Buprenorphine Telehealth Treatment Initiation and Follow-Up During COVID-19

Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies

INTRODUCTION

The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.

AREAS COVERED

In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.

EXPERT OPINION

Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.

Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders

Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.

Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19

Importance

Primary care (PC) receipt is associated with better health outcomes. How telehealth expansion and internet speed are associated with PC use is unclear.

Objective

To examine the association of telehealth and internet speed with PC use across sociodemographic determinants of health.

Design, Setting, and Participants

This cohort study performed difference-in-differences regression of the change in in-person and telehealth PC visits between pre-COVID-19 public health emergency (PHE) (June 1, 2019, to February 29, 2020) and an initial (March 1, 2020, to May 31, 2020) and prolonged (March 1, 2020, to December 31, 2021) PHE period among continuously enrolled nonpregnant, nondisabled Wisconsin Medicaid beneficiaries aged 18 to 64 years. Data were analyzed from March 2022 to March 2023.

Exposure

PHE-induced telehealth expansion.

Main Outcomes and Measures

Change in PC telehealth (using Current Procedural Terminology codes) visits: (1) count; (2) visit share completed by telehealth; (3) percentage of PHE-induced visit decline offset by telehealth. High-speed internet (HSI) defined as living in a census block group with a median block maximum download speed of 940 megabits per second or greater (June 2020 Federal Communications Commission broadband data); other census block groups classified as low-speed internet (LSI).

Results

In the total cohort of 172 387 participants, 102 989 (59.7%) were female, 103 848 (60.2%) were non-Hispanic White, 34 258 (19.9%) were non-Hispanic Black, 15 020 (8.7%) were Hispanic, 104 239 (60.5%) were aged 26 to 45 years, and 112 355 (66.0%) lived in urban counties. A total of 142 433 (82.6%) had access to HSI; 72 524 (42.1%) had a chronic condition. There was a mean (SD) of 0.138 (0.261) pre-PHE PC visits per month. In the pre-PHE period, visit rates were significantly higher for female than male participants, non-Hispanic White than non-Hispanic Black individuals, urban than rural residents, those with HSI than LSI, and patients with chronic disease than patients without. In the initial PHE period, female participants had a greater increase in telehealth visits than male participants (43.1%; 95% CI, 37.02%-49.18%; P < .001), share (2.20 percentage point difference [PPD]; 95% CI, 1.06-3.33 PPD; P < .001) and offset (6.81 PPD; 95% CI, 3.74-9.87 PPD; P < .001). Non-Hispanic Black participants had a greater increase in share than non-Hispanic White participants (5.44 PPD; 95% CI, 4.07-6.81 PPD; P < .001) and offset (15.22 PPD; 95% CI, 10.69-19.75 PPD; P < .001). Hispanic participants had a greater increase in telehealth visits than Non-Hispanic White participants (35.60%; 95% CI, 25.55%-45.64%; P < .001), share (8.50 PPD; 95% CI, 6.75-10.26 PPD; P < .001) and offset (12.93 PPD; 95% CI, 6.25-19.60 PPD; P < .001). Urban participants had a greater increase in telehealth visits than rural participants (63.87%; 95% CI, 52.62%-75.11%; P < .001), share (9.13 PPD; 95% CI, 7.84-10.42 PPD; P < .001), and offset (13.31 PPD; 95% CI; 9.62-16.99 PPD; P < .001). Participants with HSI had a greater increase in telehealth visits than those with LSI (55.23%; 95% CI, 42.26%-68.20%; P < .001), share (6.61 PPD; 95% CI, 5.00-8.23 PPD; P < .001), and offset (6.82 PPD; 95% CI, 2.15-11.49 PPD; P = .004). Participants with chronic disease had a greater increase in telehealth visits than those with none (188.07%; 95% CI, 175.27%-200.86%; P < .001), share (4.50 PPD; 95% CI, 3.58-5.42 PPD; P < .001), and offset (9.03 PPD; 95% CI, 6.01-12.04 PPD; P < .001). Prolonged PHE differences were similar. Differences persisted among those with HSI.

Conclusions and Relevance

In this cohort study of Wisconsin Medicaid beneficiaries, greater telehealth uptake occurred in groups with higher pre-PHE utilization, except for high uptake among Hispanic and non-Hispanic Black individuals despite low pre-PHE utilization. HSI did not moderate disparities. These findings suggest telehealth and HSI may boost PC receipt, but will generally not close utilization gaps.

Disparities in access to opioid treatment programs and buprenorphine providers by race and ethnicity in the contiguous U.S

BACKGROUND

The burden of drug overdose mortality varies by race and ethnicity, with American Indian/Alaska Native (AI/AN), Black, and White people experiencing the largest burden. We analyzed census block group data to evaluate differences in travel distance to opioid treatment programs (OTP) and buprenorphine providers by race and ethnicity.

