The Telepsychiatry Advantage: Episode 16

How To Spot Substance Use Risk In A Telepsychiatry Visit

The Crisis of Substance Use Disorders

Welcome back to The Telepsychiatry Advantage. I’m your host, Dr. Edward Kaftarian. We have a major problem in this country with drug addiction—substance use disorders. What if I told you that more Americans have died of a drug overdose than every single American soldier dying in every major American war combined? Well, it’s true: over a million people have died in this country of drug overdoses.

Now, that number has declined in recent years. It peaked around 2025. That was the height of the pandemic. We had over 100,000 people dying every year for a couple of years. That number peaked at over 100,000. And now that number has declined a bit. So we’re at about 70,000 people dying of a drug overdose in the year 2025. But if you think that number is not that big, let me tell you that one of the most devastating wars that we’ve had, the Vietnam War, 58,000 people died.

So more people died last year in America than all of the American soldiers in the entire Vietnam War. Have I got your attention? Are you convinced that we have a major problem with substance use disorders in this country? Well, I am, and part of the solution is going to be, of course, telepsychiatry. And so I want to talk to you about assessing and treating patients with substance use disorders.

Today we’re going to do part one of a two-part series on substance use disorders via telepsychiatry. Part one is going to focus primarily on assessing and evaluating patients that may have a substance use disorder. And part two is going to be treatment of substance use disorders via telepsychiatry.

Access To Care Can Be Difficult For These Patients

So let’s talk about treating people via telepsychiatry who have substance use disorders. Well, these are some of the same people who have trouble with access to care. They have trouble getting to a doctor: rural populations who don’t have access, people with unstable housing, difficulty with transportation, difficulty with money, poverty. These are people that are disproportionately affected by substance use disorders and have trouble getting to a doctor who’s qualified to treat them.

So what’s the solution? Telepsychiatry. So let’s say you have a patient in front of you and they may have a substance use disorder. Well, the first thing that you want to do is assess to make sure they’re stable enough for the assessment. Before you launch into the detailed substance use history, ask yourself a basic question: Is there something happening right now that requires immediate attention? Is the patient intoxicated? Is the patient experiencing an overdose? Are they in withdrawal that is extreme? Are they delirious or medically unstable? Are they acutely psychotic, suicidal, violent, or agitated? So before you get into actually assessing the patient for the degree of their substance use disorder, you want to make sure that they’re stable enough to continue the appointment.

You want to do something that is a good idea for every telepsychiatry appointment, which is make sure that you know where the patient is. Who is the patient with? Are they alone or is there somebody else with them? Where are they located—in their home, in a friend’s home, or are they on the street? Because we are now able to assess patients on the street if they have the technology.

So where is the patient? That’s important because if they are overdosing, if they are intoxicated or in withdrawal, or if it’s an emergency, you need to know how to get them to treatment. You want to ask the patient, “When was the last time you used the substance of choice?” And of course, you need to know what substance is their substance of choice.

When did they use it? How much did they use? Are they currently intoxicated? Are they experiencing withdrawal? Have they overdosed? Have they ever had a seizure when they were withdrawing? Have they experienced confusion or delirium during the withdrawal? And of course, have they harmed themselves or are they thinking about harming themselves? So the goal is to determine if the patient can safely participate in a meaningful assessment right now via telepsychiatry.

Taking A History And Diagnosing SUD

Once it’s established that it’s not an immediate emergency preventing you from continuing, then I recommend starting with an open-ended question: “Tell me about your substance use.” Have them tell you their story. When did the substance use begin? What happened? What were the life circumstances? What did the substance initially do for them?

Did it make them feel better? Was it a form of escape? And then how did the substance use progress? When did it actually become a problem and what consequences did they face? Did this make them homeless? Did this make them lose touch with their family or their social supports? Because for so many people with substance use disorders, there’s so much stigma around it, so much shame around it. It’s often considered by a lot of people in society as a moral failure, and it’s not. Addiction is a medical condition, and I’m glad that we’re starting to acknowledge that and move toward a medical model of substance use disorder treatment.

Now, for every drug that the patient may be taking, first, you want to ask essential questions like: what drug are they taking, how much, how often, when was the last use, and what happens when they stop? Then, once you’ve asked the basic questions, you can dive deeper in and understand the detailed life story about when it happened, how many times they’ve been treated—whether it’s detox, rehab, inpatient, or outpatient treatment—overdoses, withdrawals, or withdrawal seizures. There are so many questions that you would need to ask that we don’t have time to go over every single question, but make sure to get a detailed drug history.

