Signing off on overdose and dependence.
Opioid dependence and overdose has become a global health issue. In the U.S. alone we have had a 2.8-fold increase from 2002 to 2015 with some estimated 40,000 deaths in 2016. Opioids have health consequences outside of only overdoses and are a huge health care burden. How we got to this point is as complicated as treatment. Regardless, the effects to health and society are overwhelming and multiple concerted efforts are required in order to aid in the crisis.
A recently published case study in NEJM recognizes that Emergency Department (ED) providers can have a significant impact because of their prescribing history and experience treating overdoses. A working group of hospitals in Philadelphia led a grassroots movement to ensure safer prescribing practices in EDs leading to decreased prescribing between 2011-2016. There were also increased education for residents, students and providers; implementation of naloxone prescribing protocols and some improved prevention medication and strategies (1).
While this shows how local access and a cooperative effort by institutions and providers together can help with prescription practices and education, the entire issue is complicated by what to do after a hospital visit for long-term addiction treatment. While ED physicians are able to treat overdoses and be educated on pain management, the problem is what to do after. Most providers don’t know what resources are available, don’t have a consistent way of treating pain and may not be able to care coordinate. Much of these discussions also leave out the social determinants such as lack of jobs, housing, and stable environments that lead to increased addiction (2).
What role is there for Telemedicine in this epidemic? Broadly, to increase access and save costs to the entire system, both of which are part of the NQF Telehealth Measures (3). Mental health visits over telemedicine, education services on how to use Naloxone, urgent care visits for symptoms of withdrawal, group therapy or support groups for families are other possibilities.
In April, a Senate Committee advanced a bipartisan Opioid Crisis Act of 2018 that has allowances for Telehealth to help in two specific ways:
- Allow qualified providers to prescribe controlled substances in limited quantities over telemedicine.
- Allow community mental health and addiction centers to register with the DEA to treat patients over telemedicine, this would allow these centers to treat more patients especially those in areas lacking qualified providers.
Telemedicine is often thought of as a solution for wide reaching access, but is important to recognize its utility in local access to healthcare. As the NEJM case study demonstrated, local interventions and engaging ED providers in public health crises was helpful. The Opioid Crisis Act can also give more access to addiction services and would be a real incentive to get more providers using telemedicine. However, this is only a small part of the solution; being able to use Telemedicine doesn’t matter if there are still not enough resources, providers and services available and distributed. Let’s hope the recent attention and more efforts like above can make a long term beneficial impact to a crisis that affects so many.
1. Mammen MD MPH, Priya E. Sanaman MD, Peter et al. A Grassroots Effort Led by Emergency Physicians to Mitigate the Escalating Opioid Epidemic Circa 2012. https://catalyst.nejm.org/grassroots-ed-unsafe-opioid-prescribing-practices/
2. McIver, Stephen J. Seeking solutions to the opioid Crisis. Pharmacy and Therapeutics 2017 Jul; 42(7): 478.
3. NQF: Telehealth Framework to Support Measure Development 2016-2017. http://www.qualityforum.org/Telehealth_2016-2017.aspx. Accessed July 7, 2017.