On a recent call, a patient looking for help simply explained, “I don’t want to die.” His fear and loss echoed but were swept away by a sigh of relief when he heard that yes, we could help him and we could help him that day, during that telephone call.
Drug overdose deaths have surged during the Covid-19 pandemic, with provisional CDC data predicting over 88,000 overdose deaths from September 2019 through August 2020, a 27 percent increase from the prior 12-month period. While medications for opioid use disorder — like methadone and buprenorphine — cut mortality in half, they are difficult to access, especially for people of color, individuals with public insurance and those living in rural areas. Approximately 40 percent of counties do not have a buprenorphine prescriber and Black patients are significantly less likely to have access than white patients.
Like the many other converging crises in 2020, the exacerbation of the opioid crisis by the Covid-19 pandemic highlighted years of policy failures. However, and perhaps uniquely so, it also presents an important opportunity to create lasting change.
To prevent widening gaps in treatment access during the first wave of Covid-19, the federal government took unprecedented and swift action in March 2020 that allowed for technologies like FaceTime and Skype to serve patients via telemedicine in good faith. Subsequently, the DEA exercised its enforcement discretion to permit buprenorphine initiation following telephone communication without requiring video technology — as had previously been the case.
While these changes were made in response to a new public health emergency, the need to expand telehealth initiation of buprenorphine was long overdue. Telehealth had already been proven effective for managing patients who had already started buprenorphine treatment after an in-person visit.
In December of last year, the Comprehensive Addiction and Recovery Act 2.0, which proposes much-needed policy reforms and funding mechanisms to address the ongoing opioid crisis, was introduced in the Senate. Among the changes are a proposed permanent expansion to permit buprenorphine treatment after an initial telehealth consultation. While the bipartisan legislation will help expand use of telehealth for buprenorphine, it mandates that the consultation occur using a video platform, a requirement that threatens to exclude people without the needed equipment or broadband access.
Simply put, the requirement to be on video is a significant barrier to care.
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. Nearly 21.3 million Americans — 6.5 percent of the population — live in “digital deserts.” This is a problem that affects low-income urban residents as well as many parts of rural America: 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. Recent data on telehealth use during the Covid-19 pandemic suggests alarming disparities in accessing care via telemedicine overall and suggests lower video use specifically among patients who are older, Black, Latinx and/or lower income. Limiting buprenorphine access to audiovisual telehealth platforms will exacerbate existing inequities.
It would be fairly simple to amend the legislation to allow audio-only telehealth visits, which would address many of these gaps. While some may fear that this change creates the risk of patients not following up for future appointments, our experience has shown us the opposite. The short-term emergency authorizations for audio-only buprenorphine treatment during Covid-19 have helped us reach people previously unable to access treatment, missed appointments have declined and many have remained engaged in treatment.