DEA and Telemedicine Prescribing

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Psych19

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Advocates rush to Congress, White House to extend telehealth prescribing for two years, after DEA's plans leaked

The Drug Enforcement Administration is reaching the final steps of its proposed rulemaking process for the prescription of controlled substances via telehealth, but its plans have been le | The Drug Enforcement Administration was expected to publish its proposed telehealth prescribing rule in...
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Would be curious to hear predictions on how this plays out.
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The scheduling system seems really arbitrary. Benzos, ketamine and codeine are good, but methylphenidate is not. The national database check is hilarious. Is this being written with no physician input at all?
 
comp1 said:
The scheduling system seems really arbitrary. Benzos, ketamine and codeine are good, but methylphenidate is not. The national database check is hilarious. Is this being written with no physician input at all?
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There has been commentary on some forums they participate in (e.g. conferences in different metro locations and online presentations)
 
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Current 100% telehealth for controlled substances is private equity’s wet dream. ADHD is being diagnosed after 5 minute appointments. You can’t get stimulants some places because of the over diagnosis/prescribing. Other controlled meds are problematic too, benzos, ketamine. It’s not that it can’t be done responsibly, but the for profit companies are doing what they do. I personally think these restrictions are the only way to reign in the irresponsible behaviors.
 
I suspect the force of lobbying against is going to sink this proposal just like it sank the last set of rules the DEA proposed. The fact that you have bipartisan support in Congress to keep things relatively open is something the DEA is going to have a hard time ignoring.

DEA is a law enforcement agency. There is a reason your local police department is not the body in charge of issuing construction permits. Their basic mission is at direct cross purposes with the balancing act that a sensible regulator needs here.
 
It does strike me that the proposed requirement for 50% of controlled sub prescriptions to be issued in-person rather than tele would make a 100% telehealth practice and the ability to prescribe any controlled substances incompatible.
 
nexus73 said:
Current 100% telehealth for controlled substances is private equity’s wet dream. ADHD is being diagnosed after 5 minute appointments. You can’t get stimulants some places because of the over diagnosis/prescribing. Other controlled meds are problematic too, benzos, ketamine. It’s not that it can’t be done responsibly, but the for profit companies are doing what they do. I personally think these restrictions are the only way to reign in the irresponsible behaviors.
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Strongly agree. I am fine if someone is seeing their patients in-person annually, checking prescription drug monitoring every refill, and have appropriate vital signs/clinical practice around this. But doing all remote visits with patients you have never seen is a deadly process. I already have a patient who nearly died following using 3 different online services to fill stims + benzos (who struggles with both stimulant use disorder and sed/hypo use disorder). Listening to this young woman's dad's frustration that nothing can be done to stop his daughter from continuing to lookup a new NP to get these meds and watching her die is heartbreaking.
 
Merovinge said:
I am fine if someone is seeing their patients in-person annually, checking prescription drug monitoring every refill, and have appropriate vital signs/clinical practice around this. But doing all remote visits with patients you have never seen is a deadly process.
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I can appreciate this perspective. I agree there are real problems that can arise from 100% telehealth.

For the last few years I've been working with a large academic group that leaned heavily into telemedicine after the pandemic. They were doing it even before the pandemic and just expanded this service with the additional flexibilities. We work with a large and underserved rural population spread out over huge geographic areas. Most counties have very few or no psychiatrists. These are generally undesirable places to live or work. It would be difficult to persuade a psychiatrist or even a psychiatric NP to move to these areas or establish an in-person practice there. So telehealth is the best that can be done, or these patients simply won't get to see a psychiatry specialist and the already overwhelmed PCPs will be left trying to do the best they can. I think there are real ethical issues with systematically excluding these patients from treatment because they live in the wrong part of the country and can't access in-person specialist treatment. I guess you could say that telehealth can still be used, we just can't prescribe any controlled substances -- but then there are ethical pitfalls of arbitrarily limiting certain treatments available to patients.

