Last month, I took on five new patients who were already prescribed stimulants. I had not met any of them in person before. Each came to me with a diagnosis, an active Schedule II prescription, and a chart note from a telehealth visit that I cannot fully piece together. My role now seems to be continuing these prescriptions. I am concerned about the handoff, and I doubt anyone decided who would keep track of these patients over time.
This is now becoming the less discussed side of ADHD prescribing. Most public conversations focus on the numbers: more prescriptions, more diagnoses, and more stimulants being used. But that view misses something evolving. Prescribing did not just increase during the pandemic; it changed in nature.
Researchers looked at new prescriptions, not refills, for behavioral health medications in the United States from 2018 to 2022. They found something concerning. Using interrupted time-series analysis, they showed that new prescriptions for stimulant and nonstimulant ADHD medications rose sharply during the pandemic. In contrast, trends in new prescriptions for antidepressants and benzodiazepines did not significantly change.
I think most would agree that the rise of telehealth drove the change. Early in the pandemic, the Drug Enforcement Administration relaxed the requirement for an in-person visit before prescribing controlled substances. Clinicians could diagnose ADHD and start stimulant treatment entirely by video. Among Medicaid and Children’s Health Insurance Program (CHIP) patients, starting stimulants through telehealth increased sharply for both children and adults.
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I want to be clear about something here. I believe that ADHD is real, and often underdiagnosed. The in-person requirement was an obstacle for many. Telehealth helped people in rural areas, those without child care, and those who could not take time off work.
However, meeting a need and meeting it well are not the same thing. Prescription counts alone cannot show the difference. A rising line in the data could mean an adult finally received an accurate diagnosis after years of struggle, or it could mean a rushed video visit that ended with a Schedule II prescription but no background information, no rating scales, and no follow-up plan.
ADHD guidelines clearly state that diagnosis needs proof of problems in more than one setting and information from several sources. Medication management also requires ongoing checks of symptoms, growth in children, heart health, and side effects.
What concerns me most is that a stimulant prescription is not a one-time event. It should be an ongoing relationship. The stakes are not just bureaucratic. A nationwide Swedish study found that each additional year of ADHD medication use was associated with roughly a 4 percent increase in cardiovascular risk. When prescriptions increase through a system focused on access without a plan for ongoing care, patients may have an active controlled-substance prescription but no clear provider overseeing the risks.
This problem would be easier to handle if the rules were stable, but they are not. The broad telehealth prescribing flexibilities for controlled substances remain temporary. They have continued through a series of extensions, with the fourth extending them through December 31, 2026. Each extension buys more time, but each new deadline raises questions about how patients will get their prescriptions. I am not necessarily saying that we prescribed too many stimulants. I am saying that we need to know who is keeping track of what we prescribed.
Prescribing data cannot establish the size of the monitoring gap or what role telehealth played, but the question is hard to ignore. Proper monitoring should treat each new stimulant prescription as the start of an ongoing relationship, with a specific clinician formally designated and responsible for ongoing follow-up before the prescription is given. When care changes hands, the handoff should include the diagnostic rationale, treatment response, adverse effects, and recent monitoring, with a clinician explicitly accepting responsibility for follow-up.
This would involve creating registries and tracking long-term outcomes so new prescription trends match data on continued use, medication discontinuation, and side effects. It would also require a stable, thoughtful telehealth prescribing policy, which does not yet exist.
The surge in prescriptions has already happened, and we are now dealing with its effects in offices where our first visit often feels like a handoff. At this point, I feel the pivotal question is not whether we should have prescribed these medications, but whether anyone was ethically responsible for monitoring them. Too often in these handoffs, the answer is unclear.
Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.
