Steven Powell, MD
Isolated older adults may be especially vulnerable to addiction issues with the onset of the pandemic. Here’s how telemedicine can help.
From a psychiatric perspective, the older population is inherently isolated under normal circumstances. Many seniors live alone and in locations with limited social contacts and support networks, and rely on their local YMCA, church, or neighbors for socialization. When the COVID-19 pandemic hit, however, nearly all of those opportunities were eliminated. The pandemic has resulted in complete and utter isolation for many older adults, which can contribute to long-term mental illness, anxiety, and depression, and overwhelming feelings of loneliness.
Though the impacts of the COVID-19 pandemic were enormously significant for all, none were more affected than those in long-term care facilities. For these residents, the behavioral health challenges presented by the COVID-19 pandemic have been even greater because the population is more inherently isolated and immobile. Even prior to the COVID-19 pandemic, between 22% and 42% of residents in long-term care facilities experienced loneliness, and 1 study showed that more than half of US nursing home residents without cognitive impairment reported feeling lonely.1 During the pandemic, long-term care residents were essentially “frozen” within their facilities, with no physical contact or meaningful interaction with families and friends.
The Pandemic and Substance Use
Since the COVID-19 pandemic was declared a national emergency in the US in March 2020, increases in substance use and drug overdoses have been observed,2 and the negative effect of older patients with substance use disorders (SUDs) has also become a more serious public concern.3 Emerging evidence suggests that the pandemic has unfortunately exacerbated substance use and mental health symptoms in the most vulnerable populations—including older adults, as studies show that the mental and psychological problems of patients with SUDs might relapse or be exacerbated by social isolation and lockdown during a pandemic.
Increased social isolation, government shutdowns, job losses, and furloughs have also contributed to an increase in fatal opioid overdoses, which were already marching upwards before the pandemic. According to data from the Centers for Disease Control and Prevention (CDC), deaths from synthetic opioids increased by 52% between August 2019 and August 20204, and synthetic opioids were found in the bloodstream of 62% of overdose victims in 2020—compared with 41% in 2017.5 Substance abuse within the older population has justifiably become a worldwide concern during the COVID-19 pandemic, and clinicians face the daunting challenge of treating and preventing relapses amongst the US older population.
The Rise of Telemedicine
Though caring for patients in a fully remote capacity certainly presents unique challenges, the COVID-19 pandemic has taught both clinicians and patients that behavioral telemedicine is an effective alternative to face-to-face interactions. Amongst long-term care residents, we have seen the rise of telemedicine generally, and behavioral medicine specifically, for several reasons.
Facility restrictions: Throughout the pandemic, long-term care facilities have put in place restrictive policies that prevent families and friends—as well as physicians—from visiting patients onsite. These safeguards have also prohibited patients from visiting labs for testing related to addiction or treatment. As the delta variant continues to spread amidst the upcoming cold and flu season, I expect several facilities to reenter or continue their lockdown protocols.
Clinician shortages: Long-term care facilities have faced critical staffing shortages throughout the pandemic, and we have witnessed an exodus of clinicians across specialties. While many psychiatrists have retired—more than 60% of practicing psychiatrists are over the age of 55, one of the highest proportions among all specialties6—others may have burnt out, and the rest may not have been equipped to adequately leverage telemedicine to meet patients’ needs.
There is also a notable lack of physicians practicing in the geriatric space: Only 3% of licensed psychologists identify professional geropsychology as their primary or secondary specialty.6 Telehealth allows providers broader access to these scarce resources. Though general clinicians can certainly care for older patients, for many, it is not their specialty or focus, and to become a geropsychologist requires additional training. This provider shortage has arisen at an unfortunate time, as there are now more people requiring psychiatric care than ever before. Due to the pandemic, Americans’ assessment of their own mental health is “worse than it has been at any point in the last 2 decades.”7
Reimbursement: For decades, payors did not reimburse for telemedicine, and certainly not for behavioral telemedicine services. Those health plans that did reimburse typically did not do so at sustainable rates. Further, the Centers for Medicare & Medicaid Services (CMS) also introduced telehealth flexibilities, and doctors are calling for a permanent solution and more flexibility for mental health telehealth services.8 Though the pandemic has challenged the status quo, the long-term future of payor and CMS reimbursement for telemedicine remains to be seen.
Though the use of telemedicine has waned slightly since the peak of the COVID-19 pandemic, clinicians are maintaining a hybrid model—and from an industry perspective, I expect a long-term benefit of the pandemic is that psychiatrists now understand how to use telemedicine and have taken advantage of it when they otherwise would not have.
The Application of Telemedicine for Addiction Treatment
Telemedicine is a reasonably new phenomenon within the addiction space; unfortunately, challenges related to regulations and reimbursement have stagnated telemedicine adoption for years. Addiction treatment is unique from other treatment scenarios; addiction patients typically require drug screens in a timely, reliable, reproducible, and trustworthy manner. As psychiatrists, we cannot provide medications safely for addictions without this initial drug screening in nearly all settings. Traditionally, a urine drug screen was performed in the office at the time of prescribing. The regulations requiring this have not changed, and efforts are being made to streamline this process for treatment via telemedicine. Processes such as overnighting swabs for new patients and partnering with local and regional labs are all necessary to safely treat patients in a timely manner.
It is widely known that patients seeking treatment for substance abuse have a 48- to 72-hour window to enter treatment before they may relapse, but efforts to capture the needed information within those 48 to 72 hours to include drug screening has been challenging. Treating patients for substance abuse and dependency without drug screening is neither safe nor the standard of care.
Though the COVID-19 pandemic has undoubtedly presented challenges for addiction treatment, a silver lining has been the rise of telemedicine.
New diagnostic methods: First, the COVID-19 pandemic served as an impetus for the invention of oral swabs, which can be used via camera and validated in that way.
Eased regulations: Historically, there have been several laws, including the Ryan Haight Act, that prevented the prescription of controlled substances via telemedicine. For example, despite buprenorphine being used to treat addiction, it is classified as a controlled substance and so was initially impacted by state restrictions. During the pandemic, however, the federal government declared a public health emergency and several states passed laws allowing for addiction treatment via telemedicine. Under the emergency designation, practitioners approved to prescribe certain controlled substances, such as buprenorphine, are no longer prohibited from doing so without first conducting an examination of the patient in person.9
Effectiveness of Telemedicine in Addiction Treatment
For patients requiring addiction treatment—including older adults living in long-term care facilities—telemedicine presents several benefits.
Removes screening barriers: Patients can see a provider much quicker than in a brick-and-mortar setting, where they may have to navigate several providers to be able to receive the appropriate care.
Delivers care more efficiently: Telemedicine allows clinicians to clearly and efficiently view the patient. Meeting via telemedicine also enables psychiatrists to meet with more patients per day, as they can conduct sessions more quickly, and the technology removes the need to be in a clinical setting or in a lab for drug screenings.
Other benefits: Patients who do not have transportation, social anxiety, mobility issues, and other health concerns are able to receive care.
Ultimately, if not for telemedicine, many psychiatric services would not have been provided during the peak of the COVID-19 pandemic, during which patients were not allowed to be transported, and long-term care facilities were on lockdown.
To ensure the successful application of telemedicine in addiction treatment, psychiatrists must consider a number of factors.
Local, state, and federal regulations: Ensure your practice is prepared to prescribe controlled substances via telemedicine. Despite eased regulations during the pandemic, many states still have controlled substance prescribing laws that need to be adequately understood prior to providing treatment.
State license regulations: In a similar vein, it is critical to understand—and to avoid violating—regulations for state licenses. For example, when operating in New Hampshire and treating a patient who resides in New Hampshire, there should be no issue; however, if operating in New Hampshire and treating a patient who resides in Florida, the psychiatrist must be licensed in both states.
Malpractice: Psychiatrists must also make sure that their malpractice covers them; telemedicine is new to the field and may not be listed specifically.
Patient guidelines: To achieve success and ultimately improve patient outcomes, psychiatrists must set expectations and appropriate guidelines for addiction patients receiving care via telemedicine. Accustomed to in-person care, addiction patients may not be prepared to meet in a quiet, safe space for a telehealth visit and may need guidance on doing so.
Ancillary information: In the absence of face-to-face interactions and context clues, psychiatrists should understand the critical importance of ancillary information; what do other nurses, staff, clinicians, and family members think about the patient?
I have personally witnessed patients of all ages and disease states do exceedingly well via telemedicine, and believe it is just as effective as in-person interactions in treating addiction, gaining trust, and developing relationships with patients.
Dr Powell is Chief Medical Officer for MediTelecare, on staff in the Dartmouth-Hitchcock system, a Fellow of the American Psychiatric Association, and a Fellow of the American Society of Addiction Medicine. He currently works clinically as an internist and psychiatrist with a focus on Addiction Medicine.
1. Simard J, Volicer L. Loneliness and isolation in long-term care and the COVID-19 pandemic. J Am Med Dir Assoc. 2020;21(7):966-967.
2. Wang Q, Wang Y, Zuo J, et al. Factors of negative affect in elderly patients with substance use disorders during COVID-19 pandemic. Front Psychiatry. 2021;12:697472.
3. Opioid deaths in America reached new highs in the pandemic. The Economist. March 30, 2021. Accessed October 12, 2021. https://www.economist.com/graphic-detail/2021/03/30/opioid-deaths-in-america-reached-new-highs-in-the-pandemic
4. A record number of Americans died from drug overdoses in 2020. The Economist. July 15, 2021. Accessed October 12, 2021. https://www.economist.com/graphic-detail/2021/07/15/a-record-number-of-americans-died-from-drug-overdoses-in-2020
5. Weiner S. Addressing the escalating psychiatrist shortage. AAMC. February 12, 2018. Accessed October 12, 2021. https://www.aamc.org/news-insights/addressing-escalating-psychiatrist-shortage
6. Merz CC, Koh D, Sakai EY, et al. The big shortage: geropsychologists discuss facilitators and barriers to working in the field of aging. Transl Issues Psychol Sci. 2017;3(4):388-399.
7. Brenan M. Americans’ mental health ratings sink to new low. Gallup. December 7, 2020. Accessed October 12, 2021. https://news.gallup.com/poll/327311/americans-mental-health-ratings-sink-new-low.aspx
8. King R. Docs press CMS for permanent telehealth flexibility, relief from pay cuts in fee schedule comments. Fierce Healthcare. September 14, 2021. Accessed October 12, 2021. https://www.fiercehealthcare.com/practices/docs-press-cms-for-permanent-telehealth-flexibility-relief-from-pay-cuts-fee-schedule
9. Connolly B, Reynolds I.Federal agencies should extend pandemic flexibilities for treating opioid use disorder. PEW Trusts. February 23, 2021. Accessed October 12, 2021. https://www.pewtrusts.org/en/research-and-analysis/articles/2021/02/23/federal-agencies-should-extend-pandemic-flexibilities-for-treating-opioid-use-disorder