The last set of proposed rules had a provision where a PCP could see the patient for an in person visit and work collaboratively with a telehealth psychiatry provider. This was a least a nod in the direction of this underserved population.
 
Anyone manage to get the actual document? I would be interested to read it directly rather than through news outlets.

Either way, what a cluster.

Yeah it would be a bummer for anyone who wants to do 100% telehealth, but it would probably go some distance to have a verifiable physical office of some sort where you actually see patients in person. (Wouldn't even have to be all of your CS patients.) If the intent is really to curtail PE online pill mills, then one potential step would be making it harder for them to scale.
 
I see some people on psychology today based out of some distant state but list a clinic address in my town. They are 100% telehealth so will never see anyone in person, and I’m sure will never see anyone at the “local office” and would doubt if the office address listed is even set up to see patients in person. I assume they are doing this to establish the appearance of local presence to bypass possible restrictions on remote prescribing of controlled substances.
 
FlowRate said:
Anyone manage to get the actual document? I would be interested to read it directly rather than through news outlets.

Either way, what a cluster.

Yeah it would be a bummer for anyone who wants to do 100% telehealth, but it would probably go some distance to have a verifiable physical office of some sort where you actually see patients in person. (Wouldn't even have to be all of your CS patients.) If the intent is really to curtail PE online pill mills, then one potential step would be making it harder for them to scale.
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I'd frankly rather they just impose hard CS patient caps per prescriber like they used to do with Suboxone, to be honest.
 
nexus73 said:
I see some people on psychology today based out of some distant state but list a clinic address in my town. They are 100% telehealth so will never see anyone in person, and I’m sure will never see anyone at the “local office” and would doubt if the office address listed is even set up to see patients in person. I assume they are doing this to establish the appearance of local presence to bypass possible restrictions on remote prescribing of controlled substances.
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I mean, you are required to list an address in order to obtain a DEA license in that state. Insurance requires a DEA license in every state in order to be an in-network provider. Seems that everyone who practices in multiple states needs a similar setup.
 
ObsequiousAplomb said:
I mean, you are required to list an address in order to obtain a DEA license in that state. Insurance requires a DEA license in every state in order to be an in-network provider. Seems that everyone who practices in multiple states needs a similar setup.
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Not quite. Insurance requirements differ but many do not require a DEA if you write a letter saying you do not prescribe CS in that state and have a written plan in place for patients requiring CS (PCP or psych referral, ED etc).
 
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clausewitz2 said:
I'd frankly rather they just impose hard CS patient caps per prescriber like they used to do with Suboxone, to be honest.
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Preach! Suboxone is a life saving medication (literally), other notable life saving meds that are schedule II include methadone. And we know about all the redtape around prescribing that one for OUD.

Just wanted to post this to highlight the irony in this. FEDS be like... " Life saving med... lets put restrictions!@" (granted some have been relaxed like the patient cap). Then on the other hand other medications that people can live without are allowed to be handed left and right and the FEDS don't bat an eye.
 
clausewitz2 said:
I'd frankly rather they just impose hard CS patient caps per prescriber like they used to do with Suboxone, to be honest.
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I like that idea. You could set it to something ridiculous which essentially no legit full-time outpatient doc will hit but which will prevent people from just doing 100% adderall x 5 minute appointments. Like 1500. (We have some docs in our system with 1500 patients on their panel but obviously not all of those patients are on CS.)
 
littlefred said:
Preach! Suboxone is a life saving medication (literally), other notable life saving meds that are schedule II include methadone. And we know about all the redtape around prescribing that one for OUD.

Just wanted to post this to highlight the irony in this. FEDS be like... " Life saving med... lets put restrictions!@" (granted some have been relaxed like the patient cap). Then on the other hand other medications that people can live without are allowed to be handed left and right and the FEDS don't bat an eye.
Click to expand...

