Telehealth and virtual care models allow for fewer in-person contacts between patients and providers, reducing the risk that SARS-CoV-2 will spread. In some cases, they also enable a higher level of care and more frequent communication. As such, some governing bodies have temporarily changed certain regulations so that healthcare providers can do as much as possible to deliver high-quality care virtually. Some areas of care become more challenging in a virtual environment, but with the right support tools in place, these challenges can be mitigated.
In this blog, you’ll learn how these changes affect how online doctors can prescribe controlled substances.
Let’s get started.
The Telehealth boom: Patient safety and the impact of controlled substance prescribing by virtual doctors
While telehealth is not a new concept, its current use is unprecedented. There was a hundredfold increase in the use of telehealth by Medicare patients between early March and mid-April. According to an online poll of 1000 Americans, of those already using telehealth services, nearly half are likely to continue doing so post-crisis. However, a similar number of patients think that a telehealth visit is not as beneficial as an in-person visit.
CMS and the federal government have lifted many restrictions on the use of virtual care/telemedicine in order for physicians to deliver effective care through telehealth and improve patient satisfaction within the virtual environment. Many of these changes are centered around reimbursement and billings for telehealth services; as of March 1, physicians will be paid at the same rate for in-office visits and telehealth services by Medicare for all diagnoses. As well, physicians can reduce or waive Medicare patient cost-sharing for telehealth visits, virtual check-ins, e-visits, and remote monitoring services.
Not all of these changes are related to payment; new regulations have been developed by U.S Drug Enforcement Administration (DEA) surrounding online prescribing and Schedule II-IV controlled substances.
DEA flexibility on online prescribing for controlled substances: What you need to know
The Ryan Haight Act requires at least one in-person evaluation of a patient before an online doctor can prescribe a controlled substance. However, due to the ongoing pandemic, this requirement has been waived by the US Drug Enforcement Administration (DEA) for the duration of the time that COVID-19 is designated as a public health emergency.
DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:
- Telemedicine communication is performed using an audio-visual, real-time, two-way interactive communication system; and
- The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice; and
- The practitioner is acting in accordance with applicable Federal and State law.
The last point means that if a state does not permit online prescribing of controlled substances without an in-person evaluation, a practitioner is not allowed to do so, even with the new DEA flexibility.
The restrictions around online prescribing of controlled substances have been reduced. Now what?
It’s important to understand that virtual care will never be the same as in-person care. But health care providers, patients, and others in the health delivery network can adapt to the care environment by using new innovations and the right tools to increase patient safety and improve quality care.
The loosening of prescribing rules around schedule II-V drugs in the U.S. for virtual care adoption is welcome news for many, but prescribers should proceed with caution. As virtual care expands and more prescribing is done remotely, clinicians need to be even more vigilant about patient safety— especially when prescribing medications with a potential for abuse, such as opioids.
Watch out for the virtual opioid crisis: Choosing pain medications wisely
Prescription opioid addiction is a ubiquitous concern. According to the Centers for Disease Control and Prevention, more than 115 Americans die every day— one person every 12 minutes— from misuse of and addiction to opioids, heroin, and synthetic opioids.
Opioid prescriptions can pose an even greater risk if they are prescribed without knowing a patient’s pharmacogenomic results, medical history, and other medications they are taking.
It is more critical than ever to ensure that clinicians use available tools and techniques to support them in making the best choices when prescribing pain medications in order to reduce the risk to the patient and ensure they receive safe and effective treatment.
Pharmacogenetics is the study of how people respond differently to drug therapy based upon their genetic makeup. It is shown to play a role in how some patients respond to certain pain medications. In 2010, a review of studies on opioid use for chronic non-cancer pain found that over a quarter of participants discontinued use due to adverse effects or insufficient pain relief. Pharmacogenetic information could help reduce this by predicting when a particular treatment might not be suitable for a patient.
However, pharmacogenetics is only one of the many variables that affect how people react to a drug. Healthcare providers must also consider important variables such as kidney, liver functions, comorbidities, lifestyle factors, and the other drugs a patient is taking. For example, the use of CYP2D6 inhibitor medications at the same time as codeine may affect the pain relief achieved by a patient.
Manage the risk of opioid harm: Using the right tools and techniques to improve patient safety in online prescribing
How can the risk of opioid harm be managed?
One solution is a digital prescribing assistant which:
- automates medication optimization by incorporating all of a patient’s health variables, including pharmacogenetics, kidney/liver function, medical history, and other EHR-stored data points
- dynamically identifies personalized treatments, within a clinician’s workflow
- is interoperable and supportive of real-time virtual care solutions
- is evidence-based, using a comprehensive database of the most up-to-date research and guidelines from CPIC, PharmGKB, FDA PGx markers, and others.
An example is TreatGx©, the leading pharmacogenetics (PGx) integrated medication decision support system widely adopted in the market. It includes 14 Schedule II-V substances, 7 of which are opioids, in its condition-based treatment algorithms. These algorithms optimize and personalize medication treatment options for the individual. The condition-based software allows healthcare providers to identify medication treatment options, doses, and regimens to maximize patient safety and gives them the reassurance needed to make important prescribing decisions in a virtual care environment. Powered by the latest clinical evidence and guidelines, TreatGx© also includes other non-opioid medications that can be used for treatment of pain in those with substance use issues.
How can a PGx-integrated medication decision support system put patient safety first in a virtual environment?
Personalized pain management based on the patient’s CYP2D6 genotype could help optimize pain control, thereby increasing patient safety and decreasing the risk of adverse drug events. In a 2009 study, 80% of the patients who experienced adverse drug reactions to opioid analgesics had impaired CYP2D6 drug metabolism.
Using a PGx-integrated medication decision support system gives health practitioners the confidence to prescribe pain medications appropriately in a virtual care environment. A PGx integrated medication decision support system offers health practitioners automated support for critical prescribing decisions with all the clinically relevant patient data at their fingertips.
More importantly, medication decision support could help build a case for continuing to allow prescribers to virtually prescribe controlled substances to eligible patients after the pandemic subsides. A real-time virtual care system with PGx-integrated medication decision support represents an evidence-based, innovative approach to preventing adverse drug events and inappropriate prescribing, which increases patient safety and enhances patient care.
Conclusion
While telehealth is an exciting field that is already living up to its promise of widespread adoption, it is important to keep the quality of care as high as possible. When it comes to prescribing controlled substances, the risks are higher in a virtual care environment. With the right tools, like medication decision support tools such as TreatGx©, online doctors can feel confident about giving prescriptions- and patients can feel confident about taking them.
Over to you…
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