Since the COVID-19 pandemic began, deaths from drug overdoses have reportedly surged, even as a relaxing of federal restrictions and a rapid shift by treatment providers has led to an explosion in telemedicine options for receiving help with substance use disorders.
The move to telemedicine — defined as delivering clinical services using telecommunications technology — alleviates some longstanding barriers to treatment, but it also raises new questions, particularly as pandemic-related workplace closures and other stressors put people struggling with addiction at increased risk. (Telehealth is a broader term that generally encompasses clinical services as well as nonclinical services such as provider training.)
More than 20 million American adults have a substance use disorder, according to the Substance Abuse and Mental Health Services Administration, including 2.5 million who are addicted to opioids and more than 18 million with alcohol use disorder. The annual death toll from these conditions in the United States is more than 160,000. Nearly 72,000 Americans died of an overdose last year, according to the Centers for Disease Control and Prevention, with opioid overdose deaths breaking records and the number of deaths involving methamphetamine and cocaine continuing to trend upward. Meanwhile, excessive alcohol use is responsible for more than 88,000 deaths per year in America, and the misuse of other prescription and illicit drugs is on the rise.
Despite the scale of this co-occurring public health crisis, most people with substance use disorders never receive treatment. Many of them reside in rural areas where addiction specialists and treatment programs are unavailable. Stigma, insurance coverage and a belief in solving one’s own problems have also been identified as common barriers to treatment.
Telemedicine has long been seen as a potential remedy, but pre-pandemic adoption rates were low among addiction treatment providers, according to studies by Lori Uscher-Pines, a senior policy researcher at the RAND Corporation, and Haiden Huskamp, a health economist at Harvard Medical School, who, along with their colleagues, are researching telemedicine care delivery for substance use disorder treatment. Since March, they have watched a treatment paradigm historically centered on strict in-person monitoring and layers of regulation quickly transform into one that relies heavily on virtual care.
“Everything has changed since COVID-19,” says Uscher-Pines. “The regulatory barriers, patient readiness barriers, all of those things are different now… Our research shows that only about 17% of licensed treatment facilities had any telemedicine capabilities prior to the pandemic. What we’re seeing now, both qualitatively and quantitatively, is an explosion of telemedicine use.”
Virtual 12-step program meetings, online psychotherapy, and private companies offering remote medication-assisted treatment (MAT) to opioid use disorder sufferers have become the norm since the pandemic began. Early research suggests that MAT prescribers transitioned easily to telemedicine with established patients but have been hesitant to take on new ones.
The process of initiating MAT, usually with methadone or buprenorphine, is subject to specific federal and state regulations. Many of these and other regulations have been loosened to facilitate increased access to treatment via telemedicine during the pandemic, but the regulatory environment remains complex.
The following federal policy changes, detailed in a recent study by the nonprofit Center for Connected Health Policy, are in place at least for the duration of the coronavirus pandemic and have opened up options for telemedicine-delivered addiction treatment for patients with access to a computer or telephone:
- The passage of HR 6074 (the Coronavirus Preparedness and Response Supplemental Appropriations Act) and HR 748 (the Coronavirus Aid, Relief and Economic Security Act – CARES Act) made more telehealth services eligible for reimbursement through Medicare.
- A Medicare requirement that patients be located in a clinic to receive telehealth services was removed. (The SUPPORT Act of 2018 eliminated this and other telemedicine treatment barriers, but a pathway for implementation of these provisions had not been put in place prior to the pandemic). Patients in most states can now receive treatment services, including prescriptions, over the phone or computer from their homes. (State decisions about Medicaid expansion, along with other factors, have caused regional variations in telehealth accessibility.)
- An emergency exception to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 allows qualified providers to prescribe buprenorphine without an initial in-person visit. To get a prescription for methadone, which is highly regulated, patients must still be examined in person first. The Substance Abuse and Mental Health Services Administration posted this FAQ about federal policy changes related to prescribing buprenorphine and methadone during the pandemic.
- Some HIPAA restrictions have been relaxed, allowing providers to see patients via videoconference using various online platforms, including Zoom, Skype and FaceTime.
Many states have relaxed licensing requirements for providers, and reimbursement for certain addiction-related services delivered via telemedicine has become more commonplace among private health insurers and Medicaid programs.
To eliminate inadequate broadband internet access as a barrier to telehealth treatment, the Telehealth Buprenorphine Consortium, a group of clinicians and public health experts, is calling on federal policymakers to allow audio-only treatment services via telephone to continue post-pandemic.
