Opioid Crisis: Money, Telehealth Addiction Treatment with Suboxone Telemedicine & Tele-MAT

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The addiction rehabilitation industry has grown substantially in response to the opioid crisis, responsible for over 100,000 deaths in 2021. Among US veterans diagnosed with opioid use disorder (OUD), estimates were 69,132 in 2017. Since the COVID pandemic, telehealth technology has been used to bridge that gap nationwide by patients and clients to consult with prescribers for suboxone telemedicine and buprenorphine telemedicine. Such medication for opioid use disorder (MOUD) is often prescribed along with behavioral programs delivered by addiction professionals via videoconferencing or by telephone to the patient’s home or other environments. Digital and telehealth addiction treatment were also used to enable mail-in urine tests to ensure compliance with sobriety. Other features of telehealth addiction treatment include apps that offer peer support and coaching, the management of patient records, and federal confidentiality regulations as required by the Substance Abuse and Mental Health Services Administration (SAMHSA) 42CFR Part 2.

Suboxone Telemedicine, Buprenorphine Telemedicine & Tele-MAT

Suboxone and buprenorphine are opioids that are commonly used to treat opioid addiction in medication-assisted treatment (MAT). Despite being opioids, these medications have a limited potential for causing euphoria and the feeling of being “high.” Traditionally given after initial administration in person, the patient was previously allowed to administer these medications at home rather than in a clinic. 
In response to the COVID pandemic in early 2020, state and federal governments made notable changes to telehealth regulations regarding prescribing MOUD and subsequent treatment via telemedicine. The US Drug Enforcement Agency (DEA) announced that prescribers could prescribe buprenorphine and suboxone via telemedicine without conducting an initial in-person evaluation. Suppose a prescriber deemed a patient suitable for receiving buprenorphine or suboxone after a video or telephone consultation. The prescriber could immediately start prescribing that medication to the patient. Other groups similarly relaxed previous limits (e.g., Department of Health and Human Services, Federation of State Medical Boards). Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) waived requirements for initial in-person visits for buprenorphine and allowed less frequent in-person visits for patients receiving methadone. 
Also referred to as “Tele-MAT,” telehealth assessment and follow-up were approved by several other groups, including the Indian Health Service (INS). It directly addressed the added training and precautions needed by prescribers working with buprenorphine telemedicine within the Indian healthcare system. The following specialized documents were designed to help practitioners understand the needs of opioid patients under INS regulations:  

Research Addressing Suboxone Telemedicine, Buprenorphine Telemedicine & Tele-MAT

Patient Variables with Audio-Only Telehealth for MOUD

Cales and colleagues reported a recent study of telehealth efficacy with opioid treatment in 2022. Their study was designed to investigate the efficacy and safety of providing medication for opioid use disorder (MOUD) and individualized telehealth in Kentucky, where the dual impact of the opioid epidemic and the COVID-19 pandemic has been severe. Study participants rated telehealth as helpful when used in a hybrid model matching patients’ needs to available resources, including in-person care based on COVID-19 safety guidelines. Previous studies of telehealth addiction treatment using video conferencing 1 ,2  and other behavioral disorders by telephone 3 ,4  have shown high efficacy rates and acceptance by both patients and providers. However, in their study, Kang and colleagues reported on the use of treatment via telephone in suboxone telemedicine in 2022, examining 264 patients who used telephone counseling as an adjunct to MOUD. They concluded that significant patient-level barriers to telehealth, including telephone care, are worthy of attention.5  
They identified patient-level barriers to telehealth due to digital inequities, including those related to telephone care. They examined convenience and satisfaction with telephone counseling, comfort and change in relationship with a counselor, and how telephone counseling helped with behavioral health disorders and recovery. Barriers associated with poorer counseling experiences were faced by patients when using telephone counseling.6

Practitioner Variables

Many questions still arise regarding implementation safety. Mattacks and colleagues conducted semi-structured interviews with Veterans Administration clinicians at nine VA Medical Centers in eight states.7 Twenty-three VA providers participated in the study. Thirty-one percent of the sample (n = 81) reported experiencing one or more barriers to telephone counseling. Satisfaction with counseling, perceived convenience, comfort, and beneficial counseling effects on substance use was associated with increased odds of reporting no barriers (range of p.038 to <0.001). Of the themes identified by the researchers, these three observations shed light on several issues that need continued research and discussion. 

