Barriers to addiction care fell because of COVID-19; Now the challenge is keeping them down
July 1, 2020
Science Daily/Michigan Medicine - University of Michigan
The opioid and addiction epidemic didn't go away when the coronavirus pandemic began. But rapid changes in regulations and guidance made during COVID-19 response could also help many more people get care for opioid use disorder and other addiction problems.
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.
https://www.sciencedaily.com/releases/2020/07/200701125434.htm
Overdose risk factors in youth with substance use disorders
More than a quarter of young people seeking treatment had history of at least one overdose
April 24, 2018
Science Daily/Massachusetts General Hospital
A team of Massachusetts General Hospital (MGH) investigators has identified factors that may increase the risk of drug overdose in adolescents and young adults. In their report published online in the Journal of Clinical Psychiatry, the researchers describe finding that more than a quarter of those seeking treatment at Addiction Recovery Management Service, an MGH-based outpatient substance-use-disorder treatment program for youth ages 14 to 26, had a history of at least one overdose. Factors associated with increased overdose risk were disorders involving the use of alcohol, cocaine or amphetamines and histories of depression, anxiety or eating disorders.
"Very little research exists on risk factors associated with overdose in young people presenting for substance use disorder treatment," says lead and corresponding author Amy Yule, MD, of Addiction Recovery Management Service and the MGH Division of Child Psychiatry. "In addition to screening for substance-specific risk factors, it is important that providers systematically screen young patients for overdose histories and for psychiatric factors that may increase overdose risk."
Most studies of overdose risk among individuals with substance use disorders have focused on adults, and the few that specifically studied young people only assessed substance-related risk factors and not psychiatric symptoms. Yule notes that, since substance use patterns are known to differ between youth and adults, and since brain regions important to decision making do not fully mature until the 20s, it is important to investigate whether risk factors differ between the two age groups.
The research team conducted a retrospective analysis of deidentified data from intake assessments conducted at Addiction Recovery Management Service from January 2012 through June 2013. These comprehensive assessments include details of both substance use and psychiatric histories and are conducted by social workers, psychologists and psychiatrists with additional training in addiction medicine.
Of the 200 patients whose data were collected, 58 had a history of at least one overdose -- defined as substance use associated with significant impairment in the level of consciousness or an ingestion of any substance with the intent of self-harm that was reported as a suicide attempt. Among those with an overdose history, 62 percent (36 patients) had unintentional overdoses only, 31 percent (18 patients) had intentional overdose only, and 7 percent (4 patients) had a history of both intentional and unintentional overdose; 24 patients had histories of more than one overdose.
Patients with two or more substance use disorders were more than three times as likely to have a history of overdose, compared to patients with a single substance use disorder. The best substance-associated predictors of an overdose were alcohol use disorder, cocaine use disorder and amphetamine use disorder; psychiatric conditions associated with overdose history were eating disorders, depression and anxiety disorders. Patients with a history of intentional overdose were more likely than those with unintentional overdose to have a history of self-harming behavior and inpatient psychiatric treatment.
Yule notes that, since the association of eating disorders with overdose risk has never been reported previously, it needs to be replicated in future studies, but assessing for eating disorders and other psychiatric risk factors in youth with substance use disorders is essential. The lack of an association between opioid use and overdose history in this study could reflect the fact that opioid use usually begins at later ages than does use of substances such as cannabis and alcohol, which are more common among adolescents. In addition, she adds, the presence of fentanyl, which significantly increases overdose risk, was much lower in Massachusetts at the time this study's data were collected.
"It's going to be helpful to assess overdose risk among young people with substance use disorders over a longer period of time and to examine whether treatment mitigates the risk for subsequent overdose," says Yule, an instructor in Psychiatry at Harvard Medical School (HMS). "While the opioid epidemic has raised public awareness of the importance of increased access to evidence-based treatment for substance use disorders, our findings support the importance of considering all substances of misuse -- both opioids and non-opioids -- when assessing overdose risk."
Study senior author Timothy Wilens, MD, chief of Child and Adolescent Psychiatry at MGH and associate professor of Psychiatry at HMS adds, "The striking prevalence of overdose history in treatment-seeking young people reflects how common overdose unfortunately is among those with substance use disorders, no matter the age."
https://www.sciencedaily.com/releases/2018/04/180424141140.htm