Impact of the Coronavirus Pandemic on Substance Use Disorder Treatment: Findings from a Survey of Specialty Providers in California

Abstract

Background:

As the coronavirus pandemic public health emergency begins to ebb in the United States, policymakers and providers need to evaluate how the addiction treatment system functioned during the public health emergency and draw lessons for future emergencies. One important question is whether the pandemic curtailed the use of addiction treatment and the extent to which telehealth was able to mitigate access barriers.

Methods:

To begin to answer this question, we conducted a survey of specialty addiction treatment providers in California from June 2020 through July 2020. The survey focused specifically on provider organizations that served Medicaid beneficiaries.

Results:

Of the 133 respondents, 50% reported a decrease in patients since the stay-at-home order in March 2020, with the largest decline among new patients, and 58% said more patients were relapsing. Eighty-one percent of providers said that telemedicine use had increased since the stay-at-home order. Most said that telemedicine had moderately (48%) or completely (30%) addressed access barriers.

Conclusion:

More efforts are needed to ensure that patients, and in particular new patients, receive addiction treatment during public health emergencies.

Background

The coronavirus pandemic presented unique challenges for individuals with substance use disorders (SUDs). Their greater prevalence of chronic conditions heightened their risk for contracting and dying from COVID-19. ¹ The pandemic led to social isolation and economic stress and triggered anxiety, depression, and boredom which in turn fueled more substance use and misuse.^2-7 The pandemic may have also altered the illegal drug market in ways that may have led to the use of counterfeit, unknown, and more potent illicit drugs. ⁸ Increased risky substance use may have led to higher overdose deaths. The CDC estimated that overdose deaths in the United States increased by 28.8% from September 2019 to September 2020. ⁹ Data from the Overdose Detection Mapping Application Program (ODMAP) revealed a 17% increase in suspected overdoses in March 2020 relative to the weeks before the stay-at-home order. ¹⁰

Telehealth-delivered SUD treatment, which was not widely used by specialty addiction treatment providers before the pandemic, increased exponentially as a result of the pandemic.^11,12 However, research is needed to understand how well telehealth was able to mitigate access barriers during the pandemic while maintaining the quality and effectiveness of addiction treatment.^13,14

The goal of this study was to understand how the pandemic affected the use of addiction treatment by Medicaid beneficiaries, and to what extent telehealth was able to facilitate ongoing use given the constraints of social distancing imposed by the pandemic.

Methods

We conducted an online survey of specialty SUD provider organizations in California during June and July 2020. We identified providers using the Behavioral Health Treatment Locator and information provided by the California Department of Health. To be eligible, providers had to accept patients enrolled in Medicaid. We sent the survey to 399 providers and received 133 completed or partially completed surveys (33.3% response rate). The survey included 19 questions that asked respondents about changes that had occurred since the stay-at-home order was issued in California in March 2020 (see survey available in Supplemental Appendix). The survey asked providers what changes they experienced if any, in overall patient attendance, attendance among specific vulnerable populations, specific types of services, telemedicine use overall and for specific types of services, and the organization’s finances. The survey also asked to what extent telemedicine had been able to mitigate the access barriers created by the stay-at-home order, what would help improve access to addiction services via telemedicine, access to personal protective equipment (PPE) and COVID-19 testing resources, and what actions would be the most important to keep Medicaid beneficiaries engaged in substance use disorder treatment during the coronavirus pandemic. The study was reviewed and approved by the New England Institutional Review Board.

Results

Over half (58%) of survey respondents said they saw an increase in the number of patients who relapsed, 25% of respondents reported no change, 2% reported a decrease, and 15% said they were not sure (not shown in tables).

Half of the survey respondents (50%) said their organization had experienced a decrease in Medicaid patient attendance (either in person or virtual), 22% said the number had remained the same, 18% said there had been an increase, and 10% were not sure (Table 1). Examining the change in attendance by patient characteristics, the largest percentage of providers reported a decrease among new patients (55% of providers), followed by justice-involved individuals (43% of providers), women with children (38%), pregnant women (35%), homeless individuals (34%), and undocumented immigrants (20%). The average percent decrease in attendance reported by providers who said volume had decreased was 38% for new patients, 54% for justice-involved individuals, 51% for women with children, 41% for homeless individuals, 55% for pregnant women, and 28% for undocumented immigrants. Some providers also experienced no change in attendance among these populations, but few reported increases in patient attendance.

Table 1.

Number and percent of substance use disorder specialty treatment organizations in California reporting a change in the number of Medicaid patients served, overall, and by patient characteristics and service type, since March 20th, 2020.

Question	N c	Not Sure(%)	No change (%) a	Decrease (%) a	Increase (%) a
Change in Medicaid patient attendance b	132	10	22	50	18
Change in attendance by patient characteristics
New patients	119		28	55	18
Women with children	76		49	38	13
Pregnant women	80		55	35	10
Justice-involved individuals	105		41	43	16
Undocumented immigrants	91		73	20	8
Homeless	108		45	34	20
Change in attendance by service type b
Intake assessments	115		33	50	17
Intake assessment for patients needing methadone	43		67	19	14
Intake assessment for patients needing buprenorphine	56		70	18	13
Residential (ASAM 3.1)	65		29	54	17
Residential (ASAM 3.5 or 3.7)	43		26	58	16
Intensive outpatient treatment	65		48	40	12
Individual counseling	111		44	31	25
Group counseling	107		45	50	6
Drug testing	104		52	44	4
Withdrawal management	38		58	26	16
Medication management	53		70	23	8
Methadone dispensing	17		53	12	35
Buprenorphine prescriptions	33		76	9	15
Change in Telemedicine use by service type b
Intake assessments	66		21	14	65
Intake assessment for methadone	9		44	22	33
Intake assessment for buprenorphine	19		42	11	47
Residential (ASAM 3.1)	18		39	17	44
Residential (ASAM 3.5 or 3.7)	14		36	21	43
Intensive outpatient treatment	51		20	16	65
Individual counseling	83		19	13	67
Group counseling	67		27	10	63
Drug testing	11		64	27	9
Withdrawal management	9		78	0	22
Medication management	13		77	0	23
Methadone dispensing	0		0	0	0
Buprenorphine prescriptions	14		57	0	43

^aReference point for change is March 20th 2020 when the California Governor issued a stay-at-home order.

