Well-Being of Health Care Professionals Treating Opioid Use Disorder During the COVID-19 Pandemic: Results From a National Survey

Between July 14 and August 15, 2020, a total of 1,109 individuals answered the first survey question, 832 completed the entire survey, and 812 completed the survey item relevant to the current analysis. The response rate could not be calculated because of the overlap among organizations’ e-mail listservs and because the number of listserv recipients who were active prescribers of medications for opioid use disorder was unknown. The rate of missing data among variables included in regression models was <1%. The survey respondents came from all 50 states except South Dakota. Eight respondents were from outside the United States (<1% of the sample), and one was from Puerto Rico. The top five states by number of survey participants were Colorado (N=108), California (N=50), New York (N=49), Massachusetts (N=43), and New Mexico (N=35). Of the remaining states, 22 had fewer than 10 respondents.

Among the respondents, most identified their race as White (80%, N=650 of 809), gender as male (53%, N=430 of 810), and profession as physician (75%, N=536 of 718). Participant age was equally distributed across categories, except for those ages <30 years representing 1% (N=12 of 810) and those ≥70 years representing 11% (N=92 of 810) of the survey sample. Nearly half (46%, N=376 of 812) reported working in an urban area, and the remaining respondents were split between suburban (28%, N=228 of 812) and rural (23%, N=186 of 812) areas. Only slightly more than one-third of participants (38%, N=309 of 812) were board certified in addiction. More than half (57%, N=464 of 811) reported Medicaid as their patients’ primary insurance. Practice settings were diverse, with 24% (N=192 of 812) reporting multiple settings, 17% (N=136 of 812) private practice only, and 11% (N=92 of 812) opioid treatment program only. Only 16% (N=131 of 812) reported that all staff were working onsite as usual. Overall, 17% (N=136 of 812) of respondents reported that COVID-19 had caused function-impairing anxiety at work and home, and 28% (N=229 of 812) reported that COVID-19 had disrupted their work-life balance (Table 1).

Bivariate Pearson’s correlation tests indicated that about half of pairwise comparisons of organizational characteristics were statistically significant, although these correlations were mostly weak (r=−0.46 to 0.30) (see online supplement). Two factors were associated with lower odds of reporting functional impairment because of anxiety about COVID-19: male gender (odds ratio [OR]=0.60, p=0.01) and having no staff changes at work (OR=0.51, p=0.01). Two factors were associated with higher odds of reporting functional impairment because of anxiety about COVID-19: staff sick with COVID-19 (OR=2.59, p<0.01) and feeling close to patients (OR=1.97, p=0.01) (Table 2).

Male gender was associated with lower odds of having difficulty balancing work and home life (OR=0.56, p<0.01), as was being older (OR=0.76, p<0.01) and reporting no staff changes at their organization (OR=0.54, p=0.01). Characteristics associated with higher odds of difficulty included addiction board certification (OR=1.88, p<0.01), working in multiple practice settings (OR=1.78, p=0.01), layoffs or furloughs or reduced hours (OR=1.66, p=0.01), staff sick with COVID-19 (OR=1.66, p=0.01), and group meetings to check in on staff well-being (OR=1.85, p=0.01) (Table 3). Likelihood-ratio tests revealed no significant variation at the state level. No associations were found between demographic area and reporting disruptions to functioning or work-life balance.

Our findings provide insights into potential impacts of COVID-19 on HCP well-being after the transition from in-person to remote treatment of opioid use disorder. Only 16% of the HCPs were working onsite as usual during the COVID-19 pandemic period surveyed (in summer 2020), likely a dramatic change because these HCPs previously provided only minimal remote treatment. A minority reported negative impacts on well-being because of the pandemic. Disparities were found by gender and age, with male and older HCPs apparently being less affected by the pandemic. Additionally, significant associations of reported difficulties were found with addiction board certification, practice setting, organizational factors, and HCP experiences. Demographic, provider-level, and organizational-practice variables warrant further investigation of the impact of COVID-19 on HCP well-being.

The small fraction of respondents reporting functional impairment because of anxiety about COVID-19 may be explained by the timing of the survey. Associations with reduced staffing and negative impacts on work-life balance are consistent with previous research reporting that longer hours are associated with burnout (26, 27), because affected HCPs likely have had increased clinical and administrative demands. Telework was not specifically assessed, but the rapid transition to telework was likely disruptive to HCPs’ lives.

Our gender- and age-related findings are consistent with previous research showing associations between gender and age with burnout among HCPs. We did not ask respondents about having children in the home; however, associations between demographic variables (e.g., gender or age) may be explained by this factor. Our study is the first to document differences in the well-being of HCPs by addiction board certification, with those reporting either addiction medicine or addiction psychiatry board certification having higher odds of reporting difficulty with work-life balance. A previous study of physician job satisfaction reported no differences between addiction or nonaddiction specialties or between buprenorphine-waivered and nonwaivered prescribers (9). Board-certified professionals may be treating a larger number of patients with more severe substance use and co-occurring psychiatric disorders, which have worsened during the pandemic.

