Telehealth Suboxone

Methadone, the first evidence-based treatment for opioid addiction, appeared way back in 1965. In the years that followed, “methadone clinics” popped up in large cities that could financially support them. But most patients—especially those in greater Minnesota—were unable to access this potentially life-saving care.

The U.S. Food & Drug Administration attempted to remedy this health disparity by approving Suboxone in October 2002. The hope was that family physicians, internists and psychiatrists would prescribe it in their clinics, thereby creating broad access to addiction care.

Suboxone was originally available as a sublingual tablet. Source: CVS/pharmacy

Unfortunately, that idea was very slow to take off. Rural providers cited a range of barriers—time, risk, lack of ancillary mental health services—as reasons for not prescribing. As a result, Suboxone tends to be available through addiction medicine specialists (like me) who practice in large cities and are subject to federally-imposed patient limits.

About a year ago, Allina Health decided to take a different tack. We came up with a simple access strategy:

  • Addiction medicine specialists treat patients for opioid addiction via telehealth
  • Specialists transfer care to local primary care providers once patients are stable
  • Primary care providers can always consult with addiction medicine specialists or return patients to us if there are struggles
My telehealth studio (left). Laura Moldan, a nurse at New Ulm Medical Center, posing as a patient (top right). Provider interface (bottom right). Epic, the electronic health record, is running on the larger screen. Vidyo, the HIPAA-compliant audiovisual application, is active on the smaller screen. No protected health information (PHI) appears on the screens

The first provision addresses primary care providers’ concerns about treating active substance abusers. The second feature ensures that addiction medicine specialists always have capacity for new patients. The last design feature is how primary care interacts with every other medical specialty—cardiology, nephrology, endocrinology—when it comes to chronic disease management.

And it worked!

Our pilot program at New Ulm Medical Center, a critical access hospital, was a resounding success. We’re presently working to scale it to Allina’s entire service area. We’re also launching virtual visits next week, which will allow patients to be seen via their own smartphone or tablet.

All of this was a heavy lift by a committed team:

The view from my office on the 14th floor of the Medical Arts Building in downtown Minneapolis

The addiction medicine specialists are still located in a large city many hours from patients but distance is no longer a barrier to receiving care. ✸

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Postscript. I received a good question about the Ryan Haight Act. Our program is exempt from the in-person medical evaluation requirement as New Ulm Medical Center is a DEA-registered hospital. Please consult your compliance department or personal attorney about your particular clinical circumstances.

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Postscript. We launched virtual visits today (February 24th) as planned. The first patient lives near the Iowa border, two hours from both New Ulm Medical Center and the Twin Cities. The virtual visit saved him roughly four hours of driving for a 30 minute visit.

Suboxone Treatment in Jail

The Saint Cloud Times recently featured CentraCare Health’s correctional care (“jail medicine”) program. This unique public-private partnership is designed to identify and treat mental illness and addiction while inmates are in custody. We then link them to a special clinic following release to the community for ongoing management. (I serve as the medical director for the program.)

Captain Mark Maslonkowski. Photo: Jason Wachter

We launched in the Benton County Jail on October 1st, 2017, and in the Stearns County Jail on January 1st, 2o18. As outlined in the article, the early signals are promising: fewer ambulance trips between the jail and hospital, fewer detox admissions and decreased total cost of care.

As far as we know, we’re the only Minnesota counties starting inmates on Suboxone, the medication to treat opioid addiction, while in custody. And, one needs to look far and wide to find other examples nationally.

Our ever-growing provider team includes:

Providers see inmates in jail and following release to the community. This continuity of care is unprecedented. Health authorities (a statutory term) have historically focused on inmates’ immediate medical needs in jail without regard for the bigger picture. This penny-wise but pound-foolish approach doesn’t resolve some big reasons—mental illness and addiction— for criminal recidivism. Thus the revolving door.

Special thanks to my partners in crime (sorry! couldn’t stop myself):

  • Captain Susan Johnson (Benton)
  • Katy Kirchner, director
  • Captain Mark Maslonkowski (Stearns)
  • Kenzie Moehle, supervisor
  • Heather Qunell, manager