Now there are several screening tools you can use, but the screening tool is just a tool. So it just tells you kind of where to look, and the clinical interview will tell you more about what’s actually there—like what you’re dealing with with that patient, how significant the drug use is, what it means to the patient, and what it means to their functioning and their life.

For a detailed list of the criteria to diagnose somebody with substance use disorder, I’d refer you to the DSM to look at the criteria. But basically, it’s a loss of control: they’re using more than intended, longer than intended, they have cravings, they experience strong urges to use, and then they have functional consequences. In most mental disorders, one of the criteria in the DSM is: does it cause social or occupational dysfunction? So you want to think about how the drug use affects their functioning. And are they using substances in a risky way? Are they driving while intoxicated? Are they using the drug in dangerous situations? And so these are some of the ideas and concepts you need to go over.

Physical Examination And Environmental Nuances Via Telehealth

So let’s focus a little bit more specifically on telepsychiatry. What makes it different when we are assessing a patient? You don’t have the same physical examination when you are seeing a patient remotely, but that doesn’t mean that you can’t treat the patient. Some of the harder things to observe, but that are still very much possible and doable via telepsychiatry, are things that are sort of subtle—like if the patient’s pupils are dilated from a stimulant, for example, like if they’re on cocaine and their eyes are dilated.

If you don’t have a good high-resolution camera on their end, you might not see it. You also might not see if the patient is sweating, or other fine motor movements like tremors. You might not see the patient walk into the room. You might not see needle marks on their arms if their arms are outside of the scope of the camera.

So through telepsychiatry, one of the things that you need to keep in mind is you may not be seeing everything that you would see if the patient was there in front of you in person, but you can see it if you are deliberate. You can make sure to pay attention when the patient is walking into the room.

Make sure to have them stand up and show you their arms, and have them get closer to the camera so you can see their eyes. Have them show you their skin to see if they’re sweating, or get closer to the camera so you can see their fine motor movements. So these are all things that can and should be done via telepsychiatry, but you’re going to have to be a little more deliberate about it, especially if you suspect a substance use disorder.

Another thing that you need to keep in mind that is especially important in telepsychiatry encounters is you want to make sure that you establish: where is the patient right now, and what is the environment? The environment is definitely part of the assessment. I’ve said it many times and I hope you guys are learning to observe the environment, but that is an actual advantage of telepsychiatry because you can get a window into their environment.

You can maybe see other family members. Are they in a place that looks completely disheveled, like there’s drug paraphernalia, alcohol bottles, or unsafe or chaotic environments? Are there children in the background in the midst of this chaotic environment? That will give you an idea of how bad the substance use disorder is—that maybe they’re neglecting their children, or maybe they’re exposing their children to the drug use.

Another thing that you need to keep in mind is that you have to be very deliberate about the privacy of your encounter via telepsychiatry. Just like other conditions, the patient who’s seeing you may have other people listening in just outside of the camera view. And for a substance use disorder assessment, that matters because they may not disclose their actual substance use if they have another person who’s present in that environment.

So what you want to do is ask, “Is there anyone else in the room?” And if you feel like the patient can’t be forthcoming because they’re afraid of the reaction of that person, you can message them through the secure messaging app so they visually see the message and they can respond that way.

Another thing to consider is that intoxication can sometimes be harder to distinguish from technology problems via telepsychiatry. Let’s say that the patient takes a few seconds to answer a question. Well, in person you might think that they have cognitive impairment or sedation, but in telehealth, it could be that there’s just a lag in the internet. So there can be lag in the Wi-Fi signal, causing an appearance that the patient has a delay in their cognitive processing.

You want to make sure that the connection is strong on both ends so that if there’s a delay, maybe you can attribute it to the patient being intoxicated or even delirious—some sort of cognitive impairment causing them to have a delay in their speech and in their thinking. And that can give you some clues about whether they are currently in the midst of the substance use disorder.

In some cases, you might be missing something. We have a sixth sense as mental health professionals where we think, “Gosh, the patient isn’t telling me something. The patient is not being honest with me.” And people with substance use disorders conceal their addiction for all kinds of reasons. Maybe it’s stigma, maybe it’s social consequences, maybe it’s other consequences.

Maybe they have a lot of shame about it, or maybe they don’t have insight. So there are lots of reasons why they might not share their substance use disorder details with you. You have to be a little bit persistent to get as much information as you can. And if you have this sense that they’re not telling you something, then there are other ways to gather information—like collateral informants, like friends and family, as long as they give you access to that information, as long as the patient gives you access. Maybe there are people on the other end of the camera, like nurses and other people in the clinic, that can give you more information. And of course, diving into their records and doing a record review will give you some more information in that regard.

