induction phase of OMAT. TABI process of a single in-person visit (instead of three daily visits) followed by telemedicine consultations was conceived to address the substantial economic burdens associated with multiple in-person visits. This decision was informed by the high direct costs of transportation, meals, and potential accommodation, as well as the indirect costs, including loss of wages, especially for patients from lower socioeconomic backgrounds. This approach aimed to reduce logistical challenges and financial barriers to treatment adherence.
Please see Supplementary Figure 1 (1.2MB, tif) for the TABI process, and Figure 2 (976.2KB, tif) is the induction protocol.
Data collection
Patient satisfaction with the TABI was assessed using a structured questionnaire designed specifically for this study. The questionnaire included five indicators to gauge patient feelings about the telemedicine experience: “Not Satisfied,” for patients who regretted choosing home induction; “Unsure,” for those uncertain about whether home induction was the right decision; “Some Satisfaction,” for patients who felt the program was adequate but desired more support from the doctor; “Satisfied,” for those who believed home induction was the right decision but were unsure if they would recommend it to others; and “Very Satisfied,” for patients who were fully satisfied with the program and would recommend it to others. Satisfaction was measured immediately after completing the TABI.
We kept electronic records of demographic, clinical, and TABI program variables. The psychiatrists who completed the initial assessments and monitoring also inputted the electronic record until 3 months after TABI enrolment. Only the treating psychiatrist and the program supervisor had access to records.
Analysis
We performed descriptive analysis to characterize the study sample and the TABI program, the feasibility (% of patients who completed TABI, % completed at least 3 months treatment, % self-reported nonprescription opioid use during and after TABI), and acceptability (satisfaction with TABI). We examined whether any demographic, clinical, and program variables were associated with nonprescription opioid use during TABI and 3 months of treatment completion. The associations with categorical variables were tested with the Chi-square test; independent t-tests were used for continuous variables.
RESULTS
Sixty patients received the TABI program as part of their treatment during the study period. The study population comprised young (mean age 26.9 years) and employed (34, 66.7%) men who had less than 10 years of formal education (34, 56.7%). Patients mostly came from a lower-middle (28, 46.7%) or lower (30, 18%) socioeconomic background. On average, they traveled more than 60 Km to the center. Heroin (52, 86.7%) was the most misused opioid. Nearly half (26, 43.3%) of the patients had a comorbid hepatitis C infection. All patients with hepatitis C were included in the integrated care program, which offers treatment and monitoring of hepatitis C, alongside the OUD treatment.[13] Difficulties in taking leave of absence from work (due to wage loss) for in-person induction and distance were the two most common reasons for TABI enrolment. Most patients (56, 93.3%) had an adult family member to supervise the home induction.
Most patients were engaged in audio mode (39, 65%) of teleconsultations. All patients had severe opioid withdrawal symptoms (mean SOWS 25.8) before BNX initiation on the first day. Symptoms reduced significantly on the subsequent days of home induction (day 2 mean 8.1, day 3 mean 5.6, day 4 mean 1.1). The mean BNX dose on the first day was 5.3 mg (range 2–12 mg), and in 49 (81.7%) patients, the dose remained unchanged till the seventh day. Eighteen (30%) patients made additional calls between days 4 and 6. Nearly half of the patients (29, 48.3%) attended the scheduled appointments on the seventh day. The rest came early (2, 3.3%) or within a week (22, 36.7%) of the scheduled appointment. There was a mean delay of 1.6 days between the scheduled appointment and actual follow-up. Twenty-six (53%) of the 29 patients (who came for their scheduled appointments) returned the unused medications. Of the three patients who did not return the extra medications, two had to increase their BNX dose during TABI; therefore, no extra medications were left to return. Seven patients (11.7%) left TABI. Thirty-five (58.3%) and 28 patients (46.7%) reported using nonprescription opioids during and after TABI. Thirty-five (58.3%) were satisfied with the program, and 15 (25%) said they would recommend it to others. Fifty patients (83.3%) were retained in treatment at 3-month follow-up [Table 1].
Table 1.
