Controlled substances became a little less controlled during the pandemic. That benefited both patients (for their health) and telehealth startups (to make money).
Some potentially addictive medications — like buprenorphine and Adderall — are now far more available online to patients because of regulatory changes. Given the scarcity of qualified doctors to treat some of the behavioral health conditions associated with these drugs, like opioid use disorder or attention-deficit/hyperactivity disorder, doctors’ new ability to prescribe online or, in some cases, by telephone is a huge change. But easier access to the drugs has upsides and downsides, since they’re often dispensed without accompanying therapy that improves the odds of a patient’s success.
Pre-pandemic, patients sometimes traveled several hours for addiction care, said Emily Behar, director of clinical operations for Ophelia, a New York startup serving people with opioid addictions. Or patients might be struggling with multiple jobs or a lack of child care. Such obstacles made sustaining care fraught.
“How do you reach those people?” she asked.
Mariia Symchych Navrotska, Dreamstime
The COVID-19 pandemic spurred greater access to telehealth.
It’s a question preoccupying much of the behavioral health sector, complicated by the reality that most patients with opioid use disorder aren’t in treatment, said Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration.
Increased access to telehealth has started to provide an answer. Behar, the startup executive, says its patients can see expert providers at their convenience. Missed appointments are dropping, say many in the industry.
The startup has secured solid funding — nearly $68 million, according to Crunchbase, an industry database — but addiction specialists and other prescribers of controlled substances online are a mixed group. Some are nonprofits; others are large startups attracting scrutiny from the news media and law enforcement for allegedly sloppy prescription practices.
The influx of new providers is attributable to loosened requirements born of pandemic-era necessity. To help patients get access to care while maintaining physical distance, the Drug Enforcement Administration and SAMHSA waived restrictions on telehealth for controlled substances.
But whether those changes will endure is uncertain. The federal government is working piecemeal to codify new rules for prescribing controlled substances, in light of the health care system’s pandemic experience.
On Dec. 13, SAMHSA issued a proposal to codify telehealth regulations on opioid treatment programs — but that affects only part of the sector. Left unaddressed — at least until the DEA issues rules — is the process for individual providers to register to prescribe buprenorphine. The new rules “get us at least a little bit closer to where we need to go,” said Sunny Levine, a telehealth and behavioral health lawyer at the D.C.-based firm Foley & Lardner.
Congress also tweaked rules around buprenorphine, doing away with a long-standing policy to cap the number of patients each provider can prescribe to. Ultimately, however, the DEA is the main regulatory domino yet to fall for telehealth providers.
Americans’ mental health became collateral damage in the country’s fight against the COVID-19 virus—a more conspicuous physical enemy, perhaps, than anxiety or depression. At its peak over the last year and a half, more than 40% of adults reported anxiety or depression symptoms—four times the pre-pandemic rate.
But even in the decade before the emergence of the coronavirus, Americans were becoming more anxious and depressed. According to 2018 data collected by Blue Cross Blue Shield, major depression was the second most impactful health condition for commercially insured Americans, second only to high blood pressure. Between 2008 and 2018, anxiety became more prevalent across nearly all demographic subgroups, suggesting serious deficiencies in both cultural attitudes toward mental health, and access to the health care systems meant to protect an individual's overall wellbeing.
Social isolation, worry over economic stability and physical health, grief, fear, and uncertainty about the future are just some of the factors exacerbating depression and anxiety symptoms for many Americans. With the increasing prevalence of these behavioral health concerns across the population, the U.S. is also experiencing a shortage of mental health professionals to meet the rising demand.
According to a 2020 report by the Kaiser Family Foundation, more than 119 million Americans live in regions designated as mental health professional shortage areas, or HPSAs. Just over 25% of the need for mental health professionals is being met nationally.
Telehealth services are one emergent adaptation with staying power beyond the scope of the pandemic that can address this critical need at a more affordable cost. In a 2021 analysis, McKinsey found that telehealth utilization, across all medical services, increased 38 times from the pre-pandemic baseline. Of 23 medical specialities, psychiatry has the highest telehealth adoption rate with 50% of visits between April 2020 and February 2021 conducted virtually.
CirrusMD conducted a physician-led study to better understand how telemental health services can affect depression and anxiety outcomes. Study participants had access to behavioral health care via CirrusMD's telehealth platform beginning in June 2020 and were not required to self-diagnose as having behavioral health issues beforehand. The study was conducted over six months, with individual patients treated for an average of 8.1 weeks to analyze how telehealth could impact treatment for depression and anxiety. Patients' scores are captured through the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7). Participants were limited to people seeking pharmacotherapy treatment. Diagnoses scores from the PHQ-9 and the GAD-7 are clinically recognized.
