Access to MAT: Participants’ Experiences With Transportation,Non-Emergency Transportation,and Telehealth

Abstract

Introduction:

Access to medication assisted treatment (MAT) for opioid use disorder (OUD) in the United States is a significant challenge for many individuals attempting to recover and improve their lives. Access to treatment is especially challenging in rural areas characterized by lack of programs, few prescribers, and transportation barriers. This study aims to better understand the roles that transportation, Medicaid-funded non-emergency medical transportation (NEMT), and telehealth play in facilitating access to MAT in West Virginia (WV).

Methods:

We developed this survey using an exploratory sequential mixed methods approach following a review of current peer-reviewed literature plus information gained from 3 semi-structured interviews and follow-up discussions with 5 individuals with lived experience in MAT. Survey results from 225 individuals provided rich context on the influence of transportation in enrolling and remaining in treatment, use of NEMT, and experiences using telehealth. Data were collected from February through August 2021.

Results:

We found that transportation is a significant factor in entering into and remaining in treatment, with 170 (75.9%) respondents agreeing or strongly agreeing that having transportation was a factor in deciding to go into a MAT program, and 176 (71.1%) agreeing or strongly agreeing that having transportation helps them stay in treatment. NEMT was used by one-quarter (n = 52, 25.7%) of respondents. Only 13 (27.1%) noted that they were picked up on time and only 14 (29.2%) noted that it got them to their appointment on time. Two thirds of respondents (n = 134, 66.3%) had participated in MAT services via telehealth video or telephone visits. More preferred in-person visits to telehealth visits but a substantial number either preferred telehealth or reported no preference. However, 18 (13.6%) reported various challenges in using telehealth.

Conclusions:

This study confirms that transportation plays a significant role in many people’s decisions to enter and remain in treatment for OUD in WV. Additionally, for those who rely on NEMT, services can be unreliable. Finally, findings demonstrate the need for individualized care and options for accessing treatment for OUD in both in-person and telehealth-based modalities. Programs and payers should examine all possible options to ensure access to care and recovery.

Introduction

Medication assisted treatment (MAT) is an evidence-based treatment model that has been shown to save and improve the lives of people with opioid use disorder (OUD). ¹ Yet, people with OUD still struggle with access to MAT. In addition to a paucity of programs and prescribers, ² difficulty with transportation often presents a barrier to timely entry into and retention in treatment,^{3 -5} especially in rural communities, where the distance to services may prove prohibitive.^3,4,6 While Section 1262 of the Consolidated Appropriations Act of 2023 removed the requirement for clinicians to obtain a waiver to prescribe buprenorphine ⁷ and thus should encourage more clinicians to provide MAT, lack of access to reliable transportation, public or private, can create obstacles for those wishing to enroll or remain in treatment. ⁸ Unique populations such as those who are pregnant or parenting, or those involved in the justice system may face added burdens.^{9 -11}

Non-emergency medical transportation (NEMT) provided by state Medicaid programs is mandated by Federal law and has been found to be particularly critical for a subset of people with chronic diseases, including OUD, to access medical care.^8,12 Access to transportation services can significantly reduce missed clinic visits. ¹³ Additionally, investment in transportation services for chronic diseases may provide cost savings ¹⁴ and may be linked to improvements in health outcomes when combined with other interventions. ¹⁵ In spite of this, research highlights participants’ difficulties in using transportation services, including difficulty scheduling rides, delays in pick up, and delays in getting to appointments. ¹²

Telehealth is one option to increase access to MAT, especially in the face of transportation barriers and other barriers to in-person care. ¹⁶ The COVID-19 pandemic was a catalyst for increased use of video- and phone-based telehealth across healthcare services, including MAT.^{17 -19} Previous studies of patients’ perceptions of telehealth have demonstrated favorable opinions, with variability in satisfaction based on service, for example, medical versus behavioral health, group versus individual, ²⁰ and increasing willingness to use telehealth. ¹⁸ Video appointments for MAT yield comparable retention rates, urine drug screening results, and time to 30 and 90 days of abstinence when compared to in-person treatment.^21,22 Current literature on patient satisfaction with telehealth through the COVID-19 pandemic supports the continued consideration and study of telehealth as an option for access to MAT.^16,23 Further, ensuring that patients receive care in the modality of their choice, for example, in-person or telehealth, may improve patient satisfaction and retention in care. ²⁴

