Clinicians and programs should take steps to minimize in-person interactions throughout the COVID-19 crisis. Telehealth is an important tool for maintaining access to treatment while minimizing the risk of transmission of COVID-19. This section is intended to provide guidance to clinicians and programs in developing policies and practices to leverage telehealth to provide buprenorphine1 treatment. See ASAM’s Supporting Access to Telehealth for Addiction Services Guidance, which provides an overview of federal and state policy changes to enable telehealth during the COVID-19 crisis.
Despite the availability of telehealth, it is also important to recognize that not everyone may have access to these resources. Clinicians and programs do well to implement protocols and procedures to ensure continued treatment with buprenorphine for patients who may not have access to telehealth services.
Recommendation
Telehealth or telephonic visits should be used whenever possible and appropriate to provide buprenorphine treatment to patients.
Historically, an in-person medical evaluation was required prior to initiating a controlled substance prescription. However, federal policymakers have enabled exceptions during this public health emergency (which was initially declared on January 21, 2020) that allow for the prescription of buprenorphine via telehealth.
In addition, as of March 15, 2020, sanctions and penalties have been temporarily waived for healthcare clinicians who do not comply with certain provisions of the HIPAA Privacy Rule. This waiver may enable the use of non-
2Throughout this document, the term ‘buprenorphine’ will be used to refer to any formulation of buprenorphine including those containing both buprenorphine and naloxone.
HIPAA compliant telehealth applications that are widely available, such as FaceTime or Skype. (See Supporting
Access to Telehealth for Addiction Services Guidance)
Telehealth communication conducted using an audio-visual, real-time, two-way interactive communication system is preferred but telephone-based visits should also be considered. For example, some patients may not have the technical capabilities available for video visits but have access to a phone.
For stable patients, the risk of in-person visits is likely to outweigh the benefits. Patients who are unstable, or patients that do not have reliable access to a telephone (e.g. unhoused patients) may still benefit from in-person visits. Clinicians and programs should consider infection mitigation strategies for in person visits. See Infection Control and Mitigation Strategies in Outpatient Settings.
Please note that at the time of this writing, the exception to the need for an in-person evaluation does NOT apply to the provision of methadone for opioid use disorder. That is, methadone for opioid use disorder still must be initiated only after an in-person medical evaluation has taken place.
Clinicians should carefully assess whether an in-person physical exam would change the management of a given patient. For patients maintained on buprenorphine, monitoring for signs of intoxication is recommended. This assessment can be accomplished with visual inspection alone, and partially and sufficiently evaluated through an audio-only platform as well (e.g., slurred speech might suggest use of alcohol or other opioids, while pressured speech might suggest stimulant use).
For patients seeking to initiate buprenorphine, assessment of opioid withdrawal can typically be accomplished through visual inspection alone, for signs such as yawning, pupillary dilation, lacrimation, rhinorrhea, and restlessness. While an accurate COWS score may sometimes require palpation for subtle tremor or piloerection, the benefit of obtaining a COWS score with perfect accuracy is unlikely to outweigh the risk of COVID-19 exposure. Home versions of the COWS scale or the Subjective Opioid Withdrawal Scale (SOWS) can be self- administered by the patient. At-home initiation of buprenorphine (formerly called home “induction”) does
not require a perfectly accurate COWS assessment and has demonstrated feasibility and safety relative to office- based buprenorphine starts. Clinicians can carefully instruct patients on at-home initiation and provide anticipatory guidance for the management of precipitated withdrawal, should it occur.
Resources