How Telehealth is Addressing the Opioid Epidemic-The HSB Blog 4/5/21



Our Take: The rise in substance use disorder (SUD) fueled by the opioid epidemic has increased demand for behavioral health services and exacerbated the behavioral health workforce shortage. There is a marked discrepancy between the number of people who need addiction treatment in the United States compared to those who receive it. According to the American Addiction Centers, approximately 21 million people (12 and older) need substance abuse treatment, and only an estimated 3.8 million people have gotten treatment, signaling that only 18% of those who needed treatment were able to access it. Innovations such as telehealth can provide lower-cost and widely available approaches to serve as an alternative treatment option for people suffering from SUD. Telehealth can connect geographically dispersed patients and providers and is a promising approach to expanding access to those suffering from opioid use disorder and other SUDs and seeking treatment. Utilizing digital tools through companies like Eleanor Health, Genoa, Pear, and Marigold can provide supplemental, individualized treatment plans that address challenges faced with SUB exacerbated by the numbers involved with the opioid crisis.

Description: As noted above, less than 20% of those who need treatment for SUD actually receive it. Reasons for access limitations include a limited supply of rehab facilities, lack of specialty SUD treatment providers, lack of primary care physicians with experience in behavioral health treatment, and privacy and stigma concerns among those suffering from opioid and other addictions. Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. While treatment providers possess a number of effective tools, including medications for opioid and alcohol use disorder, that could likely prevent many deaths, they are still not utilized widely enough. In addition, many people who could benefit from available treatments do not seek them out because of the stigma that surrounds addiction and addiction treatment. While less common, healthcare providers may consciously or subconsciously view a patient’s drug or alcohol problem as a sign of moral weakness which may lead to substandard care. For example, patients with indications of acute intoxication or substance withdrawal symptoms are sometimes expelled from emergency rooms because staff fear their behavior, which may appear erratic, or assume that they are only seeking drugs. As a result, people with addiction may internalize this stigma, become humiliated, and refuse to seek treatment which can lead to an inability to get control of their addiction and play a part in the vicious cycle driving these addictive behaviors. Given the ability to receive care without having to appear in-person or at any type of addiction clinic, telehealth for SUD can help reduce or eliminate this stigma. In addition studies indicate that telehealth can fill the care void as evidenced by the rapid increase in telehealth services during the pandemic which demonstrated that telehealth services are an effective adjunct and substitute for in-person care of SUD. For example, a study entitled, “How is telemedicine being used in opioid and other substance use disorder treatment” analyzed claims data from a large commercial insurer from 2010-2017. The authors found that the while the number of telemedicine visits for SUD from 97 to 1,989 (~1900%) during the same period general telebehavioral health visits increased from 2,039 to 54,175 (~ 2500%) implying telemedicine visits for SUD could be more broadly used. Increased use of telemedicine can allow patients with opioid use disorder to stay in treatment and receive counseling to further their recovery. In addition, broader use can offer patients, physicians, and the health care system as a whole enhanced convenience, reduced travel time, and cost savings and thus can be used as a useful substitute or additive treatment for patients suffering from substance use. Another study, entitled, “Telemedicine-delivered treatment interventions for SUDs: A systematic review” examined the delivery of substance use treatment via video conference. It assessed the clinical impacts on substance use, treatment retention, acceptability, and feasibility. The study found that telemedicine can be associated with improved treatment retention compared to participants traveling for in-person treatment. Another systematic review of behavioral health articles conducted in three regions (United States, European Union, and Australia) indicated that telemedicine was associated with reduced depression, decreased cost, and increases in patient satisfaction, accessibility, and quality of life. Interventions included mobile health, electronic health, telephone, and two-way video. While telemedicine can be a useful substitute or adjunct to in-person therapy, there are still two pressing issues that remain to be addressed: the delivery of Buprenorphine and training. Buprenorphine is a common medication used to treat opioid use disorder, acute pain, and chronic pain. According to the American Addiction Centers, 90% of the physicians who are approved to prescribe Buprenorphine practice in urban areas. About 53% of rural counties do not have any physician who can prescribe it, and rural providers who can prescribe buprenorphine report high demand, a lack of resources, and long wait times for patients. This issue is not likely to be addressed in the short-term via telemedicine, however, longer-term thought should be given to allow other clinicians to administer Buprenorphine under the guidance or remote management of more senior providers. Similarly training of additional clinicians to treat SUD will take time. For example, according to the American Society of Addiction Medicine, treating 20.7 million Americans with a SUD will require training that is too often lacking in our nation’s current addiction workforce. The society noted there are too few clinicians with the requisite knowledge and training needed to prevent, diagnose, and treat addiction. Recognizing this need, in 2016 Congress authorized a training demonstration program within the 21st Century CURES Act. The Act authorized $10 million per year and awarded grants to medical schools and federally qualified health centers to support training for medical residents, fellows, nurse practitioners, physician assistants, and others to practice in psychiatry and addiction medicine. Here too, innovative approaches using telemedicine may help leverage the capabilities of the system to address the shortage of providers.

