Telemedicine-Related Opioid Use Disorder Services in Underserved Populations: A Qualitative Evaluation of the Waiver Era

Abstract

Introduction

: This pilot study examined access to telemedicine-related opioid use disorder (OUD) treatment in underserved communities in Houston, Texas before July 30, 2023.

Methods

: Participants, both patients and providers, were recruited in partnership with local substance use treatment clinics. Both groups shared experiences before and after the waiver era. Rapid qualitative analysis was conducted by the research team.

Results

: Fourteen qualitative interviews were conducted via Zoom with 5 treatment providers and 9 self-identified Black or Hispanic patient participants. Participants generally approved telemedicine for OUD treatment due to its technological accessibility and flexibility. However, concerns about technology, care quality, relationship building, and privacy were common among both patients and providers.

Discussion

: Our study highlights the underutilization of telemedicine for OUD treatment in underserved Houston communities. Efforts to address current limitations and leverage recent policy changes can help bridge the utilization gap in underserved areas.

Introduction

Individuals from underserved and marginalized communities who are living with opioid use disorder (OUD) encounter significant barriers to accessing and maintaining care.¹ Even for those who are able to access care, this care is often received in emergency departments or in patient settings—settings notorious for their limited focus on preventive care.^2,3 While patient-specific barriers such as privacy concerns^4,5 and provider-related challenges like limited waivers have long impeded access to care,^6,7 Hispanic communities, which often lack culturally appropriate services, and African American communities, where concerns about criminalization stand large,⁸ face disproportionate barriers to treatment. These disparities, coupled with elevated overdose rates among marginalized groups highlight the pressing need for evidence-based interventions.

With the proliferation of telemedicine following the COVID-19 pandemic, telemedicine-related OUD services have been proposed as a solution for those seeking OUD treatment, reducing stigma with increased privacy.⁹ This promising shift was marked by the passage of the CARES Act, which suspended the in-person visit requirement for controlled substance prescriptions,^10,11 and eliminated the waiver requirement to prescribe medications like buprenorphine. These regulatory changes aimed to broaden access to medication-assisted treatment, particularly through telemedicine for individuals living with OUD.

However, concerns persist in Houston Texas, a high-intensity drug trafficking city,¹² with geographic proximity to opioids through the Texas Medical Center, as well as its proximity to illicit drug trafficking from the US southern border. Complicating this is the fact that Texas ranks 47th in the PCP-to-population ratio, 50th in healthcare access and affordability,¹³ and has widespread low-to-no-patient capacity for office-based buprenorphine.¹⁴ These mutually reinforcing barriers highlight the need for location-specific, scientifically driven, and culturally informed efforts in OUD treatment. Recognizing the burden faced by Black and Hispanic individuals from underserved communities in Texas, this brief report examines access to OUD treatment via telemedicine in Houston, Texas, during the prewaiver era that ended on July 30, 2023.

Methods

PARTICIPANTS

Using purposive sampling, we recruited adults, age 18 and older from Houston, Texas, and the surrounding areas using flyers, emails, word-of-mouth, and targeted outreaches to behavioral health substance use clinics in medically underserved areas (Third Ward, East End, Kashmere Gardens). Participants completed an online screener survey to determine eligibility for the study and a single 60-minute online interview after. Patient participant eligibility was based on (1) self-identification as Black or Hispanic, (2) having a history or current experience of receiving treatment for OUD, and (3) residence in the Houston Metropolitan Area. Providers participant eligibility was limited to (1) health care providers of individuals receiving OUD treatment (including family physicians, physician assistants, advance-practice nurses, licensed chemical dependency counselors), and (2) providers who see patients in Houston-area clinics (primary care, behavioral health, substance treatment centers). The University of Houston’s Institutional Review Board approved this study procedure and data analysis plan, and all participants provided written informed consent.

INTERVIEWS

Working with our community research advisory board at the University’s Center for Addictions Research and Cancer Prevention, authors O.A. and L.G. developed two semistructured interview guides, one for patient participants and one for provider participants. These guides were reviewed for appropriateness, confirmation of relevance, and optimized recruitment strategies. Although study enrollment took place between August and October 2023, all interview question prompts referenced experiences prior to July 30, 2023. All interviews with patients and providers were conducted via Zoom (Zoom Video Communications, Inc.) and ranged in duration from 45 to 60 minutes. Patient and provider participants received gift cards as compensation for their time. All interviews were audio-recorded, and transcripts were created using Zoom and quality-checked by author M.S.

