Providers are throwing caution flags on the field of virtual substance use disorder (SUD) treatment.
Virtual SUD treatment boasts serious benefits, including convenience and accessibility, but not all patients are well-suited to receiving care through exclusively virtual means, industry insiders told Addiction Treatment Business.
While virtual therapy may be the best fit for some patients or the only option for patients unable to attend in-person appointments, the SUD industry may need to carefully consider virtual care’s role in treatment.
“For this demographic with all its comorbidities and the co-occurring disorders, you really need to see someone in person in order to tell how they’re progressing,” Lynda Micheletti, chief operating officer at Praesum Healthcare Services, told ATB. “People who have both medical and SUD or behavioral issues should be seen on a pretty regular basis, not just through a computer screen.”
Lake Worth, Florida-based Praesum has more than 30 SUD treatment centers across six states offering detox, outpatient, partial hospitalization programs (PHPs) and sober living services. In August 2023, the privately-owned company signaled interest in engaging in a private equity partnership.
Virtual SUD care was largely popularized through necessity by the COVID-19 pandemic. Its benefits include increased access and convenience and can be crucial for rural populations. What should have been a temporary measure became more permanent after social distancing recommendations lightened, Micheletti said.
“[The pandemic] springboarded virtual care, which is a needed and necessary aspect of treatment at the right time for a patient,” Micheletti said. “The pandemic put it on steroids and made it become a primary treatment course.”
Benefits of virtual SUD care
Patients have no problem engaging with each other in virtual opioid use disorder (OUD) group therapy sessions, according to Dr. Scott Weiner, director of research at Bicycle Health. He describes virtual conversation as the “reality of the post-COVID world.”
Virtual therapy also eliminates potential peer pressure issues.
“We’ve heard [that patients] go to the substance use disorder treatment clinic and outside is a drug dealer,” Weiner said. “Or you’re dealing with people who are actively in relapse. Just being around other individuals in person and in close contact sometimes might lead someone to return to use.”
Virtual opioid use disorder (OUD) treatment provider Bicycle operates in 32 states and has announced several partnerships in recent months.
The company recently laid off 15% of its workforce following the announcement that its clinicians had filed to unionize.
Even after social distancing recommendations were lightened, not all patients were interested in returning to brick-and-mortar facilities and continued telehealth appointments, according to Micheletti as well as research published in JAMA Network Open.
Some providers were also reluctant to return to in-person arrangements, preferring to avoid commutes and the overhead of an office and enjoying the additional income that may come with being able to fit more appointments into one day. Providers who are sometimes in danger of assault by patients are also guaranteed an additional level of safety.
Magellan Healthcare now has more people who want in-person care than providers who are willing to provide it, Dr. Steven Pratt, senior medical director for the employer segment within Magellan Healthcare, told ATB.
Frisco, Texas-based Magellan Healthcare is a subsidiary of Magellan Health, a leader in behavioral health and related services.
“It’s hard to find things positive about the pandemic, but it drove the industry forward in the use of virtual interventions,” Pratt said. “Now we’re at a point where we need to be more thoughtful in terms of what’s the best use of it.”
Drawbacks to virtual SUD treatment
While virtual care offers benefits for providers and can substantially increase access for patients who may otherwise struggle to get in-person care, there must be a balance of availability to efficacy, Pratt said.
Treating patients with SUD begins with an assessment, but virtual assessment of a patient is only performed adequately about 80% of the time, according to Pratt.
“That leaves a significant portion of the time where we can’t [adequately assess],” Pratt said.
Observations that would be important for a complete assessment could include if a patient appears disheveled, if there is an odor that suggests the person may not be bathing regularly, or if a person has a tremor in their hands.
The SUD industry should reflect on whether providers can conduct assessments adequately via telehealth, Pratt said.
These assessments should also include recommendations on treatment modality to allow providers to fine-tune treatment recommendations for each patient, in addition to determining what level of care a patient needs and what modality.
Some patients are not a fit for virtual SUD care due to practical reasons.
At Bicycle Health, patients must meet certain criteria to take part in virtual treatment. In most cases, patients must have a smartphone, be able to interact with their provider through Zoom, have a safe place to store buprenorphine, be able to pick up their medication at the pharmacy and take urine toxicology screens mailed to them by Bicycle.
Some patients, including those with more acute addictions, are just not a fit for this type of treatment.
“It is not a panacea solution,” Weiner said. “But it is for probably the vast majority of patients.”
While patients who live in rural settings may receive care they otherwise would not, virtual treatment still may not be a good fit. For example, a patient enrolled in a virtual intensive outpatient program (IOP) may show up to their meetings but secretly drink heavily when off camera.
“One of the tenets of medicine and being a doctor is the idea of first do no harm, so we need to make sure that we’re not enabling,” Pratt said. “We need to be willing to have that element of caution and think about whether or not something is better than nothing.”
Usually, something is better than nothing, he continued.
Some providers are more insistent that virtual care should, in most cases, only be used as a complement to in-person care.
“Look what happened with Cerebral and Adderall being able to get prescribed digitally,” Micheletti said. “Are we looking to set ourselves up for that same type of scenario again?”
ADHD treatment provider Cerebral has been in the news for alleged inappropriate prescribing practices of controlled substances, sharing patients’ health information with third-party advertisers and social media companies and having “predatory” cancellation tactics.
How the SUD industry should look at virtual care
Now commonplace, industry insiders say virtual SUD treatment is not going anywhere. Still, some say it should only be available as part of a course of treatment that also involves in-person appointments.
“Even if the DEA chooses to relax guidelines and allow for MAT to be prescribed digitally … there’s got to be the right combination of checks and balances,” Micheletti said. “It’s not one size fits all programming and it certainly cannot all be done through computer or virtual care.”
Virtual therapy should still be available for instances including when patients get sick or have an extenuating circumstance, for psychiatric evaluations that need to be performed quickly in residential treatment settings and for urine drug screens, Micheletti said. Still, she emphasized that the physical act of going to in-person treatment is an important aspect of treatment, especially in the first three months of treatment.
The SUD industry must re-negotiate its relationship with telehealth. For now, providers should focus on treating each patient individually with the treatment modality that best suits their current phase of recovery, according to Alexandra Plante, senior advisor of SUD at the National Council for Mental Wellbeing.
The National Council for Mental Wellbeing is a nonprofit industry group that works to drive policy and social change on behalf of more than 3,400 behavioral health organizations.
“[We can’t] treat every single substance use patient as the same person with the same chronicity, the same severity and the same access to treatment,” Plante said.