Update: The DEA has released a statement saying, “We recognize the importance of telemedicine in providing Americans with access to needed medications, and we have decided to extend the current flexibilities while we work to find a way forward to give Americans that access with appropriate safeguards.” CNN is working to update this story as the DEA considers proposed telemedicine rules.
For three years now, the expansion of telehealth has made care more accessible for many people, especially those in rural areas. Patients have been able to receive prescriptions from providers without seeing them in person. But that may change come May 11 when the federal government is set to end the Covid-19 public health emergency declaration that made this convenience possible.
Before the pandemic, medical practitioners were subject to the conditions of the Ryan Haight Act, which required at least one in-person examination before prescribing a controlled medicine, said Dr. Shabana Khan, chair of the American Psychiatric Association’s Committee on Telepsychiatry.
“There are seven exceptions, and one of them is a public health emergency declared by the secretary of (health and human services), which is what we’ve had for the past three years,” Khan said. “It was immensely helpful … and allowed many Americans to get their medical care without having to come in person, so we could treat patients completely remotely.”
“The administration and HHS has put out a notice that they don’t intend to renew it any further,” Khan said, “so the federal public health emergency is going to be expiring May 11.”
Returning to pre-pandemic rules means people who were prescribed controlled medications via telehealth — such as stimulant medications for attention-deficit/hyperactivity disorder, benzodiazepines for anxiety, or medications for opioid use disorder, sleep or pain — will need one in-person medical examination to continue these prescriptions or start new ones.
The US Drug Enforcement Administration’s website has a general list of controlled substances, and an exhaustive list can be found here.
Patients will still be able to get prescriptions for non-controlled medications, such as antibiotics or birth control, via telehealth. The pre-pandemic rules also wouldn’t affect telehealth care by a practitioner who has already conducted an in-person examination of a patient.
To establish some flexibility in the telehealth framework moving forward, Khan said, the DEA has put forth proposals (PDF) that would allow telehealth practitioners to prescribe one 30-day supply of buprenorphine — a medication for opioid use disorder — or Schedule III-V non-narcotic controlled medications without doing an in-person examination first. A patient would have to do an in-person exam before the second prescription of either type of medication, according to those proposals.
But there’s no guarantee that will happen — public comment on the proposals was open through March; since then, the DEA has been considering comments before drafting final regulations.
“It is really important to start planning now,” Khan said. “For many medicines, it can be a risk to abruptly stop treatment.”
People who are on medications for opioid use disorder, ADHD or anxiety and don’t get an in-person exam between May 11 and the next time they need a prescription refill could experience withdrawal requiring a trip to the hospital, or negative effects on health, relationships, employment or academics, she added.
Here’s what else you should know about the changes and steps you should take, according to Khan.
This conversation has been lightly edited and condensed for clarity.
CNN: How should people prepare to ensure their prescription routine isn’t disrupted?
Khan: It’s important for patients who may be prescribed one of these types of medicines by a telemedicine physician or other practitioner to reach out to that practitioner to discuss this issue and make sure that they have a plan. And if it’s feasible to see that telemedicine physician in person, schedule that as soon as possible.
CNN: What if you can’t see your telehealth provider in person?
Khan: Let’s say a telemedicine physician practices completely remotely — then the patient would discuss with them what next steps would be.
In the proposed rule, the qualifying telemedicine referral may allow a patient to be seen by a local DEA-registered practitioner. So, for example, perhaps their primary care doctor or pediatrician — if they are DEA-registered — might be able to go through the qualifying telemedicine referral process so that they can see them in person and continue to be prescribed the medicine. Or patients can contact their health insurance provider to get a list of local referrals.
CNN: Are there any drawbacks to seeing general physicians or pediatricians for controlled medication prescriptions?
Khan: Some may say they aren’t going to prescribe certain medications, like psychiatric medications. Some may say they are comfortable with it, and some may say they will prescribe for a short period of time until you connect with a specialist. So there is variability.
CNN: Would the patient have to continue seeing the referral provider after that first in-person appointment?
Khan: In terms of what’s required at the federal level, if a patient has that one in-person exam with a provider through that qualifying telemedicine referral process, they wouldn’t necessarily have to see that provider again unless that’s part of their treatment plan that’s discussed.
With the qualifying telemedicine referral in the proposed rule, the way it’s written, it doesn’t necessarily have to be the referral practitioner prescribing the medicine; they just need to do the in-person exam. The referral practitioner can refer the patient back to the telemedicine doctor, who can prescribe the medicine.
The other factor that’s significant here is we discussed all the proposed rules and the status at the federal level, but there’s also the state level. States also have rules around controlled medicine prescribing, and they may not always align with federal law. Let’s say the DEA puts out their final rule, and there’s some flexibility — some states might adopt the older Ryan Haight Act language from the federal level, so they might actually be stricter than what we’ll be seeing at the federal level. When federal and state laws don’t align, providers generally have to follow whatever is stricter.
CNN: Will patients need to see their provider in person every time they need a prescription refill?
Khan: The DEA has indicated that the absolute requirement at the federal level is one in-person examination. Beyond that, it would be left to the discretion of whoever the patient is seeing.
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