You can start drug addiction treatment over the phone—and thanks to COVID, more people are starting to

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Denny Bos's ministry is the foothills of Mt. Baker, in east Whatcom County, Wash., a vast forest home to hundreds of people without addresses. Some live in ramshackle RVs, some in tents, some under tarps.

People go there when they lose their jobs or homes, when their addictions get too serious, or to get away from society, Bos said.

"They just disappear into the woods," said Bos, who's had to build trust to be accepted into the camps.

When Bos, a former pastor who runs Seeds of Hope Ministries, finds someone who's ready for drug treatment, it used to be hard to get them to go see a doctor—the trip to the nearest clinic in Bellingham is 45 minutes, and the foothills' campers can be reclusive.

But that's changed since COVID-19 reached the U.S. and Washington's governor ordered the state to stay at home. In response to the pandemic, restrictions around in-person visits to prescribers for medication-assisted treatment have been suspended across the country, restrictions on billing phone visits to Medicaid were eased, and providers began expanding telemedicine options. At many clinics, you can now get a substance use disorder assessment over the phone, and pick up your prescription at a local pharmacy.

Leading experts in the field want the changes to stay, at least until expanded access can be studied. Twelve members of the federal Interdepartmental Substance Use Disorders Coordinating Committee wrote a letter to federal officials this month asking for the rule changes to stay in place after the pandemic so researchers can study their effects.

To Jim Vollendroff, director of the Behavioral Health Institute at Harborview Medical Center, who has been training providers around the state in the telemedicine expansion, it's one bright spot in the darkness that is COVID-19.

"During this time, which is a devastating time, the silver lining for healthcare in particular, is we've been sitting on the sidelines; we've been wringing our hands" when it comes to expanding telemedicine, Vollendroff said, because of complicated medical privacy regulations. But since COVID-19, "I have seen at least five years worth of progress happen in four months," Vollendroff said.

This does not mean more people are getting treatment in Washington: Between March and June, the number of Medicaid patients in Washington in opioid treatment programs, outpatient treatment, recovery houses or other services for substance use dropped 17.7%, according to data reported to the Washington State Healthcare Authority.

But the sudden jump to telemedicine could pave the way to make it much easier to get into drug treatment, Vollendroff and other experts think.

That's been true at Sea Mar, one of the biggest treatment providers in the state, where new admissions to treatment initially dropped after the pandemic began.

But at the clinic outside Bellingham, where people in rural Whatcom County can now call in to start treatment and where Bos has been connecting campers via phone, admission rates have been rising in the last two months—they're now above average across the network compared to last year, just because of the rise at that Bellingham clinic, according to Chris Watras, director of the Medication Assisted Treatment program at Sea Mar.

"I've really been preaching: There's a ton of positive outcomes with COVID and how it's changing the treatment industry," Watras said.

There are plenty of cons to telemedicine as well. UW Medicine surveyed 329 clinicians, doctors and nurses primarily serving Medicaid populations across the state, and key commonalities were that rural areas often don't have good connectivity to Wi-Fi or cell phone signals, not everyone has access to the equipment needed, and telemedicine isn't often appropriate for people who have serious and persistent mental illness, Vollendroff said.

But they're hearing about more pros than cons, Vollendroff said.

Rates of people who don't show to their first appointment appear to be down across the system, Vollendroff said: At Sea Mar, they were cut in half between March and June, according to Watras.

"My guess is, not everybody is comfortable going into a clinic and talking about their personal issues. They might be more comfortable at home," Watras said.

Meaghan Mugleston, a family nurse practitioner at Neighborcare Health at St. Vincent de Paul in Seattle's Aurora neighborhood, said initially in March there was a drop in new patients and current patients' visits. Since then, across Neighborcare's myriad services, all patient visits have dropped by almost half.

But starting in May, Mugleston began seeing a rise in patients coming to her via telemedicine, particularly for drug treatment. The number of clients Neighborcare is seeing for buprenorphine is back to pre-COVID-19 levels now, according to a Neighborcare spokesperson.

Most of Neighborcare's clients are low-income and some are homeless. Many of them, Mugleston said, haven't seen a primary care provider for years but were more willing to start that process with a call than with an in-person visit. For people whose lives can be hectic and dependable transportation hard to come by, it's provided flexibility—if they miss an appointment, Mugleston can call them back later in the day if her schedule allows.

For Nicole, 32, who didn't want to share her last name because of stigma against people who use drugs, telemedicine has made getting her Suboxone much easier. She's been taking the opioid medication for the last year or so, and once a month, she used to have to take a bus to an appointment with Mugleston at Neighborcare's Aurora clinic.

But after the pandemic hit, Mugleston told Nicole she'd just have to do a phone visit and pick up the prescription. Nicole was surprised; she'd always picked up a general sense that the system was worried about "helping too much" when it came to people with addictions.

"Just saying, 'Oh, they're addicts, we don't want them to try and take advantage of the system,'" Nicole said. "So yeah, it was nice; I can get my medicine like everybody. To be treated more like a normal person."

And after being laid off at the bar where she waitressed, it helped to have one less thing to stress about.

"This is when people would relapse under stress," Nicole said. "It's basically reduced the amount of time I had to invest in getting care for myself from potentially three hours or more to a 20-minute phone call and a 30-minute walk (to the pharmacy)."

Neighborcare's outreach nurses have even been taking donated cell phones to their homeless clients who need telemedicine services but don't have phones. These and other phones and laptops expressly for telemedicine use are from the state Health Care Authority, which has distributed more than 6,000 cell phones donated by cell companies to Medicaid clients since the pandemic hit, and a few hundred laptops to local tribes.

But while telemedicine has helped people start treatment, the pandemic has also created challenges for many in recovery from addiction, according to Jason Bliss, senior outreach director at the Washington branch of the Oxford House organization of recovery homes, shared living where people stay while in the early stages of moving beyond addictions.

Even though providers were among the quickest to get telehealth options up and running, losing an in-person connection with a counselor or an Alcoholics Anonymous or Narcotics Anonymous group is hard.

"It's started to really take a toll on some of them," Bliss said. "We've seen an increase in relapses, we've seen an increase in the decline of people's mental health. It's been rather tough."

Experts like Watras and Vollendroff see telemedicine not as a cure-all, but as an option that can help people without transportation, who live in rural areas or who are limited some other way. And they hope that whatever happens with federal law, providers will keep expanding telemedicine options now that they've started.

"Part of what COVID did was push us out of our comfort zone," Watras said. "We kicked the door open. And I don't see it closing."


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