Disparities in use of telehealth for MAT have been reported. Black and lower income individuals, as well as those with low education attainment, used telehealth less frequently pre-pandemic but use of telehealth has increased in these groups. ¹⁸ Older adults use telehealth, particularly audiovisual telehealth visits, less frequently.^18,25 While rural residents in one study were less likely than urban residents to use telehealth in the first 30 days of the pandemic, those who did use telehealth were more likely to use audiovisual visits. ²⁵ Women generally prefer and use telehealth more often than men.^18,25,26

This study builds on our previously published work on factors that facilitate and hinder entry and retention in MAT from the perspective of people seeking or enrolled in treatment in West Virginia (WV)^5,27 and aims specifically to examine the roles of transportation, NEMT, and telehealth in access to MAT care. Individuals in WV with lived experience in treatment for OUD, primarily MAT, were asked to share information about whether transportation was a factor in enrolling and remaining in treatment, whether difficulty with transportation contributed to leaving treatment, their experience with telehealth, and their opinions on telehealth as compared to in-person visits for care. WV Medicaid recipients were also asked about their experiences with NEMT.

Methods

This study used an exploratory sequential mixed methods approach to understand facilitators and barriers to accessing MAT for OUD from the perspective of individuals who are or have been in treatment. The 52-question survey was developed by a review of current peer-reviewed literature plus information gathered from 3 semi-structured interviews and follow-up discussions with individuals with lived experience in MAT. These 5 individuals, termed Participant Advisors (PAs) were recruited from several MAT programs and a harm reduction program to join the research team. PAs shared their experiences of OUD and MAT program participation. They also guided development of our survey through an iterative review process to ensure readability, appropriate reading level, and appropriate language reflective of commonly used and accepted terms. We compensated the PAs for their time and expertise. Additional content validation was provided by addiction treatment professionals. The final survey was tested and approved for distribution by the PAs.

WV MAT programs were recruited for participation using data from the WV Department of Health and Human Resources, Office of Health Facility Licensure and Certification. We recruited MAT programs across the state to include racial and ethnic diversity, different MAT modalities, and individuals previously incarcerated or pregnant while in recovery.

Individuals were eligible to take the survey if they were age 18 or older and able to understand English. Participating MAT programs received the survey materials in paper-based and electronic formats, including a cover letter detailing the study and implied consent for individuals to participate. The letter stated that respondents could have somebody not associated with the program assist them in reading and responding to the survey. We collected data using papersurvey.io software, which supports online and paper-based data collection and data validation. Programs were offered $100 for survey distribution. Survey respondents were eligible for a $200 gift card prize drawing through a separate, secure data collection process.

Our survey was conducted from February through August 2021. All results were anonymous by individual and program location to protect privacy and confidentiality. Quantitative data were analyzed via descriptive statistics and chi-square tests of association using JMP Statistical Software. Results are presented using valid percentages to account for non-response per survey question. A series of chi square tests for significance was conducted on all responses to transportation, NEMT, and telehealth focused questions to examine for statistically significant associations with socioeconomic variables, that is, age, race, ethnicity, and gender identity; incarceration; employment status; and experiences entering MAT while pregnant. Qualitative data were analyzed via content analysis using inductive open coding and synthesis to determine themes and patterns in the data. This study received West Virginia University Institutional Review Board Approval (Protocol #2001837052).

Results

Twenty-one MAT programs agreed to take part in this study and 1700 surveys were distributed. Of those, 225 were returned (13.2% response rate). We did not monitor whether sites handed out all surveys provided to them; therefore, the response rate may be higher based on the actual number of surveys distributed. Results included over 500 free-text comments. Respondent quotes are included as written and intermixed for added depth. While participants had the option of completing a paper or an electronic survey, most responses were paper based (n = 196, 87.1%).

Demographics and social factors of survey respondents are presented in Table 1. Select drug use and treatment history data are presented in Table 2. Transportation factors influencing entry and retention in MAT are in Table 3 and responses specific to NEMT are in Table 4. Experiences using telehealth for MAT are presented in Table 5.

