Hanging on: Covid gave Louisiana’s addiction patients life-saving drug treatment by phone
Hanging on: Covid gave Louisiana’s addiction patients life-saving drug treatment by phone
By Christiaan Mader, The Current, October 28, 2020
Photos available here. Photo credit: Travis Gauthier
Julie Kerry spent two decades in pain before doctors diagnosed her with breast cancer in 2019. The pain had started with fibromyalgia and scar tissue on her brain from a seizure-inducing condition called mesial temporal sclerosis. Relief was easy to come by — a former partner saw to that. Four years later, she was buying hydrocodone on the street. But after years of harboring a corrosive shame about her addiction, she finally had enough. Seeing the wonders treatment worked on her daughter’s addiction, Julie got help.
“I just couldn’t fight it anymore. I just couldn’t provide the relief for myself that I needed anymore,” Julie says. “I just went for it. I just did it. I went one day and just said, ‘Here I am, I need help.’”
At Longleaf Hospital in Alexandria, 25 miles south of her oak shaded property near Colfax, Julie enrolled in an intensive outpatient program that featured counseling and medication-assisted treatment with an opioid substitute drug called buprenorphine. She found compassion in their care.
“I guess, the very first thing I have to say is, from the moment I walked in there, I never felt judged,” Julie says. It was March 2020. Coronavirus struck. By the end of the month, Louisiana shut down.
The pandemic has been deadly for those already suffering with opioid use disorders. Drug-related deaths may have doubled in Louisiana, according to preliminary data, says Karen Stubbs, assistant secretary of the state’s Office of Behavioral Health. Louisiana reported 104 drug deaths in May of last year and 185 in May of 2020. That parallels national data detailing an opioid overdose spike of 40% that same month.
Considering the timing, you’d think Julie Kerry unlucky. But she walked into Longleaf Hospital at the exact right time.
To begin with, she had access to buprenorphine. Statistically speaking, it saved her life. Buprenorphine is shown to reduce the risk of overdose mortality by half. The care she received was compassionate and, because Longleaf takes Medicaid, affordable.
Perhaps more significantly, emergency changes to federal and state telehealth regulations allowed her to pursue care remotely by phone — sparing her the threat in-person treatment posed to her immune system, suppressed by chemotherapy. During the pandemic, she could call in for group counseling sessions and check in with her provider to manage her meds and track her progress.
It was wonderful, she says.
Buprenorphine is a relatively safe drug. It’s difficult for patients to overdose on, which makes management outside of a clinical setting safer. That also mitigates the potential risks associated with offering the treatment remotely.
In 2016, Louisiana took the Medicaid expansion funded through the Affordable Care Act, adding greater eligibility for the state’s working poor. More and more people with opioid use disorder have gotten help as a result. As of October 2020, approximately 25,000 Louisianans insured through the Medicaid expansion were enrolled in some form of medication-assisted treatment for opioid addiction, a 25-fold increase. But there’s likely a long way to go. Addiction researchers estimate only 20% of those who need help with substance abuse get it, and that’s despite large-scale efforts to get over conventional barriers.
Cost, of course, is a big one. The Office of Behavioral Health is trying to solve that problem by paying stipends on top of Medicaid reimbursements through a multi-million-dollar grant program funded by the federal government. But the reach so far is limited, Stubbs says, even as it’s growing with a second round of grants on the way. Providers are still rare and mostly concentrated in urban areas. And in most cases, they charge cash for the visit, often as much as $150 or more.
“The vast majority of treatment providers are charging cash, right? And so basically, you know, we came and used methods that are used in other states, which is that we’re going to take insurance for it, we’re going to get people into an [intensive outpatient program], get them doing well, and then get them to an outpatient center,” says Dr. Chris Rodgman, a board certified psychiatrist and addictionologist who directs the intensive outpatient program at Longleaf.
Getting to the IOP was a real problem for Julie. Medicaid would pay to send her a van to and from weekly appointments and drug screenings. But that would mean hours shuttling around central Louisiana with a debilitated system while the service scooped up other riders in the middle of a pandemic.
Because of those emergency telehealth changes, Julie didn’t have to brave a death trap. She could call in. And she could keep calling in for routine office visits after she graduated from the IOP.
