Update: On May 9, 2023, the Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration issued a temporary rule, extending telemedicine flexibilities for six months through November 11, 2023. For patients who are already seeing a doctor via telemedicine, the temporary rule extends through Nov. 11, 2024. The flexibilities were established under the COVID-19 public health emergency and had been set to expire on May 11.

Under new federal regulations proposed to take effect in May, tens of thousands of patients across the U.S. will need to schedule in-person visits to continue obtaining prescriptions for controlled drugs via telemedicine.

Patients being treated remotely with buprenorphine for opioid use disorder, Ritalin for attention deficit disorders, ketamine for depression, or testosterone for gender-affirming care, among other controlled-drug treatments, will need to schedule an in-person exam, either with their telemedicine prescriber or a local provider who is registered with the federal Drug Enforcement Administration, according to the DEA’s proposed rules.

The draft regulations, which were first announced Feb. 24, allow telemedicine providers to initially prescribe 30 days’ worth of some medications, including buprenorphine, testosterone, or ketamine, before an in-person exam is required. Patients taking narcotic pain medication, or common ADD medicines, however, will need an in-person exam before any new prescriptions can be issued. Patients and providers who established treatment relationships remotely during the pandemic, when in-person exam requirements were temporarily waived, would have 180 days to comply with the new laws.

A brief history of online drug prescription regulations

The federal regulation of online prescribing started with the 2008 passage of The Ryan Haight Online Pharmacy Consumer Protection Act, which was meant to combat rogue internet pharmacies that started selling controlled drugs online in the 1990s. The law generally required in-person medical evaluations prior to prescribing controlled substances, but carved out seven exceptions, including one for public health emergencies, such as the COVID-19 pandemic. Thus, for the past three years, telemedicine practitioners have been prescribing controlled drugs without needing to conduct in-person exams. With the pandemic public health emergency ending in May, this exemption will no longer stand.

Another exception in the 2008 law envisioned the creation of a “special registration” process through which qualified telemedicine providers could prescribe controlled drugs without in-person visits. The DEA did not create the registration process at the time but was again directed to establish it in the SUPPORT Act of 2018. As a result, most stakeholders were expecting the DEA to enact the formal registry this year.

Instead, the DEA surprised the medical, telehealth, and health policy communities by proposing a narrow set of regulations aimed at improving access to buprenorphine, an effective medication used in opioid addiction treatment, while curtailing improper prescribing and illegal diversion of controlled drugs.

“What they proposed caught a lot of people off guard, because we were all thinking they were going to create the registry,” says Mei Kwong, executive director of the nonpartisan Center for Connected Health Policy.

In its release of the proposed rules, the DEA said it had deemed the registry approach “potentially burdensome for both prospective telemedicine providers and patients.” The two proposed rules included one targeting buprenorphine treatment for opioid use disorder and a broader telemedicine rule. DEA officials said they sought to balance the goal of expanding access to buprenorphine treatment by making permanent some pandemic-era flexibilities, such as allowing substance abuse treatment via audio-only telemedicine, with the desire to prevent drug-overdose deaths in the U.S., which increased 30% from 2019 to 2020, and another 15% in 2021.

“Medication for opioid use disorder helps those who are fighting to overcome substance use disorder by helping people achieve and sustain recovery, and also prevent drug poisonings,” said DEA Administrator Milgram in a press release.

Most overdose deaths involve synthetic opioids such as fentanyl and psychostimulants such as methamphetamine. A recent cross-sectional study of overdose deaths across the United States found that pandemic-era telemedicine flexibilities did not lead to an overall increase in buprenorphine-involved drug deaths, which accounted for 2.6% of all opioid-involved overdose deaths between July 2019 and June 2021.  

What the proposed rules would do

The DEA’s proposed rules, which would be in addition to state-level regulations, affect people who have never had an in-person exam by the telemedicine provider who prescribes controlled substances to them.

Key aspects of the proposed rules include:

• Limitations and requirements in the proposed rules do not apply if the telemedicine interaction meets one of the other exceptions under the Ryan Haight Act.
• Telemedicine providers must keep more detailed records than previously required, including recording the address where the patient was during the visit. They must also check prescription monitoring databases to see whether other controlled drugs have been prescribed to patients.
• Patients being treated for opioid use disorder are required to have an in-person visit within 30 days of receiving a prescription for buprenorphine (Suboxone, Zubsolv, and Sublocade) via telemedicine, to obtain refills.
• Following the in-person exam, a patient can receive buprenorphine prescriptions via audio-only telemedicine (telephone), as an alternative to video calls.
• Patients prescribed a non-narcotic Schedule III, IV, or V drug are required to have an in-person visit within 30 days of receiving a prescription via telemedicine, to obtain refills.
• In lieu of an in-person exam by the remote provider, a local, DEA-registered health care provider, such as a primary care provider, can perform an in-person exam and then make a “qualified telemedicine referral” to a remote provider for a specific condition. Only one referral is needed for the remainder of the patient’s treatment for that condition.
• Patients must have an in-person visit or a qualified telemedicine referral to receive a prescription for Schedule II controlled substances.

Schedule II controlled drugs include narcotic pain medications like oxycodone and fentanyl, and stimulants used to treat attention deficit disorder, like Adderall and Ritalin. Schedule III drugs include testosterone and ketamine, a former club drug that has become a popular off-label treatment for depression and other mental health conditions. Drugs classified as Schedule IV (Xanax and Ambien, for example) and Schedule V (Robitussin AC and Lyrica, for example) have a lower potential for abuse and low risk of dependence. Heroin, LSD and marijuana are examples of Schedule I drugs. In general, the DEA categorizes drugs based on their abuse rate and potential to create physical or psychological dependence.

At least two US Senators have asked the Biden administration to change testosterone to a Schedule IV or V drug. Meanwhile, debate about and government consideration of reclassifying marijuana has been ongoing for nearly a decade.

More than a dozen telehealth startups providing take-at-home ketamine emerged during the pandemic, and in-person ketamine clinics also grew in number and popularity. In March, however, Ketamine Wellness Centers, the largest provider of in-person ketamine treatment in the country — with 13 clinics in nine states — abruptly closed, reportedly due to financial issues stemming from its acquisition in 2021 by Canadian company Delic Holdings Corp. Field Trip Health, another in-person ketamine treatment provider, also ceased operations. These closures are likely to send local clinic patients scrambling for remote ketamine prescriptions before the new laws take effect in May.

Widespread opposition to the DEA proposal

The DEA’s proposed rules have drawn more than 35,000 public comments, the majority of them urging the DEA to rethink its stance on the in-person exam requirements, either by eliminating them or allowing more time for patients to schedule appointments. Several advocacy groups representing patients and medical professionals have pushed back against the proposal.

In a March 31 letter to Milgram, Dr. James Madara, CEO of the American Medical Association, expressed “grave concerns” that the new rules “would cause many patients who were started on buprenorphine to have their prescriptions lapse, leading to more overdose deaths instead of closing the treatment gap.” Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, says there’s “no clinical need” for in-person exams. He calls the DEA’s proposed requirement “a clinically inappropriate barrier to care.”

“We have long been of the belief, going back prior to the pandemic, that we needed to have a regulatory regime in place that would allow for the remote prescription of clinically appropriate controlled substances” without an in-person requirement, Zebley says.

The changes come at a difficult time for the telehealth industry, when investment is already down amid rising interest rates, inflation and increased scrutiny of prescribing practices. Allowing local providers to refer patients for treatment via telemedicine represents “an improvement to the pre-pandemic status quo,” Zebley says. But, he adds, any in-person exam requirement creates a potentially life-threatening barrier, particularly for people in the early stages of opioid use disorder treatment.

Substance misuse treatment via telehealth

Research has shown that buprenorphine is a safe and effective treatment for people who suffer from opioid abuse disorder. Evidence to date does not suggest that remote prescribing of buprenorphine leads to more of the drug ending up on the street or more buprenorphine-involved overdose deaths. The DEA has acknowledged the need for increased access to buprenorphine, and in January, removed restrictions on the number of buprenorphine patients that prescribers could treat at a given time.

But the DEA also maintains its proposed rules are necessary to prevent diversion – a medical and legal term referring to the illegal transfer of a drug from the intended patient to someone else. This includes theft of prescription medications by health care providers as well as patients selling their own prescriptions of street drugs.

“Diversion of buprenorphine and other prescription opioids remains an issue across the country: in the past two years, DEA has seen Federal investigations of buprenorphine diversion across the country,” the DEA states in its proposed rule for buprenorphine telemedicine prescriptions. “Thus safeguards are necessary to mitigate the risk of diversion.”

Some researchers who study the use and efficacy of buprenorphine say the DEA’s proposed rules are “overly restrictive.” In a March 21 letter to the U.S. Attorney General, posted by the Brookings Institution, a group of top researchers write that the DEA’s proposal “fails to strike the right balance” and  “would likely create more harm than benefit.”

“Specifically, the evidence to date does not support concerns about substantial medication diversion or misuse associated with prescribing of buprenorphine via telemedicine,” they write.

The letter’s signatories are Haiden Huskamp, Dr. Ateev Mehrotra, and Dr. Alisa Busch, of Harvard Medical School; Dr. Pushpa Raja of the David Geffen School of Medicine at University of California, Los Angeles; Richard Frank from the Brookings Institution; and Dr. Michael Barnet, of the Harvard T.H. Chan School of Public Health.

The researchers recommend eliminating the in-person requirement for patients being treated with buprenorphine for opioid abuse disorder. If that is not possible, then patients should have six months to schedule an in-person exam, rather than 30 days, they write, citing long waiting periods for in-person care.

“We need to take a public health perspective here, versus a criminal justice perspective,” Mehrotra, a professor of health care policy at Harvard Medical School, says. “The criminal justice perspective is to say, ‘Hey, look at these bad actors here. We need to do whatever we can to fix that problem.’ The public health perspective is to say, ‘Hey, there are bad actors, but let’s look at the net impact on society, because we don’t want to restrict access for everybody because of a couple of bad actors.’”

What does the research say?

Evidence on the efficacy of telehealth versus in-person care for various ailments is sparse, but a flood of research studies is widely anticipated over the next few years, as more data from the pandemic period become available for study. Additionally, because any negative health outcomes potentially resulting from receiving care via telehealth will take time to materialize, many researchers have only recently begun to analyze the effects of the rapid shift to remote care that has taken place during the COVID-19 pandemic.

“In 2019, we were studying many applications of telehealth and doing randomized, controlled trials of in-person versus telehealth for things for like depression, schizophrenia, anxiety and a couple of other areas, but we didn’t have a large body of research,” says Mehrotra. “Then, suddenly in 2020, [patients] started using telemedicine for everything. So, we’re still playing catch-up to try to answer the question of, ‘When is telemedicine viable and when is it not viable?’”

Patient usage and preference are other important factors that research is only beginning to investigate. A recent survey finds that people prefer to use telemedicine for minor health issues, as opposed to chronic illnesses. Research also suggests that healthcare providers themselves have not permanently adopted telemedicine at rates once predicted during the pandemic.

The DEA’s forthcoming laws on prescribing controlled substances via telemedicine will help shape the overall telehealth industry, especially given how much of it has been built around behavioral and mental health care over the past three years. Despite the economic downturn and current regulatory uncertainty, industry analysts expect continued growth for an industry that has demonstrated its ability to connect patients with care that they otherwise might not be able to access.

Research to Explore:

Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic
Lauren J. Tanz, et al. JAMA Network Open. January 2023.

The study: Using data from the State Unintentional Drug Overdose Reporting System, the researchers conducted a cross-sectional study to examine overdose deaths across the U.S. between July 2019 and June 2021. They looked into whether there was a change in the rate of deaths involving buprenorphine in the wake of the March 2020 COVID-19 public health emergency, when the federal government took actions allowing clinicians to prescribe buprenorphine without an in-person office visit.

The findings: Of the 74,474 opioid-involved deaths in the study, which included 48 states and the District of Columbia, buprenorphine was involved in 2.6% of them. More than 90% of the buprenorphine-involved deaths involved at least one other drug. While monthly overdose deaths from opioid use increased after March 2020, the percentage involving buprenorphine fluctuated but did not increase between July 2019 (3.6%) and June 2021 (2.1%).

In the authors’ words: “The findings of this cross-sectional study suggest that actions taken by the US federal government to facilitate access to buprenorphine-based medications for [opioid use disorder] during the pandemic were not associated with an increased proportion of overdose deaths involving buprenorphine, providing evidence to inform discussions on permanent adoption of COVID-19–related buprenorphine prescribing authorities. Nonetheless, although rare, overdose deaths involving buprenorphine highlight the importance of overdose prevention and support for those using buprenorphine both under medical supervision or outside of treatment for [substance use disorder] or pain.”

Initiating Opioid Use Disorder Medication via Telemedicine During COVID-19: Implications for Proposed Reforms to the Ryan Haight Act
Haiden A. Huskamp, et al. Journal of General Internal Medicine, January 2022.

