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JAMA Netw Open
JAMA Netw Open
JAMA Network Open
2574-3805
American Medical Association

39230907
10.1001/jamanetworkopen.2024.31594
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Research
Research Letter
Online Only
Substance Use and Addiction
Telemedicine for Initiation of Alcohol Use Disorder Medications
Telemedicine for Initiation of Alcohol Use Disorder Medications
Telemedicine for Initiation of Alcohol Use Disorder Medications
Huskamp Haiden A. PhD 1
Uscher-Pines Lori PhD 2
Raja Pushpa MD MHSPM 3
Normand Sharon-Lise T. PhD 1
Mehrotra Ateev MD MPH 1
Busch Alisa B. MD MS 4
1 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
2 RAND Corporation, Arlington, Virginia
3 Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
4 McLean Hospital, Belmont, Massachusetts
Article Information

Accepted for Publication: July 10, 2024.

Published: September 4, 2024. doi:10.1001/jamanetworkopen.2024.31594

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Huskamp HA et al. JAMA Network Open.

Corresponding Author: Haiden A. Huskamp, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (huskamp@hcp.med.harvard.edu).
Author Contributions: Dr Huskamp had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Huskamp, Uscher-Pines, Raja, Mehrotra, Busch.

Acquisition, analysis, or interpretation of data: Huskamp, Uscher-Pines, Normand, Mehrotra, Busch.

Drafting of the manuscript: Huskamp.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Normand.

Obtained funding: Huskamp, Uscher-Pines, Mehrotra, Busch.

Administrative, technical, or material support: Busch.

Supervision: Huskamp, Uscher-Pines, Busch.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by National Institute on Alcohol Abuse and Alcoholism grants R01AA030539 and R01AA029267.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

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Copyright 2024 Huskamp HA et al. JAMA Network Open.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License.
jamanetwopen-e2431594.pdf

This case-control study examines the initiation of treatment with medications for alcohol use disorder (MAUD) among US adults and compares the characteristics of adults who initiate MAUD treatment via telemedicine vs in-person care.
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pmcIntroduction

Alcohol use disorder (AUD) is the most prevalent substance use disorder (SUD) in the US, affecting 29.5 million people, and deaths from excessive alcohol use are increasing.1,2 While medications for alcohol use disorder (MAUD) are efficacious3 and can be prescribed in primary care or specialty behavioral health settings, only 2.2% of individuals with AUD in 2022 received MAUD in the past year.1 Barriers to MAUD initiation include clinician shortages, cost, stigma and/or privacy concerns, and lack of transportation4; however, telemedicine could reduce some of these barriers.5 We examined telemedicine initiation of MAUD and compared the characteristics of US adults who initiate via telemedicine vs in-person care.

Methods

This case-control study was approved by the Harvard University Faculty of Medicine Institutional Review Board, who waived the need for informed consent owing to the use of deidentified claims data. We followed the STROBE reporting guideline.

We used claims data obtained from Optum Labs Data Warehouse for adults aged 18 to 64 years in all 50 states who had commercial or Medicare Advantage insurance from January 2019 to September 2023. Initiation of MAUD was identified using the first prescription fill for naltrexone, acamprosate, disulfiram, or topiramate during the period with no fills in the previous 90 days (hereinafter, the index fill date) and categorized as telemedicine if all linked outpatient visits 7 days before or 3 days after the index fill date were virtual (eMethods in Supplement 1). We required continuous enrollment in medical, behavioral health, and pharmacy benefits in the index fill month and prior 6 months to identify baseline characteristics. We excluded people who did not have an AUD diagnosis in the 180 days before and including the index fill date.

We examined the monthly proportion of initiations via telemedicine. Because telemedicine was uncommon before the COVID-19 pandemic, we focused on initiations that occurred from April 2020 to September 2023, using logistic regression (via SAS, version 9.4 [SAS Institute Inc]) to identify patient characteristics associated with telemedicine (vs in-person) initiation. The model included age; sex; US region; rural residence; household income quartile in county of residence; claims with a non-AUD SUD, mental health, or acute or chronic alcohol-related medical condition diagnosis; and clinician specialty (eMethods in Supplement 1). We used 2-sided testing with a significance threshold of P < .05.

Results

There were 19 121 MAUD initiations from January 2019 to September 2023 (patient characteristics are provided in the Table). Of these initiations, 68.5% were for oral naltrexone, 10.8% were for acamprosate, 7.8% were for disulfiram, 10.6% were for topiramate, and 2.3% were for injectable naltrexone; 58.6% were conducted by PCPs, 25.5% by psychiatrists, and 15.9% by other prescribers. Telemedicine was used in 13.9% of all initiations, reaching a peak of 26.4% in May 2020 and plateauing at 16.6% by September 2023 (Figure). Telemedicine initiations differed across drugs (naltrexone, 14.6%; topiramate, 11.8%; disulfiram, 12.8%; and acamprosate, 13.5%).

