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End of COVID-19 emergency endangers substance use treatment

Medication-assisted treatment seen as helpful for hard-to-reach populations

Doctors worry that waivers allowing medication-assisted therapies for opioid use disorder will vanish as the pandemic subsides.
Doctors worry that waivers allowing medication-assisted therapies for opioid use disorder will vanish as the pandemic subsides. (CQ Roll Call)

Members of vulnerable and hard-to-reach groups could find it more difficult to get treatment for substance use disorders if the end of the public health emergency also brings the end of policies that allow health care providers to prescribe medications through video or audio calls, experts say.

In the two years since the COVID-19 pandemic began, the Drug Enforcement Administration has allowed providers to prescribe the gold-standard addiction treatment to patients with opioid use disorder, or OUD, through telehealth without first doing an in-person evaluation that addiction experts say is a barrier to underserved communities.

The DEA said starting treatment via a telehealth visit would be acceptable during a pandemic that led people to avoid doctors’ offices and where substance abuse treatment facilities saw fewer patients. 

Some groups, including people living in rural areas and others released from incarceration, especially benefited, clinicians say. They worry that such groups won’t be able to make in-person visits at the end of the public health emergency unless Congress or the DEA takes action. 

“We were able to see patients we wouldn’t otherwise have engaged,” said Linda Wang, a physician leader at Mount Sinai Hospital’s REACH program in New York, which provides primary care and other services to people who use drugs. “We would see a drop-off in the number of new people we’re able to get into treatment.”

The public health emergency is currently scheduled to end in July. 

About 50 percent of Mount Sinai’s REACH patients currently rely on telehealth, Wang said. People who initiated medication-assisted treatment, or MAT, during the pandemic through telehealth might need an in-person evaluation to continue treatment after the public health emergency ends. 

Pandemic exacerbated problem

The DEA has said it is working to permanently allow telehealth prescribing of MAT without requiring an in-person visit, but it hasn’t released a timeline or other details.

“At DEA, our goal is simple: we want medication-assisted treatment to be readily and safely available to anyone in the country who needs it,” DEA Administrator Anne Milgram said in a statement last month. 

About 2.5 million Americans had opioid use disorder in 2020, and 11 percent of them received MAT, according to the National Survey on Drug Use and Health. Even as the pandemic brought greater flexibility for treatment, the number of people dying of an opioid overdose jumped 36 percent, to 76,000, by April 2021 compared with the previous 12 months, according to the Centers for Disease Control and Prevention. 

Experts attribute the increase to drugs being laced with fentanyl, a synthetic opioid that is 80 to 100 times stronger than morphine. 

Waiting for DEA rules

For more than a decade, Congress has been pressing the DEA to no avail to issue rules allowing some providers to prescribe MAT to new patients through telehealth. Synthetic opioids such as buprenorphine and methadone are used to help people decrease their use of illicit drugs, curb withdrawal symptoms and reduce overdose deaths. Studies have shown most buprenorphine and methadone is used to curb withdrawal symptoms and cravings and not to get high, according to the National Institutes of Health. 

Lawmakers from both parties and addiction experts say the in-person requirement poses an unnecessary barrier to the medications.

“Telehealth lowers the barrier to treatment, especially for patients who might not otherwise receive treatment in the first place,” said Sheri Doyle, a manager with The Pew Charitable Trusts Substance Use Prevention and Treatment program.

Even with the flexibility allowed by the emergency, there aren’t enough providers registered with the DEA to prescribe MAT, especially in rural and underserved areas. Only 7 percent of physicians in the U.S. have the credentials to prescribe MAT, according to the Substance Abuse and Mental Health Services Administration. 

Seventy-two percent of rural counties with high rates of addiction have low or no capacity to treat those patients, according to a January 2020 report from the Health and Human Services Department’s Office of Inspector General. 

Data collected before the pandemic shows many treatment centers also don’t offer MAT and some physicians harbor a stigma against using it. Patients cited other reasons for not using the option: lack of insurance, transportation barriers, homelessness or frequent moves, financial instability and other social factors.  