QUALITATIVE DATA ANALYSIS

The transcripts of interviews were analyzed by authors L.G. and M.S. in Microsoft Word using a rapid qualitative data analysis approach to distill themes according to their prevalence and salience in the data across the interviews. Author L.G. was involved in the interpretation and finalization of themes. Participants did not review their transcripts or the study findings for feedback.

Key Results

A total of 14 in-depth qualitative interviews were conducted, involving 5 treatment providers and 9 self-identified Black or Hispanic patients. All patients had received treatment for OUD, with 6 having used methadone and 3 having used suboxone in the past 6 months. The patient sample was 55% female, 78% Black, and the average age was 47 years old. The provider sample was 80% female, 60% Black, and 60% were waivered providers. Providers included family physicians, physician assistants, advanced-practice nurses, and licensed chemical dependency counselors. Participants highlighted several determinants that influenced their perceptions and utilization of telemedicine for receiving or providing OUD treatment services. These determinants fit into three main themes, each with associated subthemes. Table 1 presents the themes and related subthemes, along with representative quotes from providers and patients.

Table 1.

Themes and Representative Quotes from Qualitative Analysis

THEME	SUBTHEME	REPRESENTATIVE QUOTES
Telemedicine Infrastructure	Internet and technology	“Most of our clients do [have access to technology]” (Provider 5) “When COVID hit. Everything was Zoom” (Client 3). “Now, since a lot of stuff has changed through COVID. You have to do a lot of stuff online.” (Client 5) “[Some clients] can’t afford the internet or internet’s not available right? And you have some communities where [the internet is] not available. Then that’s a stopping block to the telehealth” (Provider 1). “And you know, some people don’t have the knowledge or the, you know, mind frame to go on the internet and look to do stuff like that” (Client 5). “I also did a little time in prison, so I wasn’t real savvy with technology. But I’ve gotten better now” (Client 8). “I have had clients that had like had to go to like the outside of like go at McDonald’s with some privacy, right like sit outside of McDonald’s, or like somewhere where there was Wi-Fi” (Provider 5).
Telemedicine Infrastructure	Transportation and work	“[Telemedicine] helps tremendously with the transportation barriers that we find, because transportation, I would tell you, is by far the biggest barrier to services really across the board. Right? But when you look at underserved communities where they’re using public transportation more often than other communities. And then sometimes they live in communities where there is no public transportation or their access to it is, I have to walk 3 miles to the first bus stop, right? Or I’ve gotta walk 2 miles after I get off my last bus. Then we have those transportation barriers.” (Provider 1) “I really didn’t like to commute to the current clinic [...] on the bus. It’s like it’s just long. It takes a lot out of my day, and then it will cause me to be tardy for work and things like that, and I do not like to be late for work.” (Client 2)
Telemedicine Infrastructure	Access to telemedicine options	Interviewer: “Have you ever used telemedicine or virtual visits as part of your treatment?” Client: “No. I wish.” Interviewer: “Have they ever offered that to you?” Client: “No.” (Client 9) “I don’t think the information is out there [about telemedicine options]. I don’t think they know where to go cause people would choose that over just a regular doctor, you know. Yeah, or just going inside a place because it is more convenient.” (Client 1)
Quality of Care of Telemedicine for OUD Treatment	Relationships between clients and providers	“…the connection with someone—having that connection, being able to talk to somebody. Although it is virtual and not in person and but having that connection, and clients really show up” (Provider 5). Client: “I don’t feel like [the psychiatrist] really understands me or, or the point I’m trying to get across is it’s like, for instance, if I tell you I need to, I need to up my dose on Suboxone, something’s not, not feeling right. I feel like I’m going to relapse or whatever. And you just be like, ‘Oh no, it’s okay. It’s okay. We’re just going to continue on this and on this milligram. And, you know, when we talk next time, we’ll see where it goes.’ Are you not listening to me? I will need to go up on this. I’m not, I don’t feel secure. ‘Oh, that’s the way we all feel.’ Like, you know, I feel like they’re not understanding. ‘Most of us feel that way. It’s not only because you’re an addict.’ Okay, here we go again, you know, that’s the way some people feel.” Interviewer: “Do you feel this same kind of way in person?” Client: “I do. I feel a difference because I guess, they can, she could see my actual posture and the movement and how I guess I’m responding or acting at the time were, oh, I can see a little antsy, like, you know, this and this and that. Yeah, I feel like it’s a big difference when I’m in person.” (Client 3) “It’s impersonal… I think everybody that’s on telemedicine on the other side, like the doctors, and things like that, they’ve like been deprogrammed to have bedside manner because there’s no bedside. But since there’s no bedside, doesn’t mean your bedside manners should go to shit. People were less connected to their clients. I think it just seems like, okay. They’re there, but they’re not there like we’re looked at as I feel like we’re looked at as a client number in the waiting room.” (Client 2)
