“The patient is 15 minutes late. Can you still see her?”
“He missed an appointment yesterday because the bus ran late, and he’s out of Suboxone. He’s getting agitated in the waiting room, and other patients are complaining. Could you see him right away?”
“Therapy group has already started. Is the facilitator willing to let one more patient in?”
In the halcyon days before COVID-19, these questions plagued the rural substance use disorder program where I provided medication for opioid use disorder (MOUD) side-by-side with primary care. Unscheduled arrivals from patients with substandard housing and unpredictable transportation were pitted against the need to set expectations for compliance. Compassion for individuals in difficult straights battled against the tendency toward burnout among providers who struggled to accommodate late or otherwise non-compliant patients. Maintaining an orderly clinic opposed the chaotic nature of withdrawal symptoms, early recovery, and behavioral disorders.
The rapid change-over to telemedicine in March of 2020 brought predictable challenges to health care at large and substance use disorder treatment in particular: patients without the skill set to navigate HIPAA-compliant apps, phones with too little smarts to handle video conferencing, lack of connectivity in rural and economically depressed areas. But telemedicine brought unexpected benefits: the no-show rate plummeted. Patients were more empowered by their own motivation to engage in care than limited by bus schedules’ vagaries. Suboptimal face-to-face interactions among individuals in the throes of addiction (otherwise known as “mayhem in the parking lot”) ceased immediately.
Most of all, telemedicine mitigates the stigma associated with substance use treatment. By accessing services from the privacy of their own home (or a convenient Starbucks where the Wi-Fi is always free), patients are relieved of the burden of attending clinics where their very presence might disclose their diagnosis. Widening the geographic area of service (telemedicine providers often work on a state-by-state basis due to licensure) allows patients to participate in group therapy with amicable strangers rather than cousins, neighbors, friends, or even former dealers that might compromise confidentiality or trigger a relapse. The frequency of medical and therapy visits – often weekly or more to start – can be accommodated during lunch breaks at work rather than requiring lengthy absences for travel and waiting room delays. Eliminating transportation helps focus patient investment on therapeutic interventions rather than road time. Ideally, patients can vote with their feet if a telemedicine provider is a poor match or engages in stigmatizing behaviors – an option rarely available for highly impacted in-person services that rely on limited local resources.
If the ravages of COVID-19 have offered a silver lining for the hard-hit health care profession, it is the rapid acceptance of telemedicine models – a transformation that was a long-time coming but hampered by reluctant payers and bureaucratic limitations on technology utilization. Even while working through logistical challenges (such a how to perform a drug screen in a home setting), we can glean the best of this forced evolution by offering substance use disorder patients the right to the most effective treatment in a private, less stigmatized environment – all the while tackling regional shortages of skilled providers that make substance use disorder such a deadly condition before, during, and after the COVID-19 era.
Julie Craig is an addiction medicine specialist.
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