In the poem, The Road Not Taken, Robert Frost writes of the two roads that diverged in a wood and his inner struggle to select the correct path, even if it’s not the easy one. We’ve arrived at this crossroad in our use of telehealth to care for patients in recovery for opioid use disorder (OUD).
One road, reinforced 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 on average had better outcomes and a lower risk of overdose than their pre-pandemic counterparts who received almost no treatment via telehealth.
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Brian Clear Brian Clear, MD, FASAM, is a double boarded Family and Addiction Medicine Physician who has dedicated his career to the care of patients struggling with problematic opioid use. As Chief Medical Officer, he has designed and scaled Bicycle Health's telemedicine platform and continues to publish research finds that support the success of this […]
The other road, underscored by disastrous decisions by Walmart and the state of Alabama, reverts to ending the use of telehealth for OUD care and falling back solely on our old and inadequate infrastructure of in-person programs. Walmart has stopped accepting buprenorphine prescriptions from telehealth providers unless they can demonstrate that they’ve physically seen the patient, effectively defeating the purpose of telehealth.
Which of these two roads should we take?
I am saddened and frustrated by decisions that would turn the clock back on the progress we’ve seen through telemedicine. Opioids killed more Americans than car crashes and flu combined in 2021. At 80,816 lives lost in 2021, the annual death toll approaches Covid’s.
In the days before, Alabama’s new law took effect in July, it put lives at risk. Forced to stop accepting new patients in that state, my medical group had to scramble as 400 of our 550 established patients in the state were unable to access in-person care. Our addiction specialist physicians and I are licensed in Alabama, but because we do not physically live in the state, we were unable to see patients in person to comply with the law. In order to avert tragedy, we flew our physicians to Birmingham so that our patients could complete an in-person visit with them in a hotel conference room. We saw 235 patients in a week, but that still left 165 likely facing a poor outcome.
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A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
I suspect the root of their decisions is a tendency to conflate telemedicine with lax practice. Consider Cerebral, a prominent telemedicine company that has been charged with fostering negligent prescribing of amphetamine (Adderall) without establishing a proper diagnosis. This is an allegation of negligent practice, like the negligent prescribing of opioids. However, there are also successful, crucial telemedicine programs built and run by skilled clinicians who are deeply invested in their patients and seeing excellent outcomes.
Make no mistake, it’s necessary to stop harmful practices. But in restricting the prescribing ability of all telemedicine providers regardless of care quality, the decisions by Walmart and Alabama have overgeneralized the reaction against a minority of problematic practices.
For every patient using telemedicine to recover from opioid addiction, these decisions to remove that access are potentially fatal. Buprenorphine is the only effective medication for OUD which can be provided both through in-person clinics and through telemedicine. Effective OUD treatment, for the right patients under the direction of a qualified treatment provider, blocks the effects of other opioids and protects against returning to problematic opioid use (“relapse”) and overdose. It’s effective at preventing death and disability while care continues, but when discontinued abruptly, most patients will return to problematic opioid use within a year, and many will experience an overdose. However, it has been utilized so poorly that nine out of ten Americans who suffer from problematic opioid use cannot or do not access it.
Telemedicine can address this disconnect. In July, RAND corporation published a study in the Journal of Addiction Medicine illustrating differences in patient experience between use of telemedicine versus in-person care for OUD. 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 studied were working full time.
The fact is, in-person care for OUD remains difficult to access, and care quality is variable and often unpredictable. In-person programs are often so sparse, especially in rural areas, that there’s little pressure to offer high-quality services because patients have no other option. Low quality services can be degrading, embarrassing, and incompatible with work and family life. Patients may succumb quickly to discouragement, and on average we see that about half of all patients at 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 serve patients broadly, it raises this standard for everyone by giving patients choice.
So what does telehealth, done right, look like in treating OUD?
I believe policymakers should permanently eliminate restrictions on using buprenorphine via telehealth to treat patients with OUD. I also believe telehealth providers would do well to adhere to three core principles to maintain a high-integrity, high-quality program for our patients and providers.
- Employ clinicians who are fully committed to the program and their patients. For a quality-oriented program, telehealth cannot be a side hustle. Patients must be cared for by providers who are available and responsive to their needs.
- Set the same, or higher, quality standards of care as those accepted for in-person practice. When telehealth providers assess patients for whom they can’t meet this high standard virtually, they should help direct patients to a program that can.
- Be clear about the limitations of telehealth. We can do certain things very well such as behavioral health and addiction medicine, but in-person care systems remain crucial for almost everything else. Collaborate with patients’ primary care and other providers whenever possible and work to reinforce those relationships.
The decisions by Walmart and Alabama to undermine the delivery of care for OUD via telehealth actually have little to do with telehealth. They center on the clinical practices of a specific group that failed to promote high-integrity, high-quality care. Pointing the finger at telemedicine itself is a ham fisted approach to policy making that avoids the challenge of differentiating harmful care from helpful care. As we move beyond this fork in the road, you’ll find that Walmart and Alabama will have to turn around when they realize they’ve gone the wrong way.
Photo: Anastasia Usenko, Getty Images
Brian Clear, MD, FASAM, is a double boarded Family and Addiction Medicine Physician who has dedicated his career to the care of patients struggling with problematic opioid use. As Chief Medical Officer, he has designed and scaled Bicycle Health's telemedicine platform and continues to publish research finds that support the success of this model, ultimately working to contribute to destigmatization and improved provider understanding of effective accessible OUD care.
Dr. Clear earned his Doctor of Medicine (MD) from American University of the Caribbean School of Medicine and completed his residency at the University of Kentucky Family & Community Medicine Residency Program with a focus on global health. Before Bicycle Health, Brian served as Medical Director for the integrated treatment of opioid use disorder and primary care services with BAART Programs in San Francisco.
