Telehealth More Important Than You Realize: Lessons From COVID Apply to the Opioid Crisis

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When COVID arrived in the U.S. in March 2020, most of us were completely unprepared.

At the beginning of March that year, we all watched as cities on the West Coast enacted shelter-in-place policies. Around the country, we wondered, is that going to happen here?

Before long, we all knew everything we needed to know about things we had very little experience with:

  • Social distancing
  • Face masks
  • Shelter-in-place orders
  • Essential travel
  • Essential workers
  • COVID pods, i.e., your home group: the people you allowed into your home without masks
  • Virtual school
  • Remote work
  • Zoom

One thing most of us knew about before COVID, however, was telehealth and/or video visits with healthcare providers. The benefits of telehealth/video consultations are obvious. While nothing is better than an in-person visit with a real human, we all recognize that, compared to in-person visits, remote visits can be:

  • More efficient
  • More convenient
  • Less expensive

In addition, telehealth/video consultations increase access to vital care for:

  • People in rural areas
  • People with mobility issues
  • Patients with severe health conditions
  • Immunocompromised patients

Telehealth and video care works for anything that doesn’t require a lab test or a direct physical exam. Patients can access appropriate care for common physical ailments, ask providers general non-emergency questions, refill prescriptions, and participate in therapy or counseling for mental health, substance use, and/or behavioral disorders.

This article will discuss the role of telehealth and video care in one specific area: medication-assisted treatment (MAT) with buprenorphine for people diagnosed with opioid use disorder (OUD). As addiction treatment providers, we witnessed important developments in the use of telehealth in MAT during the pandemic.

Telehealth, Addiction Treatment, and COVID

Now that the pandemic is mostly in our rear-view mirror, we’re all in the process of adjusting to the new normal, and data from the use of telehealth during the pandemic is available to the public, it’s time to review how telehealth – in the context of treatment for substance use disorder – changed during COVID. We’ll focus on medication-assisted treatment (MAT) for individuals diagnosed with opioid use disorder (OUD). We’re in the middle of a crisis of drug overdose, opioid addiction, and opioid-related overdosed fatality. Most of us know this public health emergency as The Opioid Crisis of The Opioid Epidemic.

Here are the figures that clearly illustrate the harm caused by the crisis, as reported by the Centers for Disease Control (CDC):

  • In 2019: 72,151 people died of drug overdose: over 50,000 involved opioids
  • In 2020, 92,478 people died of drug overdose: over 69,000 involved opioids
  • In 2021,107, 521 people died of drug overdose: final opioid fatality data pending

Finally, initial CDC reports for the 12-month period ending in March 2022 showed a total of 110,346 incidents of fatal overdose. If that trend persists through the end of 2022, then we expect to see an increase of around three percent for 2022, compared to 2021. That news is encouraging, in light of the increase of over 35 percent reported between 2020 and 2021.

Now let’s look at another set of data: rates of opioid use disorder (OUD) and treatment for OUD with medication-assisted treatment (MAT).

Treatment for Opioid Use Disorder (OUD): Facts and Figures  

Those overdose figures give the next set of data we share – from the 2020 National Survey on Drug Use and Health (2020 NSDUH) – additional relevance, and increase our motivation to continue the important work we do in the communities we serve. This data is on treatment. As we mention above this data refers specifically to medication-assisted treatment (MAT) for opioid use disorder (OUD).

Published by the National Institutes of Health (NIH), the 2020 NSDUH report shows that:

  • 2.7 million people met the clinical criteria for opioid use disorder (OUD)
    • That’s around 1% of adults 18+ in the U.S.
  • Among individuals diagnosed with OUD, around 275,000 received medication-assisted treatment (MAT)
    • That’s 11%

What these figures tell us is that almost 9 out of every 10 people – 89 percent – diagnosed with OUD did not get the best available treatment for OUD: medication-assisted treatment, or MAT. In the substance use disorder (SUD) treatment community, we have a name for the difference between the number of people who need treatment and the number of people who get the treatment they need. It’s called the treatment gap. The statistics tell us the treatment gap for OUD – particularly with regards to MAT for OUD – is too large. When we consider the fact that effective treatment is available, a gap of this size is unacceptable.

Before we discuss the main topic of this article – the impact of telehealth on MAT for OUD – we need to offer a brief primer on MAT.

Medication-Assisted Treatment: The Most Effective Available Treatment OUD

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines MAT as:

“The use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders.”

