Impact of COVID-19 Telehealth Policy Changes on Access to Medication Treatment for Patients with Opioid Use Disorder

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University of Michigan studies suggest that telehealth has played a major role in maintaining and increasing access to buprenorphine treatment for individuals with opioid use disorder during the COVID-19 pandemic.

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Telehealth may be an important tool for improving access to buprenorphine, particularly among underrepresented patient populations

Impact of COVID-19 Telehealth Policy Changes on Access to Medication Treatment for Patients with Opioid Use Disorder

Annual opioid overdose deaths rose to a record high of more than 56,500 Americans in 2020.1 During the same year, health care delivery underwent an unprecedented shift to telehealth due to the COVID-19 pandemic. Recognizing the need to sustain addiction care for people with opioid use disorder, state and federal agencies implemented policy changes to decrease barriers to telehealth delivery of buprenorphine care, including allowing telephone (audio-only) visits for buprenorphine treatment for the first time.2

Buprenorphine is a medication prescribed in clinics as a treatment for opioid use disorder, and studies have shown that it is highly effective and can save lives.3 However, only a minority of patients currently receive this important treatment, and rates are even lower for some populations, including Black patients, patients in rural areas, and those with complex health conditions.4–8

Increasing buprenorphine treatment is a primary goal of national efforts to address the opioid overdose epidemic.9–10 By reducing leading barriers to care such as a lack of transportation and missing work, telehealth may be an important tool for improving access to buprenorphine, particularly among underrepresented patient populations.

A University of Michigan team studied how pandemic-related policy changes in March 2020 affected buprenorphine treatment across audio-only, video, and in-person visit types, comparing trends from one year before through one year after the start of the pandemic.11 In a separate study, the team compared patient characteristics and treatment retention across phone, video, and in-person visit types.12

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Takeaways from our research

The University of Michigan studies are based on data from Veterans nationwide treated with buprenorphine for opioid use disorder through the Veterans Health Administration, the largest addiction care provider in the U.S. The research team compared trends in the use of telehealth (audio-only and video) versus in-person only visits from March 2019 through February 2021 and assessed how long patients stayed engaged in treatment. 11–12

Increase in Buprenorphine Treatment During the Pandemic

Increase in Buprenorphine Treatment During the Pandemic
The overall number of patients receiving buprenorphine treatment for opioid use disorder increased during the study period.

  • The number of patients receiving treatment increased by 14.3% (from 13,415 patients in March 2019 to 15,339 patients in February 2021).
  • Unlike many other health care services, the number of patients continued to increase even after the start of the pandemic, at a rate of 47 patients per month.
Who Stayed Engaged in Treatment?

Who Stayed Engaged in Treatment?
Patients who had at least one telehealth visit were more likely to remain engaged in treatment for at least 90 days, compared to in-person treatment. Staying in treatment is key to reducing risk for relapse and overdose.

Which Patients Used In-Person Versus Telehealth Visits?

Which Patients Used In-Person Versus Telehealth Visits?
In the year following the start of the pandemic, patients were more likely to have in-person visits rather than telehealth visits if they were younger (18–29 years old), male, Black, or Hispanic, or if they had other health conditions.

Meanwhile, among those who had at least one telehealth visit, those who were older (45–65+ years old), male, Black, or had housing instability were more likely to have only audio-only visits rather than video visits.

 

Delivery of Care Shifted to Telehealth

Delivery of Care Shifted to Telehealth

Telehealth visits for buprenorphine treatment increased significantly following the start of the pandemic in March 2020, with audio-only visits playing an important role in access.

  • 12% of visits for buprenorphine treatment were provided via telehealth in March 2019, versus 83% of visits in February 2021.
  • Importantly, audio-only visits far outpaced both video visits and in-person visits following the start of the pandemic. By February 2021, audio-only visits still accounted for 50% of visits, with video visits at 32% and in-person care at 17%.
Number of buprenorphine visits each month between March 2019–February 2021 in the Veterans Health Administration nationally, by visit type

Number of buprenorphine visits each month between March 2019–February 2021 in the Veterans Health Administration nationally, by visit type

What are the implications for policy and practice?

What are the implications for policy and practice?

The findings from the University of Michigan team suggest that telehealth has played a major role in maintaining and increasing access to buprenorphine treatment for individuals with opioid use disorder during the COVID-19 pandemic. In contrast to decreases in the use of other health care services in the early months of the pandemic, the researchers found that treatment for opioid use disorder increased for this vulnerable patient population. Furthermore, the rapid switch to virtual visits may have kept people from dropping out of care and allowed others to initiate care.

The option to use telehealth may also give providers the flexibility to provide services in a way that best meets their patients’ diverse needs. For example, audio-only visits appear to have played a key role in care and may provide flexibility to make it easier to keep people engaged in care over time, especially since people with opioid use disorder often lack high-speed internet, access to a computer, or stable housing.

Importantly, disparities in care for opioid use disorder existed prior to COVID-19, with underrepresented groups including Black people and homeless populations being less likely to receive care.4–8 The findings from the new University of Michigan studies suggest that flexibility around audio-only and video telehealth policies benefited these populations. Reversing telehealth policies and reestablishing barriers to telehealth, particularly for audio-only visits, may have negative, unintended effects on patient care and could exacerbate existing disparities. The risk for overdose increases dramatically when patients stop taking buprenorphine; thus, disruptions in access to care directly impact patient outcomes.

