Buprenorphine Prescribing through Telemedicine and Telephone Evaluation: Time for an Overdue Update in Policy
It should not be more difficult for health care providers to prescribe life-saving medications that treat opioid use disorder than to prescribe addictive opioid pills themselves. Yet, that is the reality clinicians face today.
Fortunately, there is an opportunity to address this disparity by permanently amending federal policies that allow providers to prescribe buprenorphine treatment for opioid addiction following a telemedicine or telephone evaluation.
Even as deaths from opioid overdose dramatically increased over the past two decades, patients across America continue to face barriers in accessing treatment for opioid addiction. However, the COVID-19 pandemic might be the catalyst the U.S. needs to permanently transform policies related to telehealth services for opioid use disorder and help millions of people get one step closer to entering recovery.
As many feared, the pandemic’s financial, social, and emotional toll on society has exacerbated the national rate of opioid overdose deaths. Data from the Centers for Disease Control and Prevention shows that fatal drug overdoses increased by almost 30 percent in just 12 months from October 2019 through October 2020 (CDC, 2021).
One silver lining to the pandemic that has ravaged the world is that it may have jump-started the telehealth revolution. Though the technology is not new, telehealth usage remained the exception rather than the norm before the U.S. government declared a public health emergency on January 31, 2020, due to the COVID-19 pandemic (HHS, 2020).
Since the onset of the pandemic, the U.S. has experienced an unprecedented increase in telehealth use. This increase was most apparent for behavioral health care services, with a recent report finding behavioral telehealth usage increased by 56 percent as of December 2020 (Mehrotra et al., 2021).
Amid calls for physical distancing to reduce virus transmission, the COVID-19 public health emergency declaration enabled the federal government to enact policies that temporarily exempted providers from conducting in-person medical evaluations when prescribing medications such as buprenorphine, a key treatment option for opioid use disorder.
This exemption permitted the use of telemedicine services to remotely treat and monitor patients. Such services are critical, since about 28 million people live more than 10 miles and almost three million live more than 30 miles from a buprenorphine provider (Langabeer et al., 2020). Geography plays an important role in treating opioid use disorder, with access strongly associated with the proportion of rural communities in a state.
Providers have also been empowered during the pandemic to treat patients using telephone-based evaluations, which were permitted for treatment regimens involving buprenorphine. Access to treatment by telephone may be more vital than services provided by telemedicine for people of color, those with fewer years of education, and those who live in areas where they are less likely to have a broadband internet connection at home (Pew Research Center, 2021).
These more flexible telemedicine and telephone service policies will only be in place while the COVID-19 public health emergency is in effect. After that, they are set to expire, along with the increased access that has benefited so many since the pandemic began.
The barriers to permanent use of telemedicine and telephone services for opioid use disorder treatment were implemented by policymakers with good intentions. They trace back to the 2008 Ryan Haight Online Pharmacy Consumer Protection Act, which was enacted in honor of a California teenager, Ryan Haight, who suffered a fatal overdose after buying opioid prescription drugs online without a formal physician evaluation.
This Act aimed to reduce illegal distribution and dispensing of controlled substances through the internet by requiring that qualified health professionals first conduct an in-person medical evaluation. Unfortunately, this restriction applies to all controlled substances, including treatments for opioid use disorder.
Some have argued that this overarching restriction is necessary, as all controlled substances carry some risk of drug diversion. However, research has shown that diversion of substances like buprenorphine is more likely for those who need treatment but lack access to services than it is a desire for illicit drug use or distribution (Cicero et al., 2018).
The U.S. Justice Department and the Drug Enforcement Agency have the authority to rectify policies that restrict telemedicine and telephone services for opioid use disorder treatment. In fact, plans were made to draft and implement a special registration process through the Ryan Haight Act that allows telemedicine and telephone evaluations for buprenorphine prescribing. However, the registration process has not yet been created, despite calls to move forward. Doing so would not only ensure increased access to treatment but also set the stage for systematic monitoring of telemedicine and telephone services to confirm they meet the same rigorous standards of care as in-person services. Such quality assurance efforts could promote the development of best practice guidelines and reduce variations in care as usage of these modalities increases.
Only days before the Department of Health and Human Services first released the emergency declaration for the COVID-19 pandemic, it issued a public health emergency declaration renewal for the opioid epidemic on January 24, 2020. The U.S. will most likely be living with the consequences of these parallel crises for years to come, with an increasing number of people in American communities experiencing opioid addiction and overdose.
With the arrival of the telehealth revolution, those who need treatment for opioid use disorder should have the same level of telehealth access as others who receive treatment for other medical concerns. Research has demonstrated that treating opioid use disorder with buprenorphine through telehealth services is effective (Eibl et al., 2017). As such, reinstating pre-pandemic restrictions will only serve to uphold stigmatizing addiction policies that are not based on evidence and reinforce harmful barriers to treatment access. The roadmap is clear, and now is the time for the federal government to show its commitment to following the science.
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Tweet this! Authors of a new #NAMPerspectives commentary call for an expansion in telemedicine and telephone care for people experiencing addiction, building on the successes realized during #COVID19. Read more: https://doi.org/10.31478/202201d
Tweet this! “The COVID-19 pandemic might be the catalyst the U.S. needs to transform policies related to telehealth services for opioid use disorder & help millions of people get one step closer to entering recovery.” Read a new #NAMPerspectives: https://doi.org/10.31478/202201d
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- Centers for Disease Control and Prevention (CDC). 2021. Provisional Drug Overdose Death Counts. Available at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (accessed May 16, 2021).
- Cicero, T. J., M. S. Ellis, and H. D. Chilcoat. 2018. Understanding the use of diverted buprenorphine. Drug and Alcohol Dependence 193:117-123. https://doi.org/10.1016/j.drugalcdep.2018.09.007.
- Eibl, J. K., G. Gauthier, D. Pellegrini, J. Daiter, M. Varenbut, J. C. Hogenbirk, and D. C. Marsh. 2017. The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug and Alcohol Dependence 176:133-138. https://doi.org/10.1016/j.drugalcdep.2017.01.048.
- U.S. Department of Health and Human Services (HHS). 2020. Determination that a Public Health Emergency Exists. Available at: https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx (accessed June 01, 2021).
- Langabeer, J. R., A. L. Stotts, A. Cortez, G. Tortolero, and T. Champagne-Langabeer. 2020. Geographic proximity to buprenorphine treatment providers in the U.S. Drug and Alcohol Dependence 213:108131. https://doi.org/10.1016/j.drugalcdep.2020.108131.
- Mehrotra, A., M. E. Chernew, D. Linetsky, H. Hatch, D. A. Cutler, and E. C. Schneider. 2021. The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases. The Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge (accessed August 5, 2021).
- Pew Research Center. 2021. Internet/Broadband Fact Sheet. Available at: https://www.pewresearch.org/internet/fact-sheet/internet-broadband/?menuItem=3109350c-8dba-4b7f-ad52-a3e976ab8c8f (accessed July 15, 2021).