The coronavirus has changed the face of medication-assisted treatment (MAT), in many ways, for the better.
Virus-related flexibilities have made it easier for patients to get medication, attend therapy sessions and avoid the stigma often associated with substance use disorder (SUD) treatment.
While it’s unclear what the SUD landscape will look like in the future, outpatient MAT providers hope the success they’ve had amid the COVID-19 emergency will make the case for coronavirus-related changes to become permanent post-pandemic.
One such hopeful provider is Annapolis, Maryland-based Pathways. The addiction treatment center is part of Anne Arundel Medical Center, a regional health system also headquartered in Annapolis.
Amid the coronavirus, Pathways’ outpatient MAT program has boomed, according to its director, Daniel Watkins.
“Overall, we just see such an increase in attendance and engagement because the barriers to access to treatment are decreased,” Watkins told Behavioral Health Business.
The center’s outpatient program serves about 15 to 25 patients per month, with a high percentage of those being Medicaid beneficiaries. Pathways does buprenorphine and vivitrol MAT, while also occasionally dispensing acamprosate and naltrexone tablets.
Overall, about half of all of Pathways’ outpatient MAT patients use buprenorphine — a MAT medication that’s especially benefited from COVID-19 flexibilities.
Usually, new MAT patients must be evaluated in person before they can receive MAT medication due to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. But the coronavirus changed that for buprenorphine patients.
In light of the national emergency, the Substance Abuse and Mental Health Services Administration (SAMHSA) has allowed licensed clinicians to remotely prescribe buprenorphine to new patients who have yet to be seen in person, as long as those patients can be adequately evaluated using telehealth.
The flexibility is a long-awaited victory for Watkins and other opioid treatment providers.
“This is one of the issues that we always have really pushed against because [buprenorphine] is monitored by the DEA in a way that Percocet is not,” Watkins said. “There are limitations on who can prescribe buprenorphine, how many patients the provider can prescribe buprenorphine to, and [clinicians] are required to take an additional training course to be able to prescribe buprenorphine.”
By allowing tele-prescription of the drug, new patients now have more privacy and fewer barriers to care. They don’t have to worry about explaining where they’re going, finding a babysitter or getting transportation to start MAT. As such, many SUD providers — including Watkins — would like to see the flexibility continue indefinitely to improve MAT access long-term.
“It shouldn’t depend on where you can afford to buy a house for how easy it is for you to get treatment for substance use disorder (SUD),” he said. “So taking the physical aspect out of the conversation and just letting people sign into their phone kind of puts everyone on an even playing field for access to treatment.”
Intermountain Healthcare, a not-for-profit health care system based in Salt Lake City, has benefited from the buprenorphine flexibilities, too. The health system has been working on developing a tele-MAT program for about a year, and the coronavirus led to a breakthrough on that front.
“The pandemic has been a little bit of a shining light for us because it finally solved the Ryan Haight Act issue,” Kerry Palakanis, executive director of connect care operations at Intermountain, previously told BHB. “And we’re hoping — fingers crossed — that there’ll be some long-term resolution for that, as well as to help us solve the problem of the patient needing to be in a clinical environment to receive care.”
Site of care rules have also loosed amid the coronavirus, pushing insurers to cover home as a site of care, as well as telehealth treatment, for patients with SUD.
Like Palakanis, Watkins has lauded the change and hopes it will remain post-pandemic. In fact, he says the flexibility has resulted in Pathways’ outpatient program seeing a 10% increase in attendance.
Before the coronavirus, patients in recovery had to attend group intensive outpatient programing (IOP) in person because most insurers wouldn’t reimburse for virtual attendance. But thanks to the virus-related emergency declaration, those in recovery can now attend IOP remotely, and it’s reimbursable.
“It’s really making the medication much more effective,” Watkins said. “Prior, we might have somebody on buprenorphine, and then two or three weeks into treatment, … something changed [and they stopped coming to IOP]. … So we’ve actually seen a lot less barriers to the counseling treatment access part of this, as well as the medication.”
Room for improvement
Despite the positives that have come with COVID-19 MAT flexibilities, challenges still exist. For example, it’s harder to remotely monitor patients with tools such as urine drug screenings.
Additionally, not all MAT drugs have been afforded the same flexibilities as buprenorphine. Take methadone, for example.
While Pathways isn’t licensed to provide methadone MAT, Pinnacle Treatment Centers is. In fact, the SUD treatment provider — which has 115 locations across eight states and offers the full continuum of care — specializes in Medicaid-reimbursed medication-assisted treatment (MAT) using methadone.
“We believe people should be able to access care as quickly as possible,” Pinnacle CEO Joe Pritchard previously told BHB. “We think the regulations that were eased around induction for buprenorphine and it being able to be done through telehealth was a very positive move. We were hoping they would do the same for methadone, which has not occurred yet.”
Methadone can be easier to overdose on than some other MAT drugs, which could be one reason initial tele-prescription of the medication has yet to be allowed.
Still, a large number of people using methadone for MAT are on Medicaid, and without tele-prescription flexibilities, it’s harder for those low-income patients to get treatment.
“I would cautiously say there should be easing of all MAT,” Watkins said. “Buprenorphine is kind of a no brainer, and access to methadone is equally as difficult. … That’s a covered service under medical assistance and not under most commercial insurances, so those patients struggle with the same social determinants and barriers.”
He added that reimbursement for co-occurring disorders would also be helpful.
It’s unclear what the telehealth landscape will look like for the substance use disorder (SUD) space post-pandemic, but MAT providers are fighting to keep certain flexibilities in place.
“One sad thing is that we don’t treat other diseases the same way we treat addiction,” Watkins said. “If you need to take blood pressure medicine, we don’t make you come to the office every time you need to refill, and those kinds of diseases — like high blood pressure, hypertension and diabetes — they can also be corrected with behavioral modifications like diet and exercise. … Eventually [MAT drugs] should be like you would get a heart medication: something that requires monitoring, but that isn’t so difficult to attain.”
The coronavirus has made the case for that to happen, Watkins said.
And while there are telehealth aspects that can continue no matter what — like virtual pill count and check ins — others are highly dependent on the federal government and various payers.
Providers like Watkins are hoping those stakeholders pull through to help improve nationwide access to MAT services. If they don’t, patients will suffer, he said.
“If we can’t continue MAT and outpatient SUD treatment as telehealth, then we’re going to be limited in capacity,” Watkins said. “Half of the people that we’re treating virtually would have to go somewhere else for treatment or not receive treatment because we couldn’t safely put them in the same area [due to the social distancing requirements].”