“Sign Me Up”: a qualitative study of video observed therapy (VOT) for patients receiving expedited methadone take-homes during the COVID-19 pandemic

Interviews were conducted among 12 of the 60 patients who participated in the clinical pilot and 3 of the 5 counselors. Characteristics of the patients who participated in the IDIs, as well as of the overall participants in the clinical pilot, are shown in Table 1. IDI and patient populations were fairly comparable in relation to age, gender, race and ethnicity. IDI participants were between 30 and 64 years of age, primarily identified as male (75%) and white (75%). Patient IDI participants included two with low video use, 6 with medium use, and 4 with high use.

Table 1 Description of study patients who participated in the study

Overall, participants were enthusiastic about VOT, as an alternative to traditional in-person dosing options. Our analysis team identified four major themes (Fig. 1) to explain participant experiences with VOT that may inform how VOT is used in future programming.

Fig. 1figure 1

Map of themes and exemplar quotations

Theme #1: Less frequent clinic visits supported long-term recovery goals

All patients interviewed expressed that the intensity of daily in-person dosing placed a significant burden on them that limited their ability to be successful with treatment. When compared to in-person dosing, video-observed dosing was almost universally celebrated by the study participants as a significant convenience that overcame many of the challenges associated with daily in-person dosing.

“It almost feels like a punishment coming in every day. There's not even a probation that’s that intense, you know? It’s just ridiculously intense. And almost unsustainable without assistance from somebody. For me, it’s damn near impossible to come here every day. I managed to. But if I could’ve done [VOT] from the beginning, it would've made methadone treatment long-term a lot easier on me.” – Patient 10.

For in-person dosing, many described having to structure their days around their visit to the clinic, which came with substantial opportunity costs and interfered with other life priorities. When participants had to balance other life priorities with in-person treatment, several participants described treatment interruptions or discharge from treatment when they chose to prioritize other responsibilities. Participants particularly described how daily in-person dosing interfered with employment, childcare responsibilities, attending to other medical needs, traveling, and visiting friends and family. Related to employment, in-person dosing led to missing work, being late to work, and missing opportunities for temporary work, leading to challenges to maintaining employment, a key aspect of successful recovery for many patients.

“[In-person daily dosing] really restricted what I [could get through] the temp service as far as jobs. Because they open at 5:30. So if you're not there at 5:30, those first 30 minutes is when they hand out all the jobs. So I’d have to come in for scraps after that . . . But yeah, when I got carries, it really made this place a lot more bearable.” – Patient 9

For many participants, daily transportation to the clinic was a major barrier. This was especially true for those with mobility issues or chronic pain that made the daily commute more burdensome. For some, the costs associated with transportation were prohibitive, while for others, the inconsistency of public transportation created constant daily anxiety and a feeling of always needing to “fight the clock.” The logistics and emotional stress associated with daily transportation to clinic were relieved by the opportunity to use VOT.

“At the time, I was still living close, but because of the pandemic I would have to ride the city bus to go [to the clinic]. And then, the bus schedules, they weren't running as much. And they weren't taking full passengers. . .There were several times that I would go to dose and I would have to wait till like the third bus. So I would be sitting there waiting with a bunch of people that I really didn't want to be waiting with. And in a situation I didn't really want to be. So the app just really made it a lot better for me. . .it just made it easier for me to stay sober.” – Patient 6

Of note, only one patient, who self-identified as immunocompromised cited avoiding possible exposure to infectious diseases (e.g., COVID-19) by less frequent clinic visits as a benefit of video observed dosing.

For some participants, less frequent travel to clinic aided their recovery because it allowed them to purposefully avoid triggers to relapse that they might encounter at the clinic. One patient referenced the area around the clinic as “an open drug stock exchange,” while another described having to “dodge” the “methadone mile” when visiting clinic. For some participants, it wasn’t just about avoiding the triggers, but having to continually revisit their past, that made continued visits undesirable, especially for those who were trying to, “just to get away from [drug use] and actually let the methadone work.”

“It’s the location itself [which] has become . . . kind of a hub for – well, there's people trying their best for recovery and there's people that aren’t. And there's people that are okay in their opiate side, but they're smoking crack or meth. There's always a ton of pitfalls. In the beginning, it didn't really bother me. But once I got clean, it started to bother me just being around a lot of people that weren't clean.” – Patient 1.

