(113) Use of Diverted Buprenorphine before Starting Telehealth Opioid Use Disorder Treatment

Background & Introduction: Telehealth-only provision of buprenorphine for opioid use disorder (OUD) has been made possible by COVID 19-era waivers to the Ryan Haight Act, which otherwise requires an in-person visit prior to prescribing any controlled substance, including buprenorphine (1). Subsequently, multiple large groups (including ours) were established that now collectively treat patients with OUD via telehealth in nearly every U.S. state. In preparation for the expiration of the COVID-19 Public Health Emergency in May 2023, the U.S. Drug Enforcement Administration (DEA) released draft regulations in March 2023 that would have permitted telehealth OUD treatment with buprenorphine provided there was at least one in-person visit. There was no evidence-based reason given for this requirement. The DEA received a record >38,000 comments during the public commentary period, most contesting the in-person visit mandate, which led the DEA to postpone its decision. The DEA intends the in-person visit as a means of limiting buprenorphine diversion. However, this policy assumes that diversion is uncommon via in-person care and that it is problematic. Our anecdotal experience is that many patients initiating care in telehealth programs are already taking buprenorphine and frequently this buprenorphine was obtained via diversion. We conducted this study to quantify this observation.

Methods: A retrospective cohort study was undertaken of the first 500 consecutive newly enrolled patients in our program in 2023. A chart review was performed to ascertain a) if the patient was already taking buprenorphine at the time of enrollment and b) if so, if the chart documented that buprenorphine was obtained by any other means besides a legitimate prescription to that individual, such as given to the patient by another person or purchased illicitly. Data were analyzed with descriptive statistics using JMP v.16.2.0. The study was approved by the WIRB-Copernicus Group (WCG) institutional review board.

Results: There were 500 newly enrolled patients included between January 3-20, 2023. The mean age at first appointment was 40.3 (standard deviation 10.3) years and 305 (61.0%) were male. States of residence were: Florida (n=92, 18.4%), Michigan (n=77, 15.4%), North Carolina (n=73, 14.6%), Texas (n=62, 12.4%), California (n=38, 7.6%), Colorado (n=29, 5.8%), Virginia (n=26, 5.2%) and other (n=103, 20.6%). The payment modality used by patients for their care was 59.2% (n=296) insurance and 40.8% (n=204) self-pay. There were 232 patients (46.4%) who entered the program already taking buprenorphine. Ninety-two patients (18.4% of total, or 39.7% of those already taking buprenorphine) reported they obtained the buprenorphine via diversion.

Conclusion & Discussion: In our telehealth OUD program, over one in six (18.4%) patients who sought treatment was using diverted buprenorphine. This study is limited by its retrospective design that relied on documentation of diverted buprenorphine in the patient’s chart, so it is possible that the number of patients using diverted buprenorphine prior to seeking legitimate treatment is even greater. Prior studies show that inability to access buprenorphine treatment is a motivation for using diverted buprenorphine (2, 3), and that telehealth improves access with clinical outcomes that are similar to in-person care (4). These findings indicate that patients who sought telehealth care for OUD were commonly taking buprenorphine prior to care initiation, and a significant percentage used diverted buprenorphine.

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. Rubel, S. K., Eisenstat, M., Wolff, J., Calevski, M., & Mital, S. (2023). Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review. Substance use & misuse, 58(5), 685–697.

3. Cicero, T. J., Ellis, M. S., & Chilcoat, H. D. (2018). Understanding the use of diverted buprenorphine. Drug and alcohol dependence, 193, 117–123.

4. Hailu, R., Mehrotra, A., Huskamp, H. A., Busch, A. B., & Barnett, M. L. (2023). Telemedicine Use and Quality of Opioid Use Disorder Treatment in the US During the COVID-19 Pandemic. JAMA network open, 6(1), e2252381.