Flexible delivery of opioid agonist treatment during COVID-19 in Norway: A cross-sectional survey of provider experiences

doi:10.21203/rs.3.rs-2212348/v1

Background and Aims: For patients receiving daily opioid agonist treatment (OAT) for opioid dependence, several countries relaxed treatment guidelines at the beginning of the COVID-19 pandemic. This involved longer take-home intervals for methadone and buprenorphine doses as well as a reduction in supervised dosing and drug screening. To date, little is known about the medium or long-term experience of such OAT deregulation. Therefore, we conducted a survey to explore how OAT providers perceived greater flexibility in OAT service delivery at the end of the second year of the pandemic.

Design: Nationwide cross-sectional study.

Setting: OAT units in 19 publicly funded hospital trusts in Norway.

Participants: Twenty-three (of whom 14 female; 61%) managers or lead physicians of OAT units.

Measurements: A 29-item online questionnaire comprising closed-format and open-ended questions covering: treatment provider experiences and changes in OAT service delivery during the past 12 months (January to December 2021).

Findings: In 2021, most OAT units (91.3%, n = 21) still practiced some adjusted approaches as established in the beginning of the pandemic. The most common adaptions were special protocols for COVID-19 cases (95.7%, n = 22), increased use of telephone- (91.3%, n= 21) and video consultations (87.0%, n= 20), and longer take-home intervals for OAT medications (52.2%, n = 12). The use of depot buprenorphine also increased substantially during the pandemic. According to the providers, most patients handled flexible treatment provision well. In individual cases, patients’ substance use was identified as key factor necessitating a reintroduction of supervised dosing and drug screening. Collaboration with general practitioners and municipal health and social services was generally perceived as crucial for successful treatment delivery.

Conclusions: Overall, the Norwegian OAT system proved resilient in the second year of the COVID-19 pandemic, as its healthcare workforce embraced innovation in technology (telemedicine) and drug development (depot buprenorphine). According to our nationally representative sample of OAT providers, most patients were compliant with longer take-home doses of methadone and buprenorphine. Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients.

In response to the introduction of COVID-19 social distancing measures in March 2020, drug treatment services had to quickly adapt their operating procedures to ensure continuity of care while mitigating risk of viral infection. For patients receiving daily opioid agonist treatment (OAT) for opioid use disorder (OUD), treatment guidelines were relaxed in several countries [1–4] to allow for more take-home doses of methadone and buprenorphine and decrease requirements for in-person visits and drug screening. This rapid shift to unsupervised dosing has prompted renewed calls for more flexible OAT delivery to improve access and reduce burden of treatment for patients [5].

A survey [6] conducted in July-August 2020 confirmed that more than three quarter (76–95%) of OAT units at Norwegian hospitals had implemented video- and phone consultations (“telemedicine”), extended the OAT medication take-home intervals, and reduced supervised dosing and drug screening [6]. International studies show that such greater flexibility in OAT during the first year of the pandemic was largely perceived as positive, both by treatment providers and patients [7–12]. However, reporting in these studies [ 7, 10–12] was often limited to the first wave of the pandemic in 2020, when society was fully immersed in lockdown. Meanwhile, comparatively little is known about the medium or long-term experience of COVID-19-related adaptions, including how providers have perceived flexibility in treatment as society reopened into a “new normal”.

To address this gap in knowledge, we conducted an OAT provider survey in late 2021, i.e., at the end of the second year of the pandemic. Such research can inform addiction service delivery beyond the end of the pandemic as well as during ongoing OAT reform discussions. One important aspect of a resilient health system is its capacity to adapt and learn from experiences in times of stress and shock [13]. Thus, our research question was: How did OAT providers in Norway experience adaptions in service delivery, including the use of telemedicine, in the second year of the COVID-19 pandemic?

2.1. Study design and setting

This nationwide descriptive study uses a cross-sectional design and was conducted in accordance with the STROBE statement [14]. An online questionnaire was distributed to OAT units in all 19 publicly funded hospital trusts in Norway that are responsible for the initiation and delivery of OAT treatment, in collaboration with general practitioners (GPs) and municipal health and social services [15].

