New SAMSHA Opioid Guidelines for Quarantine
SAMHSA, the Substance Abuse and Mental Health Services Asociacion, has posted a new set of guidelines in regards to the changes brought on by the COVID-19 epidemic. The page is updated frequently, with the latest update on 7/17/2020 adding a new piece about the organization’s efforts to leverage existing health establishments for greater use during quarantine conditions. This primarily includes encouraging such organizations and health centers to put greater focus on telehealth options.
In addition to the aforementioned document, the SAMHSA has put a large emphasis on incorporating telehealth systems wherever they are needed. Another document, for example, provided a means for health providers and medication distributors to circumvent the need for written patient consent for disclosure of substance use disorder records. In addition, the document also states that providers have the ability to deem a situation a “medical emergency” to allow the prescription of medications to a patient with digital signage and identifying information only.
This would in some cases eliminate the need for face-to-face contact, but the document does leave open the rulings on what a ‘medical emergency’ means. The document doesn’t shy away from acknowledging this weakness in the new guideline – rather, the final, emboldened line of the attached document reads as follows:
“We emphasize that, under the medical emergency exception, providers make their own determinations whether a bona fide medical emergency exists for purposes of providing needed treatment to patients.”
Similar amendments have been made to the requirements for prescribing medicine to Opioid Treatment Program (OTP) patients. These programs are set up by the government to help those who have developed a dependence to opioid medications.
Previous efforts to control the distribution of controlled substances are providing significant barriers to access during the COVID-19 epidemic. The Ryan Haight Act of 2008, for example, requires an authorized provided to conduct at least one in-person examination of the patient before prescribing a controlled substance. COVID-19, however, has transformed this process from a necessary barrier to a health hazard for both patient and provider.
In response, on March 16th 2020, the government activated an emergency exception to the Ryan Haight Act, through which prescriptions can be made over telemedicine. This digitization requires the use of a real-time audio-visual communication – a video call, for example.
Furthermore, the Drug Enforcement Agency (DEA) released this letter in partnership with SAMHSA. As of March 31st, 2020, this letter has allowed “authorized practitioners” to prescribe buprenorphine to new and existing OUD patients via telemedicine. The specifics on who is and isn’t an “authorized practitioner” are detailed more in the letter attached.
This amendment differs from the one made by SAMHSA in that the DEA is allowing the prescription of buprenorphine via digital communication methods that lack a video component, such as a telephone call.
These efforts to incorporate telemedical functionality into OTPs will likely help ease the struggle of writing prescriptions to those in need during quarantine. However, these changes do come with their own set of challenges.
Specifically, similar to the first detailed amendment, these changes leave much in the hands of the provider. It will be up to individual providers to determine if an evaluation can be performed over telephone or other digital means. The distance and digital nature of these evaluations may leave practitioners with less information per patient when having to decide to prescribe controlled substances.
Furthermore, some state laws may hinder or invalidate these new guidelines – specifically those with laws governing the prescription of controlled substances via telemedicine. Nebraska, for example, does not allow physicians to prescribe medications without a “physician-patient relationship, which must include an [in-person] examination”, according to an Internet Prescribing Document published by the Center for Telehealth & e-Health Law.