Table 1.

Demographics and Social Factors of Survey Respondents.

Age category	n	Valid (%)
18-34 years	83	39.2
35-54 years	108	50.9
55+ years	21	9.9
Total	212	100.0
Gender identity	n	Valid (%)
Female	109	51.2
Male	102	47.9
Transgender	2	0.9
Total	213	100.0
Race	n	Valid (%)
American Indian or Alaska Native	1	0.5
Black or African American	5	2.3
Multiracial	3	1.4
White	205	95.8
Total	214	100.0
Ethnicity	n	Valid (%)
Hispanic, Latino/a, or Spanish	6	3.3
Non-Hispanic, Latino/a, or Spanish	177	96.7
Total	183	100.0
Current working status	n	Valid (%)
Employed full-time	61	30.1
Employed part-time	24	11.8
Currently unemployed	118	58.1
Total	203	100.0
Payment source (check all)	n	Valid (%)
Medicaid	136	66.7
Medicare	40	19.6
Private insurance or insurance through employer	32	15.7
Full cost out of pocket	25	12.2
Sliding fee scale	9	4.4
Medicaid plus Medicare	8	3.9
Health system representation among participating organizations	n	Valid (%)
Community health centers/federally qualified health centers (FQHCs)	11	52.4
Hospitals/hospital affiliates	3	14.3
Comprehensive behavioral health centers	2	9.5
Free clinics	2	9.5
Private, faith-based organization	1	4.8
Private medical group practice	1	4.8
Private psychiatric practice	1	4.8
Total	21	100.0

Table 2.

Drug Use and Treatment History.

Duration of drug use as a problem	n	Valid (%)
Up to 2 years	10	4.9
2-10 years	88	42.9
11+ years	107	52.2
Total	205	100.0
Currently in a MAT program	n	Valid (%)
Yes	207	95.0
No	11	5.0
Total	218	100.0
Duration in MAT over time	n	Valid (%)
<2 weeks	11	5.4
2 weeks to 3 months	23	11.3
>3-12 months	48	23.6
>1-2 years	30	14.8
>2-5 years	53	26.1
>5-9 years	20	9.9
>9-20 years	17	8.4
>20 years	1	0.5
Total	203	100.0
Medications ever used for MAT (check all)	n	Valid (%)
Buprenorphine/Naloxone	187	88.6
Buprenorphine alone	41	19.4
Methadone	32	15.2
Naltrexone	27	12.8
Types of treatment utilized (check all)	n	Valid (%)
Outpatient MAT program	176	78.2
Detox facility	111	49.3
Residential treatment program	93	41.3
Inpatient (hospital) treatment facility	91	40.4
Intensive outpatient program	85	37.8
Outpatient program without MAT	71	31.6
Sober living setting	63	28.0
Ever kicked out of or discharged from MAT	n	Valid (%)
Yes	44	22.2
No	154	77.8
Total	198	100.0
If Yes, reasons for being kicked out or discharged from MAT	n	Valid (%)
I used, and that was against program rules	21	56.8
I missed too many appointments	10	27.0
I could not follow other program rules	5	13.5
I needed more intensive treatment (higher level of care)	1	2.7
Total	37	100.0
Have you been in jail or prison for any offense related to drugs?	n	Valid (%)
Yes	70	33.8
No	137	66.2
Total	207	100.0

Table 3.

Transportation factors influencing entry and retention in MAT.

Why did you decide to go into a MAT program?
I had transportation to get to appointments	n	Valid (%)
Strongly agree	97	43.3
Agree	73	32.6
Don’t agree or disagree	10	4.5
Disagree	14	6.3
Strongly disagree	15	6.7
Not applicable	15	6.7
Total	224	100.0
What kept you from going into a MAT program?
I didn’t have good transportation	n	Valid (%)
Strongly agree	22	10.4
Agree	28	13.3
Don’t agree or disagree	18	8.5
Disagree	52	24.6
Strongly disagree	41	19.4
Not applicable	50	23.7
Total	211	100.0
What helps you stay in a MAT program?
I have transportation to get to appointments	n	Valid (%)
Strongly agree	91	41.9
Agree	85	39.2
Don’t agree or disagree	12	5.5
Disagree	14	6.5
Strongly disagree	8	3.7
Not applicable	7	3.2
Total	217	100.0
Why did you – or would you – leave a MAT program?
I didn’t have good transportation	n	Valid (%)
Strongly agree	17	7.7
Agree	51	23.0
Don’t agree or disagree	19	8.6
Disagree	42	18.9
Strongly disagree	43	19.4
Not applicable	50	22.5
Total	222	100.0

Table 4.