Addiction treatment has a complicated history in the U.S. and continues to exist largely outside the primary health care system, despite broad recognition of substance use disorder as a medical condition. Unlike other chronic health conditions that are behavior-related, such as type 2 diabetes, substance use disorders carry a history of stigma and criminalization that some experts believe has led to a misguided focus on in-person visits and accountability in treatment.
“This paradigm of not trusting patients and assuming that they need to be hyper-monitored all the time in order to provide safe care is not patient-centered; it’s not harm-reduction oriented,” says Noa Krawczyk, an assistant professor in the population health department at New York University’s Grossman School of Medicine, whose research focuses on studying ways to address barriers to treatment and improve quality of care. “It’s not effective in making people feel welcome or in making it so that their lives are actually easier because they are in treatment, which is what we want.”
Krawczyk says the policy changes necessitated by COVID-19 and the increasing adoption of telemedicine more broadly have the potential to help reset the standard of care for addiction, depending on the extent to which the new policies remain in place after the pandemic — an open question at this point.
Combined with the limitations that social distancing guidelines imposed on in-person care, the sudden move to telemedicine — or to hybrid treatment models that blend virtual care with in-person visits — has created what researchers call a natural experiment, which enables them to study new phenomena without the typical concerns about selection bias.
Still, with so many pandemic-induced changes occurring at once, disentangling cause and effect will take some time, especially given the long lag for receiving data from Medicaid, a disproportionate payer for substance use disorder treatments, says Huskamp.
“We know the underlying need for treatment is changing, and there are all these other factors we can’t control, but we need to try to use this period to understand as much as we can about how telemedicine should be used going forward, to improve treatment and outcomes for patients.” says Huskamp, who is leading a mixed-methods research project that combines analysis of insurance claims data with provider interviews.
Although early research suggests potential benefits of telemedicine for both substance use disorder patients and treatment providers, clinicians have also reported quality concerns. At this point, much remains unknown about the safety and efficacy of providing remote care for people with addictions.
“There are no randomized controlled trials looking at the impact of medication treatment for patients at home, so we don’t know if these services are equivalent to in-person services, because there’s just a dearth of research on this model,” says Uscher-Pines. “There is research in progress, but right now policymakers have to make decisions without a lot of data.”
That said, studies published in recent years have examined the scope of telemedicine use within the addiction treatment field as well as outcomes related to specific telemedicine interventions and patient groups. What follows is a curated list of seven recent peer-reviewed studies on treating patients with addiction via telemedicine, including three papers by Huskamp and Usher-Pines, along with summaries of their most important findings.
Telemedicine-Delivered Treatment Interventions for Substance Use Disorders: A Systematic Review
Lewei (Allison) Lin, et al. Journal of Substance Abuse Treatment, June 2019
This meta-analysis reviews 13 research papers that examined the use of teleconferencing to deliver psychotherapy and medication treatment for either nicotine addiction, opioid use disorder or alcohol use disorder and that were published between 1998 and 2018. The included studies vary widely in size, quality, and design, but most found that patient satisfaction was high among those who received telemedicine interventions.
Several of the studies suggest that telemedicine could be associated with lower drop-out rates among treatment participants when compared with participants having to travel for in-person treatment.
“Retention is particularly important for medication treatment for opioid use disorder,” the researchers write, “where patients, especially those in rural areas, often have to travel long distances for treatment that is ongoing, and active receipt of medication treatment has been associated with improved mortality and other outcomes.”
The researchers note the critical need for more data and research – randomized controlled trials, in particular – to help understand the potential of telemedicine-delivered treatments for a wider range of substance use disorders.
How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?
Haiden A. Huskamp, Alisa B. Busch, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Andrew Wilcock, Bruce E. Landon, and Ateev Mehrotra. Health Affairs, December 3, 2018
A helpful overview of the pre-COVID landscape, this research article is based on claims data from 2010-2017 for a large U.S. commercial insurer. It shows a roughly twentyfold increase (from 97 visits in 2010 to 1,989 visits in 2017) in the use of telemedicine among addiction treatment providers during the study period.
Despite this growth, the study notes low overall usage rates for telemedicine, which accounted for just .1% of all substance use disorder visits reimbursed during the study period. The researchers consider this “a missed opportunity,” given the wide gap between the number of people who need addiction help and those who actually receive it.
Telehealth was most frequently used in outpatient settings, for initial evaluations, and among patients with severe opioid use disorder. The analysis suggests the most common treatment model involved physicians with addiction treatment experience performing an initial evaluation and/or prescribing medication from a remote location to a patient at a clinic. Patients frequently received telehealth support following intensive inpatient or outpatient treatment, the study results suggest.
