These Key Telehealth Policy Changes Would Improve Buprenorphine Access While Advancing Health Equity
Corey S. Davis
Elizabeth A. Samuels
SEPTEMBER 11, 202010.1377/hblog20200910.498716
Suspected opioid overdose deaths are surging during the COVID-19 pandemic, increasing by more than 40 percent in May and continuing to rise. Medications for opioid use disorder (MOUD)—specifically methadone and buprenorphine—cut mortality in half; however, only a minority of the two million people living with opioid use disorder (OUD) in the US receive MOUD. After the Affordable Care Act was implemented, treatment engagement expanded modestly. Yet, racial, income, and geographic inequities persist. Approximately 40 percent of counties do not have a buprenorphine prescriber, and Black patients are significantly less likely to have access to a buprenorphine provider compared to White patients. The economic, social, psychiatric, and emotional havoc of the COVID-19 pandemic has exacerbated an already worsening opioid crisis and highlighted the need for lower threshold access to evidence-based, life-saving OUD treatment. Moreover, the pandemic has disrupted traditional health care delivery methods, further limiting access to buprenorphine through established care settings.
Buprenorphine Telehealth Policy Changes During COVID-19 Recognizing the dire consequences of worsening access to buprenorphine treatment, the federal government took unprecedented and swift action to permit initiation of buprenorphine through video telemedicine visits. This was a significant change from the previously required in-person evaluation, as mandated by the 2008 Ryan Haight Act. This requirement was put in place to curtail illegitimate internet operations that prescribed and shipped controlled substances, mostly opioid pain medications, without medical justification. In March 2020, the Department of Health and Human Services’ (HHS’s) Office for Civil Rights waived penalties for Health Insurance Portability and Accountability Act (HIPAA) violations for health care providers using non-HIPAA compliant technologies, including FaceTime and Skype, to serve patients via telemedicine in good faith. Subsequently, the Drug Enforcement Administration (DEA) exercised its enforcement discretion to permit buprenorphine initiation following telephone communication without requiring video technology.
These changes were made in a time of crisis response, but the need to expand telehealth initiation of buprenorphine was long overdue. Telehealth had already been proven effective for managing patients who had already started buprenorphine treatment after an in-person visit, with multiple studies demonstrating similar retention and illicit opioid abstinence rates among patients managed by telehealth compared to in-person. Prior to COVID-19, the Veterans Affairs Administration successfully implemented telehealth buprenorphine management for veterans with OUD and has published a toolkit to support future expansion of telehealth buprenorphine programs. On June 30, 2020, Senator Rob Portman (R-OH) and Senator Sheldon Whitehouse (D-RI) introduced the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act to permanently expand telehealth services for substance use disorder treatment by amending the Ryan Haight Act to permit buprenorphine treatment to be initiated after a telehealth consultation. While the bipartisan legislation will help expand use of telehealth for buprenorphine, it mandates that the consultation occur using an audiovisual platform, a requirement that threatens to exclude people without access to video-based technology. Due to structural racial and economic inequities, inadequate broadband and internet infrastructure, low digital literacy, and health system barriers, audiovisual telehealth is not widely accessible. A report from the Federal Communications Commission found that about 21.3 million Americans—6.5 percent of the population—live in “digital deserts” and lack access to fixed broadband service at threshold speed. Almost half of low-income Americans and a third of rural Americans don’t have home broadband access. Many others are unstably housed and lack access to permanent phones. Limiting buprenorphine access to audiovisual telehealth platforms continues to exclude the most vulnerable people who already lack access to MOUD treatment. This approach, therefore, does not sufficiently address existing gaps and disparities in treatment access. Allowing audio-only telehealth visits, however, could address many of these gaps. Expand Buprenorphine Telehealth Access We—the Buprenorphine Telehealth Consortium, a national group of clinicians, public health experts, and health services researchers dedicated to addressing the opioid crisis and health equity—urge policy makers to make the following administrative and legislative changes to ensure sustained improvements in access to life-saving OUD treatment during and after the COVID-19 pandemic. Most Urgently The secretary of HHS should immediately waive the Ryan Haight Act’s requirement for in-person evaluation for buprenorphine initiation for the duration of the opioid crisis public health emergency. He, with the concurrence of the US Attorney General, is authorized to waive the Ryan Haight Act’s requirement that providers conduct an in-person evaluation before initially prescribing controlled substances during any public health emergency. He has used this authority during the COVID-19 emergency and should extend the waiver for the extent of the opioid emergency, which was first declared in October 2017, as well.
