Telehealth and mHealth are giving healthcare providers a well-stocked toolbox to treat people with substance abuse disorders and addiction issues, many of whom require around-the-clock, on-demand support and care coordination to stay on a treatment plan and avoid relapses.
With an estimated 115 people dying each day from opioid abuse, the issue has become an epidemic, drawing attention from the White House, Congress, law enforcement and the healthcare industry. To address the crisis, healthcare providers are looking to treatment plans that integrate addiction control with behavioral and psychiatric care, and using platforms that not only span populations but can provide personalized care.
This is where connected health technology can make the biggest impact.
In applying mHealth and telehealth technology to addiction treatment, healthcare providers are looking to create a digital profile of the patient. While traditional treatment plans have focused on group therapy and care in the doctor’s office, connected health platforms enable providers to work with the patient at any time and place, and to see what the patient goes through each day.
“We’re building a panoramic view of your life,” says Jacob Levenson, CEO of MAP Health Management, an Austin, Texas-based, nationwide network of close to 100 addiction treatment providers that has adopted digital health tools for care management and coordination. The idea, he says, is to give providers insight into what triggers a patient’s behaviors, and to create treatment plans that address those triggers and prevent relapses.
Applying Connected Care Solutions to a National Crisis
Healthcare providers are finding many different uses for connected care in the substance abuse space. Examples include:
- mHealth apps that give users access to coping skills and care resources, peer support and on-demand access to caregivers in times of crisis
- Digital messaging platforms that allow care providers, family members, or peer support group members to deliver timely messages of support
- Mobile health units, deployed to urban neighborhoods, rural communities and even high-traffic areas like schools, prisons and retail centers, that essentially bring the doctor’s office to patients with access issues
- Telemedicine and telehealth platforms that enable patients to engage in virtual visits with their care provider or a mental health specialist from the comfort and anonymity of their own home
- Telemedicine platforms that enable rural providers and those dealing with high-impact populations to collaborate with substance abuse experts and mental health experts on the latest treatments, as well as to talk about difficult cases or chat with peers
- mHealth wearables that monitor a user’s vital signs and issue alerts – to the user and/or the user’s care team – at times of stress
- Apps and wearables that measure medication adherence in medication assisted treatment (MAT) programs
- mHealth devices (including patches, ingestibles and wearables) that can deliver timed doses of medication to help users manage pain or stressful situations
“Collaboration among multiple providers and organizations that address the public health issues associated with opioid abuse are crucial,” The Health Information and Management Systems Society (HIMSS) reported in a December 2017 article. “When diagnosing and treating opioid abuse, skilled practitioners (located remotely) can provide an array of integrated patient services using telehealth technology.”
“Through telehealth, participants can receive needed treatment by accessing expert help without current barriers, receive needed medications, be taught new skills to prevent relapse, and make important connections with others with healthcare system change,” the article added.
“Telemedicine for addiction will only become more mainstream in the years to come — so we’ve only begun to tap into its vast potential to connect millions of underserved people with the help and treatment they need,” adds Candice Rasa, a Licensed Clinical Social Worker and Clinical Director of thre Florida-based Beach House Center for Recovery, in a blog published by the Arizona Telemedicine Program. “Addiction is a disease of isolation, after all. Its polar opposite is not sobriety but connection, which is the very thing that telehealth advances can exponentially multiply.”
Using Smartphones for Addiction Treatment
By virtue of its ubiquitous presence in today’s society, the smartphone is an ideal tool for substance abuse and addiction treatment. It offers a platform for both population health programs and individual treatments.
Since the smartphone rarely leaves the user’s side, it has significant value as a real-time communication device. Healthcare providers can push out messages offering support or information via text, SMS or e-mail to large groups at any time. They can also personalize the message for individual users, tying information to one’s habits, location or medical record.
For public health groups or community health clinics, a messaging platform can be as simple as a group text or e-mail or as sophisticated as a daily survey that pushes targeted information based on how each question is answered.
