In Indiana, this kind of virtual visit has been legal since early 2017. But among a dozen addiction specialists in Indiana contacted by a reporter, just one had heard of doctors using telemedicine for opioid addiction treatment: Dr. Jay Joshi.

At Joshi’s practice,Ìý in Munster, Ind., a telemedicine consultation takes place in what looks like a standard exam room with a computer. On Tuesdays, Joshi’s  patients have video chats with a psychologist who lives 140 miles away.

Elizabeth Hall is one of those patients. “The only issue I really had with it was [that] it would freeze, which is kind of inconvenient and a little bit awkward,” she said. “When it freezes you’re like, ‘What do I do? Just sit here and stare at the lady?'”

But she said she appreciates the counseling. She’s a former nurse’s assistant and has been going to Joshi for back pain and to treat a heroin addiction for about a year.

“I’m in a good place, you know?” she said. “I’m not doing nothing I shouldn’t be doing. I’m not lying to nobody. I’m not sneaking around. Plus, I have a baby. I’m really busy!”

To get her insurer to cover her addiction medicine, Hall has to prove she’s engaged in counseling. Local counselors are hard to find. By having a telepsychologist available, Joshi helps patients clear that hurdle.

Hall’s insurance also requires urine tests for drug use to keep covering her medication. But she failed her latest urine test — she had used drugs the previous week. Joshi asked Hall to talk to the telepsychologist about the relapse.

“I know you know that I haven’t done anything since last week, and I told them I’m not doing nothing no more. I can’t screw up my life,” Hall said.

Because of the failed test, her insurance may refuse to pay for Suboxone, her addiction medication. Joshi’s staff may need to intervene with the insurer by phone to keep Hall’s treatment covered. “It’s one of those situations where she’s not taking any other controlled substance,” Joshi said. “We’re seeing her every two weeks. She’s participating in the counseling. It’s just one thing.”

Hall said, “I’ve been doing really good, it’s just, you know, it’s hard.”

This is why Joshi requires in-person visits — to begin and maintain his patients’ Suboxone prescriptions. He prefers to see these patients every two weeks and will even arrange transportation before going too long without seeing them.

Occasionally he’ll prescribe Suboxone remotely, but typically only for a refill once or twice during a patient’s treatment. Seeing the patient in person is critical to their treatment, he said.

“You’re not going to get a good system of health care for primary care in these high-risk areas unless you invest time and energy into these patients,” he said.

The face-to-face interaction establishes trust, allows him to pick up on body language. Plus, it’s hard to do a urine drug test screen remotely and be sure that the sample actually belongs to the patient. A proper screen lets him know if his patients are taking their medication, instead of selling it.

He asked Hall if she mentioned her recent drug use to the counselor.

“I really don’t remember if I talked to her about it or not,” she said. Joshi said to make sure she comes in for her next counseling session.

Joshi said he has a lot of conversations that aren’t billable.

That’s partly why there is a shortage of addiction treatment doctors, said Dr. Emily Zarse. She runs the addiction treatment program at Eskenazi Health in Indianapolis.

“Telemedicine is a great idea in theory, but it doesn’t fix the workforce shortage problem,” she said.

Insurance billing takes up a lot of time and so do the complexities of addiction treatment, she said.

There is one area where Zarse thinks telemedicine would be helpful — as a tool to train providers. “That takes one expert’s time for a couple of hours a week, maybe, and you can reach 10, 15, 20 people all at one time,” she said.

In fact, Zarse plans to launch a course to train Indiana doctors to treat addiction. In January, she’ll learn more about how to do it, from , a resource for clinicians seeking virtual training tools. Zarse envisions a place where doctors from around the state can call in to video chat and walk through cases with trained psychiatrists like herself.

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Adams’ supporters say the visit is an example of how he has prioritized the opioid epidemic during his tenure as Indiana’s . Addiction specialists and advocates say he has led important progress in implementing lifesaving policies. They believe that if confirmed, Adams would use his on-the-ground experience to guide national policy.

“I believe that Dr. Adams understands the value of community grass-roots efforts, that they should be included at the table with decision-makers,” said Justin Phillips, founder of the prevention-focused group Overdose Lifeline, who toured the detox center with Adams. “They need to understand what’s realistic in the field.”

If confirmed by the Senate, Adams would be the second health official from Vice President Mike Pence’s home state to join the Trump administration. Seema Verma, who helped shape Indiana’s Medicaid expansion, now heads the Centers for Medicare & Medicaid Services.

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A practicing anesthesiologist, Adams was appointed Indiana Health Commissioner by then-governor Mike Pence in October 2014. Four months into the job, he announced in rural Scott County, Ind., after health workers documented 26 cases of HIV there. By May 2015, the number of confirmed infections had risen to 158, spread almost entirely through injection drug use. Eighty-eight percent of them also tested positive for hepatitis C. Today, the number of confirmed HIV cases has reached 219.

Health workers credit Adams with persuading Pence to allow Indiana counties to create syringe exchanges to contain the spread of the disease. “We wouldn’t have syringe exchange if it wasn’t for him,” said Carrie Lawrence, a public health researcher at Indiana University who helps implement syringe exchange programs throughout the state.

Pence had expressed moral reservations about syringe exchanges — a sentiment that Adams  he originally shared. But in March 2015, the governor acted on advice from Adams and the Centers for Disease Control and Prevention and  a 30-day emergency syringe exchange, citing a public health emergency. Later that spring, Pence signed a law legalizing syringe exchanges in Indiana.

Beth Meyerson, co-director of Indiana University’s Rural Center for AIDS/STD Prevention, worked closely with Adams throughout that period. She said that early on, when it became clear to legislators that a clean-syringe exchange program was needed to reduce the spread of HIV and hepatitis C, Adams was able to bring public health evidence to the table.

“Dr. Adams navigated the very ideological political environment that was created by then-governor Pence,” she said. “There’s just no doubt the governor wouldn’t have listened to me or listened to the leaders in the Legislature, but he would listen to Jerome Adams.”

She said she thinks Adams will have sway working with Pence on a national scale, too. “He will navigate [Washington], I suspect, the same way that he did in Indiana, which is to listen to communities, work with several partners across the arena, and bring public health evidence to the table again as an advocate for community health,” Meyerson said.

Adams has since supported other state laws aimed at curbing the opioid epidemic, including  that increased access to the overdose antidote naloxone, and that restricts the amount of opioid medication a prescriber may give to adult patients who have not previously taken opioids and to children.

Still, Meyerson said expectations about what Adams might do in Washington have to be tempered by political reality. Even in Indiana, the laws he helped pass haven’t been as comprehensive as she and other public health workers would have liked. The original syringe exchange law “was an administrative nightmare,” she said. It has since been updated by Indiana Gov. Eric Holcomb, making it easier for counties to start exchanges.

Funding also remains an issue. Indiana ranks 49th in the country in public health spending. “So all of these counties who have tried to move forward for syringe access are doing so with both hands tied behind their backs, because they do not have the resources to make this happen,” Meyerson said.

This story is part of a partnership that includes ,Ìý and Kaiser Health News.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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