Back to the Future: Advancing Opioid Use Disorder Policy and Patient Care Beyond the SARS-CoV-2 Pandemic

In the 1980s film Back to the Future, teenager Marty McFly is mistakenly sent back in time 30 years and must ensure that his would-be parents connect to guarantee his future existence—back in the future. This film illustrates how the future can look dramatically different depending on decisions made in the present, much like public health.

Telehealth Compensation and the Inclusion of Audio-Only Services
In the past 2 years, telehealth policy has sped light-years ahead. Before the COVID-19 pandemic, many healthcare professionals (HCPs) in rural and poor communities provided informal yet uncompensated telehealth for years. When people living with HIV (PLWH) were unable to access brick-and-mortar clinics, we would assess them over the phone before ordering necessary tests and treatments. This is de facto telehealth, but we weren’t routinely able to bill for it. That changed early in the pandemic when the Department of Health and Human Services (DHHS) and the Centers for Medicare & Medicaid Services made temporary provisions to allow and even encourage telehealth for both video and audio-only (ie, telephone) visits. Now, PLWH without transportation, time off work, childcare, or even a smartphone are able to access medical care via a simple phone call. 

The approval of audio-only services, rather than tele-video options only, is a critical distinction. Tele-video visits require access to a smartphone, a wireless service, and a data plan—widening disparities for poor individuals, rural individuals, and those with low technology literacy. Making audio-only services a permanent part of care delivery and ensuring that it is fairly compensated will allow us to meet marginalized patients where they are and give HCPs more flexibility as well. Waiting for more data before extending this common-sense provision will only hurt patients.

Regulatory Relaxations for Opioid Use Disorder (OUD) Treatment
In some communities, up to 30% of PLWH have a lifetime history of OUD, making recent OUD policy changes critical for the HIV community. Regulatory changes have expanded access to OUD treatment, an urgent shift in a year marked by more than 100,000 overdose deaths in the United States. Buprenorphine is an FDA-approved medication that reduces nonmedical opioid use, overdose, death, and related infections like HIV. Previously, HCPs were required to conduct an in-person evaluation before prescribing buprenorphine. But, through a recent exemption, HCPs may now initiate buprenorphine via telehealth. Same-day buprenorphine initiation is even feasible for many PLWH when they are at the highest risk of overdose, such as at discharge from the hospital or in the criminal legal setting. In my clinic where I provide integrated HIV and OUD care, I can initiate buprenorphine when my patients need it, regardless of our respective schedules and location, as long as we both have access to a phone. 

The Drug Addiction Treatment Act of 2000 previously mandated that physicians complete 8 hours of training before becoming a certified buprenorphine prescriber (ie, x-waivered). The new DHHS Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder changes this: Prescribers may now treat up to 30 patients without laborious training under certain conditions. This exemption applies to Schedule III, IV, and V drugs, like buprenorphine, but not Schedule II drugs (eg, methadone). Although promising, this is a small step when what we need is major change. It will take financial incentives, loan repayments, and normalization of addiction as a chronic disease if we are to attract and equip a robust pipeline of HIV HCPs to respond to this public health emergency.

Additional Innovations
This is an abbreviated list of health policy progress for PLWH during the SARS-CoV-2 pandemic, a silver lining during a grim time. Other innovations allow methadone take-home kits, virtual naloxone training and mail delivery, and syringe service programs. The most aspirational example is New York’s recent approval of supervised injection sites—where harm reduction can be paired with addiction, social services, and HIV prevention and treatment. Although the prospect of legal consumption is startling to some, the status quo for addiction treatment in America is clearly not working. In fact, it is not just broken, it is deadly.

Closing Thoughts
Under the weight of a crippling pandemic, we have seen important advances in health policy. Vulnerable Americans, including PLWH and those at risk for HIV, have the most to gain from these changes, making it imperative that we not lose ground in the fight for equity. We don’t need a DeLorean or even fancy technology to help save our nation in crisis, we need dramatic change and common-sense policies that accelerate access to HIV and addiction care, health, and healing.

Your Thoughts?
How have you adapted addiction service provision in your clinical setting to overcome barriers imposed by the pandemic, and how have these changes helped to address barriers that already existed for vulnerable populations such as people with HIV? Answer the polling question and join the conversation by posting a comment.