Descriptive analysis of demographic, clinical, and TABI-related variables
| Variables | Frequency (percentage)/ Mean (SD)/Median (IQR) |
|---|---|
| Demographic | |
| Age Mean (SD) | 26.8 (4.52) |
| Marital status | |
| Single | 39 (65%) |
| Married | 21 (355) |
| Region | |
| Urban | 43 (71.7%) |
| Rural | 17 (28.3%) |
| Occupation | |
| Unemployed | 26 (43.3%) |
| Employed | 34 (66.7%) |
| Education | 34 (56.7%) |
| Less than or equal to 10th standard | 26 (43.3%) |
| More than 10th standard | |
| Socioeconomic status | |
| Upper middle | 14 (23.3%) |
| Lower middle | 28 (46.7%) |
| Upper lower | 18 (30%) |
| Distance from DDTC (in Km) (Median and IQR) | 20 (4-400) |
| Clinical: | |
| Form of opioid use | |
| Heroin | 52 (86.7%) |
| Heroin and Crude Opium (Afeem) | 5 (8.3%) |
| Codeine | 1 (1.7%) |
| Adulterated heroin (Smack) | 2 (3.3%) |
| Duration of Opioid use (in years) | 4.26 (3.22) (1-20) |
| Comorbid Psychiatric illness | |
| Major Depressive disorder | 1 (1.7%) |
| No psychiatric comorbidity | 59 (98.3%) |
| Comorbid medical illness | |
| None | 30 (50%) |
| HCV infection | 26 (43.3%) |
| HBV infection | 4 (6.7%) |
| Other substance use | |
| Tobacco | 39 (65%) |
| Cannabis | 5 (8.3%) |
| Sedatives | 3 (5%) |
| None | 5 (8.3%) |
| Tobacco + Cannabis | 6 (10%) |
| Alcohol + Tobacco + cannabis | 2 (3.3%) |
| Reason for starting telemedicine-based home induction | |
| Difficulty to take leave on consecutive days | 31 (50.7%) |
| Distance | 21 (35%) |
| Health issues | 4 (6.7%) |
| Fear of relapse if one goes out of home | 3 (5%) |
| Job profile: driving to a different city | 1 (1.7%) |
| Family responsibility | 1 (1.7%) |
| Presence of at least one responsible adult family member | |
| Yes | 56 (93.3%) |
| No | 4 (6.7%) |
| Telemedicine mode | |
| Video mode | 3 (5%) |
| Audio mode | 39 (65%) |
| Both | 18 (30%) |
| TABI related | |
| Period before starting BNX (in days) Median (IQR) | 2 (1-4) [N=60] |
| SOWS score on day 0 Mean (SD) | 25.83 (12.78) [N=60] |
| SOWS score on day 1 Mean (SD) | 8.13 (6.54) [N=38] |
| SOWS score on day 2 Mean (SD) | 5.61 (5.43) [N=59] |
| Dose of BPN + NLX (mg) on Day 1 Mean (SD) | 5.30 (2.29) [N=60] |
| Dose of BPN + NLX (mg) on Day 2 Mean (SD) | 5.3 (2.94) [N=60] |
| Dose of BPN + NLX (mg) on Day 3 Mean (SD) | 5.3 (2.94) [N=60] |
| Delay in follow-up by how many days Median (IQR) | 0 (0-3) [N=60] |
| Change in dose after 1st day (via Telemedicine) | 57 (95%) |
| No change | 2 (3.3%) |
| Increase | 1 (1.7%) |
| decrease | |
| Follow up in OPD | |
| On 7th day | 29 (48.3%) |
| Delayed | 22 (36.7%) |
| No follow up | 7 (11.7%) |
| Came early | 2 (3.3%) |
| Dropped out during TABI | 7 (11.7%) |
| Yes | 53 (88.3%) |
| No | |
| Reason of Delay (n=22) | |
| Distance | 3 (14%) |
| Job issues | 1 (4%) |
| Family crisis | 3 (14%) |
| unspecified | 15 (68%) |
| Satisfaction with the home induction | |
| Not satisfied: regrets home induction | 2 (3.3%) |
| Unsure: not sure whether it was the right decision | 11 (18.3%) |
| Some satisfaction: wish there was more support from doctor | 10 (16.7%) |
| Satisfied: it was the right decision; unsure about the recommendation | 10 (16.7%) |
| Very satisfied; will recommend | 15 (25%) |