So listen to that sense inside of you that says, “I’m missing something.” And you know what? Ask them directly. Just say, “What am I missing?” Ask the patient that, because sometimes if you just shut up for a minute, the patient will actually tell you what’s happening.

Evaluating Withdrawal And Medical Needs

Now let me talk a little bit about assessing withdrawal. Well, the history is going to be really important. How much did they use? When did they stop using—like, when was their last use? Have they had withdrawal in the past? Have they had seizures when they withdraw, or delirium or hallucinations? So there are lots of questions that you can ask about withdrawal.

And then their current symptoms: Do they have a tremor? Are they sweating? Are they anxious? Do they have agitation, restlessness, yawning, rhinorrhea (which means nasal drip), or lacrimation (which means there are tears coming out of their eyes)? Do they have GI symptoms—nausea, vomiting, diarrhea, insomnia? You want to also distinguish between symptoms that may be due to another mental disorder.

So you want to be asking about withdrawal, and you might be a little bit limited at times with the telehealth evaluation, especially if you don’t have reliable access to vital signs. Now this can be solved. I mean, you can have the patient take their own vital signs if they’re skilled enough and you supervise it, or they have the ability to do that. Now, that information may be limited, and it’s probably best to have a nurse or other healthcare professional take vital signs, but take what you can get.

You’re also going to need to get access to laboratory data, and this can all be done through telepsychiatry with assistance from clinics and hospitals. So obviously you want to do a medical assessment. You want to make sure that you have the patient go to their primary care doctor for a complete physical examination when that’s possible.

And I say when that’s possible because, you know, everything needs to be put in perspective. I mean, some people just don’t have access to certain resources, and you have to work with those people. One of the most important things would be laboratory tests to see what other substances are in their body. And you want to work with a lab that’s in the patient’s area to get that information.

So this, again, can all be coordinated via telepsychiatry with help from resources that are in the patient’s area.

Co-Occurring Conditions And Risk Assessment

Like I said before, you want to make sure that you distinguish substance use from other co-occurring conditions. We used to call it dual diagnosis; now we call it co-occurring, meaning a mental health diagnosis alongside a substance use disorder.

And as you all know, substance use disorders affect medical and mental health conditions, and medical and mental health conditions can affect substance use. So some of the common co-occurring mental health conditions would be depression, anxiety, PTSD, bipolar disorder, ADHD, and lots of other conditions. Trauma is an important thing to consider with anyone with substance use disorders, because people who use drugs on the street are more likely to have been traumatized, and people with trauma might run to drug use to help them with anxiety and the feelings associated with their trauma.

So it’s kind of like the chicken-and-egg question: When did the psychiatric symptoms begin—before the substance use or after substance use? But it almost… it matters, but it almost doesn’t matter, because you have to treat both conditions at the same time. And that’s where the art of psychiatry comes into effect.

And now, a quick word from Orbit Health. Orbit Health is a telepsychiatry company that provides services to California County Behavioral Health. If you’re a psychiatrist interested in working with a company that will support you and put you in the best position to succeed, there’s no better choice than Orbit Health. If you want to learn more, go to Orbit Health. Thanks.

Now, with somebody with a substance use disorder, my recommendation is that you assess for suicide and violence risk with almost every encounter, if not every encounter. So you ask directly if they have suicidal thoughts, an intent, a plan, or means to kill themselves. Now, if they have a substance use disorder, then you automatically assume that they have the means to kill themselves because if they’re using drugs, they’re at risk of drug overdose.

And as I’ve said before, the street drug supply in this country is tainted with fentanyl. Fentanyl is everywhere. And if somebody is taking a drug thinking that they’re taking cocaine, there’s a very high chance that they’re also taking fentanyl. Whatever drug that they get on the street, there’s a very high chance of that drug being tainted with fentanyl.

And therefore, any patient that has a substance use disorder is automatically at risk of a drug overdose. In fact, there’s something that we didn’t talk about earlier, which is the drug overdoses in this country: How many of them were intentional? It’s very hard to say, because some can be intentional drug overdoses, some could be completely accidental, but then you also have something in between where the patient is using a big dose of drugs not caring whether they live or die.

