Death Sentence by Denial: Rhode Island and Alabama Turn Their Back on Addiction Treatment While Opioid Related Deaths in Both States Soar

Last month, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (HHS) released a joint statement strongly encouraging use of telehealth to treat opioid use disorder. Specifically, they encouraged the use of telehealth appointments to prescribe the lifesaving medication Buprenorphine, otherwise known as Suboxone. In the February release, the agencies stated, “In the face of an escalating overdose crisis and an increasing need to reach remote and underserved communities, making the buprenorphine telehealth flexibility permanent is of paramount importance. Our final rule permits initiation of buprenorphine if the authorized healthcare professional determines that an adequate evaluation of the patient can be, or was, accomplished via audio-only or audio-visual telehealth technology.” They went on to say that telehealth plays a critical role in expanding access to needed addiction treatment that will ultimately curb the opioid epidemic, including lifesaving medications like Suboxone that many Americans will never see without the exclusive use of telehealth.

Despite this new guidance, the Rhode Island Department of Health and the Alabama Department of Public Health have decided to ignore these key directives from our nation’s leading healthcare experts. This is leading to escalating opioid related deaths in both states. Despite the Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Department of Health and Human Services (HHS) guidance on telehealth, both medical boards continue to require in person appointments prior to starting Suboxone- a medication that reduces lethal opioid overdoses by over 50%. As a direct result, both states have some of the highest lethal overdose rates in the nation.

In an effort to help expand vitally needed access to opioid use disorder treatment via telehealth, I met with Rhode Island’s Board of Medicine last week. In this meeting, The Rhode Island Board of Medicine insisted that Rhode Island will continue to require an in-person appointment prior to starting Suboxone moving forward. Their rationale? They pointed to Rhode Island state legislation that requires an in-person appointment to start any controlled substance. This includes a very broad range of medications including stimulants for ADHD, benzodiazepines, and opioids for pain management. Suboxone, which works very differently from these other medications, is also a controlled substance. In response, I pointed them to the SAHMSA/HHS 2024 February ruling. It states, “There are no significant differences between telehealth and in-person buprenorphine induction in the rate of continued substance use, retention in treatment or engagement in services. Further to this, research demonstrates that actions to facilitate access to buprenorphine-based treatment for OUD during the COVID–19 pandemic were not associated with an increased proportion of overdose deaths involving buprenorphine.”

I hoped surely this would prompt some thoughtful reflection and reconsideration on their part. Don’t get your hopes up. They simply shrugged their shoulders and said, “Sorry. This is the regulation. We can’t change it.” I was baffled. You, Rhode Island Department of Health , are the medical leaders of your state. It is incumbent upon you to support and educate your state leaders to pass public policy health measures that align with national expert guidelines and save lives. It is also your responsibility to point out and help correct outdated policies that contradict public health recommendations and cost lives.

Faced with this unexpected resistance, I suggested that perhaps a patient’s local primary care physician could do the physical in person exam, with the patient then completing a subsequent telehealth appointment for the treatment of opioid use disorder. Again- don’t get your hopes up here. “No no,” they each quickly shook their heads, almost in unison. “The physical exam must be done by the same provider who is issuing the Suboxone prescription that very day-no one else.” I could not think of any logical medical rationale to support this arbitrary edict. They did not provide one either. It’s hard to see how a Primary Care Doc’s physical exam completed on a Tuesday would differ significantly from an Addiction Psychiatrist’s physical exam completed 24 hours later. In fact, the Primary Care doc’s physical would likely be more comprehensive. This would also have been a good time to remind them of the significant shortage of Addiction specialists in the United States. Currently, only 18% of people with opioid use disorder have access to addiction treatment-a problem greatly exacerbated in Rhode Island given their very small size.

The Rhode Island Department of State legislation regarding controlled substances and in person appointments mistakenly lumps prescription opioids for pain and medications to treat addiction into the same category. These medications classes could not be more different. Pain medications like Oxycontin and Vicodin caused the opioid epidemic. Addiction medications like Suboxone treat victims of the opioid epidemic. They could not be more dissimilar. The Rhode Island legislation does not understand this very important distinction. And thus, while rightly hindering access to addictive pain medications, they also block access to the life-saving medications used to treat the very addictions that the opioid medications created. Wrap your head around that.

The Rhode Island Department of State legislation wording on controlled substances is confusing and contradictory at best. In statute H-7131, there is wording that specifically excludes medications for Substance Use Disorder from the same restrictions as pain medications. In other places, these important distinctions are not made. Statutes like 216-RICR-20-20-4, section H discuss “Pain Medicine Physicians” and “Addiction Medicine Physicians” as if they are one and the same. These are two completely different types of doctors with different residencies, training, and background, treating very different types of conditions. Chronic Pain, which is treated by Pain Medicine Physicians, is not the same as Opioid Use Disorder, which is treated by Addiction Medicine Physicians. Nevertheless, the Rhode Island Department of Health , Department of Administration State of Rhode Island , and Rhode Island Department of State have decided that powerful opioids causing addiction like fentanyl should be categorized and treated the same as addiction treatment medications like Suboxone which are used to treat (not cause) addiction. Sigh.

We are moving in the wrong direction here. Alabama Department of Public Health also requires one in-person appointment within 12 months if issuing a controlled substance. There are no exemptions for medications approved to treat Substance Use Disorder. While not quite as restrictive as the Rhode Island Department of Health requirement, Alabama's in-person requirement also blocks access to vital, lifesaving Addiction medication. It is a decision that is not grounded in science, research, or medical necessity. The medical research overwhelming contradicts the need for in-person requirements to treat substance use disorders. As the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (HHS) point out, “Recent research has demonstrated that telehealth can be an effective tool in integrating care and extending the reach of specialty providers, and that among those patients requiring treatment with buprenorphine, there are high levels of satisfaction with the use of telehealth services.”

Why should we care? And what can we do? We should care because our fellow American brothers, sisters, mothers, fathers, cousins, and friends are dying daily from lethal overdoses. These deaths disproportionately come from states like Alabama and Rhode Island that unnecessarily hinder access to addiction treatment with in person appointment requirements. These state specific barriers are not backed by science, research or data. Rather they are grounded in a fundamental misunderstanding of addiction medications and the lifesaving hope these treatments offer to our fellow Americans. Dr. Nora Volkow, the director of The National Institute on Drug Abuse (NIDA) , recently summarized this succinctly, saying “A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives. Yet tens of thousands of people die each year because they have not received these treatments. Ending the crisis will require changing policies to make these medications more accessible.” She concluded that we could reduce opioid related deaths overnight by over 50% by increasing access and reducing barriers to Suboxone.

The life-saving medications that could and should be getting to those who need it most already exist. Instead, we are faced with apathetic state medical leaders who simply don’t care enough to advocate for needed changes in their state policies. Nothing burns me up more than privileged indifference. The citizens of Rhode Island and Alabama entrust their respective medical boards with great power. My mother always told me, “To whom much is given, much is expected.” I could be more forgiving of simple ignorance, or lack of medical knowledge. But it is tragically disappointing that even when provided with updated medical guidance from our nation’s premier authorities on Addiction treatment, some medical professionals in power still refuse to change, advocate for, or influence state health policies that could save millions of lives. “That’s just the regulation,” they simply shrugged, staring blankly back at me. “We can’t change it,” they insisted. Yes, you can. And you should. Whether from apathy, laziness, or simple aversion to change, Rhode Islanders and Alabamians deserve much, much better.