Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.
Methods:
Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake (“offset”), and the share of visits completed by telemedicine (“share”).
Results:
The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.
Conclusions:
Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.
SaitzRLarsonMJLaBelleCRichardsonJSametJH. The case for chronic disease management for addiction. J Addict Med. 2008;2(2):55-65.
2.
WeisnerCMertensJParthasarathySMooreCLuY. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001;286(14):1715-1723.
3.
CohenEFeinnRAriasAKranzlerHR. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2007;86(2-3):214-221.
4.
WuLTZhuHSwartzMS. Treatment utilization among persons with opioid use disorder in the United States. Drug Alcohol Depend. 2016;169:117-127.
5.
ConneryHSMcHughRKReillyMShinSGreenfieldSF. Substance use disorders in global mental health delivery: epidemiology, treatment gap, and implementation of evidence-based treatments. Harv Rev Psychiatry. 2020;28(5):316-327.
6.
WangQQKaelberDCXuRVolkowND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry. 2021;26(1):30-39.
7.
SchulteMTHserYI. Substance use and associated health conditions throughout the lifespan. Public Health Rev. 2013;35(2):3.
8.
ZibbellJEAsherAKPatelRC, et al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018;108(2):175-181.
9.
DegenhardtLCharlsonFStanawayJ, et al. Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: findings from the Global Burden of Disease Study 2013. Lancet Infect Dis. 2016;16(12):1385-1398.
10.
TimkoCHanXWoodheadEShelleyACucciareMA. Polysubstance use by stimulant users: health outcomes over three years. J Stud Alcohol Drugs. 2018;79(5):799-807.
11.
BasuSBerkowitzSAPhillipsRLBittonALandonBEPhillipsRS. Association of primary care physician supply with population mortality in the United States, 2005-2015. JAMA Intern Med. 2019;179(4):506-514.
12.
StarfieldBShiLMacinkoJ. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.
13.
KorthuisPTMcCartyDWeimerM, et al. Primary care–based models for the treatment of opioid use disorder: a scoping review. Ann Intern Med. 2017;166(4):268-278.
14.
ColeESDiDomenicoECochranG, et al. The role of primary care in improving access to medication-assisted treatment for rural Medicaid enrollees with opioid use disorder. J Gen Intern Med. 2019;34:936-943.
15.
LinLAFernandezACBonarEE. Telehealth for substance-using populations in the age of coronavirus disease 2019: recommendations to enhance adoption. JAMA Psychiatry. 2020;77(12):1209-1210.
16.
AnayaYBMMotaABHernandezGDOsorioAHayes-BautistaDE. Post-pandemic telehealth policy for primary care: an equity perspective. J Am Board Fam Med. 2022;35(3):588-592.
17.
SyedSTGerberBSSharpLK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976-993.
18.
EyllonMBarnesJBDaukasKFairMNordbergSS. The impact of the Covid-19-related transition to telehealth on visit adherence in mental health care: an interrupted time series study. Adm Policy Ment Health Ment Health Serv Res. 2022;49(3):453-462.
19.
GreenbergBOftACLucittLHaugNALembkeA. Qualitative exploration of the psychological dimensions of telehealth shared medical appointments (SMAs) for buprenorphine prescribing. J Addict Dis. 2024;42:14-23.
20.
MarkTLTreimanKPadwaHHenrettyKTzengJGilbertM. Addiction treatment and telehealth: review of efficacy and provider insights during the COVID-19 pandemic. Psychiatr Serv. 2022;73(5):484-491.
21.
PatelSYMehrotraAHuskampHAUscher-PinesLGanguliIBarnettML. Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States. Health Aff (Millwood). 2021;40(2):349-358. doi:10.1377/hlthaff.2020.01786
JonesCMShoffCHodgesK, et al. Receipt of telehealth services, receipt and retention of medications for opioid use disorder, and medically treated overdose among Medicare beneficiaries before and during the COVID-19 pandemic. JAMA Psychiatry. 2022;79(10):981-992.
26.
MahmoudHNaalHWhaibehESmithA. Telehealth-based delivery of medication-assisted treatment for opioid use disorder: a critical review of recent developments. Curr Psychiatry Rep. 2022;24(9):375-386. doi:10.1007/s11920-022-01346-z
27.
CoeMALofwallMRWalshSL. Buprenorphine pharmacology review: update on transmucosal and long-acting formulations. J Addict Med. 2019;13(2):93-103.
28.
SantoTJrCampbellGGisevN, et al. Prevalence of mental disorders among people with opioid use disorder: a systematic review and meta-analysis. Drug Alcohol Depend. 2022;238:109551.
29.
PossematoK. The current state of intervention research for posttraumatic stress disorder within the primary care setting. J Clin Psychol Med Settings. 2011;18:268-280.
30.
LockeABKirstNShultzCG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015;91(9):617-624.
31.
ParkLTZarateCAJr.Depression in the primary care setting. N Engl J Med. 2019;380(6):559-568.