The PHQ9 assesses symptom severity based on total score where 5, 10, 15, and 20 are thresholds of mild, moderate, moderately severe, and severe depression, respectfully. The GAD7 assesses symptom severity based on total score of 5, 10, and 15, representing mild, moderate and severe symptoms, respectfully. Patient outcomes were determined to be clinically significant if the patient experienced a 5-point or greater reduction in either score.
Read on to learn more about the outcomes of CirrusMD’s telemental health treatment of anxiety and depression in participants with various forms of insurance coverage. Charts have been included at the end of the piece that capture the findings of the study.
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- Reduction in PHQ-9 scores after six months: 10.5 (clinically significant)
--- Initial PHQ-9 score, average: 17.27 (moderately severe)
--- PHQ-9 score after treatment, average: 6.77 (mild)
- Reduction in GAD-7 scores after six months: 6.42 (clinically significant)
--- Initial GAD-7 score, average: 14.71 (severe)
--- GAD-7 score after treatment, average: 8.29 (mild)
Commercial insurance participants experienced a clinically significant reduction in both depression and anxiety scores and the greatest PHQ-9 score reduction of any insurance group. The average PHQ-9 score among commercially insured participants after six months of telehealth treatment is 6.77, indicating partial remission—or a final PHQ-9 score below 10—and improvement of symptom categorization from severe to mild. Roughly 10% of Americans have commercial insurance, also referred to as private, direct-purchase, and non-group insurance. Commercial plan holders typically either do not qualify for public programs like Medicaid, cannot receive insurance through their employer, or require insurance not offered through other available channels.
- Reduction in PHQ-9 scores after six months: 11.91 (clinically significant)
--- Initial PHQ-9 score, average: 17.72 (moderately severe)
--- PHQ-9 score after treatment, average: 5.81 (mild)
- Reduction in GAD-7 scores after six months: 4.83 (scores above 5 are considered clinically significant)
--- Initial GAD-7 score, average: 15.09 (severe)
--- GAD-7 score after treatment, average: 10.26 (moderate)
At 17.72, Medicaid users had the highest average initial PHQ-9 scores, expressing moderately severe to severe symptoms of depression. After telehealth treatment, and concurrent pharmacotherapy, participants saw a clinically significant decrease in PHQ-9 scores. Medicaid holders did not see meaningful results from telehealth treatment for anxiety, missing the 5-point reduction threshold to be considered clinically significant. Just under 20% of the population is covered by Medicaid, according to the U.S. Census Bureau. This public health insurance program provides affordable coverage and critical health care access to some of the most vulnerable populations, including those over age 65, low-income families, and people with disabilities.
- Reduction in PHQ-9 scores after six months: 8.32 (clinically significant)
--- Initial PHQ-9 score, average: 17.21 (moderately severe)
--- PHQ-9 score after treatment, average: 8.89 (mild)
- Reduction in GAD-7 scores after six months: 7.16 (clinically significant)
--- Initial GAD-7 score, average: 15.142 (severe)
--- GAD-7 score after treatment, average: 7.982 (mild)
Uninsured participants improved from exhibiting moderately severe-severe depression symptoms to mild symptoms over the course of the study. The group saw clinically significant reductions in both depression and anxiety scores. As of 2019, roughly 29 million people in the United States were uninsured, citing prohibitive costs and registration barriers. Due to a lack of affordable care options, uninsured individuals— many of the same demographic subgroups at risk of developing mental health disorders—will not seek out preventative or follow-up care. Telehealth companies have the potential to greatly improve access to critical mental health resources for those who need it most, like uninsured populations.
Srdjan Randjelovic // Shutterstock
- Reduction in PHQ-9 scores after six months: 6.33 (clinically significant)
--- Initial PHQ-9 score, average: 14.85 (moderately severe)
--- PHQ-9 score after treatment, average: 8.52 (mild)
- Reduction in GAD-7 scores after six months: 7.18 (clinically significant)
--- Initial GAD-7 score, average: 14.99 (severe)
--- GAD-7 score after treatment, average: 7.81 (mild)
Employer-sponsored insurance participants saw clinically significant improvement of both anxiety and depression symptoms over the course of the study. According to the U.S. Census Bureau, roughly 55% of the population is covered by employer-sponsored insurance, or ESI. Limited by employers’ one-size-fits-all offerings, people with ESI may face greater difficulty finding adequate in-network care to treat behavioral disorders like anxiety or depression. Some even posit that ESI will lose its prevalence in the marketplace as more workers seek out insurance coverage prioritizing customization and flexibility.
