Telehealth for Substance Abuse In the Rural Setting

 

How to Use This Information in this Paper:

For Clinicians: Consider Telehealth for Substance Abuse by linking your patients with relatively inexpensive Substance Abuse Telehealth can be achieved by using mobile applications and web-based services that have has shown to improve patient outcomes. 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, 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 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 a multitude of 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. This is where Substance abuse Telehealth can provide a substantial improvement in this common problem

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, 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) 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)

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 (2,3,4,5,6)

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 frequently can obtain needed transportation to inpatient 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 methods for clinicians 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.

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

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 traditional continuing care. (19,20)

Videoconferencing

Secure 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)

Mobile Apps

A mobile app is a software application developed specifically for use on computing devices such as smartphones and tablets. An early analysis that examined several studies on mobile device use in overall health care determined it is too early to generalize the effectiveness of this technology. (24) However, research on one smartphone app found reduced risky drinking days and higher abstinence rates than usual care. (25) Research on Telehealth for Substance Abuse another mobile app showed reduced hazardous drinking days and drinks per day.

Web-Based Treatment supports

Web-based treatment supports: Patients access web-based services over a network connection. These applications are typically “asynchronous,” meaning that people can access them any time, at their convenience.

Overall, web-based Telehealth for Substance Abuse 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 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)

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)

Challenges facing 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 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 psychotherapy (for behavioral health). (37)

Challenges facing facilities

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 rates of patient no-shows.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, as well as 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

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 rates of patient no-shows.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, as well as 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.”

Web Resources

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

    1.  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.
    2.  American Telemedicine Association. (2013, August). State Medicaid practice: Telemental and behavioral health. State Best Practice Series. Washington, DC: Author.
    3. 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.
    4. 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.
    5. 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.
    6. 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.
    7.  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
    8.  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.
    9.  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
    10. 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.
    11. 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.
    12. 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.
    13. 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.
    14. 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.
    15. 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.
    16. 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.
    17.  Molfenter, T., Boyle, M., Holloway, D., & Zwick, J. (2015). Trends in telemedicine use in addiction treatment. Addiction Science & Clinical Practice, 10(14).
    18.  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
    19.  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.
    20. Young, L.B. (2012). Telemedicine interventions for substance-use disorder: A literature review. Journal of Telemedicine and Telecare, 18(1), 47-53.
    21.  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.
    22.  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.
    23.  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.
    24. 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.
    25.  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.
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