Suboxone Telemedicine in Pandemic
When the United States declared a public health emergency on January 31, 2020, in response to the COVID-19 pandemic, federal lawmakers used an exception to the 2008 Ryan Haight Act rule requiring in-person evaluation before prescribing a controlled substance, such as buprenorphine for the treatment of opioid use disorder (OUD). Following an initial telemedicine appointment using either audio-visual or telephonic connection, DATA 2000 waivered doctors can now prescribe buprenorphine (Drug Enforcement Administration, 2020, March).
Though this provision is only in force during the public health emergency, a new bill was recently presented in Congress that would change the Ryan Haight Act to allow schedule III or IV restricted substances to be prescribed without an initial in-person examination (S.4103, 2019–2020). While the Ryan Haight Act was passed to prevent rogue Internet pharmacies from selling restricted medications online, the act's telemedicine exceptions were not explicitly specified, posing a significant hurdle to expanding telemedicine-based OUD therapy. The evidence shows that telemedicine can help buprenorphine patients achieve better treatment outcomes, such as reduced illicit drug use and more patient retention and satisfaction (Eibl et al., 2017; Lin et al., 2019; Zheng et al., 2017). Since the outbreak, telemedicine has enabled new and existing patients with low-barrier access to buprenorphine at the point of interest, frequently with same-day evaluations and prescriptions without the need to go to a traditional medical setting for a visit (Harris et al., 2020).
Prior to COVID-19, a number of barriers limited buprenorphine use among people who use drugs (PWUD) in both rural and urban settings: at the system level, a lack of waivered clinicians, racial disparities in access to buprenorphine versus methadone treatment (Hansen et al., 2013; Lagisetty et al., 2019), and long wait times for treatment (Roy et al., 2020 These constraints contribute to variations in buprenorphine access based on income, education, resident county, and race. Our COVID-19 clinical experiences have convinced us that telemedicine for buprenorphine introduction is removing many of these treatment barriers. We've seen how important this regulatory change is for creating greater health equity for PWUD, and we believe it should be kept in place indefinitely to save additional lives.
We discuss our first-hand experiences and recommendations after rapidly transitioning our in-person practices to telemedicine practices during this crisis at two harm reduction primary care programs in New York State that care for PWUD and offer buprenorphine, one in Ithaca and the other in Manhattan. While we serve two different populations—one rural, younger, and predominantly white (Ithaca) and the other urban, older, and predominantly people of color (Manhattan), our experiences are similar. The case examples below show how this regulation change has extended access to buprenorphine therapy for patients who were effectively started on buprenorphine through telemedicine during the pandemic.
We've done multiple video and phone visits to get people started on buprenorphine just after they've been released from prison. People who have been incarcerated are at an increased risk of drug-related death, and while there is growing evidence that medication for opioid use disorder treatment in correctional settings can help minimize post-incarceration overdose death, access is still limited. Having rapid access to buprenorphine after being released from prison is a vital step in reducing this danger (Binswanger et al., 2007; Green et al., 2018; Marsden et al., 2017; Merrall et al., 2010). In Ithaca, a 32-year-old woman with OUD who had previously completed successful buprenorphine treatment was freed from state jail without having to restart her treatment. She had a nonfatal overdose shortly after returning home, which prompted her to call our on-call line over the weekend to get back on treatment. The clinician recommended buprenorphine (together with naloxone for overdose reversal) after a phone consultation, with close follow-up during regular work hours. She would have had to wait several days for an in-person visit if she hadn't been given telephonic initiation, putting her at risk for another overdose and death.
We've also used videoconferencing to quickly engage patients referred to us by syringe service programs (SSPs) who don't always have access to waivered clinicians. Many of these SSPs had minimal on-site services during COVID-19. A 40-year-old man was referred to an SSP in Manhattan when several of their on-site services, including buprenorphine treatment, were temporarily closed. The patient had previously been on methadone therapy, but he called our program line to transfer to buprenorphine as soon as possible owing to a lack of flexibility with take-home dosages (the patient wished to leave New York due to fears about COVID-19 exposure). Our nurse care manager was able to examine the patient over the phone, review home induction instructions, and send buprenorphine the same day to a neighboring pharmacy in less than an hour, thanks to the help of a waivered clinician. Medical students also gave him telephonic training on naloxone overdose prevention, and we mailed him a naloxone kit. In Ithaca, a collaboration with an SSP in far northern New York, more than three hours distant by automobile, resulted in the telemedicine commencement of buprenorphine for 32 of the 55 clients on the SSP's waitlist due to a lack of available clinicians.
