The Covid-19 pandemic, in tandem with the advancement of emerging technologies such as virtual conferencing tools, has prompted us to rethink how we live our lives. Increasing proportions of the population have adapted their lives to virtual spaces with remote work and socialization. With regulations such as social distancing and other Covid-19 prevention strategies in place, many healthcare providers also began to move their services online, including mental health services that provide substance use disorders (SUD) treatments (Knopf, 2020). Compared to only approximately 40% of healthcare facilities delivering healthcare services using telecommunications devices and technologies in 2019, more than 90% of health centers have reported using telehealth in 2021. Additionally, despite fluctuations in Covid-19 case numbers, studies have found that telehealth service usage remains high and the preferred choice for many clients and providers (Demeke et al., 2021).

Additionally, as the pandemic continues to impact our physical and mental health, there has been a considerable increase in reports of substance use, worsening mental health conditions, and suicidal ideations among populations that are the most affected and vulnerable to Covid-19 (Czeisler et al., 2020). As of 2021, 13% of Americans have reported starting to use substances as a coping mechanism for Covid-19-related stress and emotional challenge. Overdose due to substance use has also spiked significantly since 2020 with a national increase of 18% in overdose-related death compared to statistics in 2019 (Abramson, 2021). This is especially true for marginalized populations such as people of color and individuals from lower socioeconomic statuses, as they have been disproportionately affected by the pandemic compared to their White or higher-income counterparts (Getachew et al., 2020).

Even before the pandemic, disparities in access to SUD treatment and care exist across different racial and socio-economic populations. While overall White people are more likely to use illegal substances than people of color, marginalized communities such as people of color and those in lower-income brackets are nonetheless disproportionately at a disadvantage to access care and more likely to receive punitive actions rather than treatment (Volkow, 2019).

Since the pandemic, in-person treatment options for SUD such as peer support groups and in-patient rehabilitation centers have become less accessible to those in need. These problems are further exacerbated with hospitals being overcrowded with more patients flooding in due to Covid-19 and healthcare professionals’ diminished capacity to look after those coming in with less pressing matters such as SUD-related issues (Volkow, 2020). This is particularly impactful for low-income populations from communities of color that depend on the safety net welfare systems as many of them could only afford to receive care from public hospitals and state-sponsored substance use treatment facilities due to disparities such as high unemployment rates and low health insurance coverage (Lew & Benjamin, 2021). Therefore, accessibility to flexible and safe treatment options for SUDs should be considered a priority for healthcare providers and mental health professionals.

With these aforementioned challenges in mind, telehealth seems to be an obvious choice that could increase the accessibility and availability of SUD treatments for those in need. For starters, telehealth works better than conventional in-person care in terms of compliance with current pandemic guidelines and could improve access to care for those living in geographically inconvenient locations such as rural communities. Additionally, studies have shown that telehealth SUD treatment options, including psychotherapy and medication-assisted treatments, have yielded similar clinical outcomes as in-person options, and clients have expressed relatively

high satisfaction rates with the quality of care, clinician-patient relationships, convenience to care, and other benefits exclusive to telehealth (Lin et al., 2019; Sugarman et al., 2021).

Furthermore, from the perspective of regulatory bodies, in response to the pandemic, the Drug Enforcement Agency temporarily canceled the requirement for in-person intake for initiation of prescriptions of controlled substances such as medications used for SUD treatment, and many states have authorized the use of telehealth for health care services and approved telehealth for medical insurance reimbursement purposes, including substance use treatment (U.S. Department of Justice Drug Enforcement Administration, 2020; NYGOV, 2020). For instance, in New York State, licensed practitioners with telehealth training can provide SUD treatment even if the practitioners reside out-of-state (NYSED, 2021). Therefore, on a policy level, telehealth for substance use disorders is here to stay.

