COVID-19 Pandemic: Natural Experiment in Telehealth on Buprenorphine Treatment in a Large Integrated Healthcare System

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PROJECT SUMMARY/ABSTRACT Expanded use of telemedicine for buprenorphine prescribing may reduce barriers to buprenorphine prescribers. However, federal regulations that require prescribers to conduct in-person medical evaluations to induct patients on buprenorphine and limit maintenance visits to real-time, two-way, interactive audio-visual communication (i.e., telehealth) has prevented research on the potential role of expanding telehealth for buprenorphine prescribing. The initial surge of COVID-19 cases in the US in March 2020 led federal agencies to ease the in-person evaluation requirement, allowing providers to use telemedicine or telephone-only visits for medical evaluations to start patients on buprenorphine. We propose a study that leverages these COVID-related regulator reforms to answer important clinical and policy questions regarding the regulations governing the use of telehealth for buprenorphine initiation and treatment among Veterans Administration (VA) patients. Serving ~5,000,000 patients each year, we will leverage the VA electronic health record data to answer three important clinical and policy questions. (1) What was the effect of the relaxed buprenorphine prescribing guidelines on buprenorphine treatment rates change during the COVID-19 pandemic overall and by treatment stage (new patients vs. long- standing patients)? (2) What is the effect on treatment outcomes of more flexible telehealth regulations on patients initiating buprenorphine treatment? (3) What is the effect of telehealth use on treatment outcomes on patients in long-standing buprenorphine treatment (in care ≥6 months)? We will answer these questions in three steps: (1) We will use time-series methods to model the monthly counts of VA patients in buprenorphine treatment prior to March 2020, predict the monthly count in treatment from April to December 2020 and compare it to the observe counts to quantify the change in buprenorphine treatment rates associated with more flexible treatment regulations; (2) Test whether: (a) clinical treatment outcomes in patients initiating buprenorphine via telehealth post-Policy changes differ from patients initiating treatment in the year before the outbreak and (b) Investigate individual, facility, and area-level modifiers of the policy effects on clinical treatment outcomes; and (3) Among long-standing patients: (a) Examine the relationship between telehealth use and clinical treatment outcomes and (b) Determine individual, facility, and area-level differences in telehealth buprenorphine treatment. Determining the effects of more flexible telehealth regulations will provide critical information on a potential policy lever to increase access to critical life-saving medications for OUD. The complementary training program comprising of formal courses, workshops, directed readings, and experiential learning will let me develop the skill and expertise to launch my career as a substance use epidemiologist and prepare me to successfully compete for R01 funding as an independent investigator with a focus on understanding the causes of addiction and policy evaluation to inform interventions, prevent, and treat OUD and its related harms.