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Telehealth has offered a safe, viable option to patients with substance-use disorder (SUD) during the COVID-19 pandemic and, in some ways, has potentially made care more accessible. Phone or video calls can help reduce the stigma wrongly linked with obtaining effective SUD treatment, and the convenience of online formats can make care more accessible.

“We’re dealing with an epidemic within the setting of a pandemic. With telehealth, during COVID-19, it’s also about transforming the way we deliver treatment to make it more accessible to patients. We can be more flexible in setting up visits and working to reschedule no-shows,” said Lewei Allison Lin, MD, MS, an addiction psychiatrist at the University of Michigan Addiction Center and the VA Ann Arbor Healthcare System. “This is definitely part of the future of care for patients with substance-use disorders.”

Dr. Lin’s comments came in a webinar, “Telehealth and SUD: Lessons From the Pandemic,” that is part of a series sponsored by the AMA and Manatt Health.

At least 21 million Americans have an SUD, but only about 10% get treatment. Among the obstacles to care, Dr. Lin said, are stigma, complex underlying symptoms of addiction, and limited accessibility to treatment because of the way care is set up historically. Many patients lack access to reliable transportation or they live in remote areas.

“We are often asking patients to come for regular visits, sometimes over years. This can be a big challenge for a lot of folks who are juggling families, jobs and everything going on in their lives,” she said.

Learn more about physician efforts to prevent overdoses with the AMA’s “2021 Overdose Epidemic Report” (PDF).
Access to evidence-based treatment

Federal agencies, states and commercial health plans have all taken steps to expand telehealth coverage, and one-third of states have passed parity laws requiring payment for telehealth, said Jared Augenstein, MPH, MA, a director at Manatt Health.

Across health care services, behavioral health has been the biggest utilizer of telehealth, which grew from less than 1% pre-pandemic to more than 5% of national claims, said Augenstein. More than half of all behavioral health care is being delivered virtually across the country.

The benefits and value of telehealth for behavioral health and SUD have been widely documented, said Augenstein. It increases access to providers, eliminates accessibility and geographic barriers, and improves continuity of care, he summarized. Physicians get to provide more timely care and experience less burnout with telehealth.

Dr. Lin has noted a dramatic shift to telehealth. In some of her research, after the pandemic’s onset telehealth accounted for the majority of all care delivery for patients with opioid-use disorder.

“Notably, we’re finding phone visits are used most often, followed by video and in-person. This suggests the importance of having different telehealth options—both phone and video—for our patients,” Dr. Lin said. “We also need more research to look at patient outcomes and to understand which approaches work best for which patients.

In Montana, telehealth made it easier to provide intensive outpatient treatment, said Zoe Barnard, former administrator with the Montana Department of Public Health and Human Services Addictive and Mental Disorders Division. This was true for audio-only and traditional telehealth methods. Barnard emphasized that telehealth expansion also required partnerships with state legislators.

“Montana’s rural areas have significant health care access needs,” she said. “Audio-only telehealth solutions for many of our residents has proven to be an important lifeline, and we’re not going back.”

Barnard noted Montana House Bill 43, a pro-telehealth measure that was unanimously passed in both chambers of the state legislature.

How telehealth can combat stigma

Obtaining care via telehealth can help ease anxiety for SUD patients who dread the waiting room and the stigma of traditional SUD treatment. Not everyone has access to reliable Wi-Fi or a video-enabled device, and some patients might even feel more comfortable talking on the phone.

“Ideally, in a post-pandemic world, we should offer options across a combination of modalities, including phone, video and in-person,” she suggested. “For example, a patient could get started in treatment by video, have some follow-up visits by phone, including with a nurse or therapist, and occasionally come into clinic in-person when they need to. And the clinician and the patient can work together to decide what’s feasible and works best.”

She recommended the “Telehealth for Opioid Use Disorder Toolkit: Guidance to Support High-Quality Care (PDF),” which offers practical advice for physicians, other clinicians and policymakers.
Privacy concerns among plans, patients

Augenstein said he’s seen some progress with coverage on audio-only services. “Where some payers have questions is around group visits. There’s privacy concerns about that too,” he said.

Although physicians and others do what they can to adhere to informed consent, “when people are trying to participate in groups there could potentially be a privacy concern or stigma associated with not knowing who else is in the room,” noted Barnard.

Telehealth’s value in SUD and behavioral health care would benefit from more evidence-based study, particularly with respect to audio only, text-based, video-based and hybrid care models, suggested Augenstein.

At the AMA’s End the Epidemic website, you can dive deeper into the data, find state- and specialty-specific resources, and read about the inspiring physicians who are helping patients with substance-use disorders or chronic pain.

The End the Epidemic website was recognized by the Academy of Interactive and Visual Arts. As part of that organization’s 27th Annual Communicator Awards, End the Epidemic was honored with an Award of Excellence in the Cause & Awareness website category.

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