Some of the communities hit hardest by the opioid epidemic are in rural America. However, many of those same communities lack access to comprehensive treatment.
To address the epidemic’s increasing reach, the White House declared a public health emergency on Oct. 26. The administration outlined a need to expand treatment in rural communities, most notably by making telemedicine more readily available. Telemedicine, also referred to as telehealth, aims to improve treatment access by allowing people to consult their provider remotely – for example, by using videoconferencing.
As a researcher of opioid treatment in Michigan, I’m excited to see the call for greater availability of telemedicine as a way to help rural communities. However, telemedicine has important limitations that need to be considered.
Drug overdose deaths are rising in rural areas across the U.S. In 2015, the overdose death rate for rural areas surpassed the death rate for urban or suburban areas. People living in rural areas were four times more likely to die from overdoses in 2015 than they were in 1999. The opioid epidemic hit states east of the Mississippi River hardest, with the highest death rates in relatively rural states: West Virginia, New Hampshire and Kentucky.
The most scientifically supported opioid treatments combine medications – like buprenorphine, methadone or Suboxone – with behavioral therapy. These opioid treatment programs help patients stop abusing opioids and promote long-term recovery.
However, people living in rural areas face a number of barriers in accessing opioid treatment. Many rural populations have a limited number of clinics that provide opioid treatment and behavioral therapy, as well as a shortage of providers who prescribe opioid treatment medications. People living in rural areas frequently travel long distances to their opioid treatment provider. Moreover, many may feel ashamed or stigmatized if they seek out opioid treatment in their local community.
In northern Michigan, for example, roughly 400,000 residents live north of the closest clinic in Otsego County that provides both methadone and behavioral therapy. People in need of comprehensive opioid treatment in these remote areas require their own transportation and finances to support multiple hours of travel.
The shortage of providers is also an obstacle for rural communities in less remote areas of Michigan. In Lenawee County, which is situated roughly an hour from Ann Arbor and Toledo, there are approximately 100,000 citizens with access to a handful of buprenorphine treatment providers. The few rural providers in areas like this typically offer opioid treatment within small family medicine practices and have limited staff to provide behavioral therapy.
Telemedicine pros and cons
One study from Ontario demonstrated that the more sessions patients attended via telemedicine, the more likely they were to stay in an opioid treatment program. Patients in the study attended telemedicine sessions under a nurse’s supervision at an affiliated opioid treatment clinic. The prescribing physicians, who likely oversee other clinics from afar, were videoconferenced in from a different location. Videoconferencing helped patients better access providers to discuss medication issues, but still required patients to travel to an affiliated clinic.
The White House has yet to provide explicit details on how expanded telemedicine services will be funded. The US$57,000 released through the public health emergency isn’t enough by itself to lead to meaningful changes and needs renewal after 90 days.
The use of telemedicine for opioid treatment also presents particular challenges. Providers are required by law to see patients for initial in-person assessment before prescribing controlled medications like Suboxone.
There are exceptions to this law, including letting the patient see other clinical staff in person while videoconferencing with the prescribing physician. The emergency declaration could offer even more flexibility.