(25) Patient Experiences with Telehealth Treatment for Opioid Use Disorder in Alabama

Background & Introduction: Telehealth-only provision of buprenorphine for the treatment of opioid use disorder (OUD) was first made possible during the COVID-19 pandemic. Previously, the Ryan Haight Act of 2008 mandated an in-person visit to prescribe controlled substances, including buprenorphine (1). This exception permitted the growth of several large telehealth-only OUD treatment providers, which now treat thousands of patients across the U.S. (2). However, despite federal permission, Alabama instituted a law in July 2022 that mandated at least one in-person visit annually in order to receive this treatment. Our group cared for >500 patients in the state, and in response to the new requirement we were able to find alternative treatment for about 20%. Some patients discontinued treatment, and we are unable to determine if they found another OUD provider or returned to use. For the remainder, we implemented a temporary clinic in Birmingham in July 2022 and saw 162 patients in person and meet the state’s requirement. This process was repeated in July 2023. This study prospectively surveyed the patients who presented to the clinic in July 2023 to determine patient impressions about the annual in-person visit requirement, and to describe perceptions of the importance of the in-person visit on OUD treatment.

Methods: Patients who were active in treatment with our group, a large telehealth-only OUD treatment provider operating in nearly every U.S. state (1), were informed that they would need to attend an in-person visit in Birmingham during a four-day period (Friday to Monday) to continue treatment. A team of healthcare workers, including two physicians who were licensed in the state, stood up a temporary clinic in a hotel ballroom. The clinic was held during a four-day period (Friday to Monday), and those days were selected in order to allow patients who work during the week to attend on a weekend day. An optional paper survey instrument was administered to patients at the time of clinic check-in. Results were transcribed and analyzed in descriptive fashion with JMP v16.2.0. The study was approved by the WIRB-Copernicus Group (WCG) institutional review board.

Results: One hundred-sixty patients attended the clinic. There were two patients who did not present due to the far distance and inability to pay for the trip and were subsequently discharged from the program because of the Alabama law. Of the 160 patients who presented, 88 patients (55%) used insurance to cover their OUD care and the remaining 45% were self-pay patients. A total of 158 (98.8%) patients completed the survey instrument. There were 144 patients (91.1%) who reported driving themselves to the appointment, including one patient who reported renting a vehicle. The remaining patients had rides from friends or family. Mean distance traveled was 86.4 (standard deviation (SD) 53.7) miles, and time required for one-way travel was mean 1.6 (SD 1.0) hours. Twenty-five patients (15.8%) reported needing to find childcare to attend the visit and, despite the weekend hours, 40 patients (25.3%) reported missing work to attend. Patients disagreed (median 2 on 1-5 Likert scale, interquartile range (IQR) < 1-3>) that it is important to see their provider in-person, that seeing their provider in-person improves care or improves their ability to succeed in treatment, and that they have other OUD treatment resources in their community. Patients strongly agreed (median 5, IQR < 5-5>) that OUD can be treated by telehealth without the need for an in-person visit. Ninety-eight patients (62.0%) reported knowing others who were harmed by the Alabama law that mandates an in-person visit to be prescribed buprenorphine.

Conclusion & Discussion: An annual in-person visits requirement to receive telehealth OUD services imposed a significant burden on patients, was not desired by patients, and may be associated with harm. This finding is particularly important in Alabama, where 82% of counties are rural. Telehealth OUD treatment has been demonstrated to show high rates of retention, both overall (3), and specifically for rural populations (4, 5). In the absence of any known medical or patient-centered benefit, the Alabama law to mandate an in-person visit should be reconsidered.

References: 1. Wang, L., Weiss, J., Ryan, E. B., Waldman, J., Rubin, S., & Griffin, J. L. (2021). Telemedicine increases access to buprenorphine initiation during the COVID-19 pandemic. Journal of substance abuse treatment, 124, 108272.

2. Rollston, R., Gallogly, W., Hoffman, L., et al. (2022). Collaborative, patient-centred care model that provides tech-enabled treatment of opioid use disorder via telehealth BMJ Innov, 8, 117-122.

3. Frost, M. C., Zhang, L., Kim, H. M., & Lin, L. A. (2022). Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic. JAMA network open, 5(10), e2236298.

4. Lira, M. C., Jimes, C., & Coffey, M. J. (2023). Retention in Telehealth Treatment for Opioid Use Disorder Among Rural Populations: A Retrospective Cohort Study. Telemedicine journal and e-health: the official journal of the American Telemedicine Association, 10.1089/tmj.2023.0044.

5. Williams, A. R., Aronowitz, S. V., Rowe, C., Gallagher, R., Behar, E., & Bisaga, A. (2023). Telehealth for opioid use disorder: retention as a function of demographics and rurality. The American journal of drug and alcohol abuse, 49(2), 260–265.