| Cannot be commented | 12 (20%) |
| Satisfaction with home induction | |
| Satisfied | 35 (58.3%) |
| Not satisfied | 25 (41.7%) |
| Any additional calls made by the patient/family between days 4 and 6? | |
| Yes | 18 (30%) |
| No | 42 (70%) |
| Did the patient use non-prescription opioids during TABI? | |
| Yes | 35 (58.3%) |
| No | 25 (41.7%) |
| Did the patient use non-prescription opioids after TABI (only applicable to those with late follow-up) | |
| Yes | 28 (46.7%) |
| No | 32 (53.3%) |
| Was the patient on buprenorphine for at least 3 months? | |
| Yes | 50 (83.3%) |
| No | 10 (16.7%) |
| Was the dose of BNX increased after TABI during the 3-month follow-up? | |
| Yes | 11 (18.3%) |
| No | 49 (81.7%) |
| Did the patient return extra BNX tables (only for those who did not increase BNX dose during TABI, n=49 | |
| Yes | 26 (53.1%) |
| No | 23 (46.9%) |
Day 0 is the day of in-person induction, Day 1 and 2 are the days of telemedicine-based care; BNX Buprenorphine-naloxone fixed dose combination (2/0.5 mg); SD Standard Deviation; IQR Interquartile range
None of the demographic and clinical variables were associated with nonprescription opioid use during TABI. Patients who missed scheduled in-person appointments on the seventh day (χ2 17.21, P < .001) and did not return unused BNX (χ2 23.46, P < .001) and were not satisfied with TABI (χ2 8.28, P = .004) had a higher likelihood of using nonprescription opioids. Patients who did not use nonprescription opioids during TABI were more likely to be in treatment at 3 months (χ2 8.57, P = .003) [Supplementary Table 1].
Supplementary Table 1.
Demographical, clinical, and TABI correlates for nonprescription opioid use (NPO) during TABI (Chi-square, t-tests)
| Variables | Nonprescription opioid use during TABI |
Unpaired t-test (P)/ Chi-square value (P) | |
|---|---|---|---|
| NO n=25 | YES n=35 | ||
| Demographic | |||
| Age | 26.96 (4.8) | 26.77 (4.38) | 0.16 (0.88) |
| Marital status | |||
| Single | 17 (68%) | 22 (63%) | 0.17 (0.68) |
| Married | 8 (32%) | 13 (37%) | |
| Region | |||
| Urban | 17 (68%) | 26 (74%) | 0.284 (0.59) |
| rural | 8 (32%) | 9 (26%) | |
| Occupation | |||
| Unemployed | 11 (44%) | 15 (43%) | 0.008 (0.93) |
| Employed | 14 (56%) | 20 (57%) | |
| Education | |||
| Less than or equal to high school | 14 (44%) | 20 (43%) | 0.008 (0.93) |
| more than high school | 11 (56%) | 15 (57%) | |
| Socioeconomic status | |||
| Upper middle | 5 (20%) | 9 (26%) | 0.52 (0.77) |
| Lower middle | 13 (52%) | 15 (43%) | |
| Upper lower | 7 (28%) | 11 (31%) | |
| Distance from DDTC (in Km) | 61.88 (88.42) | 67.34 (83.61) | -0.24 (0.80) |
| Clinical | |||
| Form of opioid use | |||
| Heroin | 21 (84%) | 31 (88.5%) | 3.55 (0.31) |
| Heroin and crude opium (Afeem) | 2 (8%) | 3 (8.5%) | |
| Codeine | 0 | 1 (3%) | |
| Adulterated heroin (Smack) | 2 (8%) | 0 | |
| Duration of Opioid use (in years) | 3.8 (2.41) | 4.6 (3.68) | -0.99 (0.35) |
| Comorbid Psychiatric illness | |||
| Major Depressive disorder | 1 (4%) | 0 | 1.42 (0.42) |
| No psychiatric comorbidity | 24 (96%) | 35 (100%) | |
| Comorbid medical illness | |||
| None | 12 (48%) | 18 (51%) | 0.15 (0.92) |
