Journal of Social Work Practice in the Addictions

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wswp20

Substance use disorders and COVID-19: the role of

telehealth in treatment and research

Bethea A. Kleykamp , Constance Guille , Kelly S. Barth & Erin A. McClure

To cite this article: Bethea A. Kleykamp , Constance Guille , Kelly S. Barth & Erin A.
McClure (2020) Substance use disorders and COVID-19: the role of telehealth in treatment
and research, Journal of Social Work Practice in the Addictions, 20:3, 248-253, DOI:
10.1080/1533256X.2020.1793064

To link to this article: https://doi.org/10.1080/1533256X.2020.1793064

Published online: 25 Aug 2020.

Submit your article to this journal

Article views: 1073

View related articles

View Crossmark data

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=wswp20
JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS
2020, VOL. 20, NO. 3, 248–253
https://doi.org/10.1080/1533256X.2020.1793064

ENDPAGE
Substance use disorders and COVID-19: the role of telehealth
in treatment and research
Bethea A. Kleykamp PhDa, Constance Guille MDb, Kelly S. Barth DOb, and Erin A. McClure PhDb
a
Research Associate Professor, Department of Anesthesiology and Perioperative Medicine, University of
Rochester Medical Center, Rochester, New York, USA; bAssociate Professor, Department of Psychiatry &
Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA

ABSTRACT KEYWORDS
Telehealth, or the use of telecommunications and virtual technology COVID-19; digital health;
to deliver health care and engage with patients outside of traditional substance use disorders;
health-care facilities, can play an important role in addressing the telehealth; telemedicine
treatment and study of substance use disorders (SUDs) during the
ongoing COVID-19 crisis. COVID-19 and related safety restrictions
have thrust healthcare workers and researchers into a new reality of
healthcare that relies heavily, or even exclusively, on telehealth
methods. These changes have forced treatment providers and
researchers to be agile in adopting these methods in order to main-
tain continuity of patient care and data collection. There are unique
considerations that should be taken into account as telehealth prac-
tices continue to augment SUD care and research, even when restric-
tions have been lifted. Overall, we propose that telehealth can
support innovation in treatment and research focused on SUDs and
should be an integral part of our work, beyond COVID-19.

Background
The ongoing COVID-19 pandemic and associated social distancing policies have created
unique challenges and opportunities for the treatment and research of substance use
disorders (SUDs). One related development is the increased reliance of health profes-
sionals on telehealth, or the use of telecommunications and virtual technology to deliver
health care and engage patients outside of traditional health-care facilities or in-person
interactions. Relatedly, the financial burden of telehealth has been addressed through
recent changes to reimbursement policies from the Centers for Medicare and Medicaid
Services which now permit similar coverage of telehealth and in-person treatment across
a range of providers including social workers (Centers for Medicare and Medicaid
Services, 2020). Telehealth not only offers the benefit of decreasing in-person exposure
risk for COVID-19 among patients and providers, but can also lessen the logistical and
transportation burdens for patients, particularly those with caregiver roles, work obliga-
tions, and those who travel long distances to access health care. Further, telehealth has the
potential to decrease some of the confidentiality concerns and perceived stigma of seeking
in-person care in an addiction specialty setting.

CONTACT Bethea A. Kleykamp Bethea_Kleykamp@URMC.Rochester.edu Department of Anesthesiology,

University of Rochester School of Medicine and Dentistry, Rochester, NY 14642
© 2020 Taylor & Francis Group, LLC
 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 249

The use of telehealth to address SUDs is not a new concept and has been discussed
at length elsewhere (Huskamp et al., 2018; Lin et al., 2019). However, there are unique
stressors associated with the COVID-19 crisis that can directly impact mental health
and substance use including social isolation, job loss or job insecurity, transitions to
remote work and remote schooling, and uncertainty/anxiety around issues of health,
access to healthcare, safety, and the future. Additionally, early evidence suggests that
there are several shared comorbidities between populations at higher risk for severe
COVID-19 complications and SUD populations, including chronic lung disease, kid-
ney or liver disease, and obesity, which could place individuals diagnosed with a SUD
at high-risk for severe COVID-related illness (Centers for Disease Control, 2020). Also
concerning is growing evidence that vulnerable subpopulations in the United States are
disproportionately impacted by COVID-19 and SUDs including racial or ethnic min-
ority groups, people with HIV or living with homelessness, and prison populations
(Centers for Disease Control, 2020). In combination, these realities highlight the
important role that telehealth can play in addressing SUDs in the current climate
and moving forward. Many clinicians have had to rapidly adopt telehealth methods in
order to maintain a continuity of care and/or data collection. However, as described
below, there are unique considerations that should be taken into account as telehealth
practices become a more common aspect of patient care and interaction over time.
While telehealth is unlikely to be the default method of care moving forward and
beyond COVID-19, we suggest that it should continue to be an integral part of clinical
care and research to augment in-person interactions, and institutions should continue
to support its use.

