Published June 11, 2019
Andrew H. Talal, MD — who pioneered the use of telemedicine to treat patients with hepatitis C virus (HCV) in opioid treatment programs — has shared the successes of this approach with the National Academy of Medicine (NAM).
The National Academies of Sciences, Engineering, and Medicine (the National Academies) are studying these issues as part of an effort to investigate best practices for integrating substance use treatment and infectious disease treatment programs.
Talal, a professor of medicine in the Division of Gastroenterology, Hepatology and Nutrition, was invited to discuss how his program can achieve better outcomes through telemedicine.
HCV is a casualty of the national opioid epidemic. A majority of those who have it are substance users who share or shared needles or other drug preparation equipment. It affects about 5 million people in the United States, and in 2014 it killed a record 20,000 Americans, according to the Centers for Disease Control and Prevention.
HCV causes more deaths than 60 other reportable infectious diseases combined. The incidence is expected to grow exponentially in the next decade, especially among opioid users, but they rarely receive treatment, says Talal.
The integration of “virtual management” of HCV treatment with opioid treatment through the use of telemedicine is seen as a way to reach and treat this vulnerable population.
So far, outcomes from pilot studies have been promising. In 2018, Talal published reports on the use of telemedicine to treat HCV in patients on methadone in the journals Clinical Infectious Diseases as well as Telemedicine and e-Health. These reports found that patients in opioid treatment programs were not only accepting of telemedicine-based HCV management, but that it is highly effective and patients prefer it to usual care (i.e., referral to an off-site provider).
His research is finding that treatment integration through telemedicine is especially well-accepted by patients from underrepresented groups. Additionally, he has found that concerns about privacy and confidentiality abate as treatment progresses.
At the NAM, Talal spoke about how his program works, how patients perceive the program and the factors that promote or inhibit the successful integration of these services.
A portion of Talal’s research is supported by a $7 million grant from the Patient-Centered Outcomes Research Institute, which Congress authorized to conduct evidence-based research to identify the most effective health care approaches.
The purpose of the award was to find an effective way to treat drug users who have HCV, a population that has traditionally been difficult to treat in conventional health care settings. Even when receiving regular treatment for substance use at methadone clinics, these patients often do not seek treatment for HCV, despite the fact that roughly half of them or more are likely to be chronically infected.
“The conventional method of treatment delivery — referral to an off-site location — has discouraged many individuals from initiating or completing treatment,” Talal explains.
“Now that we have all oral treatments with improved efficacy and almost no side effects, more patients should be lining up to be treated. The problem is that there are limited numbers of providers. The ability to link patients to providers via telemedicine removes geography as a barrier to implementation of high-quality specialty care.”
Many of these patients suffer from mental health conditions, Talal notes. They are more likely to be affected by poverty and a lack of social support, factors that may deter them from seeking treatment in conventional clinical settings. Integration of treatment services is a key component of the program’s success.
In addition, the study is employing a novel, rigorous study design. “I would like to also acknowledge Dr. Marianthi Markatou, professor of biostatistics, School of Public Health and Health Professions and lead statistical scientist on the project, for her efforts in the implementation of the study and for ensuring adherence to the highest scientific rigor.”
Talal expressed optimism that the NAM may view telemedicine as a valuable way to address HCV in substance users, noting that reimbursement for it is a key consideration.
“While telemedicine is an effective method to manage patients with reduced cost, reimbursement lags behind conventional in-person visits,” Talal says.
“In order for telemedicine to reach its full potential, reimbursement for telemedicine visits should be equitable to seeing a doctor in an office. Equitable reimbursement for telemedicine is required to ensure financial sustainability and is the next area we need to focus on,” he explains.
Talal discussed his program with the NAM on May 6 in Washington.
The NAM partners with organizations worldwide. It identifies and generates momentum around critical issues in health, marshals diverse expertise to build evidence-based solutions, inspires action through collaboration and public engagement and fosters the next generation of leaders and innovators.
The NAM is one of three academies that make up the National Academies, which are private, nonprofit institutions working outside of government to provide objective advice on matters of science, technology and health.
The National Academies are investigating best practices for integrating substance use treatment and infectious disease treatment programs as part of an effort funded by the U.S. Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy.