As drug addiction continues to challenge traditional treatment methods, advocates and activists are looking for new ways to reach those who might not respond well enough to standard outreaches. Addiction treatment through telemedicine and the Internet might be on the cutting edge of connecting with those who live on the margins, but the idea elicits controversy for channeling therapy through the screen of a smartphone.

What Is Telemedicine?

Telemedicine does not refer to a single form of treatment, but “a broad variety of technologies and tactics” that electronically delivery health, medical, and education services, according to the Center for Connected Health Policy. Telemedicine (also known as telehealth) is a collection of resources that improves care for a patient, while providing other, related services.

The idea of finding new ways to connect with patients has been extensively studied by researchers, and the advent of the Internet and smartphones have opened up myriad possibilities. The British Journal of Psychology noted that doctors can get real-time patient data regardless of how far away the patient lives; people in addiction recovery can be instantly connected to their support networks when in danger of relapsing.

As smartphones become more and more ubiquitous, it may be increasingly necessary for healthcare and treatment providers to adapt to where their patients are. More than two-thirds of Americans own a smartphone, and 19 percent of them use smartphones as their primary medium to access the rest of the world (in terms of communication and news). Within 10 years, the number of Americans who owned a landline dropped from 9 out of 10 to just 1 out of 2, meaning that smartphones are likely to be the most reliable way for doctors and caseworkers to get in touch with their patients.

As much as people have more online access now than they ever have in the past, there is an inherent convenience that comes with using digital platforms, according to Digital Trends. Clinicians are available on an immediate, 24/7 basis, which has a particular application for addiction recovery. For all the bad (if well-meaning) advice that is available on the Internet, telemedicine makes it possible for an individual to be connected to a licensed doctor or healthcare professional with the click of a button.

What Can Telemedicine Do?

The researchers in the British Journal of Psychiatry take this into account, writing that as much as this changes the paradigm of access, the rise of smartphone technology (beyond simply making and receiving phone calls) can change the entire culture of mental health and substance abuse treatment. Providing real-time, on-the-spot counseling in an emergency situation on a 24/7 basis, regardless of location, is now a real possibility. Conversations do not have to be limited to voice or text but can be face-to-face. Apps can measure a user’s heart rate and other vital signs, collecting and sending hard data to a recovery professional at the press of a button, which the professional can use to offer instant guidance and advice (as opposed to having to wait until the next session or meeting to go over what happened).

Using telemedicine and the Internet as a branch of addiction treatment allows clients and therapists to exchange information that might otherwise be difficult or even impossible. Smartphone apps that track the progress of sleep (or lack thereof) provide invaluable insights into lifestyle, stress levels, and client self-care. Insufficient sleep is a “universal risk factor” for relapse, says Medical Hypothesis, and a client may not be aware if their sleep is being broken due to relapse-related factors. An addiction treatment professional who is in a position to receive reliable and timely information about how much sleep a person is getting can stay one step ahead of a potential incident waiting to happen.

As important as it is for healthcare workers and their clients to have in-person, face-to-face conversations about recovery, this is not always possible, but apps allow clients to document their thoughts, feelings, and experiences in as much detail as they want for presentation during a therapy session. This should not be seen as a replacement for one-on-one consultations with their healthcare professional, but the technological application of smartphone apps has been warmly received by the healthcare community. The Patient Healthcare Questionnaire, a “valid and reliable measure of depression severity” in the words of the Journal of General Internal Medicine, can be downloaded as a free app from major digital distribution services. The JMIR Mental Health journal suggests that the digital version of the questionnaire might yield better data regarding a client’s mental state (especially in terms of the client having suicidal ideations) than scores derived from the standard questionnaire.

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The Potential for Addiction Treatment

It is this kind of facilitation that puts telemedicine in a position to offer “great potential for enhancing [addiction] treatment and recovery,” said the Addiction Science & Clinical Practice journal. While admitting that the use of telehealth services in recovery is limited, the ability of the technology to surpass time and distance limitations makes it a vital tool in the armamentarium of treating substance use disorders. Additionally, telemedicine and the Internet allows doctors and other clinicians to more easily stay in touch with patients after treatment, further strengthening the connections between treatment guidelines and the challenges of daily life.