| HCV infection | 11 (44%) | 15 (43%) | |
| HBV infection | 2 (8%) | 2 (6%) | |
| IV route of administration | |||
| Yes | 19 (76%) | 22 (63%) | 1.16 (0.28) |
| No | 6 (24%) | 13 (37%) | |
| Other substance use | |||
| Tobacco | 17 (68%) | 22 (63%) | 1.756 (0.88) |
| Cannabis | 2 (8%) | 3 (8.5%) | |
| Sedatives | 1 (4%) | 2 (5.7%) | |
| None | 2 (8%) | 3 (8.5%) | |
| Tobacco + cannabis | 3 (12%) | 3 (8.5%) | |
| Alcohol + Tobacco + cannabis | 0 | 2 (5.7%) | |
| Reason of starting telemedicine-based home induction | |||
| Difficulty to take leave on consecutive days | 8 (32%) | 13 (37%) | 6.59 (0.16) |
| Distance | 14 (56%) | 16 (45%) | |
| Health issues | 0 | 1 (3%) | |
| Fear of relapse if one goes out of home | 1 (4%) | 0 | |
| Job profile: driving to different city | 2 (8%) | 2 (6%) | |
| Family responsibility | 0 | 3 (9%) | |
| Presence of at least one responsible adult family member | |||
| Yes | 24 (96%) | 32 (91%) | 0.49 (0.63) |
| No | 1 (4%) | 3 (9%) | |
| Relationship of the family member with patient | |||
| Spouse | 8 (32%) | 11 (32%) | 2.50 (0.29) |
| Parent | 15 (60%) | 16 (45%) | |
| Sibling | 2 (8%) | 8 (23%) | |
| Telemedicine mode | |||
| Video mode | 1 (4%) | 2 (6%) | 0.15 (0.93) |
| Audio mode | 16 (64%) | 23 (66%) | |
| Both | 8 (32%) | 10 (28%) | |
| TABI-related: | |||
| Period before starting BNX (in days) | 5 (8.69) | 6.11 (12.40) | -0.39 (0.7) |
| SOWS score on day 1 | 25.76 (11.67) | 25.88 (13.68) | -0.04 (0.97) |
| SOWS score on day 2 (n for no=12; n for yes=26) | 10.33 (6.06) | 7.11 (6.62) | 1.43 (0.16) |
| SOWS score on day 3 (n for no=24) | 6.75 (5.98) | 4.82 (4.95) | 1.34 (0.18) |
| Dose of BPN + NLX (mg) on Day 1 | 5.28 (2.3) | 5.31 (2.32) | -0.57 (0.95) |
| Dose of BPN + NLX (mg) on Day 2 | 5.28 (2.3) | 5.31 (2.32) | -0.57 (0.95) |
| Dose of BPN + NLX (mg) on Day 3 | 5.28 (2.3) | 5.31 (2.32) | -0.57 (0.95) |
| Dose of BPN + NLX (mg) on Day 4 (n for no=3; n for yes=8) | 5 (1) | 5.75 (2.25) | -0.54 (0.6) |
| Dose of BPN + NLX (mg) on Day 5 (n for no=4; n for yes=7) | 4.75 (0.96) | 6.29 (1.79) | -1.56 (0.15) |
| Dose of BPN + NLX (mg) on Day 6 (n for no=4; n for yes=7) | 4.75 (0.96) | 6.29 (1.79) | -1.56 (0.15) |
| delay in follow up by how many days | 0 | 2.8 (3.50) | -3.98 (<0.001)*** |
| Change in dose after 1st day | 2.83 (0.23) | ||
| No change | 24 (96%) | 33 (94%) | |
| Increase | 0 | 2 (6%) | |
| decrease | 1 (4%) | 0 | |
| Follow-up in OPD | 28.58 | ||
| On 7th day | 20 (80%) | 9 (25%) | (<0.001)*** |
| Delayed | 0 | 22 (63%) | |
| No follow-up | 5 (20%) | 2 (6%) | |
| Came early | 0 | 2 (6%) | |
| Dropped out during TABI | 2.88 (0.12) | ||
| Yes | 5 (20%) | 2 (6%) | |
| No | 20 (80%) | 33 (94%) | |
| Reason of Delay (n=22) | |||
| Distance | 0 | 3 | |
| Job issues | 0 | 1 | |
| Family crisis | 0 | 3 | |
| unspecified | 0 | 15 | |
| In-person follow-up on Day 7 | 17.21 | ||
| Yes | 20 (80%) | 9 (26%) | (<0.001)*** |
| No | 5 (20%) | 26 (74%) | |
| Satisfaction with the home induction | |||
| Not satisfied: regrets home induction | 0 | 2 (6%) | 20.7 (0.001)*** |
| Unsure: not sure whether it was right decision | 0 | 11 (31%) | |
| Some satisfaction: wish there was more support from doctor | 2 (8%) | 8 (22%) | |