Quality of Care of Telemedicine for OUD Treatment	Privacy concerns	“What I’m getting at is people who are not comfortable going into clinics like that. Or some people are very discreet. Some people don’t want somebody to drop them off at the Methadone clinic. ‘Hey? What you doing here...’” (Client 2) “People kind of even dread going there sometimes. Oh, I don’t want anybody then to know cause they, if you there, they know what you’re there for, you know. ‘Oh, you got a drug problem.’ But now you can kind of be in your secret, and no one has to know you don’t have to worry about that part of it.” (Client 1) “So just making sure that there’s confidentiality, especially in a virtual space. You know. That there’s somewhere where we’re able to [talk]. Because there’s a lot of things that I’m not going to ask if there is somebody in the room. I can’t really ask those questions because they may not be able to be forthcoming with me. You know they won’t be able to tell me like then you know what really what they really have experienced. And I could tell them their expression, you know. And so I kinda like try to atmosphere not go too deep sometimes with the questions, especially in those situations in the beginning.” (Provider 5) “Some people are still afraid, you know, they don’t know, what that’s gonna do, […] some people think the police are gonna do it, that the police are gonna be listening, that the police gonna be listening and are gonna use this to find out who they are and where they live. That kind of thought process. Its ignorance a lot of times that stops people from getting involved.” (Client 7)
General OUD Treatment Concerns	Cultural considerations for minoritized populations	“I was always against [therapy], you know, especially in the Black community. I was always against therapy, just, I don’t even know why. When I think about it, just, you know you don’t hear good things” (Client 1). Client: “I know within our Hispanic culture… it’s harder for people to reach out for help.” Interviewer: “Why do you think that is?” Client: “They, just like I said, pride. Feel like they can do it on their own. They don’t need no help. But there comes a time when you’ll realize that pride is just working towards your destruction, and you do need help.” (Client 8) “That mistrust can kick in like even. ‘Oh, is this being recorded?’ ‘Who has access to this data?’ ‘Are people in the room listening.’ You know, like there’s a lot of mistrust that people just carry Black and Brown folks carry to healthcare settings. And there’s a part of me that sometimes wonders if the technological way in which we approach things actually doesn’t create some distance between us.” (Provider 3)
General OUD Treatment Concerns	Stigma	“But even within, the groups that use medication for opioid use disorder, whether it’s methadone, whether it’s buprenorphine, they get stigmatized by some of the other people in recovery who don’t use any of that which is kinda crazy. [...] But they’ll say stuff like, ‘Well, you’re not really sober because you’re using methadone.’ And then they get pressured into thinking, ‘Well, may be I shouldn’t be taking this medicine because everyone else is telling me I’m not actually sober.’ So, I will have some clients who will start tapering themselves off to suboxone because they’re getting pressure from either their AA sponsor or other groups in recovery or their parents.” (Provider 4) “The X-Waiver was not really the barrier to people like not prescribing suboxone—the barrier’s that people don’t want to take care of folks that have opioid use disorder.” (Provider 3). “I still think it’s not access, it’s still not that easy, even though there’s an opioid epidemic. I still feel like it’s barriers to getting treatment. I feel like it’s a stigma. I’ve even had a client tell me recently. Like his primary care doctors, they are not comfortable prescribing it, even though the waiver was lifted. So, I feel like it’s still barriers as far as providers’ mentality surrounding OUD in its treatment.” (Provider 2)
General OUD Treatment Concerns	Costs of treatment	“Medicaid expansion, or lack thereof. It has made it so much more difficult to provide these services to perhaps some of our most vulnerable folks. I mean uptake in Black and Brown communities has been low. Nationally. Texas was recently identified as being in the bottom of that list. When we’re looking at, and we know that Medicaid expansion is a major part of that.” (Provider 3) “I believe if there was…I feel like if everybody had a good insurance, like UnitedHealthcare, Blue Cross, Blue Shield, Medicare, whatever the insurance may be. And somebody can break it down to them, how it can help them, what doctors they can get. Maybe the world will be a lot better than just... Maybe sober even.” (Patient 3) “I did try to do suboxone doing it like that. But that was very expensive. So that’s why I could never just stay on suboxone […] now at the methadone clinic, it’s you know, state funded. So I’m blessed for that” (Client 5)