Table. Patient Characteristics and Odds of Initiation of Medications for AUD via Telemedicine vs In-Person Care, April 2020 to September 2023

Characteristic	No. (%) of patients (N = 13 961)	AOR (95% CI)	P value	
Age, y				
18-25	1119 (8.0)	1.16 (0.96-1.39)	.12	
26-40	4305 (30.8)	1.72 (1.54-1.93)	<.001	
41-50	3774 (27.0)	1.41 (1.25-1.59)	<.001	
51-64	4763 (34.1)	1 [Reference]	NA	
Sex				
Female	5848 (41.9)	1 [Reference]	NA	
Male	8113 (58.1)	0.80 (0.73-0.87)	<.001	
US region				
Midwest	4217 (30.2)	0.75 (0.67-0.84)	<.001	
West	3097 (22.2)	1.10 (0.98-1.24)	.11	
Northeast	4975 (35.6)	1.27 (1.10-1.47)	.001	
South	1672 (12.0)	1 [Reference]	NA	
Rural residence				
Yes	309 (2.2)	1.1 (0.80-1.52)	.56	
No	13 652 (97.8)	1 [Reference]	NA	
Specialty of initiating clinician				
Psychiatrist	3555 (25.5)	1.56 (1.41-1.72)	<.001	
Primary care physician	8180 (58.6)	1 [Reference]	NA	
Other	2226 (15.9)	0.86 (0.75-0.99)	<.001	
Non-AUD SUD diagnosis				
Yes	3928 (28.1)	0.86 (0.77-0.95)	.003	
No	10 033 (71.9)	1 [Reference]	NA	
Mental health diagnosis				
Yes	2943 (21.1)	1.98 (1.73-2.26)	<.001	
No	11 018 (78.9)	1 [Reference]	NA	
Alcohol-related medical condition diagnosis				
Yes	1391 (10.0)	0.73 (0.62-0.87)	<.001	
No	12 570 (90.0)	1 [Reference]	NA	
Household income quartile in county of residence				
1st	NA	1 [Reference]	NA	
2nd	NA	1.34 (1.17-1.54)	<.001	
3rd	NA	1.38 (1.21-1.58)	<.001	
4th	NA	1.71 (1.50-1.96)	<.001	
Month	NA	0.97 (0.96-0.99)	<.001	
Month squared	NA	1.00 (1.00-1.001)	.01	
Abbreviations: AOR, adjusted odds ratio; AUD, alcohol use disorder; NA, not applicable; SUD, substance use disorder.

Figure. Initiations of Medications for Alcohol Use Disorder (MAUD) Conducted via Telemedicine, January 2019 through September 2023

Due to small sample sizes, data for June 2019, July 2019, and February 2020 were not available. Instead, the value for the most recent available month prior to that month was substituted. The vertical line indicates the declaration of the COVID-19 pandemic. The shading represents the 95% CIs for each month.

Among 13 961 initiations from April 2020 to September 2023, in adjusted analyses, telemedicine was more common among psychiatrists (adjusted OR [AOR] [95% CI], 1.56 [1.41-1.72]) than primary care physicians, enrollees with a mental health diagnosis (AOR, 1.98 [95% CI, 1.73-2.26]), and in higher-income relative to lower-income areas (AOR, 1.71 [95% CI, 1.50-1.96]) (Table). Telemedicine MAUD initiation was lower among men than women (AOR, 0.80 [95% CI, 0.73-0.87]), patients with a non-AUD SUD (AOR, 0.86 [95% CI, 0.77-0.95]), and patients with an alcohol-related medical condition (AOR, 0.73 [95% CI, 0.62-0.87]) (Table).

Discussion

The findings of this case-control study suggest that while most MAUD initiations occur in person, telemedicine may play an important role in the initiation of these efficacious medications. Greater telemedicine use in higher-income areas supports concerns about how the “digital divide” may decrease access to care.6 Study limitations include findings that may not be generalizable to other populations, lack of race and ethnicity information, and an inability to observe initiations for people who pay fully out of pocket for outpatient AUD visits.

Supplement 1. eMethods

eReferences

Supplement 2. Data Sharing Statement
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References

1 2022 NSDUH annual national report. Substance Abuse and Mental Health Services Administration. November 13, 2023. Accessed May 10, 2024. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report
2 Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from excessive alcohol use—United States, 2016-2021. MMWR Morb Mortal Wkly Rep. 2024;73 (8 ):154-161. doi:10.15585/mmwr.mm7308a1 38421934
3 Jonas DE, Amick HR, Feltner C, . Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311 (18 ):1889-1900. doi:10.1001/jama.2014.3628 24825644
4 Gregory C, Chorny Y, McLeod SL, Mohindra R. First-line medications for the outpatient treatment of alcohol use disorder: a systematic review of perceived barriers. J Addict Med. 2022;16 (4 ):e210-e218. doi:10.1097/ADM.0000000000000918 34561352
5 Tele-treatment for substance use disorders. US Dept of Health and Human Services. Updated August 31, 2023. Accessed May 10, 2024. https://telehealth.hhs.gov/providers/best-practice-guides/telehealth-for-behavioral-health/tele-treatment-for-substance-use-disorders
6 Uscher-Pines L, Riedel LE, Mehrotra A, Rose S, Busch AB, Huskamp HA. Many clinicians implement digital equity strategies to treat opioid use disorder. Health Aff (Millwood). 2023;42 (2 ):182-186. doi:10.1377/hlthaff.2022.00803 36745832