Eh but suboxone has always been an outlier here even among opioids, it's all just political stuff. A surgery resident could write 30 10mg oxy q6 PRN without batting an eye but had to wade through the whole MAT training just to put one patient on suboxone.
 
calvnandhobbs68 said:
Eh but suboxone has always been an outlier here even among opioids, it's all just political stuff. A surgery resident could write 30 10mg oxy q6 PRN without batting an eye but had to wade through the whole MAT training just to put one patient on suboxone.
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Right. They can also RX methadone for pain and no problem. But for OUD... hold on to your horses... 72 hour rule this and that. Agree it's all political.

The war on drugs.
 
Psych19 said:
I can appreciate this perspective. I agree there are real problems that can arise from 100% telehealth.

For the last few years I've been working with a large academic group that leaned heavily into telemedicine after the pandemic. They were doing it even before the pandemic and just expanded this service with the additional flexibilities. We work with a large and underserved rural population spread out over huge geographic areas. Most counties have very few or no psychiatrists. These are generally undesirable places to live or work. It would be difficult to persuade a psychiatrist or even a psychiatric NP to move to these areas or establish an in-person practice there. So telehealth is the best that can be done, or these patients simply won't get to see a psychiatry specialist and the already overwhelmed PCPs will be left trying to do the best they can. I think there are real ethical issues with systematically excluding these patients from treatment because they live in the wrong part of the country and can't access in-person specialist treatment. I guess you could say that telehealth can still be used, we just can't prescribe any controlled substances -- but then there are ethical pitfalls of arbitrarily limiting certain treatments available to patients.

The last set of proposed rules had a provision where a PCP could see the patient for an in person visit and work collaboratively with a telehealth psychiatry provider. This was a least a nod in the direction of this underserved population.
Click to expand...
I understand this better than most as I worked in a rural community for 3 years (I also happen to be from a semirural town growing up for 18 years). Like it or not, the compact you are making if you choose to live in a place that is several hours away from regular medical care is one of commute/driving. I found most of our patients were not bothered at all by 2 hour drives to the nearest city with some specialty medical services, they do it, their friends do it, etc. I don't think coming in 1 day/year is overly burdensome if they want a controlled substance. Is there some low SES person who simply cant swing it, I'm sure, but I'd rather some of those folks lose out on a few controlled substances than let private equity run all over the importance of prescription medications.

If they do come up with a good way to work with PCPs who can convey vitals/physical exam, do an occasional utox, etc, that's fine with me. That system is going to be complex to setup and needs to be done in a way in which the PCP is actually attending to the patient. I'm all for allowing the broadest access of care without it coming at the lives of people literally dying to controlled substances.
 
Psych19 said:
I can appreciate this perspective. I agree there are real problems that can arise from 100% telehealth.

For the last few years I've been working with a large academic group that leaned heavily into telemedicine after the pandemic. They were doing it even before the pandemic and just expanded this service with the additional flexibilities. We work with a large and underserved rural population spread out over huge geographic areas. Most counties have very few or no psychiatrists. These are generally undesirable places to live or work. It would be difficult to persuade a psychiatrist or even a psychiatric NP to move to these areas or establish an in-person practice there. So telehealth is the best that can be done, or these patients simply won't get to see a psychiatry specialist and the already overwhelmed PCPs will be left trying to do the best they can. I think there are real ethical issues with systematically excluding these patients from treatment because they live in the wrong part of the country and can't access in-person specialist treatment. I guess you could say that telehealth can still be used, we just can't prescribe any controlled substances -- but then there are ethical pitfalls of arbitrarily limiting certain treatments available to patients.

The last set of proposed rules had a provision where a PCP could see the patient for an in person visit and work collaboratively with a telehealth psychiatry provider. This was a least a nod in the direction of this underserved population.
Click to expand...
As some one who is practicing rural. Loves rural. Rural is a scape goat excuse. People who live rural will always have less of XYZ. Not a valid reason IMO to make rural communities out to be victims. People can move. Throw a stone, you hit an urban area. I used to drink this medical/political talking point as a resident, student, etc, but no, not now. This rural less won't ever change, and it is okay that it doesn't. The less of everything is what makes rural best - especially less people. America is fundamentally a personal responsibility, freedom loving country, and these tenants require people/patients to pursue their needs - not play the victim card.