There are three medications for opioid use disorder (MOUD) approved by the Food and Drug Administration (FDA) for MAT: buprenorphine, methadone, and naltrexone. Research shows that treatment with MOUD for people with OUD can:

  • Mitigate discomfort associated withdrawal symptoms
  • Decrease cravings for opioids during withdrawal and recovery
  • Block the action of opioids in the brain

Research also shows the overall benefits of MAT for people with OUD include:

  • Reduced risk of overdose
  • Reduced overall mortality
  • Improved treatment retention, a.k.a. time-in-treatment
  • Decreased illicit drug use
  • Decreased criminal activity/involvement with criminal justice system
  • Improvements in employment
  • Improvements in relationships with family and peers

Those benefits explain why MAT is known as the gold-standard treatment for people with OUD. When people with OUD engage – and stay engaged – in MAT programs, virtually everything improves. The most important metric, however, is the fact that MAT reduces risk of overdose and death by overdose: this approach to treatment saves lives.

When COVID arrived, many SUD treatment providers worried that public health measures such as shelter-in-place orders and social distancing would have a negative impact on people in MAT programs, particularly those initiating treatment for OUD. Before COVID, federal regulations required the initiation of any MAT program – whether methadone, buprenorphine, or naltrexone – to occur in-person only. In addition, other rules required in-person counseling, therapy, and medication management.

Thankfully, however, federal authorities heard and understood the warnings issued by treatment providers, and eased restrictions around MAT for OUD. The new COVID policies significantly expanded access to care by changing rules around the use of telehealth.

Let’s take a look at those changes now.

Changes to Telehealth and MAT During COVID-19

During the pandemic, federal authorities eased restrictions around MAT. We’ll focus on the changes directly related to telehealth, beginning with methadone.

Methadone

COVID-era regulations allowed clinicians to:

  • Treat existing methadone patients via telehealth/video visits
  • Renew prescriptions for existing patients via telehealth/ video visits
  • Offer counseling and therapy via telehealth/video visits

Now let’s look at the changes related to buprenorphine.

Buprenorphine

COVID-era regulations allowed clinicians to:

  • Initiate OUD treatment with buprenorphine via telehealth/video visits
  • Continue to treat existing buprenorphine patients via telehealth/video visits
  • Renew prescriptions for existing buprenorphine patients via telehealth/ video visits
  • Offer MAT-related counseling, therapy, and support via telehealth/ video visits

It’s now 2023, close to three years after COVID arrived, and roughly a year and a half since the approval of the COVID vaccine. The epidemic is still here – the phrase rear-view mirror we use above refers to the most dangerous period od the pandemic, which was after its arrival and before the approval of the vaccine – but it’s now moving toward endemic status, similar to our yearly flu.

In light of this, federal regulators are in the process of reviewing the changes they made to MAT rules made during COVID. Of particular interest are the rules around telehealth: should the changes stay, or should we revert to status quo ante?

That’s a fancy way of asking if we should keep the new rules or go back to the way they were before.

The Data on Telehealth and MAT for OUD: About The Study

Published in October 2022, the researchers who designed the study we’ll discuss now – Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic – ask a simple question related to these changes:

Among Veterans Health Administration patients receiving buprenorphine for opioid use disorder in the year following implementation of COVID-19–related telehealth policies, did patient characteristics and retention differ across treatment modalities?

That’s a fancy way of asking who benefitted most from MAT-associated telehealth under the rules created for telehealth and MAT during COVID.

Here’s how researchers conducted the study:

  • Examined records of 17,182 patients – all patients in the Veterans Administration Health System (VA) – who received MAT for OUD between March 2020 and March 2021.
    • Patient demographics:
      • Age 30-44: 7,094
      • Age 45-64: 6,251
      • Male: 15,835
      • White: 14,085
      • Non-Hispanic: 16,292
    • Determined the relationship of telehealth/video services on treatment retention, i.e., time-in-treatment
    • Determined which patients would experience harm if federal telehealth service guidelines regarding MAT for OUD reverted to pre-pandemic parameters

Those are important avenues of research. They’re things everyone who works in SUD treatment need to know, because this data – and data from other studies like this one – will likely shape how providers deliver MAT-associated care for the next several years. As we mention above, we’re in the middle of the opioid crisis: fatalities are increasing, rather than decreasing. We’ll do anything we can do to reduce the harm caused by the opioid epidemic. If the data indicates the benefits of using telehealth for MAT outweigh the risks, then we’ll advocate for leaving the new rules in places, and look for ways we can increase the use of telehealth in our MAT programs for people with OUD.

MAT for OUD: How Important is Telehealth?

With the hard facts about the opioid crisis front of mind, let’s take a look at what the researchers found learned about telehealth and MAT for OUD.

First, the big-picture takeaways.

General Treatment Facts: VA Patients with OUD on MAT: Did They Use Telehealth?

Of the 17,182 patients in the study:

  • 12% engaged in in-person visits only
  • 50% of patients engaged in at least one (1) telephone visit but no video visits
  • 38% engaged in at least one (1) video visit

That’s important information already. At least half of patients engaged in telehealth visits: this number tells us we the significant participation we see in telehealth for MAT is prevalent across the country – it’s not just an isolated phenomenon restricted to a small group of patients.

