In the poem, The road is not taken Robert Frost writes about two roads that diverge in a forest and his inner struggle to choose the right path, even if it is not the easy one. We have reached this crossroads in our use of telehealth to care for patients in opioid use disorder (OUD) recovery.
One path, supported by a recent study published in JAMA Psychiatry, points to the continuation of telehealth. It found that people who received telehealth care for OUD during the Covid-19 pandemic had, on average, better outcomes and a lower risk of overdose than their pre-pandemic counterparts who received almost no treatment via telehealth.
The other path, highlighted by the disastrous decisions of Walmart and the state of Alabama, is back to ending the use of telehealth for OUD care and returning solely to our old and inadequate infrastructure of in-person programs. Walmart has stopped accepting buprenorphine prescriptions from telehealth providers unless they can prove they physically saw the patient, which effectively defeats the purpose of telehealth.
Which of these two paths should we take?
I am saddened and disappointed by decisions that would turn back the clock on the progress we are seeing through telemedicine. Opioids killed more Americans than car crashes and the flu combined in 2021. With 80,816 lives lost in 2021, the annual death toll is approaching that of Covid.
In the days before Alabama’s new law went into effect in July, it put lives at risk. Forced to stop accepting new patients in this state, my medical group had to struggle because 400 of our 550 established patients in the state did not have access to personal care. Our addiction doctors and I are licensed in Alabama, but since we do not physically live in the state, we have not been able to see patients in person to comply with the law. To prevent tragedy, we flew our doctors to Birmingham so our patients could complete an in-person visit with them in a hotel conference room. We saw 235 patients in one week, but that still left 165 possibly facing a bad outcome.
I suspect that at the root of their decisions is a tendency to conflate telemedicine with careless practice. Consider Cerebral, a well-known telemedicine company that has is accused of promoting the careless prescription of amphetamine (Adderall) without establishing a proper diagnosis. This is an allegation of negligent practice, such as the negligent prescribing of opioids. However, there are also successful, critically important telemedicine programs built and run by skilled clinicians who are deeply invested in their patients and seeing excellent results.
Make no mistake, it is necessary to stop harmful practices. But when limiting the possibility of prescribing everything telemedicine providers regardless of quality of care, the Walmart and Alabama decisions overgeneralized the backlash against a minority of problematic practices.
For any patient using telemedicine to recover from opiate addiction, these decisions to remove that access are potentially fatal. Buprenorphine is the only effective medication for OUD that can be provided through both in-person clinics and telemedicine. Effective OUD treatment, for the right patients under the guidance of a qualified treatment provider, blocks the effects of other opioids and prevents a return to problematic opiate use (“relapse”) and overdose. It is effective in preventing death and disability as long as care continues, but when it is stopped suddenly, most patients will return to problematic opioid use within a year, and many will overdose. However, it has been so poorly used that nine out of ten Americans who suffer from problem opiate use cannot or do not have access to it.
Telemedicine can address this disconnect. In July, the RAND Corporation published a study in the Journal of Addiction Medicine that illustrated the differences in patient experience between the use of telemedicine and in-person OUD care. Over three-quarters of patients with experience in both settings described telemedicine as more patient-centered and easier to fit into their lives, and 85 percent of those surveyed worked full-time.
The fact is that personal care for OUD remains difficult to access and the quality of care is variable and often unpredictable. In-person programs are often so scarce, especially in rural areas, that there is little pressure to offer high-quality services because patients have no other option. Low-quality services can be humiliating, embarrassing and incompatible with work and family life. Patients can quickly succumb to discouragement, and on average we see about half of all patients in in-person programs leave care within 90 days. Most then return to problematic use. When telemedicine is used to extend the reach of high-quality programs to broad patient care, it raises that standard for all by giving patients choice.
So what does telehealth, done right, look like in the treatment of OUD?
I believe policymakers should permanently remove restrictions on the use of buprenorphine via telehealth to treat patients with OUD. I also believe that telehealth providers would do well to adhere to three basic principles in order to maintain a program of high quality and integrity for our patients and providers.
- Hire clinicians who are fully committed to the program and their patients. For a quality-oriented program, telehealth cannot be a side issue. Patients should be cared for by providers who are available and responsive to their needs.
- Set the same or higher standards of quality of care as those accepted for private practice. When telehealth providers evaluate patients for whom they cannot meet this high standard virtually, they should help refer patients to a program that can.
- Be aware of the limitations of telehealth. We can do certain things very well, such as behavioral health and addiction medicine, but personal care systems remain crucial for almost everything else. Collaborate with patients’ primary care and other providers when possible and work to strengthen those relationships.
Walmart and Alabama’s decisions to undermine telehealth delivery of OUD care actually have little to do with telehealth. They focus on the clinical practices of a specific group that have failed to promote high-quality, high-integrity care. Pointing the finger at telemedicine itself is a non-intrusive approach to policymaking that avoids the challenge of distinguishing between harmful and beneficial care. When we get past this fork in the road, you’ll find that Walmart and Alabama will have to turn around when they realize they’ve gone down the wrong path.
Photo: Anastasia Usenko, Getty Images