At the Citizens Health hospital in Colby, Kansas, pandemic-driven rule changes let doctors prescribe chronic pain and mental health medications over virtual appointments.
That gave hundreds of patients in northwest Kansas access to life-changing drugs.
“Everybody struggles with access to mental health care,” said Jenny Niblock, a nurse practitioner at the medical center. “Rural Kansas struggles even worse.”
Before the pandemic, the only way to get a prescription for a federally regulated drug was through an in-person doctor's visit.
When the federal government declared the COVID-19 pandemic a national public health emergency, it let clinicians prescribe drugs remotely to reduce in-person appointments and avoid further spreading the virus.
The resulting telemedicine appointments meant a patient could get tightly controlled drugs without leaving home.
Patients liked the change. So did physicians, although fears linger that telehealth can give drug abusers more access to prescription medications.
But it has brought along some bad actors — companies and providers that have come under federal investigation over suspicion they prescribed medications without thoroughly diagnosing and monitoring their patients.
Now the U.S. Drug Enforcement Administration is looking to strike a balance between increasingly popular telehealth care and efforts to curb the abuse of drug prescriptions.
Proposed rules that the Biden administration released in February suggested restoring some restrictions on telemedicine prescriptions when the public health emergency ended on May 11.
Pushback from medical groups including the American Academy of Physicians and the American Hospital Association led to a six-month extension that allows providers to continue prescribing drugs without an in-person visit. But it still leaves medical providers unsure how to prepare themselves and their patients for the long-term.
For drugs such as Vicodin, OxyContin and Adderall, the proposed regulations would require in-person visits before prescribing those medications. Telehealth appointments would then be cleared for refills.
Citizens Health is a critical access hospital and the only way it can offer some specialty care services, including psychiatry, is through telemedicine. The sole psychiatrist doesn’t work in the hospital.
“If that psychiatrist can no longer prescribe the medicine because there’s never an opportunity to see that patient face to face,” Niblock said, “we’re gonna lose access to mental health services.”
That means people would have to wait months for an appointment or drive for several hours to a larger hospital if regulations returned and drug prescriptions required in-person appointments.
“What we see all the time is people just won’t go,” she said. “So then they have no care.”
Other medications — including buprenorphine, used to treat opioid dependence by stemming cravings — would be available for one-month prescriptions over telehealth. But they’d require an in-person appointment for a refill.
Kansas ranked second in the nation for the largest percentage increase of drug overdoses in 2021.
Substance use disorder treatment is another field short on providers, said Shane Hudson, the president and CEO of CKF Addiction Treatment in Salina, Kansas. He said some people would have trouble getting to a clinic to renew their prescriptions after the first month.
“It’s easy to say for some people that, like, ‘Well, that's no problem,’” Hudson said.
But he said living in remote areas and on limited incomes can put some forms of treatment out of reach without telehealth.
CKF helps Kansans across the state through a network of medical providers that use telehealth to help connect people with treatment. That includes medication-assisted treatment that CKF provides to about 200 patients.
Hudson said he understands why there might be some hesitancy around the flexibility of prescribing all controlled substances through virtual appointments.
“That’s a valid fear,” Hudson said. “But that doesn’t speak for all of us.”
The easing of rules during the pandemic attracted some mental health startup companies. Cerebral Medical Group and Done Global Inc. both took to social media offering quick attention-deficit/hyperactivity disorder (ADHD) diagnoses and prescriptions for Adderall and Xanax. Both companies are under federal investigation for alleged overprescribing.
“It really stems from the fact that right now, while I think it’s a very legitimate concern, that we have to limit inappropriate prescribing … we don’t see evidence that that’s a major issue right now,” said Dr. Ateev Mehrotra, professor of health care policy and medicine at Harvard Medical School.
Mehrotra said the DEA’s proposed restrictions take the more traditional criminal justice stance with controlled substance prescriptions. While oversight for bad actors is needed, he said, there also is the public health approach to remove barriers to care.
“We also need to maintain access for as many people as possible,” Mehrotra said.
Hudson said rules can curb abuse of telehealth prescriptions. But he said blanket policies hurt addiction treatment centers like his trying to reach as many patients as possible.
A 30-day comment period on the Biden administration’s proposed rules drew more than 38,000 responses.
That led to the federal administration’s recent announcement that it will extend the remote prescribing flexibility for another six months. Patients that have an established telemedicine relationship with a provider by November 11, 2023, will have a one-year grace period before having to follow any new telehealth regulations.
The delay gives provider Jenny Niblock in northwest Kansas a temporary moment of relief.
“In rural Kansas, we always used to say, like, ‘we lived another day,’” Niblock said. “So we bought ourselves six more months.”
Samantha Horton reports on health for the Kansas News Service. You can follow her on Twitter @SamHorton5.
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