Telehealth for Substance Abuse
Implementing Telehealth for Substance Abuse can easily be achieved by linking your patients with relatively inexpensive mobile applications and web-based services. Multiple studies have demonstrated improved patient outcomes for Substance Abuse. Telehealth today offers secure HIPAA compliant solutions for almost any area of healthcare. For some help understanding HIPAA and Telehealth, see our “HIPAA Compliance Tips” for providers.
For those seeking recovery: Research suggests that several smartphone applications and web-based interventions improve treatment outcomes. Some may require a fee to access while others may be free. You may want to ask a therapist or program director about how to access them.
Patients suffering from the disease of addiction usually learn the hard way addiction treatment requires much more than just checking oneself into a 28-day residential treatment program. In most cases, it involves a combination of both inpatient and outpatient treatment over months to achieve the results that lead them back to a self-directed life without active addiction. All of those that enter and complete an inpatient program is at very high in the period post-discharge of keeping sobriety intact. Residential inpatient programs provide a relatively secure setting for early recovery; however, then comes the challenge of returning to their home and the surrounding environment. Even the best-prepared patient is faced with many challenges, any one of which can cause them to fall back into their prior lifestyle routine associated while in active addiction. The result, unfortunately, for many is relapse. Telehealth for Substance Abuse can provide a substantial improvement in this common problem.
To further add to this challenge are those living in rural areas requiring a substantial distance to travel for the much-needed outpatient-based traditional services for substance abuse. Often, transportation is limited, and access to trained providers in substance abuse few and far between. Telehealth services can prove a successful bridge for patients facing these challenges in low population density areas. Providing them with clinically effective means to continue with their recovery program utilizing inexpensive and easily accessible telemedicine technology. (2,3,4,5,6)
Patients in rural or sparsely populated areas have even more obstacles than their urban counterparts
Nearly one in five U.S. residents live in rural areas. (7) Most estimates, individuals living in rural locations experience mental and substance use disorders at rates similar to (and sometimes higher than) those of their urban counterparts.(8,9,10,11,12,13) In a survey of rural health stakeholders, when participants were asked to identify the top 10 rural health priorities from a larger list of focus areas, they ranked mental health and mental disorders fourth and substance abuse fifth. (14)
Despite having a similar need for services, people in rural areas have less access to the behavioral health continuum of care than do people in urban areas. (15,16)
Telehealth for Substance Abuse Services Across the Behavioral Health Continuum of Care
|Type of Service||Telehealth for Substance Abuse Example|
|Assessment of patient status||Online patient assessment form submissions|
|Counseling Individual or Group||Cognitive behavioral health therapy through real-time video/audio Telehealth|
|Medication Assisted Treatment (MAT)||Secure two-way messages or reminders for patient medication adherence|
|Patient Education||Video webinars with content for both patients and providers|
|Provider-to-Provider Consultations||Professional Consultations via live-video Telehealth platform|
Telehealth for Substance Abuse removes geographic barriers to care
Patients in rural areas frequently can’t obtain needed transportation to outpatient substance abuse treatment programs. It is not uncommon for the inpatient treatment centers in other States to provide transportation to and from the inpatient site post-discharge. However, patients returning to their homes in rural areas often face substantial barriers to the critical continuum of care for a successful recovery. Telehealth provides a vitally needed bridge to the barrier of geography to support those in recovery. Here is our article “Top 6 Things to Look for in a Telehealth System” to help give some guidance to selecting a platform for your clients
The chronic nature of substance use disorders calls for clinicians’ methods to stay connected with patients over extended periods. (17) Telemedicine can increase access to addiction treatment services by removing the barriers of geography and stigma.
