COVID-19 Drives Innovation in Addiction Treatment

Fran Lowry

December 14, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

With the onset of the COVID-19 pandemic, there has been a rapid uptick in virtual recovery programs and telemedicine counseling sessions for patients with substance use disorders (SUDs). New research shows that these programs are acceptable and effective alternatives to in-person sessions.

Study results from three research teams at the University of South Carolina School of Medicine Greenville (USCSM-G) show that SUD counselors in the state were satisfied with their experience with telehealth and virtual recovery meetings.

In one of the studies, five counselors who utilized a virtual meeting platform after the COVID-19 pandemic made in-person visits unsafe were surveyed. The respondents said they much preferred in-person meetings. However, they could also see that virtual meetings were filling an important need for their patients.

Two other studies echoed the results from the first. Clinicians who were leery of the new technology at first became more enthusiastic after they gained experience using it.

"We have lived in a society where there has been one right way, which has always been in-person meetings for recovery, such as Alcoholics Anonymous. It is a very structured process," lead author Haley Fulton, a fourth-year medical student at USCSM-G, told Medscape Medical News.

"The onset of COVID really upended a lot of things, but...now there may not be just one right way for recovery. There are alternatives to offer," Fulton said.

The findings were presented at the American Academy of Addiction Psychiatry (AAAP) 31st Annual Meeting, which was held online this year because of the pandemic.

Huge Need

"Virtual meetings may not be ideal, but some version of recovery is better than none. If we can make these meetings accessible to more people, this could promote recovery from substance use disorder," Fulton said.

There is a huge need for counseling, and past research has shown that failure to attend meetings can precipitate relapse in many individuals.

In Fulton's study, counselors were asked to describe how they perceived the efficacy of virtual recovery meetings compared with that of in-person meetings.

The investigators analyzed how often certain words, phrases, or issues came up during seven in-person recovery meetings held before the COVID-19 pandemic as well as observational data from seven virtual recovery-support meetings held during the pandemic.

On the pro side, the respondents cited convenience, comfort at home, and increased accessibility to counseling for patients.

In addition, because there was no need to travel, virtual meetings were cost-effective. Such meetings could expand the recovery world, inasmuch as individuals could attend recovery meetings in other parts of the country.

Perceived disadvantages included challenges involving technology, because learning new apps such as Zoom could be a problem for some patients. Distractions at home and lack of privacy were also cited, but for many, the most important drawback to virtual meetings was the lessening of emotional connection with others.

Impact on SUD Treatment

In a second study, another team from USCSM-G reported similar findings when it explored the impact of telehealth on counselors as well as on patients who were undergoing SUD treatment during the pandemic.

Elizabeth Whiteside

Led by fourth-year medical students Elizabeth Whiteside and Kyleigh Connolly, the researchers assessed data from a focus group of six behavioral health counselors representing rural and city agencies throughout South Carolina.

Themes that emerged included concerns about mental health ― counselors and patients were experiencing increased stress, depression, and anxiety.

"People had to now home school, there were job layoffs, increased responsibilities at home. Also, Narcan [naloxone] distribution was decreased, and this contributed to rising overdose rates," Whiteside told Medscape Medical News.

The focus group concluded that the advantages of telehealth included greater ability to accept new patients, an increase in scheduling flexibility, and cost-effectiveness because it obviated the need for child care or transportation.

Disadvantages included problems involving privacy, because for many patients who were undergoing SUD recovery, it was impossible to be alone in a room or a designated area of their own.

The counselors also felt strongly that in-person care was needed for certain patients.

"Before COVID happened, [healthcare] barriers included transport to the actual center and finding care for children," Connolly told Medscape Medical News.

"That's where telehealth really bridged the gap for these people, and it actually became a lot easier for them to get in contact with their counselors, get into group meetings, and access other services," she said.

Many of the study participants were not very optimistic about telehealth at first, Connolly noted. "They felt a little odd going on telehealth at first, but by the end, everybody said that they loved having it," she noted.

"One of the things that came out often was that patients felt they could be more open and honest because they weren't looking their counselor right in the face. They didn't feel so horrible sharing," Whiteside added.

Some counselors reported that some clients shared more details with them and that there was an ease of connecting. If a patient was a few minutes late to an appointment, telehealth would put in a call to find out where that patient was.

The counselors also had the ability to determine which of their patients would be good candidates for telehealth counseling and which patients would not do well with telehealth and would instead need in-patient care.

"This is something that really helped the experience go better for the counselors. They were able to determine which patient fit the mold for telehealth working for them. Obviously, patients who have more acute periods of mental health problems would do better with in-person care," Whiteside said.

Here to Stay?

In the third study from USCSM-G, investigators evaluated data from a focus group of four providers of medications for opioid use disorder (MOUD) who practiced in urban and rural areas throughout the state.

The respondents reflected on their experiences in using telemedicine for prescribing MOUD.

As in the previous studies, the providers had positive experiences with telemedicine. It increased patient access, participation, and satisfaction with treatment, and the benefits of telemedicine outweighed its potential limitations.

Still, technology was cited as a barrier to care, especially in rural areas.

Kellie Shell

"We found that there was a lack of good internet in certain rural parts of South Carolina, and that lack of the proper electronic devices...could also make it difficult to access telemedicine," lead author Kellie Shell told Medscape Medical News.

As noted in the other studies, the providers expressed a desire that telemedicine incorporate safeguards that would enable clinicians to identify a particular patient's location in order that authorities could be dispatched if an emergency were to arise.

The clinicians also said that monitoring for diversion and performing pill counts were more difficult to do via telemedicine.

"We definitely have to improve infrastructure, especially in rural areas, so that all people have access to telemedicine," Shell said.

"Overall, the providers were won over with telemedicine, and some predicted telehealth and virtual visits were here to stay, even after COVID," she added.

The three posters provide useful insight into the potential advantages and disadvantages of telehealth in SUD settings, experts said.

Telehealth Data "Very Limited"

Commenting on the research for Medscape Medical News, Lewei (Allison) Lin, MD, University of Michigan Medical School, Ann Arbor, noted that "there is such limited information" about the use of telehealth for patients with SUD.

"These insights are helpful for us to start understanding the things that need to be considered, including clinician attitudes and perceptions," said Lin, who was not involved with the studies.

"It will be key to have data as use of telemedicine increases during COVID-19 to help us see exactly how it should be used and to better understand the actual impacts and whether or not it is increasing accessibility, and for which patients," she added.

Dr David Kan

David Kan, MD, chief medical officer at Bright Heart Health, San Ramon, California, has had experience with telehealth for SUD and has found that conduting pill counts with his patients has not been a problem.

"The Shell poster covers telemedicine well," Kan told Medscape Medical News when asked for comment.

However, "I disagree with their point that diversion prevention is harder via telemedicine. In my experience, it is easier, as you can do pill or wrapper counts almost on demand. You can also do daily observed dosing with pill counts if diversion is suspected," he said.

Kan also suggested ways to cope with problems involving privacy. "Privacy concerns are always an issue but can be mitigated with headphones and a scan of the room with the telehealth technology if a privacy concern arises," he said.

He acknowledged that in-person meetings, especially through well-established programs, such as Alcoholics Anonymous, will always be important. But he pointed out that people are finding ways to meet safely and have in-person connections.

"The AA has been providing virtual recovery meetings long before COVID. The common complaint is the loss of fellowship associated with recovery groups. I don't know of a way to get around this short of vaccines," Kan said. However, "people have adapted impressively with masked outdoor meetings and other forms of safe gathering."

The investigators, Lin, and Kan report no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 31st Annual Meeting. Posters presented December 11, 2020.

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