Treatment considerations related to telehealth and SUDs

Prior to the COVID-19 pandemic, from a clinical care and technological standpoint, all
SUD treatment could be successfully delivered via telehealth. However, Federal and State
laws and the lack of insurance coverage for critical components of SUD treatment [i.e.,
individual and group therapy] by key providers [psychologists, licensed clinical social
workers] prevented wide-spread adoption of SUD treatment via telehealth. In addition,
a well-intentioned Federal Law, the Ryan Haight Act, prohibited the prescribing of
a controlled substance to a patient without a prior in-person evaluation by the prescribing
provider (Drug Enforcement Administration, 2009). For those with Opioid Use Disorder
(OUD), this translated to an inability to access Food and Drug Administration (FDA)-
approved, life-saving medications for OUD, such as buprenorphine/naloxone, without
first having an in-person visit with the prescribing provider. These realities are now
changing as the COVID-19 pandemic has accelerated the use of telehealth for SUD
treatment into patients’ homes and paving a path to care for patients who would not
otherwise have access to in-person treatment due to logistical or physical limitations or
distance from healthcare settings (e.g., rural settings). In addition to individual home-
based treatment via telemedicine, SUD group telehealth treatment is possible and might
be more suitable for some subsets of patients. Group telehealth provides a unique ther-
apeutic setting that might otherwise not have been available in some regions of the
country such as rural/less populated settings.
250 B. A. KLEYKAMP ET AL.

The prescribing of SUD-related medication has also been impacted by the ongoing
COVID-19 crisis. For example, following the Health and Human Services Secretary’s
declaration of a public health emergency due to COVID-19 (Department of Health and
Human Services, 2020), and beginning March 16th 2020, the United States Drug
Enforcement Administration (DEA)-registered practitioners were granted permission to
issue prescriptions for all schedule II–V controlled substances without an in-person
medical examination. This modification stipulates that prescriptions may be issued as
long as the prescription was for a legitimate medical purpose and in the usual course of
professional practice; and telehealth communication was conducted with an audio-visual,
real-time, two-way interactive communication and in accordance with Federal and State
laws (Drug Enforcement Administration, 2020b). Further, in recognition that many
patients with SUDs may not have access to the necessary technology for a telehealth
visit, DEA-registered practitioners and those covered by Medicaid were also granted
permission to treat patients with OUD, including prescribing buprenorphine/naloxone,
via telephone (Drug Enforcement Administration, 2020a). In addition, CMS and private
sector payers have begun reimbursing for individual and group psychotherapy services via
telehealth, including services delivered by psychologists and licensed clinical social
workers.
Many of the clinical challenges that could arise in providing SUD treatment via
telehealth are the same issues that providers face during in person care such as confiden-
tiality, intoxication at the time of the appointment and risk for self-harm or harm to
others. It is important for providers to use HIPPA-compliant software and conduct
telemedicine appointments in confidential areas such as a room with a closed door.
Similarly, patients may need to be reminded to receive visits in an area that is quiet and
confidential. It is possible that receiving treatment within one’s home or private space
such as a car affords even greater confidentiality, compared to in-person care, and may be
preferable to some patients. Developing a clinical protocol in advance of starting
a telemedicine practice including identifying local or state resources that can provide
crisis or emergent interventions are an important part of ensuring the patient’s safety
during treatment.
There are obvious limitations to telemedicine for the treatment of SUD among patients
that lack access to the internet or a device that can be used for audio-video conferencing.
This concern can potentially be addressed by phone counseling depending on patient
preference. There may also be patients that have difficulty engaging in telemedicine
appointments and may require in-person treatment due to the severity of their SUD
and/or severe mental illness. Lastly, although most of a mental status exam can be
performed adequately via telehealth, SUD populations often have an increased risk for
medical comorbidities that are sometimes better assessed with an in-person physical exam.