As of late 2021, buprenorphine is the most prescribed OAT medication in Norway, accounting for two thirds of the OAT population in its three formulations: Buprenorphine monotherapy (38%), buprenorphine/naloxone (8%), and – following its introduction onto the Norwegian market in 2019 – buprenorphine depot injection (15%). Thirty-five percent of patients are prescribed their OAT medication by their GP [16]. The Norwegian OAT population encompasses 8,198 patients, of whom approximately one third are women. At an average age of 47 years, Norwegian OAT patients are among the oldest in Europe [16].

2.2. Recruitment and eligibility/participants

Recruitment occurred in December 2021 via the biannual OAT leader meeting in Norway and ended on 21 January 2022. At this event, 1-2 representatives from each OAT unit meet to discuss recent developments in clinical practice. The meeting attendees’ email addresses were used for distribution of the online questionnaire.

Respondents were eligible to participate in the survey if they were either the manager or the lead physician of the OAT unit. We requested to receive only one completed online questionnaire per unit, although the manager and lead physician were given the option to jointly discuss their responses where appropriate. Respondents were asked to indicate their gender as well as the number of patients treated at their unit. Respondents were not reimbursed for their participation.

The study was conducted as part of a service evaluation for the Norwegian Directorate of Health and did not require ethical review. Only program-level data without personally identifiable patient data were collected. The study was approved by the Data Protection Authority (reg. number: 552107) at the University of Oslo, and all data were stored in compliance with university standards. No external funding was received.

2.3. Measures

The online questionnaire was a modified and extended version of the 2020 survey [6] and covered questions related to treatment provider experiences and changes in OAT service delivery during the past 12 months (January to December 2021), i.e., the second year of the COVID-19 pandemic. The questionnaire contained 29 questions in total. Among these, 25 questions were in closed format (categorical) which assessed the duration of take-home doses, frequency of drug screens, COVID-19 vaccination among patients, and the use of telemedicine. The remaining four questions were in open-ended format, enquiring: positive and negative experiences in past 12-month OAT provision, changes in provider collaboration, and permanent changes to clinical practice. In addition, free-text comments were possible on 12 of the 25 closed-format questions.

2.4. Analysis

Quantitative data were described as frequencies and percentages if categorical, or medians and minimum and maximum values if continuous (non-normally distributed). IBM SPSS Statistics Version 26 (Chicago, IL) was used for descriptive statistical analysis.

The open-text qualitative responses were listed verbatim in a Word document and grouped according to key questions in the questionnaire and further organized by two main categories and six sub-categories, following the basic principles of Iterative Categorization [17]. This involved reviewing all text segments line-by-line, converting the text segments into simple statements, then iteratively grouping these statements into meaningful categories as shown in Table 1. We provide free text extracts to highlight key points relating to the subcategories. The qualitative analysis was led by the joint first two authors.

In our qualitative analysis, we identified two main categories and six sub-categories as presented in Table 1. Following a summary of the respondent characteristics (section 3.1.), we have structured the presentation of the results according to the two main categories: Experience of changes in service delivery (section 3.2) and collaboration with other providers (section 3.3). An overview of the results from the closed-format items of the questionnaire is provided in Table 2.

3.1. Participation and site characteristics

Responses were received from n=23 managers/lead physicians who were primarily female (14; 61%). They represented 23 publicly funded OAT units from all regions and health trusts, which were jointly responsible for the treatment of 7,789 (more than 90%) Norwegian OAT patients, with a median number of 283 patients (range: 9-1,100) per unit.

<Insert Table 1 around here>

3.2 Experiences of changes in service delivery

In 2021, most OAT units (91.3%) still practiced revised operating procedures for COVID-19 infection control as established in the beginning of the pandemic. The most common adaption was the use of special routines for suspected or confirmed COVID-19 cases (95.7%).