For example, a clinic might send out a survey each morning asking its patients how they feel, perhaps expressed through a number or emoji. Positive responses are set aside, while negative responses trigger a second message asking for more detail, or a list of resources designed to help someone in crisis. That, in turn, may trigger an alert to the patient’s care team to make contact for further treatment. At each level, back-end algorithms sift out patient responses that don’t require follow-up and allow providers to focus on those who do need help.
For individual treatment, mHealth apps are emerging as popular tools. Apps could include daily surveys, messaging or chat rooms with peer groups, links to resources, both online and in the community, messaging with one’s care provider or a substance abuse specialist, and a 911 link allowing the user to instantly access help.
While this platform enables providers to craft population health messages or treat patients individually, it also gives the patient an always-there platform to access help discreetly. In many instances, those dealing with substance abuse and addiction issues are hesitant to seek help for fear of the stigma attached to addictions.
Such a platform also offers access to large numbers of people with addiction issues, an important factor in substance abuse and addiction research.
Making Telehealth an Integral Part of Treatment
Most substance abuse issues are tied to mental health concerns, and treatment plans often include mental health care. Telehealth can play a pivotal role connecting patients to the resources they need.
Telemental health is one of the fastest growing telemedicine and telehealth specialties. Virtual care platforms offer mental health specialists like psychiatrists, psychologists and behavioral health counselors an avenue for extending care beyond the office or clinic and into communities where access is limited. For those dealing with mental health issues, treatment can be accessed at home, through a laptop or tablet, securely and in privacy.
Beyond using telehealth for individual treatment, addiction specialists can use the platform for group therapy sessions, giving them the opportunity to treat more people in several locations without the need for the provider to travel.
The platform has also proven valuable for educating front-line providers, such as community health workers, primary care physicians, school and prison nurses and those working in federally qualified health centers (FQHCs). In many instance these providers are overwhelmed and in need of assistance, but don’t have the time or money to attend classes.
Using the ECHO (Extension for Community Healthcare Outcomes) model developed at the University of New Mexico, academic health systems are setting up telemedicine platforms through which they offer biweekly or monthly online training sessions. On this platform, they can bring in addiction specialists and mental health experts to discuss the latest in substance abuse treatment, offer advice on how to deal with these issues, and collaborate on tough cases.
Some providers are even taking mobile health treatment right to those most in need. In New York, for instance, a non-profit is deploying mobile health units decked out with telemedicine equipment to provide substance abuse treatment and counseling in communities where resources are thin.
“(There are) always issues around access for people with opiate addictions, some who really have not had the access they need to get into treatment,” said Howard Hitzel, CEO of Buffalo-based BestSelf Behavioral Health, which is using a $1.7 million state grant to modify as many as six RV-sized vehicles. “It’s a street outreach program where they can reach out to folks struggling with a substance abuse disorder.”
Using Mobile and Digital Health Devices for Remote Monitoring and Care
Aside from their communication value, smartphones are also being used by healthcare providers for clinical purposes such as remote patient monitoring. Through their own sensors or paired with mobile devices or wearables, they can capture a user’s vital signs and other important data and transmit that information back to the care team.
Researchers have also been working on diagnostic attachments that can turn the smartphone into a breathalyzer, detecting alcohol or CO intake from a cigarette.
In terms of treatment, researchers and healthcare providers are developing wearables that can deliver timed or sensor-activated doses of anti-stress or anti-craving medication, much like a pump delivers doses of insulin to a patient with diabetes. Much of this research is focused on finding new ways to cope with pain, a key precursor to opioid addiction.
The federal government is looking to prompt more research along these lines.
Among those supporting the use of mHealth devices in addiction treatment is the National Institutes for Health, which kicked off the HEAL (Helping to End Addiction Long-term) Initiative in early 2018 with $1.1 billion in funding and a call to develop novel treatments for opioid abuse and pain management.
