The Telepsychiatry Advantage: Episode 17

Substance Use Disorders In Telepsychiatry: How To Treat Patients (Part 2)

Treating Substance Abuse With Telepsychiatry

Welcome back to The Telepsychiatry Advantage. In today’s episode, we’re going to cover part two of our two-part series on substance use disorders. Part one was focused on assessment of the patient. Now part two is going to be on treatment. So we’re assuming that you’ve properly assessed the patient and made a diagnosis, and so you understand what the patient’s drug of choice is and what their substance use disorder is.

So how are we going to treat it? Well, let’s first start by thinking about: what are the goals of treatment? Is the goal abstinence or reduction of use? Is the goal preventing withdrawals or overdoses? Is the goal preventing the patient from having cravings? Or maybe it’s to improve their function. But whatever the goal is, there’s always the goal of keeping the patient engaged in treatment.

Because substance use disorders, by their very nature, are chronic. They wax and wane, they go up and down, people relapse, then they get back into treatment, and on and on and on. And one of the great advantages of telepsychiatry is that it can keep the patient engaged in a way that’s easier. It’s easier for the patient because it’s easier to get into a psychiatrist appointment than getting into the car, going to the clinic, waiting in the waiting room, and being seen.

So the so-called activation energy—the amount of energy it takes to get the patient seen and treated—is lower with telepsychiatry. So in some ways, it’s better suited for substance use disorder treatment. Why do we want to keep the patient engaged? Well, it used to be that the thinking on substance use disorder treatment was that the patient has to be completely abstinent or they get kicked out of the program.

That was several decades ago. And as the art and science of drug treatment continues to evolve—and now we have medications for many of the substance use disorders that we are faced with—we understand that this is a medical model. This is a condition that the patient is suffering from. It’s like if we were to compare it to cancer treatment: if a patient had, let me say, their cancer came back, would we kick them out of treatment?

No, we would do more for the patient. We would try to get them more engaged in treatment. And the same goes for substance use disorders. When the patient relapses, that’s not the time to kick them out of the program; that’s the time to engage with them more. And so with telepsychiatry, the model could look something like this:

When the patient is in treatment and then they use, well, they have easier access. You want to give them easier access to make an appointment to see you. It could be just like a quick link to the video. It could be that when the patient messes up and drinks or uses drugs when they’re not supposed to, they have easy access to the clinic with a telephone call, and then they can get a link to see the doctor.

And what I recommend that you do is that you carve out office hours, maybe like a half an hour a day, just to give an opportunity for patients to fit into that time slot via telepsychiatry. So unlike an in-person visit that requires lots of coordination and transportation and checking in and waiting in the waiting room, a quick link to video can get the patient seen immediately after they’ve relapsed.

And this might not be realistic in certain situations, like if a person goes on a bender, but it can be used in a variety of situations where the patient feels a lot of shame about using and doesn’t want to go through all the steps to get into the office, but wouldn’t mind a quick telephone conversation or a video link.

So that’s a way to keep the patient engaged, which is accomplishing a major goal in substance use disorder treatment: engaging with the patient. And these quick, rapid-access appointments where the patient can see you don’t have to be long. It could be like 15 minutes, or even five minutes, just to touch base with the patient and give them a few words of encouragement and get them scheduled for a longer appointment next time.

So it doesn’t have to be an hour-long appointment that you have to spend with the patient every time that they use.

Treatment By Substance Type

Now let’s talk a little bit about the treatment landscape. Not every substance has the same treatment options. In fact, there are only a few drugs that have medication treatment options: opioids, alcohol, nicotine. Those are categories of drugs that do respond to medication options.

But there are other drugs that don’t really have good medication treatment options, and the treatment is going to be more of a behavioral intervention. For example, stimulants like cocaine and methamphetamine, cannabis, hallucinogens, inhalants—these are drugs that can do a lot of damage, but they don’t necessarily have a good medication option. So you want to have a behavioral intervention.

