The drugs approved by the FDA, which include buprenorphine, are considered the gold standard for the treatment of opioid use disorders (OUD). Yet only 1 in 9 people with OUD receive these drugs, which are highly regulated by the federal government.
After the start of the COVID-19 pandemic, the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration relaxed regulations to allow healthcare providers to prescribe buprenorphine to patients by phone or via an audiovisual connection without having first-person appointment.
Dr Elizabeth Samuels, an emergency physician and assistant professor in the Alpert School of Medicine at Brown University, has seen the positive impact of these regulatory relaxations on patients’ access to care through her work with the hotline. of Rhode Island Buprenorphine. This 24-hour phone service, launched in April 2020, allows her to connect with people with OCD and prescribe buprenorphine without doing an in-person exam. She is also a founding member of the Buprenorphine Telehealth Consortium, a group of leading healthcare professionals urging lawmakers to codify these COVID-era telehealth measures.
This interview has been edited for length and clarity.
Q: What are the barriers patients with OCD face in accessing buprenorphine?
A: Buprenorphine can only be prescribed by healthcare providers who obtain a special license from the DEA, commonly known as an X-waiver. Due to many factors, about 40% of counties nationwide do not have a single licensed buprenorphine prescriber.
And when we look at racial inequalities, black patients are significantly less likely to have access to or be related to a buprenorphine provider than white patients, depending on where they live. There are also racial inequalities in referral to medication for TOU regardless of geographic location.
Something much more insidious and difficult to combat is stigma. For people with OCD, this can be internalized stigma, as well as the stigma and discrimination they encounter in healthcare settings. There is also a stigma around drugs for TOU: misconceptions that using these drugs could mean replacing one drug with another, as opposed to understanding the use of drugs for TOU as evidence-based treatment that reduces the risk of overdose and death.
Q: How did the telehealth policy changes of the COVID era affect access to buprenorphine?
A: Before the onset of the pandemic, a person with OCD was required to have an in-person visit with a buprenorphine prescriber before starting treatment. Then, at the onset of the pandemic, temporary policy changes at the federal level allowed the use of both audio and audiovisual telehealth for the prescription of buprenorphine, providing access to care where it was not available. previously. I think that’s really significant, especially in low-income communities, communities that don’t have access to treatment, or places that are typically systematically marginalized in health care delivery systems.
Q: Do these new flexibilities make a difference?
A: I think these flexibilities have made a huge difference in improving access to treatment and reducing barriers to initiating treatment. We observed good treatment follow-up in people who started taking buprenorphine on the hotline and were able to put people in contact with maintenance treatment. Over 90% of people we spoke to in the first 10 months after the hotline was set up (April 2020 to February 2021) have completed the prescription written to them. And of those who filled their original prescription, over 70% filled a subsequent prescription during a follow-up visit within 30 days. I think a big part of that success is that we’ve met people where they are, on their own terms.
I think the number of deaths last year would have been even higher if these new flexibilities had not been in place. With COVID-19, the types of social stressors and tensions that people experience are very complex. So while telehealth has improved access to treatment and reduced barriers to care, many people with OCD have lost their jobs, homes, or loved ones, all of which are significant stressors, which can lead to severe stress. resumption of use. These stressors, along with the increased potency of the drug supply, fueled overdose deaths.
Having said that, I believe that these new models of care delivery present significant opportunities for reducing barriers to treatment for TOU and addressing inequalities in access to treatment.
Q: With new opportunities, of course, there are often new challenges.
A: Yes. For audiovisual telehealth to work, a person with OCD needs some form of reliable Internet access, which millions of people in the United States, especially low-income people, do not have. There are also problems with interruptions because the technology is imperfect.
Q: So what do people do if they don’t have the capacity to use audiovisual telehealth?
A: People have several options for receiving treatment with buprenorphine. They may receive treatment in person in an opioid treatment program or in a doctor’s office. They can also go to the emergency room for withdrawal treatment or to be started and linked to maintenance treatment. In Rhode Island, the Buprenorphine Helpline offers 24/7 telephone-only, audio-only assessments and treatment for opioid withdrawal and OUD. This has enabled people to access care when they are ready to access it.
Q: Telehealth critics have suggested that a lack of face-to-face interaction between people with OCD and buprenorphine providers can lead to the drug being diverted to people who would use it without a prescription. Is this concern valid?
A: We have guardrails in place to reduce diversion, and these are still in effect with the use of audio-only telehealth. All of my prescriptions are electronic; I am required to verify the prescription drug monitoring program for each patient; and people still have to go to the pharmacy to collect the drugs.
Q: Are there any anecdotes from your hotline work that highlight the importance of telehealth in drug treatment?
A: As part of a related initiative, we were calling people who had been seen in the emergency department for an opioid overdose to offer harm reduction resources and connect them to the hotline at buprenorphine. An affected patient said he was about to leave to buy opioids. They had been afraid of going to clinics because of COVID but felt that this call – reaching them at home – had saved their lives. I was particularly touched by this.
Q: What are your hopes for the future expansion of telehealth in addiction care?
A: It is really important to expand telehealth in a way that promotes health equity. We see inequities in access to drug treatment among low-income, black, Native American and rural communities, and these populations are less likely to use video services or have broadband access than individuals. other communities and settings. Policymakers need to consider these populations when implementing the expansion of telehealth. Otherwise, we will end up worsening, if not widening, inequalities, by providing more services to those who already have better access, and not to those who need them most.