Increasing Participation in a Substance Misuse Programs: Lessons Learned for Implementing Telehealth Solutions During the COVID-19 Pandemic

With the advent of the COVID-19 pandemic, the relevance of Cimarolli et al. article,¹ which focuses on participation in a substance misuse intervention for older adults, is well timed. Efforts to develop interventions for older adults with a substance use disorder, along with rigorous evaluations of their efficacy, are scarce in the gerontological literature. For example, in previous research with colleagues, we examined the leading gerontological and substance abuse journals over a 7-year period which revealed that less than one percent of articles published in these journals focused on older adults with substance use disorders, and only a handful of these articles focused on intervention studies.²

The COVID-19 pandemic has exacerbated the risk factors for abuse and overdose for older adults with substance use disorders. Psychosocial stressors and economic strain for individuals with substance use disorders during the pandemic have led to an increase in opioid overdoses throughout the United States.³ For instance, while social isolation is a major concern for all older adults during the pandemic, those who misuse substances have fewer interactions with both formal and informal supports which are critical to maintaining sobriety. Fear of accessing treatment during the pandemic, along with limitations on in-person treatment, can lead to increased risk for relapse and overdose.

Cimarolli et al. focus on the characteristics of the older adults who participate in treatment services is a useful approach for understanding older adult utilization of substance use treatment services during the COVID-19 pandemic. Often, the lack of research on the efficacy of substance and alcohol treatment services for older adults is due to a dearth of awareness of this older aged cohort and, more importantly, a lack of an understanding of the unique service needs that older adults entering treatment often require. Prior to the onset of the pandemic, researchers viewed treatment needs for older adults with substance misuse issues as inadequate because they typically did not incorporate age-related comorbidities, the sequelae of chronic pain, physical limitations in later-life, and the loss of economic resources and social supports.⁴ The need for virtual and remote services during this period of the pandemic raises even more concerns regarding the accessibility of substance use disorder services for older adults.

The overlaying of the COVID-19 pandemic on the decades long opioid crisis requires swift action from policy makers and providers to ensure that older adults are adequately supported at time when they are at increased vulnerability. As the nation deals with this dual emergency, the ability to transition medication assisted treatment and substance use related services to a telehealth model will be critical. The rapid expansion of telehealth during the pandemic has forced practitioners to “learn on the fly,” and Cimarolli and colleagues lay the foundation for the information that practitioners will need to incorporate to enhance the treatment options available to older adults. Thus, their identification of key predisposing risk factors (older age and ethnic minority status) that were associated with a reduction in participation in an in-person treatment program indicate that these factors will be more of a concern in a virtual tele-health model scenario.

As the COVID-19 pandemic evolves, leading health organizations and governmental agencies have begun to advocate for increased flexibility in participation guidelines for substance use treatment programs. These measures include easing the restrictions for buprenorphine distribution, loosening the requirements related to mandatory on-site urine drug screening, and enabling state and federal reimbursement to continue for virtual substance use disorders treatment settings. While these measures and modifications are vital to substance use disorder treatment providers, and the individuals they serve, in order to provide remote services during the pandemic, it will be important to address specific barriers that older adults who misuse substances experience in accessing telehealth services.

In a best-case scenario, transitioning substance use disorder services for older adults to a telehealth model would be a challenge since older adults have less familiarity with technology and experience in communicating via a telehealth platform. As noted by Cimarolli et al. and other researchers, the combination of social isolation and advanced age decrease the likelihood that older adults with substance use disorders will successfully access treatment.⁵ At a policy level, many of the guidelines that have been modified during the pandemic need to be made permanent to ensure providers that the investment in both hardware and personnel training is prudent and financially responsible. Effectively engaging socially isolated older adults with substance use disorders will present challenges for the full range of alcohol and substance use disorder treatment programs potentially requiring a method for providing technology enabled devices for their patients, proficiency in HIPAA regulations, and remote data security. Detailed plans for obtaining appropriate equipment, securing wifi and cellular access, and protocols for ensuring that the user experience for older adults take into account typical issues faced by older adults when using technology.

Geriatric care managers and substance use disorder providers will need to not only focus on the structural barriers for accessing telehealth treatment that exist for older adults with substance use disorders, but also on the ways in which their programs and interventions will need to be adapted in order to retain older adults in treatment that is remote and no longer in person. In addition, training for practitioners in tele-substance use disorder treatment techniques will need to become part of the formalized preparation for those practitioners working with older adults in remote settings. For over 2 decades there has been increasing concern regarding the rising prevalence and treatment of substance use in later-life and the inability of age-appropriate treatment options.⁶ Cimarolli et al., prior to the COVID-19 pandemic, documented and contributed to this literature, and the on-set of the pandemic has only raised concerns for older adults ability to access treatment. Only through a concerted effort by policy makers and practitioners can we ensure that older adults with substance use disorders do not face even more increased barriers in a time of social distancing and isolation.

AUTHOR CONTRIBUTION

Dr. Rosen was the sole author of the editorial.