As we mentioned earlier, the DEA has shared some new proposed rules around telehealth scheduled substance prescribing. You can learn more about these rules here. The DEA has opened up the rules for comment until the end of March. You can comment on the rules here.
We wanted to share the comments we submitted on the rules with you:
Dear Administrator Milgram, Principal Deputy Administrator Milione, and DEA Representatives,
As a psychiatrist, clinical informaticist, and director of a hybrid telehealth/in-person behavioral health practice, I appreciate the work the DEA and Secretary Millgram are conducting to address the needs of our patients. I have several recommendations backed by recent research that I would like to offer:
Recommendation 1:
Lift in-person requirements and instead require documentation in a clearly trackable log consistent with current log proposals.
Justification: Studies have demonstrated no difference in rates of abuse and treatment retention for the highest risk populations receiving telemedicine as compared to in-person care. Therefore, I urge reconsideration of the requirement for in-person visits or referrals. Instead, a logging system should be developed that evaluates potential clinical abuses, including patient identity confirmation, visit length, type of visit, specific provider(s) seen, selected treatment, justification for treatment, and PDMP review.
Recommendation 2:
Psychostimulants should receive the same flexibilities as buprenorphine and schedule 3-5 medications.
Justification: Stimulant medications are comparatively of less abuse risk than the schedule 4 benzodiazepines. ADHD patients in need of stimulant management tend to have much more difficulty seeking out care, and telehealth management has been found to be more helpful for these patients. A 30-day prescription allowance during which time patients can seek out referrals from their PCP or attend in-person visits with the prescribing provider would ensure that patient care is not delayed, and those who are already on medications are able to continue their treatment without suspension.
Recommendation 3:
Clarifying “qualifying telemedicine referral”
Justification: To institute an “electronic communication” standard would restrict referrals to providers within large groups or health systems. Patients receiving care at private, small, and mid-size group practices stand to be negatively impacted if within EHR communication or electronic direct messaging protocols are required.
Recommendation 4:
Providing national licensing opportunities OR limiting provider licensing requirements to no more than 1 state.
Justification: Obtaining multiple state licenses can be time-consuming and expensive for providers, discouraging them from offering telehealth services. A national registration option would allow providers to offer telehealth services across state lines without obtaining multiple licenses, which would increase access to care for patients and reduce the burden on providers.
Recommendation 5:
Maintain written log requirements in the current proposed rule.
Justification: Allowing providers who do not use electronic records to utilize written logs under 1304.03(i) would ensure we do not unnecessarily expedite the retirement of many and limit the strain on an already burdened behavioral health care system. I urge the DEA to reconsider the requirement for in-person visits or referrals for conditions such as opioid addiction and ADHD management. I also recommend providing clarity around the DEA’s recommendations for “qualifying telemedicine referral,” allowing for national licensing, and allowing providers who do not use electronic records to utilize written logs. These changes would allow patients to receive the care they need, while reducing unnecessary burden and restrictions on providers.
Thank you for your attention to this matter.
Sincerely,
Mina Boazak, MD, MMCi, Animo Sano Psychiatry
References:
Jones CM, Shoff C, Hodges K, Blanco C, Losby JL, Ling SM, Compton WM. Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2022 Aug 31:e222284. doi: 10.1001/jamapsychiatry.2022.2284. Online ahead of print. PMID: 36044198.
Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55).
