Amid the pandemic, regulatory changes around buprenorphine access are making it easier for some people with opioid use disorder (OUD) to access the life-saving medication—yet some of the most vulnerable patients are still being left behind.
In December 2020, a bipartisan group of US Senators introduced the Comprehensive Addiction and Recovery Act (CARA) 2.0. The act builds on the original CARA legislation from 2016, which authorized funding for a federal response to the nation’s opioid-involved overdose crisis. The bill is the latest effort at the federal level to expand telehealth services relating to medications for opioid use disorder (MOUD).
One of CARA 2.0’s key provisions is that it would permanently allow providers to prescribe MOUD to patients without a prior in-person visit. Currently, the 2008 Ryan Haight Act makes it illegal for a provider to prescribe a patient a controlled substance without an in-person visit.
Since January 31, 2020, OUD patients have been permitted to be prescribed buprenorphine after either an audio-visual or audio-only telehealth visit. Buprenorphine maintenance appointments can be conducted virtually as well. But that’s due to a temporary suspension of regulations by multiple federal agencies, which is scheduled to lapse whenever the coronavirus pandemic is declared over. In another notable improvement implemented for the duration of the pandemic only, providers are currently not required to test patients’ urine to monitor their adherence.
“The moment that they feel like they want treatment is the moment they should be able to access it.”
“Once the regulatory changes were implemented, we really were able to utilize telehealth to meet patients exactly where they are, whenever they are free, and wherever they are,” said Dr. Linda Wang, director of the buprenorphine treatment program at Mount Sinai’s REACH Program.
Prior to the pandemic, patients who needed buprenorphine in New York City needed to wait an average of one week to initiate treatment, according to a recent article of which Wang was the primary author. Those in Upstate New York, meanwhile, waited an average of 12 weeks.
“The moment that they feel like they want treatment is the moment they should be able to access it,” Wang said. “Things in their lives can change very rapidly, and I think the quicker we’re able to provide them with an evaluation to get them medication, the better.”
Besides the change in federal regulations, one key policy change in New York that eased the shift to telehealth services for providers was audio-visual visits becoming eligible for the same level of reimbursement as in-person visits. Prior to the pandemic, clinicians who provided audio-visual visits were reimbursed at a lower rate than if they had provided in-person ones.
Thanks to the change, “the stars were finally aligned for us” to provide telehealth services, said Tiffany Lu, the medical director at the Montefiore Buprenorphine Treatment Network. Lu authored the New York State Department of Health AIDS Institute’s clinical guidelines for OUD treatment during COVID-19.
Lu told Filter that at Montefiore, providers were able to get telehealth appointments up and running by the end of March 2020.
“Even if I try to provide the highest quality care I possibly can between a mix of phone visits and in-person visits, via reimbursement it makes it so that people who are trying to do their job engaging patients don’t necessarily get paid the same,” Lu said. “And this is a little bit punitive.”
Audio-only telephone visits are still not reimbursed at the same level as audio-visual or in-person ones.
In July, New York Governor Andrew Cuomo (D) signed Senate Bill 8416 into law, adding audio-only and video-only services to the state’s definition of teleservices. The bill also categorized these services as being eligible for reimbursement under Medicare.
Allowing audio-only telehealth services to be covered under insurance could increase access to healthcare for people who have insurance and have reliable access to a cell phone, but who are not able to videoconference. Roughly one-quarter of American adults don’t have access to home broadband service, and a disproportionate amount are low-income internet users.
A push toward telehealth may widen the digital divide that the COVID-19 pandemic has exposed and exacerbated. It may also compound existing health disparities by, for example, leaving behind patients who don’t have access to a computer, phone or housing.
Wang’s team at the REACH Program at Mount Sinai anticipated this problem early on, and acquired a grant that helped them distribute 120 iPhones with unlimited data and texting plans to their patients. But such initiatives have their limitations.
“Not all patients are savvy enough with phones to know how to use technology,” Wang said. “And the phones got stolen, or people lost them.”
Even though Lu’s office does not require the video component, many of her patients are essential workers who still face structural barriers that make it difficult for them to access telemedicine, including limited minutes on their phones.
“I’m literally having conversations with patients who are taking a break in between their shifts, and they don’t have privacy,” Lu told Filter. “If you don’t have privacy, then how can you really have meaningful healthcare with your provider?”
If passed, CARA 2.0 would also establish a five-year pilot program to study the use of mobile methadone clinics in rural and underserved communities. The bill would authorize a total of $765 million to go towards education, treatment, recovery and criminal justice programs. Of that amount, $300 million would be spent towards expanding MOUD.
Such a program would tackle the problem of long driving times to methadone clinics that residents of rural areas often face. A 2019 study focused on Indiana, Kentucky, Ohio, Virginia and West Virginia found that the average driving time facing patients in those states was at least 40 minutes. By comparison, the average driving time in large central metropolitan areas in those same states was under eight minutes.
The number of mobile methadone clinics is currently restricted due to a nationwide moratorium that the Drug Enforcement Administration placed in 2007 on approving registrations for new methadone clinics. In April 2020, the DEA proposed lifting the requirement that methadone providers must obtain a separate registration for their mobile component, but it has yet to actually do so.
In June 2020, Sen. Rob Portman (R-Ohio) introduced the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act. If passed, the TREATS Act would permanently allow clinicians to provide audio-only telehealth services for substance use disorders to patients covered through Medicare, as long as a provider has already conducted an in-person or audio-visual medical evaluation of the patient.
Cuomo announced two rounds of funding for NYS addiction telehealth services in 2020. The money came from the federal State Opioid Response Grant and was distributed through the state’s Office of Addiction Services and Supports.
Both Wang and Lu, like other providers, would like to see the temporary regulatory changes brought on by the pandemic stay even after the pandemic ends.
Wang cautioned against treating telehealth as an answer to everything. There are many unanswered questions pertaining to best practices in telehealth, such as how long providers should wait to have an in-person follow-up visit after they perform a telehealth intake.
“If this goes away, we’re just going to be shutting doors on people.”
But she also argued that it can be less stressful for some patients to have their first visit over the phone, since many institutions “can and do reproduce stigma.” She believes some clinicians find telehealth “really attractive, and it potentially could be a really positive thing to engage patients over the phone, and then follow up with them in person at some point to really solidify that relationship.”
Lu pointed to the work of the Buprenorphine Telehealth Consortium, which has advocated for the temporary removal of barriers to buprenorphine during the pandemic to become permanent.
“They should not go away,” Lu said. “If this goes away, we’re just going to be shutting doors on people.”
Photograph via Pixabay