Rethinking Telehealth's Role in Treating Addiction
November 18, 2021
COVID-19 has simultaneously made the opioid crisis much worse and given providers a new tool to fight it — telehealth. Now policymakers must decide whether to keep telehealth around going forward.
Listen to the full episode below, read the transcript, or scroll down for more information.
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Changing Telehealth Policies
Like most providers, those treating opioid addiction rarely used telehealth prior to the pandemic. Barriers included a lack of reimbursement by insurers and strict prescribing laws that required in-person visits to initiate the kinds of medications proven to treat addiction, like buprenorphine.
But temporary changes to regulations sent the proportion of treatment visits happening remotely skyrocketing — from less than 1% in March 2020 to nearly one-third by the end of May 2020.
Now, states and the federal government are deciding whether to keep those looser rules in place or go back to pre-pandemic restrictions.
Federal
Pre-Pandemic
- The federal Ryan Haight Act generally required providers to see a patient in person before they could start prescribing them controlled substances like buprenorphine, a common medication for managing opioid use disorder. (Once started in-person, providers could treat patients remotely.)
- Medicare would only reimburse remote addiction care if the patient was in certain “originating sites” — usually a rural area or another health care facility.
- The 2018 SUPPORT Act began the process of removing some of Medicare’s so-called originating site restrictions for opioid use disorder treatments and instructed the Drug Enforcement Administration (DEA) to make it easier to prescribe buprenorphine remotely. Neither process had been fully implemented when the pandemic hit.
Pandemic
- In March 2020, the DEA began temporarily allowing providers to start new and existing patients on buprenorphine over the phone (known as “audio-only”) and without seeing them in-person.
- Medicare removed all originating site restrictions, which allowed patients to receive telehealth from their homes in any part of the country. It also began reimbursing for visits conducted over the phone (in addition to video visits).
Going Forward
- The DEA has not said whether it will make any permanent changes to rules around prescribing controlled substances like buprenorphine.
- Bipartisan legislation has been introduced in Congress that would permanently allow for virtual prescribing of opioid treatment medications including buprenorphine and Medicare reimbursement for audio-only telehealth services.
- Medicare announced in November 2021 that it will permanently reimburse for tele-behavioral health (including substance use treatment) from a patient’s home and via telephone.
States
Pre-Pandemic
- All states had to abide by the restrictions of the Ryan Haight Act (see above).
- Some states had more restrictive laws or medical board regulations preventing ongoing remote prescribing and/or other treatment services, like counseling.
- Most states required commercial insurers and Medicaid to cover telehealth services, but far fewer required equal reimbursement rates for telehealth and in-person care, and only three required audio-only coverage.
Pandemic
- Many states began allowing remote prescribing of buprenorphine, eased other in-person addiction treatment requirements and expanded telehealth reimbursement by commercial insurers and state Medicaid programs.
Going Forward
- Some states (including South Carolina, Florida and Iowa) have reimposed pre-pandemic restrictions on remote prescribing.
- Other states (including Delaware and Indiana) have passed new laws allowing providers to prescribe addiction medications remotely.
- Many states continue to operate under temporary pandemic flexibilities. Some, like Ohio, are actively debating new rules around remote prescribing and care.
- Several state Medicaid programs have permanently expanded various aspects of their telehealth coverage.
The Evidence on Telehealth and Addiction Treatment
Given the limited amount of virtual addiction treatment before the pandemic, there was also little research on the topic. But the studies that did exist suggested that patients could receive equivalent care via telehealth.
Many providers report having mixed opinions about telehealth, according to a fall 2020 survey. Seventy percent said they wanted to return to mostly in-person visits. At the same time, 62.5% said they could offer equivalent care via telehealth, and 95% wanted to be able to offer telehealth in some form going forward.
As policymakers weigh whether to make pandemic telehealth expansions permanent, researchers have rushed to provide evidence that can answer key questions about the quality of virtual care. Experts say more studies are needed, but that telehealth should stay in place while those data are collected.
“To date, the evidence we have is more promising than concerning,” said Allison Lin, an addiction psychiatrist at the University of Michigan and research scientist at the VA Ann Arbor Healthcare System.
How well did telehealth work to keep people in treatment?
