Expanded Virtual OUD Medication Access Likely to be Cost-Effective

Regulatory flexibilities enabling virtual initiation and at-home doses of medications for opioid use disorder (OUD) are likely cost-effective, according to new research.

Published in the journal Drug and Alcohol Dependence, the study aimed to assess the effectiveness and cost-effectiveness of buprenorphine and methadone treatment provided through expanded regulations enacted during the COVID-19 pandemic.

Federal agencies enacted numerous waivers to curb healthcare access challenges resulting from in-person care restrictions during the pandemic. Among these was an exception issued by the Substance Abuse and Mental Health Services Administration (SAMHSA), which allowed healthcare providers to initiate buprenorphine treatment via telehealth and offer take-home doses of methadone under certain circumstances. In December 2022, SAMHSA issued a Notice of Proposed Rule Making (NPRM) to make these flexibilities permanent, and the Department of Health and Human Services (HHS) published a final rule on February 2 solidifying the exceptions.

For the study, Stanford University researchers conducted a model-based analysis of buprenorphine and methadone treatment for 100,000 OUD patients with and without regulatory flexibilities in place. The research team assessed discounted lifetime per-person quality-adjusted life years (QALYs) and costs.

Researchers estimated that buprenorphine provision would cost $19,200 per QALY gained compared to no treatment if the treatment retention rate under the regulatory flexibilities remains unchanged. If the treatment retention rate increases by 20 percent, buprenorphine provision would cost $18,900 per QALY gained compared to no treatment.

Further, they observed that methadone provision cost would be less than $20,000 per QALY gained compared to no treatment in all scenarios and less than $50,000 per QALY gained compared to methadone treatment provided without the regulatory flexibilities in place.

“The changes we’ve made to providing opioid treatment during the pandemic — such as telehealth and take-home medications — could be viable long-term solutions. In our simulation study, we show that these relaxed guidelines are both effective and cost-effective,” said Gary Qian, lead author of the study and a PhD student in management science and engineering at the Stanford School of Engineering, in a news release.

The study comes as the federal government continues to weigh telehealth-related flexibilities governing treatment and medication access.

Last February, the US Drug Enforcement Administration (DEA) released a proposed rule safeguarding some telehealth-based prescribing flexibilities while eliminating others after the COVID-19 public health emergency (PHE) was declared over in May 2023.

The proposal allowed telehealth prescriptions of a 30-day supply of Schedule III-V non-narcotic controlled medications and a 30-day supply of buprenorphine for OUD without a prior in-person evaluation. However, virtual prescribing of Schedule II controlled substances, like Adderall, Oxycodone, Vicodin, and Ritalin, would require a prior in-person examination.

Following pushback from the healthcare industry — including nearly 38,000 comments on the proposed rule and wide-ranging feedback at listening sessions last September — the DEA relented, extending allowances surrounding the virtual prescription of controlled substances, including Schedule II substances, through the end of 2024.

Research has indicated that telehealth access helped reduce the risk of fatal drug overdoses among Medicare beneficiaries with OUD.

The study, published in March 2023, included data for 105,162 patients receiving telehealth-enabled OUD care between September 1, 2018, and February 29, 2020 (pre-pandemic cohort), and 70,479 patients between September 1, 2019, and February 28, 2021 (pandemic cohort).

The researchers found that the rate of fatal drug overdoses was 5.1 per 1,000 beneficiaries in the pandemic cohort and 3.7 per 1,000 beneficiaries in the pre-pandemic cohort. After conducting a multivariable analysis of the pandemic cohort, they found that telehealth-enabled OUD treatment led to a lower adjusted odds ratio and a 33 percent lower risk of fatal drug overdose.