3.2.1 Medication dispensing

Most units maintained extended take-home intervals for OAT medications (52.2%). Similarly, almost half of sites continued with less supervised dosing (47.8%). Survey respondents expressed both positive and negative experiences related to these changes. Respondents from two units reported anecdotal evidence of a greater extent of sharing and selling of OAT medications due to more liberal dispensing. However, many units reported that patients handled the COVID-19-related adaptions well:

“We have moved form a standardized approach to more individual treatment in each case. Patients express more satisfaction with OAT in every way. Treatment availability is improved with telemedicine and more outreach work. We have increased our availability across all channels. lt is easier for our patients to contact us. We have seen surprisingly good effect of the reduction in supervised dosing and drug screens (ID #16)”

“Positive collaboration with most patients in terms of infection control. Patients spend less time collecting the medication, which improve their quality of life. Home delivery of the medication has allowed us to get a better sense of the patients’ living situation and needs (ID #01)”

Several units maintained more liberal dispensing routines if individual patient assessments allowed. For instance, one unit that had entirely waived the requirement for supervised dosing in the first year of the pandemic reported that they revised clinical practice in the second year to tighten safety measures, with only long-term stable patients being exempt from supervised dosing. A respondent from yet another unit commented that it was easier to relax safety measures than to tighten these again.

3.2.2. The use of depot buprenorphine

Regarding medication choice, respondents from two units (ID #04, #09) specifically mentioned patients switching buprenorphine medications, from daily oral formulations to the use of depot injections. They reported increased patient demand for depot injections, which were now being used in almost one third of patients of their unit (ID #04): “Many patients express positive experiences and satisfaction with [depot buprenorphine], where for some the pandemic has been decisive for this medication choice.”

3.2.3. Drug screening

Compared to pre-COVID-19 levels, most OAT units (56.5%) continued to request less drug screens from patients. A respondent confirmed that “urine drug screening has been significantly reduced” (ID #23), and some providers mentioned having “largely switched to saliva samples” (ID #01, ID #10). As one respondent explained, “[d]uring the entire COVID-19 period, individual assessments have been made [for] urine drug screening, supervised dosing, and pick-up intervals for medications, with the aim to strike a balance between treatment safety and risk of infection” (ID #08). The use of urine drug screening as a safety measure was thus limited in several units to individual assessments and based on patient need. For instance, this could be where patients needed to document abstinence for their driver’s license or for child welfare services or wished to obtain a more flexible OAT dispensing schedule or where providers perceived clinical need due to comorbidity (e.g., attention deficit hyperactivity disorder or chronic obstructive pulmonary disease) and co-prescribing (benzodiazepines) (IDs #10, #11, #16). Patients’ substance use was identified as key factor necessitating a reintroduction of safety measures: “Recently, urine drug screening has been resumed for some patients where there has been a need to assess their drug use.” (ID #11).

3.2.4. Telemedicine

The respondents reported increased use of phone (91.3%) and video consultations (87.0%) in direct contact with patients. However, some pointed to the challenges posed by patients’ “lack of digital equipment” or “lack of phone and video access” (ID #01, ID #08), requiring face-to-face outdoor meetings instead (ID #16). Several providers remained critical of telemedicine, explaining that “phone and video cannot compensate for face-to-face contact” (ID #19) as one would lose “the interaction of joint meetings with the patient” (ID #05) as well as “essential observations in treatment, such as a patient’s smell, skin color, tremor, etc.” (ID #01). Another respondent likened the use of telemedicine to some patients “hav[ing] become more isolated as there are fewer face-to-face meetings” (ID #20). One respondent specifically mentioned the most vulnerable patients’ need for face-to-face contact (ID #8).

3.3 Experiences of changes in collaboration

3.3.1 Collaboration with other providers

In general, the collaboration between OAT units in the hospital trusts and municipal health and social services were perceived as positive, both before and during the pandemic. Several OAT units underlined the importance of collaboration during COVID-19, especially regarding infection control and vaccination. As one respondent wrote: “We collaborate with GPs and municipal health and social services to promote COVID-19 vaccination (ID #5)”. Another survey participant commented: “We have had good contact with municipal health and social services over the years, but our collaboration has now improved, also with GPs (..). (ID # 16)”.

However, one respondent also noted that collaboration with municipal health and social services was negatively impacted by social distancing measures with staff working from home (ID #7).

3.3.2 Telephone- and videoconferencing

Telephone- or videoconferencing was frequently used in collaboration with municipal partners, GPs, housing managers, and substance use consultants. One respondent highlighted that telecommunication with colleagues reduced travel between sites, saved time, and facilitated collaboration and decision-making. A respondent explained: “In the first lockdown [of spring 2020], the collaboration was challenging”, adding that “digital competence among employees has increased” since and “proven OAT provision adaptable to change” (ID #09). Another respondent noted the “increased flexibility” with telephone- and videoconferencing, which would “continue to be used where appropriate” (ID #19).