Between February 2013 and June 2014, researchers writing for the journal investigated how telemedicine services (covering telephone-based care, web-based screening and treatment, videoconferencing, smartphone apps, and virtual worlds) were adopted and implemented by people who used those services in five states and one county. The study found that people who used those services were most interested in the videoconferencing and smartphone apps. Key drivers of what makes a successful telemedicine app include the money required to pay for the service (which was also one of the barriers), success stories, and the ability of the apps to meet an urgent need. Other barriers to a successful telemedicine app include a lack of reimbursement for the services, unfamiliarity with the technology, a lack of other successful models (since, as the researchers said, addiction telehealth services are limited), and confidentiality restrictions.

The researchers concluded that although there were implementation challenges, there is considerable interest in using telemedicine and the Internet as an extension of addiction treatment.

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Telemedicine and Rural Areas

A similar consensus was reached by the National Association of State Alcohol and Drug Abuse Directors, which conducted its own study in 2009 on the topic of “telehealth in state substance use disorder services.” The association wrote that telemedicine shows a lot of promise for providing services that cover addiction prevention, treatment, and recovery. The study also found that patients were very satisfied with their online experiences, on a level comparable to that of the traditional treatment format.

Telehealth has proven so valuable for rural areas that there are now federal grants to increase access to digital health platforms in underserved areas. The Office for the Advancement of Telehealth, part of the Health Resources & Services Administration, specifically provides funds to invest in the development of telehealth services in remote areas, which, when it comes to substance abuse treatment, lack basic services and experience low adoption of what services are available. Additionally, the Substance Use & Misuse journal notes that “rural clients are more geographically dispersed,” and have limited transportation options, making attending meetings and checking in for treatment prohibitively difficult; other research has found that shorter travel distances make for better completion rates of an addiction treatment program. Furthermore, rural areas often do not have specialized substance abuse services, like programs that cater to women, LGBT populations, or ethnic minorities, which may dissuade some people from seeking help, especially if they live in a culturally conservative region. With rural areas having fewer facilities, people looking for treatment may not find the anonymity and confidentiality they want from their addiction recovery.

Factors like these are what makes telehealth “especially critical in rural areas,” especially those that do not have adequate specialty care services, according to the Office for the Advancement of Telehealth. Outside St. Louis, for example, doctors and nurses work night and day at nonprofit healthcare provider and hospital system’s Virtual Care Center. Called “a hospital without beds,” the facility provides long-distance support for ICUs, emergency rooms, and other services in 38 smaller hospitals, located everywhere from North Carolina to Oklahoma. Most of them don’t have a doctor on site or on call, but the connection provided through the Virtual Care Center ensures that a healthcare professional is always available.

The DC Experiment

Even in more urban areas, particularly those that have been badly hit by the national opioid epidemic, telemedicine is being used in research projects to help low-income clients. A research project conducted in Washington, DC, between Dr. Edwin Chapman and Howard University’s Urban Health Initiative, found that the doctor’s patients – all long-term users of opioids – were receiving the buprenorphine they needed to manage their physical craving for drugs, but did not have access to the care and counseling they also needed. Working together, Dr. Chapman and the university developed a shared electronic health record platform, which, with the patients’ consent, shares relevant health data with primary care and behavioral health providers. A different telehealth program allows for Chapman’s patients to see him and a behavioral health specialist during the same office visit.

The whole project is funded by a grant from the Washington, DC Department of Health, with an eye on reducing the cost of addiction treatment.

There is the hope that if Dr. Chapman’s project proves effective in increasing access to the fuller range of addiction treatment options, thereby lowering the number of relapse incidents and in turn reducing treatment costs, that more private insurers will sign on to adopt telemedicine outreach and coverage. Doing so, says Addiction Professional, will be part of the overall solution to improve addiction treatment through the digital medium.

