The medication buprenorphine, used by patients with opioid use disorder (OUD), became easier for Americans to access in 2020 as a result of the COVID-19 pandemic. However, this access is only a temporary protection, and experts say the clock is ticking before thousands of patients lose access in 2025.
Buprenorphine, often referred to by the brand name Suboxone, is a partial opioid agonist, meaning it helps people with opiate use disorder quit using opioids by reducing cravings and lessening withdrawal symptoms. It is the only medication of its kind that primary care providers can prescribe. Before the pandemic, patients needed to be evaluated in person by a prescriber before they could start taking buprenorphine. During the COVID public health emergency, the in-person requirement was lifted, allowing providers to prescribe the medication via telehealth.
Lauren Majors, a nurse practitioner and addiction nurse practitioner program manager at Boston’s Beth Israel Deaconess Medical Center, said the ability to prescribe Suboxone online has significantly expanded the number of patients who can access treatment.
“It’s huge,” Majors said. “I was actually just talking to a patient today who lost his license due to substance use, and so getting to appointments can be incredibly challenging for patients. Many of them don’t have licenses or can’t drive, and so just by offering it, you’re reaching a broader audience.”
In 2020, an estimated 2.7 million people in the United States aged 12 and older had an OUD in the past 12 months, according to the National Institute on Drug Abuse. The opioid crisis has remained a significant issue across the country, with 107,941 people dying of an overdose in 2022, according to NIDA.
Between April 2023 and April 2024, overdose deaths declined by roughly 10 percent, according to the Centers for Disease Control, making it the largest decrease on record. The exact reason for the decline is unknown, but greater access to buprenorphine could be a contributing factor.
To prescribe Suboxone, a controlled substance, providers must obtain a U.S. Drug Enforcement Agency License by answering questions, paying a fee and waiting for their application to be processed. Rural areas may lack a nearby provider with a DEA license, so the pandemic flexibilities for Suboxone have been instrumental in allowing patients to access the medication, especially since some prescribers don’t have in-person appointments available for weeks.
Marcelo H. Fernández-Viña, who researches access to substance use treatment for Pew Research Center, said more patients than ever have been able to start and stay in treatment for OUD without an increase in overdose rates.
“Veterans, people experiencing homelessness, people that were involved in the criminal justice system, people living in rural areas, racial and ethnic minorities-they all got greater access to buprenorphine via telehealth,” Fernández-Viña said. “It really helped with barriers like transportation or finding childcare or taking time off work. And the research also showed that patients liked it and that providers liked it, too.”
But these pandemic flexibilities aren’t permanent. In March 2023, the U.S. was no longer in a state of public health emergency, so the DEA proposed changing the rules. Under the proposal, patients would have been able to get one 30-day supply of buprenorphine before having to visit their provider in person for another prescription. The DEA received over 38,000 comments in response to the proposed changes to telemedicine, with the vast majority advocating for a continuation of entirely online care.
As a result, the DEA extended the flexibilities through November 2023, and then again through December 2024. The most recent extension provides an additional year of buprenorphine access via telehealth, through the end of 2025.
Fernández-Viña said the temporary nature of these rules has made the future of OUD care uncertain for both patients and providers.
“It has left many providers hesitant to invest in telehealth services, and it leaves patients continually in danger of losing access to this treatment,” he said. “People don’t know what their treatment is going to look like after these things expire.”
With the new presidential term beginning in 2025, patients remain unsure what will happen to their Suboxone access. Extending telehealth rules takes time, as the DEA is required to offer a public comment period of 30 or 60 days before reviewing responses, addressing major concerns and finalizing the extension.
“That’s a long process. It’s a lot of bureaucracy. So that takes time,” Fernández-Viña said. “In addition to that, it’s a new administration, there’s new folks. Getting people up and running takes time, so a year is tight.”
Congress also can make these telehealth provisions permanent. The Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act was proposed in the Senate in November 2023, but it has yet to see any legislative progress. Both Congress and the DEA feel the other should oversee the policy change.
Sen. Mike Braun (R-Ind.), who serves on the Senate Health, Education, Labor and Pensions (HELP) Committee, said he favors keeping the flexibilities in place, and views it as a worthy legislative pursuit. “I love telehealth. I think you should be able to do anything through telehealth because it’s generally going to be a lower cost when it comes to that, or almost anything else in health care.”
When asked why Congress has not acted on the issue, Braun said that “the health care industry isn’t that interested in it, as they should be, because it would probably lower their revenues.”
Sen. Tim Kaine (D-Va.), another HELP Committee member, said he intends to look into the safety of buprenorphine. “I don’t have yet a conclusion about that,” he said. “It would be a mistake just to go back to where we were before. Exactly how the telehealth prescription of buprenorphine has worked, and has it been a good thing with no unintended downsides or consequences, I don’t really know. I’d want to take a look at it, but I do generally think that our use of telehealth during the COVID was one of the real smart things we did.”
President-elect Trump tapped Chad Chronister, a Florida sheriff, for DEA Administrator, but Chronister withdrew his name for consideration earlier this month. Trump later took to Truth Social, saying that Chronister did not withdraw his name but instead, pulled his support for the sheriff. A replacement has yet to be named, but lawmakers, providers and patients remain unsure how the new executive branch will proceed.
Kyle Zebley, Executive Director of ATA Action, a group affiliated with the American Telemedicine Association that advocates for the expansion of telemedicine services, noted that Congress originally granted the DEA the ability to allow providers to prescribe controlled substances without an initial in-person visit in 2008. Yet, 16 years later, a permanent solution remains elusive.
“I think that the new administration will want to take a look at what the outgoing Biden administration has done in terms of their draft rule, which is not publicly available yet, and see if they will want to continue with it or change course,” Zebley said. “I think that they will likely want to change course and put their own imprint on it. That takes time.”
The main hesitancy surrounding expanding Suboxone access is a practice called diversion—the illegal distribution of medication from a patient with a prescription to someone without one. But Fernández-Viña said that studies have proven the best way to prevent diversion is to increase access, which the pandemic flexibilities have done in a major way.
“We’ve got this one year, and then once that year is up, if nothing gets done, then people lose access,” Fernández-Viña said. “We’re really heading towards the cliff.”
