HIV Specialist - March 2021 - 42

WHY AND HOW WE CAN DO BETTER

is far outweighed by the significant benefit
of keeping patients engaged in care and safe
from the life-threatening adverse events
associated with relapsing.10
Data from a 2015 review consisting of
3,350 patients showed MOUD much more effective at saving lives and preventing relapses
than abstinence-based treatment programs.11
A 2018 study of 17,568 people who had
experienced a nonfatal overdose showed
MOUD reduced overdose and all-cause mortality compared to abstinence.12
Telemedicine
In 2018, the Drug Enforcement
Administration (DEA) partnered with the
Substance Abuse and Mental Health Services
Administration (SAMHSA) to expand access
to buprenorphine via telemedicine or telephone without first conducting an in-person evaluation.13 The American Society
of Addiction Medicine (ASAM) endorses
leveraging telemedicine to treat people with
substance use disorder (SUD). This not only
reduces the risk of exposing patients and
staff to COVID-19 but also removes many of
the barriers people living with SUD have to
life-affirming services. As with any telemedicine communication with our patients,
ASAM recommends using " an audio-visual,
real-time, two-way interactive communication system. " 14 But the organization acknowledges that when patients do not have access
to video technology, a telephone-based visit
may be utilized.
For providers concerned that patients
may participate in diversion, ASAM points
out that buprenorphine is diverted less often
than other opioids15 and usually occurs to
help others self-treat opioid withdrawal
rather than achieve euphoria.16
When buprenorphine treatment is initiated, visits can start off every few days to once a
week. As trust is built, the frequency of these
visits can be reduced and integrated into the
routine care of the patient's other medical
needs. Converting to telemedicine can reduce
some of the barriers patients might otherwise
have to these frequent office visits, such as
finding transportation, arranging for childcare, and even taking time off work.
When planning visit frequency, amount
of buprenorphine prescribed, and number of

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refills, ASAM recommends considering the
following psychosocial and community factors:
1. During healthcare disasters such
as COVID-19, does the patient fall into a
high-risk group as outlined by the CDC or
local health department? Having the patient
frequently visit clinics or pharmacies may
increase their risk of transmission, or the risk
to providers and the public.

Converting to telemedicine
can reduce some of the
barriers patients might
otherwise have to these
frequent office visits, such
as finding transportation,
arranging for childcare, and
even taking time off work.

2. Is the patient under quarantine or
caring for a loved one in isolation? Patients
will need access to an appropriate amount of
medication to support recommended public
health policy.
3. How able is the patient to safely store
different amounts of buprenorphine/naloxone formulations? Without the ability to secure it, less medication may be preferable. For
many of my patients, for example, the risk of
weekly visits to the pharmacy outweighs the
risk of a month's supply being stolen or lost.
4. Who might be able to access medications in the home, such as children, pets, or
neighbors? While buprenorphine generally
poses less of a risk for respiratory depression
compared with other opioids and methadone,
those without previous exposure to opioids,
especially children or people on certain other
medications can be harmed.
5. How stable is the patient's SUD?
Prescribing a lower quantity of medication
with more frequent refills and monitoring by
telehealth or telephone may be safer or more
effective in keeping patients in recovery.17

Clinicians should always co-prescribe or
ensure there is naloxone in the patient's home.
If naloxone access is limited, prioritize patients
at high risk for relapse because of co-occurring
benzo or alcohol use, or whose households
include children, adolescents, or individuals
with chronic cardiopulmonary disease.
Drug Testing
ASAM states that the primary purpose of
drug testing is to improve patient outcomes
by: " (a) detecting substance use that could
complicate treatment response and patient
management; (b) monitoring adherence with
the prescribed medication; and (c) monitoring possible diversion. " 18
However, drug testing should be complemented by a comprehensive approach to
support these objectives. This is even more
critical during times that in-office visits and
testing are limited. Every state now has a
prescription monitoring program (PDMP),
which should be accessed prior to prescribing
any controlled medication. Other strategies
include increased frequency of telehealth or
office visits, limiting the amount of medication dispensed, random pill counts, and partnering with psychosocial support services.
The standard frequency for drug testing
is at least monthly. Less frequent testing may
be considered for patients who are stable in
their recovery or during times that in-office
testing is not safe or practical. The guiding
principle here remains to reduce potential
harm and maintain access to life-affirming
treatment for our patients.
For more information on drug testing, please refer to ASAM's consensus
statement.19
Psychosocial Support
Although psychosocial support is important to a patient's long-term recovery,
ASAM's National Practice Guideline for the
Treatment of Opioid Use Disorder states,
" a patient's decision to decline psychosocial treatment or the absence of available
psychosocial treatment should not preclude
or delay pharmacotherapy, with appropriate
medication management. " 20 This guidance is
even more applicable during the COVID-19
pandemic and for people with other significant barriers to these services.

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HIV Specialist - March 2021

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