| Satisfied: it was a right decision; unsure about recommendation | 7 (28%) | 3 (9%) | |
| Very satisfied; will recommend | 11 (44%) | 4 (12%) | |
| Cannot be commented | 5 (20%) | 7 (20%) | |
| Satisfaction with the home induction | 8.28 (0.004)** | ||
| Not satisfied | 5 (25%) | 20 (57.14%) | |
| Satisfied | 20 (75%) | 15 (42.86%) | |
| Any additional calls made by the patient/family between day 4 and 6? | 6.61 (0.12) | ||
| Yes | 3 (12%) | 15 (42%) | |
| No | 22 (88%) | 20 (48%) | |
| Did the patient use nonprescription opioids after TABI (only applicable to those with late follow-up) | 37.5 (<0.001)*** | ||
| Yes | 0 | 28 (80%) | |
| No | 25 (100%) | 7 (20%) | |
| Was the patient on buprenorphine for at least 3 months? | 8.57 | ||
| Yes | 25 (100%) | 25 (71%) | (0.003)** |
| No | 0 | 10 (29%) | |
| During TABI was the dose of BNX increased at any time? | 0.08 (0.78) | ||
| Yes | 5 (20%) | 6 (17%) | |
| No | 20 (80%) | 29 (83%) | |
| Did the patient return extra BNX tables (only for those who did not increase BNX dose during TABI) | 23.46 | ||
| Yes | 20 (80%) | 6 (17%) | (<0.001)*** |
| No | 5 (20%) | 29 (83%) | |
*<0.05; **<0.01; ***<0.001
Similarly, no clinical and demographic variables were associated with the 3-month treatment completion. Patients were more likely to be retained in treatment at 3 months if they attended the in-person follow-up on the seventh day (χ2 = 11.23, P = .004), were satisfied with TABI (χ2 = 7.26, P = .01), and did not use nonprescription opioids during (χ2 = 8.57, P = .003) or after TABI (χ2 = 13.71, P < .001). Please see Supplementary Table 2.
Supplementary Table 2.
Demographic, clinical, and TABI correlates for retention at 3 months (Chi-square, t-tests)
| Variables | Retention of 3 months |
Unpaired t test (P)/ Chi-square value (P) | |
|---|---|---|---|
| NO n=10 | YES n=50 | ||
| Demographic | |||
| Age | 26.7 (4.39) | 26.88 (4.59) | -0.11 (0.91) |
| Marital status | |||
| Single | 6 (60%) | 33 (66%) | 0.13 (0.73) |
| married | 4 (40%) | 17 (34%) | |
| Region | |||
| Urban | 6 (60%) | 37 (74%) | 0.80 (0.45) |
| rural | 4 (40%) | 13 (26%) | |
| Occupation | |||
| Unemployed | 3 (30%) | 23 (46%) | 0.87 (0.49) |
| Employed | 7 (70%) | 27 (44%) | |
| Education | |||
| Less than or equal to high school | 5 (50%) | 29 (58%) | 0.22 (0.73) |
| more than high school | 5 (50%) | 21 (42%) | |
| Socioeconomic status | |||
| Upper middle | 3 (30%) | 11 (22%) | 0.66 (0.72) |
| Lower middle | 5 (50%) | 23 (46%) | |
| Upper lower | 2 (20%) | 16 (32%) | |
| Distance from DDTC (in Km) | 108.5 (125.43) | 56.38 (73.06) | 1.8 (0.08) |
| Clinical | |||
| Form of opioid use | |||
| Chitta | 8 (80%) | 44 (88%) | 5.50 (0.14) |
| Chitta, afeem | 1 (10%) | 4 (8%) | |
| Codein | 1 (10%) | 0 | |
| Smack | 0 | 2 (4%) | |
| duration of Opioid use (in years) | 4.1 (2.33) | 4.3 (3.38) | 1.8 (0.76) |
| Comorbid Psychiatric illness | |||
| Major Depressive disorder | 0 | 1 (2%) | 0.20 (1.00) |
| No psychiatric comorbidity | 10 (100%) | 49 (98%) | |
| Comorbid medical illness | |||
| None | 6 (60%) | 24 (48%) | 0.93 (0.62) |
| HCV infection | 3 (30%) | 23 (46%) | |
| HBV infection | 1 (10%) | 3 (6%) | |
| IV route of administration | |||