Current mal-aligned solutions of increasing ARNPs to fill the treatment 'gaps' is the wrong solution at best, or at worst a 'crisis' being fully taken advantage of.
 
Last edited:
In some ways, Release The Kraken.
Fully embrace personal responsibility.
Drop the DEA.
Let people get what ever they want from the pharmacies.
We are legalizing cannabis. We aren't doing anything sincere with borders/shipping to stop fentanyl or meth or heroin.
We are watching degree creep, scope of expansion run rampant with midlevels.
Fighting over DEA scheduling is just another battle in a lost war.
/Pessimism.
 
Sushirolls said:
In some ways, Release The Kraken.
Fully embrace personal responsibility.
Drop the DEA.
Let people get what ever they want from the pharmacies.
We are legalizing cannabis. We aren't doing anything sincere with borders/shipping to stop fentanyl or meth or heroin.
We are watching degree creep, scope of expansion run rampant with midlevels.
Fighting over DEA scheduling is just another battle in a lost war.
/Pessimism.
Click to expand...
I would love to smoke cigars with you and shoot targets. Amen
 
Ironspy said:
Not quite. Insurance requirements differ but many do not require a DEA if you write a letter saying you do not prescribe CS in that state and have a written plan in place for patients requiring CS (PCP or psych referral, ED etc).
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have you done that successfully? I got shut down by all the major insurers and told to re-apply when I had a DEA in that state. They seemed to be expecting me to have a specific clinician that I was planning on referring people to, I couldn't just say "their PCP or another psychiatrist"
 
ObsequiousAplomb said:
have you done that successfully? I got shut down by all the major insurers and told to re-apply when I had a DEA in that state. They seemed to be expecting me to have a specific clinician that I was planning on referring people to, I couldn't just say "their PCP or another psychiatrist"
Click to expand...
PM me for details but yes
 
Most countries, even developed ones, manage just fine without any Adderall whatsoever and with much fewer controlled substances overall.
 
Pessimism has hit me too as i wade through all these ADHD evals, people blatantly being prescribed stimulants when they have addiction issues/absence of ADHD, pill mills, online ketamine popups, weed clinics, etc. Mental health mcdonalds is what I call it. Drive up, get your ****ty food, get a nice quick fill, and feel like garbage in the long run. Mental health mcdonalds.

Lately every other patient claims to have ADHD. I wish we would get rid of these 100% telehealth places though, most of them are ridiculous.
 
littlefred said:
Right?

I wish there was some kind of a list. I think some countries just do with methylphenidate products.

France doesn't allow amphetamines, Japan too I think?
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I don’t think Japan allows any stimulants? I had a patient a while back spend 2 years there for college who took Wellbutrin.
 
Maybe if the French stopped smoking like Americans generally have, they'd start reaching for amphetamines.

I've never smoked myself, but I've heard it gives you a little brain boost.
 
annoyedpsychiatrist said:
Pessimism has hit me too as i wade through all these ADHD evals, people blatantly being prescribed stimulants when they have addiction issues/absence of ADHD, pill mills, online ketamine popups, weed clinics, etc. Mental health mcdonalds is what I call it. Drive up, get your ****ty food, get a nice quick fill, and feel like garbage in the long run. Mental health mcdonalds.

