key: cord-0761548-kqz7dwqg authors: Buchheit, Bradley M.; Wheelock, Haven; Lee, Abby; Brandt, Kimberly; Gregg, Jessica title: Low-barrier buprenorphine during the COVID-19 pandemic: A rapid transition to on-demand telemedicine with wide-ranging effects date: 2021-04-29 journal: J Subst Abuse Treat DOI: 10.1016/j.jsat.2021.108444 sha: 2a4a5d1053d5c277041fa2b257a25772092232fa doc_id: 761548 cord_uid: kqz7dwqg Low barrier addiction clinics increase access to medications to treat substance use disorders, while emphasizing harm reduction. The Harm Reduction and BRidges to Care (HRBR) Clinic is an on demand, low barrier addiction clinic that opened in October 2019. In the first three months of operation (November through January , 2020), HRBR saw steadily increasing numbers of patients. Oregon saw its first case of novel coronavirus in February, and declared a state of emergency and enacted a formal “Stay at Home” order in March. That same month, the DEA announced that patients could be initiated on buprenorphine through telemedicine visits without an in-person exam. Within a week of being granted the ability to see patients virtually, HRBR had transitioned to over 90% virtual visits, while still allowing patients without technology to access in-person care. Within four weeks, the clinic expanded hours significantly, established workflows with community harm reduction partners, and was caring for patients in rural areas of the state. In response to the COVID-19 crisis, the HRBR clinic was able to quickly transition from in-person to almost completely virtual visits within a week. This rapid pivot to telemedicine significantly increased access to care for individuals seeking low-threshold treatment in multiple contexts. Overarching institutional support, grant funding and a small flexible team were critical. HRBR's increased access and capacity were only possible with the Drug Enforcement Agency loosening restrictions around the use of telehealth for new patients. Keeping these altered regulations in place will be key to improving health and health care equity for people who use drugs, even after the pandemic subsides. Further research is needed in to whether addiction telemedicine impacts medication diversion rates, continued substance use, or provider practices. Oregon saw its first case of novel coronavirus in February, and declared a state of emergency and enacted a formal "Stay at Home" order in March. That same month, the DEA announced that patients could be initiated on buprenorphine through telemedicine visits without an in-person exam. Within a week of being granted the ability to see patients virtually, HRBR had transitioned to over 90% virtual visits, while still allowing patients without technology to access in-person care. Within four weeks, the clinic expanded hours significantly, established workflows with community harm reduction partners, and was caring for patients in rural areas of the state. In response to the COVID-19 crisis, the HRBR clinic was able to quickly transition from in-person to almost completely virtual visits within a week. This rapid pivot to telemedicine significantly increased access to care for individuals seeking low-threshold treatment in multiple contexts. Overarching institutional support, grant funding and a small flexible team were critical. HRBR's increased access and capacity were only possible with the Drug Enforcement Agency loosening restrictions around the use of telehealth for new patients. Keeping these altered regulations in place will be key to improving health and health care equity for people who use drugs, even after the pandemic subsides. Further research is needed in to whether addiction telemedicine impacts medication diversion rates, continued substance use, or provider practices. buprenorphine, COVID-19, low-threshold, substance use disorders, telemedicine, increased access to treatment Background: Patients seeking medications for substance use disorders (SUDs) often encounter significant barriers to care, including long wait times, counseling requirements, and complex intake processes. Low threshold or "bridge" models of care have emerged as a powerful way to provide patients with opioid use disorder access to life-saving medications. While models vary, most provide quick intake processes, brief wait times, and flexible or drop-in hours (Jakubowski & Fox, 2019) . In addition, low threshold programs generally prioritize harm reduction, do not require counseling and do not exclude patients from treatment if there is ongoing drug or alcohol use (Jakubowski & Fox, 2019) . Low barrier addiction clinics have been shown to facilitate prescription of evidence based pharmacotherapy as well as reduce substance use and improve treatment retention (Lee et al., 2019; Wiercigroch et al., 2020) . Patients report positive experiences at these clinics and appreciate the emphasis on harm reduction (Snow et al., 2019) . supplies, and clinic visits as well as medications for non-or under-insured patients. The