Pretty well.
Anecdotally, several providers told us the flexibility of telehealth made it easier for patients to stick with treatment by minimizing traditional barriers like work, childcare and transportation.
Did telehealth make it easier for new patients to access treatment?
Too soon to tell.
Is telehealth addiction treatment as good as in-person?
It probably depends.
Many providers find such tests important for treatment and a reason to do more in-person. Most agree telehealth will work better for some patients than others based on their location, addiction severity, stage of treatment, and ability to access and comfort with technology.
Is telehealth to blame for the sharp increase in overdose deaths during the pandemic?
It's very unlikely.
"We were never expecting that telehealth was going to somehow dramatically overturn an overdose epidemic," said Allison Lin. "The fact that we didn't see everyone just discontinue care and overdose rates even further skyrocket" should not be taken for granted, she said.
This episode is part of a series on improving care for people with complex health and social care needs supported by the Better Care Playbook, an online resource for evidence-based practices and promising approaches to improve care for people with complex health and social needs.
The Better Care Playbook is coordinated by the Center for Health Care Strategies and made possible by Arnold Ventures, The Commonwealth Fund, The John A. Hartford Foundation, the Milbank Memorial Fund, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation and The SCAN Foundation.
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Episode Resources
Additional Research, Reporting and Resources on Telehealth and Addiction Treatment:
Telehealth Policy Finder (Center for Connected Health Policy)
Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond (Seema Choksy Pessar, Anne Boustead, Yimin Ge, Rosanna Smart and Rosalie Liccardo Pacula; JAMA Health Forum; 11/19/2021)
Telehealth in Complex Care (Better Care Playbook, 11/18/2021)
Telehealth and SUD: Lessons From the Pandemic (Jared Augenstein, Zoe Barnard and Allison Lin; Manatt Health; 11/9/2021)
Drug overdoses surged during the pandemic. Providers are thinking outside the box to combat the opioid crisis (Anastassia Gliadkovskaya, Fierce Healthcare, 10/20/2021)
Addiction Treatment and Telehealth: Review of Efficacy and Provider Insights During the COVID-19 Pandemic (Tami Mark et al, Psychiatric Services, 10/13/2021)
Telehealth for Opioid Use Disorder Toolkit: Guidance to Support High-Quality Care (Allison Lin and Christopher Frank, Providers Clinical Support System, 10/12/2021)
Patients’ perceptions of telehealth services for outpatient treatment of substance use disorders during the COVID-19 pandemic (Dawn Sugarman et al, American Journal of Addictions, 8/17/2021)
Telehealth and Health Centers During COVID-19 (National Association of Community Health Centers, July 2021)
Treatment of Opioid Use Disorder Among Commercially Insured Patients in the Context of the COVID-19 Pandemic (Haiden Huskamp et al, JAMA, 12/15/2020)
Telemedicine-delivered treatment interventions for substance use disorders: A systematic review (Allison Lin et al, Journal of Substance Abuse Treatment, 3/21/2019)
Facing mounting opioid overdoses, Maryland doctor defies federal law (David Pittman, POLITICO, 11/15/2017)
Episode Credits
Guests:
Allie Grant, patient
Sarah Channell, MSN, APRN, CNP; Clinical Director of Addiction Services; Lower Lights Christian Health Center
Allison Lin, MD, Assistant Professor of Psychiatry, University of Michigan Addiction Center; Research Scientist, VA Ann Arbor Healthcare System
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.
This episode was reported by Ryan Levi and mixed by Andrew Parrella.
Special thanks to:
Ateev Mehrotra and Kelly Carey
Additional thanks to:
Leslie Suen, Jodi Manz, Eliza Mette, Richard Harris, Jill Hartman, Ahmed Turjoman, Mei Kwong, Christine Calouro, Joe Knickrehm, Monica Hueckel, Dana Vallangeon, Ryan Marino, Rob McMorrow, Shawn Ryan, Brian Clear, Blessing Igboeli, Michael Lynch, Chris Frank, Trent Hall, Jared Augenstein, Lauren Dunning, Eric Weintraub, Terry Keenan, Zia Agha, Lori Uscher-Pines, the Tradeoffs Advisory Board and our stellar staff!