PROVIDENCE — Throughout the coronavirus pandemic, doctors around the country have been able to prescribe an effective treatment over the phone to new patients with opioid use disorder.
In Rhode Island, doctors set up a hotline to get people started on buprenorphine, commonly known as Suboxone. Those involved in the hotline believe it has saved lives. Without it, the deadliest year on record for opioid overdoses might have been even worse, they say.
But that hotline’s future is in doubt. It only exists because the federal government waived regulations requiring doctors to see patients in person first in response to the COVID-19 pandemic. And a bill in the US Senate — introduced by senators including Rhode Island’s Sheldon Whitehouse — would put the hotline out of business once the state of emergency is over, the people who set it up say.
That’s because the bill would require people to use a video call for their first visit. The doctors who run Rhode Island’s telephone-only hotline worry that this will make it more difficult for vulnerable populations — like homeless people, people in areas without broadband, and people getting out of prison — to access buprenorphine treatment.
“I feel like we’ve been able to move nimbly, and we’ve done that by setting up this innovative care delivery service,” said Dr. Elizabeth Samuels, a Brown Emergency Medicine physician who helped set up the hotline. “I just want us to be able to continue to provide that treatment.”
Samuels is one of the volunteer physicians who answers calls on the hotline, which can still be reached by calling (401) 606-5456. She assesses patients to see if they’d benefit from buprenorphine. The hotline has received 417 calls since it started, and 113 people have begun taking the medication — which Samuels called a “gold standard” for opioid use disorder. She generally prescribes a version of it that goes under the tongue and dissolves. It can curb cravings and help people with withdrawal, and has been shown to reduce overdoses and overdose deaths.
Recently, she got a call from someone who had set up a video call with a different provider, but had run out of data on her phone plan. So instead the patient called the hotline and was able to get Samuels, who was able to help. In a time when at least 384 Rhode Islanders died from overdoses in 2020, any delay while the woman waited for her new monthly data plan to kick in could have been the difference between life and death.
“She just remarked how easy it was to get treatment when she has had such difficulties in the past,” Samuels recalled.
The Rhode Island hotline is just the beginning for people’s treatment. It’s not for continued buprenorphine treatment. It’s a good way to start, though — they call it a “tele-bridge” — and Samuels would like to see it become a permanent fixture in Rhode Island even beyond the pandemic.
But skeptics have raised the prospect of diversion — when a prescription intended for one person goes to a different person. They’ve also raised concerns over the quality of care people receive when starting off with audio-only visits.
Samuels said in an interview that the most important thing during a clinical encounter is listening to a patient, not necessarily seeing them. And the benefits of eased access to treatment, she said, far outweigh any risks about diversion. Most diverted buprenorphine is being used for therapeutic purposes, Samuels said, which shows that there’s a problem with access. And although diversion is a real issue, mandating a video call wouldn’t help address it, she said. Things like electronic prescribing and prescription drug monitoring programs are still in use.
“There’s nothing about a video visit that reduces diversion in any kind of way,” Samuels said.
Late in March, US senators introduced new legislation to deal with addiction and recovery. Whitehouse was among them.
Before the pandemic, someone who wanted to start on buprenorphine had to visit a prescriber in-person. The emergency order last spring in response to COVID allowed people to do it via telehealth, which includes phone calls or video visits.
The bill Whitehouse and other senators introduced would allow people to start on buprenorphine without an in-person visit — but it would require some sort of video visit with a prescriber first. That would effectively put Rhode Island’s phone-based system out of operation.
“The doctors and behavioral health professionals who consulted with the office on this legislation have expressed a range of opinions about the potential merits and downsides of only requiring an initial phone call to get a prescription for buprenorphine,” Whitehouse spokeswoman Meghan McCabe said in an e-mail. “Our staff will keep working with the medical experts as we continue fine tuning the legislation.”
Though no state has a hotline exactly like Rhode Island’s, the potential changes to federal rules around buprenorphine prescriptions is stirring opposition nationally. More than 600 people have signed a petition asking policymakers to continue allowing audio-only telehealth visits.
Linda Mahoney, a state official and Rhode Island’s opioid treatment authority, said in an interview that there’s a balance at play in the debate.
“You have the physicians that are saying we want to see someone at least for the initial consultation, to get that engagement, to see how the person presents. It’s difficult to do if you’re doing it on the phone,” she said. “I also understand the opioid crisis, and losing 300-plus people in a year. … I’m all about engagement, as much as I can. I also want to meet people where they are, not where I think they should be.”
Others have pointed out the drawbacks to audio-only telehealth.
Linda Hurley, president and chief executive of the behavioral health provider CODAC, is a supporter of the legislation that Whitehouse and other senators introduced. She said that there are downsides in patient care when a prescriber can’t see a patient, even over video. Seeing a patient is an important part of assessing them, she said.
“In the patients’ best interests, there needs to be a compromise with it,” Hurley said.
Hurley also said she felt that advocates for the phone-only hotline have overstated the number of people who don’t have access to smartphones with video capabilities. Few people, even people experiencing homelessness, lack the technology to be able to make a video call, Hurley said. And there’s no data around it, she said.
But doctors who work the hotline say they know firsthand what the telephone hotline can mean for people.
Dr. Wei Sum Li, who’s in the addiction medicine fellowship at Brown University and works as a provider on the hotline, recently worked to get a woman and her boyfriend access to buprenorphine. The woman told her she’d saved two lives that day.
“Most people who call are just anticipating barriers,” Li said. “There’s an incredible sense of palpable relief when they realize, you’re actually going to help.”