The Veterans Health Administration (VHA) was an early adopter of telehealth care starting in 2003. As a result of a number of telehealth initiatives, VHA conducted over a million telehealth visits in 2018. More than half of these visits provided care to Veterans located in rural areas, and 10% of these were conducted using VA Video Connect (VVC) which allows providers to see Veterans on their mobile devices or personal computers at Veterans' location of choice. In 2018, as part of the MISSION Act, the VA set the "Anywhere to Anywhere" telehealth initiative, seeking to ensure that by 2021, 100% of providers in outpatient Mental Health and Primary Care service lines nationwide would be both capable and experienced with telehealth service delivery into the home.
SARS-CoV-2, the virus that causes coronavirus disease (COVID-19), has potentially left individuals with opioid use disorder at risk of not receiving evidence-based treatment. Access to healthcare for all Veterans has been significantly decreased due to social distancing guidelines which has left some of our most high-risk Veterans, those with opioid use disorder (OUD), vulnerable to poorer health outcomes. Individuals with an OUD are at a significantly high risk of overdose, unintentional death, and a wide range of negative health related consequences. The U.S. saw a 4.1-fold increase in opioid-related deaths between 2002 and 2017, and Veterans experience opioid overdose at twice the rate of non-Veterans. Fortunately, evidence-based medications for OUD exist including buprenorphine. However, due to the potential for misuse, there are additional training requirements for providers to be certified to prescribe these types of medications, resulting in inadequate numbers of providers in some areas, particularly rural ones. Telehealth is a potentially effective method of service delivery to mitigate this access to care issue, but the Ryan Haight Act of 2008 mandates that the first visit with a prescriber of schedule II-IV controlled substances must be done in person. This is particularly challenging for rural Veterans who live in areas that already have a limited number of eligible prescribers and face significant time/travel constraints. Due to the public health emergency caused by COVID-19, the Diversion Control Division of the U.S. Drug Enforcement Agency has temporarily waived (as of March 16, 2020) the in-person requirement for OUD prescriptions issued for a legitimate medical purpose and which are in accordance with state and federal law.
Waiver of Ryan Haight Act due to COVID-19 creates potential for treatment retention for high-risk Veterans with OUD. The Ryan Haight Act waiver presents a unique opportunity to understand the impact of the VHA's preexisting telehealth structure for the treatment of OUD, and about the costs/benefits of this 12-year-old policy. Will telehealth allow for prescription maintenance, or will prescriptions drop? Relatedly, will relaxing this requirement lead to a dramatic increase in prescriptions for controlled substances? And, finally, what are the barriers and facilitators associated with this recent change in policy for substance use providers, and how can this information inform the VHA's response to future natural and/or public health disasters, particularly for high-risk Veterans?
Objective 1 - Develop methods required to conduct robust analyses assessing the impact of COVID-19 and related changes in policy and service design on access to care and medication management for Veterans with OUD.
Aim 1a: Conduct qualitative interviews with providers and key local stakeholders in the Substance Treatment and Recovery (STAR) and telehealth clinics to understand a) modes of patient interaction (i.e., in-person, telephone, VVC, or other modes of video conferencing) used, b) documentation patterns for these visits, and c) perceived facilitators and barriers to the rapid expansion of telehealth for OUD.
Aim 1b: Incorporate key stakeholder findings to accurately record and measure evolving telehealth visit modalities in order to construct structured Corporate Data Warehouse (CDW) queries to assess visits as well as prescription rates for schedule II-IV opioid medications.
Objective 2 - Conduct preliminary analyses of temporal trends in schedule II-IV narcotic prescription rates for Veterans who would normally fall under the parameters of the Ryan Haight Act using an interrupted time series design during the COVID-19 window (estimated to be from 3/16/20 - 6/30/20 at time of grant submission).
Aim 2a. Examine and compare the rate of prescriptions for buprenorphine (Suboxone®).
Aim 2b. Examine and compare the rate of prescriptions for other schedule II-IV narcotics (hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®, Percocet®), fentanyl (Sublimaze®, Duragesic®), morphine, opium, codeine, and hydrocodone, products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine®).
