When President Trump declared the opioid epidemic a public health emergency, it came with a regulatory change intended to make it easier for people to get care. Doctors are now allowed to prescribe addiction medicine virtually, without ever seeing the patient in person.
In Indiana, this kind of virtual visit has been legal since early 2017. So I called about a dozen addiction specialists in Indiana to find out how it was going. But no one had heard of doctors using telemedicine for opioid addiction treatment until I ran across Dr. Jay Joshi.
At Joshi's practice, Prestige Clinics in Munster, Ind., 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. "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. "When it freezes you're like, 'What do I do? Just sit here and stare at the lady?' "
But she appreciates the counseling. She's a former nurse's assistant and has been going to Joshi for back pain and a heroin addiction for about a year.
"I'm in a good place, you know?" she says. "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!"
To get her insurer to cover her addiction medicine, Hall has to prove she's in counseling. Local counselors are hard to find. By having a telepsychologist available, Joshi helps patients clear that hurdle.
Hall's insurance also requires urine tests for drug use to keep covering her medication. But she failed her latest urine test — she had used drugs the previous week. Joshi asks 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 says.
But because of the failed test, her insurance may refuse to pay for Suboxone, 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 says. "We're seeing her every two weeks. She's participating in the counseling. It's just one thing."
Hall says, "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 he'll 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 says.
"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 says.
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 asks 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 says. Joshi says 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 says 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 says.
She says 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 says.
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.