Kolmac founder and Chief Innovation Officer, Dr. George Kolodner was asked by the Washington Psychiatric Society to share how pivoting to telehealth and online treatment has worked following the restrictions created by the COVID-19 Pandemic. The following article appears in the January edition of the Society’s e-magazine, Capital Psychiatry.
Advances in the Treatment of Substance Use Disorders During the COVID-19 Pandemic
By George Kolodner, M.D.
In this brief article, I will focus specifically on how telehealth has improved access to withdrawal management (WM) and follow-up treatment. At the Kolmac Clinic, we are proud that we have been able to respond to requests for withdrawal treatment within one business day. For patients with alcohol withdrawal in particular, early intervention is key to preventing serious complications such as seizures and delirium tremens. Now with the use of telehealth, travel is eliminated so that the waiting time to receive an evaluation by one of our clinicians has been shortened to 30 minutes. Patients already in withdrawal can have their symptoms relieved within a few hours.
Furthermore, we have been able to initiate withdrawal treatment in the afternoon as well as the morning and monitor response to medication from 9 AM to 9 PM. In addition, we are able to provide services on the weekends as well as the weekdays so that patients presenting on Friday afternoons do not need to wait until Monday or be admitted to inpatient settings over the weekend.
Improbable as it may sound that the COVID-19 pandemic would lead to an improvement in treatment, this has occurred with regard to Substance Use Disorders (SUD). The expanded use of telehealth is the key to this accomplishment. The evidence-base for its effectiveness has been growing since the inception of telehealth 50 years ago.
The American Psychiatric Association has been active in advancing the field of telepsychiatry (https://www.psychiatry.org/psychiatrists/practice/telepsychiatry). Despite these developments, a fuller realization of the benefits of telehealth have been impeded by a web of state and federal regulations along with insurance restrictions.
Effective treatment approaches have been developed for patients with SUD such that their post-treatment prognosis is equal to that of patients with other chronic diseases, such as diabetes. Before describing how this situation has recently changed, I will focus briefly on two issues that have limited the effectiveness of addiction treatment: barriers to treatment access and fragmentation of care. Unfortunately, most people suffering with SUD do not get this treatment for two reasons.
First, many people are not able to access treatment because the ambivalence that is central to people with SUD means that their readiness to accept treatment fluctuates. When the opportunity window opens, rapid response of the treatment system is essential. Delays and waiting lists are associated with lack of follow–through, and high “no show” rates are common.
Secondly, many patients who have begun treatment do not complete it because the fragmentation of the treatment system leads to discontinuity of care. For example, effective medication protocols for alcohol, opioid, and sedative withdrawal syndromes were developed over the past 50 years and are so effective that serious complications can be avoided for almost all patients. When this treatment is delivered in an inpatient setting, however, less than 50% of these patients receive follow-up treatment for their addiction, without which the return to use rate is over 90%. By contrast, treatment in an outpatient setting can result in over 85% of patients transitioning to follow-up outpatient addiction treatment.
The addiction treatment field has been slow to adopt the telehealth tool, using it primarily to provide lifesaving buprenorphine-based treatment to rural areas of the country where opioid addiction had become a major problem, although waivered prescribers have been few. At Kolmac, we had put in place the infrastructure several years ago with the intention of exploring the utility of telehealth but could only use it on a limited basis because of the regulations and restrictions. These limitations were quickly reduced when the national pandemic emergency was declared in March of this year. Addiction treatment programs were able to offer COVID-safe treatment through the expanded use of telehealth. Because we already had the infrastructure in place at Kolmac, we were able to pivot to virtual services for all 1,300 of our patients within 48 hours.
Here is an outline of how this works:
- The patient reaches out by phone or online and is evaluated by a non-medical clinician within 30 minutes (or scheduled for a later time if preferred). If the clinician determines that a withdrawal syndrome is present or likely to occur, the patient receives a telehealth medical evaluation within 30 minutes by a withdrawal–management (WM) nurse.
- The WM nurse determines that the level of complexity and severity can be managed by telehealth. An assessment is also done of the patient’s environment and in particular to assure that a reliable support person is available to take responsibility for the medication.
- The WM nurse reviews the case with a staff psychiatrist or psychiatric nurse practitioner and prescriptions are sent in electronically to a community pharmacy convenient to the patient’s home.
- Following the directions of the nurse, the support person oversees the administration of the WM medication. Telephone contact occurs with the nurse on an hourly basis for the first 3 to 6 hours, until the withdrawal symptoms have remitted. This is supplemented by video interviewing as needed. The patient is given instructions for bedtime and overnight use of the medication.
- The patient begins attending groups in the outpatient rehabilitation program as soon as possible – preferably on the first day.
- On the second day, the patient is contacted by the WM nurse in the morning and as many times as necessary throughout the day regarding medication adjustments. This continues for the next few days as necessary until medical stability is reached.
- Once the acute withdrawal symptoms have remitted, the WM nurse coordinates with the medical staff of the patient’s permanent Kolmac treatment site to assure a smooth transition for the ongoing management of residual withdrawal symptoms.
Here is a look at our numbers thus far. From mid-March through the end of 2020, we have admitted 385 patients for WM.
- Their primary substances have been:
- Alcohol: 70%
- Opioids: 26% (compared with 35% in 2019 – a sign that despite the continued increase in overdose deaths, overall opioid addiction is declining)
- Benzodiazepines: 4%
- The gender breakdown is 60% men and 40% women. Pre-COVID, women made up 33% of this group. There is some suggestion women more than men may prefer the enhanced privacy of virtual over in-person treatment
- 89% of those who began WM successfully completed it
- 92% of those who completed WM entered into intensive outpatient rehabilitation (IOP)
Telehealth expansion has not been without its problems. One is that we are sometimes under pressure from patients whose symptom severity is too high or whose adherence to our procedures is too low for us to treat them safely outpatient. Their reluctance to accept hospitalization in these pandemic times is understandable, but we do them a disservice if we endanger them with inadequate treatment and have had to remain firm in our insistence on inpatient referral, despite the displeasure this arouses.
A second problem is that pharmacies do not always have the medications in stock that we use. Waiting a day for them to be ordered is not acceptable, given our patients’ level of acuity. Furthermore, pharmacists who are not familiar with the doses of medications necessary to manage patients who have developed high alcohol tolerance will sometimes refuse to fill our prescriptions. The solution we have pursued is to create a network of independent pharmacies who have agreed to stock our medications and have become familiar with our protocols.
In closing, I share with many of my colleagues a concern about to what extent the regulations and restrictions that are currently relaxed will be re-instituted once the national pandemic is over. Professional groups, such as the APA, are working to craft legislation and collaborate with insurance companies to work out compromises. Acceptance by patients has been high. The continued collection of outcome data, such as has been included in this article, will be a necessary component of future negotiations.