DEA Will get an Earful About Telehealth Prescribing of Managed Substances

— Proposed in-person go to necessities raises concern for psychiatry teams

by
Joyce Frieden, Washington Editor, MedPage Right now
September 12, 2023

Ought to the Drug Enforcement Administration (DEA) require a previous in-person go to earlier than permitting clinicians to prescribe managed substances by way of telemedicine? That was one of many points that DEA officers heard conflicting testimony on throughout a “listening session” Tuesday.

“Arbitrary one-time in-person analysis necessities don’t forestall abuse and diversion,” mentioned Helen Hughes, MD, medical director of the Workplace of Telemedicine at Johns Hopkins Medication, in Baltimore. “Telemedicine managed substance prescribing occurs in a wide range of settings throughout Johns Hopkins Medication, typically with out a earlier in-person encounter,” similar to pediatric sufferers being prescribed consideration deficit-hyperactivity dysfunction (ADHD) medicines and aged sufferers who’re receiving palliative care.

“The flexibility for these suppliers to prescribe managed substances and use their medical judgment for telemedicine with out a prior in-person go to permits sufferers to obtain clinically acceptable, important care by way of a handy and patient-centered modality, and we strongly imagine the in-person medical requirement ought to be eliminated in its entirety,” she mentioned. “Whereas the proposed rule would forestall or restrict prescribing within the above situations, it does nothing to stop a supplier who noticed a affected person one time in particular person — even 10 years in the past — from recklessly prescribing managed substances by way of both telemedicine or in-person care.”

Two-Day Session

Dan Reck, CEO of MATClinics, an opioid use dysfunction remedy firm that makes use of primarily buprenorphine merchandise, disagreed. “With out correct oversight of sufferers prescribed managed substances, together with common in-person visits mixed with definitive toxicology testing, there isn’t any motive to imagine that some telemedicine-only suppliers will not develop into buprenorphine mills, simply as painkiller mills as soon as flourished,” he mentioned. “We’re involved that the results of unregulated buprenorphine will contribute additional to the already lethal opioid epidemic.”

The listening session — which is able to final for two days — happened due to the big quantity of feedback the company obtained on two proposed laws, DEA administrator Anne Milgram, JD, mentioned at first of the proceedings. “This previous March, in live performance with the Division of Well being and Human Providers, DEA issued two units of proposed telemedicine regulations,” she defined. “These laws would have allowed for telemedicine prescribing of sure managed substances topic to safeguards, and would have imposed an preliminary restrict on telemedicine prescriptions to a 30-day provide. To prescribe extra … the prescribing practitioner usually would have been required to guage the affected person in particular person.”

“We obtained over 38,000 public feedback in response to these proposed laws, and we learn each single one,” she continued. “We imagine that it’s among the many highest variety of feedback we’ve got gotten within the DEA’s historical past. A major majority of these feedback expressed issues that the proposed laws place limitations on the provision of managed substances that might be prescribed previous to an in-person analysis. After evaluating these feedback, DEA wished to reopen this dialog about telemedicine prescribing and to permit for a public listening session.”

Psychiatrists’ Considerations

Psychiatry teams have been amongst these involved in regards to the proposed 30-day prescribing restrict. “The 30-day initiation interval wouldn’t be enough given the present wait instances” for psychiatric care in lots of locations, mentioned Shabana Khan, MD, a psychiatrist who spoke on behalf of each the American Psychiatric Affiliation and the American Academy of Youngster and Adolescent Psychiatrists. She famous that 55% of counties within the U.S. don’t have any psychiatrists and 70% of counties don’t have any baby psychiatrists.

The psychiatry teams additionally oppose a DEA proposal to require telemedicine prescribers to notice on the prescription that it was accessed by way of telemedicine. “[Designating] prescriptions as telemedicine will increase pharmacist hesitancy to fill the medicines with out good motive,” Khan mentioned. “We’re already discovering this in our follow. So including that telemedicine indication on there may probably make it much more tough for our sufferers to entry care.”

Sterling Ransone, MD, previous president and present board chair of the American Academy of Household Physicians, mentioned that whereas telemedicine has labored very effectively at his follow relating to treating established sufferers, the academy had issues about the best way by which use of telemedicine-only firms can result in fragmentation of care. “I follow in a rural space with my spouse, who’s a pediatrician, and we incessantly may have sufferers are available in to see us for follow-up” after a go to with a telehealth-only supplier; the sufferers don’t have any report of the opposite supplier’s analysis or remedy plan, he mentioned.

“We’ll see these of us coming in on antibiotics or different substances which we personally would not have used as a result of we all know these sufferers … plus we all know the micro organism which can be in our space,” Ransone continued. “I ask, ‘What did they do?’ ‘Nicely, they put me on a white tablet.’ ‘Do you’ve gotten it with you?’ Often they do not deliver it, after which I am scrambling making an attempt to determine what medicine they have been positioned on, in order that I do not do hurt by prescribing a medicine that may work together with the drug that they have been given … In order that fragmentation of care — the fragmentation of care has been fairly regarding for us.”

Exceptions Proposed

Different audio system argued for exceptions to the proposed guidelines. David Hoffman, JD, assistant professor of bioethics at Columbia College in New York Metropolis, urged the DEA to deal with terminally unwell sufferers in another way than different sufferers relating to prescribing managed substances to deal with ache.

“If all of the DEA needed to be involved about was elimination of alternatives for drug diversion, then the proposed ban on telemedicine for first-prescribing of narcotics would possibly make some sense,” he mentioned. “However the pursuits of sufferers in want of aid from ache and struggling, notably these sufferers with terminal sicknesses — and subsequently restricted skill to journey to physician’s appointments — have to be thought of a robust balancing consideration.”

Robert Krayn, CEO of Talkiatry, a telemedicine supplier specializing in psychiatry, recommended that hospitals and nonprofit healthcare entities be exempt from among the knowledge reporting necessities within the proposed rule.

“They’ve restricted sources on the nonprofit aspect, and if you have a look at the potential for diversion, it actually stems from people who find themselves gaining a revenue from making the prescriptions and with quite a lot of not-for-profits, that’s simply merely not the case,” he mentioned. “The information reporting necessities are cumbersome, and for sure docs who work at a number of, not-for-profit organizations treating many sufferers, these data are scattered in all places; they don’t have the cash, the sources, or the expertise know-how to make this an simply reportable part.”