Experiences using non-emergency medical transportation services.

Have you used the transportation system paid for by Medicaid (non-emergency medical transportation)?	n		Valid (%)
Yes	52		25.7
No	150		74.3
Total	202		100.0
What is your opinion of the transportation system paid for by Medicaid (non-emergency medical transportation)? (Check all that apply)	Selected		Not selected
	n	Valid (%)	n	Valid (%)
Easy to use	24	50	24	50.0
At times does not show up at all	19	39.6	29	60.4
Have to schedule too far in advance	16	33.3	32	66.7
Gets me to my appointments on time	14	29.2	34	70.8
Picks me up on time	13	27.1	35	72.9
Hard to use	9	18.8	39	81.3
Often late picking me up	9	18.8	39	81.3
Takes too much time to get to and from appointments	8	16.7	40	83.3
I can’t reach them when I need them	7	14.6	41	85.4
Often late in picking me up after my appointments	7	14.6	41	85.4
Often gets me to my appointments late	6	12.5	42	87.5
Not available in my area	4	8.3	44	91.7

Table 5.

Experiences using telehealth for medication assisted treatment.

Have you had any telehealth (video or telephone) visits in your MAT program?	n	Valid (%)
Yes	134	66.3
No	68	33.7
Total	202	100.0
Did you have any problems using telehealth for MAT?	n	Valid (%)
Yes	18	13.6
No	114	86.4
Total	132	100.0
What problems did you have when using telehealth for MAT? Check all that apply.
I don’t have a good internet connection	n	Valid (%)
Selected	10	66.7
Not selected	5	33.3
Total	15	100.0
It costs too much/uses too much data	n	Valid (%)
Not selected	15	100.0
Total	15	100.0
I don’t have a phone or computer to do telehealth	n	Valid (%)
Selected	3	20.0
Not selected	12	80.0
Total	15	100.0
I don’t have a private place to have the visit	n	Valid (%)
Selected	1	6.7
Not selected	14	93.3
Total	15	100.0
I don’t like using telehealth	n	Valid (%)
Selected	1	6.7
Not selected	14	93.3
Total	15	100.0
What is your opinion of telehealth visits (audio and video, such as Zoom) for prescription visits?	n	Valid (%)
Ok, but prefer in-person	64	48.5
Prefer telehealth to in-person	37	28.0
I don’t like telehealth	3	2.3
No preference	28	21.2
Total	132	100.0
What is your opinion of telehealth visits (audio and video, such as Zoom) for counseling or therapy visits?	n	Valid (%)
Ok, but prefer in-person	62	46.6
Prefer telehealth to in-person	44	33.1
I don’t like telehealth	4	3.0
No preference	23	17.3
Total	133	100.0
Have you had any telephone-only visits for prescriptions?	n	Valid (%)
Yes	72	54.5
No	60	45.5
Total	132	100.0
What is your opinion on telephone-only visits for prescriptions?	n	Valid (%)
It’s ok, but I’d rather meet in-person	28	41.2
It’s ok, but I’d rather have video visits	12	17.6
I’d rather have telephone visits	27	39.7
I don’t like telephone visits	1	1.5
Total	68	100.0
Have you had any telephone-only visits for counseling or therapy?	n	Valid (%)
Yes	77	58.3
No	55	41.7
Total	132	100.0
What is your opinion on telephone-only visits for counseling or therapy?	n	Valid (%)
It’s ok, but I’d rather meet in-person	36	48.0
It’s ok, but I’d rather have video visits	14	18.7
I’d rather have telephone visits	22	29.3
I don’t like telephone visits	3	4.0
Total	75	100.0