Our findings indicate that Norwegian OAT providers had mixed experiences with the flexible delivery of OAT treatment, both in interaction with patients and other providers. As previously reported [18], nearly all Norwegian OAT units continued to experience the strain of restrictions on face-to-face treatment provision in the second year of the pandemic. In response, most units in our study maintained three central COVID-19-era adaptations, namely special protocols for COVID-19 cases, the use of telemedicine, and extended intervals for OAT take-home doses. Although patient outcomes were not assessed as part of this study, providers observed that patients, by and large, handled these adaptations well.

Indeed, increased treatment flexibility is generally welcomed by patients [7, 19]. However, fear that more take-home doses and fewer monitored intakes may increase the risk of diversion and overdose is a common concern among clinicians and policymakers [1, 8, 9, 20, 21]. During the pandemic, clinicians were faced with the dilemma of having to find the right balance between access to potentially life-saving OAT medications and treatment safety (e.g., diversion) while minimizing patients’ risk of COVID-19 infection when collecting OAT medications.

In the present study, only few sites reported that the OAT medicines had been shared or sold by patients. Nonetheless, several sites scaled back on the deregulation of OAT provision by reintroducing shorter take-home intervals, more supervised dosing, and less liberal dispensing. Substance use was cited as key reason for re-introducing safety measures. By the end of the second year of the pandemic, almost half of units had reintroduced shorter take-home intervals.

Yet, alongside this partial return to the status quo ante in terms of safety measures, significant innovation occurred in OAT in Norway, as the use of telemedicine and depot buprenorphine increased during the COVID-19 pandemic. Norway is among the minority of European countries (alongside Croatia, Cyprus, Czechia, Finland, France, Greece, and Sweden) where buprenorphine is the most prescribed OAT medication [20]. In 2019, i.e., the year of its introduction in the Norwegian OAT program, just 2% of patients were prescribed depot buprenorphine. However, its use multiplied during the COVID-19 pandemic, as 15% of the Norwegian OAT patients were prescribed depot buprenorphine by the end of 2021 [16]. This trend is consistent with increased use of depot buprenorphine in Australia [10] where patients in a randomized trial also reported improved treatment satisfaction compared to those receiving sublingual buprenorphine [22]. One advantage with this formulation is that patients need to attend the clinic less often. However, further research is needed to identify which patients are most likely to benefit from extend-release formulations.

Utilization of telemedicine accelerated during the COVID-19 pandemic for many health conditions, including substance use disorders [23, 24]. For patients with OUD, telemedicine may improve access to treatment [25], and a recent US cohort study found that its use was associated with improved OAT retention and lower odds of overdose in a during vs. pre-COVID-19 comparison [26]. To compensate for reduced face-to-face meetings with patients, OAT units in Norway introduced video and telephone consultations at the start of the pandemic [6]. These became an integral part of treatment in the second year of the pandemic, even as in-person consultations resumed. OAT providers in our study appreciated reduced travel time between sites and perceived the use of video and telephone communication as generally beneficial in collaboration with other service providers. However, some noted that in interaction with patients the (exclusive) use of telemedicine made clinical judgement more difficult, as significant information (e.g., visual or non-verbal cues, smell) about patient well-being was missing. In the literature, both clinicians and patients report that some patients benefit from more structure and regular meetings with therapists [7, 9]. Clinicians are more comfortable using telemedicine for clinically stable patients [27, 28], whereas strict dosing regimens (incl. supervised dosing) for less stable patients are common [4, 7, 29].

Implications for policy and clinical practice

Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients, who should be offered the choice between modalities, where possible. Lockard et al. [30] emphasize the importance of having the flexibility to choose in their study of patient experiences with telemedicine. Telemedicine may be particularly suitable for rural regions. In line with our findings, vulnerable populations need attention [23], as lack of digital literacy, lack of equipment or lack of privacy may be a barrier for some patients [27, 31]. Thus, there is an urgent need to study what treatment modalities (remote vs. in-person) work for whom.