Lately every other patient claims to have ADHD. I wish we would get rid of these 100% telehealth places though, most of them are ridiculous.
Click to expand...
Our whole healthcare system is one large McDonalds.. not much better in general medicine from what I hear with patients seeking hormones, GLP1s, etc. More medications are not going to solve the health and mental health issues in our country
 
Merovinge said:
Strongly agree. I am fine if someone is seeing their patients in-person annually, checking prescription drug monitoring every refill, and have appropriate vital signs/clinical practice around this. But doing all remote visits with patients you have never seen is a deadly process. I already have a patient who nearly died following using 3 different online services to fill stims + benzos (who struggles with both stimulant use disorder and sed/hypo use disorder). Listening to this young woman's dad's frustration that nothing can be done to stop his daughter from continuing to lookup a new NP to get these meds and watching her die is heartbreaking.
Click to expand...
Maybe an exception needs to be carved out for suboxone because patients being able to get it remotely increases access to the drug and saves lives. People would die if restrictions are placed on suboxone.
 
ObsequiousAplomb said:
I mean, you are required to list an address in order to obtain a DEA license in that state. Insurance requires a DEA license in every state in order to be an in-network provider. Seems that everyone who practices in multiple states needs a similar setup.
Click to expand...
This isn't true. I work for a telehealth company that does not prescribe any controlled substances. I see patients in 7 states, and I'm credentialed with multiple insurance plans in every state I practice.

Generally speaking, not prescribing any controlled substances via telehealth is nice because it avoids most of the drug seeking patients and the pitfalls that can come with prescribing controlled substances through telehealth (i.e. Cerebral et al). On the other hand, at times, it limits your options to treat a patient. There are those patients who would legitimately benefit from a short-term Benzo, a z-drug, DORAs, Lyrica, and gabapentin, which is controlled in several states.

And DEA licenses are over $700 a pop, per state. The DEA should create a national PDMP database and a single national DEA license that allows one to prescribe in any given state once you have met state requirements.
 
ObsequiousAplomb said:
have you done that successfully? I got shut down by all the major insurers and told to re-apply when I had a DEA in that state. They seemed to be expecting me to have a specific clinician that I was planning on referring people to, I couldn't just say "their PCP or another psychiatrist"
Click to expand...
I think my company has to have a designated provider in every state we operate with a DEA license for insurance credentialing purposes, even though we do not prescribe controlled substances.
 
annoyedpsychiatrist said:
Pessimism has hit me too as i wade through all these ADHD evals, people blatantly being prescribed stimulants when they have addiction issues/absence of ADHD, pill mills, online ketamine popups, weed clinics, etc. Mental health mcdonalds is what I call it. Drive up, get your ****ty food, get a nice quick fill, and feel like garbage in the long run. Mental health mcdonalds.

Lately every other patient claims to have ADHD. I wish we would get rid of these 100% telehealth places though, most of them are ridiculous.
Click to expand...
Here's my admittedly anecdotal, n=1 experience. I have a patient with severe TRD. Referred him to a psychiatrist who does iv ketamine and Spravado. He did a few IV treatments but couldn't afford to keep paying for then. He gets oral ketamine shipped to him, not sure where he gets it from. He's not drug seeking. He states the oral ketamine is life changing. So it's not always bad...
 
psycho-matic said:
Here's my admittedly anecdotal, n=1 experience. I have a patient with severe TRD. Referred him to a psychiatrist who does iv ketamine and Spravado. He did a few IV treatments but couldn't afford to keep paying for then. He gets oral ketamine shipped to him, not sure where he gets it from. He's not drug seeking. He states the oral ketamine is life changing. So it's not always bad...
Click to expand...
The problem is nothing is bad until it is bad and it is a fact that some medications come with significant increased risks.
 
psycho-matic said:
Maybe an exception needs to be carved out for suboxone because patients being able to get it remotely increases access to the drug and saves lives. People would die if restrictions are placed on suboxone.
Click to expand...
I could get behind having lax laws with getting it started but I still think they need to get in-person within a year even if they live quite rural. However the partnership is worked out. Someone with an OUD needs as much point of contact with service as possible, although I would never withhold the start of suboxone due to logistics.
 
psycho-matic said:
This isn't true. I work for a telehealth company that does not prescribe any controlled substances. I see patients in 7 states, and I'm credentialed with multiple insurance plans in every state I practice.