Nevertheless, barriers to telehealth also exist from the remaining two major stakeholders’ perspectives, the patient and providers. From the patient’s perspective, studies that recommend telehealth SUD treatments based on patient satisfaction rate have been focusing on
predominantly White participants who were already enrolled in telehealth treatment. On the contrary, perceptions, and accessibilities of telehealth SUD services for marginalized communities remain relatively unknown as only a few studies have touched upon this population (Sugarman et al., 2021). From the provider’s perspective, since telehealth has been relatively new and given the unique need for observing behavioral and vital signs during SUD treatment, clinicians might experience potential barriers to building a therapeutic alliance and exhibiting the necessary cultural competence to provide adequate care for marginalized populations (Shore et al., 2018; Guerrero & Andrews, 2011).

Therefore, there is still much to explore on how telehealth could potentially benefit or create a further digital divide for marginalized communities when it comes to Substance Use Treatment. This paper leverages existing literature on substance use disorders treatment and telehealth to explore challenges marginalized communities, specifically people of color or those from lower socioeconomic statuses, might encounter when attempting to access such services, and it aims to create evidence-based recommendations to better telehealth SUD treatment options for the aforementioned communities in a more inclusive care environment.

Review of Literature

To understand how marginalized communities could benefit from telehealth treatment, it is pertinent to first examine this relatively novel treatment modality itself. Telehealth, used interchangeably with telemedicine, refers to the utilization of internet-based technologies to diagnose, treat, and provide clinical care to clients who might be geographically unavailable for in-person treatment (Tuckson et al., 2017). With the emergence of new technologies, telehealth also began to encompass online health curriculums and wearable devices that measure vital and behavioral patterns (Haynes et al., 2021).

Since the pandemic, telehealth has risen to become a leading modern solution to overcome healthcare obstacles posed by Covid-19. In particular, for SUD treatment when there is not a “one-size-fits-all” approach, telehealth could be utilized in many different ways. Firstly, it increased access to healthcare for those in areas where in-person appointments are limited. Telehealth also helped protect those who might otherwise be vulnerable to Covid-19 with at-home visits. Furthermore, telehealth also helps encourage individuals on the verge of seeking

help for substance use challenges to seek help, as it provides an additional scope of privacy and might alleviate the stigma attached to seeking mental health interventions (Abramson, 2021).
Additionally, with the emphasis on continuity in SUD treatment, appointment

non-attendance significantly affects treatment outcomes and increases the likelihood of relapse (Molfenter, 2013). Studies have shown that contingency management with consistent appointment reminders has improved treatment attendance, and implementation of technology such as text messages and email reminders has outperformed other means of communication like physical letters (Milward et al., 2014). Post-treatment recovery could also benefit from using telehealth, as clients have the option to access support chats through mobile applications and secure online spaces day or night (Molfenter et al., 2018).

Furthermore, wearable devices such as pulse oximeters paired with electronic record keepers enable clients to communicate their health statuses to their providers without the further hassle of calling the clinic. Other digital devices provide direct therapeutic support. For instance, a recent FDA-approved earpiece helps individuals going through opioid withdrawal by producing mild electrical stimulations to calm the cranial nerves down and help produce endogenous endorphins (Fantis, 2022).

Lastly, for those who are prescribed health curriculums such as asynchronous SUD educational models, telehealth could help clients overcome language barriers with translation capabilities, bridging gaps between communities with non-English native language (CMS,
2020).

Since Covid-19, practitioners in SUD treatment facilities across the country have experienced providing services through telehealth, and several benefits were highlighted.

Practitioners have reported that telehealth served as a flexible option that motivates patients who were reluctant in the past to start medication. Additionally, other practitioners have noted that telehealth seemed to be less activating for some of their patients who were triggered by the physical settings of the clinic (Aronowitz et al., 2021).