Most respondents (n = 207, 95.0%) were currently enrolled in a MAT program, with the majority (n = 121, 59.7%) reporting they had been in MAT for over 1 year and 18.8% (n = 38) reporting they had been in MAT for 5 years or longer. The vast majority of respondents said their drug use had been a problem for greater than 2 years, with 42.9% (n = 88) of respondents reporting that their drug use had been a problem for 2 to 10 years and 52.2% (n = 107) reporting 11 years or more. While most respondents reported having used buprenorphine/naloxone (n = 187, 88.6%), many had also used other medications for treatment of OUD. Two thirds of respondents (n = 136, 66.7%) identified Medicaid as their source of insurance for some or all of their care.

Patient-Centered Care

One theme that emerged in our interviews with the PAs was the importance of individualized, patient-centered care. Both quantitative and qualitative results demonstrated varied opinions and experiences. Responses to several of the survey questions did not show a clear majority preference. This was well summarized by a PA who stated, “And it all comes down to what works for you. And giving people the ability to find what works for them is probably the kindest thing that we can do.” Even during conversations among the 5 PAs there were, at times, differences of opinion on various topics. One of the PAs recognized this and reflected, “What I am saying is that everybody is so genuinely different when it comes to their path of recovery.”

Transportation as a Facilitator or Barrier to Care

When asked why they decided to go into a MAT program, 170 respondents (75.9%) agreed or strongly agreed that having transportation to get to appointments was an enabling factor. Similarly, 176 (81.1%) agreed or strongly agreed that having transportation to get to appointments helped them remain in treatment. Fifty respondents (23.7%) agreed or strongly agreed that lack of good transportation kept them from going into a program and 68 (30.6%) agreed or strongly agreed that lack of good transportation was a reason they had left or would leave treatment. Respondents who reported they were not working right now (n = 49, 43.0%) were significantly more likely to agree or strongly agree that getting help with transportation was a factor for staying in a MAT program than those working (n = 19, 22.6%), χ2 (1. N = 198) = 9.139, P = .025, OR = 2.23, 95% CI [1.37, 4.85]. Middle-aged respondents (age 35-54) and older respondents (age 55+) were more likely to identify transportation as a barrier to getting into MAT (χ² [2. N = 202] = 7.1, P < .05) and staying in MAT (χ² [2. N = 210] = 6.1, P < .05) than those under age 35. We did not find associations between people who had been previously incarcerated and responses related to transportation. We did not have enough people reporting difficulty getting into treatment while pregnant to determine whether transportation was a factor.

Use of Medicaid Non-emergency Medical Transportation

Fifty-two respondents (25.7%) had experience with using the NEMT system provided by the WV Medicaid program. Of the 48 respondents who answered the follow-up question on opinions regarding NEMT, 24 (50.0%) found it easy to use, though only 13 (27.1%) said it picked them up on time and only 14 (29.2%) said it got them to their appointment on time. Nine (18.8%) of those who had used it found NEMT hard to use due to a variety of factors, including an inability to reach the service when needed (n = 7, 14.6%); often being picked up late (n = 9, 18.8%); often being dropped off late at the appointment (n = 6, 12.5%); or being picked up late after the appointment (n = 7, 14.6%). A large percentage (n = 19, 39.6%) said that at times NEMT does not show up at all. As one of our PAs put it, “I’ve missed three appointments because they just started to not even show up. And the government is paying them to come pick me up and take me to my appointment.” Having to schedule too far in advance (n = 16, 33.3%) and the amount of time it took getting to and from appointments (n = 8, 16.7%) were other reasons identified as making the NEMT system hard to use. Four respondents (8.3%) said the service was not available in their area.

Respondents who reported they were not working (n = 35, 32.1%) were significantly more likely to use NEMT than those working (n = 14, 17.5%), χ2 (1. N = 189) = 5.128, P = .023, OR = 2.23, 95% CI [0.22, 0.91].

