For a teenager living in a rural area without easy access to substance use treatment pre-COVID-19, the benefits of telehealth are indisputable. But despite opening up numerous opportunities for treatment that didn't exist before, the widespread use of telehealth has spawned another set of obstacles that extends well beyond the pandemic and routine treatment issues.
Sarah Bagley, MD, MSc, a primary care physician at Boston Medical Center and medical director of the CATALYST Clinic, a clinical program that provides integrated medical and behavioral healthcare for adolescents and young adults (AYAs) who use substances, says she is grateful for the flexibility telehealth provides — but worries about treatment engagement and equity.
"Telemedicine has certainly offered up increased access that might not have been true before, but I also feel like it cannot be a replacement for the option of being able to see people in person," Bagley says. "I especially get concerned about worsening inequities — people who don't have secure, confidential spaces to be able to engage in treatment or good Wi-Fi for a video visit."
Existing inequities combine with new telehealth obstacles
Many groups experience barriers in telehealth access, echoing the inequities found in traditional, in-person healthcare models, a recent study found. Race, age, socioeconomic status, geographic location, and other demographic factors create a complex web of challenges when it comes to equity in telehealth care.
Bagley, who has outlined new challenges in a recent commentary in the Journal of Substance Abuse Treatment, however, says that in providing effective treatment for adolescents and young adults with substance use disorders, access isn't the only obstacle. Once a patient starts treatment, getting them to stay engaged using telehealth can also be more difficult.
Patients may disconnect early, or become distracted — whereas patients often make greater efforts to schedule around in-person appointments, they may be driving, with friends, taking care of their children, or surrounded by other life temptations or responsibilities during a telehealth appointment, Bagley and colleagues explain in the commentary. And even if a patient has access and is engaged, for providers, it can be more difficult to recruit other team members to provide support for other issues that come up during the telehealth visit.
Integrated SUD treatment via telehealth is more critical now
But as the COVID-19 pandemic continues to surge, the urgency of finding a way to provide the most useful substance use disorder treatment possible using telehealth is increasing.
"We're seeing increasing opioid overdose," Bagley says, "I think people are feeling so isolated."
These feelings of isolation due to the ongoing pandemic are tied to compounding mental health challenges among young adults during what Bagley describes as a "really key period" in their lives for education, forming peer and family relationships, and finding opportunities for growth.
"Anxiety and depression symptoms are prevalent in all adults, but they're really high among 18- to 24-year-olds," says Bagley. CDC data shows that young adults face disproportionately worse mental health outcomes, and nearly a quarter of young adults started or increased substance use to cope with pandemic stress. "In so many ways, this work is really more critical than ever."
With consequences of the pandemic placing additional stressors on successful SUD treatment for adolescents and young adults, Bagley's practice is emphasizing integrated treatment for patients with co-occurring mental health disorders. Whether a patient's anxiety predated their substance use or vice versa, it's vital that both conditions be addressed at the same time, which is why her clinic increasingly tries to implement an opt-out approach, rather than opt-in, for combined mental health treatment.
"If we see relief on the horizon, we need to do all we can to try to minimize the harms of isolation and anxiety that I think many people are feeling," she says.
So, how can telehealth meet the urgent needs of young adults with SUD?
Telemedicine's salience and transformative impact during the pandemic makes going back entirely to pre-COVID-19, in-person healthcare highly unlikely. Now, the focus should be on optimizing systems to provide the best care possible. To improve telehealth treatment engagement and outcomes for adolescents and young adults, Bagley says careful assessments that determine if patients have the resources to properly engage in care are key.
"Anything our programs can do to support that access and space they need is important," says Bagley. "We work with a lot of families, too, so figuring out how we integrate families into this telemedicine algorithm is also key."
After ensuring appropriate resources and support systems are in place, efficient coordination of care is the next crucial component of treatment. Providers need to continue to promote communication among treatment center team members, partnering care providers, Department of Children and Families (DCF), and other relevant organizations, says Bagley. It is essential to holistic and effective care.
Optimizing systems also means determining how best to combine telemedicine with in-person care
Optimizing systems also means determining how best to combine telemedicine with in-person care — which will look different across adolescent and young adult patient demographic groups.
"I certainly would like to see families who live in places that are rural or don't have access to local AYA services continue to connect with us and for us to continue to offer telemedicine treatment to them," says Bagley.
For local patients, there are lingering questions about the magnitude of telehealth's role in care.
"For patients who are local, we will have to figure out what is the right combination of telemedicine and in-person," she says. "Do we meet them in person and transition to telemedicine? How do we keep them engaged in treatment? Is there a right dose and how much do we really need to be seeing people in person? Those are questions we need to carefully evaluate with more rigorous research to help us figure that out going forward."