The study also identified characteristics of the telehealth users. More than 60% were male and about 55% were under age 40. Despite hopes that telehealth would make treatment available to people in rural areas, the researchers found that the “vast majority” of patients studied who used telehealth for addiction care lived in urban areas, and telemedicine use was more common in areas with relatively higher household incomes.
“This finding is in contrast to the results of prior research on tele-mental health use, which found that use was greatest in poorer communities,” the researchers write, adding that “targeted interventions to increase access in rural areas may be needed.”
Treatment of Opioid Use Disorder During COVID-19: Experiences of Clinicians Transitioning to Telemedicine
Lori Uscher-Pines, Jessica Sousa, Pushpa Raja, Ateev Mehrotra, Michael Barnettt, Haiden Huskamp
Journal of Substance Abuse Treatment, August 29, 2020
Based on interviews conducted in April 2020, this new qualitative study by Uscher-Pines and colleagues offers clinicians’ perspectives on the rapid transition to telehealth approaches for substance use disorder treatment during the pandemic.
The researchers interviewed 18 waivered providers (meaning they can prescribe buprenorphine) in 10 states working in both hospitals and clinics at a time when government-mandated shutdowns severely restricted in-person care. Of those interviewed, more than half were providing only telemedicine care.
Asked how their overall practice patterns had changed, some interviewees reported waiving toxicology screenings, sending patients home with more doses of medication, and reducing the number of required visits.
About 20% of telemedicine visits occurred over the telephone, with the rest involving the use of various videoconferencing platforms. Some clinicians said they were hesitant to see new patients via telemedicine; others stopped accepting new patients altogether.
Benefits of telemedicine observed by the clinicians included increased access and convenience, as well as reduced wait times, appointment no-shows, and patient embarrassment about being seen getting treatment in their communities.
But seeing patients remotely also had downsides in terms of care quality, according to the interviewees. Clinicians reported difficulty establishing rapport with new patients and difficulty observing physical symptoms of withdrawal, such as goosebumps and pupil dilation.
“Because telemedicine prevented clinicians from using their full powers of observation, they reported asking patients more questions about their physical symptoms and relying more on patient self-report than observation,” the researchers write.
Clinicians also cited technical difficulties as negatively affecting the quality of patient interactions.
The level of telemedicine care for substance use disorders that will continue after the pandemic remains unknown. Several providers said they would like to continue to use it in combination with in-person visits. Study participants also noted that their future use of telemedicine would depend on the reimbursement and regulatory environment.
Measures of Effectiveness, Efficiency, and Quality of Telemedicine in the Management of Alcohol Abuse, Addiction, and Rehabilitation: Systematic Review
Clemens Scott Kruse et al. Journal of Medical Internet Research, January 2020
This analysis of 22 research papers on telemedicine interventions for alcohol use disorder found that mobile apps and text message were the most common and effective treatment models among those studied.
Telemedicine proved effective in reducing alcohol consumption and depression among users in the majority of studies, the researchers said. Remote interventions also were associated with increased patient satisfaction and accessibility, as well as decreased cost.
“Organizations were able to expand practice without expanding square footage,” the researchers wrote, “and [telemedicine] solutions continued to provide care outside the boundaries of 8 a.m. to 5 p.m., a traditional treatment day.”
The authors note the need for further study of particular telemedicine approaches and how they improve outcomes for people seeking help with alcohol use disorders.
The included studies were conducted in the United States, European Union and Australia.
Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine A Nonrandomized Controlled Trial
Constance Guille, Annie N. Simpson, Edie Douglas
JAMA Network, Jan. 31, 2020
Opioid addiction among pregnant women in the United States quadrupled between 1999 and 2014, increasing from 1.5 to 6.5 cases per 1,000 hospital births. When exposed to opioids in utero, infants can experience withdrawal symptoms at birth, known as neonatal abstinence syndrome (NAS), the rate of which increased from 1.5 to 8 per 1,000 hospital births between 2004 and 2014.
Telemedicine has been identified as a tool to expand addiction care for pregnant women, particularly in rural areas, writes lead study author Dr. Constance Guille, an associate professor at the Medical University of South Carolina who developed the telemedicine protocol used to provide medication-assisted treatment (MAT) to the study participants.