Many of the findings around telehealth have significantly impacted those with anxiety and depression. While telehealth is a newer and less traditional form of medical care, it opens up the possibilities for greater accessibility. Between the COVID-19 pandemic, access to reliable transportation, and other accessibility barriers, telehealth can be a life-changing option for those suffering from anxiety and/or depression.
Emma Rubin // Stacker
This story originally appeared on CirrusMD and was produced and distributed in partnership with Stacker Studio.
insta_photos // Shutterstock
Telehealth has existed in various forms for decades, and more recently, has been a boon to both health care providers and patients amid the coronavirus pandemic. Telehealth and telemedicine exploded to fill a health care vacuum left in the wake of lockdowns, social distancing measures, and new variants that have overwhelmed the United States’ physical health care infrastructure.
According to a 2021 Health and Human Services report, the number of telehealth visits among Medicare beneficiaries in 2020 was about 63 times higher than in 2019. In real numbers, that’s 840,000 visits in 2019 and 52.7 million visits conducted remotely roughly one year later.
Despite having been around for decades, the data-driven impacts of telehealth on every subgroup of society are still emerging. Health care and telehealth industry leaders are conducting small-scale studies around the country, analyzing the impact of telehealth as a pandemic response and tool for the future. Directionally, their results paint a picture of telemedicine’s irreplicable value. Telemedicine is transforming health care for some groups more than others.
The efficacy of telehealth can be defined and refined by the people it serves. Before—and now exacerbated by—the pandemic, health care inequalities existed predominantly among people of color. But, according to a 2021 AARP study, telehealth adoption rates have been highest in many of these same communities, suggesting that remote consultation is one way to remove certain health care disparities and access barriers like transportation, time off from work, and mobility.
Members of the LGBTQ+ community have also been more likely—by 25%— to utilize telehealth for mental health services compared to non-LGTBQ+ peers since the start of the pandemic. This is largely due to the fact that LGBTQ+ users have experienced disproportionately higher rates of mental health challenges since the pandemic began.
Right now, in its nascent, formative stages, telehealth should also be defined by the groups it does not serve. According to the FCC, 6% of the total U.S. population—roughly 19 million people— live without access to the minimum fixed broadband speeds, an essential tool for utilizing telehealth services. Rural and tribal communities are disproportionately affected, with one quarter and one-third of those populations lacking access, respectively.
With pandemic-related emergency restrictions being removed in health care facilities across the country, the future of telehealth and its staying power among providers and patients is in question. In addition, debates around payment parity may also mean that cost-saving is no longer a benefit of telehealth, particularly for populations that use and need it most. Women from various backgrounds fall into this category.
Citing statistics collected from its own 1,000-person study and research from other organizations, including the CDC, Kaiser Family Foundation, and American Medical Association, CirrusMD compiled seven statistics on how telemedicine impacts women's health care.
Over one year, 24% of women, on average, scheduled at least one telemedicine appointment compared to 19% of men. However, women were also more likely to skip routine appointments than men. Both of these facts could be attributed to the disproportionate burden placed on women during the pandemic. Women were more likely to worry about illness, savings, and loss of income. More mothers, particularly single mothers, quit their jobs due to the pandemic compared to fathers. It is not difficult to see why skipping appointments altogether or opting for the convenience of telehealth are on the rise among women in the United States. The CDC data did not collect information on nonbinary individuals.
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Among women who have received telemedicine care, 62.8% said it was comparable to in-person care, and 25.9% said it was better than in-person appointments according to a CirrusMD study. Both CirrusMD and the Kaiser Family Foundation report favorable views on telehealth among women. More than 70% of women rated their telehealth experience with mental health services as very good or excellent. In no health care category did ratings of fair or poor surpass 15%. These similar, independent findings suggest that a comfort and even preference for telehealth exists among users.
A Kaiser Family Foundation survey found 38% of women respondents skipped routine check-ups and tests during the pandemic, with women in fair or poor health skipping at the highest rates. About 46% of women in fair or poor health were more likely to have skipped routine care than women who reported being in good or excellent health. Women with worse health were also more likely to skip recommended tests, treatments, and prescription refills. They also reported the highest rates of difficulty even getting an appointment—double that of men. Delays in essential care are leading to long-term health issues for many women. About 27% of women in fair or poor health have reported worsening conditions. Low-income women were also more likely to report health deterioration due to skipped care.
