The limits of virtual addiction treatment could soon return, making access to care more difficult
Dennis Gaudet’s home in central Maine is surrounded by Fields and forests, and miles away from anyone who can treat their opioid use disorder.
“I was on a waiting list to see a psychiatrist for over two years. [and] no one has taken in new patients since the pandemic began, “says Gaudet, 48, who has struggled with an addiction for more than half his life that began on prescribed pain medication after injuring himself on a construction job.
The lack of available treatment options, he says, has shaped his community and his own life; In the past three years, Gaudet has lost six friends to overdosing.
But last year, thanks to pandemic relaxation of prescribing rules, Gaudet was able to receive treatment from a clinic in California with a Maine-licensed addiction specialist, who claims to have helped him through many mental crises. The telemedicine clinic also fills out their prescriptions for buprenorphine, a regulated drug that curbs cravings.
Without her, he says, “I would have gone back on the streets and taken heroin and fentanyl again.”
A temporary relaxation of the rules
A growing number of Americans with an opioid use disorder benefited from a rule change at the beginning of the pandemic that allowed them to access prescriptions for their controlled drugs via telemedicine. These drugs, which are opioids themselves, are heavily regulated by the Drug Enforcement Administration.
Usually, a patient needs to see their doctor regularly – in person – to get the medication. But at the start of the pandemic, the DEA and all 50 states temporarily suspended these safeguards, even allowing prescribing by out-of-state doctors, a practice normally prohibited by medical bodies.
At a time when opioid overdose deaths were rising, these temporary expansions to telemedicine not only helped patients bypass pandemic lockdowns, but also removed some common treatment barriers that have plagued addiction treatment, such as a lack of healthcare providers to prescribe them, lack of transport to the doctor or withdrawal of driver’s license. These allowances were tied to state or federal emergencies, so once those expired – without new laws – pre-pandemic rules would apply again, including an obligation to see a doctor in person for a prescription.
A return to previous rules is required for some clinicians and regulators to prevent prescription drug abuse. Eventually, lax oversight led to pain reliever factories in the 1990s that fueled the country’s original opioid epidemic. Others argue that a return to the old method of treatment will set back patients trying to combat their opioid addiction.
Because of this, the virtual prescription of controlled drugs is the most controversial frontier in telemedicine.
And that puts politics in a difficult position.
“There are people who really need this, and telemedicine could really help them,” said Courtney Joslin, a resident fellow at the R Street Institute, an open market think tank. “On the other hand, you had this reluctance before because of the problem with the tablet factory, [so] They could be abused by both patients and providers who use telemedicine to get controlled substances. ”
The extension of Telehealth and a missing database
The growth of telehealth – which McKinsey estimated 38 times since the pandemic – has spawned a flurry of federal and federal legislative proposals. In deciding the future of telemedicine rules, policy makers are looking for data to learn the lessons – what worked and what didn’t – during this emergency.
With no evidence of abuse, according to Senator Mark Warner, D-Va., Telemedicine should continue for medically assisted opioid treatment.
“We now had 18 months to dramatically expand telemedicine. It would be a big mistake to roll back that progress, ”says Warner. “If you use appropriate protective measures to prevent this ability to administer these substances, you are really shortening the path to recovery for many people.”
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But of the estimated 1,000 telemedicine bills now pending before federal and state legislators, very few mention controlled drugs. That’s partly because Congress passed a law back in 2018 directing the DEA to set up a registry of doctors empowered to prescribe regulated drugs via telemedicine.
This database no longer exists more than two years after the deadline. The DEA did not want to comment on when it might be completed.
“The DEA has kept saying they will, but no action has been taken,” said Kyle Zebley, vice president of public policy for the American Telemedicine Association.
Therefore, says Zebley, patients who rely on them will face a “telehealth cliff” that Zebley calls after the current relaxed telemedicine rules are phased out.
“Now we have millions of Americans – so a huge cohort – relying on virtual online prescribing for controlled substances and that is going to go away,” he says. “An already exacerbated opioid and substance use crisis will only get worse.”
A debate about the limits of telemedicine
Meanwhile, the medical community disagrees with the tradeoffs.
In a November survey by drug testing company Quest Diagnostics, 75% of doctors prescribing opioids said telemedicine limits their ability to determine whether patients may be abusing drugs. On the other hand, many say they have found that they can help more patients with urgent care needs.
There is always a risk that some patients and doctors will try to abuse the rules of telemedicine to redirect drugs, says Joseph DeSanto, an addiction specialist in Huntington, California. But last year DeSanto saw more advantages than disadvantages; During the pandemic, he was able to care for 20 patients who lived outside of the state.
“We could treat anyone anywhere in the US,” until California went back to its old rules earlier this year, says DeSanto. “The response was consistently positive and we were able to see patients who would normally not have received any help,” he says.
For example, DeSanto says he treated a Tennessee man in his early 30s who called DeSanto in a rural area where there are virtually no addiction doctors. During the lockdown, the man relapsed on opioids – something DeSanto said was common among patients. DeSanto prescribed buprenorphine to combat addiction until the patient could find a doctor.
“It gave him some time, and I’m not sure if he would have had that time if he relapsed and didn’t realize he had the opportunity to see a doctor who was not around,” says he.
On the other hand, relying so heavily on pure virtual treatment also has disadvantages, says Dr. Anna Lembke, psychiatrist and professor of psychiatry at Stanford.
“We saw an increased number of patients who told us they were fine – they said they were taking their buprenorphine – who then overdosed on fentanyl,” she says. “Looking back [we] wonder [if they] would have been caught if we had normal urine [toxicology] Screens, or had we seen them in person. ”
Lembke says telemedicine has changed the field of mental health. This has enabled her to extend her reach to people who have not had access to medical care in the past, for example, but she is also aware of the risks. She wants to see better tools for remote monitoring of patient biomedical data like urine tests and blood pressure.
“I think there are probably a lot more patients who are not doing well that we don’t know about,” says Lembke. “We don’t have a good overview of who is fine and who is not because when patients relapse, part of the disease is that they are not telling the truth about what is wrong with them.”