Implications: Telemedicine is under-utilized, despite having great potential for assisting recovery and treating patients with SUDs. Telemedicine allows patients with opioid use disorder to stay in treatment and receive counseling to further their recovery. A study conducted by Yang et al. showed that telemedicine offers additional benefits for patients, physicians, and the greater health care system through enhanced convenience, reduced travel time, and cost savings.[v] Due to the lack of treatment centers in rural areas, patients may have difficulty with transportation, particularly when in outpatient treatment that may require multiple trips to a treatment center each week. Public transportation is generally not as convenient or readily available in non-urban areas and patients may live a long way away from a program. Even where patients may have access to convenient and reliable transportation, cost may be prohibitive, making telehealth a much more cost-effective means of accessing care. Companies such as Eleanor Health and Genoa are developing innovative ways integrating value-based care and evidence-based medicine to deliver more traditional therapies for those affected by addiction and SUD to help them live healthy, productive lives. Companies like Pear Therapeutics, Marigold, and WorkIt Health are incorporating new digital therapeutic (DTx) approaches to improve patient outcomes through digital applications that can be made broadly available. These companies provide evidence-based therapeutic interventions driven by high-quality software programs to increase abstinence from a patient’s substances of abuse during treatment. Despite the limitations of current studies, the researchers conclude that telemedicine-delivered treatments are a promising alternative, especially when evidence-based treatments are not readily available. For specific treatment and substance use categories, mainly when treatment adherence is a key goal, telemedicine can result in improved patient retention and treatment adherence due to increased accessibility. There is limited evidence that digital recovery support services (telehealth) effectively deal with all substance abuse situations. More and more research has been done on the brain, and the impact of chemical imbalances and susceptibility to addiction is becoming more evident. For example, brain changes are substantially influenced by factors outside of an individual's control, such as genetics or the environment in which one is born and raised. Unfortunately, along with the breadth of the opioid crisis has come better understanding and treatment, yet still more needs to be done. More studies and additional research are needed to understand the opportunities and barriers for telehealth treating behavioral health. Further evaluation should be conducted to measure the impacts of existing telehealth services and programs targeted to behavioral health solutions. Researchers have concluded that much work needs to be done to get more people to use telehealth for addiction treatment. Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Treating patients with dignity and respect is crucial for people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants. Everyone should be trained to care for people with SUDs compassionately.


How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?; Telemedicine-Delivered Treatment Interventions for Substance Use Disorders: A Systematic Review; Telemedicine’s Role in Addressing the Opioid Epidemic(subscription may be required)



Talkspace’s Controversial Reno Contract and How Users Could be Left Behind


Event: Recently STAT+ reported on Talkspace’s controversial contract with the city of Reno, Nevada. Under the deal, the City of Reno decided to spend $1.3M of expiring CARES Act funding to provide Talkspace therapy services to virtually every resident, excluding children, free of charge, for approximately one year. According to the article the contract was the idea of Mayor Hillary Scheive, who was looking to help residents following a surge in deadly COVID cases and her own personal difficulties finding a therapist in Reno after she herself was “devastated after her brother and sister both died within weeks of each other.” Local therapists opposed the plan since they were not consulted, felt that Talkspace’s services were “therapy-lite” and that patients could be left stranded when the contract expires in December 2021.


Description: As noted, the Talkspace initiative was headed by Mayor Schieve when the Mayor herself was in dire need of therapy but was unable to get an appointment for weeks and ultimately found help through the Talkspace app. Following her experience, Mayor Schieve consulted with Reno resident Kathryn Goetzke, who has been working on global mental health strategy as director of Mood Factory which sells wellness products and the International Federation for Research and Education on Depression (iFred) a non-profit. Following discussions with the company, a deal was worked out to provide therapy to virtually all residents of the city via Talkspace at the monthly rate of 55 cents per person for chat and monthly video sessions (which ordinarily the service would have cost $316/month). While Talkspace’s vision of catering to a wider range of people than typically reached by standard therapy was well received by some, there were still local therapists that were distrustful of Talkspace. The therapist's main concern was that the majority of Talkspace’s interactions would be via text-based therapy, and the quality of care delivered by the app as compared to what could be delivered in person. In addition, therapists were concerned that Talkspace could realize disproportionate profits from the deal if fewer than anticipated residents took advantage of the offer from the City. The local therapist’s were also concerned that by using Talkspace local residents could open a Pandora's box of deep psychological wounds that couldn’t be treated appropriately by Talkspace and that could potentially leave residents in the lurch without mental health services when the contract ended in late 2021. Talkspace and the City responded by noting “the company has 10 independent studies to back it’s approach” and was already looking at ways to transition patients once the contract ends. As of late March, Reno’s grand experiment with Talkspace had roughly 1,350 active users — people who had signed up for the service and communicated with a therapist.