During the pandemic, the number of women who had telehealth visits nearly tripled, with women aged 50-64 showing the most significant increase. Prior to the pandemic, just 13% of women between the ages of 50-64 ever had a telehealth appointment, according to a Kaiser Family Foundation survey. Between March and December of 2020, that number rose to 42%. When broken down by other sociodemographic factors, women with a college degree and insurance were more likely to have had a telehealth visit during the pandemic.
The top reasons women sought telehealth appointments were for minor illness or injury (21%), management of a chronic condition (18%), and mental health services (17%). According to a Kaiser Family Foundation survey, less than 10% of telehealth appointments for women were for COVID-related symptoms. This number was equally low for men. Instead, primary reasons included minor or chronic issues and mental health services. More than half of women reported that COVID-related stress negatively impacted their mental health. Additionally, according to CirrusMD, more than 25% of their study respondents stated they sought a telehealth appointment because they did not believe their issue required in-person treatment. COVID-19 restrictions early in the pandemic deemed issues like chronic pain management as non-urgent, and in-person services were paused. For many, telehealth was able to serve as an alternative treatment option.
Among women telehealth users surveyed by CirrusMD, respondents also said they would be less likely to delay care if they had access to text-based telehealth services. Text-based telehealth reduces the need for appointments, virtual waiting rooms, access to broadband services, or private space for video calls. According to a CirrusMD survey, more than 50% of women reported that scheduling conflicts with health care providers delayed care. About 23% of respondents cited financial hardship due to missing work as a reason for missing an appointment. The survey also found that 62% of women said they would delay care less often if text-based telehealth services were available and would most frequently use them to questions that arise between regular appointments.
Almost 80% of surveyed women telehealth users said they would consider using telehealth services to consult with their OB/GYN in between regular appointments. According to a Kaiser Family Foundation survey, 86% of OB/GYNs said they did not conduct telehealth visits before March 2020. Just three months later, 84% reported having telehealth offerings. However, the majority of OB/GYN’s cited challenges with telehealth, mainly relating to their inability to conduct physical examinations and diagnostic testing as well as user (patient) error. They also reported that fewer patients were seeking care during the pandemic. While some practitioners were able to provide contraceptive and STI consultations via telehealth, the vast majority of OB/GYN’s said it was at least somewhat more difficult to address a patient’s chronic gynecological conditions or preventative reproductive care. Despite these barriers from the practitioner’s perspective, a CirrusMD survey found that most women are willing to consider virtual consultations with their OB/GYN. This suggests that updated processes and technological infrastructure could help bridge the gap between patient interest and the OB/GYN experience.
This story originally appeared on CirrusMD and was produced and distributed in partnership with Stacker Studio.
In addition, pharmacies are taking a more skeptical stance on telehealth prescriptions — especially from startups. Patients were getting accustomed to using telemedicine to fill and refill their prescriptions for medications for some controlled substances, like Adderall, primarily used to treat ADHD. A shortage of Adderall has affected access for some patients. Now, though, some pharmacies are refusing to fill those prescriptions.
Cheryl Anderson, one Pennsylvanian with ADHD, said she sought online options because of her demanding schedule.
“My husband is frequently out of town, so I don’t have someone to reliably watch the baby to go to an in-person appointment,” she said. It was tough, with three kids, to find the time. Telehealth helped for about half of 2022. Previously, the DEA and state governments imposed tough rules on obtaining controlled substances from online pharmacies.
But in September, after her doctor wrote a refill prescription, she got a phone call saying her local pharmacy wouldn’t dispense medications if the prescription came through telehealth. Other local pharmacies she called took the same position.
Those denials seem to reflect a broader cultural shift in attitudes. Whereas patients and politicians hailed telemedicine at the beginning of the pandemic — first for its safety but also for its increased convenience and potential to extend care to rural areas and neighborhoods without specialists — hints of skepticism are creeping in.
The telehealth boom attracted shady actors. “You had a lot of people who saw an opportunity to do things that were less than scrupulous,” particularly in the behavioral health market, said Michael Yang, a managing partner at the venture capitalist firm OMERS Ventures. Skeptical media coverage has proliferated of startups that, allegedly, shotgun prescriptions for mental health conditions without monitoring patients receiving those medications. “It’ll settle down.”