Dan Gorenstein: While many of us have focused on the pandemic, another massive public health emergency has steadily gotten worse. 

Deaths from opioid overdoses jumped 40% last year.

COVID has made the opioid crisis worse, but it’s also offered providers a new tool: telehealth.

Now, policymakers around the country are debating whether or not to keep it around.

Allison Lin: You don’t want to risk this person dropping out of care because you know that the consequences of that are tremendous.

DG: Today, one state’s debate over rewriting its telehealth rules, and what we’ve learned about the value of treating addiction remotely. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

*****

DG: Allie Grant woke up conflicted on a cold, snowy Ohio morning in January 2021.

On one hand, she was excited. 

Allie Grant: I was happy I didn’t have to be in a house with eight other women. I didn’t have to share a room with somebody.

DG: The 24-year-old had spent the last six months living in a tightly controlled court-ordered group home.

Now she had moved in with her fiancé.

AG: It was nice being able to lay next to somebody who I love, who I’m getting ready to have a family with.

DG: But Alllie was scared.

Scared of her newfound freedom.

Scared she’d slip back into addiction.

As she lay in bed that morning, she realized she had two choices.

AG: I could either go out and go get high, or I could wake up, go get me a cup of coffee, and log on to my Zoom and talk about it. 

DG: That choice — to get addiction treatment from home — was incredibly rare before the pandemic. 

A federal law called the Ryan Haight Act generally required providers to see a patient in-person before they could start on buprenorphine, a common medication for managing opioid use disorder.

And Medicare, Medicaid and commercial insurers rarely paid for any virtual care.

As a result, less than one percent of treatment for opioid addiction took place remotely.

COVID changed all that.

By May 2020, one-third of this care had moved to telehealth.

Since then, thousands of people, including Allie, have been able to get their medication, check in with their doctors, and go to counseling with just a phone or internet connection.

AG: There’s been a lot of times where my vehicle is broke down, where I may not feel good, but I still mentally, I still want to have the opportunity to have some sort of recovery in my life. Zoom and telehealth is what gave me that. And that’s how I believe it saved my life.

DG: Allie’s been in and out of treatment for years, but it’s never stuck. 

Now, she’s been sober for more than a year — her longest stretch.

Getting pregnant last fall gave her a whole new kind of motivation.

And she says telehealth made it easier to hold herself accountable and stick with her treatment. 

AG: As soon as I started to doubt myself, you know, I just couldn’t because my phone’s right there in my hand. “Okay, well, why can’t you just get on your phone and just come on, just dial into Zoom?” Even if I only had my pajamas on, and I look like crap, it didn’t matter. 

DG: And Allie was struck by the lengths the people on the other side of those calls were willing to go to help her — to battle her cravings, to manage her triggers, to make sure her meds were working. 

AG: Some days, if the truck would break down, they’d be able to work with me. Being pregnant, I didn’t want to come and sit right next to somebody, they don’t blame you at all. “Just log on to Zoom with us.” It was just like a sense of, “Oh wow, somebody actually cares.”

DG: One of those people caring for Allie was Sarah Channell.

Sarah Channell: I think Ali is a great example of now with telehealth, you can meet people where they’re at.

DG: Sarah is a nurse practitioner at Lower Lights Christian Health Center, a safety net clinic in Marysville, Ohio, about 30 miles northwest of Columbus. 

Allie is one of 110 patients Sarah sees each month for their opioid use.

She prescribes buprenorphine and works with people to control their addiction.

Many of Sarah’s patients are low-income, working hourly jobs.

And Sarah has found herself doing a lot of video visits from inside local factories.

SC: They’re like, “Just a minute, I have an appointment with my doctor.” And you watch the video as they walk down the line or into a bathroom or into a locker room.

DG: Once they settle into a quiet, private spot, Sarah is able to do the virtual visit and have them back out on the factory floor in 15 minutes.

SC: The flexibility of being able to provide telehealth has really enabled a lot of people to stay committed and to stay connected with the services that we offer.

DG: But not everyone in Ohio is as gung-ho about telehealth.

It’s been a hot topic at the State Medical Board’s live-streamed meetings the last few months.

Board Meeting: The thorny question of telemedicine…
Board Meeting: Lots of questions around telemedicine…
Board Meeting: Let’s move into telemedicine…

DG: The board’s main concern was whether quality of care was worse with telehealth.

