Telebehavioral Health and Opioid Use Disorder

The federal government has emphasized the importance of telemental and telebehavioral health interventions in addressing the opioid epidemic in rural communities. In particular, the U.S. Department of Health and Human Services (HHS) is seeking to leverage telehealth to expand access to medication-assisted treatment (MAT). In 2018, HHS released additional guidance about using telehealth to provide MAT. This guidance describes a case scenario where a nurse practitioner in a rural health clinic works with a remotely located addiction specialist physician through telehealth to manage buprenorphine treatment for opioid use disorder.

Rural communities are using innovative telehealth approaches to provide care for people with opioid use disorder. Examples of these approaches include:

• The Mission Virtual Clinic provides telebehavioral services to rural hospitals and primary care clinics in North Carolina. Telehealth services include around-the-clock crisis assessments, consultations for inpatients, and substance use assessments. Licensed mental health providers also use telehealth to provide counseling for patients receiving MAT in rural clinics.
• The California Department of Health Care Services is implementing the California MAT Expansion Project to help address the opioid epidemic in areas with limited access to MAT, including rural communities. Several programs funded through the MAT Expansion Project are using telehealth to increase access to treatment. For example, Bright Heart Health offers a telehealth platform that connects behavioral health providers in remote locations to emergency departments (ED) in rural California. These providers can consult with the ED physician and call in or fax a buprenorphine prescription. In the ED, patients can also access the Bright Heart telehealth platform on a tablet to consent to treatment and make follow-up counseling appointments.
• The University of Vermont piloted an innovative Med-O-Wheel telehealth intervention to improve medication adherence for patients traveling long distances and facing lengthy waitlists to access MAT. Patients received a limited supply of buprenorphine or methadone in a locked pill wheel. The secure pill dispenser allowed patients to access the medication once a day, during a predetermined time window. When the device unlocked, patients used an mHealth application on a smartphone or tablet to record themselves taking the medication via video. A second study of the Med-O-Wheel found that participants who received the buprenorphine were significantly less likely to report illicit opioid use than the control group. Other states, including California, are replicating Med-O-Wheel interventions to address long waitlists for MAT services.

Implementation Considerations

Rural programs implementing telebehavioral health programs should be aware of the implications of the Ryan Haight Online Pharmacy Consumer Protection Act, which requires an in-person patient evaluation before a provider can prescribe a controlled substance. In 2018, the U.S. Drug Enforcement Administration (DEA) released a clarifying statement on the provision of MAT using telehealth that exempts DEA-registered practitioners from the requirement of conducting an in-person visit. Six states also have state laws with provisions for prescribing controlled substances through telehealth without an in-person examination.