Before our telehealth appointment ended one day last summer, my buprenorphine doctor asked me if going for monthly urine screens during a pandemic was challenging, and I stumbled over my words.
After that first troubling month of lockdown in the spring, my provider had switched to a low-barrier telemedicine model for the duration of COVID-19 out of concern for patient safety. Temporary regulations instituted by the Drug Enforcement Administration and Substance Abuse and Mental Health Services Administration allowed this.
We now conduct our business once a month over the phone in under five minutes with a series of simple, rapid-fire questions. The doctor asks me how I’m doing, if I have any cravings, and if I’m happy with my dose. “Thank you for getting your urine sample done,” is how he ends every call.
In the middle of a pandemic, I sit in a room where people draw blood and hand over bodily fluids to prove I’m not using drugs.
I also make regular trips to LabCorp, located in a nearby Walgreens, for the required urine screens.
Each month I put on a mask—sometimes two—and head out to my appointment, regardless of stay-at-home orders, infection rates and vaccine availability. In the middle of a pandemic, I sit in a room where people draw blood and hand over bodily fluids to prove I’m not using drugs. I do this to continue receiving lifesaving medication. I do this because of the stigma against people who use drugs.
The federal government’s telemedicine policies for buprenorphine patients, though temporary, are a rare bright spot in a catastrophic year for public health. But beneficial as these models are in bringing low-barrier treatment to underrepresented populations, stigma still prevents permanent implementation.
As the Pew Charitable Trusts noted recently, physicians and public health experts worry that access to treatment could become a problem when the COVID-19 public health emergency ends, as it’s set to do in April. Some groups, such as the Buprenorphine Telehealth Consortium understandably argue that an act of Congress is desirable to extend or make permanent telehealth flexibilities for buprenorphine patients. But could there be a faster immediate way of getting this done?
SAMHSA and the DEA Could Do It on Their Own
A new report from George Washington University, funded by Pew, contends that the DEA and SAMHSA have the power to act unilaterally to extend the nation’s telehealth policies for buprenorphine patients.
Beth Connolly, who directs the Substance Use Prevention and Treatment Initiative at Pew, noted that federal agencies under the Trump administration implemented telemedicine policies rather quickly in the early days of COVID-19. But Pew wanted to know if the temporary regulations in place could be extended without congressional intervention.
The organization partnered with George Washington University and asked researchers to look at a slew of regulations, including the Controlled Substances Act, the Ryan Haight Online Pharmacy Consumer Protection Act, and others, to see if outside agencies had any say in the matter.
They found that the DEA and SAMHSA have not one, but several different ways in which they can extend current telehealth policies.
“In fact, [researchers] have determined that they can be done without an act of Congress, which is huge.” Connelly told Filter.
Bridget Dooling and Laura Stanley, a research professor and senior policy analyst, respectively, at the GW Regulatory Studies Center, who wrote the Pew-funded report, found that the DEA and SAMHSA have not one, but several different ways in which they can extend current telehealth policies. And while both authors told Filter that their work focused on what could be done rather than on whether it should be done, their findings play an essential role in furthering the public conversation.
According to Dooling and Stanley’s findings, both agencies could extend telemedicine flexibilities permanently and unilaterally under a statutory exemption in the Ryan Haight Act, which, the authors note, gives the agencies broad discretion to allow practitioners to prescribe controlled substances without an in-person examination. However, such regulations only apply to X-waivered physicians—meaning SAMHSA would need to issue a companion policy to opioid treatment providers, exempting them from in-person examination requirements.
Next, the authors found that the Ryan Haight Act gives the DEA the authority to set up special registration programs for telemedicine. Another piece of legislation, the SUPPORT for Patients and Communities Act of 2018, actually directed the DEA to do so by 2019, but the agency has yet to follow through. Dooling and Stanley note that, as with the previous option, SAMHSA would also need to issue that same companion policy.
Finally, the report found that both agencies could use declared opioid public health emergencies to extend current telehealth policies although this wouldn’t make them permanent.
“The public health emergency declaration for the opioid epidemic is already on the books,” Dooling said. “We have declared that it’s a public health emergency. And so the question is, what flows from that?”