Now let’s look at the patients who were least likely and most likely to engage in telehealth while on MAT for OUD.

Patient Characteristics: Telehealth, Video Visits, In-Person Visits

  • Telehealth visits were least common among:
    • Younger patients
    • Male patients
    • Black patients
    • Patients with co-occurring mental health disorders
    • Patients with other SUD/AUD in addition to OUD
  • Among patients who used telehealth, some were less likely to engage in video visits, including:
    • Older patients
    • Male patients
    • Homeless patients
    • Patients reporting housing instability
  • In-person visits were more common among:
    • Patients between 30-64
    • Patients still connected to the armed services
    • Individuals living in urban areas
    • Patients with co-occurring depressive disorder, post-traumatic stress disorder (PTSD), or an anxiety disorder

This information can help us target our efforts in recruiting participants in our telehealth services for MAT patients. We can increase outreach to those identified as least likely to engage in telehealth, bolster services appropriate for those most likely to engage in telehealth, and encourage patients with co-occurring mental health disorders or additional SUD or AUD to engage in telehealth as a means to overcome any existing barriers to care.

We’ll close this article with the results we’re most interested in. First, we’ll look at the impact of telehealth on treatment retention,

Telehealth, MAT, and Treatment Retention

Treatment retention, also known as treatment adherence or time-in-treatment, is a critical topic is addiction treatment. Generally speaking, the longer a person stays in treatment, the better the outcome. A month is good, three months is better, and six months or more means an individual is likely to stay in recovery.

For people with OUD, it’s important to understand one fact:

Staying in recovery increases their chance of staying alive.

That’s a cold, hard fact.

That’s why anything that improves treatment retention gets our attention. If the COVID-era rules around telehealth for MAT increase treatment retention, that’s important information for local, state, and federal policymakers.

Let’s see what the researchers found. In this case, researchers determined that an individual who stayed in treatment for 90 days or more displayed treatment retention, whereas people who engaged in treatment for less than 90 days did not display treatment retention.

Treatment Retention: Telehealth, Video Visits, In-Person Visits

  • Retention of 90 days or longer was higher for patients who engaged in telehealth, compared to patients who did not engage in telehealth:
    • Retention was higher regardless of in-person treatment participation
    • Telehealth participation was higher than under pre-COVID rules
  • Retention of 90 days of longer was highest for patients who engaged in video visits and telehealth, compared to patients who engaged in telehealth but not video visits:
    • Retention was higher regardless of in-person treatment participation
    • Patients who engaged in telehealth and video health were 47% more likely to remain in treatment longer than 90 days

That’s the data we need.

It tells us that telehealth is positively associated with treatment retention for people with OUD on MAT with buprenorphine. That’s incredibly valuable: this data may influence policymakers to leave the COVID-rules for MAT-associated telehealth in place.

We think that’s a positive development, as it represents one component of an all of the above approach that helps people with OUD. In 2022, implementation and continued use of telehealth coincided with a reduction in the rate of increase in fatal overdose. The rate of increase from 2021 to 2022 was over 30 percent lower than the rate of increase between 2020 and 2021: that means we’re heading in the right direction.

We’ll close this article with one final question: what will happen if we go back to the pre-COVID rules regarding telehealth and MAT?

Back to the Past: Returning to Pre-COVID Telehealth Rules May Have Negative Consequences

When we introduced the concept of telehealth above, we indicated that people who report structural barriers to care often benefit the most from telehealth. Structural barriers to care are often related to location and resources. People in rural areas experience barriers to care based on location. People with low income or income instability experience barriers to care related to financial resources: they may lack insurance and/or ability to pay for transportation or other expenses related to seeking care.

For those people, phone visits and video visits can make seeking care practical and affordable: in short, telehealth removes barriers to care.

Now let’s look at groups of people with OUD for whom ending MAT-related telehealth would restore – rather than remove completely – a significant barrier to care.

Ending COVID Telehealth/Video Policies: Who May Experience Harm?

  • Younger patients
  • Black patients
  • Homeless patients
  • New patients
  • Patients with co-occurring mental health disorders
  • Patients with additional substance use disorders (SUD) or alcohol use disorders (AUD)
  • Patients/groups with existing disparities in access, including those who experience the following barriers to care:
    • Limited resources for transportation, insurance, and overall support
    • Poverty
    • Unemployment
    • Food insecurity

We can sum that bullet point up succinctly:

The people who would experience the most harm from a return to pre-COVID telehealth MAT rules are among those who need MAT the most.

In other words, restricting the newly increased access to telehealth would most likely harm the most vulnerable among us. At a time when the opioid crisis threatens individuals, families, and communities across the country, we encourage policymakers to consider the data published in this study. The results show telehealth is associated with increased treatment retention, and we know increased treatment retention saves lives: we’re on the side of saving lives every time.