Telehealth patients scramble for in-person care amid crackdown on online controlled substances

 Catherine was getting nervous about her ADHD prescription. In 2022, the 29-year-old New Yorker had started using Done, a direct-to-consumer telehealth company that treats attention deficit hyperactivity disorder. The medication her provider had prescribed, a stimulant called Vyvanse, was helping her manage distraction so severe that she frequently had car accidents. 

But online, she had started reading about other telehealth patients running into problems getting their ADHD medications. Increasingly, big box pharmacies were cracking down on prescriptions from online-only providers like Done and Cerebral as their practices faced intense scrutiny. And she heard that, when the Covid-19 public health emergency eventually ended, she likely wouldn’t be able to get her medication without meeting a provider in-person. 

“With the whole pandemic thing ending and restrictions happening, it was like, ‘I need to be seeing an actual psychiatrist so I don’t have my access to this cut off,’” said Catherine, who asked to be referred to by her first name only.  

When the pandemic hit, and mental health care providers were in short supply, patients like Catherine flocked to telehealth — and in many cases, obtained prescriptions for controlled substances that previously could only be prescribed in-person. But as those channels close, many of them are facing the challenge of transferring their prescriptions to in-person providers.

“People during the crisis that accessed telehealth, now they’re trying to plan for care, and there is a gap,” said Mark Stein, director of the ADHD clinic at Seattle Children’s. “Where telehealth could be a solution, in some ways it’s making it worse when you’re having fragmented or disconnected care.” 

As they attempt to transition to in-person care, some patients will likely still struggle to find providers who are comfortable treating ADHD, said Maggie Sibley, a clinical psychologist and associate professor at Florida International University who specializes in ADHD. Those providers are still scarce, and at the same time, ADHD awareness across age groups has spiked during the pandemic. 

Even if a patient is able to find a qualified doctor with openings, it’s not certain they will simply pick up with the same prescription a telehealth company offered. “From the patient’s perspective, they’re looking for somebody who can fulfill their need,” said Sibley. “But what they’re going to find, I think, is that traditional providers are going to be doing a higher level of due diligence,” possibly reconsidering stimulant prescriptions altogether.

Adult ADHD in particular can be complex to diagnose and treat, said Stein. Other mental health disorders often mimic or overlap with ADHD symptoms, and cognitive difficulties with concentration, motivation, and planning can be related to other health problems. “The idea that you could do a comprehensive evaluation online in a half an hour, I think that for many people that would not be adequate in terms of capturing their history,” he said. 

Catherine had been diagnosed with depression and post-traumatic stress disorder before reaching out to Done last February. She had long felt pigeonholed by her providers, who prescribed a series of antidepressants that didn’t work or came with negative side effects, including hallucinations. So when she sought out treatment for her attentional issues with Done, she didn’t share her previous diagnoses on an intake survey or with her prescribing provider. 

“Quite frankly, I just flat-out lied,” she said. “I was done with even remotely trusting anyone. And I was just like, I know what I need to say to get me an appointment with someone who is going to actually just give me the medication for this.” 

She knew it was a risky choice — and as her executive function symptoms improved on Vyvanse, she sought out care for other symptoms from one of her previous psychiatrists, who diagnosed and treated her for bipolar II. He was concerned, she said, about treating a patient whose medication was managed by another psychiatrist. So after establishing a stable regimen to treat her bipolar disorder and discussing the challenges of balancing the two types of medication, “he wanted to take over my stimulant prescription to figure it out and get it right together.” 

That suggestion saved her from having to figure out what to do next if she lost access to her prescription via telehealth.  

The transition to in-person care may not be as straightforward for patients without an existing history of behavioral health treatment. They’re more likely to be treated by primary care providers, many of whom don’t feel comfortable diagnosing ADHD or choosing a medication and dose for a patient. “That’s the part that feels out of their wheelhouse,” said Sibley. 

