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Andrew Talal, M.D., and Phyllis Andrews, RPA, demonstrate how a typical telemedicine visit can be conducted using real-time video conferencing. Photo credit: healio.com, HCV Next

At a clinic in East Harlem, former heroin users are no longer at the mercy of “the silent killer:” hepatitis C. They have been cured of the viral infection that attacks the liver and is often associated with injecting drugs. But unlike the typical standard of care, these patients did not have to travel to a specialist for treatment.

The men and women were part of a pilot study on telemedicine for drug users infected with hepatitis C. Its success has launched a major research project that could have vital importance in the wake of America’s opioid crisis – as intravenous drug use fuels rapid growth in new hepatitis C cases nationwide. The virus kills more Americans (nearly 20,000 deaths in 2015) than any other infectious disease, according to the U.S. Centers for Disease Control and Prevention (CDC).

Using two-way video conferencing, a remote hepatologist evaluates and treats drug users who are infected with hepatitis C. Many are not tech-savvy, but the video feed is set up in a familiar place: the methadone clinic where they are being treated for substance use. Their virtual interaction with the liver specialist, some 400 miles away, includes a prescription for new-generation, highly-effective antiviral medications.

In the pilot study, “what we found was that of the 45 patients who were treated, 93 percent achieved a sustained viral response. That means they were cured of their hepatitis C,” says principal investigator Andrew H. Talal, M.D., a professor of medicine in the Division of Gastroenterology, Hepatology and Nutrition at the Jacobs School of Medicine at the University at Buffalo.

Talal, a leading expert in liver disease, says telemedicine has “tremendous potential to deliver treatment for hepatitis C.” He aims to enroll more than 600 recovering opioid users with hepatitis C for his study, which runs through 2021. The research is underway at 12 methadone clinics throughout New York State, funded by a $7 million award from the Patient-Centered Outcomes Research Institute, a nonprofit created by Congress under the Affordable Care Act.

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A Tech Platform for Timely Care

An estimated 5 million Americans are infected with hepatitis C, a major cause of chronic liver disease that can lead to cirrhosis, liver cancer and early death. New cases of hepatitis C tripled between 2010 and 2015, and young adults ages 20-29 account for the highest number of new infections, “primarily a result of increasing injection drug use associated with America’s growing opioid epidemic,” the CDC notes.

Testing IV drug users is critical, since many of those infected with hepatitis C will show no symptoms for years or even decades as the virus damages the liver. Nearly half of people living with hepatitis C don’t know they are infected, the CDC says.

But despite having the highest prevalence of hepatitis C, drug users rarely get tested for the virus. “Only a small minority – 20 to 33 percent – will go for a hepatitis C evaluation” with a specialist, says Talal, citing the clinical research.

IV drug users may not be aware of their risks (infection can occur even after sharing needles just once). Or they may have no symptoms or fear being stigmatized by a diagnosis of contagious liver disease. Many lack a support system, distrust doctors and find it difficult to navigate the health care system, Talal adds.

What telemedicine offers is faster, easier access to disease specialists for life-saving early intervention. Screening is simplified and patients get timely care for their infection.
“That’s the beauty of bringing the specialist in remotely through the use of virtual technology,” Talal says. “The methadone treatment programs already have social workers, counselors and nurses on site who can support the patient during therapy. So really you’re adding hepatitis C treatment on top of all this existing support.”

Hepatitis C is now curable in the vast majority of situations, Talal says. Since 2014, revolutionary oral medications that destroy the virus have replaced painful, less effective interferon injections.

While curing hepatitis C infections was the primary goal of the pilot study, patient satisfaction was “extremely high” with the telehealth approach, Talal says.
“They liked the convenience of one-stop shopping, the fact that they could get all their medical needs taken care of in the methadone program,” he says. “They liked the fact that they had an HCV (hepatitis C virus) specialist taking care of them.”

Getting More People into Recovery

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Peter Yellowlees, M.D., M.B.B.S., at the University of California Davis Center for Health and Technology. For more than a decade, Dr. Yellowlees has used telemedicine to provide psychiatric consultations for patients on Indian Health reservations.

Across America, health care is increasingly delivered using the tools of telemedicine –
live video conferencing, e-mail consults with doctors, remote bedside monitoring, applications such as Skype and Facetime video chats, and web-based training programs that help patients change problem behaviors.

Virtual care could enhance recovery for people with substance use disorders – the vast majority of most of whom do not currently receive professional treatment.

