Some addiction specialists have reported benefits from the accelerated use of telehealth visits since the beginning of the coronavirus disease-2019 (COVID-19) pandemic. As with other patient populations, use of telehealth has provided a safe option for patients with substance use disorder (SUD) and could even remove some barriers to treatment and continue to prove useful after the pandemic ends.

Julie Craig, MD, an addiction specialist and family medicine physician with the start-up company Bicycle Health, published an opinion piece in the KevinMD feature of the online physician news website MedScape.1

"If the ravages of COVID-19 have offered a silver lining for the hard-hit health care profession, it is the rapid acceptance of telemedicine models-a transformation that was a long-time coming but hampered by reluctant payers and bureaucratic limitations on technology utilization," Craig wrote. "Even while working through logistical challenges (such as how to perform a drug screen in a home setting), we can glean the best of this forced evolution by offering substance use disorder patients the right to the most effective treatment in a private, less stigmatized environment-all the while tackling regional shortages of skilled providers that make substance use disorder such a deadly condition before, during, and after the COVID-19 era."

Some of the bugs that plagued the rural SUD program where Craig provided medication for opioid use disorder (OUD) side-by-side with primary care included missing appointments or arriving late because of transportation issues and arrival to the waiting room in an agitated state.

"Unscheduled arrivals from patients with substandard housing and unpredictable transportation were pitted against the need to set expectations for compliance," Craig wrote.

It was rocky at first with the rapid changeover to telemedicine in March of 2020, bringing challenges such as "patients without the skill set to navigate HIPAA-compliant apps, phones with too little smarts to handle video conferencing, lack of connectivity in rural and economically depressed areas," Craig wrote.

"But telemedicine brought unexpected benefits: the no-show rate plummeted. Patients were more empowered by their own motivation to engage in care than limited by bus schedules' vagaries."

"Most of all, telemedicine mitigates the stigma associated with substance use treatment," Craig wrote. "By accessing services from the privacy of their own home (or a convenient Starbucks where the Wi-Fi is always free), patients are relieved of the burden of attending clinics where their very presence might disclose their diagnosis."

Telemedicine also widens the geographic area of service to patients, allowing them to participate in group therapy "with amicable strangers rather than cousins, neighbors, friends, or even former dealers that might compromise confidentiality or trigger a relapse."

Travel time and waiting room delays no longer were a problem for patients who previously had to take chunks of time out of their work day.

"Eliminating transportation helps focus patient investment on therapeutic interventions rather than road time," Craig wrote.

Telehealth also empowered patients to have more choice in a provider. "Ideally, patients can vote with their feet if a telemedicine provider is a poor match or engages in stigmatizing behaviors-an option rarely available for highly impacted in-person services that rely on limited local resources."

Explosion in Remote Care Services for Substance Use Disorder

Bicycle Health (http://bicyclehealth.com) is one of the technology start-ups offering medication-assisted treatment for OUD, including remote services via telehealth.

A news article for Tech Crunch described the company's expansion: "Initially, the company worked out of a clinic in Redwood City, California, but as the COVID-19 pandemic took hold in the US earlier this year and forced treatment facilities to undertake preventative measures to stop the spread of the disease, Bicycle Health began adopting virtual treatment methods."2

Treatment via telehealth became possible after new regulations from the US Department of Health and Human Services allowed many therapies and drug treatments that previously were available only in person, to now be distributed remotely.

"The change caused an explosion in remote-care services and companies like Bicycle Health rushed to capitalize," according to the Tech Crunch article, which reported that the company was scheduled to be operating in 25 states by the end of the first quarter of 2021. Treatment includes buprenorphine and a team of coaches who meet with the company's 2000 patients as of December.2

Mayo Clinic Team Reviewed Telehealth for Substance Use Disorder

In October 2020, a team of authors published online-first in Mayo Clinic Proceedings a special article on use of telehealth to treat OUD during the pandemic.3 The corresponding author is Tyler S. Oesterle, MD, MPH, of the Department of Psychiatry and Psychology at Mayo Clinic in Rochester, Minnesota.

"Conducting telehealth medication-assisted treatment visits for OUDs represents a unique challenge," the authors wrote. "Prescribing controlled substances such as buprenorphine for patients seen exclusively via virtual visits was previously restricted, but it is now possible with temporary emergency legislative changes during the COVID-19 pandemic. However, methadone still requires in-person visits for induction. Medications for OUD require the greatest supervision and observation due to the risk of misuse and diversion."

According to the authors, "The four most common modes of telehealth in SUD treatment programs are computerized assessments (45%), telephone-based recovery support (29%), telephone-based therapy (28%), and video-based therapy (20%). Less used tools include texting, smartphone apps, and virtual reality interventions."

The most commonly used virtual interventions for SUD were assessments and treatments involving no live interaction, and offer improved ease of access to assessment. These interventions are considered asynchronous, meaning patients may access them at any time and therefore have them at critical moments in recovery.

Asynchronous and Synchronous Services

However, the authors reported that several reviews of asynchronous online smoking cessation resources showed that most programs were of mediocre quality and that the highest-quality websites attracted few visitors.3

"This may create risk if individuals are attempting to apply mediocre tools without consulting a physician for advice on quality," Oesterle et al3 wrote. "Further work is needed to determine adequate length (ie, dose) of the treatment, degree of integration needed with traditional treatment, and the sustainability of effects."

The next-most-common type of service is synchronous, requiring real-time phone contact for support or therapy from a member of the care team.

"Phone calls offer support, link patients to resources, and deliver brief interventions," Oesterle et al wrote. "They are considered minimally resource intensive, in that apart from the capacity to deliver effective brief intervention, cost of infrastructure is low."

"For a disorder where group therapy has been the mainstay treatment option for decades, social distancing, shelter in place, and treatment discontinuation have created an urgent need for alternative approaches to addiction treatment," the authors wrote. "In an attempt to continue some care for patients in need, many medical institutions have transitioned to a virtual environment to promote safe social distancing. Although there is ample evidence to support telemedical interventions, these can be difficult to implement, especially in the SUD population."

The authors review current literature for the use of telehealth interventions in the treatment of SUDs and offer recommendations on safe and effective strategies to implement such treatment.

The authors conclude: "While in-person groups and individual sessions remain the gold standard, we believe that virtual synchronous SUD-focused telehealth can be delivered in a safe and effective manner. Asynchronous modalities appear to be safe and effective when based on sound therapeutic principles and as augmentation strategies for more traditional treatments. Providers should warn patients about the possibility of exposure to mediocre-quality asynchronous modalities. For reasons of cost, service delivery, and safety, especially in the current setting of easily transmittable infectious diseases, virtual groups and sessions offer a safe and effective alternative."

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