Finally, several participants described feeling unwelcome and judged during clinic visits. They described feeling like they were always under suspicion of doing something wrong, and noted how the stringent rules at the clinic made them “feel like they’re being treated kind of like children.” For these patients, minimizing in-person dosing days allowed them to avoid stigmatization and judgement from clinic staff or conflicts with other patients.

“There are so many rules . . .For example, you cannot pass a piece of paper with a phone number on it to someone, even if they know it's a piece of paper with a phone number on it. If you pass anything, it's considered drugs. . . . Or, if someone passes a cigarette, even if they know it's a cigarette, it's still an automatic write-up, and that kind of thing..” – Patient 9.

Theme #2: Self-management of medication improved participants’ sense of autonomy and normalized treatment

For many participants, self-administering medication increased flexibility in how to structure their day. One participant described how VOT allowed him to take the medication on a full stomach to avoid the nausea and vomiting he often experienced when dosing in-person, since he no longer had to rush out of the house before eating. Another participant described how VOT dosing allowed him to start his day earlier, by providing him with the slow, relaxed time he needed each morning before methadone kicked in.

“My body isn’t really up and going until 20 minutes after I dose. I can drink coffee, but I’ll still be yawning. I’ll be in my withdrawal. But the best time for my house to the clinic is half hour to an hour… the days that I was able to just roll over and dose, it was great. I’d start my day right then and there….It was the very first bricks of having a structure. Because my life was very chaotic before.” –Patient 1.

Some participants also described how increased take-homes with VOT improved their self-worth and agency. VOT allowed them to be “in a position where I can start gaining some trust back,” feeling like it is important to have “people feeling like they can be accountable, in some ways, on their own.”

Several participants described how storing and managing their own medications helped treatment feel more “normal:”

“I haven’t used drugs in years. So [participating in the pilot] really didn’t help in that way . . . I didn’t go back to using or anything. And didn’t want to. It just made it easier . . . The closer you can come to having a normal life, the better off you are, you know? It made it a little closer, you know?” – Patient 11

Others expanded on the notion that the self-management of medications also made them feel more “normal” by allowing them to participate in activities they had not been able to while on methadone—traveling “four states away,” visiting friends and family, and going camping. Some participants expressed how this normalization of the treatment experience might affect their long-term plans for treatment:

“. . . before, I was stressing, like okay, I only need to be on methadone X amount of years. I'm going to get straight and I'm going to wean off, yadda, yadda because I don’t want to be down there every day and all these other things. But now I'm like, okay, now it’s a normal medication. Now I can take my medication in the morning and go about my day, just like with my antidepressants.” – Patient 1.

Participants did not indicate that use of VOT affected how likely they were to take their medication compared with in-person dosing. They overwhelmingly reported that they took medication only as instructed. One patient indicated that VOT helped him maintain regular adherence and transition to greater take-home responsibilities that were fast-tracked because of the pandemic:

“It made the transition a little bit better I think, instead of just having all my doses and nothing to do, not knowing—you know? So [VOT] kind of helped me just kind of remember, keep it in the front of my mind.” – Patient 4

Theme #3: Stage of recovery and communication preferences influenced acceptability of VOT

While the large majority of patients expressed enthusiasm for VOT as an alternative to in-person observed dosing, there was some acknowledgement that it may not be a helpful option for other patients, particularly those early on in their recovery. One participant indicated that “an earlier version” of himself might have “taken advantage of” VOT by feigning ingestion. Another described how the structure imposed by in-person daily dosing early in recovery is helpful by creating a routine and providing supportive interactions with others, and noted that this critical support would be absent if all patients started with VOT.

“When I first started, I was very depressed, and so going somewhere, making myself go somewhere every day, and having someone to see and interact with, helped me a ton. And I believe that has just done so much for me.”

—Patient 9.

Similarly, a counselor also reflected on her perception that in-person dosing provides a helpful scaffold for daily structure for patients with chaotic lives early in treatment.

“[T]hat's part of the thing about them coming into the clinic every day is, you know, some people actually have a ritual of just coming in the clinic every day. Their life’s a train wreck outside of here, but for whatever reason, they come here, and they dose every day. Part of it is because it's methadone, and because they're getting the meds that they want, and they're not having to detox. And the other part of it is just the ritual of actually coming in and connecting and doing that.”

