Mia Kohn

Patients like Anthony Kurz ’27 rely on drug prescriptions via telemedicine to receive their medication. However, a policy allowing for telehealth prescriptions expires in December 2024, and some patients may soon lose access to their drugs. 

Under the COVID-19 pandemic policy, patients can be prescribed Schedule II to V drugs via telemedicine. This flexible policy will expire in December 2024, cutting off some telehealth patients from their current prescriptions. School of Medicine and Yale New Haven Health signed a letter led by the Alliance for Connected Care, which calls on the White House and Congress to extend the flexible policy by another two years. 

Kurz has been taking methylphenidate for his ADHD since he was young. Methylphenidate is a Schedule II drug, meaning it is a substance accepted for medical use with a high potential for abuse. 

“When I don’t have the drug, I can’t do work. It is like there is a 50-pound weight on your body and you just don’t have the ability to do things,” Kurz said.  

After trying to find care at Yale, Kurz settled with a new psychiatrist at home via telemedicine. 

The psychiatrist, based in rural Pennsylvania, is about one hour and a half from his house in Scranton. Telemedicine was the only way to meet with his psychiatrist in a regular manner that would allow him to receive his medications every month. 

In specific situations, providers require physicians and patients to be located in the same state for telehealth appointments. Kurz occasionally had to take a five-hour train ride to get to the border of Pennsylvania in order to join the telemedicine appointment and be prescribed his medication for the month. 

“It was worth it because it is important to speak to my specific psychiatrist who will prescribe me the right medication,” Kurz said.

But the telehealth prescription may end across the country in December. Ateev Mehrotra, the chair of Brown’s Department of Health Services, Policy & Practice, is concerned about patients like Kurz who may be cut off from their medication when the policy expires. 

Mehrotra testified before the U.S. Senate Committee on Finance, Subcommittee on Health about the need for telemedicine permanency in November 2023. According to him, physicians are already grappling with how to approach care with their telemedicine patients. 

Physicians currently treating patients via telemedicine do not know if they should schedule future appointments in early 2025 or advise patients to find an in-person provider. Unsure about how much medication to prescribe and whether to account for potential lapses, physicians are under pressure to plan ahead with an uncertain future, especially when the decision could be lifesaving or life threatening. 

“I have a patient on buprenorphine right now,” which is used for the treatment of opioid use disorder. “They’re very stable, but I’ve never seen them in person. They say, ‘Doc, can I fill up my medication? What are we going to do in January? Am I going to have to get another provider because you’re 500 miles away from me?’ I don’t have an answer for that patient right now,” Mehrotra said. “I just hope that everything’s going to be fine, but what if it’s not?” 

COVID-era policy set to expire

Kurz was able to be prescribed his medications via telemedicine because of a federal policy adopted during the COVID-19 pandemic. Before then, under the Ryan Haight Online Pharmacy Consumer Protection Act, a psychiatrist had to conduct an initial in-person medical evaluation before being able to prescribe Schedule II-V drugs via telemedicine encounters. 

This act was passed in response to the death of Ryan Haight, who died after overdosing on opioids he was prescribed over the telephone. Since the pandemic, the Drug Enforcement Administration (DEA) has waived that requirement, allowing patients to receive prescriptions via video-audio-regulated telemedicine appointments without an initial in-person appointment. 

However, this policy is set to expire in December 2024. 

Earlier this month, the School of Medicine and the Yale New Haven Health system joined nearly 350 nationwide healthcare stakeholders to call on the White House and Congress to intervene to ensure that patients currently prescribed medicine via telemedicine can continue to receive care. 

The stakeholders, led by the Alliance for Connected Care, are also asking the DEA for a “two-year extension of [the current] prescribing flexibilities to allow for time to achieve a balance between patient access and diversion control.”

The University spokesperson did not comment on why the medical school signed the letter. 

Balancing benefits and drawbacks

According to John Krystal, the chair of psychiatry at the School of Medicine and the physician-in-chief of psychiatry at Yale New Haven Hospital, both telemedicine and face-to-face clinical contact have their benefits and drawbacks. 

Schedule II drugs, which include fentanyl, hydromorphone, meperidine, methadone, morphine, oxycodone, dextroamphetamine, methylphenidate, methamphetamine, pentobarbital and secobarbital are the drugs that present the greatest risks among those currently prescribed via telemedicine without an initial in-person appointment. 

Some Schedule II drugs, Krystal wrote, are opioids used primarily for pain control that have a risk of lethal overdose. Some are stimulants used to treat ADHD, narcolepsy and antidepressant-resistant symptoms of depression, among other conditions. When misused, these drugs may cause depression, psychosis, impaired judgment and impulsive maladaptive behavior.

The last two medications on the list are sedative and anxiolytic with risk for lethal overdose and potentially life-threatening withdrawal symptoms. Because of this, Krystal wrote, they are now rarely prescribed.

Krystal wrote that physicians get more direct information face-to-face and can perform “hands-on” physical examinations in person. However, telemedicine makes it possible for patients who are far from their physicians, have mobility or transportation challenges, live in rural areas or face other barriers to receive safe treatment with scheduled medications. 

Medical evaluations are important to evaluate the impact of the medication on blood pressure, heart rate and other outcomes, there are alternative ways to get these measurements such as “visiting nurses, other local physicians, or perhaps even via emerging automated technologies,” according to Krystal. 

Krystal emphasized that “closing down telemedicine options would increase rather than decrease risks for these patients.” 

Mehrotra, who testified in support of telehealth prescriptions in the Senate, agrees that the expiration of telemedicine prescription flexibility poses more risks for patients. 

Buprenorphine, an opioid used for the treatment of opioid use disorder, testosterone used for gender-affirming care and stimulants for ADHD have been the focus of the conversation concerning the benefits and drawbacks of the in-person requirement for scheduled drug prescriptions before the pandemic, Mehrotra said. 

He added that in the cases of opioid use disorder treatment and gender-affirming care, many patients live in communities where “there is no one around them who is willing to prescribe [the appropriate] medication or are comfortable with this treatment.” Telemedicine “offers a lifeline for those patients,” as they get care they would not otherwise have.  

“[Physicians] need to meet patients where they are,” Mehrotra said. 

The drawbacks of telemedicine prescription are most pronounced in ADHD stimulant prescription, according to Mehrotra. 

Research has shown that stimulants are often not abused by people who were prescribed the medication but rather by their friends. There is a lot of diversion of stimulants but “we don’t really know whether diversion is more likely with telemedicine prescribing versus in-person,” Mehrotra said. 

Another significant concern is that companies that prescribe drugs only via telehealth may care only about growth and prescribe inappropriate drugs. 

“There are many patients in the United States who will be cut off from their medications, and in particular the treatment of opioid use disorder buprenorphine, worries me most,” Mehrotra said. “That means they could lapse and then go back to using, say, heroin and die.”

The CDC reports that in 2021, 37 percent of adults used telemedicine.