“Science and technology have illuminated our understanding of the mechanisms underlying addiction,” Nora D. Volkow, MD, director of the National Institute on Drug Abuse, said of the initiative. “With these additional resources, we can develop more customized, high-quality treatments for addiction and pain, as well as harness implementation science to bring evidence-based changes to our healthcare system, including treatment for those in the criminal justice environment.”
The FDA also has a keen interest in digital health. The agency launched a 2018 innovation challenge “to spur the development of medical devices, including digital health technologies and diagnostic tests that could provide novel solutions to detecting, treating and preventing addiction, addressing diversion and treating pain.”
“Medical devices, including digital health devices like mobile medical apps, have the potential to play a unique and important role in tackling the opioid crisis,” FDA Commissioner Scott Gottlieb, MD, said in a news release posted on the FDA’s website. “We must advance new ways to find tools to help address the human and financial toll of opioid addiction.”
Using Telehealth in MAT Therapy
Medication-assisted treatment (MAT) therapy is growing in popularity as a treatment option. MAT combines behavioral health treatment and prescribed medication. In most cases, the medications used are opioids like Methadone, Naltrexone and Buprenorphine, which require special approval for prescription and need to be managed carefully.
Healthcare providers and substance abuse experts say MAT therapy has proven effective because it allows them to wean patients off of opioids by administering controlled doses of drugs that counter the opioid’s addictive effects. Because of the sheer numbers of people struggling with addictions and the limited number of treatment specialists, providers want to be able to prescribe these medications and monitor multiple patients via telemedicine.
That hasn’t been easy.
In 2008, following the 2001 death of a teenager who had ordered Vicodin through an online pharmacy, Congress passed the Ryan Haight Act. The law prohibits physicians from prescribing controlled substances electronically until they have conducted an in-person examination, or if they meet the federal definition of practicing telemedicine. The definition requires that the patient be treated by, and physically located in, a hospital or clinic which has a valid US Drug Enforcement Agency registration and the telemedicine practitioner is treating the patient in the usual course of professional practice.
While there are exceptions made for telemedicine, the language is murky. Since 2015, telemedicine advocates have lobbied the DEA to create a special registration process to prescriptions of controlled substances through telemedicine without need for an in-person exam. While the DEA has signaled in interest in agreeing to the caveat, it hasn’t yet.
Several states have passed laws to help providers prescribe controlled substances through telemedicine. But legal experts warn that federal law supersedes state legislation, so those providers have to be very careful. In Congress, several bills have been filed by lawmakers on both sides of the aisle that would open the door to more telehealth and telemedicine, including e-prescribing, but those bills have yet to move to a vote.
The Ryan Haight Act aside, MAT providers have to be certified by the state Department of Health and Human Services. But state certification classes are often held in urban locations, making it difficult for small and rural providers to attend.
That’s where ECHO programs can help. In states like Virginia, academic health systems are turning to the online platform to develop statewide programs for MAT therapy accreditation and substance abuse training. This allows solo and small practice physicians, public health officials, clinic providers and others in remote locations to get the training they need.
Congress Sets its Sights on Telehealth and Substance Abuse
By the time President Trump declared a national emergency on opioid abuse in October 2017, a number of branches of government were already looking to bring their powers to bear on the epidemic. The US Department of Agriculture has been a primary mover and shaker. The Distance Learning and Telemedicine grant program, launched in 2009, has funneled millions of dollars annually to rural health districts looking to expand their telehealth footprint.
“Because addiction treatment is often out of reach for many in rural America, expanding access to telemedicine is an important step towards making sure rural communities have the tools they need to fight the opioid epidemic,” USDA Secretary Tom Vilsack said during a June 2016 town hall in Abington, Va. “USDA is committed to provide the critical resources rural areas need to reduce the staggering increase in opioid overdose deaths that is driving up health care costs and devastating communities.”
