Telemedicine schedule II medication law changes

Started by Psychferlyfe3000
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Psychferlyfe3000

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Hi all,

Do we know for sure yet what the laws will be with regards to telemedicine prescriptions of schedule II substances starting in 2026? I am not sure how many stimulant-taking patients I should be taking on leading up to the potential need to see 50% of them in person. Thanks!
 
Psychferlyfe3000 said:
Hi all,

Do we know for sure yet what the laws will be with regards to telemedicine prescriptions of schedule II substances starting in 2026? I am not sure how many stimulant-taking patients I should be taking on leading up to the potential need to see 50% of them in person. Thanks!
Click to expand...
No
 
I've long since required that first and majority of ensuing visits are to be in person.
I've had a few patients come my way where their originating Psychiatrist or ARNP also said to find a more local person - but usually prompted by lack of that state's license.
 
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Sushirolls said:
I've long since required that first and majority of ensuing visits are to be in person.
I've had a few patients come my way where their originating Psychiatrist or ARNP also said to find a more local person - but usually prompted by lack of that state's license.
Click to expand...
I've really enjoyed keeping the first visit virtual. It makes it much easier to screen and find a population I would be comfortable being alone in a room with. Also makes it less distracting to be flipping through all the intake packets / discharge summaries in front of them.

Since attrition usually happens before the third appointment, this leads to fewer canceled in person visits and a more consolidated schedule for my in-person days.

Nothing worse than riding the metro into work to find that the in-person visit was cancelled or turned into virtual or a no-show.
 
If the argument for kids is that there aren't enough providers, that's either not a good enough argument or it's an argument to lift the requirement entirely. There are certainly rural areas in the US where it is harder to get a general mental health appointment for an adult than it is for a child psych appointment in Boston or NYC.
 
comp1 said:
If the argument for kids is that there aren't enough providers, that's either not a good enough argument or it's an argument to lift the requirement entirely. There are certainly rural areas in the US where it is harder to get a general mental health appointment for an adult than it is for a child psych appointment in Boston or NYC.
Click to expand...

There's still a fair number of pediatricians/family medicine doctors prescribing stimulants.
 
littlefred said:
Isn't that why Ryan Haight was enacted?
He was 18 (around the age you are hoping an exception is for) when he unfortunately died.

One would argue those are the most vulnerable patients.
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No, his OD was from opiates. He was 18 though. I'm suggesting that 17 and under on stimulants for adhd could have been exempted especially if treated by board-certified CAP.
 
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Stagg737 said:
Because childhood and adolescence are when the most pervasive and problematic effects of ADHD typically occur?
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Yeah but they’re saying they want an exception for kids under 18 for the telemedicine law. Honestly if you’re not seeing them in person virtual appointments for most <11-12yo you might as well not even have the kid there. This is a population that actually needs vitals monitoring regularly and the population I have to do something about growth suppression most frequently. Also why would it matter if they’re being treated by psychiatry vs PCP, why should there be an exception for psychiatry for this population? Pediatricians treat the vast majority of ADHD and it’s a basic part of pediatrics training at this point.

There’s also a lot of other things you’re not thinking of for kids that virtual appointments have the potential to completely miss and that could impact an “ADHD” diagnosis. I can’t get a great assessment of social interaction/eye contact/back and forth playing a game often esp with younger kids, they often barely want to interact virtual esp if they’re distracted by stuff in their house. I can’t be sure I’m getting a good trauma or abuse screen esp if any concern for this comes up since I can never be sure the parent isn’t just off screen or listening through a door. If I have scales I have kids fill them out with me or go over the answers together without their parents there…electronic ones always have the potential for parents looking at them. I can go on.

I also agree that if the argument is “care shortage” or something that there are wayyy more pediatricians who are comfortable treating ADHD than internal medicine/family medicine doctors managing many psychiatric conditions (including ADHD haha).
 
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calvnandhobbs68 said:
Yeah but they’re saying they want an exception for kids under 18 for the telemedicine law. Honestly if you’re not seeing them in person virtual appointments for most <11-12yo you might as well not even have the kid there. This is a population that actually needs vitals monitoring regularly and the population I have to do something about growth suppression most frequently. Also why would it matter if they’re being treated by psychiatry vs PCP, why should there be an exception for psychiatry for this population? Pediatricians treat the vast majority of ADHD and it’s a basic part of pediatrics training at this point.

