Understanding Telehealth-Enabled Opioid Use Disorder Treatment

August 22, 2023 - Over the last three decades, the United States has grappled with a growing public health crisis related to the misuse of opioids.

Starting in the 1990s, the opioid crisis worsened over the years, eventually becoming an epidemic in 2017. Then, the COVID-19 pandemic hit, significantly exacerbating the problem.

According to the Centers for Disease Control and Prevention, nearly 645,000 people died from an overdose involving opioids, including prescription and illicit opioids, between 1999 and 2021. From 2020 to 2021 alone, opioid-involved death rates increased by over 15 percent.

Numerous strategies have been employed to curb the devastating impact of opioid use disorder (OUD), defined by the CDC as "a problematic pattern of opioid use that causes significant impairment or distress." These include efforts to prevent the disease through prescription drug monitoring programs and expand access to treatments like medication-assisted therapy.

One of the ways to expand access to treatment is through telehealth, which grew in popularity during the pandemic.

Here, mHealthIntelligence delves into how healthcare providers use telehealth to expand access to OUD care, what the research says, and how regulations impact virtual OUD treatment delivery.

PROVIDER USE OF TELEHEALTH FOR OUD TREATMENT

The widespread benefits associated with telehealth use extend to OUD care as well. Telehealth has the potential to break down longstanding barriers to access for OUD patients, including the stigma associated with the condition and transportation challenges. For providers, telehealth helps expand the workforce enabling it to better meet the growing demand for OUD care.

Healthcare leaders at discussion proceedings held by the National Academy of Medicine in 2022 noted that provider organizations are using telehealth to support OUD care in many ways, including the e-prescribing of medications for OUD and providing more convenient access to case management, peer recovery, and counseling.

For instance, the Perelman School of Medicine at the University of Pennsylvania's CareConnect program uses telehealth to assist OUD patients in accessing care. CareConnect — a partnership between Penn Medicine OnDemand, the health system's virtual urgent care service, and substance use navigators — enables urgent care clinicians to conduct virtual assessments of OUD patients and provide prescriptions of buprenorphine. Buprenorphine is a medication that treats opioid cravings and withdrawal symptoms. Patients also receive support from substance use navigators through the virtual care process.

An internal assessment of the program shows that the program received 371 calls and provided 249 buprenorphine prescriptions from November 2021 through September 2022. A majority of program participants (89 percent) filled their first buprenorphine prescription during that period, and 55 percent continued a preexisting prescription for the medication at least 30 days after being engaged, indicating that they continued their treatment.

Vanderbilt University Medical Center also launched a virtual care program for OUD patients during the pandemic. The Vanderbilt Maternal Addiction Recovery Program provides telehealth appointments and medication-assisted treatment services to pregnant people with OUD. It also offers virtual recovery support groups, allowing OUD patients to engage in group sessions safely and conveniently.

Research further sheds light on healthcare providers' virtual care strategies for OUD.

A study published in JAMA Network Open in July 2023 showed that organizations used various patient-facing digital health technologies for OUD to complement available substance use disorder treatments.

The researchers analyzed responses to the 2022 National Survey of Accountable Care Organizations (NSACO), collected between October 1, 2021, and June 30, 2022.

Of the 276 organizations with ACO contracts surveyed, one-third reported that their organization used at least one of three digital health technology categories: remote mental health therapy and tracking (26.5 percent), virtual peer recovery support programs (15.1 percent), and digital recovery support for adjuvant cognitive behavioral therapy (CBT) (9 percent).

An adjusted analysis revealed that organizations with an addiction medicine specialist or a registry to track mental health were more likely to use at least one category of digital health technology compared with their peers without these resources.

RESEARCH EXAMINING TELEHEALTH-ENABLED OUD CARE

Interest in using telehealth to deliver OUD treatment grew prior to the pandemic.

An issue brief authored by members of the US Department of Health and Human Services (HHS) and RTI International in 2018 explored how telehealth can be used to improve the delivery of behavioral health services, including medication-assisted treatment for OUD, but noted that its full potential had not yet been realized.

"Several barriers to broader use of telehealth remain, including technological requirements (e.g., interoperability, standards), funding mechanisms, and workforce licensing and training needs," the authors wrote.

The COVID-19 pandemic played a significant role in breaking down some of these barriers.

A study published in JAMA Psychiatry in 2022 showed that the expansion of telehealth use during the pandemic was associated with increased use of medications for OUD treatment and reduced odds of medically treated overdoses.

The researchers gathered data on demographics, medical and substance use, and psychiatric comorbidities of adult Medicare fee-for-service beneficiaries with OUD. The data was divided into a pre-COVID-19 pandemic period and a pandemic period. The pre-pandemic cohort comprised 105,240 beneficiaries, while the pandemic cohort included 70,538 beneficiaries.

