In late February, the Drug Enforcement Administration announced a set of proposed rules that would roll back some of the flexibilities allowed during the pandemic for the prescribing of controlled substances via telemedicine. The American Medical Association recently released its comments on the DEA’s proposal, and many telehealth advocates are supporting the organization’s recommendations.
Under the DEA’s proposed rules, all prescriptions for Schedule II drugs would require an in-person physical exam, with no allowances for short-term telemedicine prescriptions. Examples of Schedule II drugs include narcotics like Percocet, Dilaudid and OxyContin, as well as stimulants like Adderall, Ritalin and Vyvanse.
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For Schedule III-V drugs, patients can receive an initial 30-day prescription via telehealth. But after that, patients will need an in-person visit. This includes drugs that treat substance use disorder like buprenorphine, as well as common psychiatric drugs like Xanax, Ambien and Prozac.
The proposed rules have been met with mixed reviews. Some people agree with the DEA, which is touting the change as a way to ensure patient safety, but many telehealth advocates argue it will greatly disrupt access to treatment for many Americans — especially at a time when the mental health and substance use crisis is growing.
The AMA is recommending that the timeframe be extended to at least six months for patients who need to refill their buprenorphine prescription after their initial supply is prescribed via telemedicine. The 30-day time window that the DEA proposed is too short, and would cause many patients who were started on buprenorphine to have their prescriptions lapse, leading to more overdose deaths, the AMA said.
Evans Rochaste voiced support for the AMA’s recommendation in a recent interview. He is the CEO of ReKlame Health, a startup that provides telehealth-based psychiatry services and addiction medication management to Black and Brown patients.
ReKlame is using telehealth to prescribe buprenorphine for opioid use disorder during a time when opioid-related deaths are at an all time high, Rochaste pointed out.
“This is going to have a major impact on patients and their ability to access life-saving care,” he declared. “We’ve seen that [buprenorphine] has saved lives. Being that it’s delivered through telehealth and more accessible, it works especially for patients who are part of underrepresented or underprivileged communities or those who live in a mental health provider desert where there aren’t providers to be able to deliver care in person.”
Geoffrey Boyce, CEO of virtual mental healthcare provider Array Behavioral Care, also agreed with the AMA’s suggestion. He said that 90 days or six months makes a lot more sense than 30 days, given how difficult it is to access an in-person appointment with a mental healthcare provider in such a short amount of time.
The AMA also recommended that the DEA extend telemedicine prescribing flexibilities to all Schedule III-V medications, as well as provide a special registration process that would extend telemedicine prescribing to Schedule II medications.
Like the American Telemedicine Association and other telehealth advocates, Rochaste is supportive of this suggestion. He pointed out that in 2008, Congress gave the DEA a mandate to create a process that would allow medical professionals to register with the agency and therefore be allowed to prescribe controlled substances remotely via telehealth. However, the DEA still hasn’t created this process.
On the other hand, Boyce likes the fact that the DEA’s proposal didn’t demonstrate an intent to create a special registration process for the prescribing of controlled substances via telemedicine.
“DEA registration in its current form is very challenging in and of itself. You have to be DEA-registered in every state in which you are practicing and seeing patients. There’s no single DEA registration — you have all these state specific ones,” he explained.
Boyce added that the way the DEA has set up registration in the past is not designed for telemedicine. Prescribers must put an address on their application, and the assumption is that the address is actually the site where they’re seeing patients.
“That address is supposed to be where you’re storing, dispensing, administering and maintaining controlled substances, but that’s just not how telemedicine works,” he declared. “The overall point is that DEA registration is already a mess and is really not centralized, so the idea that we would now add a new level of DEA registration on top of what is already a mess, is not appealing to us at this point.”
While he’s not a big fan of adding a special registration process for telemedicine prescribing, Boyce does support the AMA’s request for the DEA to have more nuance when it comes to the way it is handling Schedule II drugs.
“I think we’re a little bit uncomfortable with the fact that the DEA is kind of lumping everything together and assuming that it’s all the same for every drug that is Schedule II and for every medical discipline that has different applications for those drugs. I think we’d like to see more nuanced controls put in place around subsections of drugs and potentially subsets of patients,” he explained.
Boyce and his team at Array focus on child and adolescent mental health, so they “feel strongly” that children should be able to receive Schedule II controlled stimulants via telemedicine if they have parental permission, but “that doesn’t necessarily mean that there should be carte blanche for how stimulants are prescribed via telemedicine,” he said.
Boyce pointed out that while the DEA’s proposal is far from perfect, it is still the most guidance that the agency has ever released on telemedicine prescribing. He thinks that’s a step in the right direction and is hopeful that the rules will evolve over time to protect patient safety without hindering treatment access.
Photo: Anastasia Usenko, Getty Images