This is a nonrandomized controlled trial that included 98 pregnant women with opioid use disorder in which 44 received opioid use disorder (OUD) treatment via telemedicine from their obstetrician’s office and 54 received in-person OUD care in their obstetrician’s office. There were no statistically significant differences in rates of retention in treatment between the two groups, with more than 80% of participants in both groups remaining in treatment after six weeks. These results held when the researchers looked at diagnoses of neonatal abstinence syndrome among the newborns.
This study used a method called propensity score matching to reduce selection bias and improve generalizability of the results, given the small sample. By incorporating demographic information of the study subjects, the researchers calculated the probability of treatment assignment for each, known as the propensity score. By giving these scores different weights and matching them together, the researchers artificially created treatment and control groups, mimicking aspects of a randomized controlled trial.
A note on the research: The telemedicine protocol Dr. Constance Guille, an associate professor at the Medical University of South Carolina, and her team developed made it possible for pregnant women with opioid use disorder to receive specialized addiction services from a remote provider during their regular prenatal appointments.
Because the patients were receiving care in the presence of another provider with a Drug Enforcement Administration license (that is, an obstetrician), Guille had petitioned the South Carolina Board of Medical Examiners for permission to treat them with MAT via telemedicine without an initial in-person visit, based on a pre-COVID exemption in the federal Ryan Haight Act.
The board initially denied the request, citing the South Carolina Telemedicine Act, which conflicts with federal law, Guille says. Legally, the team was advised that they could continue, she says, but they heeded the board’s recommendation in order to maintain positive relations with the state. Later, after a pregnant woman died of an overdose while waiting to schedule an in-person visit, the research team went back and made the same proposal to the board, which reversed its original decision.
Guille says the experience highlights the complex web of federal and state regulations that treatment providers need to navigate in order to provide telemedicine services, a situation that is likely to persist post-COVID.
“There’s the whole legal aspect of it, and then there’s the issue of how you collaborate with your key stakeholders across your state to get this work done,” she says. “There’s a lot of gray area there.”
The Effectiveness of Telemedicine-Delivered Opioid Agonist Therapy in a Supervised Clinical Setting
Joseph K. Eibl, et al.
Drug and Alcohol Dependence, July 2017
This 2017 research involves a non-randomized cohort comparison study of 3,733 patients with opioid use disorder initiating medication treatment (methadone or buprenorphine) between 2011 and 2012, across 58 clinic sites in the province of Ontario, Canada. The analysis was based on a database of patients’ electronic medical records.
Of the patients studied, about 47% received more than 75% of visits via telemedicine. The rest received less than 25% of visits by telemedicine. The analysis suggests that patients treated via telemedicine were more likely to stick with their treatment programs than patients treated in-person. Telemedicine patients demonstrated a retention rate of 50% at one year whereas in-person patients were retained at a rate of 39%.
Like in the U.S., physicians who can prescribe medication for addiction treatment are in short supply in Canada because the medications themselves are regulated by the federal government as controlled substances. Providers must apply for and receive a federal waiver before prescribing methadone or buprenorphine, a requirement that remains in place in the U.S. during the pandemic. This provider shortage often leads to patients needing to travel long distances for frequent provider visits, a problem that telemedicine can address.
A Pilot Study of a Telemedicine-based Substance Use Disorder Evaluation to Enhance Access to Treatment Following Near-Fatal Opioid Overdose
Jeffrey T. Lai, et al.Proceedings of the Annual Hawaii International Conference on System Sciences, Jan. 7, 2020
This was an observational study of patients who were hospitalized in Massachusetts after receiving naloxone (the antidote for opioid overdose) following an opioid overdose. The researchers asked 27 patients who presented in a hospital emergency department whether they would be willing to test a telemedicine intervention; 20 agreed to participate.
The researchers developed a system using iPads outfitted with HIPAA-compliant software that enabled recently revived patients to undergo an initial addiction screening with a specialist immediately following overdose – a critical time for initiating treatment.
All 20 participants reported liking the technology, with two subjects describing the iPad as “cool.” One participant described the intervention as the “best thing since sliced bread and bacon, and I’m a Georgia boy so I love bacon.”
Most of the participants found that undergoing the screening via telemedicine was equivalent (or in some cases preferable) to standard in-person evaluations. They also reported feeling assured that the assessment was private and confidential.
Despite one major technical malfunction (a dead battery), the researchers deemed the intervention a success, writing that telemedicine “can enhance access to addiction treatment programs and facilitate the efficient and effective delivery of evidence-based post-overdose care, including ED-based initiation of [medication-assisted treatment].”
They write, “Our technology platform represents an innovative method of delivering treatment for opioid use disorder during the critical post-overdose period, and holds immense potential for improving access to addiction care” in underserved areas.