Nevertheless, there are unsolved issues residing on the practitioner’s side as well. Clinicians from substance use clinics have reported observing their clients using telehealth as an avoidance strategy such as logging off intentionally during sessions, particularly for clients who are deemed relatively unstable in their treatment process, consequently decreasing the quality of care delivered (Levander et al., 2021). Others have noted that treatment outcomes and the possibility of relapse of clients using telehealth appointments seem to depend on the level of engagement clients exhibit, and telehealth takes away certain elements that are necessary for engagement such as body language and face-to-face connections. Besides the level of engagement, practitioners have also expressed concerns about the collection of vital signs, as clients in certain SUD treatment programs are required to provide urine samples to maintain their eligibility (Aronowitz et al., 2021).

To fully experience the aforementioned benefits, clients need to be equipped with the appropriate resources such as access to the internet or digital literacy to understand the technology. In particular, a significant digital divide, unequal distribution of information and technology among different populations, stands between these benefits and communities of color and low-income households (Horrigan, 2016).
Barriers to access general telehealth care for people of color and individuals from lower socioeconomic status include but are not limited to physical access to the internet and devices,

financial ability to maintain technological services, an adequate level of understanding and skills to manipulate said technologies, and trust in technology (van Deursen & van Dijk, 2018).

Previous studies have shown that a major digital divide exists among communities of color. For instance, Black and Latinx households disproportionately carry less weight in computer and smartphone ownership compared to their White counterparts (Atske & Perrin,
2021). Other studies have shown that among individuals experiencing poverty and other challenges of maintaining basic life necessities, the current telehealth modalities for treatment might further exacerbate the digital divide, compared to their wealthier counterparts who seem to be benefiting more from telehealth (Bakhtiar et al., 2020).

Recommendations for a More Inclusive Environment for SUD Telehealth Treatment

Marginalized communities such as people of color and individuals from low socioeconomic statuses face obstacles to accessing technologies needed for telehealth SUD interventions. To increase accessibility, the different levels of challenges must be acknowledged.
Firstly, individuals experiencing poverty might not be able to purchase devices that are compatible with telehealth treatment such as smartphones and tablets. This could be addressed by providing clients with free devices or helping clients locate resources that do. For example, several cancer foundations have begun to provide free tablets for patients from low-income communities since the pandemic (County, 2021). Furthermore, limited or lack of access to the internet could be addressed by recommending eligible clients to apply for free internet services or broader social policy changes that increase community-level internet access.
Additionally, given the duration of SUD treatment, individuals with economic instability might not be able to maintain consistent access to devices and the internet. Flexibility and

advanced planning in the treatment course with practitioners could potentially alleviate this barrier; however, this might increase the workload and burden of care from the perspective of the practitioners and the clinic. A previous study on clinics serving individuals experiencing housing instability has found that additional actions were often needed to coordinate with individuals
who have inconsistent access to technology, but an increased number of student volunteers and staff members were able to balance the demands (Ramsetty & Adams, 2020).

In addition to physical devices for telehealth, digital literacy, the ability to use information and communication technologies with both technical and cognitive skills, also plays a crucial role in telehealth access (Loewus, 2016). Marginalized populations such as people of color or low-income communities have historically disproportionate levels of digital illiteracy (Horrigan, 2016). Therefore, to increase their access to telehealth, education on digital literacy skills must be included, and this could be addressed on three levels.
From the perspective of practitioners, providing additional educational support to clients with low digital literacy could help alleviate the discouragement and challenges the clients might face in the telehealth treatment process. Additionally, if possible, practitioners could utilize more easy-to-use HIPAA-compliant telehealth platforms over more complicated ones to help clients familiarize themselves with the process.
On a community level, local organizations have partnered with healthcare providers and advocates to help clients from marginalized communities develop digital literacy through free skills-training programs. These community-centered approaches are not only helpful for individuals needing access to SUD telehealth services but also beneficial for their overall wellbeing and other personal developments (Sheon, 2021).

Policymakers have also launched new efforts to improve digital literacy for telehealth expansion among marginalized communities. For example, the American Medical Association has launched a new three-year plan to produce programs to increase digital literacy among marginalized populations (Wicklund, 2021).

