Telehealth Buprenorphine Initiation for Opioid Use Disorder Among American Indian and Alaska Native Veterans, April 2017-March 2023.

Objective: To determine whether buprenorphine initiation among American Indian and Alaska Native (AI/AN) Veterans increased with expanded telehealth-prescribing abilities during the COVID-19 pandemic. Methods: This cohort study used the Veterans Health Administration medical record system, including 1,761 AI/AN Veterans with a new opioid use disorder (OUD) diagnosis. Exclusion criteria included buprenorphine receipt in the 3 months before diagnosis and methadone use. Primary exposures included time of diagnosis (3 years before vs. during COVID-19 pandemic, April 1, 2020-March 31, 2023), rurality, and telehealth-only versus in-person encounters. Covariates included age, gender, marital status, Deyo-Charlson Comorbidity Index, and psychiatric comorbidities. The primary outcome was buprenorphine initiation, defined by prescription at/after OUD diagnosis. Results: Of 1,761 AI/AN Veterans with OUD, the mean age was 53.8, 58.5% urban residing, and 37.5% married. Depressive (62.8%) and alcohol use disorders (38.9%) were common. The pre-COVID-19 cohort had more in-person opioid encounters (59.8% vs. 35.7%). Buprenorphine was more frequently prescribed in the pre-COVID-19 cohort (18.5% vs. 12.9%). In the adjusted main-effects model, neither time nor rurality was associated with initiation, but in-person encounters were (odds ratio [OR] = 6.09; 95% confidence interval [CI]: 4.24-8.76). Rurality × time effect modification revealed rural Veterans were more likely to initiate buprenorphine than urban Veterans during the pandemic (OR = 1.81, 95% CI: 1.10-2.99). Conclusions: Unadjusted buprenorphine initiation rates decreased during COVID-19 but were ultimately unexplained by time, with only in-person encounters associated with initiation, compared with telehealth alone. Urban Veterans saw a decline, while rural rates remained stable, likely due to less reliance on in-person care. AI/AN Veteran OUD disparities necessitate telehealth optimization and provider education.