How the pandemic revolutionized opioid use treatment.
When the Covid-19 pandemic broke out, medical services of all kinds were disrupted. One big concern was that people with opioid use disorder would not be able to access the evidence-based standard of care, including opioid replacement therapies such as buprenorphine. Fortunately, the federal government changed its rules when the pandemic shut the country down for a couple of months, expanding telehealth dramatically. Among other things, this allowed patients with opioid use disorders to initiate buprenorphine via telehealth, rather than relapse on heroin or fentanyl and risk a fatal overdose.
Buprenorphine is a long-acting opioid that reduces overdoses. It’s a partial opioid agonist, meaning that it binds to the same receptor as heroin and fentanyl, but with much less abuse potential. In short, it keeps opioid use disorder patients out of pain, without the high and other problems. It has been shown to be superior to sobriety in keeping high-risk patients alive. Unlike methadone, each dose of buprenorphine does not need to be dispensed in person, allowing recipients to live more normal lives.
New data in the JAMA Network Open shows that in Ohio and Kentucky, telehealth prescribing of buprenorphine during the pandemic worked. People who used telehealth to initiate opioid replacement therapy during the pandemic were more likely to stay in therapy, compared with those who accessed those therapies by traditional methods. Just as importantly, one of the feared downsides of telehealth—increases in overdoses due to increased access with less “supervision”—did not occur.
These findings make a strong argument for the effectiveness and safety of telehealth for initiating opioid replacement therapies, modalities which keep people alive.
Unfortunately, the benefits of telehealth are not evenly distributed. Good internet is a big piece of that puzzle. And if you think that everyone in the US has good internet in their homes in the year 2023, you’re mistaken. Tens of millions do not.
Let’s regulate.
The future of opioid replacement therapy—and therefore hundreds of thousands of lives—boils down to federal laws, regulations, and money.
Recently, after many years of advocacy, the federal government did away with its bizarre system that acted as though prescribing opioid replacement medications was somehow more fraught than regular opioids. Until this year, clinicians had to get special training to prescribe buprenorphine (a drug that is very hard to overdose on), but not oxycontin or even medicinal fentanyl (drugs which are far easier to overdose on). The whole thing made no sense. Many doctors rallied for the old system to go away, and I’m proud to have been one of those voices. (Here’s a 2019 piece I wrote in the Boston Globe with my Harvard colleague Cass Sunstein.)
Still hanging in the balance, however, is whether the federal government will continue to permit flexibility in buprenorphine prescribing (i.e., telehealth), as it has since the Covid-19 pandemic began. So far, the federal government has extended the policy past the end of the public health emergency, including a recent announcement that extends the current status quo into 2024. While the FDA is worried that some shady bad actors (for example, pop-up pill mill clinics that are not really taking good care of patients) will abuse the system, that’s not reason enough to do away with this innovation. Cracking down on offenders is the answer, not punishing everyone else who is engaging the system in good faith.
Over 42 million Americans do not have access to high-speed internet (and thus, telehealth), and cost is the big barrier. Fortunately, that should be a surmountable problem for most US residents right now. Currently, we can expand internet access to low-income communities via the Affordable Connectivity Program, a federal program that looks to address the connectivity (telehealth) gap in the United States. The ACP works to “ensure that households can afford the broadband they need for work, school, healthcare and more” by subsidizing internet access to those in need to the tune of $30 per month (or $75 per month on Tribal lands). While many eligible people have accessed this benefit, many millions of Americans have not.
Telehealth: one of the good things.
We learned many things from the Covid-19 pandemic. Most were bad. Some were good. One of the excellent things we learned is that, given the option, people are in fact able to access healthcare via telehealth—and they indeed want to. (Before the pandemic, interest was low, and progress was slow; it’s amazing how reliable the phrase “necessity is the mother of innovation” truly is). While telehealth use is fading somewhat, levels remains far higher than they ever were pre-pandemic. Doctors like it too; one primary care doctor I know reports that no-show rates are basically non-existent with telehealth appointments, but remain common for in-person ones.
Another friend and colleague Dr. Alister Martin often says that internet access is becoming akin to healthcare access. He’s right. The latest data on opioid replacement therapy and telehealth has shown that to be the case yet again.
Questions? Comments? Experience (good and bad) with telehealth? Chime in!
Dr. Faust, I am a fan and proponent of tele-med aka tele-health because we live in Western Mass and Partners owns our local rural hospital Cooley Dickinson. Tele-med worked well during the pandemic, but now it is being sporadically disrupted at B&W, MGB and Dana Farber for simple follow-up procedure wellness check-ins. Why? I’ve heard from my docs that they favor it, and rural patients in Western Mass prefer almost anything to avoid the torture of spending gridlock hours on the Mass Pike for the majority of a day so they can spend twenty to thirty minutes of usually interrupted time with their docs in person in Boston. In the medical financial food-chain, who is getting shorted by tele-med and has the political power to cause the disruption of a good program that benefits the docs and their patients? What am I missing? Do the rural docs dislike the fact that rural patients find it easier to avoid waiting months to see a specialist in the rural parts of New England by making the initial trip into Boston, establishing a relationship with a Partners Boston based doc, then continuing care with tele-med, and apparently leaving their local docs feeling abandoned and having fewer patients? This might be an unspoken point of pressure on the pols who regulate tele-med regulations. I suspect this might be one of the reasons why the patient is forced to spend their day in Mass Pike gridlock hell as a form of payback for not remaining loyal to their local docs. Tell me it isn’t so. You want to go to the big city? Prepare to spend an overnight in a Boston hotel in order to be able to not miss the early morning appointment and then worry about a rear-end collision going home. Or, stay local and not step out of the scheduling process. Whose brother-in-law if influential with the Medicare regulators? Paranoid? Nope. Just an older Massachusetts resident who has seen how Mass politics works.
I was under the impression that with the ending of the Emergency orders Medicare (or the FDA I guess) would not allow Telehealth by telephone, which also could be very helpful. Am I mistaken about this and do you not believe that such access would help too.