Clinical Update

15 Aug Telemedicine Improvements After Epidemics Collide

Posted at 1:30 PM in Clinical Update, nps

Telemedicine, or telehealth, utilizes telecommunication technologies through audio or audio/visual, real-time, two-way communication to provide clinical services to patients outside of clinical settings. Before the COVID-19 pandemic, efforts were made to increase access to telemedicine, especially for those struggling with Opioid Use Disorder (OUD) during the rising opioid crisis.1,2 According to the National Institutes of Health (NIH), OUD is defined as “the chronic use of opioids that causes clinically significant distress or impairment. Symptoms of this disease include an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when opioids are discontinued.”3 In the US, there have been three waves of the opioid epidemic since the 1990s: first with prescription opioids, second with heroin, and third with fentanyl. The opioid epidemic reached its peak in 2017, with more than 47,000 opioid overdose deaths in the US that year alone.4 Efforts were made at this time to improve accessibility to telemedicine to address the country’s opioid and substance misuse epidemic,5 however, few Opioid Treatment Programs (OTPs) or patients with OUD took advantage of expansions to use telemedicine.6 Then in 2019, the COVID-19 epidemic collided with the opioid crisis and everything changed.7 The COVID-19 pandemic significantly impacted people with OUD through social isolation, increased likelihood of using opioids in isolation, increased mental health challenges, and reduced access to health and social care.1 The NIH documented that the national drug overdose rate in the US escalated from 70,630 to 91,799 from 2019 to 2020, many of which included opioid involvement and marked the harsh beginning of the COVID-19 epidemic.8  

In response to the COVID-19 Public Health Emergency (PHE) declared on January 31, 2020, the Drug Enforcement Administration (DEA) granted temporary exceptions to rule 42 CFR 8 to implement the practice of telemedicine for patients with OUD. There were several exceptions, and this discussion will specifically focus on the changes in medication regulations. As soon as March 16, 2020, the DEA permitted buprenorphine to be prescribed through audio-visual telemedicine, and on March 31, 2020, the DEA relaxed this policy further to allow an audio-only connection.9,10 In April 2020, The Substance Abuse and Mental Health Services Administration (SAMHSA), which oversees OTPs, issued comparable telehealth prescribing guidelines through exceptions to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which originally required most practitioners to have at least one in-person evaluation before prescribing controlled substances.10,11 The change to the Act specifically allowed OTPs to initiate patients on buprenorphine through telehealth without first having an in-patient evaluation. While regulation flexibilities changed buprenorphine prescribing on March 16, 2020, SAMHSA also issued an exemption for OTPs to provide patients with unsupervised, take-home doses of methadone, a schedule II-controlled substance. Take-home doses refer to methadone that can be taken at home unobserved rather than being dispensed and consumed under observation at an OTP.10,12 The exemption allowed all stable patients in an OTP to receive 28 days of take-home doses and up to 14 days of take-home doses for those patients who are less stable but who the OTP believes can safely handle this level of methadone. This flexibility was crucial because methadone treatment is associated with a reduced risk of illicit opioid overdose death. The exemption did not, however, allow for the prescribing of methadone through telemedicine as it did for buprenorphine.10

Three years after these exemptions were granted, SAMHSA concluded that there was sufficient evidence that they had enhanced and encouraged OTPs through telemedicine at a time when fentanyl-related overdose mortality was spiking. States, OTPs, and clinicians reported that the OTP use of telemedicine increased treatment engagement and improved patient satisfaction with relatively few incidents of misuse or medication diversion.1 Utilizing telemedicine protected the public’s health and reduced the risk of COVID-19 infection among patients and providers.10,13 Additional benefits and concerns include the following:[/vc_column_text][/vc_column][/vc_row]

In February 2024, the U.S. Department of Health and Human Services (HHS), SAMHSA, and the DEA finalized Rule 42 CFR 8 to provide permanence to the telehealth flexibilities created during COVID-19 and to introduce new flexibilities into the regulation. The rule was effective April 2, and the compliance date is October 2, 2024.10 See the details of the finalized rule below:

Some OTPs who utilized the new telehealth flexibilities allowed urine toxicology screening to be used less frequently or waived completely. OTPs expressed concerns over the potential increased risk and negative consequences for the quality of OUD care as a result of less frequent drug monitoring. OTPs have established that drug testing assists OTP providers in monitoring adherence to prescribed medication, detecting substance use that could complicate treatment response, and monitoring for possible medication diversion.12,14,17 Toxicology testing is recommended throughout OUD treatment, including maintenance and recovery phases.18 Aegis Sciences Corporation offers OTPs and all providers the ability to perform observed oral fluid sample collections remotely during telemedicine appointments with Aegis Remote Telemedicine Solutions. Continuous medication monitoring throughout OTP treatment utilizing telemedicine improves the quality of OUD care and decreases risk by measuring an individual’s prescription compliance and substance use. Aegis’ oral fluid testing is a definitive, accurate alternative to urine with an expansive menu, including up-to-date Novel Psychoactive Substances (NPS).19 A complete list of Aegis test offerings is available through your local Aegis representative or by e-mailing info@aegislabs.com.