Telemedicine and Addiction Treatment Reform

The idea of using telemedicine and the Internet to improve the general landscape of addiction treatment is a buzzing topic in the industry, writes Hit Consultant. Efficacy matters, especially when it comes to insurance organizations, which include the federal government. For privacy reasons, addiction treatment providers tend to not have the kind of data that insurers like to have, and the question of how best to measure the success of addiction recovery (with there being so many potential relapse triggers, not all of which can be accounted for) is an often debated one. This has led to a disconnect between insurance providers and addiction treatment providers, says Health Data Management, which quotes the CEO of a data analytics vendor that specializes in behavioral health. It costs $560 billion a year to treat addiction in America, and insurance companies are hesitant to offer inpatient addiction treatment coverage because there is no standardization of what success looks like and what relapse look like.

Telehealth could change this. The ability to monitor the effectiveness of treatment among addiction patients could make the treatment and rehabilitation industry more cost-effective than it has ever been, so much so that almost half the number of states in the country have passed laws that require insurers to offer coverage for telemedical services. Telehealth will be a “crucial tool for substance abuse treatment,” in the words of Health Data Management, because of the way it will force substance abuse treatment providers to adapt to videoconferencing, smartphone app development, and other services on the spectrum of telemedicine. Those who can make the transition will be able to reliably and effectively communicate with clients between visits, and held to a higher standard of accountability.

Concerns about Telemedicine

For all the benefits of telemedicine and addiction treatment, there is concern that not every change the field brings is a welcome one. The Wall Street Journal wonders if patients are being forced to trade quality of care for convenient care. Skeptics of telehealth worry that the healthcare system is fragmented enough, and allowing patients – especially those in substance abuse recovery – the freedom to turn vital in-person meetings into more flexible virtual meetings diminishes the necessary accountability and discipline that are hallmarks of an effective treatment regimen. Additionally, for all the data that a smartphone app can collect, a clinician can’t be expected to thoroughly evaluate a client through a screen.

The Journal cites a study published by JAMA Dermatology, where researchers posed as patients using 16 telemedicine services and reported numerous misdiagnoses of serious conditions, “largely because [clinicians] failed to ask basic follow-up questions.” One of the lead authors of the study acknowledged that “telemedicine holds enormous promise,” but fears that the current state of the field is not ready for a mass rollout, especially to vulnerable treatment populations. Even the American Telemedicine Association warns consumers to be on the lookout for fraudulent telehealth providers.

The industry is moving to meet these challenges. In 2016, the American Medical Association approved new ethical guidelines for telemedicine providers, and called for participating doctors to base their recommendations with the limitations of telemedicine and the Internet in mind. But there is dispute as to what those limits are. Private telemedical providers can have very different approaches than those laid out by the Centers for Disease Control and Prevention, and there is no current rubric to find common ground.

Who Pays?

The question of payment also raises some concerns. While there is much promise about how telemedicine will make addiction treatment more demonstrably cost-effective, insurers tend to be less willing to pay for telemedical services when doctors use phones, emails, or videoconferencing to consult with patients. A neurosurgeon and medical director of distance health at the Cleveland Clinic put it simply: “It’s very hard to get paid unless you physically see the patient.”

Over 30 states have passed “parity laws,” which require private insurance companies to reimburse doctors for telemedical services if the same service would have been offered in person. However, Medicare is not quite there; only a small number of telehealth services (beneficiaries in rural areas, and only when the services are delivered in a licensed healthcare facility) are covered by the government’s program.

Regulating Telemedicine

How telemedicine and addiction treatment over the Internet should be regulated presents additional challenges. Regulation of healthcare has usually been left to individual states, but with telehealth presenting the opportunity for a counselor in one state to work with a client in another, rules, licensing fees, and even the understanding of what constitutes “medical practice” get very muddled. As it stands, doctors must be licensed to practice medicine in the state where the patient is located; this means that telemedical providers (and their doctors) can only connect individuals with doctors who are licensed locally. For virtual medical centers that attract patients from neighboring states (or patients from across the country), this can create numerous administrative problems.