Aim 1 Methods: Individual qualitative interviews with providers and key stakeholders.
Aim 2 Methods: We will extract data from the CDW and pharmacy databases, and will use segmented regression interrupted time series (SR-ITS) to assess changes in prescribing behavior potentially attributable to the waiver of the Ryan Haight Act to access narcotic prescriptions via telehealth. SR-ITS allows for the assessment of long-term effects on an outcome attributable to a specific event (policy intervention) in time, i.e., the implementation of legislative mandates. We will see if there are differences in the effect of the intervention by rurality, age, gender, and race/ethnicity.
We conducted qualitative interviews with providers delivering video telehealth to high-risk Veterans with OUD. Preliminary analysis of the interviews with providers new to video telehealth have shown that providers on the whole are receptive to providing mental healthcare via video telehealth. However, the perceived burden of having to deal with the extra logistical steps required to provide care via telehealth deters their use in favor of telephone contacts. Lead prescribers, in particular, appear to be more likely to prefer a phone appointment versus 'struggling' with video telehealth. Providers reported comments such as "[I] only have 30 minutes, I'm going to waste it troubleshooting. if there are issues, I just call the Veteran." When it comes to high-risk Veterans, such as those with OUD, providers also report more anxiety about ensuring the safety of their patients and/or about handling clinical emergencies over video telehealth at a time when they believe their patient loads include a higher number of severe/acute patients in need of welfare checks.
Despite the MISSION Act, and although demand for virtual mental healthcare service delivery is at an all-time high due to the COVID-19 pandemic, most of the virtual care (46%) within VHA was delivered by telephone during the study window, with only an average of 28% of visits provided via VVC. As the Ryan Haight Act waiver does not acknowledge a telephone contact as adequate or sufficient for prescribing a new patient BUP, new Veterans with OUD, particularly those residing in rural areas with few available providers, were at risk for delays in care and/or receiving suboptimal care.
With the Ryan Haight Act's in-person requirements waived, if providers are delivering care via video telehealth, prescription rates for MOUD should, in theory, remain steady despite the pandemic. We examined prescription information from the VA Corporate Data Warehouse for 42,579 Veterans diagnosed with OUD (91.6% male, 71% white, 16.8% black, 27% rural dwelling). During this 12-month window, 56.6% of the sample were prescribed suboxone, 53.6% were prescribed sedatives, and 13.8% were prescribed anxiolytics. Monthly an average of 33,323 (SD = 3,190) prescriptions were filled, with an average of 1.45 (SD = .08) medications prescribed per visit. As expected, the largest dip was seen in April 2020, with only 28,376 prescriptions filled, with 1.33 prescriptions written per visit. As of August 2020, the rates for prescriptions for controlled substances had not returned to pre-COVID levels. These data suggest that while telehealth is a legal option to appropriately prescribe controlled substances, it was not utilized in a way that replicated in person care. We are currently examining potential differences by group, such as age, gender, and race/ethnicity. Pending the outcome of these analyses, we will integrate the qualitative results from Aim 1 with the quantitative results of Aim 2 to fully describe how telemental healthcare was or was not delivered for Veterans with OUD, and potential provider-level factors underlying these results.
Findings from this rapid pilot will be of immediate relevance and impact for VA operations partners who include VA Analytics and Business Intelligence (RAPID), VA Office of Mental Health and Suicide Prevention, and VA Office of Connected Care. Further, the results of this pilot study will go to support a Merit award in the future examining the individual impact of telemental health treatment for high risk Veterans during COVID-19, with the goal of developing a toolkit enabling VHA to better respond to future natural disasters and other healthcare system disruptions.
- Myers US, Birks A, Grubaugh AL, Axon RN. Flattening the Curve by Getting Ahead of It: How the VA Healthcare System Is Leveraging Telehealth to Provide Continued Access to Care for Rural Veterans. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2021 Jan 1; 37(1):194-196.
Substance Use Disorders, Health Systems
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