Experience With Use of Telehealth Visits

Survey distribution began in February 2021 during the COVID 19 pandemic when many organizations had converted care to telehealth. Two thirds of respondents (n = 134, 66.3%) had participated in telehealth video or telephone visits while in a MAT program. Eighteen (13.6%) reported having had problems with telehealth, including not having a good internet connection (n = 10, 66.7%), not having a phone or computer (n = 3, 20.0%), and not having a private place for the visit (n = 1, 6.7%). Female respondents (75.3%) were significantly more likely than males (56.8%) to report using telehealth (video or telephone) visits in a MAT program, χ² (1. N = 196) = 7.4, P < .01, OR = 2.3, 95% CI [1.3, 4.2]. We did not find any associations between use of telehealth and age or previous incarceration.

For those who had used telehealth video visits, the survey asked about preferences for prescription (medical) visits and counseling/therapy (behavioral health) visits. Sixty-four (48.5%) preferred in-person to telehealth for medical visits. Similarly, 62 (46.6%) preferred in-person behavioral health visits.

Despite the large number preferring in-person visits, a fair percentage of respondents indicated a preference for video appointments. Thirty-seven respondents (28.0%) preferred telehealth video appointments over in-person for medical visits, while 44 (33.0%) preferred telehealth video over in-person for behavioral health visits. This point is illustrated in comments by 2 respondents: “I like it because it helps with my work” and “I like both, but telehealth I can stay home with my kids & attend. I do miss in-person.” Likewise, telehealth is important for those who travel significant distances to obtain treatment: “Would be nice to have them every other appt. Have to drive (122 miles round trip) to every appointment.” A small minority (n = 3, 2.2%) for medical and (n = 4, 3.0%) for behavioral health visits reported they did not like telehealth, while 28 (21.2%) had no preference for a medical visit and 23 (17.3%) had no preference for a behavioral health visit. As one respondent put it, “Doesn’t matter as long as I can get my session.”

Experience With Use of Telephone Visits

Over half of respondents (n = 72, 54.6%) who reported using telehealth had participated by telephone for a medical visit; a similar number had experienced a behavioral health visit by telephone (n = 77, 58.3%). For medical visits, 28 respondents (41.2%) stated they preferred in-person appointments to phone visits. For behavioral health, 36 (48.0%) preferred in-person visits. One respondent said, “My therapist’s video wouldn’t work - it wasn’t the same as being able to see her.” When asked to compare video visits to phone calls, 12 (17.7%) and 14 (18.7%) preferred video visits to phone calls for medical and behavioral health visits, respectively. Twenty-seven individuals (39.7%) preferred phone calls for a medical visit. Fewer people (n = 22, 29.3%) preferred phone calls for behavioral health visits. Even so, telephone visits were clearly an important option to have available, as this respondent indicated: “I prefer telephone not video because I’m always at work and can’t do video.”

One survey respondent noted the following regarding access to telehealth during the pandemic: “But was Grateful to have during Covid-19 - kept me in contact with my doc & therapist & kept me on track. So grateful.”

Discussion

Our results show that individuals in MAT programs want a variety of options for accessing medical and behavioral health treatment for OUD. Programs and payers should examine all possible sources to improve access to MAT, including various transportation options and telehealth.

Transportation

Our findings demonstrate that transportation plays a significant role in many people’s decisions to enter and remain in treatment. The fact that transportation did or would play a role in one-third of patients’ ability to remain in treatment is particularly concerning given that retention in MAT beyond 90 days is more likely to be associated with long term recovery. ²⁸ Additionally, one-third of respondents who had been dismissed from MAT reported this was due to missed appointments; inadequate transportation may have been a factor in being discharged from care.

Our analysis suggests that middle-aged and older participants in WV may experience more difficulties with transportation than those under age 35. Additionally, individuals who are unemployed may need transportation assistance to remain in treatment. Varied options for addressing transportation needs for chronic conditions have been examined in previous studies ¹⁵ and could be used to guide programs seeking to increase MAT participation and retention.

NEMT

Respondents’ experiences with NEMT point to a need for improvements in these services. Although our study was conducted in WV, the results are consistent with previous reports in a nationwide examination of user experience with NEMT services. ¹² The fact that, even among those who found the service easy to use, close to one-third reported delays in pickup and drop-off times illustrates the shortfalls of the current systems.

