Last month, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (HHS) released a joint statement strongly encouraging the use of telehealth to treat opioid use disorder. Specifically, they encouraged the use of telehealth appointments to prescribe the lifesaving medication Buprenorphine, otherwise known as Suboxone. In the February release, the agencies stated, “In the face of an escalating overdose crisis and an increasing need to reach remote and underserved communities, making the buprenorphine telehealth flexibility permanent is of paramount importance. Our final rule permits initiation of buprenorphine if the authorized healthcare professional determines that an adequate evaluation of the patient can be, or was, accomplished via audio-only or audio-visual telehealth technology.” They went on to say that telehealth plays a critical role in expanding access to needed addiction treatment that will ultimately curb the opioid epidemic, including lifesaving medications like Suboxone that many Americans will never see without the exclusive use of telehealth.
State-Level Challenges: Rhode Island and Alabama’s Resistance
Despite this new guidance, the Rhode Island Department of Health and the Alabama Department of Public Health have decided to ignore these critical directives from our nation’s leading healthcare experts. This is leading to escalating opioid-related deaths in both states. Despite the Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Department of Health and Human Services (HHS) guidance on telehealth, both medical boards continue to require in-person appointments before starting Suboxone. This medication reduces lethal opioid overdoses by over 50%. As a direct result, both states have some of the highest lethal overdose rates in the nation.
Advocating for Change: Addressing Rhode Island’s Policies
To help expand vitally needed access to opioid use disorder treatment via telehealth, I met with Rhode Island’s Board of Medicine last week. In this meeting, The Rhode Island Board of Medicine insisted that Rhode Island will continue to require an in-person appointment before starting Suboxone moving forward. Their rationale? They pointed to Rhode Island state legislation that requires an in-person appointment to start any controlled substance. This includes an extensive range of medications, including stimulants for ADHD, benzodiazepines, and opioids for pain management. Suboxone, which works very differently from these other medications, is also a controlled substance. In response, I pointed them to the SAMHSA/HHS 2024 February ruling. It states, “There are no significant differences between telehealth and in-person buprenorphine induction in the rate of continued substance use, retention in treatment, or engagement in services. Further to this, research demonstrates that actions to facilitate access to buprenorphine-based treatment for OUD during the COVID–19 pandemic were not associated with an increased proportion of overdose deaths involving buprenorphine.”
I hoped this would prompt some thoughtful reflection and reconsideration on their part. Don’t get your hopes up. They simply shrugged their shoulders and said, “Sorry. This is the regulation. We can’t change it.” I was baffled. You, Rhode Island Department of Health, are the medical leaders of your state. You must support and educate your state leaders to pass public policy health measures that align with national expert guidelines and save lives. It is also your responsibility to point out and help correct outdated policies that contradict public health recommendations and cost lives.
Faced with this unexpected resistance, I suggested that perhaps a patient’s local primary care physician could do the physical in-person exam, with the patient then completing a subsequent telehealth appointment for the treatment of opioid use disorder. Again- don’t get your hopes up here. “No, no,” they shook their heads, almost in unison. “The physical exam must be done by the same provider issuing the Suboxone prescription that very day – no one else.” I could not think of any logical, medical rationale to support this arbitrary edict. They did not provide one either. It’s hard to see how a Primary Care doctor’s physical exam completed on a Tuesday would differ significantly from an Addiction Psychiatrist’s physical exam completed 24 hours later. The Primary Care doctor’s physical would likely be more comprehensive. This would also have been an excellent time to remind them of the significant shortage of Addiction specialists in the United States. Currently, only 18% of people with opioid use disorder have access to addiction treatment-a problem greatly exacerbated in Rhode Island given its very small size.
Flaws in Policy: Misunderstanding Controlled Substances in Rhode Island
The Rhode Island Department of State legislation regarding controlled substances and in-person appointments mistakenly lumps prescription opioids for pain and medications to treat addiction into the same category. These medication classes could not be more different. Pain medications like Oxycontin and Vicodin caused the opioid epidemic. Addiction medications like Suboxone treat victims of the opioid epidemic. They could not be more dissimilar. The Rhode Island legislature does not understand this crucial distinction. Thus, while rightly hindering access to addictive pain medications, they also block access to the life-saving medicines used to treat the very addictions that the opioid medications created. Wrap your head around that.