Adoption of Telemedicine Services by Substance Abuse Treatment Facilities in the U.S.
Lori Uscher-Pines, Jonathan Cantor, Haiden A.Huskamp, Ateev Mehrotra, Alisa Busch, Michael Barnett
Journal of Substance Abuse Treatment, October 2020
This pre-COVID-19 study used data from the National Directory of Drug and Alcohol Abuse Treatment Facilities for a period from 2016 to 2019 to study an average of 12,334 substance use disorder treatment facilities in the United States. During the study period, facilities offering telemedicine grew from 13.5% to 17.4%.
The results of the analysis suggest the following factors positively influence telemedicine adoption: rural location; offering multiple treatment settings; offering medication-assisted treatment; and serving both adult and pediatric patients.
In 2019, there was wide state-to-state variation in facility adoption of telemedicine; less than 7% of facilities in Connecticut, Hawaii, Rhode Island, and Vermont offered telemedicine services, compared with more than 40% in Alaska, Missouri, and Wyoming.
The same team of researchers is continuing to study telemedicine adoption for substance abuse treatment since the pandemic began, including analyzing variations by state.
5 tips for reporters covering telemedicine-delivered treatment for substance use disorders
1. Get to know your state’s telehealth laws and rules. Rules and regulations for telehealth practice and prescribing vary by state. Each state’s health department and medical licensing review board can set and waive rules. The Federation of State Medical Boards maintains this up-to-date list of state licensing policy changes due to COVID-19, including when they expire. The Center for Connected Health Policy plans to update this report on state telehealth laws and reimbursement later this fall.
2. Ask questions about reimbursement. The degree to which telemedicine services can be reimbursed by insurance is likely to play a role in the degree to which providers and medical societies support their ongoing use and implementation once the pandemic eases.
For example, unlike urine toxicology screenings, saliva tests can be conducted under direct supervision via telemedicine, says Noa Krawczyk of NYU’s Grossman School of Medicine, but so far, the test is not eligible for reimbursement and is used mainly for research.
Per a 2012 Supreme Court ruling, Medicaid expansion is an optional decision for states. In states that have expanded Medicaid, a disproportionate payer for people with substance use disorders, it is easier for providers to get reimbursed for telemedicine.
3. Cover addiction as a chronic disease, not a crime. Some researchers argue that a telemedicine model for addiction treatment makes sense because it both improves access and moves away from traditional substance use disorder treatment programs that are rooted in the perspective that drug use is criminal, as opposed to behavioral.
In a new book, The Opioid Fix, Barbara Andraka-Christou, an assistant professor in the department of health management and informatics at the University of Central Florida, traces the history of treatment and argues that medication-assisted treatment should be available to all patients with a opioid use disorder.
When arguing in favor of telemedicine treatments for substance use disorders, researchers and providers often make a comparison with type 2 diabetes, which is also primarily behavioral, but patients are not as strictly monitored. PBS News Hour covers this topic in its recent piece, “Could the pandemic change addiction medicine for the better?”
4. Visit Reddit. There are many people with substance use disorders who are active on the social network Reddit, which hosts communities, known as subreddits, where people with similar interests can have discussions and promote input and responses. Krawczyk is working on a research paper that analyzes active subreddits where people are discussing changes in opioid addiction treatment during the pandemic.
Krawczyk says it’s important to include the perspectives of people with substance use disorders in research and reporting on the changes that are occurring. “Some people feel like it’s great and it’s much easier to get treatment,” she says. “And other people are saying they’re worried about, you know, having too much methadone with them at home.”
5. Use person-first language. When covering issues surrounding addiction and substance use, it’s important to avoid terminology like “addicts” and “alcoholics.” Instead, use “a person with substance use disorder,” “someone suffering from addiction.” Krawczyk says this language avoids characterizing people based solely on a medical condition and better reflects current thinking about substance abuse disorders.
Similarly, the AP Stylebook advises: “Avoid words like ‘abuse’ or ‘problem’ in favor of the word ‘use’ with an appropriate modifier such as ‘risky,’ ‘unhealthy,’ ‘excessive’ or ‘heavy.’ ‘Misuse’ is also acceptable. Don’t assume all people who engage in risky use of drugs or alcohol have an addiction. Avoid ‘alcoholic,’ ‘addict,’ ‘user,’ and ‘abuser’ unless individuals prefer those terms for themselves or if they occur in quotations or names of organizations, such as Alcoholics Anonymous.”