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May 5, 2022

Are telehealth startups overprescribing Adderall?

Daily Briefing

    Several large U.S. pharmacies have delayed or blocked prescriptions of Adderall and other stimulants from telehealth startups amid concerns about overprescribing—leading health experts to voice concerns about how such setbacks could affect the online prescription industry, as well as telehealth more broadly.

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    Pharmacies delay or block prescriptions from telehealth startups

    Throughout the pandemic, telehealth use has grown significantly, particularly for mental health issues, and with it, so have prescriptions for attention-deficit hyperactivity disorder (ADHD) treatments, such as Adderall. According to data from Iqvia Holdings, prescriptions of Adderall reached 41.4 million in 2021, up 10.4% from 2020.

    Now, some pharmacies are concerned that clinicians at Done Health and Cerebral, two telehealth startups, are writing too many prescriptions for Adderall and other stimulants, the Wall Street Journal reports. The Drug Enforcement Administration considers these drugs Schedule 2 controlled substances, which also includes cocaine, OxycContin, and Vicodin, due to their "high potential for abuse, with use potentially leading to severe psychological or physical dependence."

    In fact, some NPs at both Done and Cerebral have reported feeling pressure to prescribe Adderall and other stimulants despite believing the companies' evaluations, which are 30 minutes, do not give them enough time to properly diagnose ADHD, the Journal reports. However, both companies have said they encourage their providers to use their best clinical judgement and evidence-based best practices when making prescription decisions.

    Recently, some of the largest U.S. pharmacies, including Walmart, CVS Health, and Walgreens Boots Alliance, have reported delaying or blocking prescriptions of Adderall from clinicians at Done and Cerebral.

    Similarly, Truepill, an online pharmacy company that partners with Cerebral, last week said it is temporarily halting its prescriptions for Schedule 2 controlled substances, including Adderall and other ADHD medications, "out of an abundance of caution." During the pause, the company said it will "evaluate next steps" on how to fulfill these controlled substances, which make up less than 1% of its total prescription volume.

    In response, Cerebral has asked its clinicians to stop prescribing Adderall and said it will work with Truepill "to ensure a smooth transition for impacted clients and prevent a disruption in the client’s prescribed, evidence-backed course of treatment."

    What this could mean for online prescriptions

    According to STAT News, these pauses in Adderall prescriptions, even if temporary, could significantly impact the emerging digital pharmacy industry, as well as telehealth overall.

    Newer companies that present themselves as sources of quick medication access are "completely losing the nuance of a health care interaction and the relationship between a doctor and a patient," said Aaron Neinstein, vice president of digital health at UCSF Health and associate professor in the department of endocrinology at the University of California, San Francisco. "It's about so much more than the prescription."

    Other health experts have also expressed concerns about whether providers will be able to identify important diagnostic cues, such as body language, and decide on a best course of treatment in the short, video-based appointments offered by telehealth companies.

    "There's a lot of concern among my colleagues that a new paradigm, a new way of doing evaluations and treatments, may not be grounded in the established sort of methods that people have basically developed over years of practice," said Craig Surman, an associate professor of psychiatry at Harvard Medical School and co-chair of the Professional Advisory Board of Children and Adults with ADHD.

    Surman also said there is relatively little data on how telehealth could impact ADHD drug prescriptions, dose maintenance, or patient outcomes. Patients with ADHD who use telehealth startups may also have problems with continuity of care, particularly if their medication needs to be adjusted.

    However, other health experts say they believe online prescriptions could still be beneficial for patients, particularly if companies develop more rigorous guidelines for filling prescriptions and flagging any potentially suspicious orders.

    "We want to avoid an opioid crisis part two," said Erik Gordon, a clinical assistant professor at the University of Michigan. "Fulfilling prescriptions remotely has obvious benefits, and obvious potential for abuse. The trick is going to be to keep as many benefits as we can."

    According to Gordon, in-person prescribing also comes with a similar risk of inappropriate prescriptions. "There are clinics and doctors who will perpetrate fraud everywhere. Is it possible that telehealth allows those types of people to do so on a larger scale?" he said. "Probably, but is that reason to not make it an option for more affordable, more convenient access to care for the 99%-plus of doctors and patients for whom it's used properly."

    "The health care system is truly failing to meet so many people out there who don’t have easy access to high quality, affordable care," Neinstein said. And despite these current setbacks with online prescriptions, he said he is "still optimistic that telehealth is one of the potential solutions." (Ravindranath, STAT News, 5/4; Winkler/Nassauer, Wall Street Journal, 4/27; Winkler, Wall Street Journal, 5/2; Winkler, Wall Street Journal, 5/4)

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