And then there are substances that require special attention because of withdrawal, some of which could be dangerous withdrawal. So when we think of dangerous withdrawal, the first thing that comes to mind is alcohol. That can cause delirium tremens and even death in withdrawal. Benzodiazepines can cause a really significant withdrawal, and other sedatives and hypnotics can cause withdrawal. So withdrawal management is also something that you need to think about when you’re dealing with a substance use disorder.

Treating Opioids

Let’s start with opioids. How do we treat opioid use disorders via telepsychiatry? Well, let me talk a little bit about what opioids are being commonly abused or misused: fentanyl (yes, I said fentanyl), heroin, oxycodone, hydrocodone, hydromorphone, codeine. These are some of the most common opioids that are being used and abused.

And so what is the treatment for that? Well, one of the most standard treatments for opioid use disorder is buprenorphine. You also can treat it with methadone and extended-release naltrexone. So I do want to tell you about something that happened when I was at a conference. This was a medical conference where an anesthesiologist got up and he talked about how evil buprenorphine was, and that people who are treating patients with buprenorphine are harming them because they’re just treating one drug with another, and that it has long-term damaging effects on the body.

So that was misinformation, because the goal here often is keeping the patient alive. And to characterize buprenorphine as something that is damaging and scaring people away from taking it is not a very helpful thing. When appropriately prescribed and treated, it can be very helpful to somebody with an opioid use disorder. It allows the patient to stabilize physiologically and behaviorally.

It reduces cravings, withdrawal, and dangerous use of illicit substances. So it’s a very helpful medication when prescribed appropriately. We’re not going to go into buprenorphine induction in detail because that’s another subject for another time. But what I do want to do is tell you about some of the things to think about when you are doing the induction via telepsychiatry.

And yes, it can be safely done via telepsychiatry, but you need to explain to the patient in detail what they should do. You want to avoid vague instructions. They’re not going to be in the clinic with you, so they’re going to need to follow the instructions very carefully, and you need to be very clear about that.

After you finish explaining how the induction and the treatment is going to work, you want to make sure the patient repeats it back to you. Say something like, “Please walk me through exactly what’s going to happen when we get off of this call.” Don’t assume that the patient understands. You need to confirm their understanding of when they’re going to start, what to expect, what happens if things don’t go as planned, who to contact, and when to seek urgent care.

Again, you want the patient to have the ability to rapidly access help, whether it’s from you or from somebody else. You don’t want to just make the prescription, give instructions, and then have the patient have no ability to access help. Also, prior to the conclusion of the appointment, you want to plan: what are the next steps?

When are you going to see the patient again? And I would suggest a low bar for that. I would suggest that you see the patient more frequently and make sure that the induction is going well and that the treatment is going well. But are all patients appropriate for induction with buprenorphine via telepsychiatry? That’s a clinical judgment call.

But I would say consider some things. For example, does the patient have stable housing? You wouldn’t want to do this kind of induction on the street; you would want to do it in a more safe and secure setting. So if the patient is homeless, maybe telehealth is not the most appropriate way to do a buprenorphine induction. But again, that’s a clinical judgment call.

You also want to be more careful and consider whether the patient is appropriate if you’re moving from methadone to buprenorphine. In that case, a home induction may not be the best way to go. Now, when you’re treating the patient with an opioid use disorder, what you want to do is make sure that the patient is improving.

Telehealth is very convenient, but you want to make sure that it’s working for your patient. Is the medication working? Is the patient safe? Is outpatient treatment still sufficient or does the patient need more intensive treatment? Do you need to do a hybrid model where the patient gets support with telepsychiatry, but they go into the clinic for regular check-ins?

So you want to consider the patient’s results when deciding whether to continue with telepsychiatry. And there may be some things that cannot be done as well over video—for example, laboratory testing or toxicology. You might need the patient to go into their primary care office and have a physical examination.

So telehealth is great, but there are certain things in certain situations that make you think the patient might need to be seen in person, especially if this is an emergency, like if they are in significant withdrawal where you’re having trouble addressing the withdrawal via video. Of course, if they’re suicidal or if they’re at high imminent risk of suicide, you would want them to go to an emergency department or get more urgent care.