METHODS

The Substance Abuse and Mental Health Services Administration provided the addresses of OTPs and buprenorphine providers. The study classified block groups as majority (≥50 %) AI/AN, Black, Asian, White, no single racial majority, or Hispanic. We classified deprivation and rurality using the Area Deprivation Index and Rural-Urban Commuting Area codes. The study applied generalized linear mixed models.

RESULTS

Among all block groups, the median road distance to the nearest OTPs and buprenorphine providers was 8 and 2 miles, respectively. AI/AN-majority block groups had the longest median distances to OTPs (88 miles versus 4-10 miles) and buprenorphine providers (17 miles versus 1-3 miles) compared to other racial or ethnic majority block groups. For OTPs and buprenorphine providers, travel distances were slightly greater in more deprived block groups compared to less deprived block groups. The median distance to the nearest OTPs and buprenorphine providers were larger in micropolitan and small town/rural block groups compared to metropolitan areas.

CONCLUSIONS

Disparities exist in travel distance to OTPs and buprenorphine providers. People in block groups with AI/AN-majority, nonmetropolitan, or more deprived designation experience travel disparities accessing treatment. Future research should develop targeted interventions to reduce access to care disparities for individuals with opioid use disorder.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries

BACKGROUND

Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics.

METHODS

National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score.

RESULTS

The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10).

CONCLUSIONS

Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

How are state telehealth policies associated with services offered by substance use disorder treatment facilities? Evidence from 2019 to 2022

BACKGROUND

The COVID-19 pandemic led several states to adopt policies permitting the delivery of substance use disorder treatment (SUDT) by telehealth. We assess the impact of state-level telehealth policies in 2020 that specifically permitted audio or audiovisual forms of telehealth offerings among SUDT facilities.

PROCEDURE

Cross-sectional analysis of secondary data from between 2019 and 2022. Pre-pandemic, federal law permitted states to allow audiovisual telehealth modes for SUDT to a limited extent. 2020 laws permitted states to allow audio-only modes for the first time and strengthened ability to offer audiovisual modes. We compared national SUDT facility self-reported telehealth offerings in 2020 and beyond to 2019, in states that in 2020 had policies permitting audiovisual and audio only, compared to other states.

MAIN FINDINGS

Among outpatient SUDT facilities (n = 5227) present in all four years of our data, the proportion offering telehealth increased from 18% (n = 921) in 2019-26% in 2020, 60% in 2021, and 79% in 2022. We estimate an audiovisual and audio only policy in 2020 was associated with an increase in telehealth offering rates in 2022 of +16.5% points (pp) (95% CI [+10.4,+22.6]) compared to the rates in states with no such listed policy. There was little evidence of an influence on telehealth offering in 2020 (-2.9 pp, CI [-9.0,+3.2]) and 2021 (+0.6 pp, CI [-5.5,+6.7]).

CONCLUSIONS

The enactment of state-level telehealth policies that allow audio and audiovisual modalities may have increased SUDT facilities' likelihood of offering telehealth services two years after enactment.

Pandemic telehealth flexibilities for buprenorphine treatment: a synthesis of evidence and policy implications for expanding opioid use disorder care in the United States

Buprenorphine is a highly effective treatment for opioid use disorder (OUD) and a critical tool for addressing the worsening US overdose crisis. However, multiple barriers to treatment-including stringent federal regulations-have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 public health emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the public health emergency has been set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this narrative review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on the uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment, and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue nonrestricted use of telehealth for buprenorphine initiation.

Service users' perception and attitude toward telemedicine-based treatment for substance use disorders: A qualitative study from India

Aim

We aimed to assess the service user's acceptability, feasibility, and attitude toward telemedicine practice and compare it with in-person consultation in substance use disorder (SUD).

Materials and Methods

We recruited 15 adult patients with SUD who accessed both telemedicine and in-person care. We conducted in-depth interviews on awareness and access, facilitators and barriers, treatment satisfaction, and therapeutic relationship in the telemedicine context. We performed a conventional content analysis of the interview excerpts and used inductive and deductive coding. We assumed that social, personal, and logistic contexts influence patients' perceptions and experiences with telemedicine-based addiction care (TAC).

Results

Most participants were middle-aged men (40.5 years, 86.7%), dependent on two or more substances (86.7%), and had a history of chronic, heavy substance use (use ~16 years, dependence ~11.5 years). Patients' perspectives on TAC could broadly be divided into three phases: pre-consultation, consultation, and post-consultation. Patients felt that TAC improved treatment access with adequate autonomy and control; however, there were technical challenges. Patients expressed privacy concerns and feared experiencing stigma during teleconsultation. They reported missing the elaborate inquiry, physical examination, and ritual of visiting their doctors in person. Additionally, personal comfort and technical difficulties determine the satisfaction level with TAC. Overall perception and suitability of TAC and the decision to continue it developed in the post-consultation phase.

