The Good, the Bad, and the Unknown for Addiction Treatment in the Telehealth Explosion

The COVID-19 pandemic has turned the healthcare industry upside down, including for substance use disorder treatment and recovery. With every big change, there is the good, the bad, and the unknown. As the field of addiction wades into the technical waters of the digital age, the far-reaching effects of the explosion in telehealth technologies on one of America’s most vulnerable populations is still unfolding.

All throughout the COVID-19 pandemic, the opioid epidemic has been happening concurrently. In some states, overdoses have resulted in a greater number of fatalities than COVID-19, mainly attributed to rise in prevalence of Fentanyl. The CDC estimates that between May 2020 and April 2021 over 100,000 people died of opioid overdose, not to mention the more than 80,000 Americans that die of alcohol-related causes annually.

Historically, addiction treatment relied heavily on being in-person to build interpersonal relationships between patient and provider, cultivate peer connections and benefit from the lived experience of others, and for monitoring for the recurrence of substance use disorder symptoms (ensure the efficacy of urine or saliva test samples). Then the COVID-19 pandemic came along and triggered a relaxation in restrictions around remote prescribing practices, which historically barred telehealth providers from prescribing controlled substances such as buprenorphine and other addiction treatment medications. During this same period, we have seen the Substance Abuse and Mental Health Administration (SAMSHA) loosen rules restricting telehealth for patient communication and care, as well as improvements to federal Medicaid and Medicare reimbursement policies that have indirectly benefited addiction treatment providers.

Alongside regulatory improvements, there has been an unprecedented investment in healthcare startups. There are now more than 100 healthcare unicorns valued at one billion or more; many using telehealth technology to deliver substance use and mental health services. Healthcare unicorns such as Betterhelp or WorkIt Health continuously shape what future investors want to invest in and are at the forefront of developing new services. Investment demonstrates long-term value in telehealth and predicts sector growth.

Indicators for telehealth technology for substance use disorder and mental health point to likely increases. But how has and how will the explosion of telehealth predictably affect addiction treatment?

The Good

Increased access and accessibility from the explosion in telehealth has been one of the silver linings of the COVID-19 pandemic. From a pocket ?smartphone, one can book PCP and therapy appointments like never before. For American’s living in more rural areas especially, this can break down treatment barriers such as lack of transportation. or time off work.

One of the benefits of the new technologies, is now more than ever, one does not need to quit their job or seek leave to begin receiving treatment for a substance use disorder. For some, the less intimate nature of online services and communities can increase their comfort levels in sharing personal information and seeking out substance use services.

Cost combined with convenience creates a low barrier of entry, which may lead to people seeking out help for substance use and mental health issues earlier. The earlier one seeks help for these conditions, the better the overall prognosis.

Telehealth has decreased costs, and many providers have partnered with large insurance companies to provide in-network services and care. The age of attending $50,000 luxury rehabs may be making way for more affordable at-home or in-community care options.

In seeking out treatment for substance use disorder, it is critical that treatment strikes while the iron is hot and services are available immediately to individuals ready to engage in health behavioral change. Telehealth provides that on-demand capability of starting your recovery journey, an immediacy that is often crucial, whether through beginning to track days sober, talk to intake or peer support specialists, begin educational recovery learning modules, or by attending online peer support meetings such as AA.

The explosion of telehealth also heralds in a new day of data collection. With everything online, data collection is easier than ever. Despite data collection being easier, large-scale issues in data sharing and data transparency remain. While the new “No Surprised Act” adds in new mandates for cost transparency for services rendered, addiction apps and programs are not required to make patient outcomes during or post-treatment publically available. Despite the shortcomings, telehealth is a strong foundation on which policy makers, regulators and payers to standardize evidence-based practices to be on par with other areas of mainstream medicine. Some longer-term patient tracking data is available, although it is often proprietary information. While data may be patchy at times, users may revisit the app or keep using the app over longer periods of time than in traditional inpatient and outpatient settings, creating more long-term datasets.

The Bad

Credibility of telehealth providers continues to be an issue. Some telehealth providers can provide treatment, but laws vary by state, and many virtual or remote options were temporary designations under COVID-19 emergency statues. If you go to the app store, a whole host of addiction apps exist, but many can only provide substance use disorder “care” and not substance use disorder “treatment.” The difference here, is that the U.S. Food and Drug Administration does not yet have a widespread licensing process in the realm of apps. One app provider, Pear Therapeutics, got a new FDA designation created last year known as “digital therapeutics.”

While a plus for some, the remote nature of telehealth can interfere with human connection, relationship building, organic group processing, and connection to the local community. It is simply harder to make long-lasting connections online and without the cues of physical body language.

Controlled substances like Suboxone for treatment of opioid use disorder or Ativan (Loreazapm) for treatment of co-occurring depression and anxiety symptoms, are still not legally prescribable via telehealth. This means telehealth is not able to offer comprehensive, whole person care.

Another limitation of telehealth continues to be that it is not adept at handling individuals in crisis. In-person treatment is still the only true option for crisis care. Apps, startups and programs are not generally setup or staffed to handle emergencies. Limitation of telehealth.

Additionally, individuals with severe substance use disorder often experience homelessness, which correlates to a lack of access to Smartphone and computers, acting as a barrier to treatment access.

The Unknown

Telehealth puts large decisions on treatment approaches directly in hands of patients. For example, do you want Cognitive Behavioral Therapy (CBT), Contingency Management, Peer Support, or some combination of these? While the transparency on treatment approach and giving patients the ability to choose is definitely a plus, the majority of patients may not know what these different treatment are, the evidence base for against them, or the implications of them.

Accountability is another factor that brings unknown consequences into play. On one hand, patients can rate different telehealth providers and apps publicly through the app store, certain apps may not be able to be held legally accountable due to their unknown creators in the case that something goes wrong, with varying degrees of customer service and responsiveness to users.

Additionally, warm handoffs have gotten a little colder. Can we call them luke-warm handoffs? No longer does the referral process include walking someone to their first AA meeting. However, referrals can be an existing provider hoping on a zoom call with the patient and a new provider to introduce them. The jury is still out on the extent to which Zoom handoffs can replace in-person handoffs.

CONCLUSION

There are some implications that clearly beneficial or clearly harmful to individuals seeking out treatment for substance use disorder. But there is a whole other bucket of implications where simply don’t know, or may be both beneficial and harmful at the same time. It will be up to healthcare leaders and policy makers to embrace the rise of telehealth to bolster the good and transform the bad. As we enter a new era of healthcare we will continually need to reassess how these changes are affecting some of America’s most vulnerable populations.

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