Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

Abstract

Background: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD). Case Presentation: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/ naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later. Conclusions: COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.

Addictions in the COVID-19 era: Current evidence, future perspectives a comprehensive review

“…In-home initiation of buprenorphine is a routine in some Western countries ( Poloméni and Schwan, 2014 ) and newer long-acting injectable formulations of buprenorphine may be preferred. Buprenorphine initiation via telemedicine is legally possible in the U.S and has been successfully reported in a case report study ( Harris et al, 2020 ). A retrospective two years study found no difference between telemedicine and face-to-face buprenorphine medication-assisted treatment programs ( Zheng et al, 2017 ).…”

Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic

“…Sexual Health Care Clinics and SSPs provided examples on how to connect patients with providers during COVID-19 via telehealth [12,13], and a recent opinion paper demonstrated the utility of telehealth in preventing disruption of care for people with OUD and co-occurring mental health disorders during COVID-19 [14]. With the development of TeleMOUD, we aimed to mitigate disruptions in care by serving patients with OUD who could not receive in person care within a hospital or clinic setting.…”

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

“…Medication Assisted Treatment in the Criminal Justice System: Brief Guidance to the States. 2019 ( Substance Abuse and Mental Health Services Administration, 2019b ) California Health Care Foundation Medication-Assisted Treatment in County Criminal Justice Settings Project ( California Health Care Foundation, 2018 ) American Society of Addiction Medicine Treatment in Correctional Settings Toolkit ( American Society of Addiction Medicine, 2019b ) Principles of Drug Abuse Treatment for Criminal Justice Populations-A Research-Based Guide ( National Institute on Drug Abuse, 2014a ) Protocol for Consent to Treatment with Medications for Opioid Use Disorder in Correctional Facilities ( Massachusetts Bureau of Substance Addiction Services, 2019 ) Expanding access to MOUD treatment through telemedicine, interim buprenorphine or methadone, or medication units Medication units: electronic-Code of Federal Regulations - 8.11 ( Office of the Federal Register and Government Publishing Office, 2019b ; Substance Abuse and Mental Health Services Administration, 2015b ) Interim methadone: electronic-Code of Federal Regulations – 8.11 ( Newman, 2014 ; Office of the Federal Register and Government Publishing Office, 2019a ; Schwartz et al, 2006 ) Interim buprenorphine ( Office of the Federal Register and Government Publishing Office, 2019b ; Sigmon et al, 2016 ) Low Barrier Tele-Buprenorphine ( Harris et al, 2020 ) MOUD Bridge Programs ( Snow et al, 2019 ) San Francisco Street Medicine Team ( Carter et al, 2019 ) Telemedicine&Prescribing Buprenorphine for the Treatment of Opioid Use Disorder ( U.S. Department of Health and Human Services, 2018 ) Project “Support for Hospital Opioid Use Treatment” Webinar on Telemedicine and MOUD Treatment ( Project SHOUT and California Health Care Foundation, 2018 ) Interventions to Link to MOUD (required) Linkage Programs (all relevant settings) Within (or initiated within) Service Settings Massachus...…”

“…Expanding access to MOUD through telemedicine is especially salient as communities consider ORCCA strategies during the COVID-19 pandemic. Telemedicine models for buprenorphine treatment already existed ( U.S. Department of Health and Human Services, 2018 ), but guidance from the US Drug Enforcement Agency, SAMHSA, the Centers for Medicare & Medicaid Services, and state regulatory agencies changed rapidly ( Harris et al, 2020 ; Opioid Response Network, 2020 ; Providers Clinical Support System, 2020a ; Substance Abuse and Mental Health Services Administration, 2020c ) to allow greater flexibility of MOUD treatment via telemedicine during the pandemic. For example, the requirement for an in-person visit to begin MOUD was waived and dispensing of medications was allowed for longer periods of time.…”