Dooling and Stanley’s matter-of-fact assessment shows what the DEA and SAMHSA can do. Whether the agencies will take any of these steps is highly doubtful, however, given their well documented inherent biases—illustrated by the fact that they didn’t allow telemedicine until a pandemic practically forced them into it.
But publicizing the agencies’ powers in this area might just make this a productive avenue for public pressure.
Telemedicine Must Have a Future
Activists in the harm reduction community have long lobbied the federal government for telemedicine options to help those in rural communities and others without access to treatment providers. As the GWU report noted, places like Wyoming County, West Virginia, which had the state’s highest overdose death rate from 2014 to 2016, were also without a single physician X-waivered to prescribe buprenorphine.
As promising as the temporary telemedicine regulations are, individual physicians still have leeway to practice within their preconceived biases. Last summer, when my buprenorphine doctor asked me about the burden of going for urine screens, I knew he wasn’t really asking about me. After all, according to my chart, which was right in front of him, I went every month. The question was a compare-and-contrast with his broader patient population.
“A few other patients say it’s difficult to go for a urine,” he said. “I wanted to see if that’s true.”
As a middle-class white man who works from home and has the freedom to come and go, I’m not the best barometer. Plenty of research shows that low-income people of color, along with single mothers and other vulnerable populations, have difficulty accessing health care of any kind, pandemic or not.
Had I said yes, I could have spoken with my doctor about how marginalized people face so many more barriers than I do in getting monthly urines. But I worried it might lose me my script.
“No,” I said, like a coward. “Going for a urine screen isn’t difficult at all.”
For buprenorphine providers in the harm reduction community, such as Philadelphia’s Shoshi Aronowitz, the adoption of telemedicine for patients who would otherwise be left untreated is a net positive. Aronowitz is a research fellow in the National Clinician Scholars Program at the University of Pennsylvania. She also works as a family nurse practitioner at some of the city’s more well-established harm reduction-based substance use treatment centers.
“Telehealth is great because you don’t have to worry about how close the clinician lives to you,” said Aronowitz. She noted the model benefits both rural residents and Black and Hispanic communities—communities that are less likely to have access to buprenorphine providers than white neighborhoods.
“Then there’s lots of people also who live in areas where there are a lot of clinicians, or at least some clinicians,” Aronowitz continued, explaining that a host of reasons beyond geography can make telehealth necessary. “But maybe because of a disability, for example, they’re unable to travel to a clinic, or because of stigma they don’t want to travel to a clinic, or even because of their job or their family responsibilities having to show up at a clinic frequently—because you do for OUD treatment—is not going to work.”
She added that she “can’t even begin to think about” the number of patients who are now in her care because of telemedicine policies.
Telemedicine isn’t an answer in and of itself, as can be seen in the rise in overdose deaths during the pandemic. In addition to low-barrier treatments that bridge the digital divide, telehealth policies need to embrace holistic avenues that aren’t awash in stigma.
Aronowitz understands de-platforming stigma better than most. Earlier this year, she published an article suggesting that urine screens should no longer be central to substance use care. For those doctors who still lean on UDS, or even patients who choose to use it as a measure of their own success, Aronowitz told Filter that there are less traumatizing ways to go about it that don’t include going out to a lab in the middle of a pandemic. Urine cups and oral swabs can be sent through the mail, she said, with the latter observable by the doctor over Zoom.
And when it comes to induction via telemedicine, Aronowitz believes close contact is crucial. She said that providers should build up from smaller doses, ask lots of questions, and check-in often to see if the patient has any concerns.
“It would be horrible if [telehealth policies] were rolled back,” said Aronowitz. She added that she “can’t even begin to think about” the number of patients who are now in her care because of the policies instituted at the pandemic’s start.
“They weren’t able to come in before,” she said. “So they can’t come in now.”
My buprenorphine doctor might never read this piece—in fact, I doubt he will. If he does, perhaps we could finally have that conversation about marginalized people and the need for a buprenorphine approach that truly embraces harm reduction.
Or he may just revoke my script.