Conclusion

Our study provides an in-depth insight into the barriers and facilitators of telemedicine-based SUD treatment access, use, and retention; it also helps to understand better the choices and preferences for telehealth care vis-à-vis standard in-person care for SUDs.

Substance use disorder bridge clinics: models, evidence, and future directions

BACKGROUND

The opioid overdose and polysubstance use crises have led to the development of low-barrier, transitional substance use disorder (SUD) treatment models, including bridge clinics. Bridge clinics offer immediate access to medications for opioid use disorder (MOUD) and other SUD treatment and are increasingly numerous. However, given relatively recent implementation, the clinical impact of bridge clinics is not well described.

METHODS

In this narrative review, we describe existing bridge clinic models, services provided, and unique characteristics, highlighting how bridge clinics fill critical gaps in the SUD care continuum. We discuss available evidence for bridge clinic effectiveness in care delivery, including retention in SUD care. We also highlight gaps in available data.

RESULTS

The first era of bridge clinic implementation has yielded diverse models united in the mission to lower barriers to SUD treatment entry, and preliminary data indicate success in patient-centered program design, MOUD initiation, MOUD retention, and SUD care innovation. However, data on effectiveness in linking to long-term care are limited.

CONCLUSIONS

Bridge clinics represent a critical innovation, offering on-demand access to MOUD and other services. Evaluating the effectiveness of bridge clinics in linking patients to long-term care settings remains an important research priority; however, available data show promising rates of treatment initiation and retention, potentially the most important metric amidst an increasingly dangerous drug supply.

The Future of the United States Overdose Crisis: Challenges and Opportunities

Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.

Pandemic telehealth flexibilities for buprenorphine treatment: A synthesis of evidence and policy implications for expanding opioid use disorder care in the U.S

Buprenorphine is a highly effective treatment for opioid use disorder and a critical tool for addressing the worsening U.S. overdose crisis. However, multiple barriers to treatment - including stringent federal regulations - have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 Public Health Emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the Public Health Emergency is set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue non-restricted use of telehealth for buprenorphine initiation.

Enhancing Patient Choice: Using Self-administered Intranasal Naloxone for Novel Rapid Buprenorphine Initiation

Buprenorphine-naloxone (BUP-NX) is a lifesaving treatment for opioid use disorder. The increasing use of illicitly manufactured fentanyl, however, has made initiating BUP-NX more likely to precipitate withdrawal-an experience that deters treatment and causes return to use. If BUP-NX cannot be successfully started, it cannot work. We describe the case of a patient who was able to transition to a therapeutic dose of BUP-NX less than 3 hours after his last illicitly manufactured fentanyl use by choosing to self-administer intranasal naloxone. After the naloxone, the transition took 31 minutes, including 14 minutes of expected moderately severe withdrawal. He remains in care with BUP-NX and would recommend this transition approach to others.

Thirty-day Treatment Continuation After Audio-only Buprenorphine Telehealth Initiation

OBJECTIVES

Before the coronavirus disease 2019 pandemic, federal law required in-person evaluation before buprenorphine initiation. Regulatory changes during the pandemic allow for buprenorphine initiation by audio-only or audiovisual telehealth. Little is known about treatment engagement after buprenorphine initiation conducted via audio-only telehealth.

METHODS

A retrospective cohort study of 94 individuals who received initial treatment through an audio-only encounter between April 2020 and February 2021 was performed. Participant demographics, substance use history, withdrawal symptoms, 30-day treatment engagement, and adverse outcomes were determined by an electronic chart and REDcap database review. Subsequent buprenorphine prescriptions filled within 30 days of the initial encounter were tracked through the Rhode Island Prescription Drug Monitoring Program.

RESULTS

Buprenorphine was prescribed for 94 individuals. Most (92 of 94 [97.9%]) filled their prescription within 30 days. Most had previously taken buprenorphine, including prescribed (42 of 92 [45.7%]) and nonprescribed (58 of 92 [63.0%]). Two thirds were in opioid withdrawal at the time of the call (61 of 92 [66.3%]) with a mean Subjective Opioid Withdrawal Scale of 26.8 (range, 4-57). Four individuals experienced precipitated withdrawal (4 of 94 [4.3%]), and 2 reported persistent withdrawal at their follow-up visit (2 of 94 [2.1%]). More than 70% filled a subsequent prescription for buprenorphine within 30 days of the end of their hotline prescription (65 of 92 [70.7%]), on average of 5.88 days (range, 0-28) after completion of their telehealth prescription.