Implications: Apps like Talkspace have effectively managed to fill the gaps in the nation’s tattered mental health system. While the therapist community in Reno opposed the move, recognition has to be given to the fact that the state of Nevada ranked dead last in a composite score by Mental Health America for prevalence of mental health issues and access to care. Although the service may not have been ideal it did cater to people who otherwise may have

opted out of seeking mental health care due to stigma, cost, or lack of availability. Moreover the conflict in Reno is indicative of the tension between making limited services broadly available and perhaps making more intensive services less widely available. For example, the Talkspace program provided services to 200,000 people while an alternative proposal by local therapists would have only provided services to 12,000 people. To us the solution appears to be somewhere in the middle. Apps like Talkspace make it simple to connect with therapists with the added convenience of services like text, audio, and video messaging and they are extremely cost-efficient. However, platforms like Talkspace are not going to replace therapy for those who need intensive therapy or treatment for complex conditions although they may help bring people into treatment or provide a bridge to care until in-person care is available. Moreover, the ability of app based platforms to serve patients in multiple languages makes care more appealing and available. However, even with the attractions, these platforms do have drawbacks. The requirement of a smartphone is a necessity which is a potential barrier. Also, patients requiring long-term therapy for serious conditions should not depend solely on these apps and the apps themselves must be able to provide transitions to more appropriate care when necessary. These app-based therapy provisions are not replacements for conventional therapy but the easy accessibility and convenience in regard to cost and easily available slots for appointments with 24/7accesibility with a licensed therapist can serve to fill the gaps for an overburdened mental health system.


Inside the Battle Over Talkspace and a Grand Experiment in Mental Heal (subscription required)



Google Cloud Healthcare Projects to Keep An Eye On


Event: On March 30th, STAT+ reported on five Google projects to watch as it builds up the healthcare segment of its Google Cloud platform. The company is focusing on projects that more broadly deploy AI to “improve how doctors and hospitals manage and exchange health data” as well as how they “use it to predict medical problems and direct health systems resources”. The five projects include AI factory, Care Studio, tools to improve detection of cancer, augmenting telehealth, and improving the interoperability of health records.


Description: One of the main goals of Google’s deeper push into healthcare is to simplify the complexities associated with creating an AI empowered digital transformation. The first project is to “build an assembly line for novel artificial intelligence tools in a partnership with the Mayo Clinic.” According to the article, Google and the Mayo Clinic are hoping to build new AI products that will improve patient outcomes and make care more efficient. These products include a tool to target radiation therapy, using AI to analyze radiology images to detect chronic disease, and creating a clinical assembly line for AI solutions. More important than the specific project, Google and Mayo hope to build a process for assessing and improving AI solutions against real world situations. Another project was Care Studio, which is meant to act like a Google search engine for electronic health records. According to the article, the idea is to allow clinicians to type a query into a search bar so they may retrieve everything in a patient's history by using the company’s method of routing complicated streams of data through one portal. Google notes that the software is designed to work in tandem with existing EHR software not to replace it. The company is also working with the U.S. Department of Defense to apply AI to improve cancer detection on lung and breast images. The goal is to improve the accuracy of diagnosis through early detection and reduce the incidence of false positives via more precise analysis or tumors and tumor biopsies. In more direct consumer facing care, Google is also working with Amwell to provide cloud services and AI tools to improve the customer experience. According to the article, Amwell will use Google technology to “automate the waiting room and check out processes, responding to inquiries, and help triage patients”. The goal of the project is to improve the quality of care while helping streamline the experience for patients. The final project reviewed in the article is interoperability of health records. As the article notes, currently there is no “seamless flow of patient information within the healthcare system, that [makes] it easier to trade [or] use to inform decision making”. The goal of the project is two-fold, to help hospitals and payers adhere with new federal rules that prevent information blocking making it easier for patients to get electronic access to their data, while at the same time advancing Google’s goal of moving data to the Cloud where it will be easier for organizations to exchange and access data via APIs,


Implications: With the creation of these projects, Google is working to deepen its role in healthcare through its core competence of search. Each of these aim to improve patient/provider experience, navigation through medical records, and introduce new AI tools into healthcare. However, some have exposed Google and its partners to criticism around the steps taken to ensure data privacy and security, which will remain a core concern going forward. This is especially important during this era where more patients are having to use digital health platforms and looking for simple alternatives. Google and other new entrants are likely to be held to a higher standard as they prove they are worthy of patients' trust and as such have got to emphasize transparency and communication with both providers and patents as they work to improve the use of new technologies in the system. Google’s efforts will put them squarely in the cross-hairs of other tech and retail players such as Amazon, Walmart and Microsoft all of whom are working to gain share in healthcare. All of the players would do well to remember the recent words of one large hospital system CEO who noted that there is tons of data in healthcare but none of it is easy to get to!


5 Health Care Projects to Watch at Google Cloud (subscription required)

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