Provider and Payer Perspectives on the Impact of the COVID-19 Pandemic on Patients With Opioid Use Disorder: Multi-Stakeholder In-Depth Interviews

The United States continues to face a serious opioid epidemic, and this crisis was magnified during the COVID-19 global pandemic. In 2020, an estimated 9.5 million people aged ≥12 years in the United States misused opioids, and 2.7 million people had opioid use disorder (OUD).¹ That same year, only 798,000 people aged ≥12 years received treatment for opioid misuse, including 278,000 with a past-year OUD diagnosis.¹

Patients with OUD often require access to medications for OUD; behavioral health services, including psychosocial counseling; medical care, including treatment of underlying and comorbid conditions; case management; and other recovery support services.² Patient-centered, evidence-based treatment with approved medications for OUD, such as buprenorphine, methadone, and naltrexone, in addition to psychosocial counseling, are recommended by the American Society of Addiction Medicine’s practice guidelines for the treatment of OUD.³ To receive medications for OUD, continued interaction with the healthcare system is required for counseling, routine drug screenings, prescription refills for oral or sublingual OUD medications, and provider administration of injectable or implantable extended-release OUD-medication formulations.²

The barriers to access created by the pandemic are especially impactful for patients with OUD because they require frequent touchpoints to continue receiving treatment across several settings.¹ These treatment settings include general outpatient locations such as clinics, intensive outpatient treatment or partial hospitalization programs in specialty facilities, residential addiction treatment facilities, and hospitals.³ Clinicians have to consider a patient’s psychosocial situation, co-occurring disorders, and opportunities for treatment retention in balance with risks for diversion to determine the appropriate treatment setting.³ The many components of this multifactorial treatment approach were difficult to balance during the COVID-19 pandemic.⁴

The global COVID-19 pandemic has had a significant impact on healthcare resource distribution and utilization in the United States, thus exacerbating the ongoing challenges encountered in the management of the national opioid epidemic. During the initial stages of lockdown resulting from COVID-19, a number of patients lost their insurance coverage because of unemployment, whereas some hospitals and other healthcare facilities had significant financial losses.⁵ Furthermore, racial and ethnic disparities in healthcare have been exacerbated by the pandemic.⁵ All of these factors in unison have resulted in a public health crisis. Patients with OUD are particularly vulnerable to the impact of COVID-19 because of greater marginalization, preexisting difficulty in accessing care, imposed restrictions on drugs, the closure of treatment and recovery centers, increased risk for life-threatening withdrawal, and the use of illicit opiates.⁴ Although overdose deaths were already increasing in the months before the COVID-19 pandemic, a 2020 analysis by the Centers for Disease Control and Prevention (CDC) reported a concerning acceleration of the increase in drug overdose deaths, with the largest increase recorded from March 2020 to May 2020, which coincided with the implementation of widespread mitigation measures for the COVID-19 pandemic.⁶

Several factors associated with the COVID-19 pandemic have negatively influenced access to treatment for patients with OUD, but limited research on this topic has been published to date. Even before the COVID-19 pandemic, one study reported that among 6451 commercially insured patients with nonfatal opioid overdose, Black patients were half as likely as non-Hispanic White patients to obtain follow-up appointments for OUD care after discharge from the emergency department.⁷ The results of another study showed that racial segregation predicted differences in access to medications for OUD across 3142 US counties.⁸ These disparities are increasingly concerning because the COVID-19 pandemic has disproportionately affected vulnerable and marginalized patient populations.⁹ In addition, patients who are homeless have an elevated risk for community transmission of COVID-19 and face significant barriers in accessing healthcare.¹⁰ Protocols intended to limit person-to-person transmission of COVID-19 also limited access to care for patients with OUD, and patients also may have been reluctant to enter healthcare facilities because of fears of contracting the virus.¹¹ Furthermore, a retrospective case-control study of electronic health records demonstrated that patients with OUD had a significantly increased risk for contracting COVID-19, thus highlighting that OUD treatment is an essential component of their health and the health of their communities.¹²

To better understand the level of impact that the COVID-19 pandemic has had on the management of OUD, 20 in-depth interviews were conducted with US payers and healthcare providers from various practice settings.

