Telemedicine has the ability to provide the personal accountability that opioid addicts so desparately need.
Telemedicine, using a variety of adjunctive therapies, has the potential of mitigating one of the worst healthcare scourges of our generation – opiate addiction. Allow me to explain.
The major problem with most addictions, be it smoking, eating, gambling, pornography, or opiates, is that the addicted person simply lacks the motivation to consistently do as Nancy Reagan so famously stated: “Just Say No!” And with opiates, we know that after years of use, the neural pathways responsible for this decision are damaged to the point that the addicted are biologically disadvantaged. So we wait for the addicted to “hit rock bottom,” – the point when their lives are virtually destroyed – in the hopes that then they will finally find the motivation to act in their own self-interest.
But the cost of waiting to hit rock bottom is simply too high. Healthy productive people with the potential to have a positive impact on the community become an enormous drain on friends, family and the community. The destruction of their health and livelihood becomes the responsibility of society through numerous costly social programs. Even before that happens, many will have drained the resources of family and friends with numerous rounds of costly admissions to rehab. Once these resources are depleted, many of the addicted resort to theft, prostitution, and drug dealing to keep themselves supplied. Tragically, for thousands of Americans, they die before reaching the bottom.
Telemedicine has the potential of interrupting this cycle of destruction by assisting the addicted with the one thing that has been shown to work – a constantly available friend, a buddy, a brother or sister.
Anyone who has ever tried to lose weight, exercise more or simply read more books knows the value of a buddy. Alcoholics Anonymous has proven this. A buddy provides the motivation and accountability that you lack at the moment of weakness. However, unless that buddy lives with you, he/she is reliant on the addicted person to reach out at the moment of weakness or need. Telemetric linkage has the potential of solving this problem with a multitude of tools.
First, let’s recognize the ubiquity of the cell phone. Everyone’s got one, and if they don’t, I think most people would agree it would be a small price to pay for society to cover that cost if it resulted in fewer deaths, crime and disease. But given that anyone can be reached, it now becomes simple to check in with, track, send encouraging messages, educate the “patient”, and much, much more.
Before we unpack that a little, what if the addict refuses to carry or answer the phone? GPS tracking of phones could tell the buddy/sponsor when the phone is dormant or not where it should be, allowing the buddy to call and give encouragement or simply track the person down. Could you really do that? What about civil liberties? In the end, isn’t the addict free to ruin his/her life if they want to? Maybe not.
Under current law if a family member or friend found someone depressed and staring down the barrel of a gun, they could – and I can attest to the fact that they often do – bring the patient to the emergency room for evaluation. After hearing the story of near suicide, I have the right and responsibility to admit that patient, against their will if necessary, to a locked ward, for evaluation of their risk of harm to themselves. How different is it for a family member to discover their loved one playing Russian roulette with a needle instead of a gun? It might require a legislative expansion of current law to allow it, but my feeling is that society, urged on by family members who have stood by while the loved ones destroyed their lives, is ready to take that step.
For the sake of argument, let’s say that society is willing to put an electronic tether on the addicted individual who have been shown to be a risk to themselves. What might that look like? First, if they require medical assistance such as methadone or suboxone to detox, and they are unable or unwilling to go to a methadone clinic (many are not located in the best areas of town), they could be treated at a distant location under the direct tele-surveillance of a qualified medical specialist. Examination of the patient’s vitals, pupils, etc… can now be easily accomplished via a telemedicine link. If the patient requires daily medication supervision, such as methadone, a lock box with the patient’s daily dose could be accessed after validation of the patients ID, and abstinence from other drugs using available telemetry monitored by a trustee or trained professional.
In the end, though, it’s counseling and encouragement that will be the cornerstone of changing the way the addicted person thinks. Requiring them to “go to a meeting” every day may not be feasible. In fact, the better the patient feels, the less likely they will feel the need to attend. And that is when they are the most vulnerable to tripping up and returning to addiction. Moreover, a once a week or monthly face-to-face session with a counselor or psychiatrist may be physically and financially impossible. But what if the addicted received brief calls and messages throughout the day? They could be live, pre-recorded messages, or even AI bot calls that encouraged the patient and/or assessed their level of strength. I know we all hate telemarketing calls, but recent studies have shown that automated calls for depression monitoring are effective. And what if the automated call was from a celebrity? This particular effort is already underway as one more way to deliver information to addicts who are hard to reach.
Feedback could be allowed such that if the patient felt particularly vulnerable for some reason they could easily reach out for help. Hundreds of patients’ responses could be telemonitored on a single dashboard – stratified by color – with trained professionals reaching out to the patient or their designated sponsor, trustee, or friend if the patient drops off the grid. Even a single app with an emergency button could be used to geolocate the patient with a mental or medical emergency.
Early intervention is the key to reaching patients before they descend into the depths of addiction. Moreover, it is the intervention that is proactive, reaching out to the addicted instead of waiting for the patient to recognize their need, that has the potential of increased success. Telemedicine tools will allow more people to be reached proactively in a cost efficient manner, thus putting the most resources in the areas with the most impact for the most people. The War on Drugs was unsuccessful because, as the cartels noted, as long as there is a demand for drugs in the US, they will find a way to supply that need. Law enforcement has its place to diminish the available supply of dangerous and illegal drugs. But the war will not be won until we attack the demand side of the equation. This is a community problem that must be solved with community answers. Telemedicine tools will allow us to do just that.
Dr. Plaster thank you for your article. I wish that it pushed even more for the telemedicine ability to prescribe/administer any of the medication assisted therapy (MAT), especially buprenorphine. Our only evidence based strategy to keep addicts alive and return to function is MAT. This has even been proven effective without counseling and behavioral therapy. There is still a profound need for more of this in all of our communities and still a stigma attached with “replacing one addiction for another”. Over and over again as physicians we need to encourage initiation of MAT and ask lawmakers for support financially and logistically in the community. Telemedicine might just provide for this, as you alluded to, which I feel is even more important that encouragement. Opioid addiction is not the same as alcohol addiction and we need to expand our paradigm of treating addiction or little will change. Thank you again for all of your contributions to our specialty over the twenty years.