The study: Between late November and mid-December 2020, the researchers conducted a national online survey to gauge whether clinicians who treat opioid use disorder considered telemedicine to be a safe and effective way to prescribe medications such as buprenorphine. Some 602 clinicians participated in the survey, 506 of whom reported having initiated opioid use disorder medication for a patient during the month preceding the survey.

The findings: Among those 506 clinicians, 303 had used telemedicine to initiate treatment for at least one patient in the past month, while 203 had only started their patients on opioid use disorder medication after an in-person visit.

When asked how they felt about using video visits to treat new patients for opioid use disorder, a little over one-third of respondents reported being “somewhat” or “very” comfortable, with the rest being “somewhat” or “very” uncomfortable. Clinicians who were treating more patients with opioid use disorder reported feeling more comfortable with treating patients via video.

In the authors’ words: “Findings suggest that a permanent relaxation of the Ryan Haight requirement may not result in widespread adoption of telemedicine for OUD medication initiation without additional supports or incentives.”

Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic
Christopher M. Jones, et al. JAMA Psychiatry, August 2022.

The study: The researchers compared telehealth treatment for opioid use disorder and medically-treated overdose before and after the onset of the COVID-19 pandemic. In a longitudinal study involving 175,778 Medicare and Medicaid beneficiaries, the researchers compared two cohorts of patients – one between September 2018 and February 2020, and one receiving treatment between September 2019 and February 2021.

The findings: Overall, access to telehealth services during the COVID-19 pandemic was associated with an increase in patients sticking with their treatment and a decrease in the risk of medically treated overdose. The researchers also found that some groups were less likely to receive telehealth services for opioid use disorder treatment, including non-Hispanic Black people and people living in the U.S. South. And they reported higher odds of medically treated overdose among non-Hispanic Black people, American Indian and Alaska Native people and Asian or Pacific Islanders.

In the authors’ words: “Use of telehealth during the pandemic was associated with improved retention in care and reduced odds of medically treated overdose, providing support for permanent adoption.”

Further reading

DEA Proposed Rules

Expansion of Induction of Buprenorphine via Telemedicine Encounter

Telemedicine Prescribing of Controlled Substances When the Practitioner and the Patient Have Not Had a Prior In-Person Medical Evaluation

Related research

“Reduced No-Show Rates and Sustained Patient Satisfaction of Telehealth During the COVID-19 Pandemic,” Brenden Drerup, Jennifer Espenschied, Joseph Wiedemer, and Lisa Hamilton. Telemedicine and E-Health Journal, December 2021.

“Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits,” Kristin N. Ray, et al. Pediatrics Journal, May 2019.

“Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder,” Sarah E. Wakeman, et al. JAMA Network Open, February 2020.

“Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals,” Jae A. Puckett, et al. Sexuality Research and Social Policy, August 2017.

“Increasing rates of buprenorphine diversion in the United States, 2002 to 2019,” Mance E. Buttram, Steven P. Kurtz, Zachary R. Margolin, and Stevan Geoffrey Severtson. Pharmacoepidemiology and Drug Safety, July 2021.

The post Rules for prescribing controlled drugs via telemedicine: A research roundup and explainer appeared first on The Journalist's Resource.

From as early as age 3, people begin to form negative biases toward older people, research has shown, and as many as half of all people worldwide carry ageist beliefs. For journalists, recognizing inherent biases is key to producing better, deeper coverage of aging-related issues and stories involving older people.

The following tips, provided by two experienced journalists who have spent decades covering health and aging, are designed to help newsrooms improve their coverage of longevity and topics that matter to older adults. By developing a more informed and nuanced approach to these stories, journalists can contribute to eradicating ageism and its many harmful effects.

1. Terminology matters.

The phrases “senior citizens” and “the elderly,” once in common usage as nouns, are today sometimes considered demeaning to older people, says Paul Kleyman, a longtime journalist and the national coordinator of the Journalists Network on Generations, an organization that provides information and networking opportunities for journalists who cover aging issues. Those terms may imply that they are separate from other citizens, or frail. However, Kleyman adds, “elderly” is sometimes acceptable as a modifier.

Using the word “seniors” to describe older people as a group is generally okay, Kleyman says, but “older people” is considered the most neutral language. Be careful with “old.” While some find the phrase “old people” to be more accurate than “older people” – “We’re all perpetually ‘older’ until we’re dead, right?” says Kleyman – other people find that phrase insulting, because many people who have lived a long time don’t feel “old.” And while acceptable, the phrase “older people” is vague. When possible, it’s best to be specific when referring to population groups by age; for example, say “people aged 65 and older” or “people who are 80 years old and older.”

The AP Stylebook echoes these sentiments: “The term elderly is acceptable in headlines when relevant and necessary because of space constraints. But aim for specificity when space allows: Couple in their 90s die in Manhattan luxury high-rise blaze rather than Elderly couple die in Manhattan luxury high-rise blaze.”

In general, reporting about people in terms of their identities is hard, but carefully considering how we do so is useful. “It makes you think about the limits of our language,” Kleyman says. “We have this constant incentive to seek precision, but then we also need to understand that precision is of a cultural moment.”

It’s always possible that some people will object to the language journalists use in referring to their identities. Kleyman advises using these instances as opportunities to explore why people are objecting to a term. Journalists who are unsure about the right descriptors to use should consider asking sources how they want to be described, he says. “Of course, I had one person who I was writing about who said, ‘Just call me an old fart!’ There’s always one.”

2. Avoid using stereotypical images.

The old woman staring out a window, or sitting in a wheelchair at a nursing home. The old man with a cane sitting alone on a park bench. Images like these can perpetuate negative stereotypes about older people as less capable, lonely, sick and in decline.

Although research shows print media especially has improved significantly in this regard in recent decades, mass media portrayals remain largely stereotypical, says Liz Seegert, a longtime health and aging reporter and the aging topic lead for the Association of Health Care Journalists. “If somebody older is on a TV show, they either get portrayed as a grumpy old man or somebody who’s a little out of it,” she says. “There are very few accurate portrayals.”

When possible, using images that directly illustrate the story at hand are best. But that’s not always possible, especially on tight deadlines and tight budgets. In such instances, the best choice is the most neutral image: an older hand with a younger hand, for example.

“The simplest advice is to think about what you want your story to convey,” says Kleyman. “If you have to default at the last minute, try to go with a neutral image… In terms of your ongoing messaging as a reporter, I think it’s important to just stop and think.”

3. Flip and broaden the narrative.  

If a story is only a story because of the age of the person involved, reporters and editors should look for a broader angle — or a new story. With a little more thought and reporting, that story about an 85-year-old who ran a marathon can be transformed into a story about the increasingly active lifestyles of older people, says Seegert.

“I wouldn’t write the story on just the fact that he’s 85 and ran a marathon,” she says. “I would flip it [and explain that] Joe Smith just ran his 10^th marathon at age 85, and this is becoming a more common occurrence as people live longer.” 

That said, it’s critical to seek the individual perspectives of multiple older people when reporting on topics that affect them, because the experiences and opinions of older adults vary.

This is in sharp contrast to the damaging misperception that older people are part of one monolithic group.

“There are all these stereotypes about older people as a group,” says Seegert, “like everybody’s going to have dementia, everybody’s going to be frail, and they’re no good at technology, for example, or they can’t learn anything new. The truth is… only a very small percentage of people wind up in nursing homes. Most older people, while they may slow down a little bit or have some chronic diseases they have to manage, live pretty normal, everyday lives.”

4. Check your bias before the interview.

The biggest mistake reporters make on stories about older people, says Kleyman, is that they approach the older person as someone in a state of decline, rather than as someone at a later stage of growth and maturity, with important wisdom and experience to share. Making a mental note of your attitude before an interview can help avoid this.

5. Know the Big 4.

The United States has four primary national, interdisciplinary nonprofit organizations that specialize in aging-related issues and research: The American Geriatric Society, the American Society on Aging, the Gerontological Society of America, and the National Council on Aging. Kleyman says understanding the mission and focus of each can help inform reporter’s coverage of aging issues and related research.

American Geriatric Society: Founded in 1942, this New-York-based organization has a membership of about 6,000 geriatrics healthcare providers, including physicians, nurses, and social workers. AGS is focused on research and dissemination of knowledge to improve health care and outcomes for older adults in the U.S.

American Society on Aging: Based in San Francisco, the American Society of Aging, where Kleyman worked as editor of Aging Today for about 20 years, grew out of a regional organization in 1954 and focuses on connecting with community programs and the business community. It produces podcasts and webinars and provides resources on issues such as spirituality and aging.

Gerontological Society of America: Focused broadly on academic research and translating research to practice, GSA has about 5,500 members – including behavioral and social scientists, clinicians, biologists, psychologists, social workers, educators, economists, and policy experts – in the US and abroad. Founded in 1945 and based in Washington, DC., the organization publishes journals, newsletters and trend reports, and sponsors a fellowship for journalists covering aging issues.

National Council on Aging: A national lobbying group founded in 1950, the NCOA advocates for community service programs, particularly those that benefit lower-income and otherwise marginalized older people. The organization also provides tools and resources for community groups and individuals.

It is important to note that the field of gerontology – the study of aging, old age, and problems that affect older people – only formed about 100 years ago and started to gain momentum after World War II. Increases in longevity necessitated professional associations to share knowledge and establish best practices in studying aging processes and issues unique to older people.

“There is a social and political lag in all of this,” says Kleyman. “The systems really need to catch up.”

6. Explore other points of view.

In addition to the four major national groups, there are issue-specific nonprofits and associations involved in studying and lobbying on aging-related topics. These can be useful sources of information, but Kleyman advises to first ask or dig into where each organization gets its funding. Legal advocacy groups, like Justice in Aging, and community groups are also excellent resources.

Additionally, because women, on average, earn less and live longer than men, many chronic conditions and social issues like ageism are problems that disproportionately affect women.  Reporters should consider seeking the viewpoints of women and women’s health organizations for aging-related stories. Seek out sources through organizations such as the National Women’s Health Network, Society for Women’s Health Research, National Women’s Law Center and Women in World Foundation.

Research to explore

Old Age-Related Stereotypes of Preschool Children

Alison Flamion, et al. April 2020, Frontiers in Psychology

Global Report on Ageism

2021, World Health Organization.

Visual Ageism in the Media

Eugène Loos and Loredana Ivan. May 2018. Contemporary Perspectives on Ageism.

Take note: The Journalists Network on Generations publishes an e-mail newsletter called GBO News, which includes networking opportunities and information (including research) for journalists who cover stories about aging. Subscriptions are free to journalists.

To learn more about how to inform news coverage of issues related to aging, check out our research roundups on the impact of ageism, the epidemics of loneliness among older people and prescription drug prices.

The post 6 tips for improving news coverage of older people appeared first on The Journalist's Resource.

From failures to include older adults in clinical trials for treatments meant for older patients to internet tropes like #OKBoomer, ageism is so ubiquitous in Western society that unabashedly ageist acts often go unrecognized and unaddressed. Ageism can be structural, interpersonal, or self-directed, and it encompasses age-based thoughts (stereotypes), feelings (prejudice) and actions (discrimination).

Ageism can be overt, subtle, or even unconscious. Older adults often encounter comments, jokes, and representations of older people that perpetuate negative stereotypes and refer to them as a monolithic group, despite wide diversity in experiences and health status among older people. New research by Julie Ober Allen, an assistant professor and ageism researcher in the health and exercise science department at the University of Oklahoma, and her colleagues finds that encounters with “everyday ageism” — jokes about getting old on birthday greeting cards, for example, or comments made about older drivers — have a significant impact on health.

Older adults “are systematically disempowered, devalued and excluded from many aspects of contemporary society,” Allen said during a July 27 panel discussion on ageism convened online as part of the Journalists in Aging Fellowship Program, which helps reporters improve their aging-related coverage. “… Many examples [of everyday ageism] are perceived as humorous or considerate or even complimentary, yet they strip older adults of their individuality, and they’re used to justify treating them with less respect and fewer rights.”

Ageism may serve as a source of chronic stress in the lives of older adults, Allen explained during the panel discussion. Alternatively, older adults who believe that loneliness and depression are a normal part of aging might be less likely to seek care, take medications as prescribed, and adhere to their health care providers’ recommendations. Older adults who experience ageism in a health care setting might also be less likely to seek care.

“And I’m not just talking about their interactions with their health care providers, but also with the front office staff, with the ways that messages around them are framed and even things like systemic issues, such as procedures for making health care appointments,” Allen said.

A systemic problem

In the United States, ageism resulted in more than $63 billion in excess health care costs in 2018 alone, according to a 2020 article in The Gerontologist. Medical ageism among health care providers has been found to lead to both the overtreatment and undertreatment of disease and negative experiences that discourage older adults from seeking care. For example, negative attitudes about aging, such as the idea that depression is a normal part of getting older, often result in older people feeling demeaned or brushed off.

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not,” says Kevin Prindiville, executive director of Justice in Aging, a national legal advocacy organization. “You talk to doctors about their training in medical school, and very little of that training is specific to the needs and unique concerns of older adults. Yet when they’re out practicing medicine, they’re finding that many of the people they’re working with and serving are older people, so there’s a misalignment there.”