So is that a suicide, or is that an accidental drug overdose? It’s kind of somewhere in between, and we don’t really have access to what the patient was thinking before they died of a drug overdose. So we don’t know, but we do know that anybody that has a substance use disorder is at a high risk of suicide and a high risk of drug overdose.

Oftentimes they’re at high risk, so you have to assess for that and determine the risk level. And the risk level fluctuates, especially if they’re using drugs. Now, people are more likely to kill themselves when they’re intoxicated or in withdrawal. And the exact figure is hard to say, but if somebody is in withdrawal, then they’re more likely to harm themselves.

It’s hard to quantify, like I said, because patients will be very cagey; they will hide their drug intoxication and their withdrawal. So it’s really hard sometimes to tell what the risk level is, and we don’t have a perfect way to do this. But best practice would suggest that you do your best to get as much information as you can and treat the patient conservatively in a way—meaning assume that they have risk and treat accordingly.

Social Environment, Collaterals, And Readiness to Change

Now, one of the important things to consider in telepsychiatry is assessing the recovery environment. The patient’s environment is going to be one of the primary factors that determines whether they are going to be successful in overcoming their substance use disorder. What is their living situation like? Who lives with the patient? Somebody who is in a codependent relationship living with another person with addiction is going to be at higher risk. It’s going to be harder for them to overcome the substance use disorder. They’re going to have constant pressure to use, and it’s just not going to be a great environment.

Also, you want to assess for social supports like family, friends, the recovery community, or a sponsor. All of these things are social supports that will determine whether the patient has the resources to have a good chance of recovering. And it can also determine if there are extra risks, like I said: Are the social supports those people who also have substance use disorder? Because that’s going to make it harder for the patient to overcome their addiction.

Some of the psychosocial aspects like housing, employment, transportation, finances, and childcare—what are the social things in their lives that make it harder for a patient to overcome substance use?

The next thing I want you to pay attention to would be collateral information. So depending on the circumstances, you can get a lot of information from friends and family. Obviously, you want to respect the patient’s privacy because there’s so much stigma associated with substance use, but you want to make sure that you get as much collateral information as possible.

One of the sources of information would be the prescription drug monitoring program that’s in your state. So you want to check that program online; most states have an online database of where the patient got addicting or abused medications.

Anybody who you have a suspicion for drug use, you want to check and make sure how many benzodiazepines they’ve been prescribed, how many different doctors, how many narcotic medications or opioids. You want to get a good sense of how many prescriptions they’ve gotten, because that can show you drug-seeking behavior and the level of dependence that they may have on medications that are abused that create dependence.

The next thing I want to talk about is the motivation and readiness for change, because a lot of patients are not very motivated, and you want to increase the motivation for change. And the goal is not always complete abstinence; the goal sometimes is just harm reduction and reduction of use. You want to avoid insisting that the patient is abstinent before you provide treatment, because any amount of treatment with a qualified provider is better than no treatment at all.

Instead of saying, “Are you ready to quit? Are you ready to stop using drugs?”, use motivational interviewing—and hopefully we will get to that topic as well. Motivational interviewing is really important and is worthy of another episode, so I’ll talk about that in a future episode. But you want to focus as much as you can on the thoughts that the patient has of why they want to reduce their substance use.

So you can ask them, “What would you like to be different about your substance use?” or “How is your substance use affecting you? What do you think would be good about using fewer drugs or not using drugs?” And let them talk a little bit about the things that would be good about them reducing and stopping their drug use, instead of just the simple question of “Are you ready to quit?”

As you’re completing your telepsychiatry appointment, you want to think about the appropriate level of care. Are they meeting criteria for emergency care or inpatient units? Are they okay for outpatient care? How much telehealth follow-up do you want? Is a telehealth and in-person hybrid model more appropriate? In some cases, it could be. Do you want to get them involved in intensive outpatient treatment or partial hospitalization?

So looking at the possible options—and that may be limited depending on the patient’s resources and the area where the patient is in—you want to ask yourself: How can this patient safely and effectively manage through telehealth?

And some of the red flags that you want to think about are: maybe they’re medically unstable, severely intoxicated, or in withdrawal; maybe they have a high suicide risk; or maybe they’re violent and they have an intention to be violent toward other people.

Maybe they can’t participate meaningfully with the telehealth. Maybe they need more of a physical examination or enhanced laboratory testing. Maybe they’re in an unstable environment—you’re talking to them in a chaotic environment—or maybe they’re not able to follow the treatment plan. So these are some of the red flags that you want to think about to move beyond a routine telehealth appointment and have more of a hybrid model where you have support in person.