These were simple changes that could make a big difference, even after the pandemic is over.
Across the board, telehealth visits skyrocketed shortly after the lockdown. In January and February, Louisiana’s Medicaid office reimbursed around 3,000 telehealth claims. In March, 81,240 claims were filed. In April, that number swelled to 264,029, according to preliminary data collected by researchers at Tulane University. And anecdotal evidence suggests many of those visits happened over the phone.
Telehealth wasn’t new for Medicaid, says Dr. Marcus Bacchuber, medical director for Louisiana’s Medicaid program. But before the pandemic, options were limited, particularly for addiction, by technology requirements — HIPAA-compliant video apps only. The staggering volume suggests untapped potential.
“I think the lesson there was that coverage of telehealth doesn’t lead to utilization,” says Bacchuber.
Gradually, Julie worked her way through the Longleaf program by phone, weaning the frequency of her appointments, from weekly, to bi-weekly, to monthly. Now she sees her provider, a psychiatric nurse practitioner with an outpatient addiction clinic called Axis Behavioral Health and Recovery, which also takes Medicaid, in “office” visits by phone. Rodgman is also a clinician with Axis, on top of his work at Longleaf.
Longleaf and Axis are filling a big gap. Rural Louisiana desperately lacks primary care. Patients have to travel long distances to get basic medical needs met. It’s even trickier to deal with maintenance-intensive diseases like opioid addiction. The OBH grant program — called Louisiana State Opioid Response — is directing roughly $18 million from the federal government to test a “hub and spoke” model pioneered in West Virginia, which deploys clinics (“spokes”) as de facto outposts for opioid treatment centers (“hubs”) that offer the full range of opioid treatment options. That program is just getting off the ground, expected to reach about 1,400 people in its first two-year round, which ends in 2020. Longleaf and Axis mimic that arrangement, in effect, but aren’t part of the OBH program.
Grant Parish, where Julie lives, has eight doctors. Two are primary care providers, five are in mental health and one is a dentist, according to data compiled by the Federal Communications Commission to crossmap broadband and healthcare access.
Homes nestled into trees around rural Grant Parish, an area with few medical providers.
“I have a primary care physician that’s in my area, but unfortunately they can’t prescribe it,” Julie says.. Buprenorphine, as safe as it may be, is a controlled substance, requiring DEA waivers to prescribe. The only buprenorphine subscriber in the area, she says, just takes cash.
Telehealth is heralded to solve the distance problem in healthcare delivery, connecting patients to providers miles away from them. But as the numbers show, it didn’t. The pre-pandemic rules for requiring video visits made broadband internet a must. Grant Parish is behind on that, too. Only 38% of households there have fixed, high-speed broadband. For a lot of people, a phone is the only option.
And getting to treatment isn’t just a problem for people in rural areas, says Dr. Antiqua Smart, a nurse practitioner and assistant professor of nursing at Loyola University in New Orleans. Smart now works part-time with AppleGate Recovery, a network of clinics with offices around the state, and she quickly transitioned during the pandemic to treating patients in Metairie by phone from her office in Baton Rouge. Some of her patients don’t have smartphones or computers, or they travel in from outlying parishes for treatment. Most have limited income, some getting the cost covered by OBH stipends. But the demand outstrips the supply, Smart says, and any extra cost burden can dissuade care. When she was still doing in-office visits, Smart had a patient who was paying a friend for rides to the clinic.
“So it was really costing him more money than what he really had just to even get to the visit in person,” she says. He’s now keeping his appointments by phone.
Keeping appointments is a big deal. Medicaid insured patients are said to have a 50% “no-show rate” in behavioral health. In other words, 50% of appointments aren’t kept.
There are any number of reasons why patients miss appointments, particularly among those treated for opioid addiction. But it generally comes down to those same access barriers — few doctors, high costs, long distances. Video-based telehealth wasn’t reaching those people. But it looks like phone-based care is.