—Counselor 1

For other participants, not necessarily in early recovery, physically coming into the program was an essential part of their recovery routine. One participant who appreciated in-person interactions noted how getting two weeks of take-home medication at a time may be less helpful for him.

“I still wanted to keep this place fresh in my mind because it’s still part of the program with counselors and stuff. I’d forget about appointments if I only came in every other week.”

—Patient 10.

Participants described varied expectations and experiences communicating with counselors as a part of their recovery process. For some, communication with counselors was a key aspect of recovery, while others valued communication less. Overall, participants did not feel like the app changed communication substantially or affected their relationship with their counselor. A few participants did describe an aspect of personal connection through the app, which they felt helped them relate more to their counselors and provided an additional level of motivation early on in recovery.

“I think, if anything, it kind of felt like I was giving [my counselor] a peek into my home life and stuff. Kind of, more personal, more open. I wasn't super early in my sobriety, but it did also feel like, I don't want to say it helped keep me clean or anything. But it was definitely, like, oh my counselor’s going to see this. I definitely don't want anything going on in the background that she wouldn't like….. I think it just kind of made me, maybe, be more open. And it definitely made it feel more personal.” – Patient 5.

Theme #4: Privacy concerns and usability issues did not affect willingness to use VOT

In general, the VOT patient platform was felt to be simple, intuitive, quick, and well-functioning. Some participants reported instances where video uploads didn’t occur or were delayed which they attributed to internet connectivity issues.

“I liked the fact that I could be anywhere and show myself taking my dose….If I didn't have Wi-Fi, it might be hard. But, you know, I can't think of any place, any situation where it would be hard to get to a spot with Wi-Fi, even if I didn’t have it.” – Patient 9.

Some described physically awkward logistics of filming themselves and making sure the video satisfied requirements (e.g. medication bottle could be seen). While some participants reported feeling awkward or “camera shy”, participants generally did not express privacy concerns. When questioned, some participants indicated that they felt more comfortable knowing that their counselors were reviewing their videos as opposed to “just a random person that works for a random company.”

“I felt pretty comfortable, especially knowing that it was going mainly to my counselor and then, you know, the people in the app had access to it if there was ever a problem or something. But it wasn't, you know, just whoever could see it. So I did feel, I felt comfortable using it. I never felt like my information was in jeopardy or anything that.” – Patient 5

For others, they noted that they didn’t have a preference on whether it was their counselor or someone else reviewing their video submissions, “as long as they’re doing it properly.” At the time of the interview, a few participants had not realized that it was in fact their counselors reviewing their video submissions.

Participants also had the ability to text their counselors through the app. Their use of the in-app text function generally had to do with logistics of using the app, such as advice on taking and uploading videos. Sometimes app communication was used for appointment reminders while other times text communication allowed the patients to know that their videos were being reviewed by their counselor, which they found reassuring.

There was a small minority for whom using the technology itself created unwelcome anxiety. A few participants expressed concerns that the technology wouldn’t function correctly and wondered what effect a missed submission would have on their treatment plan. For one participant, this concern was salient enough that he would not want to participate in VOT in the future.

“I don’t want to have to worry about my phone not working or breaking. I have bad luck with the screens on my phone, breaking them because I work. If the screen breaks, the phone doesn’t work. And I've replaced this phone four times last year. [T]hat means there's going to be one morning every time where I wouldn’t have been able to use the app. And four times in a year, that might’ve been enough for them to say I wasn’t [able to continue with home dosing] – that would just be an unnecessary stressor.” – Patient 10.

The counselors also expressed that the provider interface was simple and intuitive. They indicated that initially setting a patient up for VOT could be time intensive, but daily video review and text communication was not. One counselor expressed her preference that the provider portal be incorporated into the clinic’s EHR for documentation purposes. While providers did not express usability concerns, one did express initial discomfort that observing medication adherence, which was not part of her usual scope of practice as a substance use disorder professional.

It was kind of uncomfortable, I guess, that normally it's our nurses who determine at the window who can, at that point, ingest their dose safely or not. So, I felt like I had my own criteria and awareness of their dosing appropriateness. But I also felt like a little bit like inexperienced, I guess. – Counselor 2.

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