By incorporating both in-person and telehealth modalities, clients marginalized communities might have improved access to SUD treatment options in the post-pandemic future. With the hybrid modality, multiple possibilities have emerged from both the clients’ and practitioners’ perspectives.
For clients with limited access to technology and/or low digital literacy, a hybrid modality of treatment seems to be one of the optimal options of care. Opioid use disorder clinics have begun to allow prescribers and clinicians to work remotely while case managers remain
in-person at the clinic to help clients with issues of technical difficulties, adherence to medication, vital sign intakes, urine tests, etc. Consequently, clients could still attend their appointments in person while virtually connecting with their practitioners from devices at the clinic without having to worry about affording devices and the internet, navigating the telehealth system, and accessing private spaces on their own (Talal et al., 2020).
From the practitioners’ perspective, if they can work remotely while clients with limited telehealth access could connect with them through in-person clinic visits, they would become flexible with scheduling, leading to more availability during evenings and weekends (Hughto et al., 2021). If clinic hours are also able to adjust accordingly, then this could potentially be beneficial for clients from marginalized communities who cannot afford to take time off work or have other family duties to attend to during the day.

Additionally, hybrid modality also helps address the aforementioned concern of client engagement. As some clients with SUD have found it difficult to engage and connect with practitioners virtually, by being in-person at the clinic while connecting with practitioners virtually, clients might feel more grounded and focused than exclusively virtual telehealth sessions at home.

Even before Covid-19 and the emergence of telehealth, individuals with SUD, especially people who inject drugs (PWID), have experienced significant stigma and discrimination within health care services (Paquette et al., 2018). The stigma attached to substance use is further exacerbated by marginalized identities such as racial and ethnic groups and socioeconomic statuses, and these communities also have disproportionately fewer resources to cope with such discrimination (Frederique & Frederique, 2016; Mulia & Karriker-Jaffe, 2012). Hence, it is understandable that marginalized populations might have certain levels of mistrust and skepticism toward SUD treatment (Fisher et al., 2008).
Despite the lack of study specifically on SUD and telehealth, a previous study on telehealth use and diabetes treatment has found that even with high ownership of
internet-capable devices, less than fifty percent of African American patients with diabetes sought out telehealth treatment since the pandemic, and the reason for refusal of telehealthcare was largely due to lack of trust in physician’s ability in telehealth settings and overall lack of trust in medical establishments (Rovner et al., 2021). Therefore, it is crucial to address the issue of stigma for marginalized communities to better access SUD telehealth services.
Community-based approaches could alleviate the issue of stigma. Studies have found that communicating positive stories of individuals with substance use disorders through community

educational programs has been effective when addressing the social stigma of substance use among the general public. Increasing contact with individuals with SUD and critical reflection techniques might also help reduce biases from medical professionals (Livingston et al., 2011).

This research has several limitations. Firstly, it mainly considers full pharmacological, behavioral, and psychological interventions for substance use disorders, since it does not examine low-threshold medication-assisted SUD care. Additionally, this study cannot be generalized to other populations with marginalized identities in substance use disorders such as individuals with comorbid mental health disorders.

Future studies should look into the long-term effectiveness of digital literacy programs and hybrid treatment options for marginalized communities and examine if discrepancies exist between treatment outcomes of marginalized communities compared to their wealthier, White counterparts. Additional research should also consider barriers to telehealth SUD treatment for individuals with comorbid mental health disorders and other vulnerabilities.

Telehealth has changed the landscape of how healthcare could be provided, and substance use disorders treatment is no different. Telehealth SUD treatment has helped clients in many ways; nevertheless, our growing dependence on telehealth since the pandemic has exacerbated health and treatment outcome disparities for marginalized communities living with substance use challenges. Therefore, it is more crucial now than ever to establish solutions to ensure that marginalized communities who are already more vulnerable have equitable access to telehealth substance use disorders treatments in a more inclusive health care environment.

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