Thread by @XimenaLevander

TY to all who attended @AMERSA_tweets #amersa2020 oral abstract sessions on COVID19 & addiction. For those unable to join wanted to highlight a few of my slides "Increased buprenorphine accessibility in rural communities during covid19 - a case report" @BuchheitBradley 1/

I won't include case details but can highlight general points & lessons learned. A lot of my experience in using telehealth to increase access to buprenorphine in rural areas is relevant to the X the X waiver(?) spicy debate! Excellent job @DrSarahWakeman & @DrMelissaWeimer 2/

Learning objectives
1) What are the barriers to MOUD to those living in rural areas?
2) How did policy changes due to COVID19 increase buprenorphine access via telemedicine?
3/

Our clinic is in Portland noted by red star & our patient lived in Douglas county circled in red over 2 hours away. Orange circles are <10 mi from city centers (yellow dots) w/ 40,000+ people. Light green - rural & Dark green - frontier w/ 6 or fewer people per square mile. 4/

Portland is a city of ~ 650,000 people. Our patient is in a town of ~ 1,000. The Oregon Office of Rural Health estimates ~ 33% of Oregon’s population lives in rural areas and 2% live in frontier areas. To give you an idea of distance Malheur County is the size of New Jersey 5/

We had a synchronous audio-visual appointment with the patient and based off history, chart review and physical exam we diagnosed the patient with opioid use disorder (severe), methamphetamine use disorder (in sustained remission), tobacco use disorder and low back pain 6/

Starting w/ #1 - There are complex, inter-related factors contributing to rural risk environment ⬆️ susceptibility to substance use & addiction – lack of jobs, lower educational levels, aging population, demanding/hazardous work, lower income, & fewer primary care/MH resources 7/

As we heard in debate - there is a significant lack of availability to buprenorphine esp in rural areas. In 2016, ~ 60% of rural counties had NO waivered prescribers, a slight ⬆️from 2012 when that # was 67.3%. In Oregon in 2016 there were 9 counties which had no prescribers. 8/

Plug to our amazing PA & NP colleagues who have significantly ⬆️ buprenorphine access w/ passing of Comprehensive Addiction and Recovery Act (2016). They provide a ton of care esp in rural communities! Happy PA week <3 You should Follow @la_kops 9/
aanp.org/advocacy/recen….

Continuing - just b/c county has bupe prescriber doesn't mean they're taking new patients or using waiver. Our patient lived in a county w/ >1 prescriber but still faced barriers. Those in rural areas face general barriers to accessing healthcare w/ some specific to addiction /10

They face transportation issues – poor road conditions, geographical limitations, limited public transit, and relying on others for rides. Concerns re: privacy when living in a small town & stigma. Rural areas also have healthcare shortages & insurance coverage issues /11

After a risk-benefit discussion w/ our patient they decided to start buprenorphine. They had never used any medication for opioid use disorder before. We arranged close follow up over the next few weeks - they did well on established dose. /12

COVID19 limited our pt's ability to find support communities (in-person ones had been cancelled & there wasn't tech support for virtual ones). This is something we have seen written about. Here's an article @Peter_Grinspoon touching on social isolation health.harvard.edu/blog/a-tale-of… /13

Obj2 - Telehealth changes due to COVID19. 1st a step back about pre-COVID19 Telemedicine policies. Ryan Haight Online Pharmacy Consumer Protections Act of 2008 amended Controlled Substances Act. Strict limitations to telehealth for bupe (& other controlled substances). /14

On Jan 31, 2020 public health emergency declared. Due to concerns spreading COVID-19 & wanting to ensure access to MOUD, DEA & SAMHSA announced bupe could be prescribed via telemedicine without 1st needing in-person visit. March 31,2020 clarified included telephone only. /15

Our @OHSUSOM clinic HRBR (pronounced Harbor) offers low threshold buprenorphine and barriers to care were further removed due to these COVID19 telehealth policy changes. This def is outlined in @adfoxMD & Dr. Andrea Jakubowski @JAM_ASAM paper. /16

But telemedicine is not panacea that will solve all access issues to healthcare and bupe. Rural communities often lack of Internet, phone networks, technology. They may not be aware of telemedicine services or clinics that offer them. Q - how do we "advertise" our services? /17

Rural areas may still lack other services - HIV/HCV screening and injection supplies. Once patients get prescribed bupe, they may face barriers getting meds from pharmacy. This was outlined in recent Cooper NEJM article. @landgrantdan @HillPharmD @ampeckham @JessLynnMoreno /18

Those in rural areas also face housing instability & homelessness - an area of growing concern. Some patients may not have a private space to have their telemedicine visits. They may not have access to chargers/electricity for a visit. @Voices4ORHomes /19
npr.org/sections/healt…

"Conclusions" to my presentation in the slide (alt text provided for all - thx @_HarryPaul_ ) Would love to discuss other issues people have seen in rural communities and thoughts on COVID19 telehealth policy changes! /20

Rural OR is beautiful! I shared a road trip we took to Steens Mountain located in Harney County. Happy to share fave spots I've been to via DM or email. If you are going to travel right now follow COVID19 precautions - as these areas don't have ICU level care! /21

Addiction medicine is an interdisciplinary team sport! Want to thank everyone who helped provide care to this patient and so many others. Included are my references. Information about HRBR is on our website - ohsu.edu/school-of-medi… /22

One ? from Q&A was on future balance of in-person vs. telehealth visits. This is a tough question. Patients who are able to make telehealth appts really like them - no child care, no transport/parking, can do visit where is convenient. Would love to hear others' thoughts on ? /23

Frequently asked re: urine drug testing which I found limited utility in pre-COVID. Prefer having honest convos w/ pts. Would rec recent JSAT article by @JarrattPytell on this tinyurl.com/y45v4jlk. As well @kelseycpriest, @ijdrugpolicy article pubmed.ncbi.nlm.nih.gov/30551003/ /24

Another ? on neg telehealth outcomes. Haven't seen too many but again pts who make appts are typically doing well. Will need to study these long-term outcomes & comparisons. 1 issue is pts driving (dangerous) or in public during appts (problematic). What have others seen? /25 end