Okay, now that we’ve talked about buprenorphine, what other treatment options are available for opioid use disorder? Well, as many of you know, methadone is a drug that has been used for so many decades effectively for many patients. And unfortunately, methadone prescription and management can’t be done solely through telepsychiatry. You can screen the patient for appropriateness for methadone, but the actual dispensing of the prescription and of methadone needs to be done through an OTP (opioid treatment program). So that is something that can’t be exclusively done via telehealth.

So what about the third major medication option for opioid use disorder? That’s naltrexone—extended-release naltrexone, the brand name being Vivitrol. It needs to be injected in person, so that cannot be done via telepsychiatry. But the screening, the evaluation of the patient, and the prescription can all be put in place remotely.

Then the patient needs to go to the clinic or healthcare provider to get that injection. So telepsychiatry can be very supportive of naltrexone in that way. In fact, in the prison system, we put together a program that was heavily supported by telepsychiatry to get patients on Vivitrol (extended-release naltrexone). That was a very successful program. I would say most of the heavy lifting was done by telepsychiatry, but then the patient, of course, needs their injection and that needs to be done in person.

Treating Stimulants

Let’s talk about stimulants now, like cocaine and methamphetamine. Well, there are no FDA-approved medications for amphetamine use disorder or cocaine use disorder. So the treatment is going to be different; it’s going to be more behavioral treatment and therapy. It’s going to be contingency management—that’s going to be a big one.

So what is contingency management? Well, it’s rewarding the patient with small rewards for doing the right things and making the right choices. For instance, if you have a negative screening test—like their tox screen is negative for the drug, which means they haven’t been using—maybe they get a $20 gift card, that kind of thing.

Small rewards for the behaviors that you want to see. And one of the behaviors is attending their telehealth appointment. So contingency management is a great way to keep the patient engaged, which we talked about was a really important thing since there are no FDA-approved drugs for stimulant use disorder like cocaine and methamphetamine.

Treating Cannabis

What about cannabis dependence—cannabis use disorders? There is no established FDA-approved medication for cannabis use disorder. And so again, we’re going to have to go with non-pharmacological interventions. Telehealth is very well-suited for motivational interviewing, CBT, relapse prevention, that kind of thing.

With somebody with cannabis use disorder, I mean the cliché is right: when you’re using cannabis, you’re lazy, you don’t want to do anything, so you’re probably not going to want to get into your car—and you shouldn’t get into your car—but you’re probably not going to want to motivate yourself to go to the doctor’s office if you are high on cannabis.

So having a very low bar for this one is very helpful. Telepsychiatry is very low activation energy—they just need to click on the link and see the doctor via video. For cannabis use disorder, telepsychiatry is actually really well suited.

Treating Benzodiazepines

What about benzodiazepines? Well, of course, we know that you need to taper your patient off of a benzodiazepine, in most cases through long-acting benzodiazepines and slow tapers. Telepsychiatry can be really convenient for this because you want to have a long-term plan where the patient’s medications are adjusted, and you don’t need the patient to come all the way into your office to do this.

You can do this via telepsychiatry very conveniently, but you want to be very careful because if the patient goes into very significant withdrawal, that might need to be managed more in person. Typically, withdrawal can be managed remotely as long as you’re careful about it and you are checking in with the patient frequently enough.

Treating Nicotine

 

What about nicotine? I think it’s one of the substance use disorders that can be very readily treated with telepsychiatry. It’s highly practical for repeated counseling and medication follow-ups—medications like nicotine replacement therapy, varenicline, and bupropion.

We have several options to treat nicotine with medications, and when you combine that with behavioral interventions, it’s perfect for telepsychiatry.

What about other medications or other drugs of abuse, for example MDMA or ecstasy, hallucinogens, psychedelics, ketamine? These are all medications and drugs that can be abused and may need substance use disorder treatment: inhalants, dextromethorphan. I mean, there are so many drugs of abuse out there, and for the drugs that I just mentioned, there’s no FDA-approved medication.

So really it’s going to be about contingency management, behavioral therapy, basically getting the patient continued engagement in treatment. Telehealth can be very useful even when you’re not able to prescribe a medication for a particular substance use disorder.

