The Ryan Haight Act, the TREATS Act, And Access To OUD Treatment

September 17, 2020

Everything You Need To Know About How The Ryan Haight Act, TREATS Act, And Other Telehealth Laws Affect Access To Opioid Dependency Treatment

Telemedicine services, or telehealth, offer virtual healthcare through the use of digital devices, like telephones and computers. It is a safe, effective way for patients to meet with their medical providers and is often more accessible and convenient. Many services are available and effective via telemedicine, including diagnosis and treatment of chronic disease, as well as behavioral health therapy.

Telemedicine has recently expanded to include treatment of opioid use disorder (OUD). This is crucial, as it’s not always easy for patients struggling with opioid addiction to find a provider trained to prescribe buprenorphine/naloxone (Suboxone). 

Historically, there have been many healthcare access issues for patients with addiction… some live in rural areas without access to providers trained in medication-assisted treatment with buprenorphine/naloxone (Suboxone)… others may feel stigmatized when seeking in-person treatment… and others yet may have jobs that don’t allow them time off for health appointments, thereby forcing patients to choose between paying their bills or seeking treatment for their opioid addiction—For all of these problems, telemedicine presents a solution.

Telemedicine enables patients to track their symptoms and how they’re feeling throughout each day, with that information then instantly sent to their medical providers to allow clinicians to provide the highest level of support to patients in-the-moment. 

This type of ongoing tracking and surveying throughout each day allows providers more insight into what might trigger a patient’s cravings, thereby allowing for a more specialized treatment plan. Virtual health also provides patients the opportunity to attend online support groups, which adds an extra layer of accountability and community support.

What about telemedicine laws?

There are some key telemedicine laws that govern treatment for opioid use disorder. Let’s first talk about the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which took effect on April 13, 2009. 

Ryan Haight died at the age of 18 years after overdosing on opioid prescription pills he’d bought online, from a medical provider he’d never met, and an online pharmacist who’d delivered the opioid pills to his home. Subsequently, the Ryan Haight Act was developed to combat the rogue online pharmacies selling controlled substances. The Act is enforced by the United States Drug Enforcement Administration (DEA). The Ryan Haight Act requires clinicians to conduct at least one in-person medical evaluation prior to prescribing controlled substances. The Act goes on to state that a conservative recommendation is to conduct an in-person exam at least once every 24 months.

Though the Ryan Haight Act has been more or less successful in controlling online pill mills based in the United States, it has created barriers for patients seeking telemedicine treatment for opioid use disorder. Because buprenorphine/naloxone (Suboxone) is a controlled substance, it is regulated by the Ryan Haight Act.

The American Telemedicine Association, in conjunction with partner organizations, has long been lobbying the DEA to update the Ryan Haight Act, allowing clinicians to prescribe controlled substances via telemedicine without the requirement for an in-person evaluation—this is key, since the Ryan Haight Act remains a primary barrier for providers prescribing buprenorphine/naloxone (Suboxone) via telemedicine.

Within the Ryan Haight Act, Congress gives the DEA authority to create a “special registration” of telemedicine clinicians who are exempt from the in-person medical exam requirement. It’s on these grounds that Congresswoman Doris Matsui (of California’s 6th congressional district) introduced bill H.R. 4131: Improving Access to Remote Behavioral Health Treatment Act of 2019. This bill, which is still working its way through Congress, directs the DEA to register certain community mental health centers with the authority to prescribe controlled substances via telemedicine.

And thus, until March 2020 when the COVID-19 pandemic swept across the United States, buprenorphine treatment was still limited to patients who could first be evaluated in-person by their addictions medical provider. This limits access to buprenorphine treatment for Bicycle Health patients, as well as the patients of many other telemedicine organizations.

Telemedicine laws amidst the COVID-19 pandemic

Then, as COVID surged across the United States in March 2020, the DEA temporarily waived the requirement for an in-person medical assessment prior to prescribing buprenorphine, and the Department of Health & Human Services (HHS) waived penalties for HIPAA violations, thereby allowing patient-provider medical visits via FaceTime, Google Meet, or other videoconferencing. These lifted restrictions have significantly increased access to buprenorphine treatment during times of crisis.

And this is a step in the right direction for permanent measures that allow buprenorphine treatment without the required in-person medical assessment. On June 30, 2020, Senators Rob Portman (of Ohio) and Sheldon Whitehouse (of Rhode Island) introduced the bipartisan bill S. 4103: Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act. This bill seeks to permanently expand telemedicine services for opioid use disorder by amending the Ryan Haight Act to allow buprenorphine treatment following a virtual medical assessment with a clinician—that is, the in-person assessment would no longer be required. While this bill is a step in the right direction, it would still require audiovisual patient-provider appointments, which presents obstacles for many Americans without access to videoconferencing.

Bicycle Health has signed the letter, A Call for Equity: Telehealth to Improve Buprenorphine Access, which provides recommendations for further legislative action to improve health equity regarding buprenorphine treatment. And you can read more about Bicycle Health’s work regarding health equity in buprenorphine treatment here.

How do pill mills fit into all of this?

By now, many people are familiar with the term “pill mill.” Essentially, pill mills refer to clinicians, pharmacies, and clinics where large numbers of opioids are inappropriately prescribed medication with little or no medical evaluation of the patient, no diagnostic workup of the reported health problem, and without due diligence to check if patients already have existing opioid prescriptions. Florida, amongst other states, have been recognized for their “pill mill tourism,” in which people travel from various parts of the country to obtain prescription opioids.

Pill mills are NOT SAFE… they’ve contributed significantly to the opioid epidemic in America. Pill mills are largely being outed/discovered and closed, with many clinicians and other staff now being prosecuted for pill mill facilitation. This has resulted in many pill mills going virtual, of which the ones based in the US are also being discovered by law enforcement and subsequently, shut down.

It goes without saying that telemedicine for treatment of opioid addiction is different. Treatment for opioid use disorder requires regular videoconferencing visits with medical providers, as well as health coaching, online support groups, and urine drug screen requirements. Buprenorphine/naloxone (Suboxone) is the safe, effective, lifesaving medication needed to treat the problem that resulted from in-person and online pill mills. Telemedicine providers who treat patients with opioid addiction are invested in each patient’s recovery.

Moving forward

Here at Bicycle Health, our medical providers prescribe buprenorphine/naloxone (Suboxone) to help patients stop or cut down on their opioid use. We support permanent expansion of telemedicine services for opioid use disorder by amending the Ryan Haight Act, thereby eliminating the required in-person medical assessment. The TREATS Act is an important step in the right direction, though we also advocate for further legislative action to improve health equity regarding buprenorphine treatment.

To learn more about the availability of Bicycle Health’s telemedicine buprenorphine/naloxone (Suboxone) treatment in your area, call us at (844) 943-2514, or schedule an appointment here. We’d love to walk with you as you re-shape your life’s path.

About the Author

Rebekah L. Rollston, MD, MPH

Dr. Rollston is a Family Medicine Physician at Cambridge Health Alliance, Affiliate Editor-in-Chief of the Harvard Primary Care Blog, and Founder of Doctors For A Healthy US, LLC. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine and her Master of Public Health from The George Washington University. Her professional interests focus on social influencers of health & health disparities, addiction medicine, sexual & reproductive health, homelessness & supportive housing, and rural health.

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