Curbside Consult with Dr. Jayne 11/22/21

As health systems continue to refine strategic planning for a potential upcoming influenza season or yet another wave of COVID-19 infections, telehealth is undoubtedly part of nearly everyone’s strategy. As a consultant, it’s interesting to see how different organizations have decided to use it.

For some, it’s strictly for acute visits and urgent-care type services that they can’t accommodate due to packed office schedules. For others, it’s an adjunct to their offerings for chronic care visits, which depending on the condition may be less likely to require a physical exam. Others are using it to grow their business by reaching out to previously untapped patient populations. A small number are using it as an option for physicians and other providers who may not be able to work in-person due to a personal health issue that precludes face-to-face contact with patients, or potentially having a family member at home who is at risk for infection.

I know a number of physicians who are going through cancer treatments or who are otherwise immune compromised and being able to practice virtually has kept them from going on disability or leaving medicine altogether. It’s an option that few physicians had previously and might be one of only a handful of good things that have come out of enduring a global pandemic. Not only is the option good for those individuals, but it’s good for care delivery organizations who would have otherwise lost capacity. When those physicians can keep their own panels it’s ideal since there can still be continuity, but I know that’s not always the situation, such as in the case of physicians who are in procedure-based subspecialties.

Still, there are growing concerns about how telehealth fits into the care landscape. Concerns with the cost of telehealth compared to in-person visits have been fairly straightforward, but questions about the clinical care provided have been less well defined. A recent report from Quest Diagnostics reviewed one of the concerns in more detail. The report, titled “Drug Misuse in America 2021: Physician Perspectives and Diagnostic Insights on the Drug Crisis and COVID-19,” found that almost 70% of physicians worried that signs of drug misuse were missed during pandemic-related care disruptions. The drugs in question include both prescribed substances as well as those obtained illegally.

Researchers looked at some 5 million test results performed by Quest Diagnostics, including 475,000 from the year 2020. They combined that data with survey results from the Harris Poll, which queried more than 500 primary care physicians. The report concluded that physicians are concerned about their ability to manage patients given the risks of drug misuse. In addition to worrying that they missed warning signs of drug misuse during the pandemic, 94% of primary care physicians state they are seeing an increased number of patients with mental health issues during the pandemic and “fear a correlation between rising mental health issues and prescription drug misuse.” Additionally, 98% of physicians are concerned about issues with controlled substances as a whole, compared to 75% who are concerned about opioid medications.

Specific to telehealth, 75% of physicians are concerned that telehealth visits limit their ability to identify whether patients are at risk for or already having issues with prescription drug misuse. Where 91% of physicians feel they can recognize warning signs during in-person visits, only 50% feel they can recognize issues during a telehealth visit. In my experience as a physician, most of the warning signs I’ve identified come from the patient’s history and discussion of their current situation rather than from the physical exam, so I find this phenomenon interesting. Beyond the information gathered from the patient’s story, I’ve used data such as refill patterns or information from prescription drug monitoring program records to identify potential misuse. Although I don’t question how some physicians feel, I’d be interested to understand more deeply why they feel this way and what they find lacking in a telehealth visit.

Another angle that was brought up was the idea that physicians are less willing to prescribe opioids during the pandemic, as well as the lack of alternatives for treatment for chronic pain. Nearly 80% of them are concerned that patients will turn to illicit fentanyl if they can’t get prescription medications, with 86% of them being concerned that illicit fentanyl will lead to higher death rates than prescription opioids. I totally understand not wanting to prescribe controlled substances during a non-face-to-face visit, especially since I was fairly strict in traditional practice as far as random drug testing during visits, and agree that we need better options for treating chronic non-cancer pain. The illegal drug crisis is real and it’s important for physicians to have strategies to identify such drug use, but I don’t think that a telehealth visit rules out that ability.

The report went on to look at drug testing as a component of treatment, with 81% of physicians seeing it as critical to prevent overdose deaths. However, more than half of physicians aren’t following up when presumptive drug tests are positive, and it’s not clear why. Given the capabilities of EHRs to include flowsheets for medication management as well as trackers and prompts for drug surveillance testing, I wish more of my peers would take advantage of those features so that they could more confidently care for patients. Additionally, only a third of physicians felt confident in prescribing naloxone to treat potential opioid overdose. It’s pretty easy to configure order sets that include both opioid pain medications and naloxone, so failing to do so is another missed opportunity to leverage technology. Existing clinical guidelines can be built into the EHR to help with clinical decision making and screening for changes in prescribing patterns.

I think it’s important to not overlook telehealth as a potential adjunct to pharmaceutical pain management. There are many providers out there who offer psychotherapy via telehealth, which could help as part of team-based care to identify patients who might not have their needs met with current pain management regimens. With the potential of using lower-cost resources such telehealth therapy versus in-person physician visits, patients could have more frequent check-ins about their needs as well as the ability to learn additional techniques to better manage their pain. Other options like telehealth-enabled physical therapy could be added for patients who might not be able to participate in traditional physical therapy appointments due to time or logistical limitations.

I polled a few primary care colleagues about the report, and their consensus opinion was that identifying drug misuse was more about having a relationship with the patient and ongoing contacts than it was about being in-person versus virtual. They were significantly more concerned about fragmented care as a risk factor for drug misuse as opposed to telehealth. I’d be interested to hear if any reader institutions are looking further at this issue, and whether they’re reaching different conclusions.

Have any thoughts on the connection between telehealth and prescription pain medication abuse? Leave a comment or email me.

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