Treating Patients with Substance Use Disorders During the Coronavirus Pandemic
by Dr. George Kolodner
The coronavirus pandemic has brought isolation and stress, both of which are bad for people with substance use disorders (SUD).
Liquor sales are going up. We know that 18% of people with general anxiety disorder and 13% with anxiety self-medicate their condition with alcohol1. Furthermore, a disproportionate amount of liquor and other drugs are consumed by heavy users.
Even though liquor sales are up, requests for addiction treatment are down. This would suggest that people who are struggling with alcohol and drug problems have “gone into hiding.” It also raises the possibility of a spike in patients seeking treatment after the pandemic subsides. But what are we doing to help them right now?
The shift to outpatient treatment
Because of the risk of infection, patients are particularly frightened about receiving treatment in a hospital or residential setting. Many think that treatment for withdrawal management and rehabilitation can only be done in an inpatient setting. However, there is no evidence that inpatient treatment is better than outpatient treatment.
Although many people with SUD are skeptical about their prospects for recovery in an outpatient setting, their fear of infection is driving them to try outpatient treatment during the pandemic. Kolmac has always attracted people who prefer outpatient treatment, but many patients are surprised to learn that we have taken it one step further by conducting it online instead of in-person.
Making the case for telemedicine
Telemedicine has been available since the 1970s and is gradually gaining wider acceptance. It makes treatment more accessible, especially in providing specialty expertise to areas of the country where treatment can be difficult to obtain. Many studies have documented the comparable effectiveness between telemedicine and in-person treatment, but medical practice is sometimes slow to fully embrace new developments.
Kolmac began using video-enabled telemedicine four years ago for withdrawal management. This allowed our physicians and nurse practitioners (who supervise our nurses) to see an individual patient rather than just hearing their voice on the phone. Our goal was to expand this approach in the interest of making treatment more accessible, by applying it to group therapy for our outpatient rehabilitation – the Intensive Outpatient Program (IOP).
Preliminary efforts were underway in other areas of the country, and the outcomes were promising. What prevented us from moving ahead with this plan at Kolmac was the web of federal and state regulations as well as insurance reimbursement restrictions that made the process impractical.
Kolmac’s switch to online support
Any barriers we faced were rapidly eliminated in mid-March when the virus pandemic made extensive in-person treatment dangerous. Because Kolmac had already been providing limited online care, we were in an excellent position to rapidly shift our in-person care into a fully online model. We have achieved this in two ways.
Firstly, we are conducting video-enabled group therapy sessions in both the IOP rehab and Continued Care portions of our treatment program. Using HIPAA-compliant video conferencing software, Zoom, we can see and speak with patients from the comfort and safety of their home. Evaluations are scheduled virtually during days, evenings, and weekends. All of the clinical services that we provide through Zoom are covered by insurance.
Secondly, we shifted from limited to comprehensive online withdrawal management. A responsible third party must be available to assist with this process. Prescriptions are sent to a pharmacy near the patient, and the medication is self-administered under the direction of the Kolmac medical staff and the supervision of a patient’s assistant. As with in-person treatment, the frequency of medication adjustment is hourly during the first several hours. Importantly, patients usually participate in the IOP session on the same day as they are receiving withdrawal management. Currently, Kolmac appears to be offering the most extensive of this type of service of any SUD treatment program.
Positive signs and post-pandemic plans
Since the coronavirus pandemic took hold, we have treated over 100 withdrawal management patients online and are encouraged about the positive outcomes in terms of the resolution of the withdrawal symptoms and – just as importantly — the transition into follow-up psychosocial treatment.
Our online format also allows us to start withdrawal management in the afternoon (rather than just in the morning) and seven days a week (instead of being limited to weekdays). Most patients that have experienced relapse are new rather than current patients, and those using alcohol outnumber those using opioids.
Once we return to in-person treatment, we plan to build on what we are learning during the pandemic and maintain a virtual capability to supplement our traditional approach. This will allow us to continue to expand the accessibility of our services to geographically underserved areas as well as to individuals who find the privacy of online services preferable to in-person treatment.
1Osborne, N. COVID-19 poses unique challenges for alcohol drinkers. Alcohol.org. Updated April 28, 2020.