Research considerations related to telehealth and SUDs

In addition to the challenges that SUD clinical care has faced in adapting and shifting entire
clinics to telehealth methods in a short period of time, human subject’s research focused on
SUDs and their treatment has similarly been challenged to adapt quickly. Telehealth and the
use of digital, remote technologies hold an incredible amount of promise for advancing and
 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 251

supporting novel and innovative research and treatment for SUDs, which has been discussed
in the literature (Marsch & Dallery, 2012; Riley et al., 2019), and some SUD researchers have
already adopted remote methods in their research. Yet many researchers still find themselves
conducting in-person clinical research exclusively. The transition and adoption to remote
study designs and data collection has been particularly slow in the SUD field and in
psychiatry more broadly compared to other fields of medicine (Huskamp et al., 2018).
However, as we find our clinical research studies abruptly halted by COVID-19 safety
restrictions, it is possible and critical to rely on telehealth to support aspects of clinical
research, such as; study participant communication, informed consent, data collection
(including biochemical markers of drug use), and treatment delivery.
Several reasons for the stunted adoption of telehealth and telehealth methods are well-
justified and there are legitimate barriers to implementing such methods. Specifically, reliable
access to the internet or necessary technology may be limited in particular settings, such as
rural areas, which limits access to clinical care and research participation. Research aimed at
addressing these barriers is essential for facilitating adequate enrollment and representation of
various populations in SUD research to increase the generalizability of study findings. There
are also practical considerations to shifting studies to remote designs. For example, obtaining
urine samples for point-of-care testing becomes challenging in a remote context, with little
chance of being able to objectively verify the sample belongs to the participant (unlike saliva
or breath biochemical verification). Determining if a participant is medically and psychia-
trically stable for inclusion in a trial, particularly if an investigational pharmacotherapy is
being administered, often requires a history, physical, and collection of vital signs, which may
not easily lend itself to remote methods. Additionally, obtaining informed consent from
human subjects is also challenging using telehealth, though remote options exist depending
on the institution. Of note is the reality that any telehealth methods integrated into research
will need approval from the Institutional Review Board (IRB), which will have varying levels
of familiarity with telehealth methods, security, and associated risks. IRBs will need to have
sufficient information to make determinations of human subjects protection, which will place
more burden on the researcher to provide such information.

Summary and future directions

Telehealth has become an indispensable aspect of patient care during the ongoing COVID-19
pandemic, with the unique advantage of allowing for continued and even extended treatment
which is often necessary for the chronic, relapsing nature of SUDs. Historically, telehealth has
been used less frequently for treating SUDs compared to other forms of mental health
treatment (Huskamp et al., 2018). We predict that telehealth will become even more
important for addressing substance use as the COVID-19 crisis moves forward given that
it is a scalable solution that can increase treatment access for those suffering from SUDs.
However, as noted above, there are unique considerations and challenges that must be taken
into account as we adapt to the changing landscape of telehealth.
The COVID-19 crisis has presented the unique opportunity to collect data that will
inform and expand on existing telehealth treatment and research methods. Such questions
might include:
252 B. A. KLEYKAMP ET AL.

● How do state and federal level policies pertaining to telehealth evolve as we move
beyond COVID-19? For example, what are the implications of policies that revert back
to pre-COVID-19 coverage and could such shifts create a gap in care for individuals
that will go without treatment once again due to an absence of telehealth benefits?
● Relatedly, are treatment outcomes comparable between in-person and telehealth
delivery methods to justify their continued use, even after safety restrictions have
been lifted?
● What variables predict telehealth treatment outcomes including type of technology
(phone, text messaging, video, virtual reality), telehealth setting and parameters (group
versus individual therapy), patient characteristics (e.g., age, gender, race or ethnicity),
and type of substance use disorder (e.g., tobacco, opioid, stimulant, alcohol, etc.)?
● How do we maintain the fidelity of telehealth treatment and ensure that patients are
receiving optimal care? Similarly, how can we maintain scientific integrity of tele-
health research and ensure that the data collected through these means is not biased?
● How can barriers to telehealth treatment, including the adoption of telehealth in
health systems, be overcome? Such barriers might include healthcare provider train-
ing, patient access Broadband internet, and reliable mobile network connections to
support the technology, or provider/patient comfort with using such technology?
● How can access to telehealth be increased among vulnerable subgroups such as
individuals experiencing homelessness or those that live in rural areas that have
limited access to broadband internet?
● How will telehealth impact existing models of SUD treatment and research that have
been resistant to change such as the clinic model for methadone maintenance or
biochemically verified substance use?

