- The Substance Abuse and Mental Health Services Administration (SAMHSA) has announced proposed changes that would increase the availability of telehealth and at-home treatment for those who are part of opioid treatment programs.
- Experts say that these changes, while valuable, are part of a larger shift that is needed as the country struggles under the weight of an overdose epidemic.
- Telehealth, while improving health outcomes for some, also brings forward questions about its availability, particularly in rural and marginalized communities.
The Biden administration has put forward changes to nationwide regulations that would widen the availability of certain treatments for opioid use disorder via telehealth, according to a US Department Health and Human Services (HHS) announcement.
The U.S. Centers for Disease Control and Prevention (CDC) puts the number of deaths due to an overdose in 2021 at over 107,000.
Dr. Jonathan Watanabe (PhD, PharmD) of the University of California-Irvine, who served on the White House-sponsored committee on improving access to methadone says that healthcare systems are struggling as cases mount and that this isn’t a new problem. Watanabe said it is vital to ensure more people can access treatment for drug misuse.
“If anything, we need to relax rules from what they were just to meet the past epidemic, we certainly have to get more bold and more flexible in treating patients with opioid use disorder now that it’s gotten worse. And so I think that’s why a lot of these measures that are being described [by the HHS] , they just really have to occur if you want to make a difference.”
New push to make addiction treatment easier to access
Rules around telehealth medical appointments were relaxed during the COVID-19 pandemic in order to allow more patients to get care without having to go into a physician’s office.
An August 2022 study published in JAMA Psychiatry found that people getting treatment for substance misuse benefitted greatly from telehealth appointments. They found that people getting treatment via telehealth were 27% more likely to stay on medication for opioid misuse. They had about a 33% decreased risk of having an overdose during the study period.
The proposed changes from Substance Abuse and Mental Health Services Administration (SAMHSA) include:
- Expanding the definition of an [opioid treatment program] practitioner to include any provider who is appropriately licensed to dispense and/or prescribe approved medications.
- adding evidence-based delivery models of care which would include split dosing, telehealth and harm reduction activities.
- strengthening the patient-practitioner relationship through the promotion of shared and evidence-based decision-making.
- updating criteria for provision of take-home doses of methadone;
The extended supply availability of medications like methadone and buprenorphine, and their availability via telehealth appointments, would formalize guidance published in 2020.
The changes are open for public comment until Feb. 14.
Telehealth can help, but only if people have access
Experts say that the changes around telehealth medical appointments could help many with substance misuse disorder, but that many people may not get access to these programs.
Dr. Katherine Hirchak (PhD, MHPA) of Washington State University, whose research and work is centered on American Indigenous communities, says that healthcare policymakers and providers need to make sure that they’re not prescribing urban solutions to issues facing rural communities, especially when it comes to internet availability.
“[It means] thinking about how to invest in the necessary infrastructure around that to increase internet access, or other ways of being able to receive that care, which I think is really important and needed in rural areas. So, really wanting to make sure that we don’t increase structural racism or other issues around access, and [not] just sort of taking the blueprint of what works in more urban areas and trying to apply it to rural areas.”
Watanabe says that telehealth and an expansion of the treatment options that could be provided by nurses and pharmacists came to the forefront when COVID-19 impacted the ability for patients to participate in opioid treatment programs (OTPs.)
“That was a big challenge with the OTPs in the pandemic. People had to go in every day, so waiting in line with a whole bunch of people, when there’s shelter-in-place order is not very wise in terms of anybody’s safety. So, I think that’s where a lot of these things started to resonate…providing care is actually dangerous when you think of pandemic spread.”
Hurdles for telehealth appiontments
Dr. Joseph Garbely (DO), who teaches at both Drexel and Penn. State, while also sitting on the board of directors of the American Society of Addictions Medicine, says that privacy and legal barriers also lead to concerns as telehealth access is expanded.
“The system that you’re going to be using for telehealth, is it HIPAA and 42 CFR compliant? Because we cannot violate either of those federal laws when it comes to our patients and we really need to make sure that we have the ability to reach patients in a cogent and safe way.”
Garbely is one of a number of experts who spoke to Healthline for this story who believe that the proposed removal of the X waiver (a federal rule that limits who can prescribe buprenorphine) will also expand access for those seeking addiction treatment.
The hope is that this will be done by expanding the number of professionals who can provide much-needed medication more people can access treatment. The removal of the waiver was included in the omnibus spending bill passed at the end of last year.
Stigma and drug treament
One looming barrier remains for addiction treatment: stigma.
Hirchak says that while telehealth expansion is promising when it comes to medications for opioid use disorder it’s imperative to reduce stigma while providing culturally informed care.
“Telehealth has been really helpful in continuing needed care, but it may not address all of the issues around that. And so just continuing to think that through, making sure that we continue to address stigma around [medications for opioid use disorder ] both at the patient-relative level as well as the prescriber provider and community levels [is important].”
In that vein, SAMHSA’s proposed changes include eliminating stigmatizing language such as detoxification. For Watanabe, everyone involved in addictions treatment in the United States needs to work from a place that prioritizes reducing these social barriers.
“We need to embrace de-stigmatization in all circles.”