Methods

US healthcare providers and payers participated in 30-minute in-depth interviews conducted by telephone to assess the impact of the COVID-19 pandemic on the management of OUD. Payers meeting the study’s inclusion criteria were recruited by Cencora from its proprietary managed care network, a market research panel of more than 160 managed care representatives that includes medical and pharmacy directors, healthcare executives, and other managed care experts. Qualified healthcare providers were enlisted by a third-party recruiting partner, M3 Global Research, and included physicians, nurse practitioners, physician assistants, and clinical pharmacists. The participants from various healthcare settings were recruited to provide a diverse and robust variety of responses. The represented healthcare settings included large hospitals and healthcare systems, small hospitals and healthcare systems, nonrural private practices, rural private practices, opioid treatment programs, criminal justice, and health plans. Healthcare providers were required to be waivered to prescribe medications for OUD and to be actively involved in the management of patients with OUD at their organization. Provider specialties included addiction medicine, psychiatry, emergency medicine, and family practice.

All interviews were conducted by the same Cencora consultant on behalf of the research sponsor, Indivior, between November 12, 2020, and December 7, 2020. Once interviews were completed, the participants received a prespecified honorarium payment based on fair market value. The participants were blinded to the identity of the sponsor and the sponsor was blinded to the identity of the participants. Interviews were recorded with permission of the participants and were then transcribed, with the resulting data compiled in a Microsoft Excel spreadsheet and saved on Cencora’s private servers. Coding was completed by a single author without the use of any coding tree or software. The result themes and trends were derived from the collected data in accordance with phenomenology as the underpinning qualitative methodology for this research.

The 3 primary topics of discussion were the impact of COVID-19 on patients with OUD, the impact on healthcare organizations that manage these patients, and the potential solutions to address COVID-19–related challenges and improve access to care for patients with OUD during the pandemic. To understand the impact of COVID-19 on the management of patients with OUD, the participants were asked several questions that focused on addressing the barriers that this patient population faces when accessing care, the changes in medication formulations and dosages as a result of the pandemic, and the trends in patient health outcomes throughout the COVID-19 pandemic. The participants were asked how their organizations were impacted as well; specifically, if they had any changes in providing patient access to medications or psychosocial care, changes in available staff or resources, trends in the number of patients with OUD who received treatment during the pandemic, and barriers to monitoring their patient population. In addition, the participants were asked about solutions to overcome some of these barriers, such as the use of telemedicine and other strategies implemented in their respective organizations. The participants were also asked about possible resources that drug manufacturers could provide to help manage this patient population, as well as the best practices for managing patients with OUD during the COVID-19 pandemic.

Results

A total of 20 participants were interviewed, including 17 (85%) healthcare providers and 3 (15%) payers. A detailed breakdown of the participants’ roles and practice settings is shown in the Table. The insights collected from these interviews highlighted the COVID-19–related challenges that healthcare providers and payers continued to observe during the ongoing pandemic, as well as the strategies implemented by their respective organizations to overcome these challenges to better meet the needs of patients with OUD.

The vast majority (85%) of participants agreed that patients with OUD had more barriers to care during the COVID-19 pandemic, including care accessibility, financial struggles, lockdown protocols, and lack of access to support groups. Several treatment facilities reduced the operating hours and number of appointments available, limiting the ability of patients with OUD to receive medications for OUD. In addition, many patients lost their jobs and their health insurance, and the affordability of visits and medications limited their access to care. The participants with limited resources, especially those who are homeless, had more difficulty accessing in-person care because of reduced public transportation options or virtual care as a result of a lack of internet connectivity and/or access to technology in public libraries or other facilities. Although lockdown protocols varied regionally, more strict lockdown protocols forced organizations to adapt, and many struggled to provide adequate care for the OUD patient population, especially during the initial stages of the COVID-19 pandemic.

More than half (55%) of the participants reported that, in general, their patients stayed on the same medication dosage and/or formulation during the pandemic. As shown in Figure 1, 25% of the participants noted a trend toward a greater use of extended-release medications for OUD formulations when appropriate, whereas only 5% of the participants reported that their patients switched to sublingual formulations during the pandemic. Furthermore, 25% of the participants reported that their patients received increased doses of medications and 10% reported their patients extended the duration of medications for OUD refills. Other notable trends included additions, changes, or increased doses of medications for the treatment of comorbid anxiety and/or depression, as reported by 20% of the participants.

