Telehealth controversy: Should it be ok to prescribe addiction meds virtually? : Shots - Health News A ban on using telemedicine to prescribe controlled medications was suspended in the pandemic. That's allowed many to seek opioid addiction treatment, but some worry about potential for abuse.

Limits on virtual addiction treatment may soon return, making care harder to access

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So normally a patient has to see a doctor regularly in person to get medication to treat an opioid addiction. During the pandemic, those rules have been loosened. The changes allow more people to access care virtually, just as overdose deaths are reaching an all-time high. But prescribing controlled medications online is controversial. There's a concern that fewer safeguards will lead to more abuse. Now, as telehealth policies shift back again, doctors, patients and regulators are weighing costs and benefits. NPR's Yuki Noguchi reports.

YUKI NOGUCHI, BYLINE: Dennis Gaudet's home in central Maine is surrounded by fields and woods, and he's miles from anyone able to treat his opioid use disorder.

DENNIS GAUDET: I was on a waiting list to get in to see a psychiatrist for over two years. Once the pandemic began, nobody was accepting new patients.

NOGUCHI: The lack of available treatment, Gaudet says, leaves marks on his community and his own life. In the past three years, he's lost six friends to overdose. But last year, the disabled construction worker found a clinic in California with addiction specialists licensed in Maine.

GAUDET: Anytime day and night, if I'm in crisis, I can get in touch with the virtual clinic, and they'll get me in touch with somebody that can help me.

NOGUCHI: They also prescribe him buprenorphine, a regulated drug that curbs his cravings. Without it, the 48-year-old says, he'd be at risk of overdose.

GAUDET: I would have gone back out on the streets and been doing heroin and fentanyl again.

NOGUCHI: There are many stories like Gaudet's. Early in the pandemic, the federal government and all 50 states temporarily stopped requiring in-person visits for doctors to prescribe controlled medications, even for out-of-state physicians, a practice normally prohibited by medical boards. Today rules are in flux. Thirty-one states still allow virtual prescription of regulated drugs within their borders. Only one, Arizona, changed state laws to permanently allow doctors to prescribe from out of state.

Whether to continue allowing virtual prescription of controlled medications is telehealth's most controversial frontier. Such allowances lowered barriers to potentially life-saving care, especially as the opioid epidemic intensified. But for many, returning to pre-pandemic rules, like requiring in-person visits or giving fewer doses, is necessary to protect against prescription drug abuse. After all, lax oversight in the 1990s gave rise to pill mills, which kick-started the opioid epidemic.

Courtney Joslin researches telehealth for the R Street Institute, a free market think tank. She says policymakers are in a tough spot.

COURTNEY JOSLIN: You have people who are really in need of this, and telehealth could greatly help them. On the other end, you do have that hesitancy because of the pill mill problem previously. You could have some abuse from both patients and providers using telehealth to get controlled substances.

NOGUCHI: Virginia Democratic? Senator Mark Warner Says telehealth has become essential to opioid treatment.

MARK WARNER: We've now had 18 months to have telehealth expand dramatically. It would be a huge mistake to roll back that progress. And if you cut off that ability to deliver those substances with appropriate protections, you're really cutting back on the path to recovery for a lot of folks.

NOGUCHI: State and federal lawmakers are considering many telehealth proposals, but very few mention controlled medications. That's partly because Congress already passed a law ordering the Drug Enforcement Administration to set up a registry of physicians authorized to prescribe regulated drugs using telehealth. Two years past its deadline, it hasn't done so. The agency declined to comment when it might be complete.

Kyle Zebley is vice president of public policy for the American Telemedicine Association.

KYLE ZEBLEY: DEA kept on saying they're going to do that, but there has been no action taken.

NOGUCHI: He says when the emergency rules end, many patients will face what he calls a telehealth cliff.

ZEBLEY: Now we have millions of Americans, a huge cohort, that are relying on virtual online prescribing of controlled substances. And that will go away. An already heightened opioid and substance use crisis will be significantly exacerbated.

NOGUCHI: The medical community, meanwhile, is of two minds. Joseph DeSanto, an addiction specialist in Huntington Beach, Calif., says telehealth may open new channels for abuse. But it also enabled him to care for 20 out-of-state patients last year.

JOSEPH DESANTO: The response was resoundingly positive, and we were able to see patients that wouldn't normally have gotten help.

NOGUCHI: One young man, for example, called him from halfway across the country.

DESANTO: He lived in a rural part of Tennessee where addiction doctors are - you know, it's unheard of. During the lockdown and the COVID restrictions, he relapsed during that time, which was really common.

NOGUCHI: DeSanto prescribed him medication to fight his addiction until he found a doctor in state.

DESANTO: So it gave him some time. And I'm not sure if he would have had that time if he relapsed and didn't realize that he had the ability to see a doctor that wasn't local to him.

NOGUCHI: Stanford psychiatrist Anna Lembke has seen those benefits, but has also seen it backfire.

ANNA LEMBKE: We've seen an increased number of patients who told us that they were doing fine, who then overdosed from fentanyl, that we, in retrospect, wonder, would it been caught had we been getting regular urine tox screens or had we been seeing them in person?

NOGUCHI: She wants to see better tools to help monitor the patient's physical health, like bloodwork, remotely.

LEMBKE: I think that there are probably a lot more patients that are not doing well that we don't know about. We don't have a good handle on who is doing well and who isn't because when patients relapse, you know, part of the disease is they don't tell the truth about what's going on with them.

NOGUCHI: Tackling that, she says, will be critical to ensuring telehealth works.

Yuki Noguchi, NPR News.


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