For example, doctors at Mayo Clinic can treat out-of-state patients by phone, email, or instant messaging when the patients return home, but only the conditions that were discussed in person can be treated this way. The director of the clinic’s Connected Care program told the Wall Street Journal that if a patient wants to discuss a new problem, the doctor has to be licensed in the patient’s home state to discuss it in their professional capacity. If the doctor does not have that certification, then the patient will have to talk to their primary care physician.

Trying to Define Telemedicine

So far, 17 states have agreed that a doctor licensed in one member state can quickly obtain a license to practice medicine (and offer virtual diagnoses to patients) in another. The American Telemedicine Association has welcomed the move, but the group’s CEO has pressed for a further step – that of automatically honoring licenses across states (much like how driver’s licenses are immediately valid across state borders).

Medical practice (and addiction treatment under it) is much more complex than simple driving regulations, and states are unlikely to give up the control they have over their local mental health and substance abuse specialists. Instead, more states are considering new regulations. In 2016, 42 states introduced more than 200 bills related to telemedicine, most of them regarding the scope of Medicaid services and whether insurance should reimburse for remote patient monitoring, as well as so-called “store-and-forward technologies” (which is when patients and doctors send each other images and notes at different times) in addition to real-time videoconferencing, telephone calls, and instant message chats. The chief advocacy officer for the Federation of State Medical Boards points out that “a lot of states are still trying to define telemedicine.”

Giving Medical Advice Digitally

The lack of definition leads to another roadblock on the telemedicine path, especially in a field as evolving as that of substance abuse treatment: What exactly constitutes the practice of medicine? For example, some online telemedicine services allow clients to consult with practitioners overseas, like in Europe; the doctors are not licensed to practice medicine in the United States, but the services have disclaimers that clarify they are offering only information and not medical advice. For clients desperately in need of specialty treatment, the distinction may not be apparent.

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The CEO of one such company, which puts clients in touch with a “board-certified dermatologist” within 24 hours of uploading a picture and description (for $25) clarifies that his service does not fall under the umbrella of a doctor-patient relationship since both parties remain anonymous during the interaction. Another telehealth provider states that the conversations between users and doctors are only “social interactions”; any discussion beyond those parameters costs $39.

The Wall Street Journal wonders if a medical license is required to practice telemedicine, and many states and their respective medical boards have the same question. Boards have jurisdiction over individual doctors who are licensed in their states; this does not extend to companies or overseas clinicians.

The Human Touch over a Touchscreen

Some concerns about telemedicine through the Internet are much more basic, reminds US News & World Report. No matter how ubiquitous, advanced, or user-friendly the technology, it is only as reliable as having an electrical current. Take that away, due to anything from a hurricane to a dead battery, and a client in need of a consultation with an addiction sponsor might have no way of asking for help.

Similarly, some doctors aren’t convinced that the efficacy of telemedicine is worth giving up the human touch. In a 2011 TED Talk, Dr. Abraham Verghese spoke about the “transformative, transcendent” nature of the patient-physician relationship, and his fears that technology will turn patients into mere data points. Six years later, Dr. Verghese told a Medscape town hall event on “Technology, Patients, and the Art of Medicine” that the right balance of in-person and telehealth services is an “absolutely” necessary advance in medicine.

Given the pace of technological development and evolution in the science of substance abuse treatment, the question of implementing telemedicine may come more down to “when and how,” and not “if.” Thomas Nesbitt, the associate vice-chancellor for technology at the University of California Davis Health System, told the New Yorker that telemedicine isn’t about the technology; “it’s really about a new model of care,” one that ensures an ongoing line of communication between the patient and the doctor outside of scheduled appointments. In this light, it is possible that addiction treatment through telemedicine and the Internet might bring the human touch to the touchscreen, and give people suffering from substance use disorders a new lifeline on their road to recovery.

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