Barriers to addiction care fell because of COVID-19; Now the challenge is keeping them down

That's according to experts from the University of Michigan Addiction Center and VA Ann Arbor Healthcare System, writing in this week's issue of JAMA Psychiatry.

They document the recent policy changes that have made it possible for more addiction care to take place through telemedicine, specifically video chats and even telephone calls. They also note the requirements for in-person visits for key addiction treatments that have been waived -- though only temporarily -- during COVID-19.

Yet despite the recent rapid progress, they say, it will take more changes to truly lower barriers that stand in the way of delivering evidence-based addiction care to more people via telemedicine.

If that happens, more people with substance use disorders could have access to care such as medications, psychotherapy and peer group support, they say -- even in rural areas and other places where addiction specialists are scarce.

Some of the authors already used telehealth as part of their work at the VA even before the COVID-19 pandemic began. Based on that experience, and on the intense shifts to virtual care in the past three months, they give specific recommendations for how to make telehealth for addiction a sustainable option for more providers and patients.

"Before COVID, treatment of substance use disorders was one of the least-used forms of telemedicine, because of a combination of regulatory issues, clinician comfort and patient comfort," says Allison Lewei Lin, M.D., M.Sc., the lead author and an addiction psychiatrist at the U-M and VA.

"Now, many addiction providers haven't seen their patients in the office, or have substantially decreased in-person visits, by using telemedicine in the past three months," she says. "And where we once relied on referring patients to inpatient and residential programs, many of those have not been available during this time, so outpatient clinicians have been trying to take care of sicker patients as well."

Policy shifts

Relaxation of rules such as the Ryan Haight Act, which previously didn't allow prescribers to prescribe buprenorphine and other controlled addiction treatment medications to patients they had only seen virtually, have made a big difference, says Lin.

So have changes in rules and guidance from the Substance Abuse and Mental Health Services Administration to make it easier for clinicians to communicate and care for patients with addiction via telemedicine.

Plus, the same changes to Medicare and Medicaid telemedicine reimbursement rules that have helped move non-addiction care online this spring are helping addiction providers, too.

More research needed

As the coronavirus pandemic continues, she says, many in the addiction field have a lot of questions -- ones that researchers are now scrambling to study. For instance, how are patients doing, and are they improving with telemedicine-delivered treatment? Also of intense interest: Can telemedicine potentially help patients start and stay engaged in treatment longer than they would have with traditional care?

The rapid move to virtual care has been a big switch for a field that has focused for so long on building interpersonal rapport between patient and provider -- and also on in-person checks such as urine tests to make sure patients are adhering to their treatment and spot relapses early.

"Patients are now used to telemedicine and some really like it, so we shouldn't take it away even when coronavirus wanes," Lin says. "But we have to evaluate the impacts, including if the treatments are actually effective, as we go on."

Last year, Lin led a team that published a review of the existing evidence surrounding telemedicine for substance use disorders. They concluded that much more research was needed -- but that early evidence showed efficacy and high patient satisfaction.

Key recommendations

In the new piece, she and colleagues Anne Fernandez, Ph.D., M.A. and Erin Bonar, Ph.D. recommend three key changes going forward:

• Development of treatment guidelines that include both in-person and telemedicine-based care for substance use disorders, and that provide guidance on urine toxicology practices and use of new ways to monitor treatment progress including self-monitoring apps and other practices.
• More work to increase the availability of buprenorphine via telemedicine, including by increasing the number of physicians who are trained to prescribe it and monitor patients taking it. This could especially help rural areas hit hard by the opioid epidemic. Lin and her colleagues currently lead regular training sessions to get new providers started with such prescribing, and offer ongoing support for prescribers.
• More help for people with substance use disorders who are also coping with other mental health conditions, and with the psychological and financial stress brought on by the COVID-19 pandemic. Online resources including group therapy online will be key, they say.

"In this moment when clinical care has been transformed because of real-world necessity, rather than evidence produced by research, it makes research on the effects of that transformation all the more urgent," says Lin. "We need to understand to what extent we should be offering telemedicine even after COVID-19 has subsided."

Another urgent issue: making sure that patients in rural areas without broadband Internet access aren't left behind.

Lin has been seeing addiction patients for years using telehealth, but they had to travel to a clinic in a nearby city in order to connect with her. Now she is having visits with those patients in their homes instead.

"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," she says. "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."

Lin, Bonar and Fernandez are all faculty in the U-M Department of Psychiatry, part of Michigan Medicine, as well as members of the U-M Institute for Healthcare Policy and Innovation and the U-M Injury Prevention Center.