Like most of the health care system, services for people with substance use disorder (SUD) were deeply impacted by COVID-19. As the pandemic raged, challenges emerged for patients with SUDs due to physical, economic, social, and behavioral vulnerabilities caused by shifts in drug supplies, social and physical isolation, increased unemployment, and reduced access to treatment and recovery services. The deadly result was a record 30% spike in U.S. overdose deaths accompanied by increases in non-fatal overdoses according to both national and regional sources. This blog post describes the experiences and COVID-19 induced challenges encountered by the projects funded under the Health Resources and Services Administration’s (HRSA) Rural Communities Opioid Response Program (RCORP).

RCORP background

RCORP is a large multi-year federal initiative addressing prevention, treatment, and recovery among people with SUDs. Administered through HRSA’s Federal Office of Rural Health Policy, RCORP funds hundreds of grantees in five categories: Planning, Implementation,  Expansion of Medication for Opioid Use Disorder, Neonatal Abstinence Syndrome, and Psychostimulants. Grantees comprise diverse organizations including primary care centers, Federally Qualified Health Centers, universities, critical access hospitals, local governments and health agencies, rural hospitals, and other providers and community-based organizations.

Adaptation: Advantages and benefits

As the pandemic unfolded, exposure fears, safety guidelines, and physical distancing rapidly reduced face-to-face interactions. In response, RCORP projects expanded telehealth, pivoting many services to online delivery. Some RCORP grantees already had telehealth infrastructure; others had to create it. By the fourth quarter of 2020, reporting showed 86% to 92% of RCORP grantees had expanded telehealth services (Source: December 2020 quarterly progress reports, Mun, C., Schachtner, R., Rupp, S., Kuritzky, A., Bresani, E., & Meyers, K. (2021). Reaching Rural Residents in the Era of COVID-19: RCORP Consortiums and SUD/OUD-related Service Delivery as Reported in PIMS. Report prepared for the Health Resources and Services Administration. North Bethesda, MD: JBS International, Inc.). Necessity prompted an evolution over months that may otherwise have taken years.

This pivot was enabled by many factors: a) Relaxation of regulatory barriers (e.g., online waiver certification), b) Reimbursement parity between office and telehealth visits, c) Patient buy-in, d) Relaxed cross-state licensing, and e) Appreciation for telehealth’s safety, convenience, and reduced cost.

Peer-recovery services were hard-hit but emerged as a bright spot for those who could access virtual recovery meetings allowing participants to match personalities, backgrounds, and styles to groups around the globe. RCORP attempted to track the new virtual meetings, but it became difficult to keep up with the rapidly multiplying opportunities (e.g., In the Rooms, Narcotics Anonymous Meetings, and Connections).

Adaptation: Challenges

Despite these benefits, challenges remained. Surveys reported up to a three-fold increase in anxiety and depression symptoms and a two-fold increase in the prevalence of suicidal ideation. National Emergency Medical Service data also showed a sharp rise in the rate of mental/behavioral EMS service activations. Critically, however, CDC (Centers for Disease Control) and others have shown that the COVID-19 pandemic did not consistently increase all-age U.S. suicide mortality.

• Fewer Services: In rural areas, budgets are often small due to limited economies of scale, low population density, small organization size, and high poverty rates. Many rural areas saw health services reduced or suspended. The likelihood of reviving these services in rural communities remains uncertain.
• Connectivity: Due to long distances and costs, gaps remain in landline, cellular, and broadband connectivity, with many populations left unserved in rural and frontier regions.
• Lack of Fit: Mental health disorders are common among patients with SUD. Telehealth may not be appropriate for individuals with co-occurring SUD and severe mental illness (e.g., active psychosis, suicidality) or when patient confidentiality is critical (e.g., child maltreatment, domestic violence).

Conclusions

The pivot to telehealth during the COVID-19 pandemic led to its increased acceptance by rural patients and providers. Telehealth has helped reduce transportation costs and increased access to specialists. These efforts will continue because telehealth can assist financially struggling providers, increasing the continuity of care despite the barriers presented by in-person services. The pandemic response added resources and focus and enhanced consumer familiarity with telehealth. In some SUD service settings (e.g., jail and prisons), necessity inspired novel resources and partnerships that overcame long-standing barriers.

Many RCORP grantees increasingly believe that the benefits of telehealth can be sustained. However, rural areas will also need time and resources to take advantage of gap-filling technological advancements such as 5G and satellite broadband to bring telehealth to everyone.

Telehealth during the pandemic has changed the way many RCORP providers do business. As increased in-person exams and other services resume, the blend of telehealth and in-person services that will create the right balance for different populations and settings is critical to determine, as is the appropriate reimbursement for both in-person and telehealth services.

Acknowledgement: The Rural Communities Opioid Response Program Technical Assistance (RCORP-TA) is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U6BRH32364, totaling $6,000,000 with 0% financed with non-governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.