Medication-assisted therapy via telemedicine shows promise
A Boston-based start-up company that offers patients medication-assisted therapy through telemedicine is trying remove some of the stigma associated with opioid use disorder treatment.
“Many existing medication-assisted treatment programs are offered in brick and mortar locations where patients don't want to be seen,” Ankit Gupta, a software engineer and CEO of Bicycle Health, told Healio Primary Care. “A telemedicine model like ours offers discreetness and convenience in a judgement- and stigma-free zone.”
Bicycle Health patients start by having a physician complete an assessment of their physical and mental health and substance use disorder history during one-time, in-person appointment with a health care provider that lasts about 90 minutes. At the end of the appointment, if a substance use disorder diagnosis is made, the physician prescribes buprenorphine/naloxone and develops a treatment strategy with the patient.
Then, for 1 week after the initial appointment, the physician or a health coach calls the patient or participates in an online chat with the patient every other day to see how the patient is progressing. After that, the patient schedules follow-up telehealth visits with their physician every week for the first month, every other week for the next 2 months and every month thereafter until no longer needed. Prescriptions are delivered to the patient at home or to the patient’s pharmacy — whichever location the patient prefers — and all follow-ups are done over secure video calls to ensure confidentiality, according to Gupta.
“Due to the nature of our program and the comprehensive assessment we perform, we only hire clinicians with a family medicine background, a psychiatry background, or both,” he said. “We also only hire physicians with a background in buprenorphine prescribing.”
Gupta added that other Bicycle Health support services — opioid tapering assistance, individual counseling and support groups — are offered through webcasts hosted through secure services on the company’s website, via telemedicine or the company’s app. Many of the support services are available at least 12 hours a day, 5 days a week.
Patients pay $199 a month in out-of-pocket costs to participate in the program. However, depending on the physician’s location, costs related to health coaching, care navigation and support groups may not be recoverable, Gupta said.
CMS has previously provided some guidance on which funding authorities may support health information technology efforts such as virtual treatment centers, remote counseling, prescription monitoring plans, and shared electronic care plans that could be used for the prevention and treatment of negative opioid outcomes.
Currently, Bicycle Health’s services are offered in California, but Gupta says the company plans to expand its operations.
Support for MAT and the role of telehealth
According to the CDC, 130 Americans die each day from opioid overdoses, demonstrating the need for effective approaches to treatment.
Federal agencies like the Substance Abuse and Mental Health Services Administration, the CDC and HHS support MAT, and evidence suggests it works. A review of meta-analyses, systematic reviews and individual studies published between 1995 and 2012 showed that maintenance treatment with buprenorphine improved outcomes compared with placebo for individuals and pregnant women with opioid use disorders.
The role of telehealth in MAT has also been studied, but to a lesser extent.
Wanhong Zheng, MD, an associate professor of psychiatry at West Virginia University, and colleagues found that telepsychiatry and in-person MAT were equally effective approaches to treating opioid addiction.
Zheng, who is uninvolved with Bicycle Health, told Healio Primary Care that the services the company offers — like individual counseling, group support and health recovery coaching — “are as important as buprenorphine treatment” itself.
He said the program’s individualized treatment approach is also beneficial because “there is no one-size-fits-all treatment for patients with opioid use disorder.”
However, Janice Pringle, PhD, professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy, cautioned that patients on MAT need extensive monitoring, which programs like Bicycle Health’s may not be equipped to do — a concern Zheng also shares.
“There are only a few telemedicine programs that I have seen for this population, but many of them include a urine screen component,” Pringle said. “In addition, the medication-assisted therapy that these patients are prescribed can be diverted. The majority of those who get their hands on the medication via diversion may decrease their likelihood of dying from an overdose, but they also will likely not enter stable recovery either.”
In response, Gupta said that Bicycle Health does conduct monthly urine tests on patients, which are contracted out to local labs.
“If we see that the patient hasn't done a urine test, then we consider that a positive result and/or the possibility that the patient is diverting their buprenorphine to someone else,” Gupta continued. “Buprenorphine synthesizes in the body differently than it does if you just sprinkle some of the medication in the urine test cup. This also assists in our efforts to recognize patient diversion. If the patient fails their urine test several times, we take that as a sign that this patient needs a higher level of care.”
Additionally, Gupta said Bicycle Health utilizes prescription drug monitoring programs to track if and how frequently a patient fills a buprenorphine or opioid prescription. Patients who do not fill the buprenorphine prescription or fill opioid prescriptions are suspected of diversion and/or relapse and their treatment plan will be changed accordingly.
Stefan Kertesz, MD, MSc, a primary care physician and professor of preventive medicine at the University of Alabama at Birmingham, noted that Bicycle Health is one of only a few programs that allow patients to receive MAT at home.
“There have been papers that show it is feasible to have patients connect by videoconference with the prescriber,” Kertesz said in an interview. “But the main models tested have involved having the patient come to a rural clinic where there is a nurse, and then they connect by video to a buprenorphine prescriber who is offsite.”
He also noted that some MAT programs have abused patient’s trust, which could hinder greater acceptance of the model.
“There are published papers that show many prescribers of buprenorphine engage in a cash-only business where they charge quite a bit of money for issuing prescriptions without taking deep interest in the social and emotional challenges faced by the patients. That can be exploitative and legally risky,” Kertesz said. “For Bicycle Health or similar operations to succeed, they will have to bend over backwards to show that they are offering a serious and comprehensive service.”
According to Gupta, there were 300 Bicycle Health patients in 2019. These patients rated the program 10/10 when it comes to satisfying their needs. In addition, 77% stayed in treatment and about 60% saw improvement in their motivation to stop using opioids and in depression and stress scores.
Gupta said that in theory, a program like Bicycle Health’s can plug right into a primary care clinic. Under the auspices of their PCP, patients can discretely connect with a Bicycle Health coach to get started on MAT while on site. This could shield them from unwanted attention or stigma.
“Another avenue is plugging into emergency rooms and rehab,” he said.
Pringle said she needs to see more data before considering Bicycle Health an “effective” treatment approach to opioid use disorder.
“I would classify Bicycle Health as a promising approach,” she said. “Certainly, with additional evaluation data — including the use of a control or reference group — the developers can move from ‘promising’ to ‘evidence-based.’ I would encourage them to continue that work.” – by John Schoen and Janel Miller
For more information:
Bicycle Health. https://www.bicyclehealth.com/.
CDC. Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed Feb. 5, 2020.
HHS. Addressing prescription drug abuse in the United States. https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. Accessed Feb. 5, 2020.
Pew Charitable Trusts. Medication-assisted treatment improves outcomes for patients with opioid use disorder. November 2016. https://www.pewtrusts.org/~/media/assets/2016/11/medicationassistedtreatment_v3.pdf.
Disclosures: Gupta is CEO of Bicycle Health. Zheng reports no relevant financial disclosures. Kertesz reports previously owning stock in Merck and Abbot, which he sold in 2017. Healio Primary Care was unable to determine Pringle’s relevant financial disclosures prior to this story’s posting.