The Addiction Crisis: Is Telemedicine the Answer?

The statistics about the current opiate crisis are sobering:

• Each day, more than 90 Americans die after overdosing on opioids. In 2015 alone, more than 33,000 Americans died as a result of an opioid overdose, including prescription opiates, heroin, and other powerful synthetic opioids.(1)

• An estimated 2 million people in the United States suffered from substance use disorders related to prescription opiate pain relievers in 2015, and 591,000 suffered from a heroin use disorder.(2)

• The Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including healthcare costs, lost productivity, addiction treatment, and criminal justice involvement.(3)

According to a survey by the National Institute of Drug Abuse, almost 9% of the population needs treatment, but only 1% actually receives it.(4) In light of these alarming statistics, this area of healthcare should be ripe for innovation.

Addiction Treatment

According to the National Institutes of Health, the following key principles should form the basis of any effective drug treatment program:

• Addiction is a complex but treatable disease that affects brain function and behavior.

• No single treatment is right for everyone.

• People need to have quick access to treatment.

• Effective treatment addresses all of the patient’s needs, not just his or her drug use.

• Staying in treatment long enough is critical.

• Counseling and other behavioral therapies are the most commonly used forms of treatment.

• Medications are often an important part of treatment, especially when combined with behavioral therapies.

• Treatment plans must be reviewed often and modified to fit the patient’s changing needs.

• Treatment should address other possible mental disorders.

• Medically assisted detoxification is only the first stage of treatment.

• Treatment doesn’t need to be voluntary to be effective.

• Drug use during treatment must be monitored continuously.

• Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as teach them about steps they can take to reduce their risk of these illnesses.

Patients seeking treatment for heroin and opiate addiction are eligible to receive medication-assisted treatment (MAT) from an appropriately registered healthcare provider with one of the medications approved by the FDA. Such medications include naltrexone, naloxone, methadone, and buprenorphine-containing products such as Suboxone and Subutex. According to the Substance Abuse and Mental Health Services Administration, the use of pharmacologic modalities in combination with counseling and behavioral therapies is the optimal approach to the treatment of substance use disorders.(5)

Telehealth and Telemedicine

The Federation of State Medical Boards (FSMB) defines telemedicine as the “practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider.”(6) Traditional modalities of telemedicine include live two-way interaction between a patient and a healthcare provider using audiovisual technology; store-and-forward technology that transmits a patient’s recorded health history through a secure electronic communication system to a healthcare provider; and remote patient monitoring that collects a patient’s personal health and medical data, then continually transmits it to a provider at another location.

Telehealth is broader than telemedicine. Telehealth includes nonclinical services that may support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration. “M-Heath” tools, such as wearable devices or smart phones that track health and wellness, fall within the telehealth definition.

The use of telemedicine and telehealth has led to improved access to health services, enhanced quality of care, and greater cost efficiencies for both providers and patients. With so many people in need of access to drug addiction treatment, and in light of the high relapse rates for those in treatment or in early recovery, why hasn’t telemedicine been the bridge to these shortfalls?

Barriers

Historically, when a physician treats a patient, the physician is presumed to be practicing medicine where the patient is located. For example, a California physician who provides treatment to a patient in Texas has just practiced medicine in the Lone Star state. The process to obtain licensure varies from state to state, and is dictated by each state’s Medical Practice Act.

Not only does the threshold issue of licensure pose obstacles for potential telehealth providers, but the wide variation among acceptable standards of care in the context of telemedicine further complicates the delivery of treatment through electronic media. For instance, states may have specific regulations outlining how practitioners are to verify patient identity, provide follow-up care, maintain medical records, and preserve privacy and security. Perhaps most important to the intersection of drug addiction treatment and telemedicine is how states delineate acceptable prescribing activities.

With regard to MAT, many states do not allow practitioners who have never physically examined a patient to prescribe medication [e.g., Arizona Revised Statutes 32-1401-27(ss)]. Most states consider using an Internet/online questionnaire to establish a provider–patient relationship as inadequate, and have enacted regulations explicitly prohibiting prescribing based solely upon such questionnaires (e.g., AR Code Annotated Sec. 17-92-1003(14)(B)). These regulations mirror the federal government’s position as outlined per The Ryan Haight Online Pharmacy Consumer Protection Act (henceforth referred to as “the Act”).

The Act, passed in October 2008, amended the Controlled Substances Act and the Controlled Substances Import and Export Act by adding provisions to prevent the illegal distribution and dispensing of controlled substances by means of the Internet (74 C.F.R. 15595). It was named after Ryan Haight, a teenager who died of a drug overdose after he obtained Vicodin from an online pharmacy without ever meeting a physician.

Reimbursement poses a challenging obstacle to the receipt of addiction treatment through telemedicine.

The Act places a number of restrictions on the operation of online pharmacies and the ability of practitioners to prescribe medications through the Internet. Generally, to prescribe controlled substances, including MAT medications such as buprenorphine, practitioners must conduct at least one in-person medical evaluation. However, a physician practicing telemedicine may prescribe controlled substances without an in-person evaluation if the patient is treated by and physically located in a hospital or clinic that has a valid DEA registration, and the telemedicine practitioner is treating the patient in the usual course of professional practice and in accordance with state law (21 USC 802(54)(A)). Finally, the Act imposes criminal penalties for unlawful distributors and dispensers of controlled substances.

In addition to regulatory and licensure barriers, reimbursement poses a challenging obstacle to the receipt of addiction treatment through telemedicine. Most individuals seeking addiction treatment rely primarily on Medicaid, Medicaid managed care plans, or commercial insurance for reimbursement. Coverage varies considerably by state for services, including medication costs, physician visits, counseling, and laboratory services. Coverage in many states also is subject to rules regarding prior authorization and medical necessity. Additional restrictions may control the locations within the state where services rendered through telemedicine technologies can be provided.