In all, 75% of the participants noted that patients with OUD had worse health outcomes during the pandemic than before the pandemic. As shown in Figure 2, these trends included an increase in overdose rates (45%), an increase in emergency department visits (45%), a decrease in adherence to medications (25%), a decrease in in-person office visits (20%), and an increase in relapse rates (20%).

In addition to describing COVID-19–related challenges for patients with OUD, the participants also described the pandemic’s impact on their respective organizations. A total of 85% of the participants agreed that the pandemic negatively impacted their organization and their ability to provide quality care to patients with OUD. The participants reported difficulties with coordinating care for patients with OUD and providing treatment with limited-to-no face-to-face contact during the pandemic. In addition, many organizations had to shift resources, including bed space, personnel, and funding, to the treatment of patients diagnosed with COVID-19. This unanticipated shift in resources often led to a reduction in available appointments for the management of patients with OUD. The remaining appointments had to be prioritized for new or unstable patients with OUD. The psychosocial aspect of care also became more challenging, because patients with OUD often required greater levels of psychosocial support during the pandemic than they previously did. Furthermore, the participants reported that several clinics lost a substantial amount of revenue during the pandemic, forcing some to lay off staff, reduce their hours of operation, or even temporarily or permanently shut down.

As shown in Figure 3, resource changes resulting from the COVID-19 pandemic were common, with 70% of the participants reporting substantial impacts on staffing at their organization. Nearly half (45%) of the participants reported that their organization lost staff, and 20% mentioned that their organization either had to shift staff around or reduce clinic hours. However, all 3 payer participants did not note any specific changes in staffing in their respective settings. These changes suggest that resources for the management of patients with OUD diminished during the pandemic and contributed to challenges for this patient population to access timely and regular care.

As shown in Figure 4, the number of patients with OUD who received treatment during the pandemic decreased overall, although some participants stated that they saw an increase in their organization. In all, 50% of the participants stated that the number of patients with OUD who received treatment at their organization had decreased between 5% and 50%, with an average decrease of approximately 20%. Of the participants, 25% stated that the number of patients with OUD who received treatment at their organization remained the same. A total of 20% of the participants stated that their organization treated 10% to 40% more patients with OUD during the pandemic, with an average increase of approximately 25%.

The participants reported that their organizations had a difficult time monitoring patients with OUD during the pandemic. The barriers to monitoring that were mentioned by the participants included limited access to counseling, an inability to perform urine drug screening, patient transportation challenges and income limitations, delays in establishing the telemedicine infrastructure, and worsening compliance, primarily as a result of decreased clinic access.

The participants reported that telemedicine was the most frequently adopted solution to overcoming some of the barriers to care for patients with OUD during the pandemic. Overall, 75% of the participants stated that patients responded positively to using telemedicine, whereas the remaining participants (25%) stated that telemedicine was met with a mixed response. Telemedicine worked best for younger (aged ≤50 years) and more stable patients with OUD, but it proved to be more challenging for those who were older (aged >50 years), less stable while receiving medications, or had social vulnerabilities, such as limited internet access and lack of access to smartphones or computers.

Aside from telemedicine, other solutions reported by the participants included providing medication refills without face-to-face visits, frequent remote patient outreach, curbside urine drug screening and visits, online counseling and virtual support groups, extended hours for help lines, and in-clinic telemedicine visits using computers in separate rooms. In response to these barriers, the participants noted various ways that their organizations have modified treatment for patients with OUD, including a larger reliance on nurse care managers, conducting counseling visits over the phone, conducting frequent remote touchpoints with patients, and working to adapt to the use of telemedicine.

The participants noted that telemedicine should not be viewed as a one-size-fits-all solution, and they recommended several best practices that their organizations successfully implemented to meet the needs of patients with OUD during the COVID-19 pandemic. In general, the recommended best practices centered around 2 key themes: awareness of patient vulnerabilities and the importance of tailoring care to their specific needs, and that continuous patient support and accountability were essential for success. A physician participant from a rural private practice reiterated that “this pandemic has served to reinforce how important accountability is for the patients; whenever there’s less accountability, we see an uptick in relapse.”