Experts say eliminating in-person evaluation before prescribing MAT won’t solve all of those problems, but it has increased access during the pandemic. 

Studies have shown it is a useful option for people leaving incarceration, living in rural areas, are pregnant, or are homeless, many of whom have phones.  

‘A lot of potential to fill this treatment gap’

“We know there’s a limited window when people who use drugs who are seeking treatment decide they are ready,” said Dr. Utsha Khatri, an assistant professor of emergency medicine at the Icahn School of Medicine at Mount Sinai. She also used telemedicine to treat patients with OUD earlier in the pandemic at the University of Pennsylvania’s Center for Opioid Recovery and Engagement. 

Waiting times for in-person appointments, lack of transportation and other logistical and structural barriers can be discouraging, she said. 

“I don’t foresee it replacing in-person visits, but I do think it has a lot of potential to fill this treatment gap,” Khatri said. 

It could be especially useful for people living in rural areas, which are least likely to have physicians who are licensed to prescribe MAT. 

Dr. Judith Griffin, the director of research for Reach Medical, based in Ithaca, N.Y., said the harm-reduction practice has seen disproportionate growth in new patients who live in rural areas, likely because of telehealth. 

“These are people hours away from us,” Griffin said. “In some of the rural areas, there’s just literally no access to care.” 

While the DEA has said it is working to make permanent some telehealth changes during the emergency, it isn’t clear what that will look like.  

Since 2008, when Congress passed a law regulating online internet prescriptions, it has directed the DEA to set up a special registration process allowing providers to prescribe MAT through telehealth without first evaluating a patient in person. It reiterated that directive in 2018 in legislation addressing the opioid epidemic and in the fiscal 2021 appropriations package.

Still awaiting rule

But the DEA didn’t establish that registration process despite frequent prodding by bipartisan groups of lawmakers, physicians and advocates for people experiencing addiction. 

A rule that would implement that special registration process has been published in the Justice Department’s Unified Agenda, a compilation of regulations under consideration, since 2015. 

The DEA in March submitted a proposed rule titled “special registration to engage in the practice of medicine” to the Office of Management and Budget, where it is pending review. There are no other details available. 

But the American Telehealth Association and other advocacy groups now want the government to go further than just implementing the long-awaited special registration process. They want the DEA to continue to waive the in-person requirements after the end of the public health emergency.

The ATA’s preferred approach is repealing the in-person requirement entirely, which would require Congress to act. One bill proposed by Sens. Sheldon Whitehouse, D-R.I., and Rob Portman, R-Ohio, would do that. 

“Let’s go ahead and make the current reality the permanent reality,” said Kyle Zebley, vice president of public policy for the ATA.

The DEA’s approach to audio-only health services raises another question for post-emergency flexibility. The agency has previously said in “normal circumstances” it wouldn’t consider treatment with a controlled substance “based on a mere phone call” to be consistent with the law because it “creates a high risk” of misuse. 

Audio-only care

Experts and advocates say audio-only phone calls should continue because of disparities in access to broadband or data for video calls.

HHS data shows Black, Latino, Asian and multiracial people are more likely than white people to have used audio-only telehealth. Some programs have relied entirely on audio-only telehealth for prescribing MAT during the pandemic. 

Rhode Island’s state Health Department and the Department of Emergency Medicine at Brown University set up a hotline for people with moderate to severe OUD to call 24/7 to initiate buprenorphine treatment. That wouldn’t have been possible or legal before the public health emergency. Over the past two years, the hotline resulted in 271 new buprenorphine prescriptions, a Health Department spokesperson said. 

“We know access to broadband, which is necessary for the amount of bandwidth you need to do two-way video, is limited, and it’s limited in the populations that have the highest numbers of barriers they have to overcome to get care,” said Khatri, at Mount Sinai. “For buprenorphine expansion to be equitable, only-audio is very important.”

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