Using Telehealth to Treat SUD Has its Benefits, But Needs Improvements

January 10, 2022 - When the COVID-19 pandemic hit, disrupting in-person care nationwide, those receiving treatment for substance use disorders (SUD) were suddenly cut off from life-saving services. Enter telehealth, which significantly expanded access to SUD treatment during the public health emergency and is expected to remain a key care delivery mechanism for this type of treatment.

In response to the pandemic, federal and state governments implemented temporary regulations to widen access to substance use disorder treatment. This included allowing people to receive these services remotely via telehealth. Further, research has shown that telehealth facilitates care for patients who have difficulty attending in-person appointments.

Addiction medicine and SUD providers that spoke with mHealthIntelligence largely agree that telehealth use for SUD treatment has a myriad of benefits, but there are challenges that persist and enhancements that need to be made, including broadband expansion.  

The pros and cons of using telehealth to provide SUD treatment

There are several ways in which telehealth tools can be employed to treat SUD.

One study published in 2020 shows that the four most common modes of telehealth usage in SUD treatment programs are computerized assessments, telephone-based recovery support, telephone-based therapy, and video-based therapy.

These modalities are used by addiction medicine specialists to deliver psychotherapy, cognitive behavioral therapy modules, motivational therapy sessions, relapse prevention skills support and prescriptions for needed medications.

At Northwestern Medicine Central DuPage Hospital in Winfield, Illinois, patients who require detoxification are first enrolled in inpatient programs. But once they are medically stabilized and go home, a very high percentage of them, about 60 to 80 percent, receive care via telehealth, said Jeffrey Johnson, DO, an addiction medicine physician at the hospital, in a phone interview.

Overall, telehealth has significantly expanded access to SUD treatment, especially amid the pandemic.

In some areas of the country, it might take hours for patients to travel to see a psychiatrist — a burden that telehealth can quickly alleviate.

Also, since licensing requirements were loosened during the pandemic, some specialists can get licensed in adjacent states more quickly and easily than before.

"So, they now have access to larger populations if they're dealing with less common diagnoses in whatever field they're in," Johnson said. "That's a very positive thing about telehealth."

Telehealth offers also other benefits for clinicians. For instance, in many institutions the psychiatrist has a period of time when they're on call at night, and with telehealth they can help the patient face-to-face without leaving their homes, he added.

The Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services, reports that there has been overwhelming support for SUD treatment through telehealth as well as increased patient engagement.

"Opioid treatment programs have reported that patients able to be prescribed take-home doses of methadone have said they feel more responsible and better respected, and that those effects have been encouraging them in their recovery journeys," said Christopher Garrett, senior media adviser at SAMHSA, in an email.

Additionally, the transfer of controlled medications to people other than the patient — one of the key concerns of telehealth SUD treatment — has been largely mitigated. Rates of medication diversion have been low, "though, any diversion would be considered a negative," Garrett said.

But like with any care delivery modality, using telehealth for SUD treatment has its cons.

One of the key challenges of this type of virtual care is that patients who have mental health and/or substance use issues will be discussing those, as well as private information like their medical history, on a third-party device or application, like Zoom.

"The challenge is to make sure that they are in a situation where they can really be private and confidential," Johnson said. "Most of them are at home and they may have other family members. There may be issues of conflict with other family members that they would want to discuss with a therapist. In the early days of telehealth, they'd be in a facility somewhere and they would be in a room where they could ensure it was secure."

Therapists at Central DuPage Hospital recommend that their patients participate in the virtual visit from a secure and private room, but that is not always possible.

Further, there is the question of whether patients can be completely comfortable disclosing what they need to talk about through telehealth.

Lewei Allison Lin, MD, addiction psychiatrist and assistant professor at University of Michigan Addiction Center in Ann Arbor, echoed this potential downside to virtual care for SUD.

"Some patients and providers may not feel as comfortable with telehealth visits as they do in-person," Lin said in an email. "Most important is that different patients and clinicians will have different preferences and it really depends on what the feasible alternatives are."

Because if patients do have access to privacy or a safe space, either at home or elsewhere, telehealth can help free patients from the stigma of receiving care for SUD, she added. 

Finally, there is the issue of broadband and internet connectivity, said Johnson. Restricted access to the internet, especially in rural areas, cuts people off from the benefits of telehealth, leaving many people who most need SUD treatment with no recourse.

Improving SUD treatment offered via telehealth

To ensure that telehealth remains accessible for SUD patients and providers alike, tweaks must be made both to the care modality as well as to access pathways.

First, broadband must be expanded. The federal government is making a huge push to do so by giving millions in funding to broadband providers around the country and making it a cornerstone of President Joe Biden's Build Back Better agenda.

Another key improvement is combining telehealth with remote patient monitoring strategies.

There are certain aspects of SUD treatment that just can't be done through telehealth — detoxification for example, said Johnson.

During detoxification, patients maybe emotionally upset, or they are toxic from the drug they took, or in withdrawal from the drug, which impacts their vital signs.

"The future is that technology will be able to not only see you face-to-face and talk to you, but also collect vital signs and measurements on the patients," he said.

Clinicians can use the measurements to adjust medications for patients accordingly and prevent adverse events, like relapses or overdoses.

What's next for virtual SUD treatment

The providers and experts that spoke with mHealthIntelligence see telehealth remaining a key care delivery option for SUD patients even after the pandemic — with in-person care where needed, of course.

"For some patients…the ideal model may be a hybrid of in-person and virtual care that is individualized based on patient needs and preferences," Lin said. "For example, a patient who does not have reliable access to transportation may want to have most of their visits via telehealth but have intermittent in-person visits as needed when it is feasible for them to travel to the clinic. The optimal balance should be informed by patient preference and future research to figure out which patients benefit from different mixtures of in-person and virtual care."

But this is only possible if the regulatory landscape catches up to what patients and providers already appear to know — telehealth is beneficial for SUD treatment.

SAMSHA has worked with federal partners to ensure insurance coverage of Medication-Assisted Treatment (MAT) activities, substance use disorder screenings, mental health condition treatments, virtual support groups, and more.

During the public health emergency, the Drug Enforcement Administration and SAMHSA allowed for telephone-only telehealth services delivery and waived the in-person requirement for buprenorphine for the treatment of opioid use disorder.

"We announced that we will be extending these flexibilities for MAT a year after the COVID-19-related public health emergency concludes," Garrett said.

But despite these efforts at the federal level, only handful of states are comprehensive in their approach to enabling telehealth access for SUD patients. A study published last November shows that though all states and Washington, D.C., have adopted at least one telehealth policy, only 17 states have adopted policies that improve access to SUD treatment for new patients. Further, only nine states relaxed privacy laws, which impact the kinds of technology that can be used for tele-behavioral health visits.

One reason the regulatory changes necessary may be stalled is because the evidence to support virtual SUD treatment is still growing.

"Because we are in the midst of conducting research to understand impacts of all of the changes during the pandemic, we don't have all of the robust research we need to guide policies," Lin said. "So, I think currently, there is a particular need for high-quality, transparent, accessible, up-to-date information…It's incredibly important to minimize any disruptions to patient care and also to continue to learn about impacts so we can actually improve care access in the future."

If evidence continues to grow and SUD patients become increasingly comfortable with virtual care, it is likely that telehealth use for SUD will rise, adding another use case to telehealth's tool belt.