Longleaf reported a 25% decline in no-show rates, and a 4% decline in hospital readmission among its addiction patients — that roughly translates to fewer overdoses. In Lafayette, the Acadiana Human Services district, which provides comprehensive behavioral healthcare — including addiction treatment — reported that its no-show rates declined to below 10%. A network of primary care clinics in Avoyelles Parish, which began offering buprenorphine treatment earlier this year, reported anecdotal reductions, too.
But declining no-show rates speak mostly to access. Critics say telemedicine may fall short in quality of care. Conventionally, counselors of all kinds rely on visual cues to work with their patients. A philosophical commitment to high-touch relationships is at least partially why providers were slow to come on board with telehealth generally.
“It is nice to really see the patient. You can’t really do vital signs per se [remotely]. That’s the deal with telemedicine, period,” says Smart, who describes herself as “progressive” in her field with respect to her treatment philosophy and in her embrace of telemedicine. “I can ascertain things just through their voice and inflections. I can tell when they’re down, especially because I have a rapport with them.”
With addiction, it might make sense that a phone call could make it easier for patients to deceive providers. Rodgman notes the baffling and extraordinary things the addiction-addled mind will drive otherwise level-headed people to do. But he points out that risk is baked into working with addiction patients regardless, especially when treating them with an opioid substitute like buprenorphine, which can become a street commodity.
“It’s a version of a controlled substance. …That’s kind of the main risk. Is this person doing something that they shouldn’t be doing? Yeah, it’s possible. It’s always possible.” Rodgman says. “Typically, we’re not going to catch them.”
That puts a lot of emphasis on trust and intimacy. Rapport is key.
In Julie’s case, as with many others, she was already in treatment when the pandemic forced her to call in remotely. But among the major changes pushed through at the head of pandemic were temporary waivers allowing providers to take on new patients without seeing them first, a stipulation previously carried with the old telehealth rules. By and large, providers prefer to meet patients for the first time face-to-face. There is little data supporting that more people have entered treatment because of these changes. But that’s part and parcel of how novel telehealth is in addiction medicine. Coronavirus forced a change that providers and researchers only flirted with before. Scrutiny of a much larger set of data is to come.
“If you think about it, it’s kind of a tricky question and so you’re like, ‘Is telemedicine good?’ Well, OK, so what’s the reference point? Is the reference point an in-person visit? Well, maybe it’s not as good as an in-person visit. Maybe it is, but maybe not,” says Bacchuber. “But during COVID, it’s like, ‘Well, maybe the reference point is no care at all.’ So it is a lot better than no care at all. I don’t think anyone would argue with that.”
Politicians have taken notice generally of the role telehealth has played during the pandemic. U.S. Sen. Bill Cassidy of Louisiana, a physician who has advocated ending the ACA, co-authored a bi-partisan bill directing federal health agencies to inventory telehealth initiatives to figure out what worked during the pandemic for application in future health emergencies.
But Republicans and Democrats alike appear to be overlooking a fix that could cost nothing.
Many buprenorphine proponents have taken notice of the reach extended by the emergency phone waivers. A group of addiction researchers and practitioners from prestigious institutions is pushing Congress to include audio-only (read: phones) buprenorphine treatment in another bi-partsian bill, this one drafted to make permanent those telehealth emergency changes issued at the pandemic’s headwaters. The bill in question, introduced in June, leaves phones out. Don’t wait till we solve the digital divide, the researchers argue, a workable, inexpensive solution is at hand.
Neither phones nor video calls can replace face-to-face visits, most providers say. But an array of tools is needed, and that includes offering treatment by phone.
That’s another way Julie Kerry is lucky. She has options and a supportive family. The internet beamed into her trailer by satellite is good enough to stream video. But she mostly checks in with her nurse by phone. Without those options, she would have faced a tough choice at the beginning of her treatment. Instead, months later, she’s still calling in for her appointments with the occasional trip to the doctor in town to put in a urine sample for a drug screen.
It’s October. And she’s awaiting her mastectomy. Traveling to appointments still isn’t safe, though she has no choice for chemo. Her daughter, also calling in for addiction treatment, visits often with her new baby. Her boyfriend Maurice keeps her spirits up. It’s been a rough couple of weeks since Hurricane Laura tossed live oaks around her trailer like twigs, Julie says. She was 12 days without power. It’s back on now. She’s still with the program, and doing OK.
