Online pharmacy startups have pledged to make it faster and easier than ever to get needed medications. But a high-profile series of setbacks is calling into question whether the realities of drug prescribing are clashing with those promises.
In recent weeks, major brick-and-mortar pharmacy chains have stopped filling prescriptions for Adderall and other controlled stimulants sent in by some telehealth providers including from Cerebral, an online mental health company that has come under fire for its prescribing practices and its online advertisements touting an easy way to get treated for ADHD. On Monday, the Wall Street Journal reported that Truepill — Cerebral’s “preferred pharmacy partner,” which completes online orders for drugs prescribed by Cerebral’s clinicians — would also stop filling those stimulant prescriptions out of an “abundance of caution.”
Experts say the unfolding debate about online prescribing of ADHD drugs points to the broader, unanswered questions about how to best balance the best of what telehealth can offer — easier access to necessary care for more people — with its risks and the rapidly changing regulations that govern how patients are diagnosed and treated virtually.
“There’s a real problem. There are people who have chronic medical conditions who we know need access to prescription medications, and there’s an important problem to be solved,” said Aaron Neinstein, vice president of digital health at UCSF Health and associate professor in the University of California, San Francisco’s endocrinology department. But newer companies that bill themselves as sources for speedy medication delivery are “completely losing the nuance of a health care interaction and the relationship between a doctor and a patient,” he said. “It’s about so much more than the prescription.”
The pauses, even if temporary, could have ripple effects on the fledgling digital pharmacy industry, which partners with telehealth companies and other providers to fulfill prescriptions that patients receive online and often just after a video consultation, including for controlled substances.
Prescription medications have become easier to obtain online during the pandemic, when regulatory officials waived requirements for in-person examination before certain types of drugs are prescribed. Truepill is still fulfilling Schedule III and V drug prescriptions from licensed clinicians. But the company is suspending delivery for Schedule II drugs like Adderall, which the Drug Enforcement Administration classifies as having a high level of potential abuse. In the case of stimulants, misuse has been linked to adverse effects, like heart failure or paranoia.
A Truepill spokesperson told STAT said it would use the pause to “evaluate next steps” for fulfillment of Schedule II substances, which account for less than 1% of its total prescription volume. But it could also give the company time to establish more rigorous guidelines around filling orders and flagging potentially suspicious prescriptions, University of Michigan clinical assistant professor Erik Gordon said.
“We want to avoid an opioid crisis part two,” Gordon said. Widespread overprescribing of painkillers fueled early stages of the opioid epidemic. “Fulfilling prescriptions remotely has obvious benefits, and obvious potential for abuse. The trick is going to be to keep as many of the benefits as we can.”
Gordon said the risk of inappropriate prescriptions was likely minimal, given a lack of data suggesting that virtual prescribing meaningfully drives up deaths. He added that online prescription and delivery could help patients avoid having to wait months for an in-person appointment or brick-and-mortar supply chain issues, Gordon said. Some patients are also forced to visit multiple pharmacies before pharmacists will fill prescriptions, especially if they have multiple providers — a factor that some prescription drug monitoring systems flag as an indicator of potential misuse.
“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,” said Neinstein. Despite what he sees as temporary setbacks for digital prescribing, Neinstein said he’s “still optimistic that telehealth is one of the potential solutions.”
In-person prescribing comes with its own share of risk, said Neinstein. “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? 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,” he said, adding that large pharmacy companies are investing in analytics that could pick up aberrations in prescribing.
Craig Surman, an associate professor of psychiatry at Harvard Medical School, said that while online prescribing platforms could help patients with ADHD, particularly those who live in areas with a dearth of providers, he also warned that we know relatively little so far about telehealth’s impacts on ADHD drug prescribing, dose maintenance, or patient outcomes.
In behavioral health, particularly, there are concerns that providers examining patients for the first time in short, video-based appointments may not be able to detect important diagnostic cues like body language, given the range of symptoms certain conditions can present with. Some experts have also said they’re worried about whether such quick appointments let providers get in-depth enough to decide on the best course of treatment, including non-drug options.
“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 Surman, who is also the co-chair of the Professional Advisory Board of Children and Adults with ADHD.
There are also concerns about the continuity of care at telehealth startups that patients don’t necessarily see as a source of long-term care. ADHD drug doses often need to be adjusted due to side effects or patient response. Again, that issue also arises in in-person care — but if a patient’s telehealth visits and prescriptions aren’t connected to their health care more broadly, it makes follow-up much more difficult.
In the meantime, patients who rely on online pharmacies for faster access to medication may find their care disrupted. While Truepill said it was working with Cerebral to ensure that prescriptions didn’t fall through the cracks, a spokesperson did not clarify for STAT what exactly what that process entailed.
That disruption, too, could carry risks. As Surman warned, “unpredictability is not something you want to add to the life of a person with ADHD.”