Opioid addiction treatment is collateral damage in online prescription reaction

Opioid addiction treatment is collateral damage in online prescription reaction

Pandemic-era rules around telemedicine have been a big boost to efforts to prevent opioid overdoses in the US. But those rules are also how controversial startups like Cerebral were able to prescribe Adderall and Xanax to large numbers of people, and efforts to stem that flood of prescriptions could sweep away overdose prevention efforts in the process.

Starting in 2020, doctors can prescribe controlled substances after a telehealth visit without the need to see patients in person. But that’s a big umbrella: Adderall and Xanax are controlled substances. So are buprenorphine and methadone, which are used to treat people addicted to opioids. Opioid overdoses have reached epidemic proportions in the United States, with tens of thousands of people dying each year.

Telehealth led to clear improvements in 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 that they would end increased with the public backlash against the practices of companies like Cerebral, which used these same telehealth policies to dispense large numbers of prescriptions, including drugs that are often misused. The COVID-19 public health emergency that allowed both will expire in October, although the Biden administration could extend it again. But it will end over time, and when it does, policymakers will have to decide whether to maintain some of the relaxed public health rules or return to the pre-pandemic status quo.

“We’re already thinking about contingency plans, while also trying to do everything we can to show almost anyone who will listen that this is very beneficial,” says Shoshana Aronowitz, a health services researcher at the University of Pennsylvania who offers treatment for substance use in Philadelphia and through the Ophelia Health digital platform. “It’s very easy for these things to come together 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) waived the requirement in March 2020 as pandemic restrictions made it more difficult (and the pandemic made it potentially dangerous) for people to make in-person appointments.

That waiver made it easier for people struggling with opioid overuse to make appointments and start treatment, the research found. The ability to use telehealth also helped create new types of innovative health care programs. The University of Pennsylvania, for example, created a “bridge clinic” that allows people to set up same-day telehealth visits (by phone or video) and get a short-term prescription for same-day medications that can reduce withdrawal effects of opioids and help them stop using more dangerous drugs like heroin. This would prevent them if there was a wait for an in-person appointment. “They could easily overdose and die in that time,” says Aronowitz. “Being able to bring people together even for a few days is huge. And you can’t do that if you’re not licensed to prescribe through telehealth.”

Getting more people connected to drugs that can help them has clear benefits for fighting America’s overdose epidemic, he says. “Medication for opioid use disorder is really the best evidence-based thing for treating opioid use disorder and preventing overdose.”

While offering these prescriptions via telehealth was legal under pandemic-era guidelines, Aronowitz says he still had some challenges with pharmacies, some of which wouldn’t fill the prescriptions if they came from a walk-in telehealth There are stigmas and misconceptions about using one drug to treat dependence on another drug, and some patients say they aren’t actually sober if they use something like buprenorphine. Some pharmacies had been reluctant to fill prescriptions if they were sent through telehealth from health care providers. different states.

That was even before the backlash against companies like Cerebral began: The company’s doctors said they felt pressured to prescribe ADHD drugs without a proper evaluation, the US Department of Justice opened an investigation, and, eventually, the company said it would stop prescribing controlled substances.

Faced with this news, Walmart stopped filling prescriptions for controlled substances through telehealth. This policy did not differentiate between different types of controlled substances, which are used for different types of health conditions. (ADHD, for example, is different from opioid use disorder.) Any blanket approach that lumps all controlled substances together doesn’t take into account the different types of care patients receive, Aronowitz says.

The focus of these types of decisions should be on the quality of care, not the way care is delivered. “I think the most important thing is: Is there a real treatment relationship?” says Aaron Neinstein, vice president of digital health at University of California, San Francisco Health. “Does the doctor know who the patient is and understand the care context enough to make a confident decision around the prescription?”

Telehealth allows healthcare organizations to reach more people than they could with face-to-face care. Patients don’t have to travel to the doctor’s office, and doctors can see more people in a day. Then a company that overprescribes might be able to get more patients than if it had to add the in-person component. But it’s still possible to build a very real relationship between a patient and a provider through a digital health platform, Neinstein says. It is also possible to prescribe drugs irresponsibly without a strong therapeutic relationship in a face-to-face clinic: In-person “pill mills” contributed to the onset of the opioid crisis.

“We should focus much more on what differentiates high-quality from low-quality health care, and not worry so much about whether it’s delivered virtually or not,” says Neinstein.

Aronowitz hopes that policymakers will be able to understand this distinction. Some lawmakers have indicated they are aware of the situation: Sens. 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 to ask them to allow opioid use disorder treatment through telehealth to continue.

But other lawmakers have expressed concern that wider access to telehealth makes fraud more likely. Neinstein says he’s worried lawmakers will push back on access to telehealth once the public health emergency is over. “There is a fear that it will allow bad actors in the health care environment to practice bad health care,” he says. “And those fears are real, but I think it’s probably helping more people than it’s hurting.”

So, for now, health care providers who treat patients who use opioids via telehealth are in limbo. It’s frustrating to try to create innovative programs without being sure if they can continue, Aronowitz says. She is worried about the repercussions if telehealth is to end; Some patients may not be able to connect to the treatment otherwise. But Aronowitz says she’s skeptical that decision-makers will consider those concerns and all the work she’s done in her field.

“I don’t trust that all the evidence means people will listen,” he says. “I think we’re really doing what we can to get that evidence out and keep treating as many people as possible so that it’s harder to argue that it’s beneficial to reverse it.”


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