In recent years, both patients and providers have voiced the need for increased user involvement and patient choice. The Norwegian OAT guideline from 2010 was revised in 2022 [32] and postulates that OAT patients should receive holistic and well-coordinated treatment, with a high degree of user involvement. One may argue that the COVID-19 years served as an informal trial period for the revised guidelines prior to their actual launch, with preliminary evidence suggesting that more individualized OAT provision can be maintained. Further evaluation of the revised guideline is forthcoming and will require monitoring of patient outcomes.

Strengths and limitations

Our study has at least four limitations. Firstly, as with any self-reported study, recall bias may limit the internal validity of our findings. Secondly, the free-text option in the questionnaire meant that respondents may not have entered the same level of detail. Thirdly, due to the sample size and limited statistical power, no group comparisons or inferential statistics were performed. Finally, since this study focused on provider experiences of OAT service delivery, no patient outcomes were collected.

While a Norwegian study found high awareness of COVID-19 symptoms and available services among OAT patients [33], there is uncertainty as to how changes to OAT delivery during the pandemic have impacted health outcomes.

Nevertheless, this cross-sectional study included almost all OAT centres, covering more than 90% of patients receiving OAT in Norway. The results are considered representative of the Norwegian OAT program. While it is unclear how generalizable our findings are to OAT settings in other countries, it is important to monitor providers’ ability to adopt and adapt to clinical innovation and share lessons learnt internationally as part of this evolving process.

Overall, the Norwegian OAT system proved resilient in the second year of the COVID-19 pandemic, as its healthcare workforce embraced innovation in technology (telemedicine) and drug development (depot buprenorphine). According to our nationally representative sample of OAT providers, most patients handled increased take-home doses of methadone and buprenorphine well. Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients.

OAT: Opioid agonist treatment; OUD: Opioid use disorder; COVID-19: Corona Virus Disease 2019

Ethics approval

This study was approved by the Data Protection Authority (reg. number: 552107) at the University of Oslo.

Consent for publication

Not applicable.

Availability of data and material

The dataset generated and analysed during the current study is not publicly available to protect the privacy of participants but it is available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No external funding was received for this study.

Author contributions

Rebecca McDonald Conceptualization (of the paper), methodology, formal analysis, investigation, data curation, writing (original draft). Anne Berit Bech Conceptualization (of the paper), methodology, formal analysis, investigation, data curation, writing (original draft). Thomas Clausen Conceptualization (of the survey, methodology, project administration, supervision, writing (review). All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Dr John Todd-Kvam at the Norwegian Centre for Addiction Research (SERAF), Oslo University, for the translation of provider quotes. We also thank all participating hospital trusts.

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Table 1. Main categories and sub-categories from qualitative analysis
Experiences of changes in service delivery	Experiences of changes in collaboration
Medication dispensing	Collaboration with other providers
The use of depot buprenorphine	Telephone- and videoconferencing
Drug screening
Telemedicine

Table 2. COVID-19 related adaptions in OAT service delivery in 2021 compared to pre-pandemic levels (n = 23 OAT units)
		Yes		Missing/ Unknown
	n = 23		%		n = 23	%
COVID-19 infection control
Protocol for COVID-19 cases	22		95.7		0	0
Continued use of COVID-19 safety measures	21		91.3		0	0
Availability of personal protective equipment (PPE)	21		91.3		0	0
Reduced face-to-face contact	16		69.6		0	0
Reduced outpatient treatment capacity	7		30.4		0	0

OAT uptake
Stable patient demand for OAT	20		87.0		2	8.7
Faster assessment and initiation of OAT	14		60.9		1	4.3

Medication dispensing
OAT home delivery: COVID-19 cases only	21		91.3		2	8.7
OAT home delivery: general	12		52.2		4	17.4
Take-home doses: longer intervals	12		52.2		2	8.7
Take-home doses: >7 days allowed	11		47.8		1	4.3
Less supervised dosing	11		47.8		2	8.7

Drug screening
Less drug screens	13		56.5		2	8.7

Telemedicine
Increased use of telephone consultations	21		91.3		0	0
Increased use of video consultations	20		87.0		0	0

OAT: opioid agonist treatment

Flexible delivery of opioid agonist treatment during COVID-19 in Norway: A cross-sectional survey of provider experiences

Status:

Journal Publication

Version 1

Abstract

1. Introduction

2. Materials & Methods

3. Results

4. Discussion

5. Conclusions

Abbreviations

Declarations

References

Tables

Status:

Journal Publication

Version 1