Telemedicine for Treatment of Opioid Use Disorder

Harvard Medical School, Boston MA

Investigators

Linked publications & trials

Abstract

A key challenge in combating the opioid epidemic has been connecting individuals with opioid use disorder (OUD) to evidence-based treatments. Telemedicine for opioid use disorder (“tele- OUD”) may be part of the solution. Use of tele-OUD grew rapidly during the pandemic and, in the first four years of this R01, we have made substantial progress in understanding its role in OUD treatment. To date, we have published 24 studies that examine a range of issues related to tele-OUD. These studies describe the growth of tele-OUD, examine the impact of the policy environment on tele-OUD use, and assess the quality of tele-OUD. However, key gaps in knowledge on the use of tele-OUD remain. We are proposing a renewal of our grant that uses data from Medicare, Medicaid, and commercial insurance, plus national pharmacy claims. Our Aims are to: 1) characterize clinicians who are using a fully-virtual model to treat OUD and compare clinical outcomes between virtual-only clinicians and other clinicians; 2) assess the role and quality impact of audio-only telemedicine for OUD treatment; and 3) identify trends in the number of pharmacies that dispense buprenorphine and assess the impact of pharmacy dispensing decisions on patient outcomes. The results from this project will inform provider use of tele-OUD as well as ongoing policy debates at the federal and state levels and among private health plans on payment and regulation of tele-OUD and its role in improving access and quality of care for individuals with OUD. Specific Aims Opioid overdose deaths have quadrupled since 1999, with 218 Americans dying each day,1 and death rates tragically accelerated during the pandemic.2, 3 A key challenge in combating this epidemic has been connecting individuals with opioid use disorder (OUD) to evidence-based treatments, including medications for OUD (MOUD), such as buprenorphine, methadone, and naltrexone.4, 5 Of the 2.4 million adults in the U.S. with OUD, just one in four (24.4%) receives treatment.6 While many factors play a role in this treatment gap,7 the shortage of substance use disorder (SUD) clinicians, particularly in rural areas, remains a critical barrier.8-16 Telemedicine may be a key part of the solution. When we started this R01, there was both relatively little use of telemedicine for OUD treatment (tele-OUD) and little research on tele-OUD’s impact on care. During the R01’s first 4 years, we have had 24 publications that have advanced understanding of how the pandemic-related surge of tele-OUD has impacted care, highlighting for which patients clinicians feel tele-OUD is most suitable, describing the challenges experienced by clinicians in providing tele-OUD, and estimating the clinical impact of tele-OUD on quality. Our findings have informed the debate on federal, state, and private payer policy (e.g., the Drug Enforcement Administration (DEA)’s recent proposals on tele-OUD treatment).17-22 Several issues will drive the future of tele-OUD. First, the emergence of virtual-only models for OUD (including several for-profit companies) has triggered a debate about virtual-only care. There is the hope that these models expand access and reach patients in communities that lack local SUD clinicians, but there is also a concern that virtual-only models may be less effective in maintaining patients on treatment. Second, we and others have highlighted differences in video visit use across groups, including by rural/urban status.23-25 To address these differences, many policy makers and clinicians have advocated for reimbursement of audio-only (telephone) encounters. Yet others are concerned that audio-only visits will lead to inferior care. These different perspectives are reflected in new policies for audio-only visits. Some states now mandate coverage of audio-only visits,26, 27 while others cover them only in limited circumstances or not at all. In recently proposed rules, the DEA discouraged the use of audio-only visits for prescribing controlled substances.17 These debates often neglect that audio-only visits are rarely used in isolation but rather as just one component in a pattern of care (e.g., in-person visits followed by an audio-only visit followed by a video visit). Third, an important barrier to the use of tele-OUD is the unwillingness of some pharmacies to fill buprenorphine prescriptions in general and when prescribed via telemedicine in particular.28-34 This barrier has worsened during the pandemic, as several large pharmacy chains have recently changed their policies. The impact of these pharmacy policies has never been quantified. In this renewal application, we propose to utilize an array of data sources (Medicare, Medicaid, commercial insurance, national prescription data) that encompass over half of the U.S. adult population to inform these issues. Our Specific Aims are to: Aim 1: Characterize virtual-only tele-OUD care and assess its impact on quality. We will describe the characteristics of virtual-only clinicians (i.e., prescribing clinicians who only use telemedicine for OUD care). Then, we will compare patient populations and clinical outcomes of people started on MOUD via virtual-only clinicians vs. hybrid clinicians (use both in-person and telemedicine visits) or in-person-only clinicians. Aim 2:  Assess the role and quality impact of audio-only telemedicine for OUD treatment. We will track over time the use of audio-only visits (vs. other modalities in care), characterize OUD care patterns with respect to modality of care (e.g., in person, audio-only, video), determine whether rural (vs. urban) residents receive particular patterns of care, and compare clinical outcomes of patients with the different patterns of audio-only, video, and in-person care. Aim 3: Assess trends in the number of pharmacies that dispense buprenorphine and evaluate the impact of pharmacy dispensing decisions on outcomes. We will describe which patients are affected by changes in pharmacy dispensing of buprenorphine, quantify the clinical impact on buprenorphine users when their pharmacy stops filling all prescriptions (or tele-OUD prescriptions specifically) for the drug, and examine how these pharmacy policies impact buprenorphine use in the surrounding community. Despite enthusiasm for and tremendous growth of tele-OUD, there remains uncertainty about its use in the future, and many gaps persist in our knowledge about its impact on quality of care. This renewal will allow us to continue to inform how tele-OUD is used, clinical guidelines on the use of tele-OUD, and ongoing debates about regulations and reimbursement of tele-OUD at both the federal and state levels.