Telehealth and SUD: Lessons From the Pandemic

Health Highlights

By Jared Augenstein, M.P.H., M.A., Director, Manatt Health | Zoe Barnard, M.A., Former Montana Mental Health Commissioner, Montana Department of Public Health and Human Services | Lewei Allison Lin, M.D., M.S., Assistant Professor, U. Michigan Medical School Staff Psychiatrist and Research Scientist, VA Ann Arbor Healthcare System

Editor’s Note: The COVID-19 pandemic drove significant expansion in state and federal telehealth policies, playing a critical role in ensuring access to substance use disorder (SUD) services, even during quarantine. In a recent webinar, the American Medical Association (AMA) and Manatt examined changes in telehealth policies, how those changes are impacting SUD treatment, and which new policies should be extended long term to maximize continued access to SUD services. The program also analyzed key lessons providers learned during the pandemic about using telehealth to serve those with SUDs—and how to carry those important learnings forward.

There were so many excellent questions asked during the program that we didn’t have time to cover them all. Below are six compelling questions that viewers posed, along with the responses from our panel of thought leaders. To view the full webinar free on demand and download a free copy of the presentation, click here.

Five Key Questions and Answers on Telehealth and SUD

Question 1: During the pandemic, telehealth was expanded to maintain access. Once the pandemic ends, shouldn’t a logical decision depend on comparative quality outcomes, utilization and cost data between telehealth and in-person care? If telehealth was as effective and desirable for treatment of opioid use disorder as in-person care, why didn’t opioid overdoses and deaths decrease during the pandemic?

Answer 1: Yes, a logical decision about how to move forward should depend on comparative data measuring quality outcomes, utilization and costs between telehealth and in-person care. More research is needed to ensure we have the full information needed to determine how telehealth and in-person care compare on key metrics.

Because the incidence and prevalence of opioid use disorder increased dramatically during COVID-19, the pandemic exposed and exacerbated the existing gaps in the treatment infrastructure. For example, narrow and inadequate physician networks for SUD and pain care were made even more challenging when patients could not travel to see a physician or get to a pharmacy. Adding to the challenge was the fact that only a limited number of physicians were seeing patients via telemedicine.

Getting people to access treatment is a problem that is likely to remain even after the pandemic. There continues to be a significant stigma associated with SUD—and not every person is ready for treatment.

Question 2: Are there any studies, research or other observations comparing synchronous treatment for SUD versus asynchronous treatment for SUD? If yes, what have been the conclusions or observations?

Answer 2: No comparative studies come to mind. Synchronous and asynchronous treatments are often used for different purposes. For example, synchronous treatment, such as using telephone and video-based platforms to facilitate real-time provider and client interactions, can be used for clinical assessments and ongoing care and treatment (e.g., telemedicine). Alternatively, there is a large project funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides both telephone and video-based consultations with addiction specialists to primary care and mental health clinicians in the community. This tool also is used to support providers delivering care for complex patients. Both of these uses of telehealth would be considered asynchronous (i.e., not direct patient care in real time). There are likely many other forms of asynchronous telehealth that could also be helpful, such as reminder messages for patients. More research is needed, however, to draw meaningful conclusions about synchronous and asynchronous applications.

Question 3: An in-person visit for SUD usually includes a physical exam, including some point-of-care testing, such as a urine drug screen, which would not be possible by telehealth. Do you have concerns—besides potential violations of the Health Insurance Portability and Accountability Act (HIPAA)—that limiting treatment to only verbal interactions and prescription renewals via telehealth might be a suboptimal option post-pandemic?

Answer 3: Please see the recently developed resource “Telehealth for Opioid Use Disorder Toolkit: Guidance to Support High-Quality Care,” funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) through Providers Clinical Support System (PCSS). The toolkit addresses this question by providing “clinically relevant information to support high-quality delivery of outpatient opioid use disorder (OUD) care via telehealth, while reducing barriers to starting and maintaining both medication and psychosocial treatment.” It shares specific tools and guidance to help clinicians provide tele-OUD care during and beyond the pandemic.

Specifically, the toolkit notes that clinicians have had a range of experiences with tele-OUD, including both positive impacts due to increased access for patients and challenging issues such as technology problems and less information available to support clinical decision making. The toolkit points out that research on tele-OUD is limited compared to other forms of tele-delivered care—and it remains unknown what the impact is of practice changes, such as less frequent urine drug screens, on outcomes.

Question 4: Do we have research or anecdotes that suggest for which types of patients SUD telehealth is most effective? For example, are there specific demographics, diagnoses or treatment modalities that impact outcomes?

Answer 4: There is not a lot of data available yet. The important things to consider are the realistic alternatives for the patient as well as the preferences of both the patient and the clinician. These will vary across different patients and clinicians and will change over time as a patient goes through care. For example, a patient may live 45 minutes away from a clinic. It is important to evaluate how feasible it is for the patient to attend regular appointments—particularly for treatments such as buprenorphine for opioid use disorder, which the patient may need to stay on for years. Where there would be challenges for the patient to come to all appointments in person, it may be preferable to present telehealth options. Patients who don’t have reliable internet access may require phone options, as well. Even when there are remote options, a clinician may want a patient to come in person for some appointments, based on clinical need.

Whether or not SUD telehealth would be an effective option for a patient is not just based on whether the patient lives in a rural or non-rural area. Clinicians must take into account a multitude of factors—including demographic, geographic and clinical profiles, as well as access to transportation and the internet—when deciding on the optimal mix of remote and in-person visits.

Question 5: During the public health emergency, Drug Enforcement Agency (DEA) flexibilities allowing prescribing buprenorphine and other controlled substances through telehealth without the in-person visit requirement expanded access to critical SUD and other services. How are you planning for continuity of care if the in-person requirement waiver isn’t made permanent?

Answer 5: If the telehealth flexibilities for medication-assisted treatment are not made permanent, states will have to move to pre-pandemic rules. Mobile vans may improve access somewhat, but there will definitely be people who cannot be reached. We anticipate that, post-pandemic, most states will require a patient’s first visit to be in person and then allow telehealth for maintenance.



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