The Critical Role of Telemedicine in Treating the Addiction Crisis

Telemedicine is now mainstream. The numbers speak for themselves. According to a recent industry report, the global telemedicine market is expected to be worth almost $35 billion by the end of 2020. A similar report found that while the market for telemedicine technologies stood at approximately $18 billion in 2014, that number was expected to grow at a compounded annual growth rate of approximately 19 percent. Changing consumer attitudes are helping drive the market. For example, a study found that 70 percent of patients are comfortable communicating with their health care providers via text, e-mail, or video, in lieu of seeing them in person. Another 74 percent of consumers indicate that they would use telehealth services when seeking care for certain non-urgent conditions.

As the nation wrestles with an ongoing drug addiction epidemic, one area in which telemedicine has not been used to its fullest capability is addiction treatment. As will be explored, there are potentially a number of advantages in using telemedicine to provide addiction treatment services—including telemedicine’s ability to facilitate greater access to treatment.

The Addiction Epidemic

It is indisputable that the country is in the midst of an addiction crisis. The statistics (from the Centers for Disease Control and Prevention and the American Society of Addiction Medicine) paint a daunting picture:

• Drug overdose is the leading cause of accidental death in the US;
• From 2000 to 2015, more than half a million people died from drug overdoses;
• A majority of drug overdose deaths (six in ten) involve an opioid;
• Deaths from prescription opioids have more than quadrupled since 1999;
• More than 1,000 people are treated each day in emergency departments for not using opioids as prescribed;
• About 1 in 4 people who receive prescription opioids long term for non-cancer pain in primary care settings struggle with addiction;
• Overdose rates were highest among people aged 25 to 54 years, and were higher among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics; and
• Men were more likely to die from overdose, but the mortality gap between men and women is closing.

More disturbing still are the fairly low rates of addiction recovery—assuming that such recovery services are even available. Relapse rates are over 50 percent for certain drugs, and higher for opioid addicts. Per the National Institute on Drug Abuse (“NIDA”), the chronic nature of addiction “means that relapsing to drug abuse at some point is not only possible, but likely.” Relapse rates closely mirror those for other chronic diseases such as diabetes.

In highlighting principles for treatment, NIDA notes that effective substance abuse treatment combines treatment medications with behavioral therapy, and that treatment must be continually assessed and modified to ensure that treatment reflects changing needs and circumstances. As reflected in a report from the National Center on Addiction and Substance Abuse at Columbia University, there is concern that many treatment programs do not provide effective, evidence-based care, and use treatment strategies that are outdated. Moreover, traditional treatment is limited by the availability of treatment professionals who often are not available outside of in-person care settings, and the lack of available space at treatment facilities. According to one survey, almost 9 percent of the population needs treatment but only 1 percent actually receives it. Indeed, according to a Substance Abuse and Mental Health Services Administration (“SAMHSA”) report, only 11 percent of those who need addiction treatment at a specialty facility received it.

Telemedicine and Addiction Treatment

This is where telemedicine can play a critical role. As one observer noted in a study published in Addiction Science & Clinical Practice, “because it removes barriers of time and distance, telemedicine offers great potential for enhancing treatment and recovery for people with substance and abuse disorders.”

Among other things, telemedicine allows:

• Rural patients to receive treatment in their own homes or at a local health care facility;
• Patients to continue care when released from a treatment facility;
• Individuals to participate in virtual group therapy;
• Flexibility in scheduling;
• Treatment to be provided at all times;
• Patients to avoid potential stigma from appearing at an addiction treatment center/provider; and
• Patient behavior and activity to be tracked and monitored.

Interestingly, a number of studies on the use of telemedicine in addiction treatment found no difference in patient satisfaction regarding care provided in-person or via telemedicine. More broadly, other studies have shown the effectiveness of telemental health services, including one that showed providing telemental health services to patients in rural and underserved areas significantly reduced hospitalization rates.

The federal government has taken notice. For example, the United States Department of Agriculture (“USDA”) is financing five Distance Learning and Telemedicine grants to the tune of almost $1.4 million for the development virtual treatment programs for opioid addicts in rural central Appalachia. SAMHSA, in its federal guidelines for treatment programs, discusses the use of telemedicine to treat addiction, and notes that “[a]s a result of telemedicine, individuals unable to avail or who lack access to medication-assisted treatment may receive appropriate services.” The SAMHSA guidelines also warn telemedicine providers to pay particular attention to data security and privacy, appropriate licensure, and not to use telemedicine to substitute for a physical examination. Intriguingly, the Surgeon General’s Report on Alcohol, Drugs, and Health notes that while the evidence base of technology-based treatment interventions is limited, these technologies are promising, and the Report encourages more research into telemedicine-based delivery models. States are also starting to recognize the viability of telemedicine in addiction treatment. The National Governors Association, for example, announced late last year that Minnesota, South Dakota, and Virginia are participating in a learning lab focusing on addiction treatment via teleconsultation.

Operational Challenges

Despite the promise of telemedicine in addiction treatment, some providers have raised a number of concerns. First, some argue that it is far more difficult to properly assess important nonverbal cues when communicating with patients by video, and to establish the kind of rapport necessary to make such services effective. In other words, they are arguing that in-person interactions allow people to reveal more about their thoughts and emotions. Second, there could be increased costs associated with developing and maintaining a secure and functioning telemedicine operation. Third, and related to the second point, is the belief by some providers that developing a telemedicine operation could unduly interfere with current clinical workflows thereby causing disruptions in practice that could impact the ability to provide care. Finally, there are concerns in certain provider communities regarding the perceived lack of adequate training about the proper uses of telemedicine.

It should be noted that while there are few specific guidelines or practice standards regarding the use of telemedicine in addiction treatment, there is a well-developed body of practice standards and guidelines regarding telemental health generally published by groups such as the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers.

Legal Challenges

Perhaps more challenging are the numerous legal and regulatory issues raised by telemedicine in the addiction context—such as verifying patient identity, follow-up care, privacy and security, treatment of minors, and reimbursement. Some of these issues are the province of state law which vary from state to state—leading to an inconsistent patchwork of laws and regulations making compliance difficult.

Of particular significance to telemedicine in the addiction context is the issue of prescribing of controlled substances via telehealth—governed by federal law. This is critical because treatment for addicts may involve the use of controlled substances such as methadone and naloxone. Under the Ryan Haight Online Pharmacy Consumer Protection Act, no controlled substance may be “delivered, distributed or dispensed by means of the Internet without a valid prescription.” Note, however, unless an exception applies, a valid prescription may only be obtained by a practitioner who has conducted at least one in-person medical evaluation of the patient. One of the exceptions involves the practice of telemedicine, in which a physician practicing telemedicine may prescribe controlled substances without an in-person evaluation if: i) the patient is treated by, and physically located in a Drug Enforcement Administration (“DEA”)-registered hospital or clinic; and ii) the provider is treating the patient in the usual course of professional practice, with a valid DEA registration (21 U.S.C. § 802(54)). There are other exceptions which will likely not apply in the addiction context. Ultimately, prescribing controlled substances via telemedicine is difficult and may limit the efficacy of addiction treatment via such modality.

Conclusion

The addiction crisis shows no signs of slowing, and far too many people are without adequate access to treatment services. Telemedicine may provide a viable alternative to provide treatment to more people, especially those living in areas with shortages of health care professionals qualified to provide treatment. While operational and legal challenges exist, it is difficult to imagine meaningfully addressing the addiction crisis without broader use of telemedicine.