Congress has also sought to apply mHealth and telehealth to the opioid abuse crisis, with a flurry of bills introduced in late 2017 and early 2018 designed to reduce restrictions on telehealth and telemedicine – primarily by the Centers for Medicare & Medicaid Services – and compel providers to use virtual care to treat substance abuse.
One such bill is the Expanding Telehealth Response to Ensure Addiction Treatment (eTREAT) Act, co-sponsored by Senators. Mark Warner (D-VA), John Thune (R-SD), Ben Cardin (D-MD), John Cornyn (R-TX), Brian Schatz (D-HI) and Roger Wicker (R-MS).
The bill, targeting telehealth guidelines enforced by the Centers for Medicare & Medicaid Services, aims to remove originating site requirements and facility fees from telehealth programs addressing opioid abuse and other substance abuse disorders.
The bill targets one of the more prominent barriers to improving treatment via telehealth: originating site restrictions.
Many Medicaid programs restrict where telehealth services can be delivered, usually to hospitals or clinics, making it difficult for patients who live far away from these locations or who live near locations that fill to capacity quickly. Eliminating this geographic restriction would enable providers to create new programs and services operating out of community centers, doctor’s offices or even the patient’s home.
Other bills addressing the issue include:
- The Opioid Crisis Response Act of 2018, which includes provisions to enable the US Drug Enforcement Administration create a rule allowing qualified healthcare providers to administer controlled substances via telemedicine.
- The Medicaid Substance Use Disorder Treatment via Telehealth Act, which would require the Health and Human Services Secretary to issue guidance on how state Medicaid programs can be reimbursed for substance abuse disorder treatment via telehealth.
- The Telehealth for Children’s Access to Services and Treatment (TeleCAST) Act, which would require the Government Accountability Office (GAO) to analyze Medicaid treatment programs for children with substance abuse disorders, and it would require CMS to report on how barriers can be reduced to enable more children on Medicaid to receive treatment via telehealth.
- The Opioid Addiction Treatment Programs Enhancement Act, which would require the HHS Secretary to publish comprehensive data on the numbers of Medicaid patients dealing with substance abuse disorders and services provided under Medicaid for their treatment.
- The Access to Telehealth Services for Opioid Abuse Disorders Act, which would waive certain Medicaid telehealth requirements in treatments for opioid abuse disorder or co-occurring mental health disorder.
As of August 2018, those bills had been scored and combined into one large piece of legislation designed to address the opioid crisis. But Congress had yet to vote on that package.
If history holds any clues, the path won’t be easy. Past telehealth-friendly bills have struggled to gain support, and few have passed. Often the Congressional Budget Office scores these bills as having a negative financial impact in the short term, with savings eventually coming after several years. The short-term losses are often due to the fact that telehealth and mHealth treatment requires investment early on, while results are measured in gradual health and wellness improvement.
Balancing Connected Care with In-Person Care
While mHealth and telehealth will help in addiction treatment, some worry that the technology may further isolate people in need of more hands-on care. Even though someone with an addiction problem can access help at any time on a mobile device, there is still a disconnect that could hinder treatment.
“Will technology [help] the addiction or will it exacerbate the isolation?” Lipi Roy, MD, a professor at the NYU School of Medicine’s Department of Public Health, asked during a panel session at the 2017 Connected Health Conference in Boston.
In that session, panelists said mHealth can help improve access, but it can also create a wall between the patient and society.
An effective program, they said, is mindful of that wall and ensures that patients get in-person care, particularly with people they know and trust.
With the national substance abuse epidemic showing no signs of slowing down, the healthcare industry, law enforcement and federal and state government need to work together to create a network of solutions that stress care management and coordination. A connected health platform that includes telemedicine networks and mHealth tools can help facilitate that treatment, giving front-line doctors and nurses the ability to meet those with addictions where they most need help.