In 2016, an estimated 20.1 million people met the diagnostic criteria for drug or alcohol addiction (about 1 in 13 Americans ages 12+), according to the National Survey on Drug Use and Health. But only 10.6 percent received treatment at a specialty facility such as a hospital, drug or alcohol rehabilitation center or mental health facility.

Telemedicine could help by reducing the stigma associated with drug and alcohol addiction. Often, a computer-based interaction with a doctor is more private than a visit to a specialty facility. One telepsychiatrist says the platform also puts people at ease.

“Patients quite commonly report that telemedicine consultations are more intimate than in-person consultations because they’re less embarrassed talking about very sensitive issues,” says Peter Yellowlees, M.D., M.B.B.S., a Professor of Psychiatry at UC Davis Health System, and the President of the American Telemedicine Association.

For 12 years, Yellowlees has been using hi-definition video-conferencing to reach patients in rural northern California. He treats patients with drug and alcohol addiction, and co-occurring mental health disorders. They interact with him remotely via a digital connection at their primary care doctor’s office.

“I provide better care for many of my patients on telemedicine than I do in my outpatient clinic because I never get to speak to the patient’s primary care physician in the outpatient clinic,” Yellowlees says. “The beauty of telemedicine is that you are integrating experts into the local system, which is much more convenient and better quality care. The patient can see us working together as a team.”

Clinical outcomes have been shown to be just as good with telemedicine as in-person treatment, according to a Cochrane style systematic review published in 2015.
“Seven studies that recruited participants with different mental health and substance abuse problems reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery,” the review concluded.

Yellowlees was the senior author on one study, “The Empirical Evidence for Telemedicine Interventions in Mental Disorders” which yielded similar results.
“For psychotherapy, we know that the outcomes are at least as good for telemedicine as they are in person,” he says.

Increasingly, major insurers are embracing telemedicine, and most states have laws providing reimbursement for virtual visits (some states ensure a parity with non-telemedicine, traditional clinical evaluations).

Removing Barriers for Rural America

Telemedicine can facilitate addiction recovery services such as virtual group therapy, and increase access to medical experts – a particular challenge for people battling addiction in rural areas.

“The reality is, there are very few psychiatrists and even less addiction specialists who work in rural areas,” Yellowlees says. “You’re the only person who is available so if you weren’t there, they wouldn’t be seeing anybody.”

America’s rural areas actually have a higher drug overdose death rate than urban areas – 17 deaths per 100,000 people in rural areas, vs. 16.2 deaths per 100,000 people in urban areas, according to 2015 statistics (most recent available) from the CDC.

Experts are concerned that rural America will be harmed by the government’s recent decision to abandon net neutrality protections for the Internet.

“It will be very sad if certain areas don’t have as much access to broadband (high-speed Internet) as they do now. I’m strongly opposed to the change,” Yellowlees says. “Whoever the Internet Service Providers (ISPs) are can decide what level of traffic goes where. There may be certain areas that are less competitive and get less broadband.”

“We’re talking about telemedicine being a healthcare infrastructure,” he adds. “If you affect the infrastructure as the FCC has, there may be devastating consequences.”

On the Horizon: Remote Prescribing of Suboxone, Online Recovery Support

One initiative that could be “huge” for helping more people with addiction, Yellowlees says, is remote prescribing of controlled substances such as Suboxone to prevent drug relapse.
President Trump promised to expand telemedicine and allow for remote prescribing of controlled medications when he declared the opioid crisis a national public health emergency on Oct. 26, 2017.

Doctors are still waiting on actions by the Drug Enforcement Administration to increase remote access to Suboxone and other medication-assisted treatment (MAT) for addiction.
Yellowlees says the government also needs to fund research on using telemedicine to deliver MAT therapies that reduce drug cravings and keep people in recovery. “That should be a very high priority,” he says.

Science-based behavioral interventions are increasingly available as telehealth programs. One example is Drinker’s Checkup, which helps people reduce or eliminate alcohol. Another web-based intervention is CBT4CBT, which uses the principles of Cognitive Behavioral Therapy (CBT) to teach relapse prevention skills.

“I think it’s a wonderful way of helping more people get access to this evidence-based approach. It’s hard to find a good CBT therapist in a lot of settings, and it’s particularly hard in rural areas and for under-served populations,” said CBT4CBT creator Kathleen Carroll, M.D., in an interview about the program for drugrehab.org in 2014.

“It’s also much less expensive than a live therapist,” Carroll added. “All you need is Internet access, and the program is always there, 24/7.”

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