(2025-11-02) PHTI Virtual Opioid Use Disorder Solutions Assessment

Peterson Health Technology Institute (PHTI had a session to the Chicago MATTER-Health group yesterday to review its assessment report on Virtual OUD (Opioid Use Disorder) Solutions.

Report highlights:

Letter From the Executive Director

Access (which really is about Adoption more than Access)

Today, only one in four Americans who need it receive best-in-class OUD treatment that includes lifesaving medications. Moreover, these treatment programs have dishearteningly poor retention rates, with patients suffering from frequent relapses and lengthy recovery journeys.

• biggest group (43%) refuses treatment because they don't think they need it.

The solutions assessed in this report represent a first generation of virtual OUD treatment programs—which fully leverage telehealth and digital support services—with an aim to improve access to care and keep patients in treatment longer.

• I suspect they should break out Telehealth from the other Digital interventions (report categorizes them at Digital educational (e.g., CBT) Tools, Contingency management, Peer support, Group support, Care navigation), because they're so different from each other. (Digital Therapeutics)

The results show that these programs are a step in the right direction, but the magnitude of their benefit is unsatisfying

only slightly extend treatment retention

not achieving measurable improvements in expanding the number of previously untreated patients receiving medication-based care

Caroline Pearson, Executive Director

Executive Summary

only 25% of adults in need of OUD treatment receive a medication-based intervention

PHTI Assessment Approach

This evaluation reviewed evidence across eight outcome measures, with treatment retention —particularly to buprenorphine-based (Cizdol, Brixadi, etc.) care—identified as the primary clinical outcome because it is a key proxy for sustained adherence and overdose risk reduction

improved retention in treatment is associated with better long-term outcomes, and even small gains in this area can be meaningful to patients and purchasers.

The report also examines secondary outcomes, such as abstinence from opioid use, rate of relapse, and attenuation of withdrawal symptoms. The evidence base includes several well-designed studies but is limited by small sample sizes, relatively short follow-up duration given the chronic nature of OUD, potential selection bias, single-site designs, and gaps in generalizability to the broader OUD population.

• it's "interesting" that the "primary" outcome metric is a proxy metric, and even is a proxy for adherence and non-overdose, not abstinence. I wonder about quality-of-life improvements. But of course healthcare-costs are the hidden-metric that filters everything. And quality-of-life is hard to assess, or measure for trade-offs.

Clinical Effectiveness

While several studies found improved abstinence rates among users of virtual OUD solutions, others found no significant difference compared with usual care, and relapse rates were generally comparable across groups.

Access to Care

no evidence (of serving more people)

PHTI’s recommendations include:

Advance evidence generation to demonstrate which aspects of virtual OUD solutions are improving treatment retention and for which populations

The Case for Innovation

More than nine million adults across the United States are diagnosed with opioid use disorder (OUD)1

Opioid use plays a role in approximately 80,000 deaths from overdose per year, with the number of opioid-related deaths rising by 67% between 2017 and 2023, before declining in 2024. (not because of improved treatments)

The most effective treatment for OUD involves prescription medications, sometimes in combination with therapy and other psychosocial interventions.

methadone

only one-fourth of adults with documented OUD in 2022 received recommended medications. Several barriers contribute to this treatment gap, including patients’ reluctance to seek treatment, access challenges, limited insurance coverage, social stigma, fragmented care, and an uncertain and changing policy environment regarding controlled substances and teleprescribing for medications such as buprenorphine

answer three fundamental questions: How well do these virtual OUD solutions work? For whom? And are they worth it?

Condition Overview

with growing levels of the powerful synthetic opioid fentanyl in the country, deaths from overdose have increased, by 70% since 2017

Exhibit 1 U.S. ADULTS WITH OUD IN 2022, BY DEMOGRAPHIC GROUP

Exhibit 2 THE OPIOID CRISIS, BY WAVE Number of Deaths by Overdose Overall and by Opioid Type

While many people with OUD initially become addicted through use of prescription medications, many eventually transition to illegally acquired drugs that may be laced with other chemicals, including fentanyl.

Economic Impact

patients with OUD incurred $13,000–$15,000 more in annual healthcare costs

Standard of Care for Opioid Use Disorder

MOUD, which was historically referred to as medication-assisted treatment (MAT).

often combined with substance-use counseling, individual and group therapy, drug testing, case management, and peer recovery support

Studies have shown that MOUD treatment significantly reduces overdose mortality and all-cause mortality compared with no treatment, with protective effects that persist even after treatment discontinuation

MOUD treatment typically encompasses three phases: initiation, stabilization, and maintenance

Opioid Settlement Funds

To date, more than $50 billion has been committed in settlements.46, 47 These funds are earmarked for opioid abatement strategies, including expanded access to treatment, support services for individuals with OUD, and increased availability of naloxone (narcan) and other overdose-reversal drugs

Exhibit 4 EXAMPLES OF MEDICATIONS FOR OUD

Psychosocial Interventions

MOUD treatment integrates pharmacotherapy with psychosocial interventions

Common psychosocial interventions include individual counseling or talk therapy, educational content, cognitive behavioral therapy (CBT) modules, peer support, group counseling, and connection to community resources that address social determinants of health

Some research indicates that adding psychosocial interventions to MOUD is associated with a lower risk of medication discontinuation within the first 180 days of treatment

However, studies adding CBT modules to standard buprenorphine treatment have demonstrated mixed results:

• as with the "access" vs "interest/desire" distinction, I wonder how many of these patients really want to get better. I'd imagine CBT success is associated with engagement.

