Telemedicine: A force multiplier in fighting the opioid epidemic

The U.S. is facing an opioid crisis — one so severe that on Aug. 10, President Donald Trump declared it a national emergency.

HHS estimates in 2015, 12.5 million people in the U.S. misused prescription opioids. Worse, 2 million people were diagnosed that year with prescription opioid use disorder. And while information is still preliminary, CDC data suggests drug overdose deaths rose significantly in 2016 and continues to climb in 2017.

This epidemic costs the U.S. economy $78.5 billion a year, including healthcare costs, lost productivity, addiction treatment and criminal justice involvement, as well as an average annual loss of nearly 15,000 lives, according to the CDC.

Access to OUD treatment isn't always easy. Traditionally, it's a lengthy process in which a patient may be required to travel to and from a clinic multiple times a week to receive medication in-person. 

These treatments, called Opioid Agonist Therapy, involve distributing an opioid agonist — like methadone and suboxone — in a controlled setting to prevent withdrawal and reduce cravings. Although OAT helps opioid users stabilize their lives and reduce the harmful effects of drug use, these drugs are only distributed in clinical settings under a physician's supervision — patients aren't allowed to take these agonist drugs at home until certain criteria are met.

Physicians say getting help can be especially challenging for patients who live in rural areas and may have to travel hours to specialized, dedicated clinics.

While specific guidelines may vary by state, federal law allows physicians to prescribe one take-home dose of the agonist drug methadone a week during the first 90 days in treatment, compared to one take-home dose of a different agonist drug suboxone a week during the first 30 days in treatment.

Under the Controlled Substances Act, which was most recently updated in 2010, physicians are able to use telemedicine services to provide care for certain substance use disorders. However, physicians offering buprenorphine treatments, a type of suboxone called subutex, via telehealth services face strict licensing restrictions and must obtain a federal waiver. On top of that, providing OUD care requires tailored treatment and controlled monitoring.

Despite these challenges, a study led by David Marsh, MD, chief medical director for the Canadian Addiction Treatment Centres, published in the May issue of Drug and Alcohol Dependence, suggests telehealth could be an effective option to increase access to OAT.

"Many of the more rural [clinics in Ontario] don't have physicians who are specialized in addiction medicine, so we've developed a series of services where the treatment [can be] delivered through … telemedicine," explains Dr. Marsh, who notes Canada's regulations on OAT and telehealth differ greatly from the U.S.

Instead of seeing a physician in person to receive the doses of their medication, patients received care via video conferencing. Patients were still required to meet at an on-site clinic — initially seven days a week, then gradually down to once a month — and interact with nurses and other caregivers, as well as provide other information like urine samples. These telemedicine clinics saved many rural patients 100 miles or more of travel to dedicated OAT clinics.

Compared to in-person visits, patients that received care predominantly through telemedicine services saw higher retention rates — 50 percent of patients in the telemedicine group lasted the entire 365 days of treatment while only 39 percent of patients from the in-person group were retained the full first year.

"In OAT, the longer people are retained in care, the more likely they are to show benefits," Dr. Marsh adds.

He added that those living in more rural locations benefited even more from the telemedicine option than those in urban locations who were still offered treatment via telemedicine. Dr. Marsh thinks this may have to do with motivation.

"Where patients have to travel on average of … 100 miles to see their doctor, the patients who entered care are much more motivated and that may be a predictor of their outcomes, compared to [urban areas], where they are within 10 miles of their physician," he suggests.

Dr. Marsh, however, warns that too few providers offer OUD treatments because physicians often the lack the necessary training.

One U.S. initiative, which rolled out last year, may be closing those critical skills gaps. In July 2016, the Agency for Healthcare Research and Quality, an organization under HHS, launched a three-year, $12 million to promote the use of telemedicine services for opioid treatment at rural healthcare facilities. Practices involved in the initiative use mobile apps, online training and specialist consults to help primary care physicians with medication-assistant treatment therapy. Similar to OAT, MAT treats OUD with FDA-approved opioid agonists, however it also requires psychosocial therapy.

"Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies, as provided in MAT, is most successful. The trouble is that many primary care physicians, particularly those in rural areas, find it difficult to introduce MAT into their practice," says David Meyers, MD, CMO for the AHRQ. Specifically, they often lack the training necessary to deploy MAT and effectively treat OUD.

Practices involved in the initiative will focused on remote training and expert consultation using the Project ECHO modelProject Echo was developed by the Albuquerque-based University of New Mexico. It uses telementoring to train primary care professionals in the newest evidence-based care practices.

"It is what we like to call a force multiplier and focuses on doctors and nurses who, if given more support, could care for more patients," Dr. Meyers adds.

AHRQ allocated the grants from HHS to four researchers across the U.S. — Susan Heil, PhD, in Oklahoma; Jack Westfall, MD, in Colorado; Dale Adair, MD, in Pennsylvania; and Sherri Green, PhD, in North Carolina.

By linking specialists at an academic hub to primary care providers in rural communities, these AHRQ grants will increase access to MAT to over 20,000 individuals struggling with OUD in the U.S.

Researchers are working toward changing the trajectory of the opioid epidemic through telemedicine — either treating patients directly or mentoring their peers. For one, Dr. Marsh's study shows telemedicine for OUD treatment is working, and he urges others to explore it more.

"Doctors should be encouraged to consider telemedicine as a treatment modality and to use their clinical judgment to decide when it is appropriate and when the patient needs to be seen in person," Dr. Marsh says.

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