Accessing (or not) telemedicine to treat opioid use disorder during covid-19: an ethnographic study in new york state

Caulfield, Christopher, Patrick
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Gordon, Tamar
Kinchy, Abby
Udo, Tomoko
Campbell, Nancy, D
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Science and technology studies
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This dissertation presents an in-person and digital ethnography of people in New York State who use drugs and seek treatment for opioid use disorder (OUD) using phone or video connection to receive healthcare (telecare) including interviews prior to and during the COVID-19 pandemic. The interviews focus on how the shift to telecare during the pandemic has affected people seeking treatment for opioid use disorder (OUD). I leverage a feminist Science and Technology Studies (STS) approach to elucidate how the political, clinical, and juridical framing of people who use drugs shapes the interconnections of care (or inaccessible care) that are discernable. The findings described below provide a heuristic for grasping how structural stigma has intersected with the U.S. treatment system during the COVID pandemic to reproduce increased rates of use, relapse, and overdose death. Telecare offers some benefits of increased access to medication for OUD (MOUD), but people need access to the technology and the knowledge and capacity to use it, and localized resources continue to be a key barrier for accessing treatment. The narratives of people seeking treatment are analyzed through the theoretical lenses of Nelly Oudshoorn’s analysis of the technogeography of care and Nancy Fraser’s analysis of the US juridical-administrative-therapeutic in/justice system. I offer the concept of the technogeography of harm reduction (THR) to help me trace and problematize how telecare contributes to redefining the experience of familiar places, such as home, into spaces of both care and surveillance, and how the technology of telecare presents both affordances and foreclosures to accessing care and reducing harms as people struggle to conform with the requirements of telecare in order to receive care. Key findings are that the significance of hugs and tactile connection is sorely missed by people using telecare for group therapy. The proximity to in-person services even while using telecare is critically important. The resistance strategies of telecare users to surveillance mechanisms shed light on how the system of treatment continues to fall short of meeting people where they are at and accepting that their self-defined goals should govern their treatment plan. The continued stigmatization of drug use and treatment acts as a key barrier to people who are striving to produce the identity of a patient who is clinically stable for take-home medication. Mental illness has been shown to be associated with an increased prevalence of substance use disorder (SUD) (RachBeisel, Scott, and Dixon 1999), and people who experience both mental illness and SUD must contend with a twofold barrier of stigma directed at both their mental illness and their SUD, a harsh reality that was present in several of my interviews. This dual diagnosis resents a key challenge for treatment providers to reach and treat these patients (Priester et al. 2016), especially in a treatment system that prioritizes those with money and resources, a key factor for access to telemedicine especially during the economic turmoil of the pandemic (Watson et al. 2022). The importance of peers for providing compassionate care, truly meeting people where they are at, emerged as a key element of successful treatment, for both telemedicine and in-person care. Peers have gone through the treatment system themselves, and some professional peer roles in NYS, such as the Certified Recovery Peer Advocate (CRPA), are not mandated reporters, which means that people can tell their CRPA that they had a relapse and the CRPA is not legally required to tell the judge or their doctor, thereby enabling a level of openness and the establishment of a therapeutic alliance (without any need to hide a relapse) which may be foreclosed to a mandated reporter, such as a Credentialed Alcoholism and Substance Abuse Councilor (CASAC). The narratives described below provide a heuristic for understanding how addiction is (re)produced by the clinical and juridical systems that intersect with telecare for OUD, and one implication of my research is that in order to reverse the drug overdose crisis, the United States needs a complete reimagination and overhaul of the juridical and therapeutic systems that (re)produce the problem of addiction. A second implication centers on the prospect that people who use drugs (PWUD) may avoid using telecare phone apps because of concerns that they could be subject to data and privacy breaches, an issue that grows more urgent and potentially harmful as increasing numbers of people develop a reliance upon apps for telecare. Therefore, a second implication of this research is to affirm the importance of legal and professional protections of digital individual privacy and algorithmic fairness, a topic that is increasingly important as AI machine learning enters the space of healthcare apps and telecare.
School of Humanities, Arts, and Social Sciences
Dept. of Science and Technology Studies
Rensselaer Polytechnic Institute, Troy, NY
Rensselaer Theses and Dissertations Online Collection
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