How to Use This Information in this Paper:

For those seeking recovery: Clinical research suggests 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.

For service providers: Consider linking your patients with free or relatively inexpensive mobile applications and web-based services that have been shown to improve patient outcomes

Patients suffering from the disease of addiction, and their families, usually learn the hard way that it is not just as simple as checking oneself into a 28-day residential treatment program and your “cured”.  In most cases it requires a combination of both inpatient and outpatient treatment over a period of months achieve the results that lead them back to a self-directed life without active addiction. All of those that enter and successfully complete an inpatient program are at very high in the period post-discharge of keeping sobriety intact. Residential inpatient programs provide a relative secure setting for early recovery however, then comes the challenge of returning back to their home and the surrounding environment.  Even the best prepared patient is faced with a multitude challenges any one of which can cause them to fall back into their prior lifestyle routine associated with while in active addiction. The result unfortunately for many is relapse.

To further add to this challenge are those living in rural areas where it can require a substantial distance to travel for the much needed outpatient-based traditional services for substance abuse.  Often times transportation is limited and access to trained providers in substance abuse few and far between. Telehealth services can prove to be 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) According to most estimates, individuals living in rural locations experience mental and substance use disorders at rates that are 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)

Telehealth Services Across the Behavioral Health Continuum of Care

Type of Service

Telehealth Example

Assessment

Online substance abuse feedback form

Treatment

Group and/or individual Cognitive-behavioral health therapy through real-time video/audio telemedicine

Medication Management/Monitoring

Secure two-way messaging and/or reminders

Continuing Care

Group Counseling and/or chat forums to prevent relapse

Education

Video webinars with content for both providers and patients

Provider-to-Provider Consultations

Interactive Consultations via real-time Telehealth platform

Patients in rural areas oftentimes are able to obtain needed transportation to inpatient substance abuse treatment programs.  In fact, 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. 

The chronic nature of substance use disorders calls for methods for clinicians to stay connected with patients over extended periods of time. (17) Telemedicine can increase access to addiction treatment services by removing the barriers of geography and stigma.

Telehealth Applications for Substance Use Disorders

A variety of electronic delivery methods are increasing the use of telehealth in addiction treatment and recovery including:

The Hazelden Betty Ford Foundation outlined the following definitions for Telehealth in substance abuse in a paper released December 2018

Telephone-based Support

Telephone-based support: One of the earliest methods of delivering telehealth 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 traditional continuing care. (19,20)

Videoconferencing

Videoconferencing: Videoconferencing occurs through secure portals on personal computers or dedicated telemedicine equipment. Studies on videoconferencing for addiction services have found equivalent results and patient satisfaction compared with care provided in person or by video.5, 6 Meta-analyses of videoconferencing for psychiatry services have found similar positive results. (22,23)

Secure Text Messaging

Secure Texting: 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 addiction treatment is inexpensive and has the potential to be widely accessible in real-time.(26)

Web-Based Treatment Supports

Overall, web-based telemedicine services have been found to be more effective at reducing alcohol consumed per week than comparison conditions.(27,28)

For web-based alcohol screening, assessment, and feedback or brief intervention, the Drinker’s Check-Up (DCU) has demonstrated positive results in several clinical trials.(29,30)

Therapeutic Education Systems (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)

Computer Based Treatment for Cognitive Behavorial 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 for CBT4CBT compared to treatment as usual or treatment provided solely by clinicians.(33)

Challenges facing rural patients are more than just geography

Certain characteristics of rural populations—such as their treatment preferences, preferred languages, and comfort with technology—have been minimally studied; therefore, how to responsibly adapt telehealth 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 is 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 that there is sufficient research on telehealth effectiveness to support its use for remote monitoring, communication, and counseling of patients with chronic medical conditions, and for psychotherapy (for behavioral health).(37)

Barriers facing facilities

Telehealth for rural areas is a small part of the larger behavioral health treatment and service system and is subject to the same limitations, such as insecure funding for programs, low reimbursement rates for providers, and high rates of patient no-shows.22 However, telehealth programs also present with their own particular challenges.

They can have high upfront costs, and studies to date on implementation and operational costs of various telehealth programs, as well as cost effectiveness, are not generalize.(5,38) To protect patient privacy, telehealth care systems require password-protected files, network firewalls, document encryption, and reliable technical support. Data ownership and privacy standards remain to be settled. 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 is in compliance. Prospective users must carefully evaluate whether or not the services meet the requirements of these regulations.”

Conclusion

Bridging the gap between rural and urban substance abuse treatment services involves addressing many complex barriers and developing creative solutions to complex challenges that are often unique to rural areas. However, rural clients and professional service providers are not alone in tackling these issues. There are many professional organizations charted to help improve adoption of telehealth in the delivery of all behavioral health include substance abuse treatment. Professional journals such as the Journal of Rural Mental Health publish regularly articles centered in rural behavioral health care. Also the National Association for Rural Mental Health support and promote the continuing development and replication of successful programs. Telehealth may be part of the solution to improving access to behavioral health services in rural areas and increasing the likelihood that individuals living in rural locations will engage with the behavioral health system. In addition, telehealth presents an opportunity for tremendous growth—not only is technology continuing to advance at a rapid pace, but also changes in healthcare laws are extending coverage for telehealth services, making them available to an increasing number of individuals

Other Useful Drexly Pages

Web Resources

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

www.integration.samhsa.gov/operations-administration/telebehavioral-health

U.S. Department of Veterans Affairs—VA Telehealth

Services www.telehealth.va.gov

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

 

Other publications

The National Frontier and Rural ATTC www.attcnetwork.org/find/news/attcnews/epubs/addmsg

/april2013article.asp

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






Notes

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