Buprenorphine Opioid Treatment During the COVID-19 Pandemic—Reply

In Reply We thank Luigi et al for their thoughtful comments highlighting the policy context of our study.¹ Continued access to buprenorphine during the COVID-19 pandemic may be attributable to federal emergency guidelines allowing increased telehealth care.¹

We agree with their observation that many vulnerable populations with opioid use disorder (OUD), such as individuals with limited digital literacy and those who cannot afford broadband internet or have unreliable access, will require specific attention to achieve equal benefits from any transition to telehealth.² Another particularly vulnerable population is criminal justice system–involved individuals who carry a disproportionally higher burden of both OUD and COVID-19. A study³ reported that only 4.6% of justice-referred clients received buprenorphine or methadone in specialty treatment vs 40.9% of those referred by other sources. Directed efforts to ensure that people receive assistance accessing online platforms, and communities have adequate infrastructure, will be necessary to support these populations during the pandemic.

As Luigi and colleagues note, prescriptions that were paid for out of pocket declined, compared with greater stability in prescriptions paid with Medicaid or private insurance. Many people who self-pay for care are uninsured or reluctant to use their health insurance. This plausibly relates to unprecedented job disruptions since March 2020. Rising uninsured rates will lead to greater cost-related barriers: a recent study⁴ found buprenorphine prescribers charged $250 or more as out-of-pocket fees for treatment initiation among cash-only patients. Although changes in the job market associated with COVID-19 may cause millions to lose their employer-sponsored health insurance plans, many of those losing insurance coverage can apply for Medicaid.⁵ As Medicaid expansion may provide safety nets to alleviate income and health insurance coverage losses, it will be helpful to disaggregate the trends in buprenorphine use across Medicaid expansion vs nonexpansion states in future research.

Luigi and colleagues rightly note that little is known about the effects the pandemic has had on methadone use via opioid treatment programs. Under the public emergency opioid treatment programs, health care professionals treating existing patients with methadone may dispense up to 28 days of take-home methadone dose; however, they cannot admit new patients without a complete physical evaluation. Future research is needed to better understand the effects of these regulatory changes on treatment access via opioid treatment programs.

Our study¹ contributes to a rapidly evolving policy landscape where there may be further opportunities to expand points of access to buprenorphine treatment via telehealth. These measures are especially worthy of consideration during a period of heightened overdose risk.

Corresponding Author: Thuy D. Nguyen, PhD, Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, M3234 SPH II, Ann Arbor, MI 48109-2029 (thuydn@umich.edu).

Published Online: April 12, 2021. doi:10.1001/jamainternmed.2021.0774

Conflict of Interest Disclosures: None reported.

Additional Information: We wish to thank the remaining coauthors of our original research letter—Kosali I. Simon, PhD; G. Caleb Alexander, MD, MS; Sumedha Gupta, PhD; and Engy Ziedan, PhD—who substantially contributed to this Letter in Reply.