The Digital Divide and Tele-MOUD: A Qualitative Study of Opioid Community Coalition Perspectives During COVID-19

Background: The rapid expansion of telehealth-delivered medication for opioid use disorder (MOUD) during the COVID-19 pandemic highlighted critical digital divide issues in communities. How community context influences the digital divide remains unclear, creating uncertainty about ameliorating the gaps in access to tele-MOUD. Methods: We qualitatively examined the perspectives of 315 opioid community coalition members who were part of the HEALing Communities Study (HCS) to understand how the digital divide created access barriers in urban and rural communities. Primary coding for all interviews used a deductive approach with codes derived from the Reach, Effectiveness, Adoption, Implementation, Maintenance/Practical Robust Implementation and Sustainability Model overarching HCS framework. Secondary coding used the nine determinants of Lythreatis's 2022 digital divide framework, and inductive thematic analysis was used to identify themes with each of the nine determinants. Results: Shared issues across communities related to the digital divide, including trust, social support, technological infrastructure, digital literacy, policy changes, and pandemic-related disruptions, critically influenced telehealth expansion and effectiveness. Rural communities reported specific barriers around infrastructure and socioeconomics, whereas urban communities reported specific barriers around sociodemographic factors. Conclusions: To address these digital divide issues, policymakers should continue to invest in rural infrastructure and improve internet access for underserved populations. Clear guidelines are also needed for when tele-MOUD is appropriate versus in-person visits and when urine drug screening is necessary. Additionally, emphasizing patient choice and maintaining in-person care is important to support equitable access to these services.