clinic bills insurers in instances where patients have active insurance. The HRBR care model is lean, including a licensed independent practitioner (LIP), a care transition coordinator (CTC) who welcomes new patients and connects established patients to ongoing care when it is desired, and a peer recovery specialist. HRBR patient demographics can be seen in Table 1 . A noted limitation of the clinic is its physical location at OHSU where there is limited space available for new clinics, and which is not easily accessible to drug users in many other areas of the city. As a partial solution to these issues, when it first opened, HRBR operated from 4PM to 8PM, when clinic space was available. In the first three months of operation (November through January 2020), HRBR saw steadily increasing numbers of patients, most from the Portland metro area, many reaching the clinic by city bus. On January 21 st , 2020 the CDC confirmed the first case of Coronavirus in US (Centers for Disease Control and Prevention (CDC), 2020). Subsequently, on January 31 st , 2020, the Secretary of the Department of Health and Human Services declared a public health emergency(US Department of Health and Human Services, 2020). Table 2 for timelines, number of new patients seen, number of patient visits and percentages.) Oregon saw its first case of novel coronavirus on February 28 th , 2020, and declared a state of emergency on March 8 th , 2020 (Oregon Health Authority, 2020). On March 16 th , OHSU declared mandatory telework for all employees who were able, and the DEA announced that patients could be initiated on buprenorphine through audio and visual telemedicine visit (virtual visit) without an in-person exam (Drug Enforcement Agency -Diversion Control Division, 2020). HRBR completed its first virtual visit on March 19 th , while continuing to remain open to walk-ins between 4-6PM. The clinic transitioned to more than 90% telehealth (virtual visits and telephone-only visits) visits by March 23, 2020 when Oregon's governor ordered shelter-in-place. Because virtual visits do not require exam rooms, by March 25 th , the clinic was also able to expand hours, opening at noon and closing at 8:00pm. On March 31 st , the DEA further relaxed regulations for initiation of buprenorphine-naloxone in new patients via telephone-only visits (Drug Enforcement Agency -Diversion Control Division, 2020). This change in regulations allowed HRBR to further collaborate with a local needle exchange and local harm reduction outreach workers, performing the first virtual visit coordinated by a harm reduction worker with a patient on the street on April 6 th and the first virtual visit with a patient at the needle exchange on April 10 th . Finally, HRBR saw the first patient from rural Oregon on April 14 th . The clinic continues to see patients at the needle exchange, via harm reduction outreach workers and in rural parts of the state. In sum, within a week of being granted the ability to see patients virtually, HRBR had transitioned to over 90% virtual visits, while still allowing patients without technology to access in-person care. Within four weeks, the clinic had taken advantage of increased regulatory flexibility to expand hours significantly and establish workflows that allowed patients previously unable to access care anywhere to access medication for SUDs at the HRBR clinic. In response to the COVID-19 crisis, the HRBR clinic was able to quickly transition from in-person to almost completely virtual visits within a week resulting in the following lessons learned: Telemedicine allowed HRBR to increase access to treatment for people with SUDs by expanding the clinic hours, even without the availability of additional physical space, and by expanding access to the populations that the clinic was able to serve. With telehealth, HRBR could see patients from remote parts of the state which would have previously required a 5-hour drive for an in-person visit. Telehealth also allowed HRBR to connect with patients within the city who normally would have difficulty getting to the clinic due to its physical location and their lack of resources. HRBR staff had strong relationships with community partners prior to COVID-19, though many of the most vulnerable individuals served by those partners were unable to access the clinic due to lack of transportation. As soon as telehealth was allowed, HRBR worked with community partners Outside In (OI) and Portland People's Outreach Program (PPOP) to rapidly develop new workflows. OI's Injection Drug Users Services is one of the oldest needle exchanges programs in the US (Levander et al., 2021) . PPOP is an all-volunteer organization that provides need-based syringe and harm reduction services, often via bicycle outreach (Levander et al., 2021) . New patients were able to engage with HRBR via technology offered by those partners at both the exchange and during mobile outreach. HRBR was able to quickly transition from in-person to almost completely