Here’s how one board member put it back in August.

Board Meeting: There’s nothing like seeing the patient like, Dr. Reddy said, examining the patient, talking to the patient in person. It makes a difference.

DG: Lots of people share this concern in Ohio and around the country.

Many providers told us they can build more trust face-to-face, pick up on subtle body language cues, and test their patient’s urine to make sure they’re taking their buprenorphine and not taking other drugs.

In a national survey last fall, 70% of addiction specialists said they would prefer to do the majority of their care in-person after the pandemic.

And in June… 

Board Meeting: Is there motion? 

DG: …the Ohio medical board voted to once again require doctors to administer buprenorphine and meet with patients in person starting in September.

Board Meeting: Dr. Rothermel.
Yes.
Dr. Saferin.
Yes.

DG: But after a year and a half, many providers have come to see telehealth as invaluable.

In that same national survey, 62% of providers said they could offer the same level of care virtually, and 95% said some form of telehealth should be an option going forward.

Sarah Channell embodies this fundamental tension.

She prefers to do a patient’s first couple of visits in the office.

But the threat of losing the option to do virtual care scares her.

SC: I worry that it’s too difficult to come to the office for every appointment, and we’ll see more relapses, we’ll see a spike in overdoses and people will die. 

DG: After the board’s June vote, providers pushed back, urging the board to keep telehealth in place.

At its November meeting, the board reversed course without backing down.

Board Meeting: We know that telehealth is here and we know that telehealth is here to stay and we continue our mantra that we need some guardrails put back into telehealth. 

DG: Board members want to add guardrails onto legislation that appears set to give providers in Ohio the green light to offer telehealth permanently.

Which raises the question: Is there research that can tell policymakers what those guardrails should look like?

When we come back, we dig into the evidence — what we’ve learned and what we still don’t know about telehealth and addiction treatment.

MIDROLL

DG: Welcome back. We just heard about a situation in Ohio that’s playing out in other states and at the federal level — providers, patients and policymakers are all trying to figure out where to redraw the lines when it comes to telehealth and substance use disorder treatment.

Now we’re going to talk to a researcher who can help put that debate into context.

Allison Lin: Hi, my name is Allison Lin. I am a addiction psychiatrist at the University of Michigan and the Ann Arbor VA, and I also work as a researcher, as a research scientist for the VA Ann Arbor Healthcare System.

DG: And you are an early adopter in prescribing buprenorphine to patients via telehealth. 

AL: Mmhm. That’s right. I have been using telehealth within the VA system for about the last four or five years. 

DG: In 2019, Allison and her colleagues reviewed the limited research in this area.

There were just a handful of studies covering opioid use disorder, but the findings were promising.

AL: All of these studies seemed to indicate that telehealth delivered substance use disorder care was no less effective than in-person care. Patients seemed to stay in treatment about the same length of time as in-person care. However, we don’t have the type of gold standard studies that we would love to have, which are these large, randomized controlled trials.

DG: So, Alison, I know these more relaxed telehealth rules have been in place for just 20 months, which is nothing in research terms. But it seems like there are at least two key questions that we should probably now have some answers for.

And the first is how well did telehealth work to keep people in treatment? 

AL: So that is a really important question. And you’re also right that this is a very short period of time. But I think we’re already starting to get some data from research indicating that the overall number of patients being treated has probably remained fairly stable. And although that doesn’t seem earth shattering, I think when I say it, it is really important because these are the folks that I think we were all worried about at the beginning of the pandemic that would have been the exact group that would have stopped care. 

DG: And then what about this next question: Has telehealth been able to expand treatment to more people? Because again, you would think telehealth, convenient — this is going to make it easier to get?

AL: So I think this is a question that a lot of us are wrestling with right now, and I don’t think we have enough data yet. Anecdotally, though, we are continuing to see new patients in care, some of whom are telling me that telehealth has actually made it a lot easier for them to get treatment. In some of our preliminary data that has not been peer reviewed yet, we’re actually finding that the number of patients who are receiving opioid use disorder treatment has increased almost 15%. That includes both new patients as well as patients who are staying in treatment longer. 

DG: Allison says more studies are needed to confirm these early findings.

And then build on them.

Which patients respond best to virtual care? 

What’s the right balance of in-person, phone and video visits?

Researchers have started asking these questions, but we’re a ways out from having definitive answers.