| Yes | 5 (50%) | 36 (72%) | 1.86 (0.26) |
| No | 5 (50%) | 14 (28%) | |
| Other substance use | |||
| Tobacco | 5 (50%) | 34 (68%) | 4.62 (0.46) |
| Cannabis | 2 (20%) | 3 (6%) | |
| Sedatives | 0 | 3 (6%) | |
| None | 1 (10%) | 4 (8%) | |
| Tobacco + cannabis | 1 (10%) | 5 (10%) | |
| Alcohol + Tobacco + cannabis | 1 (10%) | 1 (2%) | |
| Reason of starting telemedicine-based home induction | |||
| Difficulty to take leave on consecutive days | 4 (40%) | 16 (32%) | 7.61 (0.18) |
| Distance | 5 (50%) | 26 (52%) | |
| Health issues | 0 | 4 (8%) | |
| Fear of relapse if one goes out of home | 0 | 3 (6%) | |
| Job profile: driving to different city | 1 (10%) | 0 | |
| Family responsibility | 0 | 1 (2%) | |
| Presence of at least one responsible adult family member | |||
| Yes | 9 (90%) | 47 (94%) | 0.21 (0.53) |
| No | 1 (10%) | 3 (6%) | |
| Relationship of the family member with patient | |||
| Spouse | 4 (40%) | 15 (30%) | 0.59 (0.74) |
| Parent | 5 (50%) | 26 (52%) | |
| Sibling | 1 (10%) | 9 (18%) | |
| Telemedicine mode | |||
| Video mode | 1 (10%) | 2 (4%) | 2.62 (0.27) |
| Audio mode | 8 (80%) | 31 (62%) | |
| Both | 1 (10%) | 17 (34%) | |
| TABI-related: | |||
| Period before starting BNX (in days) | 2.5 (2.5) | 6.28 (11.86) | -0.99 (0.32) |
| SOWS score on day 1 | 22.4 (16.17) | 26.52 (12.07) | -0.3 (0.36) |
| SOWS score on day 2 (n for no=8; n for yes=30) | 5.5 (6.55) | 8.83 (6.48) | -1.29 (0.20) |
| SOWS score on day 3 (n for no=10; yes=49) | 5.9 (7.99) | 5.55 (4.86) | 0.18 (0.85) |
| Dose of BPN + NLX (mg) on Day 1 | 5 (3.01) | 5.36 (2.15) | -0.45 (0.65) |
| Dose of BPN + NLX (mg) on Day 2 | 5 (3.01) | 5.36 (2.15) | -0.45 (0.65) |
| Dose of BPN + NLX (mg) on Day 3 | 5 (3.01) | 5.36 (2.15) | -0.45 (0.65) |
| Dose of BPN + NLX (mg) on Day 4 (n for no=2; n for yes=9) | 8 (0) | 5 (1.73) | 2.35 (0.4) |
| Dose of BPN + NLX (mg) on Day 5 (n for no=2; n for yes=9) | 8 (0) | 5.22 (1.39) | 2.7 (0.02)* |
| Dose of BPN + NLX (mg) on Day 6 (n for no=2; n for yes=9) | 8 (0) | 5.22 (1.39) | 2.7 (0.02)* |
| Delay in follow-up by how many days | 6.3 (4.7) | 0.7 (1.18) | 7.48 (<0.001)*** |
| Change in dose after 1st day | 0.63 (0.73) | ||
| No change | 10 (100%) | 47 (94%) | |
| Increase | 0 | 2 (4%) | |
| Decrease | 0 | 1 (2%) | |
| Follow-up in OPD | 20.72 | ||
| On 7th day | 0 | 29 (58%) | (<0.001)*** |
| Delayed | 10 (100%) | 12 (24%) | |
| No follow up | 0 | 7 (14%) | |
| Came early | 0 | 2 (4%) | |
| Dropped out during TABI | 1.585 (0.59) | ||
| Yes | 0 | 7 (14%) | |
| No | 10 (100%) | 43 (86%) | |
| Reason of Delay (n=22) | 4.25 (0.23) | ||
| Distance | 2 (20%) | 1 (2%) | |
| Job issues | 1 (10%) | 0 | |
| Family crisis | 0 | 3 (6%) | |
| Unspecified | 7 (70%) | 8 (16%) | |
| In person follow up on Day 7 | 11.23 | ||
| Yes | 0 | 29 (58%) | (0.004)** |
| No | 10 (100%) | 21 (42%) | |
| Satisfaction with the home induction | |||
| Not satisfied: regrets home induction | 1 (10%) | 1 (2%) | 10.35 |
| Unsure: not sure whether it was right decision | 4 (40%) | 7 (14%) | (0.66) |
| Some satisfaction: wish there was more support from doctor | 2 (20%) | 8 (16%) | |
| Satisfied: it was a right decision; unsure about recommendation | 0 | 10 (20%) | |
