Online Prescribing of Controlled Substances for Mental Health Issues: a View of the Current Landscape
Controlled substances, such as benzodiazepines, narcotic pain medications, and stimulants, can be helpful in the treatment of a wide variety of mental and physical conditions. In order to limit the improper use and abuse of these medications, the state and federal governments regulate how controlled substances are prescribed, distributed, and dispensed. Telemedicine physicians are often reluctant to utilize controlled substances out of fear and uncertainty of the rules. This represents a barrier to the expansion of telemedicine practice and development of new systems within accountable care organizations, resulting in patients being deprived of opportunities to obtain appropriate treatments. This article briefly defines and reviews online prescribing, controlled substances (history, current practices), telehealth (general, videoconferencing), and legal/regulatory practices (state, federal). Cases are provided to informally stratify the prescribing landscape and risk into categories of low, medium, and high risk of prescribing and to illustrate cases in which prescribing would probably require a policy change. The policy landscape pertaining to the prescription of controlled substances via telemedicine is complex and confusing to many. This primer for clinicians, administrators, and health care administrators provides information and an approach to evaluate issues and make decisions. It is intended to encourage further discussion and advocacy for policies that facilitate, rather than inadvertently impede, appropriate prescription of controlled substances via telemedicine. Clinicians, professional organizations, and telehealth organizations need to collaborate with others to adjust policies to improve access. More research on clinical care (best practices, barriers/obstacles) related to online prescribing is needed and how online prescribing is working and/or not working (e.g., barriers are arising).
KeywordsControlled substances Mental health Telehealth Prescribing Online Technology
- American Medical Association Telemedicine Guideline. (2014). Retrieved from https://wire.ama-assn.org/ama-news/telemedicine-prompts-new-ethical-ground-rules-physicians and https://integrationacademy.ahrq.gov/resources/new-and-notables/ama-telemedicine-policy. Accessed: February 1, 2019.
- American Psychiatric Association Policy on Telepsychiatry. (2015). Retrieved from https://psychiatry.org/psychiatrists/practice/telepsychiatry. Accessed: February 1, 2019.
- American Psychiatric Association Toolkit for Telepsychiatry. (2019). Retrieved from https://psychiatry.org/psychiatrists/practice/telepsychiatry. Accessed: February 1, 2019.
- American Telemedicine Association. (2009). Practice Guidelines for Videoconferencing-Based Telemental Health. Retrieved from http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-videoconferencing-based-telemental-health.pdf?sfvrsn=6. Accessed: February 1, 2019.
- American Telemedicine Association. (2013). Practice Guidelines for Video-based Online Mental Health Services. Retrieved from http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services.pdf?sfvrsn=6. Accessed: February 1, 2019.
- American Telemedicine Association. (2017a). Practice Guidelines For Telemental Health With Children and Adolescents. Retrieved from: https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/Practice%20Guideline%20Covers/NEW_ATA%20Children%20&%20Adolescents%20Guidelines.pdf. Accessed: February 1, 2019.
- American Telemedicine Association. (2017b). State Telemedicine Gaps Analysis: Physician Practice Standards & Licensure. Retrieved from https://higherlogicdownload.s3-external-1.amazonaws.com/AMERICANTELEMED/2017%20Physician%20Licensure%20and%20Standards_New%20GAPS%20Report.pdf?AWSAccessKeyId=AKIAJH5D4I4FWRALBOUA&Expires=1515018464&Signature=iLShzWha9FAXsRH9FPfhp%2FD0cK8%3D Accessed February 1, 2019.
- Center for Connected Health Policy. (2019). Online Prescribing. Retrieved from http://www.cchpca.org/online-prescribing-0. Accessed February 1, 2019.
- Controlled Substances Act. (2010). Overview. Retrieved from http://criminal.findlaw.com/criminal-charges/controlled-substances-act-csa-overview.html. Accessed February 1, 2019.
- Cooke, B. K., Worsham, E., & Reisfield, G. M. (2017). The elusive standard of care. Journal of the American Academy of Psychiatry and the Law, 2017, 45(3), 358–364.Google Scholar
- Hilty, D. M., Chan, S., Torous, J., Mahautmr, J., & Mucic, D. M. (2015). New frontiers in healthcare and technology: Internet- and web-based mental options emerge to complement in-person and telepsychiatric care options. Journal of Health and Medical Informatics, 6(4), 1–14.Google Scholar
- Kung, K. (2017). Texas telemedicine Saga finally over? The Texas Medical Board substantially revises telemedicine regulations. National Law Review, February 1, 2019.Google Scholar
- Leichter, L. (2013). The Ryan Haight Act and the Changing Face of Telemedicine. Retrieved from http://www.txmedicallicensinglaw.com/2013/08/articles/texas-medical-board/the-ryan-haight-act-and-the-changing-face-of-telemedicine/. Accessed February 1, 2019.
- North Carolina Medical Board. (2019). Resources & Information Position Statements Writing of Prescriptions. Retrieved from https://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/writing_of_prescriptions. Accessed February 1, 2019.
- U.S. Department of Justice, Drug Enforcement Administration. (2009). Diversion Control Division: Title 21 United States Code (USC) Controlled Substances Act, Section 823. 2012 Edition. Retrieved from https://www.deadiversion.usdoj.gov/%2021cfr/21usc/823.htm.%20Accessed%20November%207,%202016#startcontent. Accessed February 1, 2019.
- U.S. Department of Justice, Drug Enforcement Administration H.R. 6353 (110th). (2009). Ryan Haight Online Pharmacy Consumer Protection Act of 2008. Retrieved from https://www.govtrack.us/congress/bills/110/hr6353/text. Accessed February 1, 2019.
- U.S. Department of Justice, Drug Enforcement Administration. (2010). Electronic Prescriptions for Controlled Substances (EPCS). Retrieved from https://www.deadiversion.usdoj.gov/ecomm/e_rx/index.html. Accessed February 1, 2019.
- U.S. Food and Drug Administration. (2010). Rules – 2010 Interim Final Rule With Request for Comment: Electronic Prescriptions for Controlled Substances. https://www.deadiversion.usdoj.gov/fed_regs/rules/2010/fr0331.htm. Accessed February 1, 2019. Retrieved from
- U.S. Food and Drug Administration. (2019a). The 1906 Food and Drugs Act and Its Enforcement. Retrieved from https://www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054819.htm. Accessed February 1, 2019.
- U.S. Food and Drug Administration. (2019b). The 1938 Food, Drug, and Cosmetic Act. Retrieved from https://www.fda.gov/AboutFDA/WhatWeDo/History/ProductRegulation/ucm132818.htm. Accessed February 1, 2019.
- U.S. Food and Drug Administration. (2019c). Kefauver-Harris Amendments Revolutionized Drug Development. Retrieved from https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm322856.htm. Accessed February 1, 2019.