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not.”

— Kevin Prindiville, executive director of Justice in Aging.

At the individual level, median survival is seven and half years longer for people with a positive outlook on growing older, compared with people who internalize negative beliefs about aging, according to a longitudinal study by Yale psychologist Becca Levy and her colleagues. Decades of research by Levy and her team, employing a variety of methods to measure how negative attitudes about aging affect health, has shown that internalizing negative stereotypes about aging increases the risk of dementia, heart attack, mental illness and more.

These issues are particularly acute in Western society — with its youth-obsessed culture and “anti-aging” industries — but ageism is present elsewhere as well. More than half of the world’s population is ageist against older adults, according to the World Health Organization’s Global Report on Ageism, which also found that ageism is more prevalent in developing countries, and that women, minority groups, and people with lower levels of education are more likely to experience its adverse health effects.

Despite the ubiquitous and deeply ingrained nature of ageism, however, research also suggests that ageist views can be changed through education and increased intergenerational contact.

“We have found evidence that that these [ageist] processes can occur unconsciously, and if people don’t know it’s happening, it’s harder to challenge it and fight it,” Levy, author of Breaking the Age Code: How Your Beliefs about Aging Affect How Long and Well You Live, tells The Journalist’s Resource. “But on the other hand, our research has found that it is possible that these age beliefs are malleable, and they can be changed. So, I think there is definitely room to increase awareness of these negative beliefs and find ways to overcome them.”

Policy efforts at the federal level

In broad economic terms, the consequences of ageism are astronomical, with one study by AARP estimating unrealized gross domestic product growth in the U.S. at $850 billion for 2018, due to discrimination against a burgeoning population of older workers. That figure could reach $3.9 trillion by 2050, according to the report. As a result, older Americans are increasingly experiencing housing vulnerability and homelessness, which greatly exacerbates negative health outcomes, says Justice of Aging’s Prindiville.

Although the proportion of people over age 65 is growing quickly in the United States, policies to address issues that are common among people in this age group have historically been low priority at the state and federal level. Some research even suggests that aging-related policies can have the unintended consequence of intensifying age discrimination. Recently, however, the federal Centers for Medicare and Medicaid Services (CMS) rolled out proposed changes to section 1557 of the Affordable Care Act, which includes anti-discrimination provisions for protected groups, including older adults and people with disabilities.

Other policy work at the federal level is focused on making it easier for older people to receive the same medical care in their homes that they are entitled to receive in nursing facilities under Medicaid, explains Prindiville. These efforts are modeled on the success of advocacy groups for younger people with developmental disabilities who have worked to transition care for that population from institutions to homes and community-based programs.

“We’re looking to make a similar shift for other people with disabilities and for older adults,” Prindiville tells The Journalist’s Resource. “There is a coalition of people working on this in DC, and there are coalitions that are growing and building at the state level.”

States Undertake Master Plans for Aging

A few months before the start of the COVID-19 pandemic, California embarked on a campaign to collect input about aging-related issues and supports from stakeholders, policymakers and the public. This information-gathering effort kicked off a process to develop a 10-year master plan to prepare the state to better serve its fastest-growing population segment. Now, two years into implementation, the far-reaching California Master Plan for Aging is propelling an aging-related policy agenda in the state, says Prindiville, a member of the advisory committee that worked on the plan.

“Having the master plan has helped educate the state administration and different government agencies and departments about the aging population in California, has helped identify particular needs and priorities, and then has helped those agencies develop more specific action they can take for a community that otherwise, sometimes, is overlooked,” he says.

Other states are following California’s lead. The governors of New York and New Jersey have signed executive orders aimed at beginning similar planning efforts. The nonprofit Center for Healthcare Strategies is working with a coalition of 10 states — Colorado, Illinois, Indiana, Minnesota, North Carolina, North Dakota, Oregon, South Carolina, Tennessee, and Vermont — on master plans for aging.

“At the state level, sometimes it’s difficult to get momentum to take political and policy action on aging issues because they’re not seen as hot button political issues,” says Prindiville. “The master plans provide a vehicle and a framework to help a state get organized and to start to educate and elevate some of the issues.”

Research roundup

Recent research has examined the prevalence and health effects of ageism and negative age beliefs, as well as the efficacy of various policies and direct interventions, including intergenerational interactions or “cogeneration.” Below are summaries of seven curated peer-reviewed studies on ageism and health, including two by Levy and her team and one systematic review that she participated in as part of the WHO campaign.

Among the key findings in this research roundup:

• People with positive beliefs about aging live longer than those who internalize negative beliefs and stereotypes about getting older.
• Negative beliefs about aging increase a person’s risk of experiencing a cardiovascular event, such as angina attacks or stroke, later in life.
• More than 95% of studies that have examined the connection between ageism and health over the past 25 years have found that ageism results in worse health outcomes.
• In the U.S., 1 out of every 7 dollars (15.4%) spent on the eight most-expensive health care conditions among people ages 60 and older is linked to ageism.
• Research suggests 93.4% of people ages 50-80 regularly experience some form of ageism in their daily lives.
• Educating people about the aging process and providing opportunities for younger people to interact with older people are effective ways of reducing negative attitudes toward older people.

Longevity Increased by Positive Self-Perceptions of Aging
Becca Levy, Martin Slade, Suzanne Kunkel and Stanislav Kasl. Journal of Personality and Social Psychology, August 2002.

This was the first longitudinal study that connected negative health outcomes with individuals internalizing negative beliefs about growing old. Levy and her team relied on a comprehensive survey of residents from the town of Oxford, Ohio, which has a population of about 15,000 and is home to Miami University, and studied the effects of their perceptions about aging as they got older, for up to 23 years. They found that participants who held positive beliefs about aging “lived 7.5 years longer” compared with those who had internalized negative stereotypes.

The research included 660 individuals aged 50 and older who participated in the community-based survey known as the Ohio Longitudinal Study of Aging and Retirement (OLSAR). These participants were first recruited to take the OLSAR by a professor at Miami University starting in 1975, and participants were interviewed in six waves. Levy and her team conducted the survival analysis by matching the OLSAR data to mortality data from the National Death Index.

Although the study’s findings were in keeping with previous research showing that self-perceptions of stigmatized group identities, such as those related to race and gender affect behavior and functioning for people in those groups, the researchers theorized that self-perceptions of aging operate differently.

“Unlike race and gender stereotypes, which individuals encounter while developing group self-identities, individuals acquire age stereotypes several decades before becoming old,” they write. “Thus, younger individuals are likely to automatically accept age stereotypes without questioning their validity.”

In a follow-up longitudinal study, Levy and her team found that negative age beliefs acquired earlier in life significantly increased the likelihood that a person would experience a cardiovascular event later in life. The 89 cardiovascular event types studied included angina attacks, congestive heart failures, and strokes.

Global Reach of Ageism on Older Persons’ Health: A Systematic Review
E-Shien Chang; et al. PLoS One, January 2020.

This systematic review, conducted in conjunction with the World Health Organization’s Global Campaign to Combat Ageism, included more than 7 million participants in 422 studies from 45 countries on five continents over a span of 25 years. 

“Ageism led to significantly worse health outcomes in 95.5% of the studies and 74% of the 1,159 ageism-health associations examined,” the researchers write. “The studies reported ageism effects in all 45 countries, 11 health domains, and 25 years studied, with the prevalence of significant findings increasing over time (p < .0001).”

The study specifically examines “individual ageism” which refers to the “impact of culture-based negative age stereotypes and negative self-perceptions of aging on the health of older persons.” The review, which draws on the Stereotype Embodiment Theory developed by Levy, finds that ageism is more prevalent in less developed countries and that people with less education are more likely to experience the adverse health effects of ageism.

Ageism Amplifies Cost and Prevalence of Health Conditions 
Becca Levy; et al. The Gerontologist, February 2020.

This was the first study to examine the financial costs of ageism in terms of its health effects. The study, conducted by Levy and her team at the Yale School of Public Health, concludes that ageism resulted in $63 billion in excess health costs related to the eight most-expensive conditions (cardiovascular disease, chronic respiratory disease, musculoskeletal disorders, injuries, diabetes mellitus, treatment of smoking, mental disorders, and non-communicable diseases) for people ages 60 and older in 2018. In other words, 1 out of every 7 dollars (15.4%) spent on those conditions was linked to ageism, after adjusting for age, sex, and overlapping costs.

“This is greater than the total amount the United States spent on health care costs of morbid obesity for the same year,” the researchers write.

The costs were further broken down; $11.1 billion was attributed to age discrimination, $28.5 billion was attributed to negative age stereotypes, and $33.7 billion was linked to negative self-perceptions of aging. The study authors also estimated that ageism was responsible for 17.04 million cases of those eight most-expensive health conditions in 2018. The highest expenses were attributed to cardiovascular disease.

The research combined the results of previous ageism-health studies with 2013 data on health care spending from the Institute of Health Metrics and Evaluation. The research team used a variety of statistical checks to reduce the likelihood of health affecting ageism, as opposed to the other way around.

Experiences of Everyday Ageism and the Health of Older US Adults
Julie Ober Allen; et al. JAMA Open Network, June 2022.

This study made use of data from the University of Michigan National Poll on Healthy Aging that was collected in December 2019 from a nationally representative sample of 2,035 people aged 50-80. The analysis found that 93.4% of respondents regularly experienced at least some form of everyday ageism in their daily lives.

“Everyday ageism” was broken down into three groups: exposure to ageist messages; ageism in interpersonal interactions; and internalized or self-directed ageism.

Participants with lower levels of education, lower income, retirees not working for pay and people living in rural areas reported higher levels of everyday ageism than their counterparts. Older adults who spent more time online, watching television and reading magazines also reported being exposed to higher levels of everyday ageism, according to the study.

These higher levels of everyday ageism were associated with all four physical and mental health indicators the researchers examined — fair or poor physical health, number of chronic health conditions, fair or poor mental health, and depressive symptoms.

Interventions to Reduce Ageism Against Older Adults: A Systematic Review and Meta-Analysis
David Burnes; et al. American Journal of Public Health, August 2019.

This was the first systematic review and meta-analysis to assess the relative effects of interventions aimed at reducing ageism, the effectiveness of which remain poorly understood, according to the WHO’s global ageism report. Three types of interventions designed to reduce ageism among youths and adults were assessed — education providing information and addressing misperceptions about the aging process, intergenerational contact and combined education and intergenerational contact.

The review looked at 63 studies, including five randomized controlled trials, with a total of 6,124 participants, with most of the studies conducted in the United States. The research team found that ageism interventions had a significant effect on participants’ attitudes, knowledge and comfort level in interacting with older adults, but had no significant effect on anxiety about one’s own aging or interest in working with older adults (in the fields of geriatrics or gerontology). Interventions that included both education and contact between older and younger generations had the largest effects on attitudes. The effects were strongest among women and adolescent and young adult groups.

The paper also notes that “studies that examined the effect of ageism interventions among older adults themselves were lacking.”

Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change
Angelica P. Herrera; et al. American Journal of Public Health, April 2010.

This paper looks at the issue of under-representation of older adults in clinical trials through a policy lens, reporting on the severity of the problem through a review of past research and outlining potential policy solutions.

Older people are sometimes excluded from clinical trials if they have multiple diseases, or they may have lower-functioning organs, such as the kidneys, which are important for drug processing. The result of this exclusion is underrepresentation. For example, two out of three cancer patients are older than 65, but only about 25% of participants in clinical trials for cancer treatments are in that age group, according to a 2003 study.

“Clinical trial participation of older adults is also low in research on Alzheimer’s disease, arthritis, epilepsy, incontinence, and cardiovascular disease,” the researchers write. “These failings may limit generalizability, provide insufficient data about positive or negative effects of treatment among specific populations, and hinder much-needed access to new treatments.”

The study recommends the development of standardized protocols for recruiting clinical trial participants, establishing guidelines for the inclusion of older people based on physiological rather than chronological age, using age-friendly methods of communication, making trial participation less costly and improving education and federal monitoring.

Ageism and Psychological Well-Being Among Older Adults: A Systematic Review
Hyun Kang and Hansol Kim. Gerontology and Geriatric Medicine, April 2022.

The authors of this paper reviewed 13 quantitative studies of the relationship between ageism and the mental health of older adults. The study confirmed that an increase in experiences of ageism has a negative effect on older adults’ psychological well-being, but it also identified some important mitigators.

According to the research, older adults with a “high level of psychological well-being,” especially those who were proud of their age group, were more optimistic about aging and their future, were more self-confident about their bodies, were flexible in setting goals, and were more resilient to the negative effects of ageism on their mental health. 

The researchers conclude that, overall, studies on the efficacy of interventions to combat the harmful effects of ageism are lacking. “Significant scholarly attention should be given to ageism,” they write, “considering its importance and universality, as it encompasses every generation and the growth of the population of older adults.”

