Fans of the HBO series “The Sopranos” might recall a scene in which mob boss Tony Soprano enters a bakery through the front door only to exit through the back door so that he can cross an alley to the back door of his therapist’s office. This interest in preserving anonymity is not uncommon and can be of particular concern in small communities. It is a concern, as well, that can be addressed through telehealth, and may be added to the list of considerations that may drive teletherapy for substance use disorders (SUD) in rural spaces.
A 2019 report found that substance use, on average, begins at an earlier age in rural areas than urban areas. Alcohol abuse, particularly, was found to be a particular problem in rural spaces. And, while cocaine usage is higher in urban spaces than rural areas, use of methadone, OxyContin, and Oxycodone occurred at higher rates in rural spaces than urban.
And these conditions are exacerbated by several additional characteristics of rural spaces. In the first instance, many rural areas are beset by a shortage of physicians or other treatment specialists. Moreover, cultural acceptance of behavioral health therapies are reportedly lower in rural spaces than urban, leading to increased interest in anonymity in communities whose small size can make privacy preservation more difficult. Accordingly, teletherapy for SUD may promise special advantages for rural spaces.
Several potential benefits are identifiable:
- Telehealth conquers the challenge of distance by enabling providers to meet with patients who may lack local resources; rural areas constitute great swaths of designated Health Professional Shortage Areas
- Teletherapy can solve for privacy concerns as it can be conducted from the privacy of one’s home; neighbors need not see a friend’s car outside a practitioner’s office. The U.S. Office of National Drug Control Policy in 2019 cited broadband access as a tool in combatting SUD and the opioid crisis.
Nevertheless, research on the effectiveness of telehealth for SUD is at a nascent stage. While the benefit of telehealth, generally, has been demonstrated in numerous reports, current literature indicates that additional investigations will be necessary before the most effective protocols for mental health via telehealth are evaluated. Moreover, questions regarding appropriate training, licensure and reimbursement must be addressed. Nevertheless, the immediate impression of telehealth for SUD treatment indicates a positive alternative in areas where in-person therapeutic access may be difficult or not available.
The COVID pandemic has accelerated the use of telehealth: Medicare added 135 services to the “telehealth eligible” list for reimbursement; the U.S. Department of Health and Human Services reported that 43.5% of Medicare primary care visits in April 2020 were conducted via telehealth; telehealth encounters in the United States increased 50% from 1Q19 to 1Q20. At the same time, close attention is being paid to teletherapy and SUD treatment. Recent publications of the National Institutes of Health (NIH) and Journal of the American Medical Association (JAMA) suggest that regulatory measures that open channels for teletherapy should yield information that will help practitioners develop telehealth alternatives to in-person treatments.
While in-person therapy remains the most-desired approach, the growing use and understanding of teletherapy alternatives promises opportunities for improved outcomes in rural areas without sufficient access to mental health care. It is a good and necessary step worth pursuing.