Inter-Visit Planning and Relapse Management

Now that we’ve talked about some of the treatment options and whether they can be done via telehealth, let me talk about the plan between visits. The patient only spends a little bit of time with you, and most of their time is spent without you. You want to be able to understand what happens when the cravings hit. You want to have that discussion of what the patient’s going to do. Who are they going to contact? What will they do if they return to use?

What happens if they miss a medication or if they experience unexpected symptoms? What happens if they can’t reach the treatment team? Basically, we need to have contingencies in place, and we need to have a plan to understand what’s going to happen when the patient is not in the visit, like when they’re out in the real world doing the things that they’re doing.

Again, I go back to having a rapid access plan. So maybe carve out, like I said, a half an hour or longer in your day so that you can see patients who are having trouble, or have your staff—maybe therapists and other people—check in with the patient when they’re having trouble.

Because after all, most of the time that the patient is spending in their lives is not going to be with you; it’s going to be outside of the appointment. You want to make sure that you understand and you ask what is going to happen when the cravings hit. Do they have a plan? Who are they going to contact?

What happens if they relapse and they return to use? What happens if they miss the medication that you prescribed, like a dose of the medication? What happens if they have unexpected symptoms? These are all things that you need to discuss with the patient to make sure that you and the patient have a clear understanding of what the plan is after the patient appointment ends. You could even have a written treatment plan, a relapse prevention plan.

You want to have, of course, the medication plan. But my recommendation is that when everything fails, you provide a way for the patient to have rapid access to help, whether it’s you or your staff, therapists, or other healthcare personnel. You want the patient to be able to have access to help when they relapse, because inevitably they will relapse.

I mean, how many people have decided to quit and then never relapsed, never had a craving, never had a withdrawal? Obviously with substance use disorders, that’s what’s so hard about it, because there’s this massive desire to use again. And when the patient has that desire or uses again, they need help, and you need to provide recommendations and avenues for that help.

So what happens if the patient does relapse? That doesn’t automatically mean that the medication failed, the treatment failed, and that the patient should be discharged. Like I said earlier, we don’t need the patient to be 100% abstinent for them to remain in treatment. In fact, engagement is so important.

Comparing it to cancer: let’s say the patient is being treated for cancer and then the cancer returns. Are you going to stop treatment and kick them out? No; what you’re going to do is assess if the treatment is not adequate, and you want to make adjustments to the treatment. So in substance use disorders, you want to make sure that the patient is actually taking the medication and complying with the treatment, even if it’s not medication-related.

You want to make sure that the treatment is adequate. Are the cravings being controlled or are they not being controlled? Are there new substances that have been introduced? Is there an untreated psychiatric illness? Has the patient’s environment changed? Do you need to have more frequent treatment? These are all things to consider when the patient has relapsed.

Telehealth is a major opportunity for these relapses because it requires less shame. They don’t have to go into the office. They don’t need to feel like they’ve disappointed the clinician, because the clinician can rapidly just see the patient and reassure them that this is part of the course of illness, and that you don’t want to drop out completely—you want to remain engaged in treatment.

So the idea of a rescue visit is really important. After a relapse or a craving, a rescue visit to get them back on track is really helpful. And the faster you can do this, the better, because it’s like if a patient is off course: if you’re driving and you take the wrong exit and now you’re off course, you want to get back on that highway.

A rapid access rescue visit with telehealth can do this where an onsite visit can’t—again, one of the ways telehealth can actually be better than an onsite visit.

What happens when a patient misses their appointment? This can be an indicator that they’re using and maybe they’re ashamed of their relapse. Maybe it’s not that at all; maybe they just got busy with their lives. But in any case, if a patient is using, you want to get them seen rapidly and you want to have that rescue appointment to get them back on track.

If you can’t get a video visit, make a phone call or even send a secure text message—just anything to get them back into engagement. Again, telehealth and all the telehealth modalities are usually very useful tools to keep the patient engaged.