The post The impact of ageism on health and health care: A research roundup and explainer appeared first on The Journalist's Resource.

Loneliness is a distressed feeling arising from the perception that one’s social needs are not being met. For decades, it was considered strictly an emotional and mental health concern, studied mainly by psychologists, philosophers, and poets.

Today, however, health researchers and clinicians across specialties recognize it as a social determinant of health, a factor, like economic stability or access to high-quality education, that greatly influences overall health outcomes. In recent years, loneliness has also been described as an epidemic and elevated to a public health crisis, one intensified by social distancing guidelines during the COVID-19 pandemic.

But unlike most other public health crises, loneliness isn’t all bad. About 20% of the population is experiencing a normal, even helpful level of loneliness at any given time, says Liz Necka, a program director in the Division of Behavioral and Social Research at the National Institute on Aging. “That should be expected, because loneliness can be motivating to promote social connection,” Necka says. “The issue is when loneliness becomes chronic.”

Neuroscience and studies of isolated animals suggest that when left untended loneliness triggers an immune response in the body, sparking cycles of inflammation that can lead to a variety of illnesses, ranging from depression and anxiety to high blood pressure, diabetes, stroke, and heart disease. The resultant state of hypervigilance is associated with shifts in personality and decision-making and puts people at higher risk for cognitive impairment and dementia. Oft-cited research places the increased risk of premature death among lonely people at 26%, a rate on par with smoking.

Despite these troubling correlations, however, new evidence suggests that even chronic loneliness might bestow some benefits. Recent neurological research has found that brain regions dealing with reminiscing, imagining, and self-reflection are bulkier and more strongly wired in lonely people.

Loneliness is complicated and hard to measure, and much remains unknown about how and when it predicts poor health or early death. But those and other questions have motivated an explosion of new research over the past few years, particularly since social distancing during the pandemic gave rise to new fears about loneliness levels worldwide.

All the lonely people

Research suggests that 15-30% of the general population is chronically lonely. In the U.S., before the pandemic, about 19% of adults over age 55 were “frequently” lonely, according to data from the Health and Retirement Study (HRS), which is considered the gold standard of representative surveys and is conducted biennially at the University of Michigan.

Contrary to narratives suggesting a growing rate of loneliness among seniors, the prevalence of self-reported “frequent loneliness” among older adults in the U.S. remained relatively flat from 1998 to 2016, according to a recent analysis by James Raymo, a demographer and sociology professor at Princeton University.

“There are little bumps and blips here and there,” says Raymo, who used HRS data and population statistics to identify the effects of loneliness on life expectancy among different population segments, “but it is largely stable over this period, which is a period of time in which attention to and concern about loneliness, and the description of the loneliness epidemic has, from my perspective, grown.”

Polling data suggests that the rate of loneliness among older adults spiked during the pandemic, but younger people seem to have suffered from loneliness at even higher rates as a result of social distancing.

People experience loneliness at all stages of life, but older adults are at a much higher risk of experiencing the related adverse health outcomes, says Necka.

“Older adults have generally been much more resilient than younger adults to social distancing, which I think is somewhat surprising to a lot of people,” she says. Early evidence suggests that, with the reopening of businesses and the easing of social distancing guidelines, loneliness is returning to pre-pandemic levels, Necka adds.

Research hurdles and future directions

Loneliness is complex, nuanced and confusing in that there’s a lack of uniformly accepted terminology surrounding it. For example, social isolation – defined as an objective lack of social contacts – is often conflated with loneliness. But these concepts are distinct; a person can be content without social contact, or lonely despite plentiful social ties, if those connections are not perceived as meaningful.

In addition, while loneliness is linked with increased risk of developing serious health conditions, many of those conditions also increase a person’s risk of experiencing loneliness. This creates a vicious cycle in the lives of patients and a potential endogeneity problem for researchers. (Endogeneity – when a variable not included in a statistical model is related to a variable that is included – can obscure causality in research.)

“I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

Dr. Ashwin Kotwal

Loneliness is also difficult to measure, in part due to problems with pinpointing when loneliness starts and stops and when it persists for too long, as well as the use of various assessments. Further, because it’s unethical to conduct randomized experiments in which people are assigned to be lonely, researchers rely on survey data. But whether those surveys are conducted over the phone or in writing can change the results (research suggests people are more willing to identify as lonely in writing).

The prevalence of loneliness varies among different population segments. Much research has been devoted to understanding which groups are most at risk for experiencing chronic loneliness. People living in poverty and those who suffer from cognitive impairments, mobility issues, and sensory impairments, such as hearing and vision loss, are at the highest risk. A 2020 report by the National Academies of Science, Engineering and Medicine also highlights immigrants and people who identify as LGBTQ+ as being at higher risk.

Medical professionals are increasingly recognizing their role on the front lines of the battle against loneliness. Indeed, for the millions of chronically lonely older adults in the U.S., a quick chat with a doctor is one of very few conversations about their own health and wellbeing.

Dr. Ashwin Kotwal, a researcher and palliative care physician at the University of California in San Francisco, says the pandemic helped to destigmatize loneliness, and more clinicians are now asking their patients about their social wellbeing. But systemic change is needed, he says, to accelerate social prescribing  (when patients are prescribed social support from community programs) and funding for existing programs.

“We need to start breaking down these boundaries between social needs and medical needs,” says Kotwal. “I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

A broad range of interventions

Because the experience of loneliness varies at the individual level, there is no universally effective intervention.

“You can think of loneliness like setting your thermostat,” explains Necka, of the NIA. “I might prefer my house a little bit warmer; you might prefer your house a little bit colder. What will make us feel socially connected, in terms of the objective interactions we’re having, will differ from person to person.”

Prior to the pandemic, many interventions focused on developing cognitive skills – teaching people how to socialize, an approach based largely on a 2010 meta-analysis of intervention studies. More recently, researchers have seen promising results associated with enrolling lonely people to help others through volunteer programs, Necka says, but these findings have not yet been published. Training social support personnel, such as Meals on Wheels delivery drivers, to practice empathetic listening has also shown promise as a potentially scalable intervention.

The pandemic forced many older people to become comfortable with technologies like videoconferencing to keep in touch with friends and family. This has led to a growing emphasis on digital technology, with many newer intervention studies involving the provision of direct social contact via videoconferencing. Robot companions have also been shown to reduce feelings of loneliness and anxiety.

Both inside and outside of the health care community, there’s a broad recognition of the need for holistic approaches that bring together various disciplines and stakeholders. Experts in a variety of fields, ranging from psychology to public transportation to the arts, have already spent decades studying loneliness and ways to provide relief.

Amy McLennan, a senior fellow in the school of cybernetics at Australian National University, expressed concern in a 2018 letter to the Lancet that health care professionals run the risk of stifling broad-based collaboration by describing loneliness as a health problem to be solved by the medical community. McLennan, who primarily researches obesity, says she’s seen this phenomenon before.

“It’s been really hard to have a conversation around obesity as more than a medical concern because the public imagination of it by now has taken on board this idea of it being a medical thing that needs to be treated by doctors and diagnosed by doctors,” she tells The Journalist’s Resource. “The narratives that we put into the public domain do get picked up by the public, and they’re very hard to unwind later.”

Kotwal, who treats terminally ill patients, sees the pandemic and the growing volume of loneliness-related research as fueling important progress toward an inflection point in health care. Ultimately, he says, without systemic changes that facilitate increased social prescribing and spending on patients’ social wellbeing, the potential for clinicians to help alleviate suffering from chronic loneliness will be severely limited.

“How can we take a little bit of what we’re spending on medical care and redirect it to social care?” asks Kotwal. “I think clinicians have to be advocates for that change. Many of these other disciplines have been trying to do this for a long time, and we are playing catch-up, honestly. We’ve been behind for a long time here. I’m hopeful that the pandemic and some of the growing evidence in this space will push people to start doing this.”

Studies published in recent years have examined the prevalence of loneliness and links between low levels of human contact and poor health outcomes, as well as the efficacy of intervention delivery methods and specific interventions. Below is a curated list of seven peer-reviewed studies on loneliness and social isolation, along with summaries of their most important findings and additional insights from interviews with some of the authors.

Research Roundup:

Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review

Julianne Holt-Lunstad, Timothy Smith; et al. Perspectives in Psychological Science, March 2015.

One of the most-cited studies on loneliness and social isolation, this paper concludes that a lack of human connection is as detrimental to health as other established risk factors, like smoking and obesity. The researchers examined 70 studies conducted between 1980 and 2014, for a total sample size of more than 3.4 million adults with an average age of 66, in an effort to determine the extent to which social isolation, loneliness, and living alone influenced the likelihood of death among the sample population.

They concluded that the increased likelihood of death was 26% for reported loneliness, 29% for social isolation, and 32% for living alone. The differences in these effect sizes was not statistically significant, explains Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University, and most of the studies included in the analysis did not look at more than one condition to determine overlap (i.e. whether someone who lived alone was also lonely). All of the studies did, however, control for initial health status, as a way to rule out reverse causality. The results suggest that social isolation and living alone are as much a predictor of early death as loneliness, but the reasons why are presumed to be different.

“If you’re having a heart attack, and there’s no one in your home to call 9-1-1, that’s going to have a significant effect on whether you survive that heart attack or not,” Holt-Lunstad tells The Journalist’s Resource.

While age and prior health status were significant in determining effect size, the results were consistent across genders and world regions, according to the study. Social isolation was more predictive of death in people younger than age 65, the researchers found.

A Meta-Analysis of Interventions to Reduce Loneliness

Christopher Masi; et al. Personality and Social Psychology Review, August 2010.

In this meta-analysis, the researchers examined 50 randomized group comparison studies on the efficacy of various loneliness interventions, concluding that the most effective among them addressed issues with social cognition, or how people process and apply information about other people.

A lonely person, in other words, might interpret social interactions as more negative than they are and use these negative interpretations to confirm thoughts about their own lack of social abilities or worthiness, thus perpetuating loneliness. The researchers theorize that this pattern stems from the state of hypervigilance associated with persistent loneliness, which can impair executive function and decision-making.

This led to a series of intervention strategies addressing “maladaptive social cognition,” though many proved ineffective after further study.

The Epidemiology of Social Isolation and Loneliness Among Older Adults During the Last Years of Life

Ashwin Kotwal; et al. Journal of the American Geriatrics Society, August 2021.

In this study, the researchers looked to understand the rates and risk factors of social isolation and loneliness among people who were within four years of death. By modeling data from the Health and Retirement Study combined with other data sources, the researchers found that about 19% of people in the study sample experienced social isolation, 18% experienced loneliness, and 5% experienced both.

Risk factors for both isolation and loneliness included having an individual net worth of less than $6,000, hearing impairment and difficulty preparing meals. Factors associated with loneliness, but not social isolation, included being female, having pain, incontinence, and cognitive impairment.

“We really are now thinking about addressing these social needs as an important opportunity to improve people’s quality of life when people are seriously ill or even finding ways to integrate them into their medical goals,” says Kotwal.

Accompanying the research paper, in the same issue of the journal, is an editorial, written by two physicians at Icahn School of Medicine at Mount Sinai in New York. Drs. Diane Meier and Sean Morrison advocate for increasing government support for addressing the social determinants of health, which play a considerable role in the health experiences of older adults in America.

“Despite recognition of the foundational role of social factors in achieving health, we continue to put nearly all of our taxpayer-funded healthcare dollars into direct medical services (more than 95% of healthcare dollars at a cost of >$10,000 per person per year),” they write. “This mismatch between spending and need results in our healthcare quality being ranked 37th among that of 100 developed nations, behind Costa Rica, and just ahead of Cuba and Slovenia.”

Loneliness at Older Ages in the United States: Lonely Life Expectancy and the Role of Loneliness in Health Disparities

James Raymo and Jia Wang,. Demography, June 2022.

Using data from the University of Michigan’s Health and Retirement Study, the researchers applied the statistical tools of demography to calculate a measure they call “lonely life expectancy” to understand the impact of loneliness on average life expectancy for various population segments. For example, men 55 years and older, on average, spend about 3.4 years lonely, which equates to roughly 14% of their total average life expectancy. This study also found that rates of loneliness among older adults remained relatively steady from 1998 to 2006.

One of the surprising findings from the research was that disparities in rates of loneliness along racial lines depended on how loneliness was defined, says lead study author James Raymo, a demographer and sociology professor at Princeton University. Using scales that measure respondents’ “sense of belonging” and “feeling left out” resulted in higher discrepancies in rates of loneliness among racial and ethnic minorities compared with whites.

The study also showed that higher rates of loneliness among disadvantaged groups do not directly correlate to higher rates of mortality or disease, Raymo says.

“We show that Blacks are lonelier than whites,” Raymo tells The Journalist’s Resource. “We show that less educated people are lonelier than higher educated people. But [further] analysis shows that, despite the fact that we know loneliness to be related to health outcomes and mortality, the concentration of higher levels of loneliness among more disadvantaged people does not account for their higher levels of mortality or higher probability of onset of disability and things like that. So that was a little bit surprising – how little salience loneliness had in accounting for, at least in a statistical sense, the differences in these various health outcomes across the racial, ethnic, and educational groups.”