32.
MorlandLAWellsSYGlassmanLHGreeneCJHoffmanJERosenCS. Advances in PTSD treatment delivery: review of findings and clinical considerations for the use of telehealth interventions for PTSD. Curr Treat Options Psychiatry. 2020;7:221-241.
33.
KrzyzaniakNGreenwoodHScottAM, et al. The effectiveness of telehealth versus face-to face interventions for anxiety disorders: a systematic review and meta-analysis. J Telemed Telecare. 2024;30(2):250-261.
34.
SnoswellCLChelbergGDe GuzmanKR, et al. The clinical effectiveness of telehealth: a systematic review of meta-analyses from 2010 to 2019. J Telemed Telecare. 2023;29(9):669-684.
35.
GuillenAGReddyMSaadatSChakravarthyB. Utilization of telehealth solutions for patients with opioid use disorder using buprenorphine: a scoping review. Telemed J E Health. 2022;28(6):761-767.
36.
TilhouASDagueLSalonerBBeemonDBurnsM. Trends in engagement with opioid use disorder treatment among Medicaid beneficiaries during the COVID-19 pandemic. JAMA Health Forum. 2022;3(3):e220093.
37.
CiccaroneDShoptawS. Understanding stimulant use and use disorders in a new era. Med Clin North Am. 2022;106(1):81-97.
38.
EdinoffANKaufmanSEChauncyTM, et al. Addiction and COVID: issues, challenges, and new telehealth approaches. Psychiatry Int. 2022;3(2):169-180.
39.
CoughlinLNSalinoSJenningsC, et al. A systematic review of remotely delivered contingency management treatment for substance use. J Subst Use Addict Treat. 2023;147:208977.
40.
CoughlinLNZhangLBohnertASMaustDTGoldstickJLinL. Patient characteristics and treatment utilization in fatal stimulant-involved overdoses in the United States Veterans Health Administration. Addiction. 2022;117(4):998-1008.
41.
HootsBVivolo-KantorASethP. The rise in non-fatal and fatal overdoses involving stimulants with and without opioids in the United States. Addiction. 2020;115(5):946-958.
42.
SuenLWDavy-MendezTLeSaintKTRileyEDCoffinPO. Emergency department visits and trends related to cocaine, psychostimulants, and opioids in the United States, 2008-2018. BMC Emerg Med. 2022;22(1):19.
43.
WinkelmanTNAdmonLKJenningsLShippeeNDRichardsonCRBartG. Evaluation of amphetamine-related hospitalizations and associated clinical outcomes and costs in the United States. JAMA Netw Open. 2018;1(6):e183758.
44.
HerbstCO’ConnellMMeltonBLMoellerKE. Initiation of antipsychotic treatment for amphetamine induced psychosis and its impact on length of stay. J Pharm Pract. 2023;36(6):1324-1329.
45.
MorisanoDBaborTFRobainaKA. Co-occurrence of substance use disorders with other psychiatric disorders: implications for treatment services. Nord Stud Alcohol Drugs. 2014;31(1):5-25.
46.
AntonRFO’MalleySSCirauloDA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003-2017.
HanBJonesCMEinsteinEBPowellPAComptonWM. Use of medications for alcohol use disorder in the US: results from the 2019 National Survey on Drug Use and Health. JAMA Psychiatry. 2021;78(8):922-924.
49.
BertholetNDaeppenJBWietlisbachVFlemingMBurnandB. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165(9):986-995.
50.
AndersonPO’DonnellAKanerE. Managing alcohol use disorder in primary health care. Curr Psychiatry Rep. 2017;19(11):79. doi:10.1007/s11920-017-0837-z
51.
RomboutsSAConigraveJHSaitzRLouieEHaberPMorleyKC. Evidence based models of care for the treatment of alcohol use disorder in primary health care settings: a systematic review. BMC Fam Pract. 2020;21(1):260. doi:10.1186/s12875-020-01288-6
52.
RoereckeMVafaeiAHasanOS, et al. Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis. Am J Gastroenterol. 2019;114(10):1574-1586.
53.
BellSDaskalopoulouMRapsomanikiE, et al. Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records. BMJ. 2017;356:j909.
54.
KamathCCKelpinSSPattenCA, et al. Shaping the screening, behavioral intervention, and referral to treatment (SBIRT) model for treatment of alcohol use disorder in the COVID-19 era. Mayo Clin Proc. 2022;97:1774-1779.
55.
KelemenAMinarcikESteetsCLiangY. Telehealth interventions for alcohol use disorder: a systematic review. Liver Res. 2022;6:146-154.
56.
ConnorJPStjepanovićDLe FollBHochEBudneyAJHallWD. Cannabis use and cannabis use disorder. Nat Rev Dis Primers. 2021;7(1):16.
57.
GatesPJSabioniPCopelandJLe FollBGowingL. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016;2016(5):CD005336.
58.