Behavioral Treatment and Multidisciplinary Care

All right, let’s talk about some of the behavioral treatments that are available with substance use disorders. Motivational interviewing is key. If you don’t know what that is, I highly suggest that you review it because it’s one of the most powerful skills that a psychiatrist can have.

Motivational interviewing, in a nutshell, is getting the patient to put more energy behind the good choices and good behaviors than the bad behaviors, and you emphasize the good. We might do a whole episode on this because it’s so important.

There’s also CBT (cognitive behavioral therapy), relapse prevention, contingency management, working with families, peer support—these are all some of the behavioral treatments that you can consider. You don’t have to provide every service as the psychiatrist. Telehealth can be involved in not only the prescription of the medication, but in coordinating these other therapies with therapists, other programs, addiction programs, or IOP outpatient programs.

Telehealth can be a point where all these services can be coordinated. And then, like I said before, a hybrid model might sometimes be necessary. Telehealth doesn’t necessarily mean that everything happens remotely. Labs and toxicology can and should be done, and it’s oftentimes a hybrid model that allows this to be done.

10 Common Treatment Mistakes in SUD Telehealth

Okay, now that we’ve discussed SUD treatment via telehealth, let me talk about some of the common mistakes that people make with telehealth and SUD:

• Mistake Number One: Not seeing the patient frequently enough in treatment. Having that frequent touchpoint is really helpful.
• Mistake Number Two: Giving vague medication instructions, especially with buprenorphine induction. The patient needs very clear instructions, and you ideally would want to discuss this with the patient verbally and also give them written instructions—like email them or communicate written instructions.
• Mistake Number Three: Assuming that the patient knows what they need to do. Instead of assuming it, have them repeat it back to you. Tell them to tell you what was discussed.
• Mistake Number Four: Not having a plan in place between visits, like contingencies in case things go wrong, which they almost always do. When a patient has relapsed, not having a plan is a mistake.
• Mistake Number Five: Treating relapse as a treatment failure and stigmatizing it, adding shame, and saying that the patient needs to be abstinent before they’re treated. Relapse is not treatment failure; it’s just another reason to get them engaged.
• Mistake Number Six: Punishing them for being honest. If a patient is honest with you and tells you about their relapse, you don’t want to punish them by adding shame and giving them a hard time about it. It’s just data that you use to get them back into treatment.
• Mistake Number Seven: Keeping the patient in telehealth exclusively because it’s convenient, even if the patient no longer remains clinically appropriate for exclusively telehealth. That’s a clinical judgment call. Some situations where I would be cautious are: if the patient appears to have an altered mental status, if they have respiratory depression, chest pain, signs of acute intoxication with medical risk, or potentially dangerous withdrawal (especially alcohol, and sometimes benzodiazepine withdrawal).
• Mistake Number Eight: Forcing telepsychiatry on unstable patients. Patients with acute suicidal ideation or homicidal risk, or who are severely psychotic or manic, may need a higher level of care. Maybe the patient needs more monitoring, like cardiovascular monitoring, or maybe they have malnutrition or are dehydrated.
• Mistake Number Nine: Overlooking environmental and technology barriers. Maybe the patient’s environment isn’t safe and there’s no private place to talk, or maybe they can’t reliably use the technology or participate in it. These are all reasons why a patient may not be appropriate for telepsychiatry.
• Mistake Number Ten: Treating every patient as if they are appropriate for telepsychiatry. The mistake would be to assume telepsychiatry fits everyone. I love telehealth—I wouldn’t be doing this podcast if I didn’t love telepsychiatry—and I think in the vast majority of situations, telepsychiatry can be used for SUD treatment. But there are some cases where telepsychiatry is no longer appropriate.

In closing, telepsychiatry is a really useful tool for substance use disorder treatment because it allows the patient to get into treatment faster, providing rapid access and frequent visits to keep the patient on track. It’s a lower bar for the patient to click on a link and see the doctor as opposed to getting on the road and fighting traffic to go to the doctor’s office.

So telepsychiatry can be a really useful way of treating SUDs. Thank you for joining The Telepsychiatry Advantage. I hope this episode was valuable to you and you got some nice pearls out of it. And until next time, keep raising the standard.

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