| Very satisfied; will recommend | 0 | 15 (30%) | |
| Cannot be commented | 3 (30%) | 9 (18%) | |
| Satisfaction with the home induction | 7.26 (0.01)** | ||
| Not satisfied | 8 (80%) | 17 (34%) | |
| Satisfied | 2 (20%) | 33 (66%) | |
| Any additional calls made by the patient/family between day 4 and 6? | 0.57 (0.47) | ||
| Yes | 4 (40%) | 14 (28%) | |
| No | 6 (60%) | 36 (72%) | |
| Did the patient use non-prescription opioids after TABI (only applicable to those with late follow-up) | 13.71 | ||
| Yes | 10 (100%) | 18 (36%) | (<0.001)*** |
| No | 0 | 32 (64%) | |
| Did the patient use non-prescription opioids during TABI (only applicable to those with late follow-up) | 8.57 | ||
| Yes | 10 (100%) | 25 (50%) | (0.003)** |
| No | 0 | 25 (50%) | |
| During TABI was the dose of BNX increased at any time? | 0.56 (0.67) | ||
| Yes | 1 (10%) | 10 (20%) | |
| No | 9 (90%) | 40 (80%) | |
| Did the patient return extra BNX tables (only for those who did not increase BNX dose during TABI) | 9.18 | ||
| Yes | 0 | 26 (52%) | (0.003)** |
| No | 10 (100%) | 24 (48%) | |
*<0.05; **<0.01; ***<0.001
DISCUSSION
The findings underscore the potential of TABI in addressing the OUD treatment gap in the global south. The high 7-day (88%) and 3-month (83%) retention rates and patient satisfaction signal the acceptability of this approach, particularly among employed individuals facing challenges in accessing traditional in-person treatment.[14,15,16] Moreover, TABI might lower the barrier to treatment for a substantial proportion of patients from LSES (>75%) by reducing the direct and indirect costs of daily in-person visits. Only one patient who should have returned the additional BNX tablets failed to do so. He might have given them to his friend to help with his opioid withdrawal symptoms. The study highlights the effectiveness of remote monitoring in managing withdrawal symptoms and adjusting medication dosages, emphasizing the role of telemedicine in overcoming logistical barriers.
The retention rate between 4 and 6 months in the traditional BNX-based OAMT programs varies from 20% to 82.5% in clinical trials and from 20.2% to 78.3% in observational studies.[17] Therefore, the retention rate in the TABI program is comparable with the traditional OAMT, indicating the feasibility and acceptability of TABI among patients with OUD.
Although the presence of an adult family member to supervise medication use was a preferred criterion for inclusion in the TABI program, four patients without such supervision were still enrolled. This decision was made based on an assessment of the patient’s ability to adhere to the program independently. Factors considered included the patient’s level of understanding of the medication regimen, demonstrated responsibility in other areas of self-care, and the presence of stable housing and a support network outside of the immediate family. Additionally, these patients were provided with extra educational support. This approach was taken to maintain the program’s feasibility and inclusivity, allowing for flexibility in cases where strict adherence to the original criteria could exclude patients who might still benefit from the program.
