Dennis Gaudet’s home in central Maine is surrounded by fields and woods, and several miles from anyone who can manage their opioid use disorder.
“I had been on a waiting list to see a psychiatrist for over two years, [and] since the start of the pandemic, no one has accepted new patients, ”explains Gaudet, 48, who has spent more than half of his life battling an addiction that began with prescribed pain relievers after suffering injuries during of construction work.
The lack of available treatment options, he says, has left a mark on his community and his own life; in the past three years, Gaudet has lost six friends to overdoses.
But last year, thanks to relaxed prescribing rules linked to the pandemic, Gaudet was able to seek treatment at a clinic in California with a licensed addiction specialist in Maine who he said helped him go through many mental health crises. The telehealth clinic also fills their prescriptions for buprenorphine, a regulated drug that curbs their cravings.
Otherwise, he says, “I would have gone back to the streets and taken heroin and fentanyl. “
Temporary relaxation of regulations
A growing number of Americans with opioid use disorders benefited from a rule change early in the pandemic that allowed them to access prescriptions for their controlled drugs, via telehealth. These drugs, which are themselves opioids, are heavily regulated by the Drug Enforcement Administration.
Normally, a patient has to visit their doctor regularly – in person – to obtain the drugs. But at the start of the pandemic, the DEA and all 50 states temporarily suspended those safeguards, even allowing prescribing by out-of-state doctors, a practice normally prohibited by medical boards.
At a time when opioid overdose deaths were on the rise, these temporary extensions of telehealth have not only helped patients bypass pandemic blockages, but they have also removed some common barriers to care that have hampered drug treatment, such as a shortage of healthcare providers able to prescribe them, lack of transportation to get to the doctor, or having a suspended driver’s license. These allowances were tied to state or federal states of emergency, so once these end – in the absence of new legislation – the pre-pandemic rules will return, including the requirement to see a doctor immediately. no one for a prescription.
For some clinicians and regulators, a return to the previous rules is necessary to protect against the abuse of prescription drugs. After all, lax regulatory oversight in the 1990s gave birth to painkiller pill mills, which fueled the country’s original opioid epidemic. Others argue that reverting to the old method of treatment will delay patients trying to tackle their opioid addiction.
This is why the virtual prescription of controlled drugs is the most controversial frontier of telehealth.
And that puts policy makers in a difficult position.
“You have people who really need it and telehealth could really help them,” says Courtney Joslin, resident researcher at the R Street Institute, a free market think tank. “On the other hand, you have this hesitation because of the pill mill problem, before, [so] you may be abused by patients and providers who use telehealth to obtain controlled substances.
The expansion of telehealth and a missing database
The growth of telehealth – estimated by McKinsey to have increased 38-fold since the pandemic – has spawned a wave of federal and state legislative proposals. To decide the future of telehealth rules, policymakers are looking for data to understand lessons learned – what worked, what didn’t – during this time of emergency.
In the absence of evidence of abuse, says Sen. Mark Warner, D-Va., Telehealth should continue for medically assisted opioid therapy.
“We have now had 18 months for telehealth to develop significantly; it would be a huge mistake to reverse this progress, ”says Warner. “If you take away that ability to provide these substances with the proper protections, you really are reducing the road to recovery for a lot of people. “
Yet of the estimated 1,000 telehealth bills pending before state and federal lawmakers, very few mention controlled drugs. This is in part because Congress already passed a law in 2018 directing the DEA to set up a registry of physicians authorized to prescribe regulated drugs using telehealth.
More than two years after the deadline, this database does not exist. The DEA declined to comment when it could be completed.
“The DEA kept saying it was going to do it, but no action was taken,” said Kyle Zebley, vice president of public policy for the American Telemedicine Association.
Therefore, says Zebley, once the current relaxed telehealth rules expire, patients who depend on them will face what Zebley calls a “telehealth cliff.”
“Now we have millions of Americans – so, a huge cohort – relying on online virtual prescribing of controlled substances that will disappear,” he says. “An already worsened opioid and substance use crisis will be dramatically exacerbated. “
A debate on the limits of telemedicine
The medical community, for its part, has two opinions on compromise.
In a November survey by drug testing company Quest Diagnostics, 75% of doctors who prescribe opioids said telehealth limits their ability to determine whether patients are potentially abusing drugs. On the other hand, many say they have found they can help more patients in urgent need of care.
There is always a risk that some patients and doctors will try to abuse telehealth rules to divert drugs, says addiction specialist Joseph DeSanto in Huntington, Calif. But last year, DeSanto found more pros than cons; during the pandemic, he was able to treat 20 patients living out of state.
“We could treat anyone, anywhere in the United States,” until California reverted to its old rules earlier this year, DeSanto says. “The response has been overwhelmingly positive and we have been able to see patients who would not normally have received help,” he says.
For example, DeSanto says, he treated a Tennessee man in his early 30s who called DeSanto from a rural area where drug-addicted doctors are virtually unheard of. During the lockdown, the man relapsed on opioids – something DeSanto said was common for patients. DeSanto prescribed buprenorphine for the patient’s addiction, until the patient found a suitable doctor.
“It gave him time, and I don’t know if he would have had that time if he had relapsed and if he hadn’t realized that he had the possibility of seeing a doctor who was not in his region, ”he says.
On the other hand, there are downsides to relying so much on purely virtual treatment, says Dr. Anna Lembke, a psychiatrist and professor of psychiatry at Stanford.
“We have seen an increased number of patients who told us they were okay – saying they were taking their buprenorphine – who then overdosed on fentanyl,” she says. “In retrospect [we] wonder [if they] we would have been caught if we had had regular urine [toxicology] screens, or had we seen them in person.
Lembke says telehealth has transformed the field of mental health. This has allowed her to broaden her reach to include people who could not access care in the past, for example, but she is also keenly aware of the risks. She wants to see better tools to allow remote monitoring of patient biomedical information, such as urine tests and blood pressure.
“I think there are probably a lot more patients who aren’t doing well that we don’t know,” Lembke says. “We don’t have a good idea of who’s doing well and who isn’t, because when patients relapse part of the disease is they don’t tell the truth about what’s going on with them. “