Substance Use Disorder and Telemedicine: Opportunity and Concern for the Future
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and Sarah Wakeman, MD
Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06299-8 © Society of General Internal Medicine 2020
pandemic has forced health systems across T hetheCOVID-19 USA to adapt, innovating systems of care for the protection of patients and public health. The most apparent transformation is the sudden shift to telemedicine across specialties. Prior to the crisis, nearly 13,000 Medicare beneficiaries received telemedicine care each week; in the last week of April alone nearly 2 million patients received telemedicine services. This rapid expansion in telemedicine services has included care for patients with substance use disorder (SUD) where access issues have long prevented adequate care delivery. 1 There are clear benefits to telemedicine in delivering care for patients with SUD. In addition to reducing transmission risk of COVID-19, telemedicine also has the potential to increase access. A phone visit reduces the barriers of coming to the office for a patient who might be reliant on public transportation, may need extra time off for work, or might need to find child care. Importantly, for opioid use disorder treatment in particular, telemedicine may offer access to medication treatment for patients who have not previously been able to initiate care in a brick and mortar clinic. New policy changes now allow for the initiation buprenorphine over the phone; this with aligned reimbursement could increase access to lifesaving care even during periods of lock down.2 The move to telemedicine presents an opportunity to positively impact the lives of patients with SUD, but its implementation must be deliberate to not exacerbate the structural inequities that already plague the care of these patients. Given the overall increased risk of mortality among those with SUD relative to other patients, especially those with a history of non-fatal overdose, it is imperative that a shift to telemedicine does not impact the quality of care for these patients. Preliminary data already indicates that overdose
Received September 10, 2020 Accepted October 5, 2020
deaths have skyrocketed since the start of the pandemic, with some areas recording a near doubling of deaths.3 While the benefits cannot be overstated, concerns have already been raised about the potential of the shift to telemedicine to exacerbate disparities already driven by racism and poverty. Patients with SUD likely also face more significant telemedicine access issues than other patient populations due to ongoing structural inequities. SUD disproportionately affects patients experiencing homelessness and poverty.4 The overdose crisis is also dramatically impacting Black and Latinx patients, who experienced the highest rates of increase in overdose deaths from 2013 to 2017, largely driven by illicitly manufactured fentanyl.5 And yet, because of racist drug policy, Black and Latinx individuals are disproportionately criminalized and have lower access to and retention in effective SUD care.
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