Retention in Telehealth-Delivered Buprenorphine Treatment for Opioid Use Disorder: Multistate Retrospective Cohort Study.

Abstract

Buprenorphine is an effective treatment for opioid use disorder and is associated with reduced mortality when retention is high; however, national studies show low retention. Evidence from outpatient settings, including telehealth, remains limited, despite population-level analyses suggesting improved retention with virtual care. Further research is needed to better understand retention and optimize care for people with opioid use disorder. This study aimed to describe patient retention in a telehealth-delivered buprenorphine program over 24 months, both overall and by treatment transition pathway. We conducted a retrospective cohort study of adults initiating opioid use disorder treatment in a multistate, telehealth-only addiction treatment program between May 1, 2019, and April 30, 2025. Before March 2020, participants completed an in-person visit before transitioning to telehealth. Participants completed an intake appointment and either continued on a stable dose of buprenorphine started prior to care entry or transitioned to buprenorphine treatment via 1 of 6 treatment pathways (high dose, standard low dose, standard, Quick Start, low dose, or other). Retention in care was defined by ongoing clinical engagement, specifically through a completed medical visit or a patient-initiated secure message, each of which was required to continue buprenorphine treatment. Retention was analyzed both overall and by patient characteristics and treatment pathway. Chi-square tests and absolute risk differences with 95% CIs were used for comparisons. Among 22,064 patients, the mean age was 41.2 (SD 9.9) years, 48.6% (10,542/21,676) were female, 33.8% (7464/22,064) lived in rural areas, 78.5% (16,826/21,446) were enrolled in Medicaid, and 37.1% (8181/22,064) transitioned to buprenorphine. Retention declined from 86.8% (19,154/22,064) at month 1 to 71.0% (11,488/16,183) at month 6 and then declined gradually through 24 months. At month 6, retention was higher among patients with prior buprenorphine exposure (8613/12,230, 70.4% vs 586/1128, 52.0%; risk difference: 18.5 percentage points, 95% CI 15.5%-21.5%). Retention varied by pathway, with high dose showing the highest early retention (2330/2870, 81.2% at month 1), while patients already receiving buprenorphine at intake had higher retention than all other transition pathways. In this large, multistate study of telehealth-only buprenorphine treatment, retention was comparable to or markedly higher than national benchmarks. These findings underscore the potential of low-threshold, harm-reduction telehealth models to support long-term retention in opioid use disorder care during a period in which illicitly manufactured fentanyl predominates in the drug supply.