However, restrictive telemedicine guidelines, criminal-justice-oriented drug policies, and patient engagement issues continue to pose challenges. The preference for audio-mode teleconsultations over video consultations hints at limited digital literacy or privacy concerns.[14] Patient engagement issues, evidenced by a higher likelihood of nonprescription opioid use and treatment attrition among those dissatisfied with TABI, highlight the need for refining the program to enhance patients’ experience. To address these issues, future iterations of the TABI could include more personalized follow-up calls. Additionally, incorporating feedback mechanisms where patients can voice their concerns and suggestions could help improve engagement and satisfaction. Tailoring the telemedicine approach to individual patient needs, such as offering flexible scheduling and a choice between audio or video consultations based on patient comfort, could also enhance engagement.
The need for an in-person induction on the first day due to national telemedicine guidelines represents an initial hurdle.[10] Future studies could investigate the safety and effectiveness of a fully remote induction process to inform potential policy adjustments. In the future, randomized controlled trials should examine the comparative effectiveness of TABI versus traditional opioid agonist maintenance treatment (OAMT), conduct cost analyses, and evaluate qualitative patient experiences to better understand the benefits and limitations of each approach.
Our retrospective study might be affected by confounders such as socioeconomic status, geographical location, comorbidities, and technological literacy. For instance, patients from higher socioeconomic backgrounds or urban areas may have better access to telemedicine resources, potentially leading to higher retention rates. Conversely, patients with comorbidities or lower technological literacy might experience difficulties with telemedicine, affecting adherence and satisfaction. Additionally, biases such as selection bias could occur if patients more willing to engage in telemedicine were overrepresented in the study sample. Conducted at one addiction treatment center, the results might not be generalizable to other settings or populations, limiting broader applicability. Without a control group, that is, in-person MAT, it is difficult to attribute outcomes directly to the intervention (TABI), reducing the strength of the conclusions. We did not collect data from those who left treatment during the first 7 days. These patients might have returned to nonprescription opioid use or diverted or misused the prescribed BNX.
While the study’s design does not allow us to directly conclude that reducing the number of mandatory in-person visits lowers economic and logistical barriers or improves treatment adherence, the high retention rates (88% at 1 week and 83% at 3 months) observed suggest that the TABI program may offer a promising approach to overcoming some of the challenges associated with traditional in-person care. Future research, including studies with comparison groups and cost-effectiveness analyses, is needed to confirm these potential benefits. As telemedicine gains prominence, advocating for policy reforms and addressing technological and engagement challenges will be vital for its sustained impact on global healthcare.
Declaration regarding the use of generative AI
The author(s) attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures, or other informational content of this manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Flow diagram of the TABI process. The diagram illustrates the patient’s journey from referral to the outpatient department (OPD) through initial in-person assessments, informed consent, and BNX initiation. Following induction, telemedicine consultations are conducted during the first 3 days, with an in-person follow-up on day 7. Subsequent follow-ups occur in person once every 2 weeks to monitor treatment progress and make necessary adjustments
Flow diagram of the TABI induction protocol outlining key steps from initial patient assessment and buprenorphine initiation on day 0 to in-person follow-up on day 7. The diagram details the dosing strategy, including repeat assessments, telemedicine check-ins, and the dispensation of doses for the first week of treatment
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Associated Data
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Supplementary Materials
Flow diagram of the TABI process. The diagram illustrates the patient’s journey from referral to the outpatient department (OPD) through initial in-person assessments, informed consent, and BNX initiation. Following induction, telemedicine consultations are conducted during the first 3 days, with an in-person follow-up on day 7. Subsequent follow-ups occur in person once every 2 weeks to monitor treatment progress and make necessary adjustments
Flow diagram of the TABI induction protocol outlining key steps from initial patient assessment and buprenorphine initiation on day 0 to in-person follow-up on day 7. The diagram details the dosing strategy, including repeat assessments, telemedicine check-ins, and the dispensation of doses for the first week of treatment