Friends from the Future: A Scoping Review of Research into Robots and Computer Agents to Combat Loneliness in Older People

Norina Gasteiger, Kate Loveys, Mikaela Law, and Elizabeth Broadbent. Clinical Interventions in Aging, May 2021.

Based on a review of 29 studies, this paper concludes that current research points to “social robots” as an effective way to reduce loneliness in older adults, “using features that encourage direct companionship and facilitate social interactions.” Because the majority of the studies reviewed (24) dealt with robots – like Paro, a robotic baby seal used to comfort nursing home residents – the research was inconclusive on the efficacy of “computer agents,” like chatbots.

Elizabeth Broadbent, a professor in the Department of Psychological Medicine at the University of Auckland in New Zealand, was an author on this paper, as well as past research on Paro, which was developed in Japan.

“It makes these little seal noises, like helpless animal noises,” she says. “And that makes you want to pick it up and comfort it and cuddle it and pat it and talk to it as well.”

The majority of studies showed that robots or computer agents positively impacted at least one loneliness outcome measure. Some unintended negative consequences on social outcomes were reported, such as sadness when a robot was taken away from a study participant.

Overall, the robots helped combat loneliness by acting as a direct companion (69%), a catalyst for social interaction (41%), facilitating remote communication with others (10%) and reminding users of upcoming social engagements (3%).

Evaluation of the Effectiveness of Digital Technology Interventions to Reduce Loneliness in Older Adults: Systematic Review and Meta-analysis

Syed Ghulam Sarwar Shah; et al. Journal of Medical Internet Research, June 2021.

This paper outlines results from an evaluation of six studies of loneliness interventions designed to facilitate increased social connections using digital technologies, including five clinical trials. A total of 646 people (66% of them women) with an average age of 73-78 participated in the six studies, each lasting three months or more, examining interventions involving live videoconferencing, as well as Alexa-like audio and televised video support.

The overall effect estimates showed no statistically significant difference in the effectiveness of digital technology interventions compared with that of usual care or other interventions. However, the researchers note that the quality of evidence was very low to moderate in the trials.

Lead researcher Syed Ghulam Sarwar Shah, a physician and senior research fellow at Oxford University, says he believes the results demonstrate that digital technology interventions are no substitute for human interaction in the real world. As a result, he is working on developing an app called Evzein, which seeks to leverage local restaurants and pubs as places where lonely people can meet and connect.

Shah says additional research is needed to determine whether digital technology interventions are effective in reducing loneliness among young people and other specialized groups that were disproportionately affected by loneliness during the pandemic.

Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits

Namkee G. Choi, Renee Pepin, C. Nathan Marti, Courtney J. Stevens, and Martha L. Bruce. American Journal of Geriatric Psychology, July 2020

These researchers modified a short-term intervention known as “behavioral activation” that is usually used to address mild depressive symptoms in older adults, with the goal of reducing loneliness. A randomized controlled trial showed promising results for the intervention, both initially and during a follow-up study conducted a year later.

Behavioral activation involves educating recipients about the condition it is looking to address, in this case loneliness, in an effort to normalize it. An interventionist trained in BA assists people in identifying activities that hold particular value for them and finding new ways to engage in them, despite the functional or health limitations they might be experiencing. If church is really important to someone, for example, but they no longer attend because they don’t have a driver’s license, behavioral activation focuses on helping them find another way to get there, explains Renee Pepin, an assistant professor of community and family medicine at Dartmouth College’s Geisel School of Medicine.

In the study, Meals on Wheels recipients in New Hampshire and Texas were split into two groups. One group received regular behavioral activation sessions via teleconference; the other group received friendly chats via teleconference, without the specialized intervention. Compared to the group that received friendly visits, the behavioral activation group experienced a 10% greater increase in social interaction, 20% greater decrease in loneliness, 39% greater decrease in depressive symptoms, and 21% greater decrease in disability.

“The intervention holds promise for scalability in programs that already serve homebound older adults,” the researchers write.

Pepin says participants hired to deliver the intervention in the study were not Meals on Wheels drivers. “We tried to select people with similar characteristics as people who work for home-delivered meals,” she said. “A next step for this line of research is absolutely to see, does it work the same way or similarly if we actually do employ people who work within these agencies to deliver this intervention?”

Tips for Reporters Covering Loneliness Among Older Adults

1. Know the difference between social isolation and loneliness. Social isolation is defined as an objective lack of social contact, whereas loneliness is the subjective desire to have more or higher-quality social connections than one is currently experiencing. Some people can be socially isolated without feeling distressed, and others can feel lonely despite having regular social contact; it’s rare for people to experience both at the same time. Research suggests that chronic social isolation and chronic loneliness are associated with negative health outcomes, but in different ways.

2. Seek sources outside of health care. Clinicians know how to address problems within the confines of the health care system, but loneliness is a social issue addressed by a variety of other community stakeholders. Senior centers, nonprofit support programs, arts organizations, public social services agencies, and others have been confronting and working hard to address the problem of loneliness for decades.

3. Tell personal stories. Because the experience of loneliness is personal and varies at the individual level, it’s important to talk to people who are experiencing it, as this can help to reduce stigma and spur policy change. Home meal-delivery services and other local nonprofits serving seniors can be good starting points for finding sources.

4. Explain where people can go for help. Many older people who are lonely as well as those who care about seniors experiencing loneliness don’t know where to turn. Urging readers, viewers and listeners in these situations to reach out to a trusted family member, physician or community support worker is helpful, as are lists of resources, such as the Eldercare Locator.

5. Check your bias. Because loneliness is universal, people often think back to their own experiences for context, but that can unknowingly introduce bias into the conversation. People tend to remember what helped them overcome a specific bout of loneliness and believe the same solution would be helpful to others. However, because social needs and circumstances vary so much, there is no universally effective intervention for loneliness.

Additional Resources

Commit to Connect – a public-private campaign and resource clearinghouse hosted by the federal Administration for Community Living.

Foundation for Social Connection – nonprofit charitable organization promoting evidence-based research and interventions.

Coalition to End Social Isolation and Loneliness (CESIL) – Advocacy group supporting policy changes aimed at reducing loneliness and associated negative health effects.

Social Isolation and Loneliness Outreach Toolkit – This page from the National Institute on Aging features videos, graphics, flyers and brochures for use by media and community organizations to raise public awareness and reduce stigma surrounding loneliness and social isolation.

Eldercare Locator – A service of the US Administration on Aging, the Eldercare Locator connects people to local services for older adults and their families.

Project UnLonely – This national initiative by the Foundation for Art and Healing raises awareness about the negative effects of loneliness and empowers people to connect with each other through the arts.

Programs Promoting Interaction

The AARP recommends the following intergenerational programs to ease loneliness in older adults:

Big & Mini – An organization that matches older people with younger people for online chats and friendship.

SAGEConnect – a phone-buddy program that matches older LGBT people with volunteers for weekly phone calls.

Eldera – This service pairs mentors 60 and older in the U.S. with children ages 5 to 18 from 22 countries for video chats.

Dorot Caring Calls – Connects older adults with volunteers 18 and up for weekly phone calls, based on participants’ preferences.

Create the Good – This AARP site lists thousands of local and national volunteer opportunities and pairs seniors with volunteer work that matches their preferences.

The post Loneliness among older people: A research roundup and 5 tips for covering the topic appeared first on The Journalist's Resource.

With the rapid expansion of telemedicine in response to the COVID-19 pandemic, researchers have begun to explore how a new emphasis on virtual care might exacerbate persistent racial and ethnic disparities in U.S. health care — and, perhaps, help repair them.

Recent research and anecdotal evidence point to significantly lower levels of telemedicine usage among Black and Hispanic patients, particularly those over age 65, as compared with white patients, since the pandemic’s onset. Ellerie Weber, an assistant professor in population health science and policy at Mount Sinai’s Icahn Medical School, saw it firsthand during the initial COVID-19 surge in New York City.

“There were these huge lines for the ER, and for testing,” says Weber, lead author of the study “Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic.”

Many of those waiting in line were Black and Hispanic, she says, “and people who were higher [socioeconomic status], younger, more white, more Asian, you just heard, anecdotally, that they were calling their doctor or getting a telehealth appointment to at least say, ‘Hey, do I have COVID? Do I need a test?’”

Telemedicine is the delivery of clinical services using telecommunications technology, including video conferencing and telephone calls. (Telehealth is a broader term that generally encompasses clinical services as well as nonclinical services such as provider training.)

Despite evidence of lower rates of telemedicine use among racial and ethnic minorities, other research suggests that seeing patients in a standardized way on a screen might reduce providers’ biases and the resulting disparities in health care. Take, for example, the results of a recent study in which researchers analyzed electronic health records of patients in New York City at the pandemic’s initial peak, titled “Telemedicine and health care disparities: a cohort study in a large health care system in New York City during COVID-19.”

The results suggest that suspected COVID-19 diagnoses among Black patients, who on average were sicker when they sought care, were more likely to happen in telemedicine visits than in-person.

“It seems like, on the telemedicine system, it’s maybe a more equal playing ground for the Black patients and white patients to get treated the same,” says the study’s lead author, Rumi Chunara, an assistant professor at New York University’s Tandon Engineering School, whose research aims to inform the development of telemedicine tools and platforms.

Historically, stark differences in the way people of color access, experience, and receive health care, as compared with their white counterparts, have been well-documented. And while progress has been made in increasing insurance coverage and improving overall population health in recent years, the data show that some gaps in access to and quality of care have widened, according to the 2018 National Healthcare Quality and Disparities (NHQD) Report.

Released by the Agency for Healthcare Research and Quality, part of the US Department of Health and Human Services, the NHQD Report outlines persistent disparities for Black patients, as compared with whites, including the number of new HIV cases per 100,000 people over age 13 and hospital admissions for asthma per 100,000 population, among children age 2-17.

Likewise, past research on the so-called digital divide has shown that much of the world is still cut off from the internet. People who lack access to broadband internet – due to cost, availability or the technological literacy to leverage online tools and information — are at a disadvantage in terms of health care and other aspects of life.

With the explosion in telemedicine in recent months, due to the convergence of social distancing guidelines and emergency government policies aimed at facilitating virtual care, researchers are just beginning to learn what happens when telemedicine is introduced at scale.

“There hasn’t been much research into how the digital divide influenced telemedicine use in particular,” explains Weber, “because prior to COVID, telemedicine use was actually not that widely taken up. People were trying for a long time; people kept saying we were on the verge of a telehealth revolution, but it wasn’t really used much for a variety of reasons.”

Health care digital divide

In San Francisco earlier this year, a team of clinicians and researchers affiliated with the University of California San Francisco, led by Dr. Sarah Nouri, noticed that after their primary care practices quickly shifted almost entirely to remote patient visits because of the pandemic, Black and Hispanic patients used telemedicine at significantly lower rates than white patients. They attributed the differences to disparities in access to technology and digital literacy.

“This has alarming implications for inadequate chronic disease management that may result in increased disparities in clinical outcomes as some patients disproportionately lose frontline access to primary care,” Nouri and her colleagues write in a May commentary published in the journal Innovations in Care Delivery.

To address access concerns, some insurers, including Medicare, have started covering audio-only visits conducted via telephone at the same rates as in-person and video visits. However, Weber’s research suggests that even when taking these telephone visits into account, Blacks and Hispanics, particularly in older age brackets, are still less likely to use telemedicine.

Moreover, audio-only visits might sometimes be inadequate, even if they are reimbursed at the same rates. During the pandemic’s initial surge, as emergency federal policies facilitated increased reimbursement for telemedicine services, the combined use of video and audio-only telehealth among Medicare beneficiaries skyrocketed nearly 13,000% over pre-pandemic levels, according to the Centers for Medicare & Medicaid Services (CMS).

But a study by Eric Roberts, an assistant professor of health policy at the University of Pittsburgh, and Dr. Ateev Mehrotra of Harvard Medical School, finds that more than 26% of Medicare enrollees living in the community (as opposed to residential facilities such as nursing homes) have neither a smartphone with a data plan nor an internet-connected personal computer. That figure is more than 37% among Black patients on Medicare, according to their research, published in August in JAMA Internal Medicine.

In addition to expanding broadband access through policies at the federal, state, and local level, other efforts have been shown to help narrow the digital divide, which impedes telemedicine access among lower-income and older adults, as well as minority groups. These include increasing digital literacy and subsidies for internet access to low-income consumers, and providing low-cost digital devices to qualifying patients.

In terms of understanding how health outcomes might vary across different population groups as a result of the quick pivot to telemedicine, it could take “several years” before academics have access to the health insurance claims data that would enable such research, says Roberts, who studies issues surrounding care access and quality among marginalized patients enrolled in public health care programs.

“It’s not like somebody who has a video visit or who’s only able to have a voice-only visit today is going to have a hospitalization for exacerbation of their diabetes tomorrow,” Roberts says. “It’s going to take a while for those disruptions in care to have measurable health effects that one could detect in claims.”