Types of Telehealth for Substance Abuse Use Disorders
A variety of electronic delivery methods are increasing the use of telehealth for Substance Abuse in addiction treatment and recovery including:
The Hazelden Betty Ford Foundation outlined the following definitions for Telehealth for substance abuse in a paper released December 2018
|Definition of Telehealth Service||How Telehealth Technology Can be Used||Telephone-based Support||Telephone-based support: One of the earliest methods of delivering telehealth for substance abuse services, telephone-based care has been used to provide continuing care for substance use disorders.(17,18) Study results for telephone-based continuing care generally show better results than regular continuing care. (19,20)|
|Secure two-way Text Messaging||Texting is the transmission of short electronic messages between mobile devices. Positive results have been attributed to texting interventions using mobile device apps. (25) Text messaging-based telehealth for substance abuse addiction treatment is inexpensive and has the potential to be widely accessible in real-time. (26|
|Computer-based Treatment for Cognitive Behavioral Therapy||Another web-based treatment approach that has been examined in research studies is Computer-Based Treatment for Cognitive Behavioral Therapy (CBT4CBT). Research has shown positive outcomes with Telehealth for Substance Abuse for CBT4CBT compared to treatment as usual or treatment provided solely by clinicians.(33)|
|Therapeutic Education System (TES)||The Therapeutic Education System (TES) is a web-based substance-use disorder (SUD) treatment consisting of 65 modules based on the Community Reinforcement Approach (CRA). Studies are showing that TES results are comparable to those for the CRA delivered in person by highly trained clinicians.(31,32)|
Challenges facing Telehealth Substance Abuse treatment for rural patients are more than just geography
Specific characteristics of rural populations—such as their treatment preferences, preferred languages, and comfort with technology—have been minimally studied; therefore, how to responsibly adopt Telehealth for substance abuse to the diversity of rural populations is not well understood. (5,34) Cultural competency experts have noted that “we do not know whether and what types of adaptations and modifications of an evidence-based program are needed to ensure that its implementation does not create or exacerbate disparities across cultural groups.”(35) Which rural clients would benefit most from which technologies are still unclear.
Although videoconferencing is a commonly studied telehealth approach, a systematic literature review on videoconferencing for psychotherapy showed that more research is needed on a range of issues, including consent, telehealth contraindications, and the effect of gender, race, and ethnicity on outcomes. (36) However, a 2016 report found sufficient research on telehealth effectiveness to support its use for remote monitoring, communication, and counseling of patients with chronic medical conditions and psychotherapy (for behavioral health). (37)
Challenges facing facilities in Telehealth Treatment for Substance Abuse
Telehealth for Substance Abuse for rural areas is a small part of the broader behavioral health treatment and service system. It is subject to the same limitations, such as insecure funding for programs, low reimbursement rates for providers, and high patient no-shows rates.22 However, Telehealth for Substance Abuse programs also presents with their particular challenges.
They can have high upfront costs, and studies to date on implementation and operational costs of various telehealth programs and cost-effectiveness are not generalizable. (5,38) Patient privacy using virtual care with Telehealth for Substance Abuse systems require password-protected files, network firewalls, document encryption, and reliable technical support. Data ownership and privacy. Responsibility for being HIPAA compliant rests with the program or individual using any particular modality because, as one study noted, “no accreditation system documents that a telemedicine system complies. Prospective users must carefully evaluate whether or not the services meet the requirements of these regulations.”
Conclusion on Telehealth Substance Abuse Treatment
Telehealth for Substance Abuse for rural areas is a small part of the broader behavioral health treatment and service system. It is subject to the same limitations, such as insecure funding for programs, low reimbursement rates for providers, and high patient no-shows rates.22 However, Telehealth
programs also present with their particular challenges.
They can have high upfront costs, and studies to date on implementation and operational costs of various telehealth programs and cost-effectiveness are not generalizable. (5,38) Patient privacy using virtual care with Telehealth Telehealth systems require password-protected files, network firewalls, document encryption, and reliable technical support. Data ownership and privacy. Responsibility for being HIPAA compliant rests with the program or individual using any particular modality because, as one study noted, “no accreditation system documents that a telemedicine system complies. Prospective users must carefully evaluate whether or not the services meet the requirements of these regulations.”
