Reimagining better addiction treatment services through telemedicine : a complex systems approach

In 2022, the United States, Scotland and Canada had among the highest drug-related death rates in the world, at 329 per million, 193.3 per million, and 190 per million of the population respectively. The use of Telemedicine to provide Medications for Opioid Use Disorder (TMOUD), such as buprenorphine or methadone, has been identified as an innovation which could increase access to evidence-based treatment. The COVID-19 pandemic saw a sharp rise in the use of TMOUD in North America. In Scotland, despite national efforts to drive telemedicine uptake during the pandemic, the number of addiction-related telemedicine consults fell by 67%. Three peer reviewed publications are presented in this thesis to inform a complex systems understanding of this discrepancy and to identify ways of maximising the potential of TMOUD in mitigating the DRD crisis in Scotland. Paper 1 synthesises the peer-reviewed literature to conceptualise TMOUD as a multifaceted healthcare delivery system. Paper 2 applies Normalisation Process Theory (NPT) to the peer-reviewed literature to understand the work required of stakeholders to embed and normalise TMOUD into routine practice. Paper 3 uses the Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) framework, collating evidence from Paper 1 and 2 with practice-based knowledge and expert opinion to develop a TMOUD implementation model. This thesis applies the accumulated knowledge from these three papers to make the case for TMOUD in re-imagining addiction treatment services in Scotland. Key findings applicable to both the Scottish and international contexts include the potential for telemedicine to enable low-barrier access, continuity of care, complex care management and improved service resilience. Further, the uptake and spread of TMOUD requires health equity driven, multi-level whole-systems policy and practice interventions which address structural stigma, siloed funding, data and services and power imbalances between clinicians and people who use drugs.