Another patient who ultimately got care from Done had talked to her primary care doctor about her ADHD-like symptoms for years. “He’s always suggested that I get tested, as he suspected it as well,” she wrote in an email to STAT. “But he never felt comfortable diagnosing.” After reaching out to Done in early 2022, she received a prescription for Concerta, which helped her sleep better, avoid overthinking, and cut down on anxiety.

It wasn’t long before her local Walgreens cracked down on filling telehealth prescriptions. She was able to find a local pharmacy that would distribute the medication, “but that doesn’t come without fear that they’re going to cut me off,” she shared.

Along with the looming end of controlled substance prescribing online and growing stigma around telehealth prescriptions of stimulants, “that was ultimately the pushing point for me to switch,” she wrote. Recently, she reached out to her primary care doctor to discuss the problem — and this time, she said, he felt confident enough in her treatment history to take over the prescription. 

That can be fairly common among PCPs, said Sibley. “Once we figure out what works, they feel comfortable overseeing continued care.” But she and other providers expressed concern that some telehealth patients — especially those who were diagnosed recently online — may need more careful assessment by a new provider before stimulant prescriptions can be safely continued. 

“These companies are under scrutiny, and questions have been raised publicly about whether they are being discerning enough with their patients,” said Sibley. “So I think any responsible doctor should be, regardless of who they’re getting care from, should be making sure that they do due diligence to collect full information.”

But the Done patient who is transferring her prescription to her primary care doctor said she avoided sharing details with him about her current provider, given that scrutiny. “You hear ‘telehealth’ and you’re automatically stuck wearing the ‘pill mill,’ ‘drug seeking’ stigma like a backpack, no matter where you go,” she wrote. “Thankfully he didn’t ask for too many details.”

A successful care transition to primary care is “a lot easier when someone comes in with really good documentation about their symptoms and their impairment and their treatment history and you know them,” said Stein. “But we don’t have that sometimes if someone just comes in fresh from telehealth.” In those cases, a patient may need further evaluation from a specialist — which could leave patients frustrated and facing gaps in medication as they work to establish a treatment history with a new physician.

“ADHD is a disorder that, from a professional’s perspective, takes a lot of detective work,” said Sibley. “The patients have to learn to advocate for themselves, but also have to learn to trust the new providers that they may be doing due diligence.”

With a psychiatrist now managing her prescriptions for both ADHD and bipolar disorder, in-person care feels like the right fit to Catherine. But she still sees telehealth as a valuable tool for ADHD patients — especially those with more straightforward medical histories — who have long struggled to access care and found an easier path during the pandemic. 

“Telehealth, I think for a lot of people, is a really lucky in to getting a first treatment,” she said. “You can then be able to prove to someone like, ‘Hey, this actually works for me.’” 

That ‘in’ is still somewhat available, for now. While some pharmacies have stopped filling online prescriptions, federal health secretary Xavier Becerra this month extended the public health emergency for another 90 days. But it will at some point end, and Done said it is committed to minimizing disruptions in care when that happens. 

“We are working on a plan to switch to a hybrid model of in-person care and remote chronic care management for all the new members, while continuing to take care of our current members in accordance with federal and state regulations,” wrote Done clinical leader Zoe Martinez in a statement to STAT. “We are taking all necessary precautions to ensure a smooth transition for our patients and will keep them informed throughout the process.”

Other providers, including Stein, see potential for hybrid models to manage complex disorders like ADHD, which can spiderweb into many so many aspects of a patient’s health. But it will need to include careful coordination to make sure that patients get the best care from both specialists and primary care providers — and avoid the interruptions that some are experiencing today.

“These telehealth companies kind of filled the gap in terms of doing evaluations and providing some aspects of care,” said Stein. “But they really weren’t a long-term solution in terms of reducing the fragmentation of ADHD care.” 

https://www.statnews.com/2023/01/17/adhd-drug-telehealth-done-cerebral-prescription-access/