She was taking several prescribed medications for an anxiety disorder, but her doctor worried she would become addicted to them.
The doctor, who treats patients at a Muskogee clinic, wasn’t sure how to treat her.
Fifty miles away, a panel of specialists in Tulsa advised the doctor through a video chat via webcam.
The conversation took place during a recent session of the Addiction Medicine ECHO program at Oklahoma State University Center for Health Sciences near downtown Tulsa.
In Oklahoma, where 435 people died from prescription opioid overdose in 2016, and access to substance use disorder treatment is restricted especially in rural areas, medical providers are tapping into new ways to combat addiction and opioid abuse.
Telemedicine, also called telehealth, has increasingly been utilized as a way to alleviate the shortage of physicians who specialize in addiction medicine.
“(Telemedicine) has been really, really helpful especially in a state like ours where we have so many rural areas,” said Carrie Slatton-Hodges, deputy commissioner of treatment and recovery for the Oklahoma Department of Mental Health and Substance Abuse Services.
However, although the use of telemedicine by doctors and consumers is growing, there are hurdles.
“It has just been a wonderful addition in getting people need into treatment, but there are some barriers, in particular in medication addiction treatment,” Slatton-Hodges said.
Telemedicine in Oklahoma
There are 144 telemedicine sites in 70 communities in the state’s mental health network, according to the Oklahoma Department of Mental Health and Substance Abuse Services. For substance use disorders, Oklahoma has the second-highest percentage (11.9 percent) in the nation.
Telemedicine isn’t limited to addiction medicine. It is also used in psychiatry, patient monitoring and several other areas.
Sandra Harrison, director of regulatory and legal affairs for the Oklahoma Hospital Association, said telemedicine is a powerful tool when used properly.
“The biggest thing is you have different specialities that you could never afford to have in your rural area, and people are still able to the stay in their communities with their loved ones,” Harrison said.
The hospital association worked with state lawmakers on SB 726, which established new telemedicine standards, Harrison said. The bill, which went into effect Nov. 1, allows doctors to establish physician-patient relationships through telemedicine without an in-person exam. The bill excludes audio-only conversations.
The state’s medical board, which oversees doctors, already had regulations on telemedicine. A 2013 statement from the Oklahoma State Board of Medical Licensure and Supervision recognized doctors can establish patient relationships via telemedicine.
Still, the hospital association wanted to ensure the law was carefully written, Harrison said.
“We’re really careful about using telemedicine responsibly,” she said.
For example, Harrison said, it’s appropriate to treat patients for colds via telemedicine, but for a more serious illness, it’s important to seek in-person care.
Last month, President Donald Trump declared opioid abuse a national public health emergency. Trump’s plan, among other inititiatives, would include expanding the use of telemedicine services, specifically in rural areas.
However, federal laws can hinder medication-assisted addiction treatment. Before a physician can prescribe certain medications, they must first establish a patient-doctor relationship in person.
For several years, the American Telemedicine Association has pushed for the federal government to allow opioid treatment through telemedicine.
“We hope the treatment of addiction issues isn’t more burdensome than when a doctor gets someone addicted,” Slatton-Hodges said. “It helps on the counseling side, and it helps once that client relationship has been established face to face, those continued visits can happen telemedicine.
But the problem we have right now is getting that face to face visit in rural communities.”
Other hurdles to implementing telemedicine?
The cost, technology and reimbursement can also prove to be barriers.
Despite the obstacles, the potential for telemedicine to treat opioid addiction is large.
“I would say we’ve got a good sustainable (telemedicine) network out there, but I have seen it continue to grow and improve year by year,” Slatton-Hodges said.
More than 1.5 million Oklahomans live in areas that have a mental health professional shortage, according to the U.S. Department of Health and Human Services Resources and Services Administration.
Telemedicine isn’t new to Oklahoma, but with state physician and nurse shortages, telemedicine will likely continue to play a bigger role, Harrison said.
“Because that’s a way you can extend, I’m talking about those specialists, extend the ability to treat other folks, she said.
Doctors at OSU Health Services hope Project ECHO can bypass some of those barriers.
Instead of a doctor-patient relationship, the program establishes a doctor-to-doctor-to-patient exchange.
The program is designed to work as a guided practice model and aims to increase access to specialty care. Project ECHO, which has hubs around the world, is led by doctors who use videoconferencing to conduct virtual clinics.
The program is needed particularly in rural areas, said Dr. Jason Beaman, chair of the Department of Psychiatry and Behavioral Science at Oklahoma State University Center for Health Sciences.
“You have a patient addicted to opioids, the doctor doesn’t know what to do, refers them to a doctor in Tulsa or Oklahoma City,” Beaman said. “That takes six to seven months, then the patient has to drive hundreds of miles, get the prescription, go home and then have to go back every month.”
The project aims to help community providers assess and treat patients who are in need of specialty care. With the help of the specialists in Tulsa, ideally, the providers would eventually be able to treat patients themselves.
OSU Health Services launched its program in spring 2016 and started Addiction Medicine ECHO in May. A focal point of the addiction medicine program is teaching doctors how to properly treat patients with suboxone — a medication used to minimize opioid withdrawal symptoms and cravings.
Before a doctor can prescribe suboxone, he or she must complete a course, Beaman said. OSU is working to make that training free and more frequent, he said.
The program differs from other types of telemedicine that involve a direct doctor-to-patient relationship.
One of the obstacles is convincing doctors not to simply refer their patients to a specialist, which takes less work, Beaman said. They also have to give up an hour of their time to join the call.
“When you do these things it’s not easy. There’s a learning curve to it.” he said.
Ideally, Beaman said, OSU would get funding to pay doctors to participate in the program. Though doctors aren’t paid, it is free for them to join in on the calls.
“They learn from us, and we learn from them, they learn from each other,” Beaman said. “I’ve learned so much… It makes us all better.”