DEA extends telemedicine option for prescribing controlled medications

The federal government will allow doctors to keep using telemedicine to prescribe certain medications for anxiety, pain and opioid addiction, extending for six months emergency flexibilities established during the coronavirus pandemic.

The Drug Enforcement Administration and Substance Abuse and Mental Health Services Administration made the announcement Tuesday, two days before the telemedicine flexibilities were set to expire along with the coronavirus public health emergency.

The ability to prescribe controlled medications remotely will run through Nov. 11, 2023. And that deadline will be longer still if doctors have already established a telemedicine relationship with patients. In that circumstance, physicians can keep prescribing the medications virtually through Nov. 11, 2024.

The extension was announced after the DEA received tens of thousands of complaints about its proposal to reinstate stricter rules governing the prescribing of controlled substances that had been loosened at the dawn of the pandemic. The extension will allow officials to review the comments while developing a permanent rule. The controlled medications include drugs such as the attention-deficit/hyperactivity disorder pill Adderall, the painkiller oxycodone and buprenorphine, which is used to treat opioid-use disorder.

“We strongly support policies that promote access to effective and safe treatment for opioid use disorder, including through telemedicine platforms, and ensuring continued access to necessary controlled medications past” the end of the public health emergency, Miriam E. Delphin-Rittmon, the Department of Health and Human Services’ assistant secretary for mental health and substance-use services, said in a statement.

In early 2020, as the U.S. government sought to limit the spread of the novel coronavirus, it issued an emergency rule allowing doctors to prescribe the controlled medications without face-to-face visits with patients. That led to a telehealth boom, with myriad new companies emerging to treat and prescribe medications for thousand of patients for conditions including depression, anxiety and addiction. It also helped lead to a shortage of drugs for ADHD such as Adderall.

As the pandemic eased, the federal government this year had proposed draft rules that would have allowed doctors to prescribe remotely an initial 30-day supply of some controlled medications, such as buprenorphine, or testosterone for hormone replacement therapy. But under the proposal that is now back on the shelf, patients looking to get refills beyond that initial window would have needed to see a physician in-person.

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Other drugs with a higher risk for abuse or dependency, such as Ritalin for ADHD, would have required an in-person evaluation from the start. The proposals would have given a six-month grace period to patients already receiving prescriptions through telemedicine.

At the time the proposal to restrict telemedicine prescribing surfaced, the DEA had said the tighter standards were aimed at ensuring that patients would be adequately screened by their doctor and at combating potential abuses, such as improper prescribing of controlled medications by telehealth companies. The agency has been facing pressure from law enforcement and even some health providers over concerns about the emergence of digital “pill mills,” allowing people to get prescription drugs without a legitimate medical reason.

But the proposals sparked a public backlash, particularly regarding buprenorphine, a medication that is commonly prescribed to treat opioid-use disorder at a time when overdoses are killing more than 100,000 people a year.

The Biden administration has embraced the expansion of treating addiction with medication, including buprenorphine, often known by the brand name Suboxone. In January, the federal government did away with a requirement of extra training for doctors wanting to prescribe the medication, as well as limits on how many patients they can treat. Now, any physician with standard DEA registration can prescribe buprenorphine.

Telemedicine advocates say there is no evidence that remote prescribing has led to more buprenorphine being diverted to the streets, or an increase in overdose deaths involving the medication. Buprenorphine - which is weaker than heroin, and less prone to misuse and dependency - helps reduce cravings and withdrawal symptoms from opioids such as fentanyl, now the deadliest street drug in the United States.

As part of the rulemaking process, the public is allowed to send comments to the DEA - and the proposed telemedicine restrictions sparked a record 38,000 comments. Many came from patients and industry groups who argued the restrictions could alienate vulnerable people, including those who are homeless, live in rural areas or have disabilities that limit mobility.

Scores of patients with Boulder Care, a telehealth addiction treatment company with headquarters in Portland, Ore., submitted testimonials. The company treats thousands of patients in five states, many of them in rural Ohio, Washington and Oregon, the majority covered by Medicare.

“It’s very difficult in treatment in general to get buprenorphine, but for those covered by Medicare it’s nearly impossible to find a provider,” Boulder Care CEO Stephanie Strong said in an interview. Strong said she met with representatives from the DEA and Congress to advocate for continued access to telemedicine.

The pandemic shift to telemedicine also proved successful for people dealing with addiction while juggling the demands of everyday life, said Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates.

“Convenience is a real issue,” Schorr said. “It’s a hardship dealing with child care or work schedules.”

The public pressure appeared to be pay off. The DEA last week announced it would be extending the telemedicine flexibilities but did not offer details on how long they would last. Then on Tuesday, in a statement announcing the six-month extension, DEA Administrator Anne Milgram noted the record number of comments, saying “we take those comments seriously and are considering them carefully.”

The decision was applauded by groups such as the American Society of Addiction Medicine, which believes telemedicine prescriptions for buprenorphine are crucial during the overdose crisis. In a statement last week, Brian Hurley, the society’s president, said the extension is “significant because ensuring continued access to medications for addiction treatment is critical for saving lives.”

Telemedicine prescribers of other controlled medications also hailed the decision.

The online health business has mushroomed since the pandemic, particularly for companies focused on behavioral health. In 2022, for example, telehealth visits accounted for more than 38 percent of prescriptions for stimulants, including Adderall, up from just more than 1 percent the year before the pandemic, according to an analysis of insurance claim data by the analytics firm Trilliant Health.

Before this week, Vermont psychiatrist Adam Pruett - who prescribes ketamine for depression, anxiety and post-traumatic stress disorder - had been preparing patients for changes. He treats patients from as far away as Alaska and Hawaii. Some were preparing to eventually have to fly to Vermont for visits, he said.

Telehealth has “allowed me to grow my practice and treat people all over the country who have never had access to this medication,” Pruett said, adding of the DEA’s announcement Tuesday: “It gives people a lot of breathing room.”

Supporters of telemedicine predict that the DEA, when the temporary extension is winding down later this year, will end up proposing less stringent rules on prescribing controlled medications remotely, reflecting the groundswell of public feedback.

“If they intended to just plow forward [with the restrictions], they would have just done it,” said Krista Drobac, executive director of the Alliance for Connected Care, which advocates for remote visits as an important component of the health system.