Alcohol and drug use care goes virtual with COVID-19

Kaiser Permanente Washington researcher Joe Glass advises integrating digital prescriptions into existing care

By Joseph E. Glass, PhD, MSW, associate investigator at Kaiser Permanente Washington Health Research Institute

With uncertainty, anxiety, and isolation from the COVID-19 pandemic, researchers who study substance use are concerned about people drinking and using drugs to cope. We have also seen evidence that smoking cannabis and vaping, which harm lung health, may exacerbate COVID-19 illness, and alcohol can affect immune system response. All the while, health care systems are faced with decisions about how to provide most of their health care virtually and are searching for safe and effective ways to provide care for substance use online.

To understand why it is so important to find new ways to deliver care for alcohol and drug use, consider several ways that COVID-19 has decimated the treatment landscape, for now:

• Fewer people are visiting their health care providers for routine primary care, where they may be asked questions about their alcohol and drug use. These conversations can lead to on-the-spot interventions, or can serve as a gateway to care elsewhere.
• Addiction treatment agencies in the community, which provide the right level of care for people who struggle with very difficult problems, are often not equipped to conduct care virtually. Counseling has traditionally been provided to people in groups, and some services are done better in-person, such as daily methadone dispensing or collecting tests to detect drug or alcohol use. Also, addiction treatments often encourage and facilitate community connections through meaningful work and social activities. These are hard to do given social distancing.
• Community-based support groups like Alcoholics Anonymous, Narcotics Anonymous, or SMART Recovery, by definition, are often in person, in groups.

It is important to note that some organizations are now making treatment for alcohol and drugs available via telehealth. Health care workers, leaders, and members of these organizations deserve significant gratitude for their hard work during this epidemic.

What are digital therapeutics and how do they fit?

Health systems may be evaluating the use of new digital therapeutics, which are validated online treatments for health conditions that can be delivered by apps or websites. Some of these online platforms help patients identify their own patterns of drinking and drug use, learn new ways of coping, and give and get support from the comfort of home. Examples that have been evaluated in research studies include reSET and reSET-O by Pear Therapeutics and several platforms marketed by CHESS Health. Dozens of other platforms exist, including several supported by some research evidence.

For systems that are exploring the use of digital therapeutics, our research team can share advice. Indeed, these online treatments could potentially help to fill some of the current gaps in care for substance use disorders. But before selecting any particular solution, health systems first need to appraise the evidence behind each platform and carefully evaluate how well they fit with their patient population and clinical workflows. Digital therapeutics are rarely used by health care organizations, so it is not yet widely understood how best to incorporate these platforms in routine care. Clinicians will need adequate training; minimally, they will need to know enough to learn how to offer these tools to patients and to teach them to start using them. Persistent follow-up is also required, because patients will inevitably stop using these treatments if they do not receive follow-up. Some of these services could be contracted out to digital therapeutic companies, but health systems will need to evaluate their own needs for implementation.

Here are some lessons we’ve learned from patients, clinicians, and health system leaders in some of our recent studies on how to incorporate digital therapeutics for substance use disorders into health care:

• Both patients and clinicians want app-based treatments to be integrated into their ongoing health care for their substance use—not as an aside.
• Patients and clinicians want to see each other invested in, and accountable for, using these apps. Others have called this “supportive accountability.”
• Alcohol and drug use is a sensitive topic. Even if treatment is conducted with the help of an app, patients would benefit from a caring and trusting relationship with their clinician; patients also want to know that the app can protect personal and data privacy.
• In addition, patients speak about how treatment apps and interactions with their health care need to be convenient, integrated with one another, and seamless.
• Clinicians and patients recognize that health care when assisted by an app cannot be “one size fits all.” It must accommodate differences between people, such as each patient’s readiness to change, motivation, tech savviness, schedule, personality, and other health problems.

A few of the themes that we found in our recent studies suggest digital therapeutics can’t just be an afterthought or a tool that clinicians simply point patients to. Implementing these interventions effectively requires meaningfully integrating them into patients’ existing health care visits—and providing plenty of follow-up and accountability.  My research team is now making use of these findings as we partner with Kaiser Permanente to lead research funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse (NIDA). For instance, our 5-year Digital Treatments for Substance Use Disorder (DIGITS) in Primary Care trial will evaluate ways to boost adoption and use of digital therapeutics for substance use disorders in primary care.

With COVID-19, we believe that care with digital therapeutics can be done virtually, with conversations between clinicians and patients done via videoconference, telephone, and secure messages. But building rapport and a therapeutic alliance between clinicians and patients remain key. Health systems will need to monitor these treatments to understand how virtual care can be delivered equitably. Here’s hoping that soon, the COVID-19 pandemic will be behind us, and health systems will have gained valuable experience doing care virtually to prepare us for any future shocks to the addiction treatment system.

Disclosures

Pear Therapeutics, one of the companies mentioned above, is providing prescriptions for their digital therapeutics at no cost during the pilot phase of the DIGITS trial, which the author of this post leads. Pear Therapeutics did not contribute to this post. The author is supported by NIAA and NIDA. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.​​​​​​