There’s also a lot of other things you’re not thinking of for kids that virtual appointments have the potential to completely miss and that could impact an “ADHD” diagnosis. I can’t get a great assessment of social interaction/eye contact/back and forth playing a game often esp with younger kids, they often barely want to interact virtual esp if they’re distracted by stuff in their house. I can’t be sure I’m getting a good trauma or abuse screen esp if any concern for this comes up since I can never be sure the parent isn’t just off screen or listening through a door. If I have scales I have kids fill them out with me or go over the answers together without their parents there…electronic ones always have the potential for parents looking at them. I can go on.

I also agree that if the argument is “care shortage” or something that there are wayyy more pediatricians who are comfortable treating ADHD than internal medicine/family medicine doctors managing many psychiatric conditions (including ADHD haha).
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I was more just addressing the point on growth suppression which I think is pretty overblown, but the rest of this I agree completely with.
 
VA Hopeful Dr said:
Not a shock as there are way more of us than there are of y'all.
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Its also a factor of higher propensity to prescribe if this, admittedly outdated, research article continues to hold true, which I would assume:
pubmed.ncbi.nlm.nih.gov

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions - PubMed

PCPs appear to be sole physician managers for care of 4 in 10 US children with ADHD, and one-third with mental health conditions overall. Efforts supporting mental health in primary care will reach a substantial portion of children receiving mental health services.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

"PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or α-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%)."
 
oliversacks4thewin said:
Its also a factor of higher propensity to prescribe if this, admittedly outdated, research article continues to hold true, which I would assume:
pubmed.ncbi.nlm.nih.gov

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions - PubMed

PCPs appear to be sole physician managers for care of 4 in 10 US children with ADHD, and one-third with mental health conditions overall. Efforts supporting mental health in primary care will reach a substantial portion of children receiving mental health services.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

"PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or α-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%)."
Click to expand...
Why would psychiatrists only prescribe medication to 61% of children with ADHD? For that matter, why would only 74% of us do that?
 
VA Hopeful Dr said:
Why would psychiatrists only prescribe medication to 61% of children with ADHD? For that matter, why would only 74% of us do that?
Click to expand...
Lots of reasons, a few off the top of my head:
1) Evidence does not support the ADHD diagnosis, but you carry it forward at the first few visit(s). I know you've been in practice long enough to recognize that a diagnosis put into a chart does not always equal that person having had that diagnosis.
2) Pt/family prefer to use behavioral/school interventions prior to starting medications
3) I'm not sure if it was discussed in this article, but starting a NRI instead of a psychostimulant/a2a is indicated for a significant number of children/adolescents.
 
Merovinge said:
3) I'm not sure if it was discussed in this article, but starting a NRI instead of a psychostimulant/a2a is indicated for a significant number of children/adolescents.
Click to expand...
I think this is probably the biggest difference. Every CAP I know is very comfortable prescribing Strattera and most are comfortable with Qelbree. Most non-psychiatrists I know haven't even heard of Qelbree and couldn't tell you anything about dosing Strattera.
 
Stagg737 said:
I think this is probably the biggest difference. Every CAP I know is very comfortable prescribing Strattera and most are comfortable with Qelbree. Most non-psychiatrists I know haven't even heard of Qelbree and couldn't tell you anything about dosing Strattera.
Click to expand...
No shortage of samples in my area. I have gotten several new children either on Qelbree or who had trialed it over the past year.
 
Stagg737 said:
I think this is probably the biggest difference. Every CAP I know is very comfortable prescribing Strattera and most are comfortable with Qelbree. Most non-psychiatrists I know haven't even heard of Qelbree and couldn't tell you anything about dosing Strattera.
Click to expand...
I believe general peds sees more young kids and thus has (rightly so) become more comfortable with Tenex/Intuniv. That said, Strattera and Qelbree are relatively easy meds to use and have few to no adverse effects that are not seen with psychostimulants. They do tend to require multiple titration states which might bog down PCPs but so do alpha-2-agonists and stimulants.

I guess AACAP needs to be putting on some NRI training for AAP. Particularly in kids with first degree relatives with (true) bipolar disorder or schizophrenia, I would really like to see more non-stimulant usage first. I've seen so many kids become psychotic/manic with stimulants and it's absolutely harrowing for the kid and the family.
 
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