When President Trump declared the opioid epidemic a public health emergency in late October, it triggered a regulatory change intended to make it easier for people to get care in places with provider shortages. This declaration allows for the prescribing of addiction medicine virtually, without doctors ever seeing the patient in person. (The regulatory change is not fully implemented until the DEA issues further rules.)
In Indiana, this kind of virtual visit has been legal since early 2017. But it turns out, it’s rarely used. Of nearly a dozen addiction specialists Side Effects reached out to in Indiana no one had heard of doctors using telemedicine for opioid addiction treatment except for Dr. Jay Joshi who runs Prestige Clinics in Munster, Ind.
And even Dr. Joshi rarely uses telemedicine for prescribing addiction medications. He prefers to use it to connect patients with counseling, a necessary component of managing their disease. Like many addiction specialists we spoke to, Joshi, thinks the disease is best treated with regular in-person visits.
At Joshi's practice, a telemedicine consultation takes place in what looks like a standard exam room with a computer. On Tuesdays, his patients video chat with a psychologist who lives 140 miles away.
Elizabeth Hall is one of those patients. She's a former nurse's assistant and has been seeing Joshi for back pain and opioid addiction for about a year. Her first telemedicine appointment with the counselor went well.
"The only issue I really had with it was [that] it would freeze, which is kind of inconvenient and a little bit awkward," she said.
But she appreciates how counseling helps her stay on track in her recovery.
"I'm in a good place, you know?" she said. "I'm not doing nothing I shouldn't be doing. I'm not lying to nobody. I'm not sneaking around. Plus, I have a baby. I'm really busy!"
For Joshi, the real benefit of telemedicine is that it helps him manage one component of a very complex treatment regime.
Most insurance plans will refuse to cover addiction medicines like the drug Suboxone that Hall is taking, if patients can’t prove they’re in counseling. Local counselors are hard to find. By having a telepsychologist available, Joshi helps patients clear that hurdle.
It’s one of many hurdles he helps clear for his patients with addiction. For example, this week Hall failed her latest urine test — she had used drugs the previous week. Her insurance also requires urine tests for drug use to keep covering the her medication. Joshi asked Hall to talk to the telepsychologist about why that keeps happening.
"I know you know that I haven't done anything since last week, and I told them I'm not doing nothing no more. I can't screw up my life," Hall said.
But because of the failed test, her insurance may refuse to pay her addiction medication. Joshi's staff may need to intervene with the insurer by phone to keep Hall's treatment covered. "It's one of those situations where she's not taking any other controlled substance," Joshi said. "We're seeing her every two weeks. She's participating in the counseling. It's just one thing."
Hall said, "I've been doing really good, it's just you know, it's hard."
This is why Joshi requires in-person visits — to begin and maintain his patients' Suboxone prescriptions. He prefers to see these patients every two weeks and will even arrange transportation before going too long without seeing them.
Occasionally Joshi will prescribe Suboxone remotely, but typically only for a refill once or twice during a patient's treatment. Seeing the patient in-person is critical to their treatment, he said. He treats the whole patient, not just their addiction, treating other chronic illnesses at the same time.
"You're not going to get a good system of health care for primary care in these high-risk areas unless you invest time and energy into these patients," he said.
The face-to-face interaction establishes trust, allows him to pick up on body language. Plus, it's hard to do a urine drug test screen remotely, and be sure that the sample actually belongs to the patient. A proper screen lets him know if his patients are taking their medication, instead of selling it.
He asked Hall if she mentioned her recent drug use to the counselor.
"I really don't remember if I talked to her about it or not," she said. Joshi said to make sure she comes in for her next counseling session.
Joshi has a lot of conversations that aren't billable.
That's partly why there is a shortage of addiction treatment doctors said Dr. Emily Zarse. She runs the addiction treatment program at Eskenazi Health in Indianapolis.
"Telemedicine is a great idea in theory, but it doesn't fix the workforce shortage problem," she said.
She said insurance billing takes up a lot of time. So do the complexities of addiction treatment.
There is one area where Zarse thinks telemedicine would be helpful — as a tool to train providers. "That takes one expert's time for a couple of hours a week maybe and you can reach 10, 15, 20 people all at one time," she said.
In fact, Zarse plans to launch a course to train Indiana doctors to treat addiction. In January, she'll learn more about how to do it, from Project Echo, a resource for clinicians seeking virtual training tools. Zarse envisions a place where doctors from around the state can video call-in and walk through cases with trained psychiatrists like herself.