The Substance Abuse and Mental Health Services Administration's 2024 Final Rule includes a comprehensive set of regulations distributed by the organization. These rules serve as guidelines and standards for opioid treatment programs across the United States, with the 2024 Final Rule significantly shifting and modernizing guidelines for the operation of OTP and the administration of medication-assisted treatment, known as MAT.
In addition to adding more inclusive language, the new rule expands access to MAT, including enabling nurse practitioners and physician assistants to order medications for opioid use disorder, expanding the timeframe for interim treatment, and making telehealth options more permanently available to patients.
Prior to the COVID-19 pandemic, federal regulations and SAMHSA guidelines required in-person evaluations and dosing observation. These guidelines forced opioid treatment programs to process a large number of in-person patients daily, limiting resources and adding to provider and staff burnout.
Easier access to programs
The 2024 SAMHSA Final Rule made COVID-era flexibility around telehealth treatment and take-home doses permanent. Previously, nearly all aspects of intake, treatment and follow-up had to be conducted in-person.
Under the new rules, intake, treatment initiation and dosing can all take place remotely via telehealth and take-home medication programs, enabling more patients to easily access these treatments and easing the in-person treatment burden for providers and OTP staff.
MAT is the clinical practice of administering medications, in combination with counseling, therapies and peer support, to treat substance use disorders, like opioid use disorder, explained Kelly Collins, vice president of digital adherence at Dimagi, the maker of CommCare, a digital platform designed for a range of critical health programs, from public health and behavioral health to infectious disease management. The company works with 24 states.
"In addition to traditional therapy and support, providing patients with controlled doses of methadone, buprenorphine or naltrexone helps to normalize brain chemistry, blocking the effects of opioids and relieving drug cravings, without the negative effects associated with these dangerous substances," she said.
"Patients with substance use disorders can be referred to a MAT program or locate a community program on their own," she continued. "These patients complete an assessment and intake to help the program personalize their treatment plan, including the specific medications, dosages, frequency of administration and other counseling components."
Achieving stability
During this assessment step, providers also query other program enrollments to ensure individuals aren't enrolled in another program at the same time. Patients complete their plan with regular follow-up appointments to receive their medication and counseling services and slowly taper from weekly to monthly and so on, as stability is achieved.
"While this traditional approach to MAT provides strong support for those struggling with SUD, often these patients face challenges traveling to clinics," Collins noted. "Providing virtual options dramatically lowers barriers for these patients, allowing them to better access support and treatment, increasing their likelihood of program completion."
Factors such as lack of access mean only one-quarter of people who need MAT in the U.S. actually receive it. Patients enrolled in MAT programs often grapple with time and costs associated with traveling for their treatments, not to mention social stigma around their condition.
In some programs, this can drop retention rates to nearly one-half, dramatically increasing the likelihood of patient relapse. Telehealth tools allow patients to overcome these barriers while still receiving the proper medication and therapy, Collins said.
"Enrolled patients are provided with a secure medication dispenser, which allows them to safely access only the correct dosages at the correct times, avoiding overdose or abuse," she explained. "Patients can take their medication during a scheduled call with a provider, who can observe and verify adherence in real time.
"Alternatively, new VDOT systems also allow for asynchronous video uploads," she continued. "Patients can take a video of themselves taking their approved dosages and send it via secure app to their providers. This allows providers to oversee the administration while maintaining flexibility in their days, reducing administrative burden and speeding the observation process."
Counseling via virtual care
Counseling and therapy sessions also can be conducted via telehealth, further saving patients from unnecessary travel to access the support they need.
Previous SAMHSA telehealth restrictions played a key role in limiting the usage of virtual tools in the delivery of MAT. However, during and post-COVID, when telehealth flexibilities were established, many OTPs have still hesitated or struggled to adopt these sometimes life-saving tools that can enable more patients to access critical care, Collins observed.
"Though patient volume can vary based on clinic location and size, it's not uncommon for these facilities to see hundreds of MAT patients daily," she said. "Staff and providers are simply trying to keep their heads above water with their current processes and patient loads, and don't have time to onboard and train themselves on a new process such as virtual MAT.
"Another key barrier to the adoption of telehealth tools at these clinics revolves around reimbursement," she continued. "Often, it's unclear whether providers will get reimbursed the same or a lesser amount for telehealth MAT visits, so they are somewhat disincentivized to provide them. It's a shame considering that most MAT programs boast a 50% retention rate after 12 months, and studies have shown that virtual options can increase that number to more than 90%."
The good news is that with the expansion of the SAMHSA guidelines on telehealth usage in MAT, it may become more mainstream for clinics to be reimbursed a comparable amount for tele-services compared to in-person visits, Collins said.
"This raised reimbursement expectation, along with providers increasingly seeking proactive ways to curb burden, means telehealth MAT programs may start to become more common," she added.
A big milestone
The 2024 SAMHSA guidelines are a significant milestone in normalizing telehealth for MAT. One of the most impactful changes is the permanent allowance of audio-visual (telehealth) evaluations for buprenorphine initiation – eliminating the previous requirement for an in-person visit before starting treatment.
Additionally, the new rules allow for up to 28 days of take-home methadone for stable patients, giving programs the flexibility to tailor treatment intensity based on individual needs.
"These changes create new opportunities for hybrid care," Collins noted. "A patient might start MAT via video visit, receive a take-home prescription, and submit asynchronous video check-ins as proof of dosing. Providers can monitor adherence remotely, maintain regular engagement and intervene quickly when risks arise. Crucially, these workflows reduce the burden on patients while ensuring clinical oversight remains strong.
"Clinics are now navigating how to operationalize these expanded flexibilities," she continued. "Some have existing payer contracts that allow them to bill for asynchronous services, like care coordination or remote monitoring. Others are working with public health agencies or managed care organizations to develop pilot programs and secure coverage."
What's clear is the path forward depends not just on the guidelines themselves, but on clinics having the tools, training and payment support needed to implement them successfully, she added.
How Vermont has tackled the challenge
In the early 2000s, overdose-related deaths began to rise steadily in the U.S., including in Vermont, but studies have found that roughly two-thirds of individuals were unable to access treatment associated with a mental health condition.
This issue of access was a major concern for Vermont Care Partners, a statewide network of sixteen non-profit, community-based agencies providing mental health, substance use, and other services and support to its communities.
"After finding that only 55% of enrolled patients were being retained in treatment, primarily due to burdens associated with daily travel to the clinic, the organization partnered with SureAdhere to provide VDOT support to qualifying patients," Collins recalled.
SureAdhere is a video directly observed therapy, or VDOT, system that provides remote treatment video support tools for a wide variety of uses. The VDOT was created to support traditional DOT with an offline-capable asynchronous video platform for affected people and providers to support TB treatment adherence.
Acquired by Dimagi, Collins' company, in 2022, SureAdhere has expanded to support HIV and MAT programs, among others.
Patients upload videos
"The virtual program provided secure medication dispensers, as well as easy-to-use, compliant technology that would allow Vermont patients to upload a video of themselves taking their prescribed medication and send it to providers for observation," Collins explained. "Along with the asynchronous video capabilities, the program also provided two-way SMS chat and virtual visits to further ease strain related to accessibility.
"The program resulted in a 98% retention rate after one year and saved patients an average of 5.5 hours and $72 dollars per week associated with traveling to see providers in person for services and dosages," she concluded. "In 2022, the findings were so compelling, Vermont Care Network received $1.15 million from SAMHSA to expand the program and its telemedicine approach to providing these vital services."
Follow Bill's HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
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