American Psychological Association Committee on Rural Health www.apa.org/practice/programs/rural/committee
American Telemedicine Association www.americantelemed.org
Contemporary Rural Social Work (online journal) http://journal.und.edu/crsw
Federal Office of Rural Health Policy www.hrsa.gov/ruralhealth
International Network on Therapeutic Jurisprudence https://law2.arizona.edu/depts/upr-intj
Mid-Atlantic Telehealth Resource Center www.matrc.org/telepsychiatry-telemental-health
National Association for Rural Mental Health www.narmh.org
National Center for Frontier Communities http://frontierus.org
National Center for Rural Health Works www.ruralhealthworks.org
National Frontier and Rural Addiction Technology Transfer Center www.attcnetwork.org/national-focus-areas/?rc=frontierrural
National Rural Health Association www.ruralhealthweb.org
National Rural Social Work Caucus www.ruralsocialwork.org
Rural Health Information Hub www.ruralhealthinfo.org
Rural Health Research Gateway www.ruralhealthresearch.org
Rural Health Value http://cph.uiowa.edu/ruralhealthvalue
SAMHSA-HRSA Center for Integrated Health Solutions
U.S. Department of Veterans Affairs—VA Telehealth
Relevant publications from SAMHSA
(available through http://store.samhsa.gov)
Considerations for the Provision of e-Therapy
The TEDS Report: A Comparison of Rural and Urban Substance Abuse Treatment Admissions
Treatment Improvement Protocol (TIP) 59: Improving Cultural Competence
TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services
The National Frontier and Rural ATTC www.attcnetwork.org/find/news/attcnews/epubs/addmsg
American Telemedicine Association Practice Guidelines http://thesource.americantelemed.org/resources/telemedicine-practice-guidelines
The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary www.nap.edu/read/13466/chapter/1
Telehealth Services (Rural Health Series) www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
- Substance Abuse and Mental Health Services Administration. (2015).Using technology-based therapeutic tools in behavioral health services. Treatment Improvement Protocol (TIP) Series 60. HHS Publication No. (SMA) 15-4924. Rockville, MD: Substance Abuse and Mental Health Services Administration.
- American Telemedicine Association. (2013, August). State Medicaid practice: Telemental and behavioral health. State Best Practice Series. Washington, DC: Author.
- Center for Substance Abuse Treatment. (2009). Considerations for the provision of e-therapy. HHS Publication No. (SMA) 09-4450. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse, and Mental Health Services Administration.
- Chung-Do, J., Helm, S., Fukuda, M., Alicata, D., Nishimura, S., & Else, I. (2012). Rural mental health: Implications for telepsychiatry in clinical service, workforce development, and organizational capacity. Telemedicine and e-Health, 18(3), 244–246.
- Clarke, G., & Yarborough, B. J. (2013). Evaluating the promise of health IT to enhance/expand the reach of mental health services. General Hospital Psychiatry, 35(4), 339–344.
- Montes, J. M., Medina, E., Gomez-Beneyto, M., & Maurino, J. (2012). A short message service (SMS)-based strategy for enhancing adherence to antipsychotic medication in schizophrenia. Psychiatry Research, 200(2–3), 89–95.
- U.S. Census Bureau. (n.d.). How many people reside in urban or rural areas for the 2010 Census? What percentage of the U.S. population is urban or rural? [Webpage]. Retrieved October 3, 2016, from https://ask.census.gov/faq.php?id=5000&faqId=5971
- Cicero, T. J., Surratt, H., Inciardi, J. A., & Munoz, A. (2007). Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiology and Drug Safety, 16(8), 827–840.
- Meit, M., Knudson, A., Yu, A. T.-C., Tanenbaum, E., Ormson, E., TenBroeck, S., et al. (2014). The 2014 update of the rural-urban chartbook. Retrieved October 3, 2016, from https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf
- Probst, J. C., Laditka, S. B., Moore, C. G., Harun, N., Powell, M. P., & Baxley, E. G. (2006). Rural-urban differences in depression prevalence: Implications for family medicine. Family Medicine, 38(9), 653–660.
- Rosenblum, A., Parrino, M., Schnoll, S. H., Fong, C., Maxwell, C., Cleland, C. M., et al. (2007). Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug and Alcohol Dependence, 90(1), 64–71.
- Substance Abuse and Mental Health Services Administration. (2012). The TEDS Report: A comparison of rural and urban substance abuse treatment admissions. Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Young, A. M., Havens, J. R., & Leukefeld, C. G. (2012). A comparison of rural and urban nonmedical prescription opioid users’ lifetime and recent drug use. American Journal of Drug and Alcohol Abuse, 38(3), 220–227.
- Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kask,B. A., Schulze, A., & Helduser, J. W. (2015). Rural healthy people 2020: New decade, same challenges. Journal of Rural Health, 31(3), 326–333.
- Borders, T. F., & Booth, B. M. (2007). Research on rural residence and access to drug abuse services: Where are we and where do we go? Journal of Rural Health, 23(Suppl.), 79–83.
- Petterson, S., Williams, I. C., Hauenstein, E. J., Rovnyak, V., & Merwin, E. (2009). Race and ethnicity and rural mental health treatment. Journal of Health Care for the Poor and Underserved, 20(3), 662–677.
- Molfenter, T., Boyle, M., Holloway, D., & Zwick, J. (2015). Trends in telemedicine use in addiction treatment. Addiction Science & Clinical Practice, 10(14).