They found that receiving telehealth services was linked to increased odds of retaining patients in programs providing medications for OUD and a lower likelihood of medically treated overdoses in the pandemic group compared with the pre-pandemic group.

Another study also found that Medicare beneficiaries who engaged in OUD-related care through telehealth during the COVID-19 pandemic experienced a lower risk of fatal drug overdoses.

The study, which assessed data for 105,162 patients in a pre-pandemic cohort and 70,479 patients in a pandemic-era cohort, found that the rate of fatal drug overdoses was 5.1 per 1,000 beneficiaries in the former group and 3.7 per 1,000 beneficiaries in the latter group.

Not only that, but telehealth also appeared to support OUD care for underserved populations during the pandemic.

A study at a south-central Pennsylvania-based federally qualified health center (FQHC) revealed that telehealth helped safety-net facilities retain OUD patients in a treatment program involving the provision of buprenorphine.

But despite these positive results, other evidence throws into question the efficacy of telehealth use for OUD treatment.

According to a study published in January 2023, clinical outcomes did not vary among OUD patients receiving treatment from clinicians with high or low telehealth use. The study population consisted of 11,801 patients who received treatment from 1,768 clinicians. Researchers found that though the use of telehealth for OUD increased between pre-pandemic and mid-pandemic periods, the total visit volume for OUD for each patient episode was similar among clinician groups with high and low telehealth use rates.

Thus, they concluded that while using telehealth for OUD treatment was an effective alternative to in-person care, no evidence suggested that telehealth can increase access to or improve the quality of OUD treatment.

Other research noted the adverse impact of the digital divide on telehealth access among OUD patients. Published in 2021, the study involved interviewing 22 OUD treatment prescribers and staff working in outpatient programs in Philadelphia in July and August 2020. One theme that emerged from the interviews was the impact of a "layered digital divide" that prevented patients, particularly marginalized patients, from reaping the benefits of telehealth.

Further, as COVID-19 cases fell from pandemic highs, OUD clinicians returned to in-person care.

A survey conducted in two waves — December 2020 and March 2022 — shows that clinicians used telehealth to conduct 41.5 percent of all OUD visits in March 2022, a significant drop from 56.7 percent in December 2020. The use of audio-only visits also declined from 20.2 percent of all OUD visits in December 2020 to 11.6 percent in March 2022.

REGULATIONS IMPACTING TELEHEALTH ACCESS FOR OUD PATIENTS

Despite the mixed clinical evidence backing telehealth utilization, regulatory support for the virtual treatment of OUD appears strong.

At the onset of the COVID-19 pandemic, the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) exempted opioid treatment programs from the requirement to perform an in-person evaluation for patients who require buprenorphine if is determined that an adequate evaluation can be performed via telehealth. SAMHSA has extended this flexibility to May 11, 2024. 

SAMHSA also enacted a flexibility during the pandemic that allowed states to request a "blanket exception" for patients in an OUD treatment program deemed stable to receive up to 28 days of take-home doses of their medication. States could further request a 14-day take-home supply of medication for patients deemed less stable but who program practitioners believe "can safely handle this level of take-home medication."

Last December, HHS proposed updates to federal regulations that encompass OUD treatment standards to allow Americans to receive 14-to-28 days' worth of take-home doses of methadone, as well as give providers the ability to initiate buprenorphine prescriptions using telehealth as part of opioid treatment programs.

Other pandemic-era flexibilities are in flux, however. During the public health emergency, the Drug Enforcement Agency (DEA) waived requirements outlined in the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. The act required practitioners to conduct an in-person medical evaluation before prescribing controlled substances through telehealth.

In February 2023, the DEA announced proposed rules allowing virtual prescriptions of a 30-day supply of buprenorphine for OUD treatment without an in-person evaluation beforehand. The flexibility was not extended to other controlled substances, like Adderall, Oxycodone, Vicodin, and Ritalin.

Healthcare trade associations, mental healthcare organizations, and providers, along with lawmakers, expressed concerns regarding the proposals and advocated for the permanent extension of the virtual prescribing of buprenorphine. For instance, in a letter to the DEA sent in March, Kyle Zebley, executive director of ATA Action, the advocacy arm of the American Telemedicine Association, stated that the 30-day limit on supplies of buprenorphine for OUD treatment and Schedule III-V non-narcotic substances is arbitrary and could do more harm than good.

In response to an overwhelming number of comments on its proposed rules, the DEA extended waivers for the remote prescribing of controlled substances via telehealth through November 11, 2023.

Amid evolving regulations, there appears to be a growing consensus that using telehealth for OUD treatment and services is safe and as effective as in-person care. While future utilization remains to be seen, telehealth-enabled OUD care is progressing.