In many cases, telehealth can do a lot of the heavy lifting, but in some cases you do need, as I said before, support from onsite resources.

So putting it all together: When you’re seeing a patient with a substance use disorder, you want to first assess: Is this an emergency? Are they in a safe place? Is this a safe situation? What is their location? What is their current state? Are they intoxicated or withdrawing? And are there subtle signs that you may not be seeing on camera or hearing in their voice? And so you want to make sure that you get those subtle signs addressed.

What is the substance use history? Are they meeting diagnostic criteria for substance use disorder—the DSM criteria? What’s their medical risk? What are the medical conditions? How about their risk of suicide and violence? What’s their environment like—what’s surrounding the patient? What resources do they have? What temptations and other barriers do they have, and what is their motivation for change?

Then, toward the end, and as you go, you assess: What is the appropriate level of care, and try to get them there.

 

10 Common Mistakes In SUD Telehealth Assessment

Now that we’ve talked about how to assess a patient, let’s talk a little bit about the common mistakes that telepsychiatrists make in an SUD (substance use disorder) assessment:

• Mistake Number One: Assuming that because the patient appears okay on video, they’re medically stable. Especially if it’s a brief video visit, they may be hiding things, and you may not see all the ways that the patient may be medically unstable. You can assess that via telepsychiatry for the most part, but make sure to spend enough time with the patient and pay attention to the details.
• Mistake Number Two: Failing to establish the patient’s physical location. If the patient has some sort of emergency, you want to be able to know how to address that patient’s problem, and knowing where the patient is located is really important.
• Mistake Number Three: Assuming that the patient is alone because nobody else appears on camera. Like I said, there may be other people that appear outside of the camera view, and you want to know that.
• Mistake Number Four: Relying exclusively on what the patient reports. You want to look at collateral sources of information. Best practice would be trying to get a statement from friends or family as long as the patient is allowing it. Look at past records. Look at laboratory testing. Don’t just rely on what the patient says, because a lot of patients with substance use disorders have become masters at manipulation, masters at concealing their drug use. And, you know, that’s just something… it doesn’t make them a bad person. It’s just something that happens a lot with substance use because the substance overpowers them and gets them to do things that they wouldn’t ordinarily do.
• Mistake Number Five: Equating substance use with a substance use disorder. Not everybody with substance use has a disorder, and you want to look at the criteria and carefully decide whether they meet criteria and whether they need treatment.
• Mistake Number Six: Failing to assess for withdrawal. Just because they’re not telling you that they’re in withdrawal doesn’t mean that they’re not in withdrawal, and you want to again observe the subtle signs of withdrawal. You can do that with the camera, but you have to be a little more deliberate about it.
• Mistake Number Seven: Ignoring the fact that they may have a polysubstance use condition where they have multiple drugs that they’re dependent on, that they’re using to the point at which it’s harming their social and occupational function.
• Mistake Number Eight: Focusing on the diagnosis while neglecting immediate safety. You want to get a diagnosis, but you want to also determine the immediate situation when it comes to the patient’s safety.
• Mistake Number Nine: Trying to force an inappropriate patient into telehealth. As a telehealth expert and somebody who does this for a living, many patients—probably most patients who have a substance use disorder—can be assessed on camera. But there are certain patients who are not appropriate for a telehealth appointment. Some of the reasons why they would not qualify or why you may have to consider other ways of addressing the problem are: if they are medically unstable, if they’re severely intoxicated, if they’re going through some sort of dangerous withdrawal, or if they have a high psychiatric risk with an imminent risk of suicide and need to be hospitalized, maybe against their will. Maybe there’s a need for an immediate physical examination or immediate vital signs, or maybe they’re in an unsafe or inappropriate environment. So there are lots of reasons why a patient could be inappropriate for telepsychiatry. But again, I think most people are appropriate for it, and you just have to incorporate local resources.
• Mistake Number Ten: Failing to consider the environment—failing to look at the background and incorporate that into your assessment. The background and the environment are so important. The people that the patient runs into can determine the social supports that they do or do not have. So failing to assess the environment, the patient’s background, and social supports—that is also very, very important.

So that’s part one of our two-part series on substance use disorder treatment. Today we talked about how to assess the patient, what some of the things are that you need to consider, some of the risks involved, and some of the ways that you need to be extra careful with telepsychiatry. Now we will go to part two: What do we do about it? How do we treat somebody with substance use disorders via telepsychiatry?

And that’s going to be part two of our series on substance use disorders. So until next time, keep raising the standard.

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