SAMSHA offers an online treatment services locator to help consumers find behavioral health providers in their region. But this web tool also demonstrates the shortage of substance use treatment providers in many rural areas.

Meanwhile, between 1999 and 2015, opioid-related overdose death rates in rural areas quadrupled among those 18 to 25 years old and tripled for females, according to the Centers for Disease Control and Prevention.

“Looking at SAMSHA’s map of Michigan, pretty much anywhere above Grand Rapids, there is only a dot here or there. And there is a huge need for mental health services and substance use treatment,” says Scott Smith, MA, LPC, CAADC, a clinical supervisor at Pine Rest Christian Mental Health Services in Traverse City.

With a grant from SAMHSA, Pine Rest has launched a telehealth program to provide assessment and therapy to expand outpatient treatment for substance use disorders and co-occurring conditions to adults in underserved rural areas in northern Michigan.

Pine Rest offers counseling with a certified addiction counselor through an online video connection using a computer, tablet or smartphone to individuals living in eight counties.

 “Instead of having to travel a long way in bad weather, this allows people to go online for treatment,” says Smith, who is supervising the grant for Pine Rest. Another benefit, he says, is that it provides an added element of confidentiality for professionals who work as physicians, first responders or police officers in small communities. When dealing with substance use issues, they might compromise their professional standing if they’re seen entering a treatment center.

Grant programs

SAMHSA continues to support programs that address the potential connection between telehealth and the opioid crisis in rural America. The federal Health Resources and Services Administration’s (HRSA) Office of Rural Health Policy has given grants to three organizations to establish a Substance Abuse Treatment Telehealth Network.

“Substance abuse treatment is an excellent use of telehealth,” says William England, director of HRSA’s Office for the Advancement of Telehealth.

Particularly relevant in addiction treatment is the convenience factor for patients who otherwise would travel long distances to see a provider. And telehealth can enable them to get the care that they might otherwise skip, he says, helping to reduce relapse rates.

In September 2017, Avera Health in Sioux Falls, S.D., was awarded a three-year grant of $746,000 as part of the HRSA program.

“There are a lot of different ways we measure shortages, but by most of those measures, South Dakota is one of the states most desperately in need of more services,” says Matthew Stanley, a psychiatrist at Avera Medical Group University Psychiatry Associates in Sioux Falls. “A large percentage of our counties are in shortage areas. We don’t have enough psychiatrists for our population. A two- or three-hour drive is not unusual, and it can be a two-month wait to get an appointment.”

He says primary care doctors often feel overwhelmed by the number of health issues they are being asked to screen for, treat and monitor. With telehealth, family physicians can refer to a specialist quickly for supporting care services.

Avera’s telehealth has helped to create an easy handoff to a mental health professional in Sioux Falls from primary care providers in other areas of the state.

“The local practice or community might not be large enough to have those practitioners. [With telehealth,] we can connect them to Sioux Falls, where we do have the resources,” he adds. “We are trying to extend SBIRT [Screening, Brief Intervention and Referral to Treatment] a little bit by having a licensed chemical dependency counselor available in our central hub.”

The providers who conduct telehealth sessions in the Avera network are dual-licensed—mental health and chemical dependency—so they can go through an extensive intake interview and determine the best treatment plan for that patient.

“Beyond that, we have extended medication-assisted treatment,” Stanley says. “That is probably the harder but more necessary service with the opioid crisis. We can connect a patient to medication-assisted treatment through telemedicine.”

Avera also is providing access to naloxone prescriptions directly to consumers through its mobile app, AveraNow.

“Naloxone is a big lifesaver if you can get it to people experiencing acute overdose,” Stanley says. “We want people to have an opportunity to have naloxone—like having an EpiPen around if you have an allergy.”

By signing up on a smartphone, consumers can directly talk to a physician who will review the criteria, determine the need and issue a prescription to a local pharmacy if the consumer is determined to need on-hand naloxone. The cost is $49.

Logistical hurdles

Large integrated health systems with rural service areas also are looking to add telehealth treatment of substance use disorders. David Hasleton, MD, is a practicing emergency physician and associate chief medical officer for Intermountain Healthcare in Salt Lake City. With its large, rural geography in two states, Intermountain is increasingly turning to telehealth for specialist care, and Hasleton says planning has begun on including substance use treatment in the array of telehealth services it offers.

“With medication-assisted treatment, which is one aspect of treating opioids, the hard part is that the practitioner has to be licensed in a particular way,” he says. “We are working through a bunch of legal questions around that. There are some challenges, but it is doable.”

Ensuring proper licensing is essential for telemedicine of any kind. According to the Federation of State Medical Boards, physicians who treat or prescribe through online services sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients receive care. It’s the location of the patient that determines the licensing requirements.

Another challenge telehealth pioneers face is the uneven insurance reimbursement landscape. For example, the Medicaid policies involving telehealth vary state by state.

“Some insurers will cover mental health or psychiatry via telehealth but not substance use treatment,” says Pine Rest’s Smith. In Michigan, Blue Cross Blue Shield will cover substance use treatment via telehealth now, but Medicaid will not.

“Medicaid patients are probably the largest population in rural areas that deal with substance use issues,” he says. “That hurt us in the first year—not being able to take Medicaid clients.”

Also, rural areas are likely to experience a lack of broadband Internet access, which can make connecting telehealth sessions difficult. For the patient population most in need of services, internet access can be costly as well.

“There is not a lot of high-speed Internet in Northern Michigan,” Smith says. “Some clients have to sit in a certain part of their house just to get a signal. It is ironic because there are areas up there with multimillion-dollar homes, but they just switched from dial-up not too long ago.”

Conducting substance use treatment assessments and sessions via telehealth also requires some extra training for providers. Smith says it’s important to set up web cameras so the patient and the provider can see each other at eye level, for example.  “Also, you have to make sure the client is in a place where they feel safe and secure—not in a dorm room with friends or in a public library.”

Before they have experience, providers tend to think that a telehealth consult is going to be awkward or that they are not going to be able to read the patient well.

“But once they have done some telemedicine, both patients and practitioners describe being pretty satisfied with the experience,” says Avera’s Stanley. “Because we operate this out of a hub where there are a lot of other telemedicine practitioners, we do a fair amount of orientation and walkthrough and make sure we are using validated tools.”

HRSA’s England says its grant program has asked grantees to report on an array of metrics regarding the efficacy of pilot programs, and it’s the first time the agency has made an award in telehealth for substance use disorder treatment. “This is one of the priorities for the department, and we are excited to be able to showcase what telehealth can do.”

One of HRSA’s goals is for the programs to attain sustainability, which largely depends on the reimbursement environment at the state level. Many states have made progress with legislation, England says, but it’s ultimately the reimbursement that will drive the adoption.

David Raths is a freelance writer based in Pennsylvania.