virtual visits, in part because of the support from a large institution. OHSU was moving toward increasing virtual visits before the COVID-19 pandemic, which made implementation a matter of online training for providers, and which meant that appropriate equipment already existed. However, although relying heavily on the institution to quickly transition to virtual visits, having a small team allowed for quick implementation -only 3 providers needed to be trained ensuring everyone was onboard within days. Furthermore, the HRBR coordinator's ability to adapt quickly to the new clinical context and then coach patients through technological challenges or confusion was critical to a successful transition. If other health care systems seek to replicate aspects of the HRBR clinic model, those systems should consider recruiting staff who not only bring the appropriate clinical skills but who also have some comfort with telemedicine platforms and the rapidly changing technological landscape. HRBR is currently funded through State Opioid Response funds. This funding allowed the quick transition from in-person visits to mostly telemedicine visits without the concern of varying reimbursement rates for telemedicine encounters. This support, in hand with billable visit revenue, made it possible to increase provider full time equivalent (FTE) and expand clinic hours from 4 hours a day to 8 hours a day very quickly. This expansion was accomplished by asking current part-time LIPs to increase their FTE. HRBR continues to pursue long-term financial sustainability by offering expanded services (e.g. hepatitis J o u r n a l P r e -p r o o f Journal Pre-proof C treatment), increasing visit numbers, and working with the state Medicaid insurer (the primary insurer of HRBR patients, see Table 1 ) to develop enhanced case rates to account for non-billable services that the clinic offers. The clinic is also working closely with OHSU's Population Health Program to determine the effect of engagement with HRBR on patients' subsequent rate of hospitalizations and ED visits, thus furthering an argument for increased institutional support. More research is needed to study the impact of telemedicine reimbursement and long-term financial sustainability in the absence of outside funding. Potential benefits of addiction telemedicine include fewer barriers and improved access. HRBR has noted continued growth and expansion in the number of patient visits completed and the breadth of the patients served. One notable limitation to telehealth visits in HRBR is that many of the most vulnerable patients do not have access to a phone, wireless connection or data plan. It is important to note that many HRBR patients who were not able to participate in care via virtual visit, were able to borrow a phone to complete a telephone visit. The use of borrowed phones resulted in added complexity around privacy and ability to contact patients, but was a viable option for some. Telemedicine visits also both limit and expand the clinical information available to providers. Without in person visits, it is difficult to complete an accurate physical exam, draw screening labs or send urine toxicology. However, providers were often able to gain a more intimate understanding of a patient's living environment and social context by seeing the patient over video connection. In general, HRBR patients receiving care via telemedicine did not complete urine toxicology testing. In the rare case that a provider felt that urine toxicology was needed, patients were asked to follow up in-person or sent to the lab. Further research is needed in to whether addiction telemedicine impacts medication diversion rates, continued substance use, or provider practices. Furthermore, it would be remiss not to note that HRBR could not have transitioned to nearly all virtual visits without the Drug Enforcement Agency loosening the previous restrictions limiting the use of telehealth for prescribing controlled substances. Keeping these altered regulations in place will be key to improving health and health care equity for people who use drugs, even after the pandemic subsides. First Travel-related Case of 2019 Novel Coronavirus Detected in United States Drug Enforcement Agency -Diversion Control Division Defining Low-threshold Buprenorphine Treatment Brief Report: Low-Barrier Buprenorphine Initiation Predicts Treatment Retention Among Latinx and Non-Latinx Primary Care Patients Low-Threshold Buprenorphine via Community Partnerships and Telemedicine-Case Reports of Expanding Access to Addiction Treatment During COVID-19 Oregon announces first, presumptive case of novel coronavirus OHSU opens walk-in buprenorphine clinic to help tackle opioid epidemic Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: A qualitative study of a bridge clinic Secretary Azar Declares Public Health Emergency for United States for A rapid access to addiction medicine clinic facilitates treatment of substance use disorder and reduces substance use