The Rhode Island Department of State legislation wording on controlled substances is confusing and contradictory at best. In statute H-7131, there is wording that expressly excludes medications for Substance Use Disorder from the same restrictions as pain medications. In other places, these important distinctions are not made. Statutes like 216-RICR-20-20-4, section H discuss “Pain Medicine Physicians” and “Addiction Medicine Physicians” as if they are the same. These are two completely different types of doctors with different residencies, training, and backgrounds, treating very different conditions. Chronic Pain, which Pain Medicine Physicians treat, is not the same as Opioid Use Disorder, which Addiction Medicine Physicians treat. Nevertheless, the Rhode Island Department of Health, Department of Administration State of Rhode Island, and Rhode Island Department of State have decided that powerful opioids causing addiction, like fentanyl, should be categorized and treated the same as addiction treatment medications like Suboxone, which are used to treat (not cause) addiction. Sigh.
Similar Barriers in Alabama: Examining State Requirements
We are moving in the wrong direction here. Alabama Department of Public Health also requires one in-person appointment within 12 months if issuing a controlled substance. There are no exemptions for medications approved to treat Substance Use Disorder. While not quite as restrictive as the Rhode Island Department of Health requirement, Alabama’s in-person requirement also blocks access to vital, lifesaving Addiction medication. It is a decision not grounded in science, research, or medical necessity. The medical research overwhelmingly contradicts the need for in-person requirements to treat substance use disorders. As the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (HHS) point out, “Recent research has demonstrated that telehealth can be an effective tool in integrating care and extending the reach of specialty providers, and that among those patients requiring treatment with buprenorphine, there are high levels of satisfaction with the use of telehealth services.”
Why should we care? And what can we do? We should care because our fellow American brothers, sisters, mothers, fathers, cousins, and friends are dying daily from lethal overdoses. These deaths disproportionately come from states like Alabama and Rhode Island that unnecessarily hinder access to addiction treatment with in-person appointment requirements. These state-specific barriers are not backed by science, research, or data. Instead, they are grounded in a fundamental misunderstanding of addiction medications and the lifesaving hope these treatments offer to our fellow Americans. Dr. Nora Volkow, the director of The National Institute on Drug Abuse (NIDA), recently summarized this succinctly, saying, “A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives. Yet tens of thousands of people die each year because they have not received these treatments. Ending the crisis will require changing policies to make these medications more accessible.” She concluded that we could reduce opioid-related deaths overnight by over 50% by increasing access and reducing barriers to Suboxone.
The life-saving medications that could and should be getting to those who need it most already exist. Instead, we are faced with apathetic state medical leaders who don’t care enough to advocate for needed changes in their state policies. Nothing burns me up more than privileged indifference. The citizens of Rhode Island and Alabama entrust their respective medical boards with great power. My mother always told me, “To whom much is given, much is expected.” I could be more forgiving of ignorance or lack of medical knowledge. But it is tragically disappointing that even when provided with updated medical guidance from our nation’s premier authorities on Addiction treatment, some medical professionals in power still refuse to change, advocate for, or influence state health policies that could save millions of lives. “That’s just the regulation,” they shrugged, staring blankly back at me. “We can’t change it,” they insisted. Yes, you can. And you should. Rhode Islanders and Alabamians deserve much, much better.
If you or a loved one is struggling with an addiction to opioids, other drugs, and/or alcohol and need help in Maine, New Hampshire, Massachusetts, Connecticut, Rhode Island, Virginia, Georgia, Florida, Ohio, Kentucky, or Indiana, the recovery teams at Aware Recovery Care are here to help. And we come to you, regardless of where you live. Our unique in-home treatment model of care gives clients a significantly better chance of recovery than traditional inpatient rehab care.We are now offering Virtual Detox and Medication Assisted Treatment in New Hampshire, Connecticut, Virginia, Georgia, Indiana, Kentucky, and Ohio. Please get in touch with one of our Recovery Specialists to learn more.
About the author…Dr. Lauren Grawert MD.
Dr. Grawert is a double board-certified Addiction Psychiatrist. She completed her medical school training in 2009 and a General Psychiatry Residency in 2013 at the Medical University of South Carolina (MUSC). She then went on to complete an Addiction Psychiatry fellowship at MUSC, which she completed in 2014. After fellowship training, Dr. Grawert served as the Chief of Psychiatry and Addiction at Kaiser Permanente of the Mid-Atlantic. She has also worked in private practice specializing in general psychiatry, substance use disorders, and medically assisted treatment (MAT). Dr. Grawert has served as an expert for the San Diego Community Response to Drug Overdose Task Force, the Addiction Committee Leader for Kaiser Permanente National Mental Health & Addiction Leadership Organization, and a Professor of Psychiatry at Penn State College of Medicine. She likes to write, travel, and spend time with her two young children in her spare time.