Even more concerning for those relying on NEMT is missing appointments altogether. Since programs may penalize or even discharge people from care for tardiness or missed appointments, unreliable services jeopardize people’s retention in care and therefore their sobriety. Further, unreliable NEMT services may make scheduling other activities, such as work or childcare, more difficult for MAT participants. One study in a Medicaid population found that treatment for OUD with medication was associated with a higher likelihood of being employed and higher earnings compared to those not in treatment. ²⁹ Our results suggest that higher reliability of NEMT services may help individuals remain in treatment and may increase the likelihood that they become employed. Beyond merely complying with the Federal mandate for NEMT, states should work to make sure services are reliable, timely, and easy to access and schedule.

Telehealth

Similar to previous findings that reported a preference for in-person care,^30,31 more respondents in our study preferred in-person visits to audio-video visits (such as Zoom) or telephone visits, though the number preferring in-person visits did not reach a majority. However, a substantial number preferred telehealth and very few responded that they did not like telehealth. Programs should consider flexibility and patient preference with respect to in-person versus telehealth appointments.

Findings from our study show that telehealth options will help some people remain engaged in care, particularly women, as well as those with work or family obligations. Similarly, telehealth could provide an alternative for middle-aged and older individuals who are struggling with transportation. Congress extended certain telehealth flexibilities through December 2024 through provisions in the Consolidated Appropriations Act of 2023 ⁷ and a final set of regulations on telehealth by the U.S. Drug Enforcement Administration (DEA) and the Department of Health and Human Services (HHS) is expected by fall of 2024. ³² We support making these flexibilities permanent. However, additional changes are needed to ensure that telehealth can be accessed equitably.

Given that almost 15% of respondents reported problems with telehealth, programs and payers should work to bolster systems that enable those services to remain a choice for patients. States, particularly rural states, with limited broadband access should continue to make expansion of broadband services a high priority. Federal initiatives such as Internet for All ³³ are one source of partnership and support, including funding. To further support the sustainability of telehealth, payers should provide adequate reimbursement for telehealth services.

Limitations and Strengths

Our survey was distributed primarily through community based Suboxone (buprenorphine/naloxone) programs in WV Community Health Centers/Federally Qualified Health Centers, and results may not be applicable to other geographic regions or treatment settings. Only 4 respondents indicated they had used methadone exclusively, which limited our ability to perform analyses on this group; therefore, our results may not fully reflect the perspective of individuals in methadone programs. Most respondents were White, non-Hispanic, and English-speaking, reflective of the demographics of WV, ³⁴ and results may not reflect the experience of more diverse populations.

While our estimated 13.2% response rate could be seen as a limitation, we believe that results from 225 respondents is robust for this population and a strength of the study.

This study adds to the literature by reporting the perspectives of people in recovery on barriers to entry into and retention in treatment. Additionally, this study provides a more in-depth look into participant experience with NEMT than is currently available.

Implications for Future Research

While our study was conducted during the COVID-19 pandemic, we did not attempt to determine whether respondents’ experience with transportation, NEMT, and telehealth differed compared to use pre-pandemic. Further study is needed to examine access barriers experienced by people in methadone treatment, those previously incarcerated, and parents and people who have been pregnant while in treatment. Future research should examine the use of telehealth compared to broadband access. Emphasis should be placed on exploring and disseminating successful approaches to facilitating telehealth access, especially for low-income and rural populations.

There is very little published on the use of NEMT and whether those services are meeting patients’ needs. Frequent monitoring and public reporting of patient experience with NEMT services can help inform policy and hold Medicaid programs and NEMT vendors accountable for providing adequate services. In addition, future research could further explore whether access to transportation services improves the likelihood of becoming or remaining employed during treatment for OUD.

Conclusions

This study demonstrates that access to MAT remains a barrier for many people seeking treatment and that transportation is an important factor in people’s ability to enter and remain in MAT for OUD. Additionally, both NEMT and telehealth are important options for access to MAT in WV. Programs and payers can improve entrance and retention in MAT by ensuring that these options are available and accessible to people with OUD. Patient preference should be taken into account when determining options for telehealth or in-person visits for medical and behavioral health visits. NEMT programs should be monitored to assure timely, reliable service. Finally, additional, creative options for addressing transportation needs should be considered.