Telehealth in opioid use disorder treatment: policy considerations for expanding access to care

For the last two decades, the United States has been facing an opioid epidemic resulting in close to 2.7 million individuals diagnosed with opioid use disorder (OUD) [1]. This highlights the critical need to guarantee access to life-saving treatment. Buprenorphine and methadone, FDA-approved opioid agonist medications, are recognized as the gold standard for OUD treatment due to their demonstrated efficacy in higher treatment retention rates, reducing opioid use, and preventing the transmission of HIV and Hepatitis C [2]. Meta-analysis confirmed that patients on methadone or buprenorphine maintenance therapy for OUD have a significantly decreased risk of death during treatment [3]. However, regulations imposed by the state, The Drug Enforcement Administration (DEA), and Substance Abuse and Mental Health Services Administration (SAMHSA) have restricted prescribing and dispensing practices of these controlled substances, therefore creating treatment barriers [3].

One example of these regulations includes The Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which mandates an in-person evaluation before a clinician can prescribe controlled substances. This law was passed after a California teenager overdosed on opioids that he had bought online without being formally evaluated by a physician [4]. While this law initially targeted online diversion of controlled substances and restricted online pill mills, it poses challenges for patients with limited access to medications for opioid use disorder (MOUD) clinics, particularly those patients residing in rural areas [4].

Interestingly, the Haight Act does provide limited exceptions that allow clinicians to prescribe controlled substances via telemedicine. The Attorney General and Secretary of Health and Human Services (HHS) possess the authority to establish rules enabling clinicians to prescribe medication through telemedicine without an in-person evaluation, subject to certain conditions [5, 6]. This exception was granted in response to the COVID-19 Public Health Emergency declared by the HHS Secretary on January 31, 2020 [5]. The authorization allowed the use of audio or video telemedicine encounters to ensure continuity of care while adhering to social distancing guidelines.

This flexibility has been a source of research focusing on whether these modifications have compromised treatment plans or led to adverse outcomes. Postpandemic research thus far has concluded that telemedicine does not lead to unnecessary or inefficient healthcare services. In fact, a recent study found that telemedicine is comparable to in-person care [7]. A pilot study conducted by Weintraub et al. [4] looking at the first 177 patients treated in the telemedicine program over 15 months, revealed that buprenorphine treatment through telemedicine in rural settings is effective in retaining patients in treatment and helping them maintain abstinence, with retention rates exceeding 50 % after a year. Another study found that the incorporation of videoconferencing in 101 new MOUD outpatient programs resulted in 88 % of patients retaining their appointments, compared to a 77 % retention rate during the previous month when only in-person visits were available [8]. Thus, the use of flexible telehealth platforms alongside standard treatment methods often yielded even better treatment outcomes [8].

These implications are significant, particularly for addressing OUD in rural and remote areas where access to qualified physicians is limited and where opioid misuse is a critical concern. Telemedicine can offer several advantages, including enhanced convenience, reduced travel time to and from clinics, and cost savings. As a result, the utilization of synchronous video conferencing via telemedicine has proven effective in increasing access to and usage of buprenorphine by overcoming geographical and logistical barriers [8]. In line with these findings, and with the conclusion of the Public Health COVID-19 Emergency, on March 1, 2023, the DEA proposed expanding access to the prescription of controlled substances via telemedicine [9].

It is important to recognize the DEA as an important stakeholder in this policy. Its primary mission is to enforce controlled substance laws and regulations of the United States, including combating illegal manufacture, distribution, and trafficking of controlled substances to ultimately protect the public. SAMHSA, on the other hand, is responsible for leading efforts to advance behavioral health and reduce the impact of substance abuse and mental illness on individuals, families, and communities. SAMHSA works to fund and support prevention, treatment, and recovery programs for individuals with substance abuse and mental health disorders. These two large stakeholders have played an important role in the recent legislation that sought to increase access to the scope of telemedicine practice.

One of these includes the introduction of the Telehealth Response for E-prescribing Addiction Therapy Services Act (or TREATS Act) in 2021 [9]. This act advocates for the prescription of certain controlled substances for telehealth-based healthcare (TBH), specifically endorsing the tele-prescription of MOUD without mandating an in-person evaluation [1]. Furthermore, in January 2022, the American Telemedicine Association, with support from numerous professional organizations and telehealth stakeholders, called upon Congress to take several key actions: extend telehealth waivers until 2024, compel HHS to conclude telehealth evaluations to inform telehealth legislation by the end of 2023, and introduce evidence-based permanent telehealth legislation in 2024 [1].

It is worth noting that both the DEA and SAMHSA have issued statements assuring that the full range of telemedicine flexibility for prescribing will remain in effect until November 11, 2023 [10]. During this period, the DEA will continue its efforts to finalize regulations that facilitate the safe practice of telemedicine, ensuring public health, safety, and effective control against diversion.