Since the COVID-19 Public Health Emergency (PHE) was declared in January, the use of telehealth has skyrocketed. This is in part because many restrictions on it have been lifted for the duration of the PHE in order to make healthcare services more accessible to patients while maintaining physical safe distance. Some of the temporarily waived restrictions include Drug Enforcement Agency limitations on the use of telemedicine to prescribe controlled substances.
Normally, the DEA requires that any prescription of a controlled substance be issued by a DEA-registered practitioner who has conducted at least one in-person medical evaluation of the patient, with a few exceptions. These include the patient being located in and treated by a DEA-registered hospital or clinic or the patient being in the physical presence of another DEA-registered practitioner during the evaluation.
One provider who has experienced the challenges of prescribing controlled substances remotely with these restrictions in place is Sara Gibson, MD. She is the medical director and psychiatrist for Little Colorado Behavioral Health Centers in St. Johns and Springerville, AZ, towns of about 3,500 people and 1,900 people, respectively. Both are located in Apache County, a large, very rural, sparsely populated region taking up more than half of the state’s eastern border.
Gibson, based in Flagstaff, AZ, has been treating patients in Apache County via telemedicine since 1996. She cites one of the populations most affected by the DEA telemedicine restrictions: people with opioid use disorder (OUD) who live in underserved areas. One of the best studied and most efficacious treatments for OUD is buprenorphine, a Schedule III controlled substance. But prescribing it requires a very specialized provider who’s taken a special training.
“Finding those providers and getting them to the places they need to be in order to treat this population is what telehealth is uniquely suited for,” Gibson says. But, according to the National Council for Behavioral Health, mental health clinics in many states don’t meet the narrow requirements for DEA registration. And that has been the case in Arizona. And the alternatives to using telehealth are problematic. “Most of our providers in northern Arizona are a two-and-a-half- to three-hour drive away from the patient,” says Gibson. “That’s six hours in an eight-hour day, and those are hours that we need to be seeing people, not driving. Are we going to throw everyone on a bus and drive them to Flagstaff and have them see a provider and miss a day or two of work? Or pull a kid out of school for a whole day or two days? It just wouldn’t happen; patients wouldn’t come in.”
Gibson says there have been proposals to get around the distance barrier by having patients wait for providers to come to them on rotation, every two to four weeks or so. “If somebody is using heroin, and they are requesting help, we need to intervene right now, before the overdose happens. We don’t have the luxury of waiting,” she says. “What if it’s a pregnant woman who has an opioid use disorder? That is a medical emergency.” (The issue, she explains, is that if the woman goes into withdrawal by running out of opiates or attempting to quit cold-turkey, serious harm to the fetus can result. And if the woman keeps using, the newborn will suffer Neonatal Abstinence Syndrome.) “We need to get that woman and her developing baby into treatment immediately. And that involves the prescribing and use of controlled substances. Telehealth is ideal because it can be there immediately.”
But the DEA restrictions imposed significant barriers on telemedicine prescribing before the PHE. “We faced the challenge of telling patients they have to go to another county or another city for care, or go inpatient,” Gibson says. “In the case of Apache County, they would have to go to ChangePoint Psychiatric Hospital, which is in the next county over. A pregnant woman using substances may have kids at home, so she may not be able to go into the hospital and may choose not to seek care. It’s a huge barrier to care.” Gibson points out that pregnant women with OUD also might avoid crucial prenatal care, knowing they’ll be drug-screened at their OB/GYN office and told they have to go to a faraway hospital.
“We were able to figure out some workarounds where patients would be in their primary care provider’s office and we would video in,” Gibson says. Most PCPs do have DEA registrations, but not the special buprenorphine waiver, so their patients could be seen in their offices by a remote buprenorphine-waivered practitioner. But, Gibson says, that creates an unnecessary, duplicative medical service. “The PCPs are really overburdened, and they have to be in the physical presence of the patient, so how do you bill for two providers seeing the patient in the same session?”
During the PHE, the DEA has allowed real-time, two-way telemedicine sessions with both audio and video to substitute for the required, in-person initial session with a patient. And, for patients with OUD, it has allowed buprenorphine to be prescribed to new patients on the basis of a telephone call alone. “That has been vital,” Gibson says. “Not only do we have an infectious disease pandemic, we have a mental health epidemic. Part of that, which we are seeing in our clinics and all over the country, is an increase in overdoses, both suicides and unintentional, and a huge increase in the amount of substance abuse that’s going on in terms of alcohol and opioids, specifically heroin. People are home, and they’re stressed, and they’re using substances to cope, and they’re dying.”
During the PHE, the behavioral health clinics in the county are closed, so patients are seen at home via telemedicine or telephone. Gibson views this as a plus. “Even when the clinics reopen, there’s a big population that may not make it in because it’s a barrier for them to get to the clinic—or to be seen seeking services at the clinic. Our no-show rate with telephone is near zero. In person, it’s about 60 percent,” she says, citing the huge size of the county with only two community behavioral health clinics and the fact that people often don’t have gas money or transportation.
Stay tuned for the second half of this blog, next week, focusing on a different patient population.