THEME 1: TELEMEDICINE INFRASTRUCTURE

Internet and technology

Study participants emphasized the crucial role of Internet access and technology affordability for engaging in telemedicine services. While many patients reported having the necessary technology and internet access, lack of comfortability was particularly evident among individuals with limited technological exposure, such as older adults or those previously incarcerated. Despite these challenges, patients demonstrated resilience by finding alternative solutions, such as utilizing public internet or seeking support from clinics, family, and friends.

Transportation and work

Participants emphasized the significant impact of telemedicine in mitigating transportation challenges, particularly in eliminating the need for public transportation. One patient also noted that telemedicine saves time and reduces the potential threat of being late for work. Consequently, telemedicine offers greater accommodation to patients’ transportation needs and work schedules.

Access to telemedicine options

While many participants highlighted the benefits of telemedicine for OUD treatment, some reported not being offered this option. Limited awareness of telemedicine services in the community was also noted by certain patients.

THEME 2: QUALITY OF CARE OF TELEMEDICINE FOR OUD TREATMENT

Relationships between patients and providers

Participants held diverse opinions regarding the potential of telemedicine to foster relationship-building and trust between patients and providers. While one provider viewed telemedicine as an avenue for cultivating relationships via virtual platforms, several patients expressed concerns about the “quality of care” received. They cited the absence of physical and nonverbal cues in virtual visits (for example not being touched by the provider), a sense of being rushed, and perceived deficiencies in providers’ bedside manner, which they felt compromised the personal nature of interactions.

Privacy concerns

Participants expressed varied perspectives on how telemedicine influenced the privacy of OUD treatment. While some patients appreciated the anonymity and discretion afforded by telemedicine, citing the avoidance of potentially recognizable encounters at the clinic, others harbored concerns about privacy and confidentiality. These concerns ranged from worries about the presence of unauthorized individuals during telemedicine sessions to fears of law enforcement surveillance. Such apprehensions may impede patients’ openness and honesty with their providers, potentially impacting treatment outcomes.

THEME 3: GENERAL OUD TREATMENT CONCERNS

Cultural considerations for minoritized populations

Both patients and providers noted a culturally-rooted resistance to mental health treatment, potentially deterring individuals from seeking services. Patients shared personal biases against mental healthcare, while providers acknowledged the exacerbation of medical mistrust among minoritized populations in healthcare settings, especially concerning technology use. Providers and organizations must remain cognizant of these cultural considerations to effectively support minoritized patients.

Stigma

Participants recognized stigma stemming from two sources: within the treatment community regarding the medications used, and from providers and organizations offering or refusing treatment services. Providers cited reluctance among peers to prescribe medication-assisted treatment, despite the removal of the X-Waiver requirement for treating OUD. This stigma persists, impeding mental health treatment for underserved populations.

Costs of treatment

Both patients and providers acknowledged the financial barriers preventing underserved patients from accessing OUD treatment. These barriers include lack of insurance, exacerbated by the absence of Medicaid expansion in Texas, and limited access to other forms of insurance. However, some patients noted access to treatment through state-funded programs.

Discussion

This qualitative study examines patients’ and providers’ utilization of telemedicine for initiating and retaining OUD treatment in Texas. To our knowledge, it is one of the few studies documenting this during the waiver era that existed before June 30, 2023. This documentation is particularly significant as underserved populations often encounter the intersectionality of state-specific access to care barriers, cultural obstacles, and the digital divide, which can perpetuate treatment disparities.

