At the time of initial presentation to a virtual
Ms. A’s presentation is consistent with opioid use disorder (OUD), severe, as evidenced by escalating amounts of opioid use over time, unsuccessful attempts to quit or cut down use, craving, continued use despite persistent interpersonal problems and health consequences, and spending an excessive amount of time obtaining opioids. Numerous factors predisposed Ms. A to developing OUD and perpetuating her continued use as well as preventing her from receiving treatment. Medical professional, psychosocial, and economic factors included overprescribing of opioids at the time of hospital discharge without a clear plan for cessation; lack of medical providers’ knowledge about addiction and how to safely taper prescription opioids; lack of social and instrumental support in the postpartum period; nonpaid maternity leave and early return to work; availability of opioids through friends and family members; emergence of depressive symptoms while attempting to taper opioids; lack of health insurance and its many implications, including lack of access to contraceptive care; and other gender-specific barriers to care, such as childcare responsibilities and legal consequences specific to substance use in pregnancy, including child welfare services involvement.
The standard of care for the treatment of perinatal OUD includes medication for OUD, with either methadone or buprenorphine (1), as part of a comprehensive treatment program including prenatal care, psychological interventions for relapse prevention, treatment of comorbid mental health conditions, and addressing psychosocial needs of women and the mother-infant dyad. Medication for OUD is a critical component of care. Continuation of medication treatment is associated with lower rates of relapse, longer duration of treatment, and improved maternal and obstetric outcomes, compared with discontinuation of treatment (2–4). Barriers to receiving the standard of care for OUD are numerous, including a paucity of available and accessible comprehensive treatment programs. The use of telehealth technology has the potential to increase access to and availability of comprehensive specialty services; however, federal and state laws and lack of health insurance coverage for critical components of this care have prohibited widespread adoption. Out of necessity to respond to the COVID-19 public health crisis, our health systems have been forced to reconsider and leverage telemedicine to deliver health services.
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Epidemiology of OUD in Pregnancy
Use and misuse of opioids among pregnant women has increased fivefold over the past decade (5–7), and more than 20,000 opioid-exposed births occur annually (8). From 1999 to 2014, the number of pregnant women with OUD in the United States more than quadrupled, increasing from 1.5 to 6.5 cases per 1,000 hospital births (9). The increasing prevalence of perinatal OUD and its effects on pregnant women and infants are of increasing public health concern, given the significant morbidity and mortality associated with this chronic disease (10, 11). Rates of relapse are extremely high in the early postpartum period (12), and drug overdose is a leading cause of death during the postpartum year (13).
Telemedicine for Medication Treatment of OUD and Integration With Prenatal Care
Traditional methods of identification and treatment of OUD in pregnancy occur through the obstetrician/clinician or self-identification. The rate of identification is very low, and the rate of treatment is even lower. Only about 25% of pregnant women with OUD receive treatment, and fewer receive medication for OUD, even though it is the gold-standard treatment for OUD (14). Even among women who initiate medication treatment for OUD, over half (56%) will discontinue their medication by 6 months postpartum (4). Given the limited access to care among pregnant and postpartum women with OUD, telehealth serves as an effective and plausible treatment, with data indicating that rates of retention in treatment and substance use did not differ between those receiving integrated OUD treatment via telemedicine compared with those receiving it in person (15). Fortunately, few adaptations are needed to ensure safe and appropriate prescribing of medications for OUD via telemedicine, including, for example, in-home salivary toxicology screens that can be collected and interpreted during a telehealth video visit. If necessary, samples can be sent to a laboratory for confirmatory testing.
Critical barriers to uptake and accessibility of medications for OUD, particularly for rural and low-resource populations, were recognized well before the COVID-19 pandemic. Buprenorphine treatment, with its lower overdose risk profile and ability to be prescribed beyond traditional opioid treatment program settings (i.e., in primary care settings by waivered physicians), has long been touted as a potential tool for increasing access and uptake of medication treatment for OUD. However, two key regulatory barriers have limited the potential impact of outpatient buprenorphine on the OUD treatment landscape: 1) the requirement for a Drug Addiction Treatment Act of 2000 prescribing waiver and associated limits to patient census (16), and 2) the requirement of initial in-person medical evaluation prior to initiation of buprenorphine (17). Various patient and health care advocacy organizations have been lobbying for changes to these requirements since 2015, culminating in the Mainstreaming Addiction Treatment Act, which was presented on the Senate floor in July 2019 but ultimately failed to gain sufficient support.
Given the nationwide impacts of the COVID-19 pandemic, on March 19, 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) exempted opioid treatment programs from the requirement that they perform an in-person evaluation prior to initiating buprenorphine treatment (18). On March 31, 2020, in a joint statement, the Drug Enforcement Administration and SAMHSA announced that controlled substance prescriptions could be issued to patients via telemedicine without first conducting an initial in-person evaluation (19). Since the implementation of these changes, various groups have called for them to extend in perpetuity beyond the COVID-19 public health emergency (20).
The aforementioned policy exemptions made the telemedicine services for Ms. A possible. These exemptions have greatly facilitated access to OUD treatment during pregnancy, but the postpartum period remains a critical gap when health insurance benefits lapse for many women, increasing their risk for relapse, overdose, and death (13). Permanent changes to telemedicine policies and the extension of health insurance for the postpartum year has great potential to reduce maternal and newborn morbidity and mortality associated with untreated OUD.
Evaluation data from telemedicine services during the COVID-19 pandemic has the potential to inform an evidence-based reconsideration of restrictions and limitations that have traditionally hampered access to medications for OUD while still ensuring the appropriate balance between benefit and risk to the patient. Key data points from programs such as the one described in this case study will be important guideposts for future decisions regarding lifting regulations. Examples of key data points that are currently being collected include changes in program access since transition to a full virtual platform; changes in referral rates from obstetric providers across the state; changes in adverse event counts potentially related to waiver of initial in-person evaluation; treatment engagement and retention rates; and qualitative patient and provider insights regarding their experience with the full telemedicine program.
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