番茄社区

Although telemedicine has improved treatment access for some patients with substance use disorders during the pandemic, it doesn't meet all of the needs of an already vulnerable population, specialists told 番茄社区.

Regulatory agencies have loosened restrictions on treatments like buprenorphine, allowing prescriptions to be written through telehealth appointments during the public health emergency. But since the pandemic began, overdoses have started to increase again after a period of relative stability, indicating that disruptions to care due to COVID-19 are already having consequences for this population.

"Substance-using patients are particularly vulnerable and access to treatment was already a challenge [before the pandemic]," said Allison Lin, MD, of the Veterans Affairs Ann Arbor Healthcare System in Michigan. "COVID-19 is an additional blow making it even more important to think about treatment for this population."

Pre-pandemic, telehealth was identified as a among patients with substance use disorders, but uptake was moving at a "glacial pace" because it was not often reimbursed by payers, said Lewis S. Nelson, MD, of Rutgers New Jersey Medical School in Newark.

In April, the Substance Abuse and Mental Health Services Administration (SAMHSA) requiring an initial in-person visit to prescribe buprenorphine to new patients. It also allowed existing patients to be prescribed buprenorphine and methadone via telehealth, and increased the number of doses that could be prescribed to stable patients during the public health emergency. The Centers for Medicare & Medicaid Services has also expanded the types of telehealth services that can be reimbursed.

However, patients with substance use disorders often attend group therapy sessions and require intense monitoring through urine toxicology, two aspects of treatment that may be difficult to translate to telehealth services, Lin penned in a .

Group counseling is one of the tenets of addiction treatment, and establishing that face-to-face connection is irreplaceable to some patients, said Ximena Levander, MD, of the Oregon Health & Science University in Portland. Losing a sense of purpose with the loss of a job could also trigger some patients to use again, she added.

"Not having that available or having that change has been really challenging for a lot of people," Levander told 番茄社区. "You can't turn to your usual coping mechanisms and strategies and you maybe haven't developed new ones yet."

Patients with substance use disorders have an . Both substance use and mental health problems can be exacerbated by stressors related to the pandemic like soaring unemployment rates and stay-at-home measures that increase feelings of isolation or reduce social connectedness.

Patients with substance use disorders can also be particularly susceptible to the virus itself, wrote Nora Volkow, MD, director of the National Institute on Drug Abuse in an . For example, methamphetamine use can cause pulmonary damage and hypertension, increasing susceptibility to COVID-19 infection.

Lin said some of her patients have embraced telemedicine because it eliminates transportation and time barriers involved with traveling to appointments.

But patients who are uninsured, homeless, or who do not have access to wifi or broadband to make these virtual appointments are not engaging at the same rate, Nelson said. Patients with substance use are and to have struggled pre-pandemic for healthcare access.

Nelson, chair of emergency medicine at Rutgers, said the number of patients with substance use visiting his emergency department fell by about 50% when COVID-19 hospitalizations peaked in the Northeast region. But now, the number of overdoses they are seeing in the emergency department has returned to pre-pandemic levels and the number of patients coming in for alcohol intoxication is about 30% above what it was before the pandemic, Nelson said.

In various states, the number of opioid-related overdoses have also reached record highs; 39 states have reported increases, according to a .

Despite the advances made with telehealth reimbursements for substance use disorder treatments, other programs for patients with addiction .

In conducted by the North American Syringe Exchange Network, 43% reported decreased available services in the pandemic. Although the demand for these services remained high, nearly all of the staff who completed qualitative interviews said these programs were not included in the emergency planning response by policy makers.

Moreover, when the public health emergency declaration expires, it is unclear whether the guidelines that were loosened by SAMHSA and CMS will remain. That will largely depend on whether telehealth services proved effective during the pandemic, Lin said.

Some researchers are beginning to answer that question. For example, the RAND Corporation and Rutgers are analyzing how the move towards telehealth is .

"For lasting improvements to occur in treatment access, we need to make these changes permanent," Lin argued in her piece in JAMA Psychiatry. "Hopefully, years from now, we will look back at this moment not only as a tragedy but also as a period of rapid improvements in our ability to provide care for patients with [substance use disorders] and other mental health disorders."

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