The coronavirus pandemic pushed companies throughout the health care industry to dramatically increase their use of telehealth.
Doctors and patients alike learned how to navigate primary care visits over Zoom. Regulators loosened rules governing telehealth. Clinicians started using internet connected devices much more frequently to measure patients’ weight, blood pressure and oxygen levels from home.
In the addiction treatment industry, the shift towards telemedicine was especially dramatic. Most addiction treatment providers provided little or no telehealth options before the pandemic. During widespread lockdowns during the spring, many addiction treatment clinics across the U.S. moved almost all their clients in outpatient therapy to online groups.
The Brentwood-based company American Addiction Centers operates dozens of addiction treatment centers in eight states. Tamara Hall, who leads the company’s clinical operations, said AAC didn’t offer telehealth at any of its centers before the pandemic. Now, it’s standard at every facility.
"This has gone from zero to 60 overnight, especially for substance abuse,” she said. “It went from basically nobody doing it to, if it isn't part of what you're doing then you've really missed the boat.”
Hall, and leaders at other addiction treatment companies, say telehealth can make it easier for patients to find treatment, especially if they live in rural areas far from a treatment center. In some cases, participation in therapy groups increased online. Those advantages will make telehealth a useful tool during and after the pandemic. However, some leaders warned that virtual therapy may turn out to be less effective because it can be harder to create human connections over video calls.
“That's what helps people get back into society. That's what helps people find a job again, because they rebuild relationships they lost,” Steve Priest, the CEO of the Brentwood-based addiction treatment company Spero Health, said. “That human connection is critically, critically important from our perspective for really helping patients succeed over the long haul.”
When the new coronavirus started spreading rapidly in the U.S. last spring, regulators temporarily modified rules, allowing companies to more easily provide treatment over video calls. Insurers also quickly agreed to pay addiction treatment centers for virtual visits.
Those decisions removed some major obstacles, but addiction treatment companies still had to train employees how to provide treatment for addiction online. Hall said that AAC counselors got training in telehealth and new licenses that would allow them to treat patients across state lines.
“We created what we call the telehealth playbook … We literally had to create a book saying, here's all the things you have to do and all the things you have to remember,” Spero CEO Priest said. “It’s the little things.”
For example, counselors had to make sure that both ends of the call were private. That’s not always an easy task when patients and counselors are confined to homes shared with family members or roommates.
Priest said that Spero made the decision early on to keep all of their clinics open because not all of their patients would be able to use telehealth. Still, Priest said that in April 98 percent of the company’s group counseling sessions and about 75 percent of all visits took place online. By December, 70 percent of groups were still online.
Other companies took more drastic steps to keep patients from getting the coronavirus. The Arizona-based addiction treatment company Landmark Revcovery, which is currently moving its headquarters to Williamson County, decided to move all of its outpatient clients online. It wasn’t until November that the company started offering in-person group sessions again.
Hall said patients at AAC treatment centers have responded positively to online treatment sessions. She said that digital therapy groups have higher rates of attendance and more active participation.
"I don't know if it's just because the computer is in your living room and it's easier to join,” she said. “When I talk to the clinicians on the ground. They say the individuals on the digital health group are very active.”
Meanwhile, Landmark Recovery CEO Matthew Boyle said his company saw the opposite effect. Patients participated less and they missed the human connection offered at in-person groups.
“When you're dealing with mental health it's a very sensitive topic that involves a lot of talking and talking about your feelings,” Boyle said. “A lot of our patients said it felt really awkward to do that by Zoom.”
While leaders from Landmark Recovery, Spero and AAC said that the transition to telehealth went relatively smoothly, there isn’t a lot of research about how effective virtual treatment will be on such a large scale. Those companies have been gathering efficacy data from their own patients, but it’s still too early to make solid conclusions.
Wanhong Zheng, a doctor and researcher based at West Virginia University, said the limited research conducted so far suggests telemedicine could work well for substance abuse, especially when it’s impractical for patients to get in-person treatment.
The authors of a 2019 review on the efficacy of telehealth for substance abuse from the Journal of Substance Abuse treatment agreed with Zheng, but noted that the more studies are needed to confirm the preliminary research.
In 2018, Zheng led a small research project that found a treatment plan using telemedince was just as effective as in-person treatment for patients receiving a medication to help them stop using opioids.
This year, he has continued to treat people with substance abuse disorders online, and said he believes it can be effective. In October, he and other physicians at WVU reported that the no-show rate for virtual substance abuse visits was similar to the in-person no-show rate from 2019.
Still, Zheng says telemedicine is best deployed as an occasional convenience or a stop-gap measure where in-person treatment isn’t available. Some of his patients had tech trouble when connecting to online sessions. More importantly, he said it’s harder to communicate with patients over the phone.
“Personally, I prefer in-person groups because I pay attention to patients affect and body language,” he said. “It's hard for me to do that (using telehealth), but it's doable.”
For the most part, leaders in Williamson County have come to the same conclusion. Telehealth will likely be a tool that expands access to substance abuse treatment for people in hard-to-reach areas, but’s it’s far from a panacea.
"I don't believe that telehealth is the be-all end-all for our care. I do believe it's a wonderful tool in our toolbox, and I'm hopeful that we can keep it in the toolbox," Priest said. "But it will be a tool. It won't be the model of the future for Spero health."