The medical community has been working to provide accessible treatment for opioid use disorder to those who are in hard to reach areas, particularly in rural America. Telehealth, or the use of videoconferencing, texting and mobile apps are all being used to aid in recovery.
But as COVID-19 sweeps across the U.S., closing businesses and schools and forcing many to stay home, telehealth treatment for substance abuse may now be more critical than ever.
With many “shelter in place” rules in effect, the nonprofit Hazelden Betty Ford is rushing to make sure its patients still have access to the care they need. The organization, located in Minnesota, is the largest in the U.S. specializing in substance use disorders.
Before the nation’s public health crisis with the spread of COVID-19, Hazelden was in the process of implementing a virtual care system for patients. However, amid COVID-19, the nonprofit has expedited the rollout of its virtual care program, officially launching this week.
“We want to make sure people get the care. It’s scary out there right now,” said Mark Mishek, president and CEO of Hazelden Betty Ford. “You’re going to have patients unwilling to come into a brick and mortar facility and we need to get them into virtual care as soon as possible.”
The opioid epidemic has cost the U.S. more than 400,000 lives since 2000, and approximately $696 billion in 2018 alone. Hazelden’s virtual outpatient care program was originally borne out of a need to make treatment accessible in remote places. Doctor shortages in non-metropolitan areas have led to long wait times, and that does not account for those patients who live hundreds of miles away from the nearest clinic — potentially lacking the financial, transportation, childcare or physical means to get there.
Studies also show that telehealth can expand access to treatment in these communities — with the potential to be just as effective, if not superior, to in-person care because of its accessible nature.
“The fallacy is this belief that good care is available everywhere. But it’s definitely not true in some of the health care deserts,” said Robert Poznanovich, Vice President of Business Development at Hazelden.
The problem has only been further exacerbated due to COVID-19, prompting the medical community to turn to telehealth as a way to provide more comprehensive opioid addiction care, particularly during the time of social distancing.
Treating patients remotely
Hazelden Betty Ford’s virtual outpatient care program, called RecoveryGo, utilizes video conferencing for counseling and treating patients in a non-clinical setting.
Accessible using a computer, phone or any device with an internet connection and a camera, a counselor video conferences a patient for a one-on-one session, or multiple patients for group therapy. Poznanovich said that an important part of recovery is the group setting and learning from other’s experiences to better understand the disease. The peer group becomes a form of intervention, he said.
Early trials of the program indicate that the attendance rate was higher in virtual groups than facility-based groups. Patient testimonials reported positive experiences, despite initially being apprehensive about involvement in a virtual program.
Virtual care attempts to address a number of variables that keep people — especially in rural areas — from seeking addiction treatment in a clinical setting, like those who are single parents, who may not own a car, or who have a disability, to name a few examples. It’s also now attempting to address the physical restrictions now put in place due to COVID-19.
The Hazelden Betty Ford Foundation’s virtual outpatient care is now available in Minnesota, California, Washington, Oregon, Illinois, New York and Florida — with the goal of becoming active in all 50 states. They are currently working with states to understand their individual laws when it comes to telehealth — some of which may require a combination of virtual and in-person services, or that a provider be licensed in the state where a patient is receiving care.
Because of COVID-19, many states are issuing emergency declarations to help pave the way for launching telehealth services at a faster rate. Although the foundation always worked to make sure the program would be covered under insurance plans, Mishek said that Hazelden is providing virtual services regardless of the sort of coverage a patient may have.
“This is moving so fast right now that we just need to focus on our patients,” he said.
Overcoming the stigma of opioid treatment
The Trump administration has suggested limiting gatherings to no more than 10 people. That affects the group setting that Hazelden said plays an essential role in recovery.
“People that are ill often are living lives that are secretive,” said Mishek. “Getting out, going in and relating to all the other human beings in your group — that’s a huge part of getting well. A lot of that physicality is not going to happen now.”
That’s where telehealth could again play a critical role in providing a way to access a group setting while at home. Even before COVID-19, experts saw how telehealth could reduce the stigma surrounding opioid addiction.
Lori Uscher-Pines, a Senior Policy Researcher at the RAND Corporation, said some patients may be reluctant to get treatment for opioid use disorders because they don’t want to be seen parked outside of a treatment facility or don’t want to be in a therapy session that could potentially involve neighbors and colleagues.
“It’s hard to be anonymous, especially in a small town,” she said. “So being able to seek treatment from your home offers increased privacy for some people.”
Obstacles to virtual addiction treatment
Multiple experts told the NewsHour that the Ryan Haight Act of 2008 — a law that generally requires a physician to examine a patient in-person before prescribing a controlled substance — had been a big barrier to treating substance use disorder via telehealth, not only because transportation to visits could be difficult, but wait times could cause delays in treatment.
However, because Health and Human Services Secretary Alex Azar declared a public health emergency for COVID-19, Drug Enforcement Agency-registered practitioners may now issue prescriptions without requiring an in-person medical evaluation first. This move lifts the restrictions that were facing telemedicine, especially during the COVID-19 global pandemic.
Under normal circumstances, doctors and other public health advocates say virtual care should not replace brick-and-mortar rehabilitation facilities. Some cases require higher levels of care, and those patients are typically screened out from using telemedicine services in favor of in-person care.
“The home setting can be pretty chaotic,” said Uscher-Pines, emphasizing uncontrollable variables, like childcare, pets, or unforeseen visitors during telehealth visits. “There’s a lot of these sorts of things that you can’t control that can impact the flow of the visit. In a health care setting, it’s easier to control the circumstances of the visit.”
Remote learning is quickly being adopted across the country — but even before the nation’s health crisis, it’s what a program called Project ECHO had already been implementing, with a focus on training doctors.
“I wanted to exponentially improve the capacity to deliver best practice care,” said Dr. Sanjeev Arora, who started the program in 2003. He explained that the idea behind the project was to figure out a way to continue offering treatment in his clinic while spreading the knowledge needed to save lives across the country.
ECHO’s “hub and spoke model” connects rural providers to central medical centers which train physicians virtually, through two hour sessions once a week. Physicians discuss their cases with other physicians, seeking advice or expertise.
The program has seen significant results. Arora said that after using the Project ECHO model, his usual 8-month wait had been reduced to 2 weeks because there were more physicians available to treat. The project has also now mobilized COVID-19 response ECHO networks in the U.S., and is working with the Centers for Disease and Control to connect doctors across 20 countries.
Dr. Haiden Huskamp is a professor of health care policy at the Harvard Medical School who studied how telemedicine is being used to treat opioid and substance use , alongside Uscher-Pines of RAND. She said that much work still needs to be done to get more people using telehealth for addiction treatment.
Their study found that by analyzing claims data from a large commercial insurer from 2010-2017, the number of telemedicine visits for substance use disorder increased from 97 to 1,989. However, these visits accounted for just 1.4 percent of telemedicine visits for any health condition over the period. Comparatively, telemental health visits increased from 2,039 to 54,175 — and accounted for 34.5 percent of all telemedicine visits in that same time period.
“These low rates of use really are a missed opportunity because it’s being used for other types of care and very effectively,” said Huskamp. Uscher-Pines agreed, saying that the lack of research on telehealth for substance use disorder in the home is a gap that needs to be filled.
Hazelden Betty Ford is awaiting the results of how their new virtual care program will impact patients amid COVID-19.
But, Mishek said that, “we literally got feedback yesterday from a group of patients who said they feel safe here.” The patients added, “thank you for doing what you’re doing.”