Use of telehealth for opioid use disorder treatment in primary care settings serving the underserved: A mixed-methods study

Context: COVID-19 provided an unprecedented opportunity to understand the use of telehealth for opioid use disorder (OUD) treatment in primary care settings. Objective: 1) Assess characteristics associated with having more telehealth vs. in-person visits and 2) understand clinical team members' experiences delivering OUD treatment via telehealth. Study Design: Mixed methods. Analysis: Logistic regression; Inductive qualitative approach. Setting: Two family medicine clinics (1 rural; 1 urban federally-qualified health center (FQHC). Population: EHR data from patients with 31 primary care visit and 31 OUD medication order from 3/8/2020-9/1/2021 (N=741 patients). Semi- structured interviews with clinic team members of OUD treatment programs at each clinic (N=10). Outcomes: 1) Binary variable: 350% of visits via telehealth vs. 350% in-person by patient characteristics and 2) clinical experiences treating OUD via telehealth. Results: Most patients had 31 telehealth visit, with the majority by phone vs. video. Patients in the rural clinic (vs. urban FQHC; OR=0.05; 95% CI:0.03-0.08), those with 31 psychiatric diagnosis (vs. none; OR=0.49, 95% CI:0.29-0.82) and new patients (vs. returning; OR=0.47; 95% CI:0.27-0.83) had lower odds of having more telehealth visits than in-person. Interviews supported quantitative findings. Respondents noted telehealth constraints, including among patients in rural areas with limited/no internet access, those with more psychological burden who tended to respond better to the intangible benefits of in-person visits (e.g., seeing more subtle visual cues), and those who were more socioeconomically disadvantaged who did not always have phone/internet access. Building rapport in telehealth visits was described as being more challenging with newer patients compared to returning patients, though not impossible. Noted benefits of telehealth included convenience and increased flexibility for patients for whom coming to the clinic on a regular basis could be burdensome. Conclusion: Findings revealed differences in preferred delivery mode (i.e., telehealth vs. in-person) and modality (phone vs. video) for treatment by certain patient characteristics. Clinicians identified drawbacks and benefits of use of telehealth to treat OUD. Length of time in OUD program, patient resources, and comorbidities should be considered in determining the most appropriate OUD treatment mode and modality in primary care settings providing care to underserved popula