Being cognizant of each patient’s social determinants of health and evolving circumstances during the pandemic was important when considering telemedicine as an alternative to in-person care. A physician assistant participant from a large health system stated, “Don’t be overly restrictive. Give the patient the ability—if they can—to get their care remotely. If they have that access and if they feel comfortable with it, then let them do it. Try it and see how they do, and if they do well, or they do well enough, then continue that remote patient monitoring with Halo or whatever telemedicine application that you use.” One payer participant noted that his organization loosened restrictions and prior authorization criteria to improve access to medications for OUD during the pandemic. Frequent touchpoints for patients and proactive communication were also important practices to maintain for optimal patient monitoring during the pandemic, either virtually or in person, if possible.

The participants also described the importance of coordinating care with other institutions and understanding federal and state regulations regarding reimbursement for phone-based and telemedicine-based patient interactions. As a nurse practitioner participant from an opioid treatment center shared, “One of the things I learned from being where I am now, that was different from before the pandemic, was appreciating how essential it is to have a health coach available and case management or a social worker to help with patient transitions.” Overall, the participants felt that organizations must find a balance between implementing COVID-19 safety precautions and providing timely access to care for patients with OUD.

Finally, participants were asked about resources that pharmaceutical manufacturers could provide that would help with the management of the patient population with OUD. Some of the suggestions included providing a hotline for emotional support, developing educational resources for providers and patients, increasing the availability of patient assistance programs and rebates, and providing resources to connect patients with treatment facilities.

Discussion

The COVID-19 pandemic had a significant impact on the management of patients with OUD, especially in 2020. The participants in this qualitative study with US healthcare providers and payers highlighted multiple barriers to accessing care and organizational difficulties that have resulted in worse health outcomes for patients with OUD during the pandemic. The most common barriers noted by participants were care accessibility, financial struggles, lockdown protocols, and access to support groups. The organizational difficulties that were noted included challenges with providing high-quality care, reduced personnel, meeting the increased need for psychosocial care, and sizable losses in revenue. Although telemedicine and other solutions offer some promise to overcoming these barriers, they are not effective tools for every patient. The management of OUD requires a very individualized approach, and additional solutions to ensure continuity of care are necessary to improve outcomes in this vulnerable patient population.

Insights from these in-depth interviews align with the findings of other studies that have examined the negative impact of the COVID-19 pandemic on patients with OUD.^13,14 The results of a data analysis of emergency medical services in Kentucky from January 2020 to April 2020 showed a 17% increase in the number of opioid overdose–related calls by emergency medical services for transporting patients to an emergency department and a 50% increase in emergency medical service calls for suspected opioid overdoses with deaths at the scene.¹³ Another study described changes in a large primary care institution where in-office visits and in-person urine drug screening were halted during the pandemic, resulting in patients having difficulty in accessing care.¹⁴ Consequently, the institution had to rapidly adopt telemedicine services to provide care virtually.¹⁴

The rapid shift to telemedicine was essential to providing care to this patient population during the pandemic in 2020, but it is unclear if this approach constitutes an equitable long-term solution for managing patients with OUD. The findings from this qualitative study suggest that telemedicine is more likely to be successful with certain patient subgroups, specifically younger (aged ≤50 years) and more stable patients. Organizations that continue fully relying on telemedicine as a solution to providing care to patients with OUD may create further health disparities in an already marginalized patient population. Of note, a recent systematic literature review identified poor technical literacy as a key barrier to using telemedicine in older (aged >50 years) patient populations.¹⁵

A common suggestion by interview participants was improving access to support services and other resources for patients with OUD, including educational materials and helplines. The Health Resources and Services Administration provides links on its website to several publicly available resources to help providers and patients manage OUD, including grants and best practices for the implementation of telemedicine to improve access to treatment in rural, frontier, and underserved communities with high need.¹⁶ Similarly, the CDC provides a list of COVID-19–related questions and answers for patients with OUD and medical professionals, as well as a toolkit of COVID-19 resources for organizations working with this patient population.^17,18 In addition, the CDC has developed a Health Alert Network Advisory to alert public health departments, healthcare professionals, first responders, harm reduction organizations, laboratories, and medical examiners of the trends in patients with substance use disorder, such as the concerning increase in drug overdose deaths that occurred in 2020.⁶ Furthermore, the American Society of Addiction Medicine published a 2020-focused update to the National Practice Guidelines for the treatment of OUD, stating that following these guidelines is especially critical in the context of the negative impact that the COVID-19 pandemic has had on patients’ access to evidence-based treatment.^3,19

