June 2023

In This Issue: HSR&D Research on Telehealth

Using Telehealth to Expand Treatment Access for Veterans with Opioid Use Disorder

Feature Article

Takeaway: Untreated opioid use disorder among Veterans leads to serious and preventable harms including overdose and suicide. The medication buprenorphine can help prevent these harms, but many Veterans with opioid use disorder do not receive this life-saving treatment. Treatment barriers include a lack of trained buprenorphine providers, stigma of opioid use disorder, and limited accessibility of care. This study is examining the effectiveness of telehealth, including video and phone visits, for vulnerable Veterans with opioid use disorder.

Untreated opioid use disorder (OUD) among Veterans leads to serious and preventable harms including overdose and suicide. The medication buprenorphine can help prevent these harms, but due to barriers such as a lack of trained buprenorphine providers, stigma of OUD, and limited accessibility of care, many Veterans with OUD do not receive this life-saving treatment.

COVID-19 ushered in policy changes that allowed new widespread use of telehealth to treat Veterans with OUD and created a natural experiment to study the effects of telehealth. This ongoing study (April 2019–March 2024) seeks to inform improvements in access to OUD treatment by examining the effectiveness of telehealth compared to in-person buprenorphine care for Veterans with OUD by examining changes that occurred after the start of the COVID-19 pandemic. The study aims to:

• Use national VA data from pre- to post-start of the pandemic to enhance understanding of variations and changes in OUD care across VA facilities.
• Compare the effectiveness of telehealth (phone and video) to in-person OUD care on key outcomes including treatment rates, treatment retention, overdose, and care use outcomes.
• Interview Veterans and clinicians across a spectrum of experiences with telehealth delivery of OUD treatment to understand experiences and to help improve existing models of OUD care.

Findings

• Buprenorphine treatment for OUD was maintained and even increased during the COVID-19 pandemic across the VA healthcare system through a rapid shift to telehealth, at a time when other healthcare delivery decreased.
• Among Veterans receiving buprenorphine treatment, the proportion of telehealth visits increased dramatically from 12% in March 2019 to 83% in February 2021.
• Audio-only visits far outpaced video and in-person visits throughout 2020. By February 2021, audio-only visits accounted for 50% of the buprenorphine-related visits each month, with video visits at 32% and in-person care at 17%.
• Veterans who were younger, male, Black, Hispanic, or who had certain health conditions were less likely to receive any telehealth services.
• Importantly, those who received any telehealth services were more likely than those who received only in-person treatment to be retained on buprenorphine for at least 90 days, a key quality metric.

Implications

This study found that pandemic-related policy changes were associated with a dramatic increase in video and phone visits for buprenorphine treatment, at the same time as increases in the number of Veterans receiving treatment. Although differences remain regarding which Veterans receive telehealth, treatment via telehealth was associated with improved retention in care. As the U.S. debates changes to telehealth policies and VA clinics wrestle with potentially discontinuing telehealth options, study findings suggest changes may contribute to unintended disruptions in care and should be carefully considered.

Future work

Future work will focus on understanding which patients benefit from which treatment modalities (telehealth or in-person) and compare additional outcomes to understand what role telehealth should play for this Veteran population. In addition, findings will inform improvements to telehealth models and policies to engage more Veterans and further optimize care.

Principal Investigator

Lewei (Allison) Lin, MD, MS, is an HSR&D Career Development Awardee and part of HSR&D’s Center for Clinical Management Research in Ann Arbor, MI.

Related research by this investigator

Lin LA, Zhang L, Kim H, Frost MC. Impact of COVID-19 telehealth policy changes on buprenorphine treatment for opioid use disorder. American Journal of Psychiatry. October 2022;179(10):740–747.

Frost MC, Zhang L, Lin LA, et al. Use of and retention on video, telephone, and in-person buprenorphine treatment for opioid use disorder during the COVID-19 pandemic. JAMA Network Open. October 3, 2022;5(10):e2236298.

Frank CJ, Lin LA. Defining and supporting high-quality telehealth for patients with opioid use disorder: The promise and potential pitfalls of telehealth expansion. Substance Abuse. January 1, 2022;43(1):1370–1373.

View study abstract.