HCPs working in multiple practice settings were more likely to report negative impacts on work-life balance, possibly because of increased administrative demands. Feeling close to patients was associated with functional impairments from anxiety. Although this association was unanticipated, the survey item was included to understand the impact on rapport between HCPs and patients. It is possible that increased rapport coincided with increased worry for patient well-being. Associations between difficulty with work-life balance and meeting to check in on well-being as a group might be related to perceived infringement of work-life barriers or conversely may indicate an increased need for well-being check-ins. However, no significant association was found between functional impairments and well-being check-in meetings or between feeling supported by the organization and either well-being metric.

We hypothesized more negative impacts on well-being among those working in urban settings because of the precipitous impacts of COVID-19 in large U.S. cities early in the pandemic. However, we found no significant associations between demographic area and either measure of HCP well-being after accounting for clustering of HCPs within states. The reason for this finding likely is that our measure was overly simplified because some urban centers were significantly more affected by the pandemic early on (28). With a larger sample, an analysis comparing highly affected regions with less affected ones may provide a better understanding of the impact of infection rate severity.

A limitation of our survey was that we recruited a convenience sample through e-mail listservs and had a low number of responses relative to the total listserv subscribership and to the total number of known buprenorphine-waivered prescribers; this low response rate limited generalizability of our findings to all HCPs who treat patients with opioid use disorder. HCPs who were differentially affected by the COVID-19 pandemic may have varied in their willingness or ability to complete the survey. However, we believe that the large number of responses within a relatively small subspeciality in a short time frame provides important insights to better understand the well-being of HCPs who have treated patients with opioid use disorder during the pandemic. Findings related to gender and age were consistent with those of previous research, increasing our confidence in the reliability of the results, which highlight that women and younger HCPs were particularly affected by the pandemic.

Additionally, a low number of responses were received from providers of color, with Black and Hispanic HCPs making up only 3% and 6% of the respondents, respectively. Although our survey attempted to reach a diverse group of prescribers of medications for opioid use disorder through the listservs of large organizations, we relied on voluntary participation. The percentage of Black and Hispanic physicians in the United States is approximately 5% and 6%, respectively (29), which was approximated by our sample. This convenience sample provides early insights that should be further evaluated among HCPs who treat patients with opioid use disorder.

We note that the changing course of the COVID-19 pandemic and survey timing may have affected our results. Survey responses were obtained during a summer 2020 COVID-19 peak in national case numbers. This surge was followed by a period of relative stability in the fall of 2020, followed by another surge in the winter, with a 7-day average more than three times that in the summer (28). Notably, the winter surge coincided with COVID-19 vaccine rollouts in the United States. Numerous variables may have affected HCP well-being at various time points during the pandemic, and our survey provides only a snapshot of these impacts.

We also measured well-being broadly and did not use validated burnout scales. Our intention with the survey was to begin to understand HCP practice changes related to COVID-19 as well as HCP perceptions and impacts of changes. In this analysis, “functioning” and “work-life balance” were identified as potential proxies for HCP well-being. We recognize that well-being and burnout are multifactorial and are not fully encompassed by these dependent variables and therefore warrant further investigation with validated instruments.

Our findings highlight the importance of emphasizing HCP well-being and strategies to reduce burnout. A meta-analysis found that organization-directed interventions had significantly greater effects than physician-directed interventions (30). Effective organization-directed interventions included reducing or modifying work or on-call shifts and initiating targeted quality-improvement projects (26, 27, 31), and effective physician-directed strategies included mindfulness-based interventions (32, 33). A narrative review identified several organizational approaches to prevent or manage burnout among staff: developing and publicizing employee assistance programs; scheduling genuine break time; and having regular meetings to discuss goals, hours, tasks, and fairness (34). Five physician-level principles were also identified: establishing work-life balance; making career decisions by first identifying what is energizing or else draining; nurturing well-being strategies, social networks, and self-care; becoming engaged or reengaged; and building resilience.

This multiorganizational collaborative study sought to understand the impacts of organizational changes related to the COVID-19 pandemic on the well-being of HCPs who treat patients with opioid use disorder. We identified an impact on HCPs’ ability to balance professional and personal lives adequately during the pandemic. Our results should inform organizational leadership of what pandemic-related changes are associated with changes in HCP well-being. We propose that employers should consider the specific needs of women, younger HCPs, and HCPs who work in multiple settings; employers should also carefully evaluate the intention of well-being check-ins and consider the structure and frequency to focus on genuine well-being needs and avoid infringement on work-life balance. Further research should study trends to determine whether COVID-19–related functionally impairing anxiety and work-life balance disruptions persist and what interventions should be implemented to mitigate harms; a particular focus should be given to HCPs who are Black, Indigenous, and other people of color, given known differential impacts on and disparities in health care delivery for these groups before and during the COVID-19 pandemic (35–38).