Beyond documented factors such as access to technology and variations in health and digital literacy, some researchers suggest there may be other community-specific social factors, including mistrust of the health care system and skepticism about health technology, driving what early research suggests is inequitable access to telemedicine-delivered care.

The role of policymakers and health care providers

Increasingly, hospitals themselves are creating programs and centers devoted to rooting out the causes of health disparities and finding ways to deliver equitable care in their own communities. Based on recent events in the United States and ongoing demands for racial justice, these centers are becoming even more proactive, says Dr. Gezzer Ortega, the lead faculty for research and innovation for equitable surgical care within the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston.

Ortega and a group of colleagues recently analyzed the emergency federal policies put in place to facilitate the explosion in telemedicine use since the pandemic began. The result was “Telemedicine, COVID-19, and disparities: Policy implications,” a paper outlining a series of policy prescriptions and practice recommendations, published in September in the journal Health Policy and Technology.

Most critical among the authors’ recommendations is the need to create equitable and overarching federal policies surrounding insurance coverage and financial reimbursement for telemedicine services, says Ortega.

“Early on [in the pandemic], states adopted various policies and health insurance companies had different policies, and that variation made it a little bit challenging depending on what health insurance you had to access some of these services,” he says. “I think providing access via health insurance and reimbursement is critical at the federal level.”

Moving forward, the development of policies that standardize personal and data privacy will need to strike a careful balance between being user-friendly and secure, while keeping equitable access (by making platforms multilingual, for example) at the forefront, Ortega adds. “I think transparency is key,” he says. “Patients need to be aware of where their information is being stored and to know that this is an encrypted means of communication, and other technology needs to be adapted to that.”

Addressing mistrust

Finding ways to address deeply rooted mistrust of the health care system will require more time and effort, says Ortega. Based on past traumas, such as the exploitation of Henrietta Lacks and the decades-long Tuskegee Syphilis Study, and more recently with allegations of unnecessary medical procedures occurring at US border with Mexico, communities of color have historically distrusted the health care system.

“I think, in order to regain that trust, one of the things we need to do is one diversify the workforce,” says Ortega. “People are more willing to trust if there’s some level of concordance… I also think that reaching out to these communities that the health care centers serve, making them part of the health care system, making them part of the billboards, part of the population that they’re working to attract to these centers, is important. And more community engagement, partnering with trusted community leaders in these communities to provide health care services is important.”

Collecting data on modes of health care used and outcomes for various patient groups is another important function for health care organizations in addressing health disparities, Ortega says, particularly as telemedicine is expected to retain its more prominent role in the system post-pandemic, at least to some degree. Armed with the numbers, health care professionals can begin to craft outreach and education programs in concert with community partners.

“It’s complex,” Ortega says. “I think it’s going to take different approaches at multiple levels in order for us to address the inequities, but it’s important work that needs to be done so that the health of our society will improve.”

Significant promise

Despite the risk that telemedicine might be out of reach for some disadvantaged groups and potentially exacerbate persistent racial and ethnic health disparities, the use of telemedicine also holds significant promise, including bringing higher quality care to people who live far away from top health centers.

Additionally, telemedicine provides opportunities for real-time professional consults by distant specialists and health education for large audiences who can participate in webinars and workshops remotely. Remote patient monitoring, wearable devices, and the Internet of Things offer new ways providers can interact with patients, with the potential to reduce costs and improve outcomes. In a way, technology can also help transport diversity and inclusion.

“I was actually on a call yesterday with someone from central Michigan, and they had never seen a Latino physician in their lives, because they don’t have any where they work,” Ortega says. “And I was just talking to this person – we were talking about some non-health-related activities — but it presented them with the idea that, ‘Oh, wow. I’m actually having a conversation with someone that looks like me, who’s a health care provider, whereas I live in a community where that does not exist.’

“I think that this is an example of where technology can help mitigate these disparities,” he adds. “There is a ton of potential there with technology and what we can do to improve a lot of the disparities and equity.”

What follows is a curated list of recent peer-reviewed research studies on racial and ethnic disparities related to the use of telemedicine, along with summaries of their main findings. We also offer five tips for journalists reporting on inequities in telemedicine-delivered care.

————

Telemedicine and Healthcare Disparities: A cohort study in a large healthcare system in New York City during COVID-19

Rumi Chunara, et al., Journal of the American Medical Informatics Association, August 2020

This study analyzed health records for 140,184 patients in New York City who sought care either in person or via telemedicine between March 19 and April 30, 2020, at one of New York University’s Langone Health system’s four hospitals and more than 500 ambulatory locations.

Black patients were about half as likely as white patients to seek care for possible COVID-19 symptoms via telemedicine within the NYULH system, where the majority of patients have insurance coverage and access to broadband internet.

When Black patients did use telemedicine, they were more likely to receive a suspected diagnosis of COVID-19 and subsequently test positive for COVID-19, as compared with white patients, suggesting that Black patients “may be sicker when seeking care through telemedicine compared to white patients.”

The researchers also note, however, that these results could be due to an increased likelihood of getting tested among white patients.

In contrast, when both telemedicine and in-person visits were taken into account, Black patients were less likely to receive a suspected COVID-19 diagnosis than white patients, suggesting that more equitable care occurs over telemedicine. This could be because “the online platform normalizes interactions between the clinician and patient through the virtual medium and decreases healthcare diagnosis biases, offering a possible mitigating role for telemedicine with respect to healthcare disparities.”

With the goal of informing the design of telemedicine tools and platforms, the researchers suggest including diverse perspectives in a “participatory design” process and incorporating “cultural and linguistic adaptations,” including building multilingual platforms. Ensuring representativeness among providers offering care via telemedicine, “removing as much individual discretion of providers as possible,” and targeting outreach to communities identified as experiencing barriers to care are also encouraged.

Characteristics of Telehealth Users in NYC for COVID-related Care during the Coronavirus Pandemic
Ellerie Weber, Sarah J. Miller, Varuna Astha, Teresa Janevic, Emma Benn, Journal of the American Medical Informatics Association, November 2020.

This study used a Mount Sinai COVID-19 database that was quickly made available to researchers, without patients’ names, to analyze the demographic characteristics of patients who sought care via telemedicine as an entry point to a single health care system during the pandemic’s initial peak in New York City.

Analyzing 39,229 initial contacts with the health care system, the researchers found that 38.3 percent were via emergency room and 38.5 percent were via telehealth. The rest occurred at an outpatient office. Patients older than 65 had the lowest likelihood of telemedicine use, including audio-only telemedicine visits.

Black patients had 4.3 times higher odds of seeking care at the ER than white patients, and Black and Hispanic patients over the age of 65 were most likely to visit the ER, even when controlling for other health conditions.

The researchers hypothesize that “patients without a source of usual care (e.g., a primary or specialty care physician) would be more likely to go to the ER, and less likely to seek telehealth treatment through previously established care relationships.”

Severity of COVID symptoms, which the data did not indicate, might also have contributed to the findings. The researchers also note that: “We include race as a predictor in our model because documenting racial/ethnic differences for public awareness is a necessary first step in reducing disparities, however we view race as a social construct.”

The Digital Divide in Health-Related Technology Use: The Significance of Race/Ethnicity
Uchechi A. Mitchell, Perla G. Chebli, Laurie Ruggiero, Naoko Muramatsu, Genterologist, November 2018

This study analyzes data from 1,336 white, Black, and Hispanic adults age 54 and older who completed the 2014 technology module of the University of Michigan Institution for Social Research Health and Retirement Study to identify differences in technology usage among different population groups. The research did not look at telemedicine specifically, due to its relatively low use prior to the pandemic. Compared with whites, older Black and Hispanic respondents were “less likely to use technology for health-related purposes after accounting for demographic characteristics, education, and health conditions.”

The disparities among whites and other racial and ethnic groups in the use of health management systems, social media use and searching online for health information became evident around age 62, which corresponds with people born prior to 1952. “Although the disparity widened with age for Blacks, it remained relatively similar at all ages for Hispanics,” the researchers wrote.

However, the study found a lag in usage rates such that Hispanics at age 62 have levels of technology use similar to whites who are 20 years older.

“Differences were not apparent for the use of text messaging, email, or health-related mobile applications,” the study authors add.

The effects of telemedicine on racial and ethnic disparities in access to acute stroke care
Michael J. Lyerly, Tzu-Ching Wu, et al., Journal of Telemedicine and Telecare, June 2015

This study sought to uncover whether previously reported racial and ethnic disparities in access to emergency or urgent stroke care were present in the use of telemedicine among racial and ethnic minorities in Texas. They found that the availability of telemedicine service gave Black patients similar access to acute stroke services, compared with white patients.

The researchers interviewed hospital personnel to determine the availability of acute care and emergency telemedicine services for stroke patients and “summing the population that could reach a primary stroke center or (PSC) or telemedicine spoke within specified time intervals using validated models.”

They found that 1.5 million more residents were able to access emergency or urgent-care stroke expertise through telemedicine, with the odds of Black patients being able to access stroke care within 60 minutes similar to that of white patients, even controlling for urbanization.

Rapid implementation of outpatient teleneurology in rural Appalachia: barriers and disparities
Roy E. Strowd, et al., Neurology Clinical Practice, July 2020

This study analyzed 1,011 telehealth neurology patient visits among patients in Appalachia, 44% of which were video and 56% of which were phone-only. Patients who chose to complete a video visit were younger, more likely to be female, white, and not have Medicare or Medicaid insurance. The most common barrier to scheduling video visits was technology limitations (46%). While patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits.

This paper was covered succinctly in NeurologyToday.

Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine
Eric Roberts and Ateev Mehrotra, Health Care Policy and Law, August 2020

For this research letter, Roberts and Mehrotra analyzed 638,830 responses to the 2018 American Community Survey by community-dwelling Medicare beneficiaries to determine the proportion who had access to a smartphone with a data plan or a desktop computer with high-speed internet access.

They examined those who had access to neither method of internet connection on a number of demographic and social dimensions. They found that individuals who reported having less than a high school education were the least connected, with 44.8% reporting no personal internet access. Among those respondents who were widowed, 40.6% reportedly did not have access to a connected smartphone or personal computer.

Among Black and Hispanic respondents, the proportions that did not have internet access were 37.3% and 31.6%, respectively. Among the total number of respondents, the proportion without any form of internet access was 26.3%.

For these patients, audio-only visits may be the only telehealth option, and although very little research has been done on the efficacy of such visits, “audio-only visits might be inadequate in some situations, such as when visual monitoring or diagnosis is important for care,” the researchers write.

“Although Medicare’s payment for audio-only visits at the same rate as video and in-person visits may be associated with improved access to care for those without digital access,” they add, “the inability to have a video visit may be associated with increased disparities in access to care.”

Telemedicine, COVID-19, and disparities: Policy implications
Gezzer Ortega, et al., Health Policy and Technology, August 2020

In this paper, a team of physicians reviews recent federal policy changes put in place to facilitate the rapid growth of telemedicine as a way to promote social distancing following the onset of the COVID-19 pandemic. They outline recommendations for government officials and health care centers designed to reduce the risk telemedicine exacerbating persistent racial and ethnic health care disparities.

They contend that access to telemedicine is driven by three main barriers: access to broadband internet; financial barriers to reimbursement; and lack of institutional commitment to equity in telemedicine.

The authors urge a national unified effort at the federal level to expand broadband internet coverage, as well as overarching policies to standardize reimbursement rates for telemedicine services, to the extent possible.

Federal policies that protect data security for patients are also critical, especially in the context of community of color, which have a history of mistrust in the health care system, the authors write. They also advocate for hospitals and other health care organizations taking a lead role in lobbying for necessary policies, promoting digital access and literacy, and developing “versatile, user-friendly, and culturally tailored tools” for patients.

“If equity is made an integral part of telemedicine now, it will help ensure that all can benefit from these innovative technologies moving forward.”

The Association Between Physician Race/Ethnicity and Patient Satisfaction: an Exploration in Direct-to-Consumer Telemedicine
Kathryn A. Martinez, et al., Journal of General Internal Medicine, July 2020

Bias against non-white physicians, as measured by patient satisfaction, was the subject of this study, which analyzed data on patients seeking care on a large, nationwide direct-to-consumer (DTC) telemedicine platform between July 2016 and July 2018 and their physicians.

Patients ranked their physicians on a scale of 1 to 5 stars, with 5 being the highest, and the rankings were made public for other patients to use in deciding on a telehealth provider. Increasingly, these types of patient experience measures are being used to determine physician compensation, the researchers explain, and lower ratings have been found to negatively affect physician job satisfaction.

“Physician bias against non-white patients has been widely documented,” the researchers write, “while patient bias against non-white physicians has been reported, but not well-studied.”

The sample included 119,016 encounters with 390 physicians, 233 of whom were classified as white American. The researchers controlled for patient age, gender and geographic region, based on those defined by the US Census Bureau. They also controlled for physician gender, specialty and geographic region.

