Telehealth for Addiction, Confidentiality: Real Concerns in Virtual Settings

This post was originally published on April 23, 2020 at The Medical Care Blog.

As of April 17, 2020, the novel coronavirus has infected more than 2.4 million people globally and led to 170,000 deaths. The global response to the COVID-19 pandemic largely emphasizes social distancing and shelter-in-place ordinances. These policies impact everyone, also upending the lives of those not directly affected by the virus COVID-19 pandemic. Like other services, social distancing has limited access to healthcare. Many organizations have responded to these extreme circumstances by relaxing regulations to allow greater flexibility and access to services via telehealth. This has accelerated the adoption of telehealth in most disciplines, including the use of telehealth for addiction.

Behavioral health providers have also been quick to embrace telehealth solutions to continue caring for their clients. However, although video and other technology-based solutions have a growing body of evidence in many disciplines, the evidence for addiction services is limited. Still, the Substance Abuse and Mental Health Services Administration (SAMHSA) is strongly recommending telehealth [pdf] for the evaluation and treatment of clients with substance use disorders during the pandemic.

The speed of adoption presents several implementation challenges. Telehealth requires additional processes and technology solutions to ensure confidentiality, privacy, and security. These elements are essential for addiction treatment and recovery support (one prominent program even has the word "anonymous" in its name). Providers, counselors, and facilitators have a responsibility to take steps to protect information and identity. Concerns about confidentiality, privacy, and security are likely to reduce participants' trust and psychological safety. Participants may hesitate to share personal details of their lives in meetings with counselors or 12-step groups if the threat of Zoom-bombing is a legitimate issue, for example. So, what are the main concerns facing addiction services regarding confidentiality, privacy, and security? And, how can these concerns be resolved or mitigated?

Potential challenges to confidentiality in accessing addiction services and supports through telehealth

Finding a safe space to participate when sheltering in place

Lack of access to regular recovery supports, such as 12-step groups, is a serious issue for participants. The use of telehealth has led to substantial discussion focused on technology issues. However, quarantine contexts bring up new worries related to privacy. In particular, clients need safe spaces to be able to speak freely and privately. Finding a private space at home may be a real challenge when others are also stuck inside. This may result in clients declining to participate in telehealth treatment interventions.

Concerns about new telehealth platforms under relaxed regulations

Relaxed regulations allow the use of google and zoom platforms, among others. However, clients not used to receiving therapy or services in these spaces are appropriately concerned they might be recorded. Even with secure technology, those with legitimate access (participants or providers/counselors) may be able to record sessions.

Confusion about federal confidentiality regulations

Providers who have not used telehealth may be unaware of rules and policies. Some providers may be hesitant to implement telehealth due to confusion regarding adherence to the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2. Providers may also worry about clinical or legal implications. Recent guidance [pdf] from the Office of Civil Rights helps relieve some potential concerns. Of note, the policy states that covered health care providers will not be subject to penalties for violations of the HIPAA privacy rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency.

Concern regarding the psychological safety of clients using telehealth

Psychological safety is the ability to show and employ one's self without fear of negative consequences. A climate of psychological safety permits one to engage in interpersonal risk-taking, an important component for participation in addiction treatment and recovery. Since telehealth is a relatively new phenomenon in addiction treatment, it remains to be seen if clients feel comfortable speaking up. The COVID-19 pandemic may raise fears and anxiety that could make clients more hesitant to share. Additionally, clients may be less likely to speak up if they are new to telehealth or are have concerns related to privacy and confidentiality. This could also influence preferences favoring individual interventions over group models, which could strain existing resources further. On the other hand, individuals may feel more comfortable sharing over telehealth from the safety of their own homes.

Decreased therapeutic connection with some telehealth platforms

Telehealth interventions can be conducted over video or with audio-only communication. While audio-only services may help alleviate some concerns regarding privacy and confidentiality, it could also reduce the fidelity of the intervention. With audio-only communication, clients may not form effective relationships with providers, or in the case of group services, other clients. Clients also may not experience the full therapeutic effect of opening up and sharing with others.

There are several steps that providers and clients can take to address these challenges:

Recommendations for providers of treatment and recovery support services

1. Providers should address privacy concerns with clients before offering services and recovery support. Ideally, this should be done before the first session. During sessions, reiterate that clients' privacy and safety is your top concern. If privacy situations change throughout the session, reschedule if necessary. Additionally, providers should encourage clients to choose a modality with which they feel comfortable. Audio-only may be less effective than video, but it could be a first step moving a client towards using telehealth.
2. Providers should also ensure that client informed consent processes mentions whether sessions are recorded or stored. The privacy and security features of the telehealth system should be thoroughly discussed with the client.
3. Providers can access federal resources to ensure the effective provision of telehealth addiction services and supports. For example, SAMHSA provides guidance for virtual recovery resources [pdf]. The Centers for Medicare and Medicaid Services (CMS) offers an updated telehealth and telemedicine tool kit [pdf] for providers who wish to care for clients through virtual services that may be temporarily used during the COVID-19 situation. CMS also developed a Health and Human Services Agency COVID- 19 toolkit to assist providers during these trying times.

Recommendations for clients

1. Clients should think about whether they feel safe in their space. Questions clients can ask themselves include:
   • When are times when you will have the most privacy?
   • Can you access or purchase a noise-canceling machine or other equipment? Sometimes an air purifier might be enough.
2. Ensure that internet connections are secure and test them before appointments.
3. Discuss any concerns about privacy and other potential issues with providers. For example, what should be done if calls are disconnected?
4. Clients should be kind to themselves. Accepting that telehealth might be different or awkward, will go a long way in helping them adjust.
5. If clients still feel uncomfortable, they should ask providers for alternative options. Are there educational materials they can read or listen to? Are telephone sessions an option, at least initially? Voice concerns about security, whatever they may be. Most likely, this is not the first time a provider has heard these concerns.

The COVID-19 pandemic has impacted the world of addiction treatment providers in an unprecedented manner. The situation has required changes for both providers and clients. Initial efforts in the provision of telehealth for addiction services have focused on ensuring access for much-needed addiction treatment services. Security concerns have been equally important. The next steps should focus on ensuring clients feel safe and comfortable. This will allow for more effective interventions.