Drug treatment of veterans with opioid use disorder increased during the first year of the pandemic, according to a new study, suggesting that the rapid shift from in-person to telehealth visits at VA medical centers enabled patients to get access to care despite Covid-related disruption.
The study, published Thursday in the American Journal of Psychiatry, found that the number of Veterans Health Administration patients receiving buprenorphine for opioid use disorder increased 14% in the first year of the pandemic compared with the preceding 12 months. This coincided with a huge jump in use of telephone and video telehealth visits for prescribing buprenorphine, from 11.9% of visits in March 2019 to 82.6% in February 2021.
Buprenorphine is one of only two treatments associated with reduced mortality among people with opioid use disorder and the only one that is easily accessible at clinics and doctor’s offices.
The lead researcher, University of Michigan addiction psychiatrist Allison Lin, acknowledged that it’s difficult to tease apart the effects of Covid — such as an increase in opioid use, overdoses, and need for care — from the effects of increased telehealth use on the rise in continuing buprenorphine. But clearly telehealth visits played an important role in easing access to treatment at a time when overdose deaths soared.
“We know that the biggest contributor to overdose is ongoing addiction, including opioid use disorder,” said Lin, who also works at the VA Ann Arbor Healthcare System. “We do have some highly effective treatments. But the vast majority of people with opioid use disorder don’t receive these treatments.”
It’s difficult for hospitals to make big changes in a small amount of time, but Covid was the “experiment you never asked for” that transformed health care overnight, Lin said. Beginning in March 2020, providers were able to prescribe buprenorphine without the initial in-person visit normally required for controlled substances, using an exception under the public health emergency declaration. Accompanying policy changes included insurance coverage for telehealth appointments.
“It wasn’t just that people were using more telehealth, it was that the vast majority of buprenorphine care transitioned to telehealth and the most commonly used modality was phone,” Lin said.
During the pandemic, telephone visits were most used — accounting for 86.7% of visits among over 13,000 patients continuing buprenorphine, followed by video calls, and then in-person visits.
Haiden Huskamp, a professor of health care policy at Harvard Medical School who was not affiliated with the research, said the dramatic flip in how care is provided and the number of audio-only visits is striking.
Based on the national Veterans Health Administration data, the overall increase in use was attributed to fewer patients discontinuing buprenorphine treatment in the pandemic’s first year. The number of patients initiating the drug decreased over the same time period.
“It is not clear if these findings generalize to other settings,” said Lori Uscher-Pines, a senior health policy researcher at the RAND Corporation who was not involved with the study. “The VHA faces fewer barriers to delivering telehealth visits in high volume and had more sophisticated telehealth programs prior to the pandemic than other settings.” She added that future research should address what is driving the trend toward fewer initiations of buprenorphine treatment.
When the public health emergency declaration expires, patients relying on telehealth would have to make in-person visits once again if the law isn’t changed. “I’m not sure what would happen to these patients who’ve been receiving their buprenorphine treatment via telehealth, who’ve only known care via telehealth,” Lin said, advocating for continued use of telehealth after the pandemic ends.
While there were more patients staying on buprenorphine treatment through virtual appointments, researchers found a drop in other treatments for substance use disorders during the pandemic.
Given that most health care use — from preventative treatments to care for chronic conditions — decreased during the pandemic, Lin said it is possible that telehealth policies are more complex to implement for forms of addiction like alcohol use which require therapy, not just medication.
A common concern with telehealth is the potential for inappropriate prescribing. However, Lin explains there is not any proof that in-person visits reduce unnecessary or harmful prescriptions nor is there evidence that telehealth systematically leads to increased misuse.
“Who the heck cares?” said Ateev Mehrotra, a professor of health care policy at Harvard Medical School who studies telemedicine, acknowledging that this is his personal opinion on a contentious issue. “If one person with opioid use disorder gives buprenorphine to another person with opioid use disorder and diverts it … if they’re using it to control their withdrawal symptoms, and they’re less likely to use heroin or fentanyl and die, maybe this is a good thing.”
Mehrotra points out that studying the effect of telehealth on patient outcomes is challenging because “people who use telemedicine are typically more educated, more sophisticated, they’re really going to do better anyways,” and it’s difficult to find a controlled way to compare a group of patients who receive telemedicine options to those who do not.