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

Background: 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. Objective: This study aimed to describe patient retention in a telehealth-delivered buprenorphine program over 24 months, both overall and by treatment transition pathway. Methods: 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. Results: 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. Conclusions: 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.