Encounters with South Asian or East Asian physicians were less likely than those with white American physicians to result in 5-star ratings for patient satisfaction. Compared with encounters with white American physicians, those with Black American physicians, South Asian physicians, and East Asian physicians were more likely to result in reports of patient dissatisfaction (2 stars or fewer). The odds of a patient reporting dissatisfaction were the same with Middle Eastern and Hispanic physicians as they were with white physicians.

The effects were persistent even when adjusting for whether the patient received a prescription, “which has been shown to be the strongest predictor of satisfaction with telemedicine care,” the researchers write.

“Our findings indicate that in DTC telemedicine, patients express somewhat less top-box [5 star] satisfaction but considerably more dissatisfaction with some groups of non-white American physicians,” the study authors conclude. “This may have implications for these physicians’ compensation, reputation, and professional well-being.”

Five tips for journalists reporting on racial and ethnic disparities in telemedicine

1. Seek out experts focused on equitable health care and patient representatives. Hospitals and other health care organizations, particularly those associated with academic institutions, are increasingly establishing centers specifically designed to ensure equitable health care within their communities. Experts in health care disparities and the barriers to access for specific populations groups can be useful sources when reporting on research findings or other stories related to health care and communities of color.

Dr. Gezzer Ortega is the lead faculty for research and innovation for equitable surgical care within the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston. He says centers such as the one where he works are growing in number and becoming more proactive in their efforts to address inequities in health care.

Additionally, many hospitals have set up patient advisory councils that are designed to be representative of the patient population. Members of these councils can be good sources for stories. Journalists can also consider asking for comments from professional associations that represent physicians and other health care professionals from specific  communities, such as the National Medical Association, which is the largest and oldest organization of Black physicians in the United States.

2. Ask researchers about the choices they made when conducting a study. To increase sensitivity in reporting on issues of racial and ethnic disparity in health care or along other dimensions, it’s important for journalists to ask and report on the reasons why researchers and others break out specific patient groups to highlight inequity.

“When someone does a disparities-related study or puts out a disparity statistic,” Ortega says, “I think it’s important to understand and to put upfront why they’re looking at that. So, when you look at a specific underserved population and you’re examining their outcomes, why did you look at that population? What was the rationale for categorizing a certain group in a certain way?”

3. When reporting on telemedicine tools or technology systems, ask whether the potential for bias was considered. Software developers in the past have admitted to creating widely used platforms without ever having considered the possibility that the design of an interface could inadvertently facilitate user bias. Putting users’ profile pictures and names front and center has been shown to increase bias.

Journalists can serve readers by finding out whether specific telemedicine tools or systems are multilingual or adaptable to multiple styles of interaction by users, says Rumi Chunara, an engineering professor at NYU, whose research focuses on finding ways to use data to improve public health. It can also be useful to identify whether participatory design was employed and whether user testing involved a diverse group of testers that were representative of the patient population.

4. Explore how community outreach is conducted. How do health care institutions and medical or mental health practices inform prospective users of telemedicine tools and systems about their availability and how they work? It’s important to understand whether outreach is occurring in partnership with community leaders and organizations that marginalized groups can trust and where they feel comfortable.

5. Ask about reimbursement. Policies regulating the availability and reimbursement of telemedicine services vary by state. Medicare is governed by federal policy, but states oversee Medicaid guidelines and decisions about Medicaid expansion, and commercial insurers’ policies can vary substantially.

For further reference, the Center for Connected Health Policy recently issued an updated State Telehealth Laws and Reimbursement Policies Report.

For more on covering the topic of telemedicine, see our roundup of research on telemedicine for substance use disorder treatment.

The post Racial disparities in telemedicine: A research roundup + 5 reporting tips for journalists appeared first on The Journalist's Resource.

Since the COVID-19 pandemic began, deaths from drug overdoses have reportedly surged, even as a relaxing of federal restrictions and a rapid shift by treatment providers has led to an explosion in telemedicine options for receiving help with substance use disorders.

The move to telemedicine — defined as delivering clinical services using telecommunications technology — alleviates some longstanding barriers to treatment, but it also raises new questions, particularly as pandemic-related workplace closures and other stressors put people struggling with addiction at increased risk. (Telehealth is a broader term that generally encompasses clinical services as well as nonclinical services such as provider training.)

More than 20 million American adults have a substance use disorder, according to the Substance Abuse and Mental Health Services Administration, including 2.5 million who are addicted to opioids and more than 18 million with alcohol use disorder. The annual death toll from these conditions in the United States is more than 160,000. Nearly 72,000 Americans died of an overdose last year, according to the Centers for Disease Control and Prevention, with opioid overdose deaths breaking records and the number of deaths involving methamphetamine and cocaine continuing to trend upward. Meanwhile, excessive alcohol use is responsible for more than 88,000 deaths per year in America, and the misuse of other prescription and illicit drugs is on the rise.

Despite the scale of this co-occurring public health crisis, most people with substance use disorders never receive treatment. Many of them reside in rural areas where addiction specialists and treatment programs are unavailable. Stigma, insurance coverage and a belief in solving one’s own problems have also been identified as common barriers to treatment.

Telemedicine has long been seen as a potential remedy, but pre-pandemic adoption rates were low among addiction treatment providers, according to studies by Lori Uscher-Pines, a senior policy researcher at the RAND Corporation, and Haiden Huskamp, a health economist at Harvard Medical School, who, along with their colleagues, are researching telemedicine care delivery for substance use disorder treatment. Since March, they have watched a treatment paradigm historically centered on strict in-person monitoring and layers of regulation quickly transform into one that relies heavily on virtual care.

“Everything has changed since COVID-19,” says Uscher-Pines. “The regulatory barriers, patient readiness barriers, all of those things are different now… Our research shows that only about 17% of licensed treatment facilities had any telemedicine capabilities prior to the pandemic. What we’re seeing now, both qualitatively and quantitatively, is an explosion of telemedicine use.”

Virtual 12-step program meetings, online psychotherapy, and private companies offering remote medication-assisted treatment (MAT) to opioid use disorder sufferers have become the norm since the pandemic began. Early research suggests that MAT prescribers transitioned easily to telemedicine with established patients but have been hesitant to take on new ones.

The process of initiating MAT, usually with methadone or buprenorphine, is subject to specific federal and state regulations. Many of these and other regulations have been loosened to facilitate increased access to treatment via telemedicine during the pandemic, but the regulatory environment remains complex.

The following federal policy changes, detailed in a recent study by the nonprofit Center for Connected Health Policy, are in place at least for the duration of the coronavirus pandemic and have opened up options for telemedicine-delivered addiction treatment for patients with access to a computer or telephone:

• The passage of HR 6074 (the Coronavirus Preparedness and Response Supplemental Appropriations Act) and HR 748 (the Coronavirus Aid, Relief and Economic Security Act – CARES Act) made more telehealth services eligible for reimbursement through Medicare.
• A Medicare requirement that patients be located in a clinic to receive telehealth services was removed. (The SUPPORT Act of 2018 eliminated this and other telemedicine treatment barriers, but a pathway for implementation of these provisions had not been put in place prior to the pandemic). Patients in most states can now receive treatment services, including prescriptions, over the phone or computer from their homes. (State decisions about Medicaid expansion, along with other factors, have caused regional variations in telehealth accessibility.)
• An emergency exception to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 allows qualified providers to prescribe buprenorphine without an initial in-person visit. To get a prescription for methadone, which is highly regulated, patients must still be examined in person first. The Substance Abuse and Mental Health Services Administration posted this FAQ about federal policy changes related to prescribing buprenorphine and methadone during the pandemic.
• Some HIPAA restrictions have been relaxed, allowing providers to see patients via videoconference using various online platforms, including Zoom, Skype and FaceTime.

Many states have relaxed licensing requirements for providers, and reimbursement for certain addiction-related services delivered via telemedicine has become more commonplace among private health insurers and Medicaid programs.

To eliminate inadequate broadband internet access as a barrier to telehealth treatment, the Telehealth Buprenorphine Consortium, a group of clinicians and public health experts, is calling on federal policymakers to allow audio-only treatment services via telephone to continue post-pandemic.

Addiction treatment has a complicated history in the U.S. and continues to exist largely outside the primary health care system, despite broad recognition of substance use disorder as a medical condition. Unlike other chronic health conditions that are behavior-related, such as type 2 diabetes, substance use disorders carry a history of stigma and criminalization that some experts believe has led to a misguided focus on in-person visits and accountability in treatment.

“This paradigm of not trusting patients and assuming that they need to be hyper-monitored all the time in order to provide safe care is not patient-centered; it’s not harm-reduction oriented,” says Noa Krawczyk, an assistant professor in the population health department at New York University’s Grossman School of Medicine, whose research focuses on studying ways to address barriers to treatment and improve quality of care. “It’s not effective in making people feel welcome or in making it so that their lives are actually easier because they are in treatment, which is what we want.”

Krawczyk says the policy changes necessitated by COVID-19 and the increasing adoption of telemedicine more broadly have the potential to help reset the standard of care for addiction, depending on the extent to which the new policies remain in place after the pandemic — an open question at this point.

Combined with the limitations that social distancing guidelines imposed on in-person care, the sudden move to telemedicine — or to hybrid treatment models that blend virtual care with in-person visits — has created what researchers call a natural experiment, which enables them to study new phenomena without the typical concerns about selection bias.

Still, with so many pandemic-induced changes occurring at once, disentangling cause and effect will take some time, especially given the long lag for receiving data from Medicaid, a disproportionate payer for substance use disorder treatments, says Huskamp.

“We know the underlying need for treatment is changing, and there are all these other factors we can’t control, but we need to try to use this period to understand as much as we can about how telemedicine should be used going forward, to improve treatment and outcomes for patients.” says Huskamp, who is leading a mixed-methods research project that combines analysis of insurance claims data with provider interviews.

Although early research suggests potential benefits of telemedicine for both substance use disorder patients and treatment providers, clinicians have also reported quality concerns. At this point, much remains unknown about the safety and efficacy of providing remote care for people with addictions.

“There are no randomized controlled trials looking at the impact of medication treatment for patients at home, so we don’t know if these services are equivalent to in-person services, because there’s just a dearth of research on this model,” says Uscher-Pines. “There is research in progress, but right now policymakers have to make decisions without a lot of data.”

That said, studies published in recent years have examined the scope of telemedicine use within the addiction treatment field as well as outcomes related to specific telemedicine interventions and patient groups. What follows is a curated list of seven recent peer-reviewed studies on treating patients with addiction via telemedicine, including three papers by Huskamp and Usher-Pines, along with summaries of their most important findings.

Research Roundup:

Telemedicine-Delivered Treatment Interventions for Substance Use Disorders: A Systematic Review
Lewei (Allison) Lin, et al. Journal of Substance Abuse Treatment, June 2019

This meta-analysis reviews 13 research papers that examined the use of teleconferencing to deliver psychotherapy and medication treatment for either nicotine addiction, opioid use disorder or alcohol use disorder and that were published between 1998 and 2018. The included studies vary widely in size, quality, and design, but most found that patient satisfaction was high among those who received telemedicine interventions.

Several of the studies suggest that telemedicine could be associated with lower drop-out rates among treatment participants when compared with participants having to travel for in-person treatment.

“Retention is particularly important for medication treatment for opioid use disorder,” the researchers write, “where patients, especially those in rural areas, often have to travel long distances for treatment that is ongoing, and active receipt of medication treatment has been associated with improved mortality and other outcomes.”

The researchers note the critical need for more data and research – randomized controlled trials, in particular – to help understand the potential of telemedicine-delivered treatments for a wider range of substance use disorders.

How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?
Haiden A. Huskamp, Alisa B. Busch, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Andrew Wilcock, Bruce E. Landon, and Ateev Mehrotra. Health Affairs, December 3, 2018

A helpful overview of the pre-COVID landscape, this research article is based on claims data from 2010-2017 for a large U.S. commercial insurer. It shows a roughly twentyfold increase (from 97 visits in 2010 to 1,989 visits in 2017) in the use of telemedicine among addiction treatment providers during the study period.

Despite this growth, the study notes low overall usage rates for telemedicine, which accounted for just .1% of all substance use disorder visits reimbursed during the study period. The researchers consider this “a missed opportunity,” given the wide gap between the number of people who need addiction help and those who actually receive it.

Telehealth was most frequently used in outpatient settings, for initial evaluations, and among patients with severe opioid use disorder. The analysis suggests the most common treatment model involved physicians with addiction treatment experience performing an initial evaluation and/or prescribing medication from a remote location to a patient at a clinic. Patients frequently received telehealth support following intensive inpatient or outpatient treatment, the study results suggest.

The study also identified characteristics of the telehealth users. More than 60% were male and about 55% were under age 40. Despite hopes that telehealth would make treatment available to people in rural areas, the researchers found that the “vast majority” of patients studied who used telehealth for addiction care lived in urban areas, and telemedicine use was more common in areas with relatively higher household incomes.

“This finding is in contrast to the results of prior research on tele-mental health use, which found that use was greatest in poorer communities,” the researchers write, adding that “targeted interventions to increase access in rural areas may be needed.”