- Page, C., Beck, A.J., & Buche, J. (2017). An analysis of behavioral telehealth authorization in scopes of practice. Retrieved from behavioralhealthworkforce.org/wp-content/uploads/2017/11/Y2FA3P1_ Telehealth_-Full-Report.pdf
- McKay, J.R., Lynch, K.G., Shepard, D.S., & Pettinati, H.M. (2005). The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Archives of General Psychiatry, 62(2), 199-207.
- Young, L.B. (2012). Telemedicine interventions for substance-use disorder: A literature review. Journal of Telemedicine and Telecare, 18(1), 47-53.
- McKay, J.R. (2009). Continuing care research: What we’ve learned and where we’re going. Journal of Substance Abuse Treatment, 36(2), 131-145.
- McKay, J.R., Van Horn, D.H., Oslin, D.W., Lynch, K.G., Ivey, M., Ward, K., … Coviello, D.M. (2010). A randomized trial of extended telephone-based continuing care for alcohol dependence: Within-treatment substance use outcomes. Journal of Consulting and Clinical Psychology, 78(6), 912-923.
- Hyler, S.E., Gangure, D.P., & Batchelder, S.T. (2005). Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparative studies. CNS Spectrums, 10(5), 403-413.
- Hilty, D.M., Ferrer, D.C., Parish, M.B., Johnston, B., Callahan, E.J., & Yellowlees, P.M. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine and e-Health, 19(6), 444-454.
- Free, C., Phillips, G., Galli, L., Watson, L., Felix, L., Edwards, P., … Haines, A. (2013). The effectiveness of mobile-health technology-based health behavior change or disease management interventions for health care consumers: A systematic review. PLoS Medicine, 10(1), e1001362.
- Keoleian, V., Polcin, D., & Galloway, G.P. (2015). Text messaging for addiction: A review. Journal of Psychoactive Drugs, 47(2), 158-176.
- Khadjesari, A., Murray, E., Hewitt, C., Hartley, S., & Godrey, C. (2010). Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review. Addiction, 106(2), 267-282.
- Gainesbury, S., & Blaszczynski, A. (2011). A systematic review of the Internet-based therapy for the treatment of addictions. Clinical Psychology Review, 31(3), 490-498.
- Hester, R.K., Delaney, H.D., Campbell, W., & Handmaker, N. (2009). A web application for moderation training: Initial results of a randomized clinical trial. Journal of Substance Abuse Treatment, 37(3), 266-276.
- Squires, D.D., & Hester, R.K. (2004). Using technical innovations in clinical practice: The Drinker’s Check-Up software program. Journal of Clinical Psychology, 60(2), 159-169.
- Marsch, L.A., Guarino, H., Acosta, M., Aponte-Melendez, Y., Cleland, C., Grabinski, M., Edwards, J. (2014). Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment. Journal of Substance Abuse Treatment, 46(1), 43-51.
- Bickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent outpatients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.
- Carroll, K.M., Ball, S.A., Martino, S., Nich, C., Babuscio, T.A., Nuro, K.F., … Rounsaville B.J. (2008). Computer-assisted delivery of cognitive-behavioral therapy for addiction: A randomized trial of CBT4CBT. American Journal of Psychiatry, 165(7), 881-888.
- Morgan, A. J., Jorm, A. F., & Mackinnon, A. J. (2012). Email-based promotion of self-help for subthreshold depression: Mood Memos randomised controlled trial. British Journal of Psychiatry, 200(5), 412–418
- Blase, K. A., & Fixsen, D. L. (2003). Evidence-based programs and cultural competence (p. 18). Tampa, FL: Louis de la Parte
- Backhaus, A., Agha, Z., Maglione, M., Repp, A., Ross, B., Zuest, D., et al. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9(2), 111–131.
- Totten, A. M., Womack, D. M., Eden, K. B., McDonagh, M. S., Griffin, J. C., Grusing, S., & Hersh, W. R. (2016, June). Telehealth: Mapping the evidence for patient outcomes from systematic reviews (Technical Brief No. 26). AHRQ Publication No.16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality.
- Molfenter, T., Boyle, M., Holloway, D., & Zwick, J. (2015). Trends in telemedicine use in addiction treatment. Addiction Science and Clinical Practice, 10, 6.
- Adler, G., Pritchett, L. R., Kauth, M. R., & Nadorff, D. (2014). A pilot project to improve access to telepsychotherapy at rural clinics.Telemedicine and e-Health, 20(1), 83–85.