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References:

  1. Tay Wee Teck J, Butner JL, Baldacchino A. Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review. J Telemed Telecare. Published online September 4, 2023. doi:10.1177/1357633X231195607
  2. National Institute on Drug Abuse (NIDA). (2023, October 18). Telehealth supports retention in treatment for opioid use disorder. National Institutes of Health. https://www.nih.gov/news-events/news-releases/telehealth-supports-retention-treatment-opioid-use-disorder
  3. Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. [Updated 2024 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553166/
  4. The Centers for Disease Control and Prevention. National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC website. Accessed August 3, 2024.
  5. Lohse J, Lerner B, & AHLA’s Behavioral Health Task Force. (n.d.). AHLA – Support Act: Highlights of the 2018 opioid legislation. American Health Law Association. https://www.americanhealthlaw.org/content-library/publications/bulletins/d73a0f8e-2dd3-4637-84f3-2b9029ee276f/support-act-highlights-of-the-2018-opioid-legislat#:~:text=In%20addition%20to%20expanding%20some,of%20services%20addressing%20high%2Drisk
  6. Creedon TB, Schrader KE, O’Brien PL, Lin JR, Carroll CD, Mulvaney-Day N. Rural-Nonrural Differences in Telemedicine Use for Mental and Substance Use Disorders Among Medicaid Beneficiaries. Psychiatr Serv. 2020;71(8):756-764. doi:10.1176/appi.ps.201900444
  7. Becker, W. C., & Fiellin, D. A (2020). When epidemics collide: Coronavirus disease 2019 (COVID-19) and the opioid crisis. Annals of Internal Medicine, 173(1), 59–60. https:// doi.org/10.7326/M20-1210.
  8. National Institute on Drug Abuse (NIDA). (2023, October 18). Telehealth supports retention in treatment for opioid use disorder. National Institutes of Health. https://www.nih.gov/news-events/news-releases/telehealth-supports-retention-treatment-opioid-use-disorder
  9. Krawczyk, N., Rivera, B. D., King, C., & Dooling, B. C. E. (2023, March 17). Pandemic Telehealth flexibilities for buprenorphine treatment: A synthesis of evidence and policy implications for expanding opioid use disorder care in the U.S. medRxiv : the preprint server for health sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10055597/#:~:text=On%20March%2016%2C%202020%2C%20DEA,a%20prior%20in%2Dperson%20visit.&text=On%20March%2031%2C%202020%2C%20DEA,allow%20an%20audio%2Donly%20connection.
  10. The Federal Register. A Rule by the Health and Human Services Department. (n.d.). https://www.federalregister.gov/documents/2024/02/02/2024-01693/medications-for-the-treatment-of-opioid-use-disorder
  11. Huskamp HA, Riedel L, Uscher-Pines L, et al. Initiating Opioid Use Disorder Medication via Telemedicine During COVID-19: Implications for Proposed Reforms to the Ryan Haight Act. J Gen Intern Med. 2022;37(1):162-167. doi:10.1007/s11606-021-07174-w
  12. Hunter SB, Dopp AR, Ober AJ, Uscher-Pines L. Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study. J Subst Abuse Treat. 2021;124:108288. doi:10.1016/j.jsat.2021.108288
  13. Methadone take-home flexibilities extension guidance. SAMHSA. (n.d.). https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines/methadone-guidance
  14. Uscher-Pines L, Sousa J, Raja P, Mehrotra A, Barnett M, Huskamp HA. Treatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine. J Subst Abuse Treat. 2020;118:108124. doi:10.1016/j.jsat.2020.108124
  15. S. Department of Health and Human Services. (2023, October 18). Telehealth supports retention in treatment for opioid use disorder. National Institutes of Health. https://www.nih.gov/news-events/news-releases/telehealth-supports-retention-treatment-opioid-use-disorder
  16. Hammerslag LR, Mack A, Chandler RK, et al. Telemedicine Buprenorphine Initiation and Retention in Opioid Use Disorder Treatment for Medicaid Enrollees. JAMA Netw Open. 2023;6(10):e2336914. Published 2023 Oct 2. doi:10.1001/jamanetworkopen.2023.36914
  17. Yang YT, Weintraub E, Haffajee RL. Telemedicine’s Role in Addressing the Opioid Epidemic. Mayo Clin Proc. 2018;93(9):1177-1180. doi:10.1016/j.mayocp.2018.07.001
  18. Statutes, regulations, and Guidelines. SAMHSA. (n.d.-b). https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines
  19. Comprehensive Drug Testing Solutions. Aegis Sciences Corporation. (2024, June 6). https://aegislabs.com/
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