Written by: Caroline Capriccio, Wellspring Intern
It is no secret that the United States is facing a major drug epidemic. Substance abuse has become a public health crisis that demands urgent priority and innovative solutions.
But with the advent of the Internet and smartphones, researchers have found new ways to connect with patients.
Telehealth is a promising tool for treating and supporting individuals with substance use disorders. Telehealth uses technology to provide access to services and makes it possible for patients to receive screenings and counseling without traveling to a provider's office.
Telehealth is not limited to a single form of technology. Platforms include computerized screening and assessment tools, telephone-based services, smartphone applications, video-conferencing, and secure recovery support chats.
There are many reasons to pursue treatment through telehealth, and often they’re related to overcoming barriers to care. These might include the stigma associated with seeking help, lack of access to providers in remote areas, the inability to take time away from a job or other responsibilities, and the costs of traveling to a provider’s location.
While telehealth is not a substitute for in-person care, its use could increase treatment engagement and outcomes. For instance, a patient can attend rehab sessions virtually and take part in support groups and other community meetings from the comfort of their home. This reduces burden on the system and ensures greater participation from individuals. Telehealth also significantly increases the retention of patients needing extended care after completion of rehab.
Despite its promises to improve access to treatment, telehealth is a tool that remains relatively underused. This is due to the fact that restrictive federal regulations have prevented providers from using telehealth to its full capabilities. For example, the ability for practitioners to prescribe controlled substances is limited by the Ryan Haight Online Pharmacy Consumer Protection Act of 2008.
The Haight Act was passed in response to an overdose death by a teenager who purchased prescription painkillers online without ever meeting a physician. Although the act was intended to stop the proliferation of internet pharmacies from selling controlled substances online, its effects are more widespread. It now prevents any provider from prescribing medication via telehealth unless one in-person exam has been conducted. With that said, Congress is pushing to make telehealth a key component to combat substance abuse. The SUPPORT for Patients and Communities Act, a new opioid law which will be implemented in 2019, includes some key features that are intended to ease some of the restrictions to the Haight Act and give doctors more leeway to prescribe controlled substances.
Data privacy and security are also areas of concern surrounding adoption of telehealth. The Health Insurance Portability and Accountability Act (HIPPA) contains regulations that guide the privacy and security of health information. HIPPA requires that this health information be encrypted that way only authorized users can read it. But simply using HIPPA-compliant software is not enough to guarantee protection of confidential patient data being stolen. This adds more pressure on the healthcare system to train staff, design new clinical workflows, utilize secure-servers, and hire an IT team. Another barrier is the shortage of substance abuse providers. This is a challenge due to the fact that about 21 million Americans have a substance use disorder related to alcohol, opioids, or other drugs. Thus, demand for treatment is a huge factor, but not enough providers are available to implement this technology.
Legal concerns regarding insurance coverage and reimbursement remain an issue. New Jersey Medicaid must provide coverage and payment for telehealth delivered services on the same basis as when the services are delivered through in-person contact and consultation. Medicare must also provide coverage for individuals seeking telehealth but these plans may not completely cover all costs. Private payer plans must provide coverage, but certain plans may have restrictions. A carrier may limit coverage to services, but private plans are not allowed to charge a higher deductible, co-payment, or coinsurance that exceeds the amount charged at an in-person consultation. In addition, a private health care plan may not require a covered person to use telehealth in lieu of receiving an in-person service from an in-network provider.
Telehealth raises some concerns for patients and providers.
For patients, effective addiction treatment involves a three step process of detox, therapy, and extended care. While telehealth may improve participation in this treatment process, the lack of face-to-face contact may be too impersonal for some individuals. For many, personal interaction with counselors and others suffering from similar issues is what makes the difference in breaking down the walls of denial. Additionally, research remains inconclusive about which treatments are suitable for telehealth and which are better done face-to-face. For providers, training in online therapy is a key concern. It can be difficult to take a provider who has been doing face-to-face work all their lives and put them in front of a camera.
Furthermore, subtle considerations need to be made when working with a patient over an electronic connection. For example, during face-to-face sessions, when a provider looks away from a patient to take notes, no real connection is typically lost. But for a client being treated over a computer screen, a provider looking away might indicate that they are distracted or uninterested in what a client is saying. Providers also need to adjust their cameras to eye level to ensure proper eye contact with a client. They also need to check that the volume is at a comfortable level so they do not come off as extremely assertive or aggressive. Other concerns include educating patients in telehealth technology and assuring them that their information will be kept confidential.
Overall, experts have deemed telehealth to be an effective tool for combating substance abuse. Technology can play a huge role in convenience, increasing access to care, and improving the chances of each individual’s long term success. But given the severity of the opioid epidemic, low rates of telehealth usage represent a missed opportunity. While many providers have their concerns about telehealth, they understand and recognize the demand for this new form of therapy. And as technologies continue to develop, telehealth may become the new norm for diagnosing and treating substance use disorders.
Rural Health Information Hub https://www.ruralhealthinfo.org/toolkits/substance-abuse/2/care-delivery/telehealth
The Recovery Village https://www.therecoveryvillage.com/recovery-blog/7-use-cases-telemedicine-addiction-treatment/#gref
Addiction Center https://www.addictioncenter.com/community/telemedicine-and-addiction-treatment/
Health IT Outcomes https://www.healthitoutcomes.com/doc/the-rise-of-telemedicine-in-treating-addictions-0001
American Bar Association https://www.americanbar.org/groups/health_law/publications/aba_health_esource/2017-2018/may2018/telemedicine/
MHealth Intelligence https://mhealthintelligence.com/news/congress-turns-to-telemedicine-to-take-on-substance-abuse-epidemic
Center for Connected Health Policy https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies?jurisdiction=59&category=All&topic=All
American Psychological Association https://www.apa.org/monitor/2011/06/telehealth
The Recovery Village https://www.therecoveryvillage.com/recovery-blog/telemedicine-answer-for-addiction-treatment/#gref