A Missed Opportunity

Telemedicine use for treating substance use disorder remains low, despite unmet need

Looking over a doctor's shoulder, we see a patient video conferencing on the doctor's laptop.
Miage: iStock

Despite the enormous unmet need for treatment of substance use disorders and the promise technology holds for filling some of the gaps in care, telemedicine remains woefully underused, according to research led by investigators from the Blavatnik Institute at Harvard Medical School.

The study, published in the December issue of Health Affairs, analyzed patterns of telemedicine use and showed that overall use remains low despite some increase in the use of this tool.

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“The low rates of telehealth visits for substance use disorder that we found represent a missed opportunity to get people the help they need, especially in the context of the ongoing opioid epidemic,” said study author Haiden Huskamp, the 30th Anniversary Professor of Health Care Policy at HMS.

In what is thought to be the first study of telemedicine for the treatment of substance use disorder, the researchers used insurance claims from 2010 to 2017 to identify characteristics of telehealth users and patterns of use.

Specifically, the analysis showed that the rate of telehealth visits for substance use disorder increased quickly during the study period: from 0.62 visits per 1,000 diagnosed (97 visits) in 2010 to 3.05 visits per 1,000 diagnosed (1,989 visits) in 2017. Despite this increase, telehealth visits for substance use disorder remained dismally low, representing just 1.4 percent of telehealth visits for any health condition. The number of telehealth visits for substance use disorder accounted for only 0.1 percent of all substance use disorder visits.

Approximately 21 million Americans have a substance use disorder related to alcohol, opioids or other drugs, according to the 2016 National Survey on Drug Use and Health. Deaths from opioid overdose nearly quadrupled from 1999 to 2016, according to the U.S. Centers for Disease Control. There are several treatment options for substance use disorder, including medications and psychotherapy or counseling, but fewer than one in five people struggling with the disorder receive treatment, the researchers said. 

Experts have deemed telemedicine to be one way to improve access to substance use disorder treatment, particularly for people in remote and underserved communities. While telehealth is not a substitute for in-person care, its use could increase treatment engagement and outcomes by helping patients overcome transportation, distance or stigma barriers to treatment for substance use disorders, the study authors said.

The study also showed significant geographic variation in use of telemedicine for substance use disorder. While per capita rates of telehealth for substance use disorder treatment were higher among rural residents, the vast majority of people receiving telecare were in urban areas. Targeted interventions to increase access to telehealth in rural areas are needed to address the significant unmet need for substance use disorder treatment options outside urban areas, the researchers noted.

The researchers also found that telehealth treatment for substance use disorder is being used almost exclusively as a complement to in-person care rather than as a standalone treatment. In these cases, telehealth may ease access to follow-up care for some patients or provide access to a particular type of service that may be unavailable in their community. 

There are a number of barriers that preclude the wider use of telehealth for substance use disorder, the researchers said. Important among them is the shortage of substance use disorder providers, particularly in rural areas, the researchers said.  Other barriers include regulatory and reimbursement hurdles. While it’s possible to do telehealth visits from just about anywhere with a fast internet connection, rules for reimbursement and restrictions on prescribing controlled substances, including those used for substance use disorder treatment, often require patients to come to a qualified facility like a clinic or a hospital which has a telehealth facility that they can use to meet remotely with a clinician at another location.

The SUPPORT for Patients and Communities Act, a new opioid law which was signed in October 2018 and to be implemented in 2019, includes some key features that are intended to ease some of these restrictions.  

With growing interest in using telehealth to deliver care for mental health and substance use disorder, the researchers said their study would provide an important baseline for understanding how telehealth is being used now and for monitoring whether efforts to encourage the use of telehealth are having the intended results.

“Many experts believe that mental health conditions and substance use disorders may be particularly well-suited to telemedicine because their treatment doesn’t require an in-person exam,” Huskamp said. “I think more and more providers are getting interested in delivering telemedicine for these conditions in part because they view it as a way to expand access and possibly improve engagement in treatment for these conditions where access is a real problem.” 

Study co-authors included Ateev Mehrotra, Alisa Busch, Jeffrey Souza, Sherri Rose, Andrew Wilcock and Brucle Landon, all of HMS, and Lori Uscher-Pines of the RAND Corporation. This research was supported by the National Institute of Mental Health (grant no. R01 MH112829) the National Institute on Drug Abuse (grant no. P30 DA035772) and an unrestricted gift from Melvin Hall and Comprehensive Health Services.