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A new Health Affairs blog urges the federal government to continue telehealth waivers for substance abuse treatment during the COVID-19 emergency and asks for permanent changes to safeguards around the use of buprenorphine.

By Eric Wicklund

September 18, 2020 – A group of clinicians and public health experts is pressing the federal government to make permanent telehealth policy changes that would improve access to care for people undergoing substance abuse treatment.

In a recent blog in Health Affairs, the Buprenorphine Telehealth Consortium is urging the Health and Human Services Secretary to waive a requirement in the Ryan Haight Act that mandates an in-person exam for emergency treatment during the ongoing coronavirus pandemic. This would allow providers to use telehealth to determine whether a patient undergoing treatment for substance abuse and prescribe buprenorphine, an opioid medication used to treat addiction.

Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, certain healthcare providers were allowed to prescribe controlled substances for treatment as long as they’d first had an in-person examination with the patient. That law offered several instances in which the in-person requirement could be waived. On March 16, the US Drug Enforcement Agency (DEA) waived that requirement under by invoking the public health emergency exception.

The group is continuing an argument long supported by substance abuse care providers and telehealth advocates, who say providers should be able to conduct that initial in-person exam by telemedicine or even a phone, and also use the platform to prescribe medications. With substance abuse rates soaring across the country even before the current emergency, providers see connected health as a much-needed channel to expanding access to care.

Beyond the COVID-19 emergency, the consortium is urging the US Attorney General to create regulations governing special registrations that would expand the in-person exam exemption and allow providers to use telehealth to treat patients dealing with substance abuse. That pathway was laid out in the Ryan Haight Act and included in the SUPPORT Act of 2018, but has so far been ignored.

“What is more, instead of relying on temporary regulatory waivers and special registrations, Congress should modify the Ryan Haight Act to permit providers to conduct a remote evaluation for buprenorphine OUD treatment initiation and follow-up via telehealth, including audio-only technology where necessary, without an in-person visit,” the group says. “This would represent a permanent legislative solution and could be done through an audio-only amendment of the already introduced TREATS Act.”

The TREATS Act, introduced in June, mandates the use of audio-visual telemedicine. The consortium is calling for an amendment to that bill to allow for the use of audio-only phones.

“Due to structural racial and economic inequities, inadequate broadband and internet infrastructure, low digital literacy, and health system barriers, audiovisual telehealth is not widely accessible,” the group says. “A report from the Federal Communications Commission found that about 21.3 million Americans – 6.5 percent of the population – live in ‘digital deserts’ and lack access to fixed broadband service at threshold speed. Almost half of low-income Americans and a third of rural Americans don’t have home broadband access. Many others are unstably housed and lack access to permanent phones. Limiting buprenorphine access to audiovisual telehealth platforms continues to exclude the most vulnerable people who already lack access to MOUD treatment. This approach, therefore, does not sufficiently address existing gaps and disparities in treatment access. Allowing audio-only telehealth visits, however, could address many of these gaps.”

In its blog, the consortium rebuts an argument that telehealth would increase substance abuse.

“This concern is unfounded; in fact, the opposite may be true,” they wrote. “Diversion of buprenorphine has been shown to be a consequence of limited access to medically supervised buprenorphine treatment. Studies have found that the primary use of diverted buprenorphine is for therapeutic purposes, including treatment of withdrawal and cravings, and to abstain from other, higher-risk opioid use. This suggests that expanded access to low threshold buprenorphine treatment may actually decrease diversion. Furthermore, any effective regulatory efforts to prevent, identify, or address diversion would not depend on whether a patient’s visit was conducted in person or using audiovisual or audio-only telehealth.”

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