As emergency medicine physicians and substance use disorder researchers, we frequently provide our patients with a drug called buprenorphine, or Suboxone, an FDA-approved medication used to treat opioid use disorder. Although it is extremely effective at saving lives, it is notoriously difficult for patients to get a prescription.
However, since April 2020 under rules adopted during the pandemic, clinicians like us have been able to provide buprenorphine treatment over the phone to people struggling with opioid use disorder. This policy change has had great results, improving our ability to provide treatment to people who otherwise would not be able to access care.
While poison control centers have been providing telephone-delivered medical advice across the United States for decades, it is not the traditional model of medical care delivery. Traditional telehealth, which includes a two-way audio-visual platform, exponentially expanded during the pandemic. But for our patients with opioid use disorder, this mode of communication would have been a significant barrier added on top of the ones they already face, including a limited number of providers, few appointments, no transportation and limited or no Internet access.
On a recent call, a patient looking for help simply explained, “I don’t want to die.” His fear and loss echoed but were swept away by a sigh of relief when he heard that yes, we could help him and we could help him that day, during that telephone call.
Drug overdose deaths have surged during the Covid-19 pandemic, with provisional CDC data predicting over 88,000 overdose deaths from September 2019 through August 2020, a 27 percent increase from the prior 12-month period. While medications for opioid use disorder — like methadone and buprenorphine — cut mortality in half, they are difficult to access, especially for people of color, individuals with public insurance and those living in rural areas. Approximately 40 percent of counties do not have a buprenorphine prescriber and Black patients are significantly less likely to have access than white patients.
Like the many other converging crises in 2020, the exacerbation of the opioid crisis by the Covid-19 pandemic highlighted years of policy failures. However, and perhaps uniquely so, it also presents an important opportunity to create lasting change.
To prevent widening gaps in treatment access during the first wave of Covid-19, the federal government took unprecedented and swift action in March 2020 that allowed for technologies like FaceTime and Skype to serve patients via telemedicine in good faith. Subsequently, the DEA exercised its enforcement discretion to permit buprenorphine initiation following telephone communication without requiring video technology — as had previously been the case.
While these changes were made in response to a new public health emergency, the need to expand telehealth initiation of buprenorphine was long overdue. Telehealth had already been proven effective for managing patients who had already started buprenorphine treatment after an in-person visit.
In December of last year, the Comprehensive Addiction and Recovery Act 2.0, which proposes much-needed policy reforms and funding mechanisms to address the ongoing opioid crisis, was introduced in the Senate. Among the changes are a proposed permanent expansion to permit buprenorphine treatment after an initial telehealth consultation. While the bipartisan legislation will help expand use of telehealth for buprenorphine, it mandates that the consultation occur using a video platform, a requirement that threatens to exclude people without the needed equipment or broadband access.
Simply put, the requirement to be on video is a significant barrier to care.
Due to structural racial and economic inequities, inadequate broadband and internet infrastructure, low digital literacy and health system barriers, audiovisual telehealth is not widely accessible. Nearly 21.3 million Americans — 6.5 percent of the population — live in “digital deserts.” This is a problem that affects low-income urban residents as well as many parts of rural America: Almost half of low-income Americans and a third of rural Americans don’t have home broadband access. Many others are unstably housed and lack access to permanent phones. Recent data on telehealth use during the Covid-19 pandemic suggests alarming disparities in accessing care via telemedicine overall and suggests lower video use specifically among patients who are older, Black, Latinx and/or lower income. Limiting buprenorphine access to audiovisual telehealth platforms will exacerbate existing inequities.
It would be fairly simple to amend the legislation to allow audio-only telehealth visits, which would address many of these gaps. While some may fear that this change creates the risk of patients not following up for future appointments, our experience has shown us the opposite. The short-term emergency authorizations for audio-only buprenorphine treatment during Covid-19 have helped us reach people previously unable to access treatment, missed appointments have declined and many have remained engaged in treatment.
It only makes sense to make these changes permanent. While this policy could also be made through regulatory changes by the DEA and the Substance Abuse and Mental Health Services Administration, legislative action by Congress is necessary to ensure the treatment expansion is permanent.
Expanding access to buprenorphine will save the lives of the patients who struggle most to be connected to treatment. To address the opioid crisis and social inequities, we must remove outdated legal and administrative barriers to ensure treatment is equitably accessible to everyone.
The opinions expressed in this article do not represent those of the University of Pennsylvania Health System, the Perelman School of Medicine or Brown Emergency Medicine.