Expansions in telehealth services and increased use of medications for opioid use disorder (MOUD) were associated with significant decreases in fatal drug overdoses during the pandemic, a new study of Medicare beneficiaries shows.
Telehealth services for opioid use disorder (OUD) were used far more often during the pandemic than before COVID-19, and those who used them were 33% less likely to die of a drug overdose.
Investigators also found a significant increase in MOUD use during the pandemic. Fatal drug overdoses were 59% less likely among individuals who received MOUD from an opioid treatment program and 38% less likely among those treated with buprenorphine in an office-based setting.
The results come as policymakers are preparing for the end of the public health emergency that prompted the expansion of OUD-related telehealth and MOUD prescribing and are deciding whether to make those expansions permanent.
"The expansion of telehealth during the COVID-19 pandemic appears to have had positive effects on patients receiving MOUD, improved retention among patients who received MOUD, and lowered risks for both nonfatal and fatal overdose," lead investigator Christopher M. Jones, PharmD, DrPH, director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, Atlanta, Georgia, told Medscape Medical News. "Our results suggest that telehealth is a valuable tool in the toolbox for expanding access to and improving retention on MOUD."
The findings were published online March 29 in JAMA Psychiatry.
Increase in Treatment
The study included 105,162 Medicare beneficiaries who began OUD treatment between March and August in 2019 (prepandemic cohort; 67.6%
aged 45–74 years), and 70,479 who began treatment between March and August of 2020 (pandemic cohort; 66.3% aged 45–74 years).
Participants had not received OUD treatment in the 6 months leading up to study enrollment and were followed for 6 months after treatment began.
Significantly more study participants received OUD-related telehealth services during the pandemic than prior to 2019 (19.6% vs 0.6%; P < .001). Receipt of MOUD was also significantly higher in the pandemic cohort (12.6% vs 10.8%; P < .001).
The rate of drug overdose deaths was higher in the pandemic cohort (5.1 deaths vs 3.7 deaths per 1000 beneficiaries; P < .001). But the percentage of deaths due to drug overdoses did not differ between groups (4.8% in the prepandemic cohort vs 5.1% in the pandemic cohort; P = .49).
In the pandemic cohort, fatal drug overdoses were 33% less likely among those who received OUD-related telehealth services (aOR, 0.67; 95% CI, 0.48 – 0.92); 59% less likely among those who received MOUD from opioid treatment programs (aOR, 0.41; 95% CI, 0.25 – 0.68), and 38% less likely among those who received buprenorphine in office-based settings (aOR, 0.62; 95% CI, 0.43 – 0.91).
Risk of fatal overdose was significantly lower among women and those aged 65 years and older. There were no significant differences in risk based on urban or rural residency or on ethnicity.
"Against the backdrop of a highly potent illicit drug supply driven by illicit fentanyl and fentanyl analogues and historically large increases in overdose deaths during the COVID-19 pandemic, MOUD was still highly effective at reducing risk for fatal overdose," Jones said.
While the use of buprenorphine in office-based settings was associated with a decreased risk of overdose death, use of extended-release naltrexone was not.
"Prior research has demonstrated the effectiveness of extended-release naltrexone in the treatment of opioid use disorder," Jones said. "However, research has also shown that patients have challenges getting started, or inducted, on extended-release naltrexone."
An earlier study by Jones and colleagues showed that rates of retention were lower with extended-release naltrexone compared to buprenorphine in office-based settings or MOUD from opioid treatment programs.
The new study included only a small number of individuals who were receiving extended-release naltrexone, which may have influenced the findings. In addition, challenges with induction and retention may be driving the results, Jones noted.
"Efforts to improve induction and retention with extended-release naltrexone are important areas for future research and clinical practice," he added.
An Important Engagement Tool
A number of questions about telehealth care for OUD remain, including whether increased access to care accounts for the reduction in drug overdose risk that the investigators found or whether other factors are at play.
"There is still more we need to understand about telehealth, such as the quality of care provided and the particular aspects of care provided by telehealth and how this influences health outcomes," Jones said.
The results also suggest treatments for OUD are still not finding their way to patients who might benefit, he added.
"Despite the positive findings and the prior research showing that MOUD is highly effective, we found that only 1 in 5 patients received telehealth services and only 1 in 8 received any MOUD. This really underscores the need to expand these services across clinical settings," he added.
These and earlier findings demonstrate the potential benefits of continuing pandemic-era expansion of OUD-related telehealth services and MOUD access, Jones said.
In preparation for the end of the public health emergency on May 1, the Drug Enforcement Agency recently released a proposal that would allow providers to prescribe a 30-day supply of buprenorphine, but for patients to receive additional prescriptions, a face-to-face meeting would be required. The proposal has drawn criticism from addiction medicine specialists.
The current study didn't explore if or how the proposal might affect patients with OUD or whether it could blunt the positive effects of the findings.
"Prior research shows that keeping individuals engaged in treatment, including on medications, is a critical part of reducing the negative health and social impacts of opioid use disorder. Our results suggest that telehealth can be an important tool in helping patients engage in and stay connected in care," said Jones.
The study was funded by the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and the National Institutes of Health. Johnson reports no relevant financial relationships.
JAMA Psychiatry. Published online March 29, 2023. Full text
Kelli Whitlock Burton is a reporter for Medscape Medical News covering psychiatry and neurology.
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Image 1: Centers for Disease Control and Prevention
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Cite this: Telehealth Services Tied to a Major Reduction in Opioid Overdose Deaths - Medscape - Mar 29, 2023.