The U.S. is facing a significant mental health crisis that has united us in our efforts to make positive changes across the health care ecosystem for those in need of care. As health care providers and experienced clinicians, we hope our joint dedication to addressing barriers to care and expanding digital services to those experiencing mental health challenges can make a lasting impact and start to improve health outcomes.
To that, the Drug Enforcement Agency (DEA) recently received more than 38,000 public comments on its proposed telemedicine rules. Subsequently, the Agency, jointly with the Department of Health and Human Services, released a year-long extension of its allowance for telehealth providers to continue to offer controlled substances through telehealth.
While we appreciate this extension, we believe there is already adequate information to allow the DEA to move forward with permanent policy – including responsible guardrails against abuse – as it’s crucial to expanding access to care and ensuring patients receive adequate, safe support throughout their health journeys.
How we got here
With our deep experience treating patients with mental health needs and oversight of more than 1,600 mental health professionals who treat hundreds of thousands of Americans each year, we have an important perspective to share on the regulation of prescribing controlled substances through telehealth.
It has been more than 14 years since Congress, recognizing that telehealth is an important part of expanding access to mental health services, gave the DEA authority to create a separate process for approving the prescribing of controlled substances through telehealth. That process is called a “special registration” and is meant for providers who would apply and, if approved, be permitted to use telehealth to prescribe certain controlled substances. This was meant as an additional guardrail to the existing DEA registration to protect against illicit diversion that may occur online.
After avoiding using this authority for more than a decade, the DEA granted flexibility for prescribing via telehealth during the COVID-19 pandemic to avoid lapses in care. Providers were allowed to prescribe controlled medications via telemedicine even when an in-person medical evaluation wasn’t conducted for the patient. This included stimulants and other medications approved and clinically appropriate for the treatment of mental health and substance use disorder conditions.
Eventually, the Agency published a draft regulation on how prescribing via telehealth could continue after the pandemic. The Agency, still not using the authority given to them to create a special registration, instead created a regulation that caused an outcry.
The issue with access
The outcry is a result of the growing mental health crisis across the U.S. The number of adults with any mental illness increased from 39.8 million to 51.5 million, a nearly 30 percent increase over 11 years, which only continued to worsen during the pandemic. In parallel, the U.S. is experiencing a provider shortage. Only 28 percent of people in the U.S. live in an area with enough psychiatrists and other mental health professionals available to meet the needs of the population.
Other barriers to care include high costs, social or cultural stigma, lack of awareness, fear of unfamiliar care, health system complexities, and distrust of providers. Each barrier prevents access to quality, safe care that many Americans are in need of today.
As a result of untreated mental health conditions, people become more prone to physical illnesses, experience unnecessary disability and inappropriate incarceration, suffer from substance abuse, and have poorer quality of life, amongst many other challenges. The economic cost of untreated mental illness is also more than 100 billion dollars each year in the United States.
The path forward
Fortunately, the DEA has committed to listening to patients, providers, families, and others impacted by mental illness and re-work the regulatory proposal to better balance safe prescribing with access to care. This is not an easy job, but we believe there is a clear solution: going back to Congress’s intent for a special registration should be the basis for the road forward.
Modifying the normal DEA registration with enhanced guardrails can achieve the twin goals of access and safety. We have presented the Agency with a variety of guardrails that can be implemented alongside a special registration, including requiring regular virtual patient visits, ensuring only providers trained in the prescribing of controlled substances can offer them, and limiting the total number of controlled substance prescriptions.
Finally, we believe our approach takes care not to create additional and undue burdens on the practice of medicine while requiring reasonable policies to maximize the effectiveness of a special registration. These include streamlining the normal DEA registration and the enhanced telehealth registration, ensuring that additional barriers to care across state lines are not created as part of this process, finding an appropriate balance for reporting to the DEA, and providing clarity to pharmacies on their roles and responsibilities when filling telemedicine prescriptions.
For many Americans, telehealth is their only viable path to treatment, be it from provider shortages, stigma, or the many other barriers to care. We call on others to join in our vision for a reasonable path forward to continue mental health treatment for patients in need.
Our recommendations in detail can be found here. We welcome all to join us in the pursuit of safe, accountable mental health treatment through telehealth.
Georgia Gaveras is a physician executive.
