In March 2020, I was directing a federally qualified health center in rural New Mexico when the first flashover of COVID ripped through the state. In two days, the clinics transitioned from an entirely in-person model to a near-total remote model. The transformation was raw and unplanned, trialing mediocre communications platforms in real-time and stumbling through the vagaries of electronic prescribing. As we got our feet under us, unexpected upsides of telemedicine began to emerge: the no-show rate plummeted to just north of zero, even for the most unstable patients. The churn of tardy arrivals faded from a daily battle to a low background roar. In the negative space surrounding the pixelated individual at the opposite end of a Zoom lens, we caught clear insights into our patients’ lives that defied the limitations of the clean, well-lit clinic, from comfortable middle-class living rooms to substandard housing and homeless encampments.
Half a year later, I left primary care for full-time opioid use disorder (OUD) care on a telemedicine platform. The COVID emergency measures loosened regulations to allow experimentation in radically new ways to reach and treat patients, encouraging innovation in real-time – operationalizing remote drug screening, managing complex fentanyl-to-buprenorphine induction from afar, pairing services with a custom app to allow asynchronous communication. Telemedicine took us deep into rural Wyoming, urban Pennsylvania, and suburban Arizona, providing discrete and personalized services for these highly stigmatized patients of this highly stigmatized condition. Telemedicine carved out space for disabled patients to receive opioid use disorder services in their own homes without the deal-breaking burden of frequent appointments. These advantages have borne out measurable effects on outcomes, with retention rates (a primary measure of treatment success in OUD) that defy industry standards.
Passage of the MAT Act in December of 2022 ended the federal X-waiver – the special licenses needed to prescribe buprenorphine/naloxone for OUD – opening up the hopeful prospect of throwing the doors aside to OUD treatment in every primary care and urgent care clinic if indeed those types of providers wished to provide such treatment. On February 28th, the Drug Enforcement Administration (DEA) whiplashed that giddy optimism by releasing proposed regulations to drag telemedicine back to the pre-COVID era.
Under the confusing header of “Expansion of Induction of Buprenorphine via Telemedicine Encounter,” the DEA proposed to single out buprenorphine-based treatment for specific limitations, primarily the requirement that all patients attend an in-person visit by the prescribing provider within 30 days or be referred by a brick-and-mortar provider who must send a provider-specific (not the more reasonable agency-specific) referral to the telemedicine provider. In an era of critical access gaps in primary care, a patient can only hope that they can navigate this landscape while struggling with opioid dependence.
This flies contrary to best practices in the OUD treatment space, which is to offer immediate intervention when a patient reaches out – a recognition of what author Beth Macy called the “liminal window”: the narrow band of time when an addicted individual seeks treatment before giving up and returning to opioid use. Instead of immediately accessing a board-certified physician or highly trained advanced practice clinician in the telemedicine space, patients will be forced to wait for an appointment with a non-expert provider or to have the clock ticking on their treatment from the moment they start with a telemedicine provider unless they can find an in-person referral source. And while any provider with a DEA license can now prescribe buprenorphine, transitioning patients from opioids to buprenorphine in the era of fentanyl is risky in the hands of inexperienced providers that patients may encounter while searching for a referral.
The cost of these proposed regulations to telemedicine providers will also be dear, especially a return to the pre-COVID stipulation that providers must carry a unique DEA license in each state of practice at $731 per state on top of general licensure costs and controlled substance registration fees in the twenty-five states and territories whose pharmacy boards require this additional bureaucratic hurdle. Providers may not see telemedicine patients unless they hold a DEA license in the precise state where they are located at the moment of the appointment, nor can they see patients in states where they do not have a unique DEA license, even if all other licensure is in place. For providers like myself with over 20 state licenses, the state-by-state DEA licensure requirement amounts to over $14,000 every three years for the privilege of providing critical service to patients who struggle to access care. It seems doubtful that my skills and attentive care diminish when I traverse the invisible boundary that bisects the Colorado River between Kingman, AZ, and Needles, CA. Still, I must maintain DEA licenses in both to see patients on either side.
Addiction medicine is uniquely suited to telemedicine – it is almost all talk. It is a thorough review of the path that a person took to opioid use and the doorstep of recovery, as well as common comorbidities that drive problematic drug use and make sobriety so hard to achieve: chronic pain, anxiety, depression, post-traumatic stress disorder, insomnia, attention deficit disorder, and other neuropsychiatric conditions. When physical interventions are required (such as attention to an injection site infection), referral to local in-person acute services is entirely appropriate – just as an addiction psychiatrist who has not drained an abscess since medical school would do. With no evidence that in-person exams improve outcomes or prevent diversion, telemedicine under rigorous regulatory compliance is not a second-rate stopgap level of care; instead, it sets new standards for excellence that brick-and-mortar services will be hard-pressed to match.
I believe that the DEA is populated by people whose hearts are in the battle to end the overdose crisis and that these proposed regulations are a correctable misstep in saving American lives. If you have opinions, the DEA’s commentary period is open until March 31st, 2023.
Julie Craig is an addiction medicine specialist.