Our findings suggest that patients were frequently not presented with telemedicine options for OUD treatment and a lack of awareness exists regarding telemedicine for OUD treatment. This observation is consistent with previous research by Huskamp et al., who noted a substantial gap in telemedicine usage between mental health and substance use disorders (SUD), including OUD.¹⁵ These findings underscore an opportunity to enhance awareness about telemedicine and encourage healthcare providers to actively offer telemedicine as an option for patients in need of care.

In considering telemedicine adoption, persistent issues such as cultural competence, socioeconomic disparities, and geographic gaps may be amplified by the additional infrastructure and equipment needs associated with telemedicine.¹⁶ Recent analyses postpandemic emphasize the importance of robust infrastructure for telemedicine, correlating with increased utilization.¹⁷ However, the digital divide remains a significant concern in the U.S., with many lacking access to high-speed internet, necessary technology, and adequate digital literacy.^18,19 Identifying telemedicine champions and offering educational resources and training programs can enhance patients’ digital literacy and promote broader adoption of telemedicine.

Numerous patients emphasized their comfort with utilizing telemedicine platforms and highlighted the convenience they offer in terms of transportation and time-saving potential. These findings echo those of Sousa et al., who revealed that over three-quarters of patients receiving in-person treatment for OUD perceived telemedicine as advantageous, particularly in terms of transportation and time efficiency.²⁰

While several patients perceive telemedicine as providing “less quality” care due to the absence of physical and nonverbal cues, feelings of being rushed, and perceived deficiencies in bedside manner during online visits, others appreciate the speed and option to choose treatment modalities based on individual situations and needs for continuing OUD treatment.

Cultural influences and perceptions of trust and confidentiality significantly impact patients’ willingness to engage with telemedicine services, particularly among marginalized populations historically subjected to discrimination and mistreatment in public sectors such as health care and law enforcement.²¹ Concerns about privacy contribute to a lower preference for telemedicine for OUD treatment initiation and retention. For instance, patients may fear unauthorized recording and legal implications of telemedicine conversations or the possibility of friends or family overhearing their conversations related to OUD treatment.^22
–24

Finally, our findings suggest OUD-related telemedicine can overcome both provider- and patient-level stigma that fuels low OUD treatment uptake in underserved communities. Providers indicated OUD-related telemedicine reduced stigma from their peers, including being labeled a “junkie provider.” Patients indicated that OUD-related telemedicine removed community stigma in underserved populations. Addressing the stigma surrounding help-seeking among the underserved population is crucial. By implementing culturally sensitive interventions, the healthcare system and society can promote understanding of diverse perspectives on seeking help, including mental health and OUD treatment. Normalizing and promoting help-seeking behaviors can encourage underserved individuals to seek the support they need.²⁵ As telemedicine becomes increasingly utilized for OUD treatment by patients, successful experiences can serve as positive examples, potentially fostering trust among those who are skeptical about the system.

Conclusions

The use of telemedicine in OUD treatment is gaining traction due to its comparable effectiveness to in-person treatment, as shown in multiple studies.^26,27 However, it is crucial to tailor care plans to individual needs rather than adopting a one-size-fits-all approach. This emphasis on personalized care is supported by research promoting shared decision-making between patients and providers to determine the most suitable service modality.²⁸ Telemedicine offers several benefits, including improved access to health care, cost reduction, and increased flexibility in treatment delivery.²⁹ In addition, it fosters collaboration among health care professionals, enhancing satisfaction among patients and providers through streamlined communication and enhanced care coordination.²⁹

However, telemedicine may not be suitable for all patients or disorders, emphasizing the need for further research to develop tailored interventions effectively. Overall, by refining our understanding of when and how telemedicine can be most beneficial, healthcare providers can optimize its use as a complementary tool in delivering high-quality, patient-centered care.

Footnotes

Authors’ Contributions

O.E.A. conceptualized and designed the study, drafted the initial article, and critically reviewed and revised the article. C.P. contributed to the initial draft and critically reviewed and revised the article. M.S. participated in the qualitative analysis under the guidance of L.R.G. L.R.G. codesigned the analysis, led the qualitative analysis, and critically reviewed and revised the article. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Data Disclosure

Our IRB approval prohibits us from sharing the data used for this study.

Disclosure Statement

All authors declare that they have no conflicts of interest.

Funding Information

This study was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) Award Number 3U54MD015946-04S2. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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