Answers to the above questions will likely evolve as the field of telehealth responds to
technological innovation, changing regulations, and demands for alternative mental health
treatments. Further, this evolution will undoubtedly be influenced by the potential for
future waves of COVID-19 and other unanticipated health crises. However, from our
vantage point, which encompasses SUD clinical care, research, and policy, telehealth has
a critical role to play in supplementing existing treatment and research methods aimed at
easing the suffering associated with SUDs. And we propose that the availability of
telehealth as a SUD treatment option will result in an overall net positive for individuals
struggling with substance use who might have otherwise not sought or had access to the
level of care that is now available to them.

Disclosure statement
No other authors have funding or disclosures to declare.

Funding
Bethea A. Kleykamp is currently supported by the Analgesic, Anesthetic, and Addiction Clinical
Trial Translations, Innovations, Opportunities, and Networks (ACTTION) a public-private partner-
ship with the US Food and Drug Administration (FDA) [U01-FD005936], which has received
research grants, contracts, and other support from the FDA, multiple pharmaceutical and device
 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 253

companies, philanthropy, royalties, and other sources (a list of ACTTION’s industry sponsors is
available at http://www.acttion.org/partners). She was previously employed by the healthcare con-
sulting firm, Pinney Associates from 2014 to 2018. During her employment, she provided consult-
ing advices to pharmaceutical companies, the e-cigarette company NJOY, and the tobacco
company, RAI Services Company on non-combustible tobacco products including e-cigarettes.
Dr. Kleykamp received compensation in 2019 from the health technology assessment company,
Hayes, Inc./TractManager, for contract medical writing on topics unrelated to topics covered in the
present manuscript.

References
Centers for Disease Control. (2020). People who need to take extra precautions. Centers for Disease
Control. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html
Centers for Medicare and Medicaid Services. (2020). Medicare telemedicine health care provider fact
sheet. Centers for Medicare and Medicaid Services. https://www.cms.gov/newsroom/fact-sheets
/medicare-telemedicine-health-care-provider-fact-sheet
Department of Health and Human Services. (2020). HHS public health emergency declaration.
Department of Health and Human Services. https://www.phe.gov/emergency/news/healthac
tions/phe/Pages/2019-nCoV.aspx
Drug Enforcement Administration. (2009). Implementation of the Ryan Haight Online Pharmacy
Consumer Protection Act of 2008. Interim final rule with request for comments. Federal Register,
74(64), 15595.
Drug Enforcement Administration. (2020a, March 31). DEA policy: Use of telephone evaluations to
initiate buprenorphine prescribing (DEA068). Drug Enforcement Administration. https://www.
samhsa.gov/sites/default/files/dea-samhsa-buprenorphine-telemedicine.pdf
Drug Enforcement Administration. (2020b). Title 21 United States Code (USC) Controlled
Substances Act. Subchapter I - Control and enforcement; Part A – Introductory provisions;
Section 802 (54)(D). Drug Enforcement Administration. https://www.deadiversion.usdoj.gov/
21cfr/21usc/802.htm
Huskamp, H. A., Busch, A. B., Souza, J., Uscher-Pines, L., Rose, S., Wilcock, A., Landon, B. E., &
Mehrotra, A. (2018). How is telemedicine being used in opioid and other substance use disorder
treatment? Health Affairs, 37(12), 1940–1947. https://doi.org/10.1377/hlthaff.2018.05134
Lin, L. A., Casteel, D., Shigekawa, E., Weyrich, M. S., Roby, D. H., & McMenamin, S. B. (2019).
Telemedicine-delivered treatment interventions for substance use disorders: A systematic review.
Journal of Substance Abuse Treatment, 101, 38–49. https://doi.org/10.1016/j.jsat.2019.03.007
Marsch, L. A., & Dallery, J. (2012). Advances in the psychosocial treatment of addiction: The role of
technology in the delivery of evidence-based psychosocial treatment. Psychiatric Clinics of North
America, 35(2), 481–493. https://doi.org/10.1016/j.psc.2012.03.009
Riley, W. T., Oh, A., Aklin, W. M., & Wolff-Hughes, D. L. (2019). National institutes of health
support of digital health behavior research. Health Education & Behavior, 46(2_suppl), 12–19.
https://doi.org/10.1177/109019811986664