CONCLUSIONS

Expanding telehealth-delivered buprenorphine care has the potential to address treatment gaps and facilitate delivery of on-demand services during peak motivation. This evaluation of audio-only buprenorphine initiation found high rates of unobserved buprenorphine initiation and treatment continuation with low rates of complications.

Buprenorphine Treatment Episodes During the First Year of COVID: a Retrospective Examination of Treatment Initiation and Retention

BACKGROUND

During the COVID pandemic, overall buprenorphine treatment appeared to remain relatively stable, despite some studies suggesting a decrease in patients starting buprenorphine. There is a paucity of empirical information regarding patterns of buprenorphine treatment during the pandemic.

OBJECTIVE

To better understand the patterns of buprenorphine episodes during the pandemic and how those patterns compared to pre-pandemic patterns.

DESIGN

Pharmacy claims representing approximately 92% of all prescriptions filled at retail pharmacies in all 50 US states and the District of Columbia.

PARTICIPANTS

Individuals filling buprenorphine prescriptions indicated for treatment of opioid use disorder.

MAIN MEASURES

The number of active, starting, and ending buprenorphine treatment episodes March 13 to December 1, 2020, and the expected number of such episodes in 2020 based on the growth in treatment episodes from March 13 to December 1, 2019.

KEY RESULTS

The observed number of active buprenorphine episodes in December 2020 was comparable to the expected number, but new treatment episodes starting between March 13 and December 1, 2020, were 17.2% fewer than expected based on the 2019 experience. Similarly, the number of episodes that ended between March 13 and December 1, 2020, was 16.0% fewer than expected. Decreases from expected episode starts and ends occurred throughout the period but were greatest in the 2 months after the declaration of the public health emergency.

CONCLUSIONS AND RELEVANCE

Beneath the apparent stability of buprenorphine patient numbers during the pandemic, the flow of individuals receiving buprenorphine treatment changed substantially. Our findings shed light on how policy changes meant to support buprenorphine prescribing influenced prescribing dynamics during that period, suggesting that while policy efforts may have been successful in maintaining existing patients in treatment, that success did not extend to individuals not yet in treatment.

Defining and supporting high-quality telehealth for patients with opioid use disorder: The promise and potential pitfalls of telehealth expansion

Many patients with opioid use disorders do not receive evidence-based treatment. The COVID-19 pandemic expanded the use of telehealth for prescribing medications for opioid use disorder (OUD). The uptake of telehealth has been variable, and this uneven expansion has created natural experiments to test assumptions and answer key questions about what improves outcomes for patients with OUD. Many current quality of care measures are not patient centered and do not focus on the practical questions that clinicians face. What criteria should be met before prescribing buprenorphine? Are physical exams necessary? Does the frequency and type of drug testing predict clinical outcomes? Are short check-in visits by phone or video better than less frequent in-person visits? Answering these questions can help define the essential components of high-quality care for patients with OUD. Defining the features of high-quality care can help create guardrails that will help protect our patients from potentially exploitive and ineffective care. Telehealth will likely end up being one additional tool to deliver care, but the scientific questions that can be answered during this period of rapid change can help answer some of the fundamental questions about providing high-quality care-and that will help all our patients, no matter how care is delivered.

Demographic Predictors of Telehealth Use for Integrated Psychological Services in Primary Care During the COVID-19 Pandemic

OBJECTIVE

Prior to the COVID-19 pandemic, growing mental health needs were well documented, particularly those of diverse patient populations. The current study aims to better understand racial and psychosocial factors associated with patient utilization of integrated psychological services via telehealth during the COVID-19 pandemic within a diverse primary care clinic.

METHODS

Retrospective chart reviews were completed for patients seen by an integrated psychology team within a general internal medicine clinic at a large urban health system during the year 2020. Demographics were extracted from the medical record. Multivariate logistic regression analyses were conducted to examine demographic predictors for (1) telehealth video visits vs. audio only telehealth visits and (2) in-person vs. telehealth visits (both video and audio).

RESULTS

Older patients, Black patients, and those with Medicare and Medicaid were more likely to complete audio only telehealth visits vs. video visits. There were no significant demographic predictors when comparing in-person vs. telehealth (both video and audio).

DISCUSSION

Some underserved and vulnerable patient populations are more likely to utilize audio-only integrated psychological visits to video visits. The utilization of audio visits over video for certain demographics speaks to the need to better understand how this type of care may benefit psychological services in the future and continued advocacy to extend audio mental health visits beyond the public health emergency to address patient populations with significant mental health needs.