Telehealth, Addiction Treatment, and COVID-19

When the coronavirus pandemic arrived in the U.S., another nationwide health crisis was in full swing: the opioid epidemic. Related to the opioid epidemic was another troubling aspect of addiction in the U.S. that was beginning to get attention: the treatment gap, which refers to the difference between the number of people diagnosed with alcohol and/or substance use disorder (AUD/SUD) and the number of people who receive appropriate, specialized treatment for their disorder. But public awareness and concern for the opioid epidemic and the addiction treatment gap, like all other things not related to the coronavirus pandemic, was eclipsed by the immediate necessity of flattening the curve and preventing unnecessary illness and death due to COVID-19.

The pandemic forced a shift in the way we do everything. One thing that changed was the way we visit the doctor. Under shelter-in-place orders, authorities encouraged citizens to leave home for essential activities only, and to consider virtual options for things like routine medical care or regular office appointments with providers like mental health specialists. The result was a dramatic increase in the use of telehealth for a broad range of medical issues. Although no public data yet exists on the increased use of telehealth for alcohol or substance use disorder treatment, anecdotal evidence from frontline treatment providers indicates a similar increase in the use of telehealth for addiction treatment.

Regulatory Changes Remove Barriers

At the onset of the coronavirus pandemic, the Department of Health and Human Services (HHS) acted to increase access to telehealth by waiving a host of regulations that formerly governed telehealth and virtual treatment. Officials instituted this regulatory easing in order to allow people to access routine healthcare while decreasing the risk of contracting COVID-19. In addition to accomplishing this goal, the new regulations appear to have increased access to treatment – relative to pre-COVID levels – for people with alcohol and substance use disorders.

Here are the policy changes that led to this increase in access:

  1. Prescription medication. The Drug Enforcement Agency (DEA) relaxed rules prohibiting the prescription of schedule II-V medications for patients that doctors had not seen in person. This includes medications like buprenorphine, which evidence shows is an effective medication for the treatment of opioid use disorder (OUD).
  2. HHS announced a waiver of Health Insurance Portability and Accountability Act (HIPAA) penalties for physicians employing “good faith use of telehealth.”
  3. The Centers for Medicare and Medicaid Services waived restrictions on reimbursement for telehealth services.
  4. The Substance Abuse and Health Services Administrations (SAMHSA) released new rules for opioid treatment programs (OTPs) that increased the allowable amount of take-home medication and enabled providers in OTPs to prescribe buprenorphine via telehealth.
  5. SAMHSA relaxed regulations around HIPAA compliance specific to alcohol and substance use disorder treatment that previously made telehealth/virtual treatment for AUD/SUD difficult.

We’re reluctant to talk about silver linings with regard to the coronavirus pandemic. However, one result of these policy changes is an increase in the availability of treatment for alcohol use disorder or substance use disorder for people in rural areas, people with insufficient access to transportation, and people reluctant to seek addiction treatment due to public stigma or other personal reasons.

How to Sustain Increased Access to Telehealth

In an interview published by the University of Michigan Health Lab Blog, Dr. Allison Lewei Lin, a psychiatrist specializing in addiction treatment at the U of M, observed:

“These past few months have been a natural experiment for substance use disorder treatment, much of which has traditionally been largely outside the realm of other types of medicine. It will be important to see how things change, for better or worse. When we have the option for in-person care again, we will also need to determine which is better – telemedicine or the traditional approach – and for which patients, to keep them engaged and make care more accessible, especially for vulnerable populations.”

Dr. Lin and colleagues published a new article containing a list of three recommendations for leveraging the recent increase in the use of telehealth for substance use disorder treatment when the window for relaxed regulations around telehealth expires.

Here’s a summary of what they advise:

  1. Creating a set of guidelines and best practices for virtual/telehealth treatment for AUD/SUD. Guidelines for telehealth in general practice exist, but experts have yet to create a set of best practices of the AUD/SUD telehealth treatment.
  2. Initiating a comprehensive research effort to assess the efficacy of telehealth for AUD/SUD, as well as assess and improve telehealth interventions that involve the treatment of opioid use disorder.
  3. Providing additional resources for people with AUD/SUD and co-occurring mental health disorders. Specifically, resources that facilitate the delivery of individual psychotherapy, group therapy, and community support will warrant review and consideration.

Included in the details of their recommendations are provisions for ensuring continued access to telehealth for rural populations. Dr. Lin and colleagues also recognize the need to address the practical issues surround increased use of telehealth, such as enhancing technological infrastructure and revising billing and reimbursement policies.

A Treatment Option for the Present and Future

Nothing beats in-person contact with compassionate professionals dedicated to the long-term success of people in recovery from alcohol and substance use disorder. For people at high-risk or relapse or deep in active addiction, evidence shows residential treatment leads to the best possible outcomes. At the same time, we should recognize the validity and practicality of AUD/SUD treatment via virtual and telehealth platforms. In some cases, it may be the only viable treatment option available, and the most realistic way for people in need of treatment to get the support they need.