Prescribing regulations are relaxed to keep recovery on track
Michelle Cangiano, MD, typically sees patients in person to keep them on track with their medication-assisted treatment (MAT) for opioid use disorder.
Under existing rules for prescribing buprenorphine, a drug used to reduce opioid cravings and the effects of withdrawal, providers must meet face-to-face with patients before renewing their medication. But since Vermont Gov. Phil Scott declared a state of emergency in an effort to stem the spread of the novel coronavirus, many primary care clinics are not offering routine office visits.
In March, Scott signed legislation that allows doctors providing buprenorphine to bypass the required office check-up so patients can refill their prescriptions during the coronavirus lockdown. The rule change is part of a bill aimed at easing access to health care services during the pandemic. One section specifically addresses buprenorphine, recognizing the vulnerability of patients in recovery who risk relapse and overdose if they can’t get their medication.
For these patients, keeping up with treatment is crucial, said Dr. Cangiano, a University of Vermont Medical Center family physician and MAT team member who practices at Family Medicine-Hinesburg. “It helps them to have some stability in their lives.”
For the last few weeks, Dr. Cangiano’s team has conducted video visits to connect with patients online. Dr. Cangiano began testing the practice of telemedicine last summer, and she observed that it worked well for some of her MAT patients who have full-time jobs and couldn’t come to the office during regular hours. Her plans to ramp up the telemedicine program were accelerated by the novel coronavirus.
Normally, Dr. Cangiano sees patients who are just entering recovery about once a week, while MAT patients who have been in recovery for longer might come in only every two or three months. Providers can write buprenorphine prescriptions for a maximum of three months at a time.
Video visits qualify as face-to-face interaction. Some patients, though, lack a computer or smartphone. Others don’t have adequate Internet access for video streaming. For them, MAT providers have switched to phone calls, but those were a “grey area” in terms of fulfilling the criteria for prescriptions – until the new legislation was passed, Dr. Cangiano said.
“So, for my patients who don’t have the capabilities or are not that tech savvy to do the video visits, I can do the telephone calls,” she added.
Methadone treatment is more tightly regulated and isn’t addressed in the Vermont legislation. Patients who receive methadone treatment must regularly visit one of Vermont’s regional “hubs,” the clinics licensed to administer the medication. However, federal guidelines allow exceptions in special circumstances, including the current pandemic. Howard Center, which operates the Chittenden Clinic, has adjusted its rules for “take-homes” of dosages for eligible patients in accordance with those federal guidelines, said Adam Brooks, a spokesperson for Howard Center.
Depending on their time in treatment and other factors, patients who could previously take home six doses now are allowed 13, and those who could leave with 13 were bumped to 27, Brooks said. The change aims to cut back on the number of necessary clinic visits, he said.
During the state of emergency, patients who typically don’t qualify for methadone take-homes are given up to four a week in a staggered fashion – they visit the clinic every other day and receive a take-home for the “off days,” as well as for Sunday when the clinic is closed, Brooks added.
People in treatment for addiction rely on their medications the same way patients with other chronic conditions like diabetes do, said Robert Purvis, executive director of the Turning Point Center of Central Vermont, a peer-support organization for people in recovery.
“The last thing you want is for somebody to go into withdrawal,” Purvis said.
That would increase their likelihood of returning to illicit drugs such as heroin and fentanyl, he explained. Patients who relapse are at greater risk of overdose, because they no longer have the tolerance they did when they stopped using.
That’s why the Vermont legislation is crucial for MAT patients, Purvis said. “The bottom line is that our first order of business is to keep people alive.”
This is a particular concern for incarcerated individuals who have received MAT in jail or prison and get released without an established relationship with a provider in the community. They would normally go see a doctor right away to continue treatment, so the legislation waiving that requirement will help them avoid a lapse, said Kim Blake, MD, an obstetrician/gynecologist and MAT provider with Howard Center’s Safe Recovery, a program that supports people with substance use disorder.
“It’s extremely important that they continue their medication,” Dr. Blake said. “If they miss a few doses, they’re going to go into withdrawal, and they may return to use of opiates. So while phone and telehealth options are crucial during this pandemic, we all look forward to being able to resume in person visits to care for our patients.”
Care for those in recovery goes beyond MAT and involves other support programs, including counseling and participation in group sessions. People who have struggled with addiction are especially vulnerable to stress – which often triggers their substance use. Dr. Cangiano’s MAT team nurse has reached out to some patients who said they are worried about getting sick with COVID-19, and other challenges they’re facing, such as job layoffs and isolation from friends and family.
“They’ve been texting my MAT nurse every other day because of their anxiety around this,” Cangiano said.
The MAT team has adapted to other changes amid the coronavirus outbreak. They now can send pharmacies electronic prescriptions for buprenorphine, which they previously had to print out and write in manually, Dr. Cangiano said. They have discussed an alternative for processing urine samples for patients who have been going to a local lab that might soon shut down.
Most group sessions for people in recovery at this point have moved to the Zoom online platform or one similar. That requires a computer or at least a smartphone, and some people in recovery don’t have that access, Blake said.
The meetings provide a crucial connection to others who understand the struggle and can provide support, Purvis said: “The challenges are trying to create community when you can’t be in the same room.”
This story was reported by Carolyn Shapiro, for the UVM Health Network.