Using Telemedicine to Treat Opioid Addiction
Using Telemedicine to Treat Opioid Addiction
By Tina Rosenberg, New York Times, August 4, 2020
Getting medication long meant seeing a licensed provider. Now a strategy for evading Covid-19 makes treatment available via the web.
Covid-19 has made life much harder for people with opioid addiction. But the response to the virus has also revealed a way forward that could radically expand effective treatment and reduce overdose deaths.
Until now, getting effective treatment depended on where you lived. Forty percent of American counties — much of Appalachia, for example — have no providers licensed to prescribe buprenorphine, the most successful treatment so far.
But the pandemic has made it possible to see a licensed provider from home, and that could make buprenorphine treatment available anywhere.
Michelle (she asked me to not use her family name) is 57, lives near Wilkes-Barre, Pa., and works from home as a customer service representative. Her computer allows her to live a good life — after eight years on heroin that followed many years on other drugs.
Over the internet, she sees a psychiatric nurse practitioner, Roseanna Melle, who offers light counseling and prescribes the widely used drug Suboxone — a combination of buprenorphine and the overdose reversal drug naloxone. It blocks her cravings and prevents withdrawal symptoms, but doesn’t get her high. She feels … normal.
Before starting telemedicine in April, Michelle got Suboxone at a local addiction medicine clinic. “It was a revolving door — sometimes standing room only,” she said. “Who wouldn’t want to just do your appointment in the comfort and privacy of your own home?”
Robert, 30, another of Ms. Melle’s patients, from nearby Scranton, said: “Home treatment lessens the shame for me. I don’t have to worry what doctors around here think. My Suboxone — it’s just a medication. I don’t think about it. I just take it and go about my day.”
Ms. Melle is one of two — soon to be four — providers at a new telemedicine company in Pennsylvania called Ophelia. It’s one of several companies started in the last few years that prescribe Suboxone: Bicycle Health, Bright Heart Health, Workit Health, PursueCare, Boulder Care. Each is slightly different and they operate in different states.
The science is unequivocal: The only effective treatment for opioid use disorder is what is called “medication-assisted treatment.” Medication makes patients far more successful in treatment and less likely to overdose.
But at least 80 percent of people who could benefit from it don’t receive it. Some are deterred by the stigma still attached to taking Suboxone. But likely more important is the shortage of local providers. In 2016, the Obama administration increased the number of providers and allowed them to treat more patients. It’s still far from enough.
So people buy Suboxone from their drug dealer. “I bought it on the black market — a lot of people do,” Michelle said. “They sometimes try it because they can’t get their drug of choice. Or they’re thinking about getting clean, and they don’t have insurance and don’t want to go through the red tape.”
Ophelia’s medical director, Arthur Robin Williams, an addiction psychiatrist and assistant professor at Columbia University said, “It is easier for people to get the dangerous drugs than to get the treatment for addiction.”
Some clinics have been using telemedicine for the last few years, but patients still faced many barriers to treatment. The first visit had to be in person — which meant that access to treatment still depended on where you lived. Doctors were paid a pittance for telehealth appointments, so few doctors offered them. A patient could get only a week’s supply of buprenorphine at a time.
Advocates for treatment have campaigned to remove these barriers — unsuccessfully until Covid-19.
The pandemic has led to regulatory changes: Treatment can now be entirely virtual, including the first appointment. Medicare now pays providers the same for a video appointment as a conventional one — many insurers and Medicaid programs have followed. Patients can get a month’s prescription for buprenorphine instead of just a week’s.
These changes are temporary, but everyone I talked to wanted them made permanent.
“This has just catapulted through this crisis,” said Allegra Schorr, a Manhattan doctor and the president of Compa, a New York State coalition of medication-assisted treatment providers and advocates. “Now everybody’s doing it,” she said. “Within this environment, it certainly seems to be working.”
Prevention Point Philadelphia is among the largest harm reduction centers in the country. It offers syringe exchange, medical care, social services — and now, food. The majority of its patients are without homes, and most suffer from multiple mental and physical illnesses.
Prevention Point has offered medication-assisted treatment for 12 years and now treats 268 patients — many out of a mobile van. “We try to wipe out any barriers,” said Silvana Mazzella, associate executive director.
In mid-March, Prevention Point started prescribing Suboxone through telemedicine. But many of its patients can’t do the “tele” part. They don’t have phones or have no-data phones and can’t afford the airtime for an appointment. Prevention Point has given patients some donated phones with data and minutes of usage included, and is seeking more.
Ms. Mazzella said telemedicine has helped the patients who can use it. “It’s a reduction of the hassle, wait times, anxiety and fear of withdrawal in a waiting room,” she said. But the switch has also changed the foundations of treatment,” she added. “We have moved to more of a harm reduction model. We have taken away drug screens and things that feel punitive, things patients must do to prove they’re a good patient. We’ve removed the stigma and the power dynamic that typically exists in a clinic. We are putting the same level of trust in patients as you would with diabetes or hypertension.”
She said telemedicine patients have proven more likely to fill their prescriptions than patients who had appeared in person in the past.
Although Prevention Point doesn’t do video drug tests, other practices do. Ophelia sends Robert a kit. On camera, he unseals the box, which has test strips built in to identify buprenorphine and 11 other drugs. Then he fills a tube with saliva to be tested for the presence of opioids, fits the tube into the box so that the test strips can work and shows Ms. Melle the result.
Ophelia markets to consumers. It has 90 patients, all self-pay while the company waits to be accepted by insurance plans and Medicaid.
Some other telehealth companies offer therapy. Ophelia doesn’t, but neither do most doctors who prescribe Suboxone. Zack Gray, Ophelia’s founder, explained: “We want to make the barrier as low as possible for people to opt into treatment — then give them the choice to opt into therapy.”
Dr. Williams, the medical director, said: “When I first heard about Ophelia, I was terrified. I thought the idea was ludicrous.” He worried about doing proper clinical management over video.
Both Robert and Michelle, by contrast, said that their previous doctors had left them feeling rushed and judged, and that Ms. Melle knows them far better.
“Bringing this into the home may not be quite as robust and nuanced as in-person care,” but it is necessary, Dr. Williams said. “The U.S. has 40,000 to 45,000 people dying from opioid overdoses every year,” he continued. “We haven’t done anything at the level needed, and it’s been 20 years.”