In late 2022 and beyond, with many COVID-19 restrictions being lifted, it will be important for healthcare providers to reassess their care strategies and care delivery models for patients with OUD. Finding a balance between virtual and in-person meetings based on patients’ outcomes and preferences will be essential. Although telemedicine provides a convenient way to deliver care, that convenience should never come at the cost of the quality of care the patient is receiving. For example, if a patient is less attentive or less engaged during telemedicine visits, the provider may want to opt for a hybrid model where the patient can alternate between in-person appointments and virtual ones. Similarly, if a patient’s outcomes seem to be declining, increasing the frequency of office visits and having more opportunities to connect through in-person appointments may be beneficial. On the other hand, tech-savvy patients who consistently miss in-person appointments because of transportation challenges (eg, having no access to a reliable car or living in a rural area that is far from the nearest available clinic) may be switched to a more remote healthcare delivery model, as appropriate.

Furthermore, policies that successfully expanded access to medications for OUD during the initial stages of the COVID-19 pandemic should be maintained in states where they were enacted and mirrored by states that have not yet adopted those policies. Given that <15% of patients with OUD received treatment with medication before the pandemic,¹ continuing to promote policies that improve access to all formulations of medications for OUD will hopefully increase the percentage of patients who benefit from treatment with medication in the future.

Limitations

Overall, the findings of this qualitative analysis support a growing evidence base that suggests that patients with OUD had significant barriers to care during the pandemic; however, there are several limitations that should be considered when interpreting the results of this study. First, the collected insights were qualitative in nature and were based on a relatively small sample size of 20 participants; therefore, the findings should not be considered generalizable to the broader healthcare provider or payer populations in the United States.

Second, participant responses to interview questions varied widely, indicating that adaptations to providing care during the pandemic likely differed considerably based on the organization type, financial resources, practice setting, patient demographics, geography, county-specific COVID-19 restrictions, and other variables. Furthermore, changes in access to care and solutions to overcome them have substantially evolved from the initial lockdown phase in March and April 2020 to the later stages of the pandemic, where many restrictions were reduced and eventually lifted. Payer insights were limited to only 1 participant from the health plan perspective and 2 participants from the criminal justice perspective.

Finally, patient-related insights were shared from the payer and provider perspectives because patient interviews were not included in the scope of this research.

Conclusion

This qualitative analysis provides a baseline for understanding the impact of the COVID-19 pandemic in 2020 on patients with OUD and the organizations that offer care to these patients; however, further research is needed to gauge the magnitude of those impacts in 2021 and beyond. Database analyses could be conducted when sufficient data are available to quantify the changes in health outcomes that patients with OUD had in 2020, 2021, and 2022 to observe how trends have evolved from the initial lockdown to COVID-19 restrictions being progressively lifted.

Additional studies may also be conducted to better understand how solutions such as telemedicine have impacted care for certain subgroups of patients with OUD, including patients who are elderly and those with various social vulnerabilities. The balance between in-person appointments and virtual patient visits continues to vary widely across healthcare organizations, providers, and patients in today’s OUD care delivery model. Policies that improve access to medications for OUD should continue to be encouraged to increase the percentage of patients receiving medication as part of their treatment plan.

Acknowledgments
The authors would like to thank Maria Rugani, for her support with coordinating the recruitment of interview participants, and Christina Schnell, for her support with copyediting the manuscript.

Funding Source
This study was fully funded by Indivior.

Author Disclosure Statement
At the time this research was completed, Dr Abdel-Sattar, Dr Cook, and Dr Maiese were employees of Cencora (formerly Xcenda/AmerisourceBergen), which received funding to assist in the completion of this study. Dr Cook and Dr Maiese have no financial competing interests to declare. Dr Abdel-Sattar became an employee of Indivior in mid-January 2024, approximately 3 years following the completion of this research. Dr Wheeler, Mr Mullen, and Dr Heidbreder are employees of Indivior. Dr Santoro received honorarium at fair market value for his contributions to the study design and analysis of results.

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