Buprenorphine freed Amy McKean from “that white-knuckle mode of holding on by your fingertips,” she says. Now telemedicine is helping her, too.
The 46-year-old mom and graduate student from the Denver suburbs started medication-assisted treatment in the fall of 2011 after admitting to her pain doctor that she’d been exaggerating her symptoms (migraines, neck aches from whiplash) in order to satisfy an oxycodone habit.
McKean started her buprenorphine treatment in a doctor’s office, sitting under observation “until I had enough medication in me that I felt better,” she recounts. But now, for three out of four monthly refills, McKean opens an app on her cellphone to video conference with her doctor or one of his physician assistants. The app saves her the drive into Denver—40 minutes without traffic. “I just have to remember to make sure I brush my hair,” she says.
When President Trump declared the opioid epidemic a public health emergency last October, he called for expanded access to telemedicine. Advocates of the practice say it extends a lifeline to patients in rural counties, where opioid overdose rates exceed those in cities.
But because buprenorphine is itself an opioid, susceptible to diversion and abuse, access to it—including by telemedicine— is tightly regulated by both federal and state law. Congress and the Drug Enforcement Administration are now considering whether to ease those restrictions.
Under federal regulations, physicians can’t prescribe buprenorphine without completing eight hours of specialized training. Unfortunately, not many physicians do. As a result, only about half the counties in the U.S.—and just 40% of rural counties—had even one qualified buprenorphine prescriber in 2016, according to the Rural Health Research Center.
Using telemedicine to prescribe bupe, as it’s called, is subject to its own legal hurdles. Foremost among them is a 2008 federal law known as the Ryan Haight Act, named after a California teenager who fatally overdosed in 2001 on Vicodin he purchased online. That law requires a physician to conduct at least one in-person examination of a patient before he or she can prescribe a controlled substance remotely. Its exceptions are narrow: a provider can conference with a patient who is inside a DEA-registered hospital or clinic, or in the same room as a DEA-registered doctor. (A bill now pending before the House Energy and Commerce Committee would extend the exceptions to include a patient located in a community mental health or addiction treatment center—though not one located in his or her home.)
Many states have enacted their own versions of the Ryan Haight law, and a few of those are even stricter than the federal version. (Connecticut, for instance, bars any prescription of buprenorphine by teleconference, even after the first, in-person visit.)
Patients and physicians also face an array of divergent state rules governing Medicaid reimbursement for telemedicine sessions. The rules vary depending on the type of service and the location of the patient. Forty-eight states and Washington, D.C., offer reimbursement for at least some kinds of live-video telemedicine, according to the National Telehealth Policy Research Center, but only six states provide it for patients conferencing from home, like McKean.
Even requiring that the first visit to a buprenorphine prescriber be in-person can pose a nearly insuperable obstacle in some parts of the country. In Alaska, for example, 80 percent of communities aren’t even connected to a road system.
“Our communities are a thousand people or smaller, so we have a really hard time recruiting even nurse practitioners and physician assistants, let alone physicians,” says Jennifer Harrison, CEO of Eastern Aleutian Tribes. Harrison, who is based in Anchorage, oversees eight community health centers on the Aleutian Islands off southwest Alaska–commercial fishing hubs where she says heroin-related overdoses are on the rise.
There aren’t any doctors on the islands authorized to prescribe buprenorphine, she says, and flights to Anchorage cost about $1,000—out of reach for low-income residents.
Former California Representative Mary Bono, who co-sponsored the Ryan Haight Act back in 2008, now favors amending it. “We didn’t even envision that we would be in this opioid epidemic,” she said in an interview. “It’s definitely time that we revisit this.”
The Drug Enforcement Administration is empowered to make exceptions to Ryan Haight, and, in 2015, announced plans to do so. But it has yet to act. In January, Sens. Dan Sullivan (R-Alaska), Lisa Murkowski (R-Alaska) and Claire McCaskill (D-Mo.) wrote the DEA demanding a pathway for physicians to prescribe by video conference. (In Missouri, McCaskill’s state, 98 of 101 rural counties lack a single licensed psychiatrist.)
In an emailed statement, DEA spokesperson Melvin Patterson says the agency is drafting regulations now, but declines further comment.
“DEA believes access to opioid treatment options is incredibly important,” the statement says, “but it must be done in a way that balances care and the mitigation of diversion risks.”
Lifting the in-person requirement on the first visit “would be a real game changer,” says Lisa Mazur, co-chair of the Digital Health Practice at McDermott Will & Emery, where she represents telepsychiatry companies.
“Because that means that psychiatrists could get in front of these patients more quickly,” she says. “Which could have a real promising result on the patient’s condition and chances of recovery.” Mazur hopes that the states with their own laws would follow Congress’ example if it amends Ryan Haight.
But eliminating the legal barriers won’t necessarily compel facilities to set up telemedicine technology and start seeing buprenorphine patients, advocates warn. Some people are just reluctant to deal with opioid users.
“Believe it or not, some providers think [opioid use disorder] is a choice and not a disease,” says Amnah Anwar, director of the Indiana Rural Health Consortium. Her state, which suffered a 23% increase in overdose death between 2015 and 2016, has 18 opioid treatment facilities, all of which are clustered in urban areas. Nevertheless, Anwar struggles to convince doctors to launch telemedicine services for buprenorphine patients. “The greatest concern is diversion,” she says: “that these patients would take the pills, give them to others, sell them, or abuse them themselves.”
Other practitioners think the diversion risk is overblown. “If an adult who has never taken opioids takes bupe, they will get high,” says Jeffrey Junig, a psychiatrist in Fond Du Lac, Wisconsin. But veteran users will not. Furthermore, he adds, “it’s very difficult to die from bupe alone.” Overdose is unlikely, he says, unless the drug is mixed with another respiratory suppressant, such as Xanax or Klonopin.
Still, some telemedicine providers simply believe that having the first visit be in-person is the best practice as a clinical matter. One psychiatrist in suburban Minnesota, who spoke on condition of anonymity because he did not have his employer’s authorization, says he sees many buprenorphine patients via video conference, and refills their prescriptions that way, too. “I talk to them about their triggers, what their cravings have been like, how they’re managing, make sure they’re not on other drugs,” he continues.
But a year ago he started requiring patients to come to his office for their initial appointment, even though they fell within an exception under the Ryan Haight law. Patients “don’t seem as invested in the recovery,” he says, “unless I actually put my hands on them and do a physical evaluation and let them know that I’m a real person. I got the sense that some of them were treating it almost like a video game.”