Saved by the bell: Permanent rules protect telehealth treatment for opioid use disorder
Key Takeaways
Emerging evidence supports the efficacy of using telehealth to treat opioid-use disorder (OUD) with controlled substances.
The DEA has recently proposed permanent rules to cover the practice.
Flexible accommodations for the continued coverage of telehealth to treat OUD were enacted by Medicare and Medicaid, including compensation for the intervention at the same rates as in-person treatment.
During the pandemic, the Centers for Medicare & Medicaid Services (CMS) covered the treatment of opioid-use disorder (OUD) via telehealth at the same rates as in-person services. Experts supported this move, and emerging research suggested its efficacy. This coverage permitted patients to be served while at home and without potential exposure to COVID-19, according to a DEA press release.[]
Treating OUD with telehealth
With the public health emergency (PHE) instituted by the Trump administration in 2020 winding down, many worried that the end of the PHE exception of the Ryan Haight Act would reintroduce previous restrictions to the telehealth prescribing of controlled substances—a move that could interfere with patient access to medications, according to the authors of a review in Current Psychiatry Reports.[] In welcome news, however, both the DEA and CMS are making allowances to the treatment of OUD with telehealth.
What’s new with the DEA?
On February 24, 2023, the DEA published a press release with permanent rules that cover the prescribing of controlled agents by telemedicine, thus expanding access to “critical therapies” beyond the COVID-19 PHE.
The rule would protect telemedicine consultation by a medical practitioner who has never seen the patient in person in the context of the prescription for a controlled substance.
In these cases, physicians can prescribe a 30-day supply of schedule III-V non-narcotic controlled medications, as well as a 30-day supply of buprenorphine, according to the DEA.
In the press release, DEA Administrator Anne Milgram stated that the “DEA is committed to ensuring that all Americans can access needed medications."
"The permanent expansion of telemedicine flexibilities would continue greater access to care for patients across the country, while ensuring the safety of patients."
— Anne Milgram, DEA administrator
"DEA is committed to the expansion of telemedicine with guardrails that prevent the online overprescribing of controlled medications that can cause harm,” Milgram added.
What’s new with CMS?
CMS covered telehealth-based OUD treatment at the exact rates as in-person service during the pandemic. In a bid to continue to maintain broader access, CMS has issued certain flexibilities, which are summarized by the Pew Charitable Trusts, which supports the move.[]
CMS will cover audio or visual visits for OUD treatment for patients at their homes, as well as other locations. Previously, patients had to visit designated facilities for telehealth coverage.
Here is what else CMS has planned:
Audio-only options for those who lack internet will be covered at the same rate as in-person visits.
Medicare will continue to permit opioid treatment programs (OTPs) to use telehealth to initiate buprenorphine treatment. The agency plans to permanently cover this and related services (such as physical exams) as long as the Substance Abuse and Mental Health Services Administration finalizes rules to permanently permit OTPs to start buprenorphine via telehealth.
CMS will remunerate federally qualified health centers and rural health clinics that employ telehealth to diagnose and treat patients with OUD and other disorders at the same level as in-person care.
It should be noted that after December 31, 2024, or the end of the PHE, those patients already receiving telehealth-based mental healthcare will need to see their HCP in person at least every 12 months to sustain their coverage. On the other hand, new patients will need to see their HCPs in person within 6 months of starting treatment and at least once every 12 months thereafter.
After asking CMS whether buprenorphine was covered, Pew claimed that “although the agency did not explicitly reference the medication in this section of the rule, it still implicitly covers the drug by noting that it will pay for telehealth-based care for OUD.”
Telehealth proves promising
Although more publications are addressing the effects of telehealth treatment in terms of OUD, long-term data are lacking. Nevertheless, extant research is favorable regarding the potential benefits of this intervention, as noted by the authors of the review in Current Psychiatry Reports.
"Findings indicate favorable outcomes such as improvements in retention and abstinence rates, positive experiences, and improved feasibility with the relaxation of regulatory measures."
— Authors, Current Psychiatry Reports
"With increased adoption, clinician and patient perceptions appeared largely positive. Negative findings, albeit minor, were primarily associated with workflow adaptation difficulties and limited access of underserved populations to technology and internet connection,” they added.
“Additional financial, logistical, outreach, and training support for clinicians, patients, and support staff is recommended, in addition to permanent evidence-based regulatory reforms, to scale and optimize tele-MOUD [medication-assisted treatment for opioid use disorder] services. Comprehensive recommendations to overcome limitations are expanded therein,” the authors concluded.
Findings from a retrospective study published in Heroin Addiction and Related Clinical Problems also supported the efficacy of telehealth treatment of OUD with buprenorphine and naltrexone.[]
In the retrospective study involving 472 patients treated in collaboration between an urban academic medical center and rural drug treatment center between August 2015 and April 2019, the US investigators found an approximately 50% engagement at 3 months, which is on par with non-telemedicine treatment models.
“Our findings and clinical experience confirm the viability and sustainability of delivering buprenorphine via telemedicine to patients enrolled in a rural drug treatment program,” the study authors wrote. "It is essential that other models and settings for SUD [substance-use disorder] treatment via telemedicine be evaluated and disseminated."
What this means for you
Proponents for the treatment of OUD by means of telehealth cite recent evidence supporting its efficacy and are encouraged by policy changes to support the practice. Looking forward, however, these stakeholders would like to see further entrenchment of the practice and continued research into its efficacy. HCPs who treat OUD via telehealth should take note that they can continue to provide such life-saving services at the same rates of compensation, per CMS and the DEA.