  • Video calls provided a rare window into veterans’ lives. 
  • Providers experienced numerous challenges with virtual visits. 
  • Providers wrestled with paternalism and trust.

Digital Inequities in Telehealth Addiction Treatment

As reported by Garrett and his research team in 2021, the efficacy of suboxone telemedicine, buprenorphine telemedicine, and Tele-MAT are also subject to digital inequalities,8 such as limited access to technology, skills to leverage the technology for desirable outcomes, and social resources, in clinicians as well as patients. In addition, when considering patients, digital health literacy plays an integral part in the capacity of individuals to appraise opioid medication-related online information. Their paper explores the role of digital inequalities in the uptake of treatment for opioid use disorder. Complex challenges have been reviewed. For example, Moreland and colleagues outlined several barriers to providing MAT, “with the most significant barrier including the lack of medical staff to prescribe buprenorphine (47%).” The study highlighted the gap between treatment need and capacity for OUD patients and identified factors associated with barriers to MAT adoption in state-funded county drug and alcohol agencies in South Carolina.9

Startups Offering MOUD Via Tele-MAT

Addiction telehealth startups have gained attention and have received considerable funding since the pandemic started. These include QuickMD Quit Genius (a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence), Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring. Many are already providing services to self-insured employers, payers, and providers.* The investment firm StartUp Health has launched a series of models to provide different approaches to addiction treatment. The degree to which these startups follow the evidence base is left to the reader to determine before seeking employment. 

Conclusion

The pandemic has spurred a seismic shift in OUD treatment, allowing the nationwide use of suboxone telemedicine, buprenorphine telemedicine, Tele-MAT, and the behavioral therapies they require. Given the success of stand-alone MOUD telehealth and hybrid approaches to telehealth and in-person care, it is reasonable to expect that addiction telehealth will grow along the lines that Zhu and colleagues predict in 2022 that telehealth is here to stay.10
See TBHI’s previous articles for information regarding telehealth addiction treatment benefits:

*TBHI Telehealth.org has not investigated these companies and in no way suggests them as models or employers. 

References

  1. Fletcher, T. L., Hogan, J. B., Keegan, F., Davis, M. L., Wassef, M., Day, S., & Lindsay, J. A. (2018). Recent advances in delivering mental health treatment via video to the home. Current psychiatry reports, 20(8), 1-9.
  2. Mattocks, K. M., Moore, D. T., Wischik, D. L., Lazar, C. M., & Rosen, M. I. (2022). Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic. Journal of Substance Abuse Treatment, 10877
  3. Castro, A., Gili, M., Ricci-Cabello, I., Roca, M., Gilbody, S., Perez-Ara, M. Á., … & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: a systematic review and meta-analysis. Journal of affective disorders260, 514-526.
  4. Irvine, A., Drew, P., Bower, P., Brooks, H., Gellatly, J., Armitage, C. J., … & Bee, P. (2020). Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders265, 120-131.
  5. Kang, A. W., DeBritz, A. A., Hoadley, A., DelaCuesta, C., Walton, M., Hurley, L., & Martin, R. (2022). Barriers and poor telephone counseling experiences among patients receiving medication for opioid use disorders. Patient Education and Counseling.
  6. Cales, R. H., Cales, S. C., Shreffler, J., & Huecker, M. R. (2022). The COVID-19 pandemic and opioid use disorder: expanding treatment with buprenorphine, and combining safety precautions with telehealth—Journal of substance abuse treatment, 133, 108543.
  7. Mattocks, K. M., Moore, D. T., Wischik, D. L., Lazar, C. M., & Rosen, M. I. (2022). Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic. Journal of Substance Abuse Treatment, 10877
  8. Garett, R., & Young, S. D. (2021). Potential effects of digital inequality on treatment-seeking for opioid use disorder. International Journal of Mental Health and Addiction, 1-6.
  9. Moreland, A., McCauley, J., Barth, K., Bogdon, C., Killeen, T., Haynes, L., … & Brady, K. (2020). Assessing the needs of front-line providers in addressing the opioid crisis in South Carolina. Journal of substance abuse treatment, 108, 4-8.
  10. Zhu, J. M., Myers, R., McConnell, K. J., Levander, X., & Lin, S. C. (2022). Trends In Outpatient Mental Health Services Use Before And During The COVID-19 Pandemic: The study examines trends in outpatient mental health service use before and during the COVID-19 pandemic. Health Affairs, 41(4), 573-580.
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