BhallaIPStefanovicsEARosenheckRA. Clinical epidemiology of single versus multiple substance use disorders. Med Care. 2017;55(suppl 9):S24-S32.
59.
MackayLBachPMilloyMJCuiZKerrTHayashiK. The relationship between crystal methamphetamine use and methadone retention in a prospective cohort of people who use drugs. Drug Alcohol Depend. 2021;225:108844.
60.
SchneiderKEParkJNAllenSTWeirBWShermanSG. Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: a latent class analysis. Drug Alcohol Depend. 2019;201:71-77.
HochheimerMUnickGJ. Systematic review and meta-analysis of retention in treatment using medications for opioid use disorder by medication, race/ethnicity, and gender in the United States. Addict Behav. 2022;124:107113.
64.
BureshMSternRRastegarD. Treatment of opioid use disorder in primary care. BMJ. 2021;373:n784.
65.
BrackettCDDuncanMWagnerJFFinebergLKraftS. Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model. Subst Abuse. 2022;43(1):240-244.
HailuRMehrotraAHuskampHABuschABBarnettML. Telemedicine use and quality of opioid use disorder treatment in the US during the COVID-19 pandemic. JAMA Netw Open. 2023;6(1):e2252381.
68.
Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS): 2019. Data on Substance Abuse Treatment Facilities. Substance Abuse and Mental Health Services Administration; 2021.
69.
JonesCMByrdDJClarkeTJCampbellTBOhuohaCMcCance-KatzEF. Characteristics and current clinical practices of opioid treatment programs in the United States. Drug Alcohol Depend. 2019;205:107616.
70.
BachhuberMASouthernWNCunninghamCO. Profiting and providing less care: comprehensive services at for-profit, nonprofit, and public opioid treatment programs in the United States. Med Care. 2014;52(5):428-434.
71.
McGintyEEStoneEMKennedy-HendricksASandersKBeachamABarryCL. US news media coverage of solutions to the opioid crisis, 2013-2017. Prev Med. 2019;126:105771.
72.
CiccaroneD. The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry. 2021;34(4):344-350.
73.
CanoMOhSSalas-WrightCPVaughnMG. Cocaine use and overdose mortality in the United States: evidence from two national data sources, 2002-2018. Drug Alcohol Depend. 2020;214:108148.
FarahmandPArshedABradleyMV. Systemic racism and substance use disorders. Psychiatr Ann. 2020;50(11):494-498.
76.
StahlerGJMennisJ. The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US. Drug Alcohol Depend. 2020;212:108067.
77.
StahlerGJMennisJ. Treatment outcome disparities for opioid users: are there racial and ethnic differences in treatment completion across large US metropolitan areas?Drug Alcohol Depend. 2018;190:170-178.
78.
YearbyRClarkBFigueroaJF. Structural racism in historical and modern US health care policy: study examines structural racism in historical and modern US health care policy. Health Aff (Millwood). 2022;41(2):187-194. doi:10.1377/hlthaff.2021.01466
79.
SchiffDMWorkECFoleyB, et al. Perinatal opioid use disorder research, race, and racism: a scoping review. Pediatrics. 2022;149(3):e2021052368.
80.
Mulvaney-DayNDeanDJrMillerKCamacho-CookJ. Trends in use of telehealth for behavioral health care during the COVID-19 pandemic: considerations for payers and employers. Am J Health Promot. 2022;36(7):1237-1241.
81.
BaxterLSr BrownDLHurfordDM, et al. Appropriate use of drug testing in clinical addiction medicine. J Addict Med. 2017;11:163-173.
82.
DagueLBadaraccoNDeLeireTSydnorJTilhouASFriedsamD. Trends in Medicaid enrollment and disenrollment during the early phase of the COVID-19 pandemic in Wisconsin. JAMA Health Forum. 2022;3(2):e214752.
83.
LagisettyPGarpestadCLarkinA, et al. Identifying individuals with opioid use disorder: validity of International Classification of Diseases diagnostic codes for opioid use, dependence and abuse. Drug Alcohol Depend. 2021;221:108583. doi:10.1016/j.drugalcdep.2021.108583
84.
ShenKBarretteEDafnyLS. Treatment Of opioid use disorder among commercially insured US adults, 2008-17. Health Aff (Millwood). 2020;39(6):993-1001. doi:10.1377/hlthaff.2019.01041
85.
ShigekawaEFixMCorbettGRobyDHCoffmanJ. The current state of telehealth evidence: a rapid review. Health Aff (Millwood). 2018;37(12):1975-1982.
86.
ForsterSETorresTMSteinhauerSRFormanSD. Telehealth-based contingency management targeting stimulant abstinence: a case series from the COVID-19 pandemic. J Stud Alcohol Drugs. 2024;85(1):26-31. doi:10.15288/jsad.23-00016
87.
DagueLBurnsMFriedsamD. The line between Medicaid and marketplace: coverage effects from Wisconsin’s partial expansion. J Health Polit Policy Law. 2022;47(3):293-318.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