Treatment of Opioid Use Disorder During COVID-19: Experiences of Clinicians Transitioning to Telemedicine
Lori Uscher-Pines, Jessica Sousa, Pushpa Raja, Ateev Mehrotra, Michael Barnettt, Haiden Huskamp
Journal of Substance Abuse Treatment, August 29, 2020

Based on interviews conducted in April 2020, this new qualitative study by Uscher-Pines and colleagues offers clinicians’ perspectives on the rapid transition to telehealth approaches for substance use disorder treatment during the pandemic.

The researchers interviewed 18 waivered providers (meaning they can prescribe buprenorphine) in 10 states working in both hospitals and clinics at a time when government-mandated shutdowns severely restricted in-person care. Of those interviewed, more than half were providing only telemedicine care.

Asked how their overall practice patterns had changed, some interviewees reported waiving toxicology screenings, sending patients home with more doses of medication, and reducing the number of required visits.

About 20% of telemedicine visits occurred over the telephone, with the rest involving the use of various videoconferencing platforms. Some clinicians said they were hesitant to see new patients via telemedicine; others stopped accepting new patients altogether.

Benefits of telemedicine observed by the clinicians included increased access and convenience, as well as reduced wait times, appointment no-shows, and patient embarrassment about being seen getting treatment in their communities.

But seeing patients remotely also had downsides in terms of care quality, according to the interviewees. Clinicians reported difficulty establishing rapport with new patients and difficulty observing physical symptoms of withdrawal, such as goosebumps and pupil dilation.

“Because telemedicine prevented clinicians from using their full powers of observation, they reported asking patients more questions about their physical symptoms and relying more on patient self-report than observation,” the researchers write.

Clinicians also cited technical difficulties as negatively affecting the quality of patient interactions.

The level of telemedicine care for substance use disorders that will continue after the pandemic remains unknown. Several providers said they would like to continue to use it in combination with in-person visits. Study participants also noted that their future use of telemedicine would depend on the reimbursement and regulatory environment.

Measures of Effectiveness, Efficiency, and Quality of Telemedicine in the Management of Alcohol Abuse, Addiction, and Rehabilitation: Systematic Review
Clemens Scott Kruse et al. Journal of Medical Internet Research, January 2020

This analysis of 22 research papers on telemedicine interventions for alcohol use disorder found that mobile apps and text message were the most common and effective treatment models among those studied.

Telemedicine proved effective in reducing alcohol consumption and depression among users in the majority of studies, the researchers said. Remote interventions also were associated with increased patient satisfaction and accessibility, as well as decreased cost.

“Organizations were able to expand practice without expanding square footage,” the researchers wrote, “and [telemedicine] solutions continued to provide care outside the boundaries of 8 a.m. to 5 p.m., a traditional treatment day.”

The authors note the need for further study of particular telemedicine approaches and how they improve outcomes for people seeking help with alcohol use disorders.

The included studies were conducted in the United States, European Union and Australia.

Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine A Nonrandomized Controlled Trial
Constance Guille, Annie N. Simpson, Edie Douglas
JAMA Network, Jan. 31, 2020

Opioid addiction among pregnant women in the United States quadrupled between 1999 and 2014, increasing from 1.5 to 6.5 cases per 1,000 hospital births. When exposed to opioids in utero, infants can experience withdrawal symptoms at birth, known as neonatal abstinence syndrome (NAS), the rate of which increased from 1.5 to 8 per 1,000 hospital births between 2004 and 2014.

Telemedicine has been identified as a tool to expand addiction care for pregnant women, particularly in rural areas, writes lead study author Dr. Constance Guille, an associate professor at the Medical University of South Carolina who developed the telemedicine protocol used to provide medication-assisted treatment (MAT) to the study participants.

This is a nonrandomized controlled trial that included 98 pregnant women with opioid use disorder in which 44 received opioid use disorder (OUD) treatment via telemedicine from their obstetrician’s office and 54 received in-person OUD care in their obstetrician’s office. There were no statistically significant differences in rates of retention in treatment between the two groups, with more than 80% of participants in both groups remaining in treatment after six weeks. These results held when the researchers looked at diagnoses of neonatal abstinence syndrome among the newborns.

This study used a method called propensity score matching to reduce selection bias and improve generalizability of the results, given the small sample. By incorporating demographic information of the study subjects, the researchers calculated the probability of treatment assignment for each, known as the propensity score. By giving these scores different weights and matching them together, the researchers artificially created treatment and control groups, mimicking aspects of a randomized controlled trial.

A note on the research: The telemedicine protocol Dr. Constance Guille, an associate professor at the Medical University of South Carolina, and her team developed made it possible for pregnant women with opioid use disorder to receive specialized addiction services from a remote provider during their regular prenatal appointments.

Because the patients were receiving care in the presence of another provider with a Drug Enforcement Administration license (that is, an obstetrician), Guille had petitioned the South Carolina Board of Medical Examiners for permission to treat them with MAT via telemedicine without an initial in-person visit, based on a pre-COVID exemption in the federal Ryan Haight Act.

The board initially denied the request, citing the South Carolina Telemedicine Act, which conflicts with federal law, Guille says. Legally, the team was advised that they could continue, she says, but they heeded the board’s recommendation in order to maintain positive relations with the state. Later, after a pregnant woman died of an overdose while waiting to schedule an in-person visit, the research team went back and made the same proposal to the board, which reversed its original decision.

Guille says the experience highlights the complex web of federal and state regulations that treatment providers need to navigate in order to provide telemedicine services, a situation that is likely to persist post-COVID.

“There’s the whole legal aspect of it, and then there’s the issue of how you collaborate with your key stakeholders across your state to get this work done,” she says. “There’s a lot of gray area there.”

The Effectiveness of Telemedicine-Delivered Opioid Agonist Therapy in a Supervised Clinical Setting
Joseph K. Eibl, et al.
Drug and Alcohol Dependence, July 2017

This 2017 research involves a non-randomized cohort comparison study of 3,733 patients with opioid use disorder initiating medication treatment (methadone or buprenorphine) between 2011 and 2012, across 58 clinic sites in the province of Ontario, Canada. The analysis was based on a database of patients’ electronic medical records.

Of the patients studied, about 47% received more than 75% of visits via telemedicine. The rest received less than 25% of visits by telemedicine. The analysis suggests that patients treated via telemedicine were more likely to stick with their treatment programs than patients treated in-person. Telemedicine patients demonstrated a retention rate of 50% at one year whereas in-person patients were retained at a rate of 39%.

Like in the U.S., physicians who can prescribe medication for addiction treatment are in short supply in Canada because the medications themselves are regulated by the federal government as controlled substances. Providers must apply for and receive a federal waiver before prescribing methadone or buprenorphine, a requirement that remains in place in the U.S. during the pandemic. This provider shortage often leads to patients needing to travel long distances for frequent provider visits, a problem that telemedicine can address.

A Pilot Study of a Telemedicine-based Substance Use Disorder Evaluation to Enhance Access to Treatment Following Near-Fatal Opioid Overdose
Jeffrey T. Lai, et al.Proceedings of the Annual Hawaii International Conference on System Sciences, Jan. 7, 2020

This was an observational study of patients who were hospitalized in Massachusetts after receiving naloxone (the antidote for opioid overdose) following an opioid overdose. The researchers asked 27 patients who presented in a hospital emergency department whether they would be willing to test a telemedicine intervention; 20 agreed to participate.

The researchers developed a system using iPads outfitted with HIPAA-compliant software that enabled recently revived patients to undergo an initial addiction screening with a specialist immediately following overdose – a critical time for initiating treatment.

All 20 participants reported liking the technology, with two subjects describing the iPad as “cool.” One participant described the intervention as the “best thing since sliced bread and bacon, and I’m a Georgia boy so I love bacon.”

Most of the participants found that undergoing the screening via telemedicine was equivalent (or in some cases preferable) to standard in-person evaluations. They also reported feeling assured that the assessment was private and confidential.

Despite one major technical malfunction (a dead battery), the researchers deemed the intervention a success, writing that telemedicine “can enhance access to addiction treatment programs and facilitate the efficient and effective delivery of evidence-based post-overdose care, including ED-based initiation of [medication-assisted treatment].”

They write, “Our technology platform represents an innovative method of delivering treatment for opioid use disorder during the critical post-overdose period, and holds immense potential for improving access to addiction care” in underserved areas.

Adoption of Telemedicine Services by Substance Abuse Treatment Facilities in the U.S.
Lori Uscher-Pines, Jonathan Cantor, Haiden A.Huskamp, Ateev Mehrotra, Alisa Busch, Michael Barnett
Journal of Substance Abuse Treatment, October 2020

This pre-COVID-19 study used data from the National Directory of Drug and Alcohol Abuse Treatment Facilities for a period from 2016 to 2019 to study an average of 12,334 substance use disorder treatment facilities in the United States. During the study period, facilities offering telemedicine grew from 13.5% to 17.4%.

The results of the analysis suggest the following factors positively influence telemedicine adoption: rural location; offering multiple treatment settings; offering medication-assisted treatment; and serving both adult and pediatric patients.

In 2019, there was wide state-to-state variation in facility adoption of telemedicine; less than 7% of facilities in Connecticut, Hawaii, Rhode Island, and Vermont offered telemedicine services, compared with more than 40% in Alaska, Missouri, and Wyoming.

The same team of researchers is continuing to study telemedicine adoption for substance abuse treatment since the pandemic began, including analyzing variations by state.

5 tips for reporters covering telemedicine-delivered treatment for substance use disorders

1. Get to know your state’s telehealth laws and rules. Rules and regulations for telehealth practice and prescribing vary by state. Each state’s health department and medical licensing review board can set and waive rules. The Federation of State Medical Boards maintains this up-to-date list of state licensing policy changes due to COVID-19, including when they expire. The Center for Connected Health Policy plans to update this report on state telehealth laws and reimbursement later this fall.

2. Ask questions about reimbursement. The degree to which telemedicine services can be reimbursed by insurance is likely to play a role in the degree to which providers and medical societies support their ongoing use and implementation once the pandemic eases.

For example, unlike urine toxicology screenings, saliva tests can be conducted under direct supervision via telemedicine, says Noa Krawczyk of NYU’s Grossman School of Medicine, but so far, the test is not eligible for reimbursement and is used mainly for research.

Per a 2012 Supreme Court ruling, Medicaid expansion is an optional decision for states. In states that have expanded Medicaid, a disproportionate payer for people with substance use disorders, it is easier for providers to get reimbursed for telemedicine.

3. Cover addiction as a chronic disease, not a crime. Some researchers argue that a telemedicine model for addiction treatment makes sense because it both improves access and moves away from traditional substance use disorder treatment programs that are rooted in the perspective that drug use is criminal, as opposed to behavioral.

In a new book, The Opioid Fix, Barbara Andraka-Christou, an assistant professor in the department of health management and informatics at the University of Central Florida, traces the history of treatment and argues that medication-assisted treatment should be available to all patients with a opioid use disorder.

When arguing in favor of telemedicine treatments for substance use disorders, researchers and providers often make a comparison with type 2 diabetes, which is also primarily behavioral, but patients are not as strictly monitored. PBS News Hour covers this topic in its recent piece, “Could the pandemic change addiction medicine for the better?”

4. Visit Reddit. There are many people with substance use disorders who are active on the social network Reddit, which hosts communities, known as subreddits, where people with similar interests can have discussions and promote  input and responses. Krawczyk is working on a research paper that analyzes active subreddits where people are discussing changes in opioid addiction treatment during the pandemic.

Krawczyk says it’s important to include the perspectives of people with substance use disorders in research and reporting on the changes that are occurring. “Some people feel like it’s great and it’s much easier to get treatment,” she says. “And other people are saying they’re worried about, you know, having too much methadone with them at home.”

To read active subreddits, visit: www.reddit.com/r/addiction, www.reddit.com/r/redditorsinrecovery, www.reddit.com/r/opiatesrecovery and www.reddit.com/r/stopdrinking.

5. Use person-first language. When covering issues surrounding addiction and substance use, it’s important to avoid terminology like “addicts” and “alcoholics.” Instead, use “a person with substance use disorder,” “someone suffering from addiction.” Krawczyk says this language avoids characterizing people based solely on a medical condition and better reflects current thinking about substance abuse disorders.

Similarly, the AP Stylebook advises: “Avoid words like ‘abuse’ or ‘problem’ in favor of the word ‘use’ with an appropriate modifier such as ‘risky,’ ‘unhealthy,’ ‘excessive’ or ‘heavy.’ ‘Misuse’ is also acceptable. Don’t assume all people who engage in risky use of drugs or alcohol have an addiction. Avoid ‘alcoholic,’ ‘addict,’ ‘user,’ and ‘abuser’ unless individuals prefer those terms for themselves or if they occur in quotations or names of organizations, such as Alcoholics Anonymous.”

The post Telemedicine for drug addiction treatment: A research roundup and 5 reporting tips appeared first on The Journalist's Resource.