Pandemic-era rules regarding telemedicine have significantly boosted efforts to prevent opioid overdoses in the United States. But these rules also explain how controversial startups like Cerebral have been able to prescribe Adderall and Xanax to large numbers of people — and efforts to stem that flood of prescriptions could wipe out overdose prevention efforts in the process.
As of 2020, doctors can prescribe controlled substances after a telehealth visit without needing to see patients in person. But that’s a big umbrella: Adderall and Xanax are controlled substances. The same goes for buprenorphine and methadone, which are used to treat people who are addicted to opioids. Opioid overdoses have reached epidemic proportions in the United States, with tens of thousands of people dying every year.
Telehealth has dramatically improved access to treatment for people with opioid addiction or dependence, also known as opioid use disorder. But the policies that led to these improvements are not guaranteed to stay in place. They could end, and the risk of them ending has increased with public reaction to the practices of companies like Cerebral, which have used these same telehealth policies to dispense large numbers of prescriptions, including for drugs. conducive to abuse. The COVID-19 public health emergency that allowed the two is set to expire in October, although the Biden administration may extend it again. But it will eventually end, and when it does, policymakers will have to decide whether to keep some of the relaxed public health rules or return to the pre-pandemic status quo.
“We are already thinking about contingency plans, while trying to do everything we can to show almost everyone who will listen that this is very beneficial,” says University health services researcher Shoshana Aronowitz. of Pennsylvania. provides treatment for substance use disorders in Philadelphia and through the Ophelia Health digital platform. “It’s very easy for these things to coalesce in people’s minds and then also in politics.”
Before the pandemic, doctors couldn’t prescribe controlled substances without at least one in-person visit. The Drug Enforcement Administration (DEA) lifted the requirement in March 2020 because pandemic restrictions made it harder (and the pandemic made it potentially unsafe) for people to book in-person appointments.
This waiver made it easier for people struggling with excessive opioid use to schedule appointments and begin treatment, the research found. The ability to use telehealth has also helped create new types of innovative health care programs. The University of Pennsylvania, for example, has set up a “bridge clinic” that allows people to arrange same-day telehealth visits (by phone or video) and get a short-term prescription the same day. for drugs that can reduce the withdrawal effects of opioids and help them quit using more dangerous drugs like heroin. It would delay them if there was a wait for an in-person appointment. “They could easily overdose and die then,” Aronowitz says. “Being able to connect people even for a few days is huge. And you can’t do that if you’re not licensed to prescribe via telehealth.
Getting more people connected to drugs that can help them has clear benefits for tackling the overdose epidemic in the United States, she says. “Medication for opioid use disorder is truly the best, most evidence-based thing to treat opioid use disorder and prevent overdoses.”
Even though offering these prescriptions via telehealth was legal under pandemic-era guidelines, Aronowitz says she still ran into trouble with pharmacies — some of which wouldn’t fill the prescriptions if they came from a visit. of telehealth. There is stigma and misconceptions around using one drug to treat addiction to another drug, with some patients telling themselves that they are not really sober if they are using something like buprenorphine. Some pharmacies had been reluctant to fill prescriptions if they were sent via telehealth by health care providers. different states.
This was even before the backlash against companies like Cerebral began – the company’s doctors said they felt compelled to prescribe ADHD drugs without proper assessment, the US Department of Justice opened a investigation and the company eventually said it would stop prescribing controlled substances.
In the face of this news, Walmart stopped filling prescriptions for controlled substances via telehealth. This policy did not distinguish between different types of controlled substances, which are used for very different types of health conditions. (ADHD, for example, is different from opioid use disorder.) Any blanket approach that lumps all controlled substances together fails to account for the different types of care patients receive, Aronowitz says.
For these types of decisions, the focus should be on the quality of care, not how care is delivered. “I think the most important thing is – is there a real treatment relationship?” says Aaron Neinstein, vice president for digital health at University of California, San Francisco Health. “Does the physician know who the patient is and understand the health care context well enough to make a safe choice around the prescription?”
Telehealth allows healthcare organizations to reach more people than they could with in-person care. Patients don’t have to travel to a doctor’s office and doctors can see more people in a day. A company that overprescribes might then be able to treat more patients than it could if it were to add the component in person. But it’s still possible to establish a very real relationship between a patient and a provider through a digital health platform, Neinstein says. It is just as possible to prescribe drugs irresponsibly without a strong therapeutic relationship in an in-person clinic – in-person “pill mills” helped start the opioid crisis.
“We should be much more focused on what differentiates high-quality health care from low-quality care, and not worry so much about whether it’s delivered virtually or not,” Neinstein says.
Aronowitz hopes policymakers are able to understand this distinction. Some legislators indicated that they were aware of the landscape – the senses. Rob Portman (R-OH) and Sheldon Whitehouse (D-RI) sent a letter to the DEA and the Department of Health and Human Services in April of this year asking them to allow treatment for disorders related to telehealth opioid use.
But other lawmakers have expressed concern that wider access to telehealth makes fraud more likely. Neinstein says he fears lawmakers will reduce access to telehealth once the public health emergency is over. “There are fears that this will allow bad actors in the health community to practice bad health care,” he says. “And those fears are real, but I think that probably helps more people than hurts.”
So, for now, healthcare providers treating patients who use opioids via telehealth are in limbo. It’s frustrating trying to come up with innovative programs without being sure they can continue, says Aronowitz. She worries about the repercussions if telehealth is to stop; some patients may not be able to connect to treatment any other way. But Aronowitz says she’s skeptical that policymakers will really heed those concerns and all the work done in her area.
“I don’t believe all the evidence means people will listen,” she said. “I think we’re really doing what we can to get that evidence and continue to treat as many people as possible so that it’s harder to make the case for going back.”