Generally speaking, not prescribing any controlled substances via telehealth is nice because it avoids most of the drug seeking patients and the pitfalls that can come with prescribing controlled substances through telehealth (i.e. Cerebral et al). On the other hand, at times, it limits your options to treat a patient. There are those patients who would legitimately benefit from a short-term Benzo, a z-drug, DORAs, Lyrica, and gabapentin, which is controlled in several states.

And DEA licenses are over $700 a pop, per state. The DEA should create a national PDMP database and a single national DEA license that allows one to prescribe in any given state once you have met state requirements.
Click to expand...
psycho-matic said:
I think my company has to have a designated provider in every state we operate with a DEA license for insurance credentialing purposes, even though we do not prescribe controlled substances.
Click to expand...
You're essentially saying opposite things here, and ultimately agreeing with what I said. I said that insurance requires DEA for credentialing, you're saying that another provider seems to satisfy this for you. You're also saying what Ironspy was saying. With a specific person to refer someone to, you can get around this. Ideally, based on my response from insurance companies, this is essentially an NP being supervised by a physician in the other state. Aren't you an NP?
 
ObsequiousAplomb said:
You're essentially saying opposite things here, and ultimately agreeing with what I said. I said that insurance requires DEA for credentialing, you're saying that another provider seems to satisfy this for you. You're also saying what Ironspy was saying. With a specific person to refer someone to, you can get around this. Ideally, based on my response from insurance companies, this is essentially an NP being supervised by a physician in the other state. Aren't you an NP?
Click to expand...
I *think* that's how they get around it, but I don't know that conclusively. I reached that conclusion because my company contacted me once and asked if I would be the designated agent for a certain state because I hold a DEA license in said state. They said it had something to do with insurance. I politely declined. However, I don't recall all the details because that was a couple of years ago. All I know for sure is that I don't have a DEA license in 4 of the 7 states where I practice and I am credentialed with all major insurance companies in those states. Yes, I'm an NP, but does this have to do with supervision? I don't require supervision in the state in question.
 
ObsequiousAplomb said:
You're essentially saying opposite things here, and ultimately agreeing with what I said. I said that insurance requires DEA for credentialing, you're saying that another provider seems to satisfy this for you. You're also saying what Ironspy was saying. With a specific person to refer someone to, you can get around this. Ideally, based on my response from insurance companies, this is essentially an NP being supervised by a physician in the other state. Aren't you an NP?
Click to expand...
I wrote a letter saying I do not prescribe controlled substances in those states with a plan if patients require controlled substances —ED for emergencies, refer to pcp, transfer care to another psychiatrist etc. I did not name a specific person
 
littlefred said:
It's paywalled. From what I read, they outsourced to China... but how?
I thought you had to be in a US Territory and be licensed in the state where the patient is in order to do telemedicine?
Click to expand...

Basically the company leadership all relocated to China after the feds cracked down and has an US "subsidiary" that's like some empty office space "The address listed on Done’s website points to a private mailbox in what is currently an empty storefront in San Francisco."

The workaround of course is that they just have a bunch of NP "contractors" and they have a few US pharmacy partners that will ship their Adderall to people's houses since all the mainstream pharmacies won't touch their scripts anymore.
 
calvnandhobbs68 said:
Basically the company leadership all relocated to China after the feds cracked down and has an US "subsidiary" that's like some empty office space "The address listed on Done’s website points to a private mailbox in what is currently an empty storefront in San Francisco."

The workaround of course is that they just have a bunch of NP "contractors" and they have a few US pharmacy partners that will ship their Adderall to people's houses since all the mainstream pharmacies won't touch their scripts anymore.
Click to expand...
How can they not be going after these pharmacies? That's almost more absurd than the NPs...
 
I don't see a date it's set to expire. Anyone know?
 
Does anyone have any more insight into whether it will be permanently extended? I am wondering how many purely telehealth folks it is safe to take on.
 
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