Editor's note: The Omnibus Appropriations Bill released this week extends some telehealth flexibilities but does not make them permanent. The House and Senate will vote on the bill later this week.
Late one afternoon last summer, a dispatcher from New Hampshire’s substance use disorder hotline transferred a crisis call to the addiction clinic I direct at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire. The caller, a woman in her 30s, was starting to experience opioid withdrawal, a terribly distressful set of symptoms that can include nausea, diarrhea, extreme sweating, anxiety, and insomnia.
Withdrawal often drives people back to drug use, so we faced time pressure to get the caller into treatment. The goal was to prescribe buprenorphine, a medication for opioid use disorder (MOUD) that alleviates opioid withdrawal and decreases drug cravings. But the woman was about 45 minutes away, with no car and no public transportation between her rural town and our clinic.
Our options were limited. We could suggest the caller go to her nearest emergency department (ED) in the hopes that a physician there would prescribe buprenorphine. Or we could see if she might be able to arrange transportation to our clinic the next day, but that time lag might have allowed her to access a new supply of opioids.
Though the caller ultimately went to the ED, where she was fortunate to receive buprenorphine, the dilemma we dealt with that day is not one that providers ever want to face.
Withdrawal often drives people back to drug use, so we faced time pressure to get the caller into treatment. … But the woman was about 45 minutes away, with no car and no public transportation between her rural town and our clinic.
The constraints on addiction providers’ ability to help this caller — and tens of thousands like her — stem mostly from rules surrounding the prescription of MOUDs via telemedicine.
Usually, federal law requires providers to conduct an in-person evaluation before prescribing buprenorphine. During the COVID-19 public health emergency, these federal regulations were relaxed, allowing the prescribing of buprenorphine via telehealth. But physicians must practice under both federal and state law, and at the time of the call, New Hampshire rules — since changed, thankfully — prohibited the initiation of buprenorphine treatment via telehealth.
In order to save lives, we need to reform MOUD telehealth policies at both the state and federal levels.
In the United States, overdose deaths involving opioids rose to 80,816 in 2021, up from 70,029 in 2020, according to the Centers for Disease Control and Prevention. What’s more, recent data indicate that over 9 million people in this country misuse opioids.
As an addiction psychiatrist, I have seen too many lives cut short by overdoses and other complications of drug use. But I have also seen many people turn their lives around with treatment.
Research suggests that MOUD use reduces the risk for a fatal opioid overdose by more than 80%. In addition, MOUD treatment is associated with many other positive outcomes, including a lowered risk for contracting HIV and hepatitis C. Importantly, prescription of a MOUD via telehealth during the pandemic was associated with a significant decrease in opioid overdoses for those who had access to it.
Telehealth expands treatment to people who struggle to access an in-person appointment for various reasons, including the need to travel long distances. In the United States, nearly 90% of large rural counties lack a sufficient number of opioid treatment facilities. And telehealth may also be crucial for people hesitant to seek in-person treatment because of the stigma that persists around substance use disorders.
In order to save lives, we need to reform MOUD telehealth policies at both the state and federal levels.
Several factors threaten access to lifesaving MOUD telehealth.
One key concern is the looming end to the federal public health emergency. Currently set to expire on January 11, 2023, the emergency state may be extended, but it’s not clear for how long. When it ends, federal law will once again prevent providers from prescribing buprenorphine without an initial in-person visit.
Congress can act to forestall that setback, though.
The Ryan Haight Act, named for a teenager who died from an overdose of an opioid pain medication obtained online, was passed in 2008 with the good intention of curtailing internet prescriptions for potentially dangerous substances. However, the law makes no distinction between specific controlled medications. Those distinctions matter: Buprenorphine differs from full-agonist opioids such as heroin and morphine in that it is a partial agonist with a vastly superior safety profile.
So, congressional action allowing doctors to prescribe buprenorphine without an initial in-person visit is crucial. But federal action alone is not sufficient.
Many states have their own regulations regarding telemedicine prescribing of controlled substances, and physicians must follow the more restrictive of federal and state regulations. In addition to limiting access to MOUDs, this creates unnecessary complexity and potential confusion over appropriate medical practice. States therefore need to align their regulations to make them no more restrictive than federal laws regarding telemedicine prescription of MOUDs.
Also crucial is appropriate insurance reimbursement by public and private insurers, with parity between telemedicine and in-person visits. During the federal public health emergency, the Centers for Medicare and Medicaid Services (CMS) is reimbursing telehealth MOUD visits at the same rates as in-person visits, but that will likely end when the flexibilities tied to the public health emergency terminate. Without adequate reimbursement for telemedicine, we risk denying care to patients who can’t afford to pay for it — and thereby exacerbating health inequities.
Ideally, when it comes to telemedicine parity, payers should also reimburse for audio-only visits on par with audiovisual ones. Audiovisual visits may be difficult for patients who lack devices necessary for video visits, have unreliable internet service, or cannot afford to pay for connectivity.
Insurance reimbursement rates not only affect patients but can also limit the ability of providers to offer MOUD treatment. Approximately 70% of patients in our clinic are insured by Medicare or Medicaid. Because CMS reimbursement rates for in-person office visits are often too low to offset our operating costs, we rely on our nonprofit hospital system to help subsidize our work. If insurers reimburse at even lower rates for telemedicine, it is unlikely that treatment programs such as ours could afford to offer adequate numbers of telehealth visits.
What lies ahead
Although access to MOUDs through telemedicine is essential, it is still a fairly new mode of treating opiate use disorder. As a field, we therefore must study its effects and develop recommendations for policy approaches and best practices that balance treatment availability against the possible risks of unsafe or ineffective prescribing.
For example, MOUD telemedicine access without any limits could lend itself to abuse by profit-driven providers who operate exclusively online. These providers may not conduct a thorough evaluation to verify an opiate use disorder diagnosis or may fail to institute proper monitoring to limit the likelihood of buprenorphine misuse or diversion.
Some in-person contact for MOUD treatment may make sense for other reasons. For example, drug testing is generally considered an effective component of monitoring patients’ medication use and treatment progress. Drug testing via telemedicine is possible, but it is usually more costly and complicated than in-person monitoring. In addition, the accountability that is ingrained in face-to-face visits can be an important part of promoting recovery.
We have treatments that are proven to help reduce such losses, and it would be tragic if we failed to use telemedicine to reach the huge numbers of Americans who need them.
Until research reveals more, a nuanced approach to MOUD telehealth makes sense. That means physicians should be able to initiate treatment without an initial in-person visit to provide rapid access to crucial care. Afterward, one in-person visit within the first month and every six months thereafter might work well. To move forward, providers need federal and state laws that support telemedicine MOUD treatment, and then we must follow up with thorough research to ensure we are providing the best care.
Every year, the United States loses more people to opioid overdoses than the entirety of U.S. military deaths during the Vietnam War. What’s more, the majority of those dying are young, with decades of lost potential. We have treatments that are proven to help reduce such losses, and it would be tragic if we failed to use telemedicine to reach the huge numbers of Americans who need them.
Editor’s note: For information on effective telemedicine, access the AAMC’s recent report on telehealth competencies.