Expansion and Developments

We need new, innovative medications and technologies to treat opioid addiction. The existing MAT medications effectively reduce illicit opiate use when they are utilized and patients adhere to their treatment plan. Also essential is access to behavioral health treatment. Remote patient monitoring through smartphones and wearable devices can facilitate additional compliance safeguards. Simply stated, telemedicine can enhance the delivery and quality of such treatment, if done correctly. Studies show no difference in patient satisfaction regarding care provided in person or via telemedicine.(7)

To address licensure portability and an inconsistent patchwork of laws and regulations making compliance difficult, the FSMB has designed an Interstate Medical Licensure Compact to create an expedited licensure process for licensed physicians to apply for licenses in other states. Participating state medical boards retain their licensing and disciplinary authority, but would agree to share information and processes essential to the licensing and regulation of physicians who cross state borders. Access to more licensed practitioners will facilitate greater access to care.

Additionally, some states are expanding or clarifying pertinent regulations for telemedicine. Ohio, for example, released new rules in March 2017 that permit a physician to prescribe a non-controlled substance to a person for whom a physician has never conducted a physical examination and who is at a remote location when certain requirements are satisfied. Requirements include establishing the patient’s identity and physical location; obtaining informed consent for treatment through a remote examination; and completing a medical evaluation that is appropriate for the patient and meets the standard of care, which may include portions of the evaluation having been conducted by another healthcare provider. Providers shall also establish a diagnosis and treatment plan, document such plan in the patient’s medical record, and provide appropriate follow-up care or recommend follow-up care with the patient’s primary care provider or other appropriate healthcare provider or facility.

Additionally, Ohio’s new telemedicine prescribing rules permit controlled substances to be prescribed to a person for whom the practitioner has not performed a physical examination and who is located in a remote location, so long as the practitioner has met the steps outlined above and one of the following situations exists (Ohio Admin. Code 4731-11-09):

• The person is an “active patient” of a healthcare provider who is a colleague of the physician and the drugs are provided pursuant to an on-call or cross-coverage arrangement. “Active patient” means the patient has received at least one in-person medical evaluation within the previous 24 months.

• The person has been admitted as an inpatient to or is a resident of an institutional facility.

• The physician is a hospice practitioner and the patient is hospice-enrolled.

• The patient is being treated by, and in the physical presence of, an Ohio-licensed physician or other DEA-registered provider, and the remote physician provides services in accordance with the current standards of practice.

• The physician has received a special DEA registration to provide controlled substances in the particular situation.

Ohio, and other states including Indiana, Florida, Michigan, and West Virginia, have enacted laws expressly permitting telemedicine prescribing of controlled substances.(8) This is encouraging news for providers using telemedicine in their practice, because controlled substances can be a critical component of certain specialties, including addiction medicine.

Finally, as of January 2018, 34 states and Washington, DC, have enacted “parity” laws generally requiring health insurers to cover and pay for services provided via telehealth the same way they would for in-person service.(9) Parity can incentivize and stimulate healthcare providers to adopt telemedicine and telehealth services. In 2014, less than 50% of large employers offered telemedicine services as part of their employee health plans. At the end of 2017, more than 90% of employers are offering telemedicine services as an employee benefit.(10) The aforementioned increases in reimbursement and coverage reinforce the notion that telemedicine is gaining mainstream acceptance as a viable modality for healthcare.

Although telemedicine is not the “cure” to the opiate and heroin epidemic, it does offer some solutions to expanding access to addiction treatment if done correctly. Additionally, patients receiving treatment via telemedicine could also avoid the perceived stigma of being identified as a patient of an addiction medicine treatment provider or center. Nonetheless, addiction and behavioral health providers engaging in telemedicine must be mindful of the many intersecting state and federal laws regulating prescribing and standards of care. With far too many people denied adequate access to addiction treatment services, telemedicine provides a viable means to bridge such shortfall.

References

1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm655051e1.

2. Center for Behavioral Health Statistics and Quality (CBHSQ). 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.

3. Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54:901-906. doi:10.1097/MLR.0000000000000625.

4. NIDA. (June 25, 2015). Nationwide Trends. www.drugabuse.gov/publications/drugfacts/nationwide-trends . Accessed August 20, 2017.

5. SAMHSA. Director’s letter on the expansion of access to medication-assisted treatment for opioid use disorders. www.samhsa.gov/medication-assisted-treatment .

6. FSMB. Model policy for the appropriate use of telemedicine technologies in the practice of medicine. April 2014. http://www.fsmb.org/globalassets/advocacy/policies/fsmb_telemedicine_policy.pdf .

7. Molfenter T, Boyle M, Holloway D, Zwick J. Trends in telemedicine use in addiction treatment. Addiction Science & Clinical Practice. 201510:14 DOI 10.1186/s13722-015-0035-4.

8. Michigan telemedicine prescribing and controlled substance laws. Health Care Law Today. June 22, 2017. www.foley.com/michigan-telemedicine-prescribing-and-controlled-substance-laws-06-22-2017/ .

9. State Telemedicine Legislative & Regulatory Trackers. American Telemedicine Association. www.americantelemed.org/main/policy-page/state-policy-resource-center.

10. Comstock J. Large employer telemedicine adoption will hit 96 percent next year, survey says. MobiHealthNews. August 9, 2017. www.mobihealthnews.com/content/large-employer-telemedicine-adoption-will-hit-96-percent-next-year-survey-says .