Contingency management (CM) is an evidence-based psychosocial intervention that reinforces positive behaviors through incentives. Drugs activate the brain’s reward pathways77 and CM approaches tap into these same pathways by providing immediate rewards—such as an added balance on a debit card or a gift certificate to a store—for adherence to a care plan.

• aka you get a cash reward for doing good things

CM has been studied with positive results across several substances, including stimulants,78 alcohol,79 and nicotine.80 It is considered the “gold standard” of care for stimulant use.

The evidence for CM as an intervention for OUD is more limited.

supporting treatment for OUD, it is important that they be delivered in conjunction with medication. Research shows that these interventions are less effective as standalone treatments

Two of the medications used for OUD treatment—buprenorphine and methadone—are controlled substances governed by the DEA. These medications are subject to many federal and state regulations that determine where and how they can be dispensed.66 Until recently, outpatient providers needed to obtain special authorization (an “X-waiver”) from the DEA to prescribe buprenorphine for OUD

Prescribing Controlled Substances for the Treatment of OUD

Exhibit 5 HOW PATIENTS ENTER THE OPIOID USE DISORDER TREATMENT SYSTEM

Barriers to Access and Care

Of those who did not receive any treatment, SAMHSA estimates that 95% do not believe they need treatment.

West and Northeast, leaving large areas of Midwest and South with fewer than 25 providers per 100,000 people, despite rising overdose rates

While teleprescribing has expanded since the COVID-19 pandemic, a patchwork of state licensing rules limit national scaling of virtual clinics and force physicians to navigate a patchwork of state-specific rules

Average wait times to first appointments often exceed six days in high-mortality areas, which can significantly increase overdose risk

Exhibit 6 U.S. OPIOID OVERDOSE DEATH RATES PER 100,000 PEOPLE, BY DEMOGRAPHIC GROUP, 2023

The 90-day period following treatment termination is associated with high overdose risk—approximately 40% of all deaths from overdose occur within the first two weeks of leaving treatment.97

there have historically been two philosophies to care: 12-step programs like Narcotics and Alcoholics Anonymous have focused on “complete abstinence from all drugs,”98 while low-barrier approaches focus on removing obstacles to treatment. The low-barrier approach generally encourages patients to continue MOUD treatment even if they do not want to be in counseling or participate in peer support or other components of a care plan.

Given the effectiveness of medications such as buprenorphine and methadone at preventing overdoses, there is now general consensus in support of low-barrier approaches

Low-Barrier Care

The Rise of Virtual Care for Treatment of OUD

In 2019, the SUPPORT for Patients and Communities Act exempted SUD (substance abuse disorder) and co-occurring mental health disorders from specific telehealth requirements under Medicare

During the COVID-19 pandemic, additional flexibilities were granted to ensure people retained broad access to treatment

buprenorphine became available to individuals without first having to be seen in person by a healthcare provider

Similar telehealth flexibilities remain in place today

Virtual Solutions

16 companies

additional support services, like therapy and CM

to employers, payers, or health systems/providers; and

Solution Categories

solutions can be grouped into two broad categories

1 Medication-Focused Solutions: Provide virtual MOUD prescribing capabilities, supplemented with support services—such as therapy, peer support, or CM—that aim to enhance care coordination and treatment outcomes

2 Digital Wraparound Solutions: do not offer direct MOUD prescribing

Company Overview

Exhibit 9 CATEGORIES OF VIRTUAL OUD SOLUTIONS

CORE COMPONENTS OF VIRTUAL SOLUTIONS FOR OUD—MEDICATION-FOCUSED SOLUTIONS

CORE COMPONENTS OF VIRTUAL SOLUTIONS FOR OUD—DIGITAL WRAPAROUND SOLUTIONS

Patient Perspectives

Clinical Effectiveness

Primary Clinical Outcomes

*Exhibit 15 DETAILED SUMMARY OF CLINICAL, USER EXPERIENCE, AND HEALTH EQUITY OUTCOMES Exhibit 16 TIME-BASED RETENTION ON TREATMENT OUTCOMES FOR VIRTUAL OUD SOLUTIONS COMPARED WITH USUAL CARE

Exhibit 17 PATIENT-BASED RETENTION ON TREATMENT OUTCOMES FOR VIRTUAL OUD SOLUTIONS COMPARED WITH USUAL CARE

Summary of Primary Outcomes

virtual OUD solutions deliver comparable or slightly better treatment retention than usual MOUD care

• this is actually a surprise for many people, who believe that in-person interaction is important

Expanding Access and Treatment

Secondary Clinical Outcomes

Clinical advisors and professional societies deemphasize abstinence as a primary goal for treatment, favoring retention and continuity of care as core outcomes

family members and improves both clinical and functional outcomes. Fourteen studies in this review report abstinence rates, measured by urine screening or self-report. Among the nine comparator studies of interest, evidence was mixed: Five studies demonstrated statistically significant improvements in abstinence rates for digital-solution users compared with control arms, while two found no significant improvement between groups (see Appendix E). Two studies had mixed results

User Experience

Health Equity

Few studies stratify their results by demographic group

Study samples were primarily composed of white participants aged 30–50, with slightly higher female representation than male. (WEIRD)

Economic Impact

Summary Ratings

Exhibit 23 PHTI RATINGS FOR VIRTUAL OPIOID USE DISORDER SOLUTIONS BY CATEGORY

Next Steps