In both cases, telemedicine allowed patients who needed buprenorphine to begin treatment right away without having to wait for an in-person evaluation. People would have no choice but to continue using nonprescribed opioids, frequently illicit fentanyl, if there was a wait, which in pre-COVID periods was on average 12 weeks in upstate New York and one week in New York City. Limited in-person clinical services and clinician availability at the height of the COVID-19 pandemic threatened to further delay buprenorphine commencement, putting PWUD seeking treatment at danger of overdose-related fatality. The Ryan Haight Act was meant to encourage safe controlled substance prescribing, however it restricts access to buprenorphine by requiring an in-person contact before to start. While there is some evidence that in-person visits are more effective than telemedicine visits in terms of improving treatment outcomes or minimizing diversion, there is currently no evidence that in-person visits are more effective than telemedicine visits in terms of improving treatment outcomes or minimizing diversion. The COVID-19 pandemic is likely to have aggravated the opioid crisis, making it more vital than ever to increase access to buprenorphine therapy. In-person visits are still an important aspect of clinical care, and they should be combined with telemedicine to improve treatment adherence. The use of telemedicine for buprenorphine initiation, on the other hand, removes significant hurdles to treatment commencement and brings us closer to eliminating the OUD treatment gap. As a result, we believe that the ability of telemedicine to expand access outweighs the risk of buprenorphine overuse.
Telemedicine has the ability to revolutionize existing patterns of referral and participation of PWUD in buprenorphine treatment, in addition to providing a low-barrier treatment approach. In Ithaca, we provided a smartphone to a community health worker to conduct telemedicine visits during outreach to a local homeless encampment, and we engaged 7 homeless patients for the first time and put them on buprenorphine. We're working on a program in Manhattan where peer responders to nonfatal overdoses in the community can link interested persons with a physician via telemedicine to start buprenorphine when it matches the client's requirements rather than the health care facility's schedule.
There are obstacles to increasing buprenorphine distribution via telemedicine. To begin, we acknowledge that there are inequities in telemedicine access for all disease management: rural residents, racial minorities, older adults, and those with low income have limited access to digital technology and digital literacy, and rural areas have limited Internet coverage or cell service (Nouri et al., 2020; Rodriguez et al., 2020). Many of our patients, especially those who are older, have weak English skills, or are from low socioeconomic backgrounds, do not have access to a functional smart phone. To solve this, we bought 120 iPhones with unlimited data and messaging contracts and are handing them to patients in need in Manhattan. Patients are taught how to use the devices to obtain telemedicine services remotely by medical students and patient navigators. Second, practitioners require evidence-based telemedicine procedures for how frequently to visit patients (remotely or in person), how many refills to give, how to educate patients on proper initiation to avoid triggered withdrawal, and when to employ urine toxicology. Clinicians may also be concerned that telemedicine will provide insufficient treatment structure or result in increasing medication diversion. Third, it's unknown which patients would benefit more from telemedicine vs in-person care, as well as which technique would lead to better patient retention.
Our experiences in both rural and urban settings show that telemedicine for buprenorphine has the potential to expand access to OUD treatment at a critical time when pandemic stress, increased trauma due to racial injustice, financial hardship, and loss of housing may trigger nonprescribed opioid use. There has never been a more critical time to ensure that PWUD have continuous, low-barrier access to buprenorphine. Even after COVID-19 is no longer a public health emergency, the opioid epidemic will persist; telemedicine will be critical in closing the OUD treatment gap and lowering mortality rates. We intend to keep working for structural improvements that will remove barriers to prescribing buprenorphine, minimize racial inequities in buprenorphine access, and erase stigma associated with opioid use. We will also advocate for policy changes at the local, state, and federal levels to increase digital literacy and access, as well as pay parity for all payers for telephone and video visits. Buprenorphine introduction via telemedicine, which became accessible during the COVID-19 pandemic, has quickly become a vital technique for treating PWUD with OUD. We urge researchers, clinicians, policymakers, and activists to fight to keep this regulatory change in place.