Additionally, the DEA should permit the initial evaluation for buprenorphine initiation to be conducted via telephone for the duration of the opioid crisis public health emergency. The DEA has administrative discretion to permit the initial evaluation to be conducted via audio only (that is, telephone) in addition to audio-visual, real-time, two-way interactive communication systems. It used this discretion to permit telephonic consultation during the COVID-19 emergency and should extend the use of that discretion for the extent of the opioid emergency as well.
. Long-Term Access Solutions Per the SUPPORT Act of 2018, the US Attorney General was required to create regulations governing “special registrations” that expand in-person exemptions to the Ryan Haight Act within one year of the act’s enactment. As this is already overdue, the US Attorney General should quickly promulgate regulations that permit the initial prescription of buprenorphine via telemedicine without an initial in-person evaluation. The DEA should continue to use its enforcement discretion to permit this consultation to occur without the use of video.
What is more, instead of relying on temporary regulatory waivers and special registrations, Congress should modify the Ryan Haight Act to permit providers to conduct a remote evaluation for buprenorphine OUD treatment initiation and follow-up via telehealth, including audio-only technology where necessary, without an in-person visit. This would represent a permanent legislative solution and could be done through an audio-only amendment of the already introduced TREATS Act.
An Opportunity Some have voiced concern that expanded use of telemedicine for buprenorphine treatment would increase diversion. This concern is unfounded; in fact, the opposite may be true. Diversion of buprenorphine has been shown to be a consequence of limited access to medically supervised buprenorphine treatment. Studies have found that the primary use of diverted buprenorphine is for therapeutic purposes, including treatment of withdrawal and cravings, and to abstain from other, higher-risk opioid use. This suggests that expanded access to low threshold buprenorphine treatment may actually decrease diversion. Furthermore, any effective regulatory efforts to prevent, identify, or address diversion would not depend on whether a patient’s visit was conducted in person or using audiovisual or audio-only telehealth. The primary goal of regulatory changes and legislation governing the treatment of OUD should be to eliminate barriers to evidence-based care that is proven to both reduce death and other harms related to opioid use (that is, overdose, HIV, hepatitis C, and so forth) and improve quality of life.
The short-term emergency authorizations for audio-only buprenorphine treatment during COVID-19 have helped us reach people previously unable to access treatment, and these changes should be made permanent. With improved access, more people will benefit from buprenorphine. As the National Academies of Sciences, Engineering, and Medicine recently declared, confronting the major barriers to MOUD is critical to addressing the opioid crisis. The damaging effects of the COVID-19 era will reverberate for years to come, but we have the opportunity to implement improved access as a result of challenges introduced by the pandemic. We can allow the opioid crisis to stay on the same, ever-intensifying course; or, in this time of profound uncertainty, we can expand access to buprenorphine, a medication proven to save lives, by making it accessible to the patients who struggle most. To address the opioid crisis and social inequities, we must remove outdated legal and administrative barriers to ensure treatment is equitably distributed among all persons.
Authors’ Note To sign a letter supporting continuation of audio-only buprenorphine telehealth please click here.
In addition to the authors listed in the byline above, the following members of the Buprenorphine Telehealth Consortium contributed to this piece: Seth A. Clark, MD, MPH, Division of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Ulrike Muench, PhD, RN, FAAN, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California; Jeanmarie Perrone, MD, professor, emergency medicine and medical toxicology, director, Center for Addiction Medicine and Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Neha Reddy, MPH, Alpert Medical School of Brown University, Providence, Rhode Island; Hannah Snyder, MD, Department of Family and Community Medicine, University of California, San Francisco, California; Joanne Spetz, PhD, Philip R. Lee Institute for Health Policy Studies and the Healthforce Center, University of California, San Francisco, California; Jessica L. Taylor, MD, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts; Babak Tofighi, MD, Department of Population Health, New York University Grossman School of Medicine, New York City, New York; Rahul Vanjani, MD, MSc, Division of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Alexander Y. Walley, MD, MSc, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts; Rachel S. Wightman, MD, Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island; Caroline Wunsch, MD, Division of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and Erin A. Zerbo, MD, assistant professor, Department of Psychiatry, Rutgers New Jersey Medical School, Newark, New Jersey.