So why are we going backward?
The DEA’s newly proposed “guardrails” are more aptly “roadblocks” for addiction patients and providers alike.
After decades of restrictions on buprenorphine, the federal government recently lifted arbitrary administrative barriers to prescribing, only to erect a new one: an in-person visit requirement within 30 days of starting addiction medication.
This rule will disproportionately harm the most marginalized patients, while doing nothing to actually regulate telehealth quality.
And it comes at a time the government is calling on family practitioners like me to step up in the midst of a severe provider shortage, and against the backdrop of a worsening overdose crisis.
It sets us up to fail.
Nationwide, community clinics are underfunded and overwhelmed. Skeleton crews cannot possibly dedicate the time and resources needed from patients struggling with substance use. Waitlists for bare-boned opioid treatment are months long, particularly for low-income patients in rural areas.
When I worked at a community health center in 2019, we were flooded with demand as the only option for opioid treatment in multiple counties. Primary care and pediatrics patients could no longer get appointments. People dropped out for “safety concerns,” as multiple overdoses occurred in the waiting room and illegal drugs were sold in the parking lot.
Specialized addiction facilities are often worse: hollowed out shells that resemble warehouses, herding patients like cattle to get prescriptions for cash.
Being face-to-face clearly does nothing to guarantee quality. Even if it did, thirty days is insufficient time to find a provider that has appointment availability, is willing to see addiction patients, and accepts insurance.
What medical need does an in-person exam serve? Experts agree for this condition it’s “nice to have” a liver panel and toxicology screen, for example, but there’s rarely urgency. Tests can be ordered at home or to a local lab. Our illicit drug supply has become so deadly, nothing we’d find in a test result would kill a person faster than disrupting their buprenorphine treatment.
In my experience, virtual care enables better quality standards than office-based addiction medicine ever has – and the impact has been profound.
I have seen folks blossom under my care. Our lengthy video visits create space for rich, inspiring conversations. I’ve met spouses, children, and pets. Patients give me entire tours of their homes out of sheer pride.
Unlike anywhere I’ve ever practiced, patients are retained long enough for me to get a complete picture of their health over multiple years.
My patients say they’re relieved to no longer be treated as a number in a revolving-door system. They engage with comprehensive social services and peer support we offer online. Unlike in-person pill mills exchanging drugs for cash, we accept all insurance types and are accountable for our outcomes in order to get reimbursed. Taken together, I am certain these innovations represent the right direction for our country.
Sufficient “guardrails” already exist for buprenorphine in all 50 states, including strictly enforced prescription drug monitoring programs. If anything, telehealth offers more tools to prevent misuse: enabling us to see patients more frequently, visually observe their medication dosing and drug tests, and keep a longitudinal patient record.
For nearly five years, the federal government has promised us thoughtful, balanced guidance for controlled substance prescribing over telehealth. Instead, they reverted to an outdated concept that will be devastating to our collective progress.
My heart aches for those who will suffer most if this rule is made:
- Patients with chaotic caregiving responsibilities and no transportation.
- Workers who can’t afford to miss a single shift.
- The homeless and uninsured who will lose the telehealth prescription that has kept them out of the ER the last several years, and never be heard from again.
- The mother of a newborn – one-year sober – refusing to see a provider in fear they’ll discriminate based on her medical history and skin color, and take her child away.
- The father in a rural community who can’t seek treatment in person without risking his social standing.
Expanding virtual care won’t ease all the formidable burdens patients carry when seeking recovery. But the least we can do is give them a fighting chance.