Telehealth prescribing ups SUD risk among some ADHD patients

Though telehealth prescribing of controlled substances for attention-deficit/hyperactivity (ADHD) disorder treatment did not increase the risk of substance use disorder (SUD) in most cases, adults between the ages of 26 and 34 were at higher risk of SUD when starting treatment via telehealth, new research reveals.

Published in Health Affairs, the study aimed to evaluate whether starting ADHD medications via telehealth during the COVID-19 pandemic was associated with a greater risk for newly diagnosed SUDs compared with in-person medication initiation. During the pandemic, the DEA waived a requirement of the Ryan Haight Act stating that healthcare practitioners providing virtual prescriptions for controlled substances must have previously conducted at least one in-person medical evaluation of the patient.

For the study, researchers from the University of Michigan and Massachusetts General Hospital conducted a cross-sectional analysis using data from the 2020–22 Merative MarketScan Commercial and Multi-State Medicaid Databases. The study sample included 77,153 patients, ages 12-64, who initiated ADHD stimulant medication therapy between Jan. 1 and Dec. 31, 2021. The primary outcome was a new SUD diagnosis within one year of starting the medication.

The researchers found beginning stimulant medication therapy via telehealth was not an independent risk factor for new SUDs overall. The prevalence of new SUDs was higher in the telehealth group (3.7% of 21,229 patients) than the in-person group (3.2% of 55,924 patients); however, that higher risk was eliminated when the analysis accounted for the fact that people using telehealth to start stimulant therapy were also more likely to have mental health conditions.

"These findings suggest that telehealth is an important means of initiating stimulant therapy among patients with non-ADHD psychiatric comorbidities for whom telehealth has been efficacious and acceptable," the researchers wrote.

However, there was a subgroup of patients who remained at higher risk of developing an SUD even after accounting for mental health conditions: adults between the ages of 26 and 34 who started their ADHD stimulant medications through telehealth.

"Telehealth can be an essential way to access care, but this study suggests an ongoing need to balance such access with protecting safety, through guidelines for providers about screening and follow-up," study lead author Joanne Constantin, PhD, a postdoctoral research fellow at the Susan B. Meister Child Health Evaluation and Research Center within the University of Michigan Medical School, said in a press release.

The finding is especially significant as the aforementioned pandemic-era prescribing flexibility is set to expire at the end of the year. The expiration date was extended by one year from Dec. 31, 2024, following pushback from telehealth stakeholders about the DEA's proposal to limit the flexibility.

In 2023, the DEA released a proposed rule that would allow healthcare practitioners to provide telehealth prescriptions for Schedule III-V controlled medications without a prior in-person exam; however, the in-person exam requirement would be reinstated for Schedule II controlled substances, including popular ADHD medications Adderall and Ritalin.

The agency received nearly 40,000 comments on the rule, and in listening sessions held in September 2023, it heard comments that largely called for permanently extending the telehealth prescribing flexibility.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.