AL: Hopefully what we’ll see in a post-pandemic time is really the ability to match these preferences and offer more choices and to really have the data to guide who might do well with what.

DG: So, Allison, you seem pretty bullish on telehealth.

But there are some real concerns.

Like how telehealth could make it easier for docs and nurses to commit fraud.

And we saw this 40% jump in opioid overdose deaths last year. 

That’s something one member of the Ohio State Medical Board jumped on at their August meeting.

Board Meeting: Overdose deaths are soaring, right? We have telemedicine now. They have access now. You would think it would be going down or leveling off, but it’s hockey sticking and soaring up.

DG: So, Allison, do we have any data on why we’re seeing this jump in overdose deaths?

AL: We have to remember that over the last year and a half, what we’ve been doing is trying to address the epidemic of addiction within the setting of a pandemic. And we were never expecting that telehealth was going to somehow dramatically overturn an overdose epidemic because there are so many factors contributing to it. We know that the vast majority of people overdosing these days, it’s due to the types of substances that they’re using, the potency of them. And there’s nothing about telehealth nor the pandemic that’s necessarily made that any better. In fact, all of the other things that have come with the pandemic, the things that we all worry about when it comes to generally how people have been doing, those have gotten a lot worse.

DG: Another big concern people have is around accountability.

We talked about this in the first half of the show, Allison, that some providers feel like it’s a lot harder for them to know if their patient is struggling or potentially using drugs again without being able to test their urine, which is obviously harder to do remotely.

How big of a concern should this be?

AL: I very much empathize with the concerns. We have seen a study that’s been published with early pandemic data that has shown decreased frequency of urine toxicology screens. But we currently don’t have any idea how that’s impacted outcomes. One thing that we forget is that we’re not measuring outcomes by whether or not someone uses a substance or not one day to the other. We know that these are chronic diseases. People are going to have lapses and relapses. More important is trying to keep people engaged in care, coming back to talking to us, being honest and telling us what’s going on with their lives so that we have the opportunity to help them.

DG: I want to zoom out for a second, Allison, and take stock of what you’ve said.

One on hand, the early evidence is pretty clear that telehealth has helped people stay in treatment during the pandemic and even broken down some barriers to allow more people to get help.

But more research is needed, and there are doctors who are concerned about whether virtual care is as good as in-person.

The State Medical Board of Ohio talked about wanting to put “guardrails” back into telehealth.

Based on the evidence, do we need some guardrails here, and if so, what are one or two specific examples you would recommend lawmakers put into place?

AL: I honestly am not sure. To date, the evidence or the data that we have is more promising than concerning. It’s totally understandable for there to be concerns. However, that’s balanced by the knowledge that there are also patients receiving care, getting into treatment for the first time via telehealth. And we have to make sure that we can sustain care for those folks as we’re gathering data. What we really need is data on how patients do with telehealth and how that compares to traditional in-person care. How is their substance use outcomes? What about hospitalization rates and overdose rates and things like that?

DG So, Alison, what is the one idea or fact that we have now learned, what’s the one thing we can definitively say that we know that we did not know before the pandemic that you think policymakers need to hold in their minds?

AL: I think it’s simply that we’ve been able to treat patients in a completely different way of delivering care. And we’ve been able to keep patients in care in a pandemic who are most likely to have suffered the impacts of the pandemic. I think that alone suggests that we need to further evaluate this and think about how to use this momentum to further improve care.

DG: Allison, thank you so much for taking the time to talk to us on Tradeoffs. Really appreciate it. 

AL: Thank you. I really enjoyed it.

DG: It seems like insurers are coming around to the idea of telehealth. 

Medicare even just announced it would continue paying for virtual addiction treatment including phone visits. 

Some states, like Delaware and Indiana, have passed new laws making it easier for docs and nurses to offer this care.

But others — South Carolina, Florida, Iowa — they’re back to their pre-pandemic restrictions 

Most states, like Ohio, are in limbo.

What they do will depend in part on whether the DEA goes back to requiring providers to prescribe buprenorphine in-person. 

And whether Congress passes legislation to expand telehealth. 

With all this is up in the air, Allie Grant from Columbus, Ohio, just hopes policymakers remember one simple thing. 

AG: If you take it away, you could be taking a lot of people’s sobriety away.

DG: I’m Dan Gorenstein, and this is Tradeoffs.