Additional research is needed to better understand patient and clinician experiences and preferences, and to further evaluate the quality of telehealth-delivered care and long-term patient outcomes of telehealth care for opioid use disorder.

References

  1. Overdose Death Rates. National Institute on Drug Abuse. Accessed July 21, 2022. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates.
  2. Telehealth for Substance-Using Populations in the Age of Coronavirus Disease 2019: Recommendations to Enhance Adoption. Lin LA, Fernandez AC, Bonar EE. JAMA Psychiatry. 2020 Dec 1;77(12):1209-1210. PMID: 32609317. doi:10.1001/jamapsychiatry.2020.1698.
  3. Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. Santo T, Clark B, Hickman M, et al. JAMA Psychiatry. 2021 Sep 1;78(9):979-993. PMID: 34076676. doi:10.1001/jamapsychiatry.2021.0976.
  4. Injectable Naltrexone, Oral Naltrexone, and Buprenorphine Utilization and Discontinuation Among Individuals Treated for Opioid Use Disorder in a United States Commercially Insured Population. Morgan JR, Schackman BR, Leff JA, et al. J Subst Abuse Treat. 2018 Feb;85:90-96. PMID: 28733097. doi:10.1016/j.jstat.2017.07.001.
  5. Use of Opioid Agonist Therapy for Medicare Patients in 2013. Lembke A, Chen JH. JAMA Psychiatry. 2016;73(9):990–992. doi:10.1001/jamapsychiatry.2016.1390.
  6. Changes in Substance Abuse Treatment Use Among Individuals With Opioid Use Disorders in the United States, 2004–2013. Saloner B, Karthikeyan S. JAMA. 2015 Oct 13;314(14):1515–1517. doi:10.1001/jama.2015.10345.
  7. Growing Racial/Ethnic Disparities in Buprenorphine Distribution in the United States, 2007–2017. Schuler MS, Dick AW, Stein BD. Drug Alcohol Depend. 2021 Jun 1;223:108710. PMID: 33873027. doi:10.1016/j.drugalcdep.2021.108710.
  8. Polysubstance Use and Association with Opioid Use Disorder Treatment in the US Veterans Health Administration. Lin LA, Bohnert ASB, Blow FC, et al. Addiction. 2021 Jan;116(1):96–104. doi:10.1111/add.15116.
  9. The Helping to End Addiction Long-term (HEAL) Initiative of the National Institutes of Health. Baker RG, Koroshetz WJ, Volkow ND. JAMA. 2021 Sep 21;326(11):1005–1006. PMID: 34436519. doi:10.1001/jama.2021.13300.
  10. State Targeted Response to the Opioid Crisis Grants Program: Preliminary Findings from Two Case Studies and the National Cross-Site Evaluation. High PM, Marks K, Robbins V, et al. Journal of Substance Abuse Treatment. 2020 Jan;108:48–54. doi:10.1016/j.jsat.2019.06.008.
  11. Impact of COVID-19 Telehealth Policy Changes on Buprenorphine Treatment for Opioid Use Disorder. Lin LA, Zhang L, Kim HM, et al. American Journal of Psychiatry. 2022 Jul 28. doi:10.1176/appi/ajp.21111141.
  12. Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic. Frost MC, Zhang L, Kim HM, et al. JAMA Netw Open. 2022;5(10):e2236298. PMID: 36223118. doi:10.1001/jamanetworkopen.2022.36298.

Additional Published Research

  • Defining and supporting high-quality telehealth for patients with opioid use disorder: the promise and potential pitfalls of telehealth expansion. Frank CJ, Lin LA. Subst Abus. 2022;43(1):1370–1373. PMID: 36222798. doi:10.1080/08897077.2022.2127140.
  • Comparing Telemedicine to In-Person Buprenorphine Treatment in US Veterans with Opioid Use Disorder. Lin LA, Fortney J, Bohnert ASB, et al. J Subst Abuse Treat. 2022 Feb;133:108492. PMID: 34175175. doi:10.1016/j.jstat.2021.108492.
  • Telehealth for Opioid Use Disorder Toolkit: Guidance to Support High-Quality Care. Lin LA, Frank CJ. Providers Clinical Support System. 2021 Oct 12. https://pcssnow.org/wp-content/uploads/2021/10/OUD-Toolkit_FINAL_10.2021.pdf.
  • Telemedicine-Delivered Treatment Interventions for Substance Use Disorders: A Systematic Review. Lin LA, Casteel D, Shigekawa E, et al. J Subst Abuse Treat. 2019 Jun;101:38-49. PMID: 31006553. doi:10.1016/j/jsat.2019/03.007.

Authors

Lewei (Allison) Lin MD, MS,1,2,3 Lan Zhang, PhD,1,2 Hyungjin Myra Kim, ScD,1,3,4 Madeline C. Frost, PhD, MPH 5,6

Affiliations: 1 VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2 Department of Psychiatry, University of Michigan, 3 Institute for Healthcare Policy and Innovation, University of Michigan, 4 Center for Statistical Consultation and Research, University of Michigan, 5 Department of Health Systems and Population Health, University of Washington School of Public Health, 6 Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System

For more information: Please contact Eileen Kostanecki, IHPI’s Director of Policy Engagement & External Relations, at [email protected].

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