^bPatient attendance could be in person or virtual.

^cOnly providers that served the populations or offered the service were asked whether the volume of patients served changed. Providers who stated they did not serve the population or provide the services or who did not answer the question were not included in the N.

Examining the change in attendance by service type, the most frequently reported decrease was for residential treatment (54% and 58% for ASAM level 3.1 and 3.3/3.7 respectively), group counseling (50%), and intake assessments (50%). Some providers reported no change in demand for services and few reported increases in demand for services. The service that most providers saw an increase in demand for was methadone dispensing (35%).

Most survey respondents said that telemedicine had moderately (48%) or completely (30%) addressed access barriers (not shown in Tables). However, 21% of respondents said telemedicine had helped only a little. Notably, none of the respondents said that telemedicine has not been at all effective in mitigating access barriers. Nearly 3-quarters (74%) of survey respondents reported providing SUD services via telemedicine after the stay-at-home order at the time of the survey (not shown in tables). Eighty-one percent of providers reported an increase in the number of Medicaid patients being treated via telemedicine since the stay-at-home order (not shown in Tables).

Telemedicine was able to mitigate access barriers for some services and populations more than for others. The types of services that most providers reported an increase in delivering via telemedicine were individual counseling (67%), intensive outpatient treatment (65%), intake assessments (65%), and group counseling (63%). The services that most providers reported no change in providing via telemedicine were withdrawal management (78%), medication management (77%), and drug testing (64%). Respondents were asked what would help improve access to addiction services via telemedicine. Most survey respondents said that providing telemedicine access equipment and access points for Medicaid patients (63%), increasing telemedicine Medicaid reimbursement (52%), and providing additional regulatory flexibilities (46%) would be helpful (not shown in Tables).

In-person treatment was still needed to fully offset access barriers created by the pandemic; however, providers reported challenges in accessing personal protective equipment (PPE) and COVID-19 testing resources. About 27% of respondents reported not having enough PPE to treat patients and 41% reported not having enough COVID-19 testing resources. Moreover, providers reported being financially stressed during the pandemic due to higher expenses and lower revenues.

When asked what would be the most important action that could be taken to keep Medicaid beneficiaries engaged in treatment during the pandemic, providers selected: improving their ability to deliver telemedicine (28%), providing bridge financing to providers to sustain their services (27%), improving access to PPE, testing, and other tools to be able to deliver care in person safely (16%), reducing client fear/avoidance of receiving treatment (15%), reducing staff fear/avoidance of delivering treatment (8%), and other (6%) (not shown in Tables).

Limitations

This research has some limitations. First, the results are based on providers’ self-reported data. Analyses based on administrative data, such as claims data, could confirm providers’ accounts of the decline of addiction service use during the pandemic. Second, the survey had a 33% response rate; however, the providers who did respond were from all counties in California and represented a diversity of modality types (eg, residential, outpatient). Provider organizations that did not respond were much more likely not to accept patients with public insurance, thus they were likely not eligible for the survey.

Conclusions

During the summer of 2020, addiction treatment provider organizations in California reported that the number of patients they were treating had declined dramatically because of the pandemic. Although the survey did not reveal the cause for the decline, our discussions with providers indicate that it was caused by a combination of factors: patients’ reluctance to seek treatment because of fears of becoming infected, clinicians’ reluctance to provide treatment because of fears of infection, challenges with the transition to telemedicine, and lack of resources, such as PPE, and space in residential settings, to treat as many people in person as would be ideal.

One of the factors that contributed to the decline in new patients attending treatment may have been that providers found it difficult to initiate new patients via telehealth. There are several reasons why this could be. Providers may have been uncomfortable doing intake assessments remotely because they could not observe the patient closely or collect biomarkers such as blood pressure and drug tests. Additionally, clinicians were probably not trained to conduct remote intakes. Further, providers may not have made it clear to new patients that they could start treatment via telehealth. Given that future pandemics or disasters may also require a rapid pivot to telehealth, more research and planning are needed to understand how best to initiate new patients into addiction treatment via telehealth. A recent literature review found only 8 studies that compared addiction treatment via telehealth to treatment in-person. ¹⁵ More generally, the pandemic highlighted the need for more robust and widespread broadband internet access.

The pandemic posed tremendous challenges for persons with SUD disorders. Although telehealth helped mitigate some access barriers, physical distancing requirements prevented the delivery of needed services and the treatment of new patients. This barrier might have been reduced if addiction treatment had been recognized as a high priority service, providers had been designated as essential healthcare settings and prioritized for PPE and other resources, and individuals with SUD had received information on how they could safely obtain treatment during the pandemic. Greater integration of SUD treatment in primary care and emergency care settings may also have benefited persons in need of addiction treatment.