DEA Urged to End ‘Red Flag’ Policy for Pharmacies

By Pat Anson, PNN Editor

A coalition of telehealth companies is urging the U.S. Drug Enforcement Administration to stop telling pharmacies to be careful about filling prescriptions for opioids and other controlled substances that originate from out-of-state.

The DEA’s “red flag” policy has had a chilling effect on doctors and patients nationwide, including those that use telehealth services. Many pain patients have found that pharmacies won’t fill opioid prescriptions written by doctors that are not near them geographically.  

In an open letter to the DEA, the American Telemedicine Association and a handful of telehealth providers said “clearer green lights” were needed from the DEA on how to safely dispense controlled substances, not more red flags.

“The DEA should provide explicit guidance to the pharmacy community that geography of a prescriber in relation to the patient or the pharmacy should not be a ‘red flag’ when a prescription is a result of a telehealth visit,” the letter states. “The distance of a telehealth prescriber from the patient alone should not give a pharmacist a signal that the prescription may be illegitimate.”

The DEA relaxed telehealth rules three years ago at the start of the Covid-19 pandemic, to allow for opioids, stimulants, sedatives and other controlled substances to be prescribed remotely via telehealth. Those temporary rules have been extended until the end of 2024, to give the DEA more time to develop permanent ones to govern telehealth.

Many pharmacies haven’t gotten the message. In a recent PNN survey, over 90% of pain patients with an opioid prescription said they had trouble getting a pharmacy to dispense their medication. Drug shortages are the primary cause, but so is the fear of some pharmacists that they could get in trouble or even lose their jobs if they filled a prescription deemed suspicious because it comes from out-of-state.

“In conversations with the pharmacy community and in our experience as prescribers, we have determined many pharmacies and pharmacists are currently considering geography as a ‘red flag.’ While red flags are not defined in statute or regulations or other official guidance, in the wake of the overprescribing and overdispensing contributing to the opioid epidemic, pharmacists have been directed to do so as a part of their corresponding responsibility, or due diligence to ensure that prescriptions are legitimate,” the letter from the telehealth coalition states.

‘An Unusual Distance’

Federal laws and regulations may not clearly define what a red flag is, but the onus is clearly put on pharmacies to catch them:

“[A] pharmacist or pharmacy may not dispense a prescription in the face of a red flag (i.e., a circumstance that does or should raise a reasonable suspicion as to the validity of a prescription) unless he or it takes steps to resolve the red flag and ensure that the prescription is valid.”

Under a 2022 opioid litigation settlement, drug distributors and big chain pharmacies agreed to tightly limit the supply of opioids and be on the lookout for suspicious orders. That includes patients with prescriptions for “highly diverted controlled substances” written by doctors from a zip code 50 miles or more from a pharmacy. Pharmacies with a high volume of those prescriptions risk having their drug supplies further restricted or cutoff.

DEA investigators and federal prosecutors have long targeted doctors and pharmacies that have out of state patients. In 2021, for example, DEA suspended the license of a Florida pharmacy that “repeatedly ignored obvious red flags of abuse or diversion,” including a high number of patients who traveled “an unusual distance” to obtain their prescriptions.

Contrary to popular belief, opioid diversion is rare. The DEA estimates that less than one percent of oxycodone (0.3%) and hydrocodone (0.42%) medications are lost, stolen or diverted.

Another example of a provider being red-flagged came in 2022, when DEA suspended the controlled substance license of Dr. David Bockoff, a California physician who treated many chronically ill patients from out of state who couldn’t find local providers.

Within days of Bockoff’s suspension, one of his patients and his wife died by suicide at their home in Georgia. A few weeks later, another patient died at her home in Arizona, apparently from complications caused by opioid withdrawal. Neither of those patients were using telehealth to see Dr. Bockoff, but their deaths highlight how red flags and heavy-handed oversight of medical providers can have serious consequences.    

“DEA must use this opportunity to make clear what their expectations are for pharmacists in filling telehealth prescriptions of controlled substances,” the letter from the telehealth coalition warns. “If DEA simply adds recordkeeping, reporting, or data requirements to the overwhelming workload pharmacies and pharmacists already face, access issues will only be exacerbated.”

How Technology Could Improve Healthcare in Underserved Communities

By Barby Ingle, PNN Columnist 

This year I was fortunate to visit all 15 counties in Arizona, from large cities and rural areas to those considered “frontier” and tribal reservations. I talked to patients, providers and caregivers about the stress points in their access to healthcare. I was in towns with no EMS, no hospital, and no specialists.

Seeing these disparities in healthcare closeup was an eye-opener for me. Imagine being injured or needing surgery, and you must take a helicopter to get immediate care. It’s like living on another planet.  

We can ensure that underserved communities have equal access to healthcare services, regardless of location, by providing remote and rural areas with access to telemedicine. Although the ability to access the internet is still difficult in some areas, services like Elon Musk's Star Link are being utilized to improve healthcare no matter where you live. 

With the recent pandemic, we were able to utilize telemedicine more often and see advancements in digital health solutions. Healthcare professionals can now remotely diagnose, treat and monitor patients from a distance. But will relaxed telehealth rules continue in the same form now that the pandemic has ended? Many of the details are still being worked out.

Mobile applications and wearable devices enable patients to monitor their vital signs and share the data with providers, allowing for remote monitoring and proactive intervention. They can also empower patients to more closely monitor their own health, receive medical advice, and manage chronic conditions from their homes.

With the increased availability of internet connectivity and mobile networks, technology has the potential to revolutionize healthcare delivery and improve health outcomes in remote and underserved regions. Several steps can be taken to address the digital divide in healthcare between urban and rural areas.

First, it is crucial to educate individuals about the benefits of technology and digital health tools. Technology can reduce transportation barriers, provide on-demand health advice, and minimize the risk of exposure to infectious diseases by enabling patients to stay at home.

Second, partnerships between stakeholders, such as academia, the private sector and government can help narrow the digital divide by leveraging resources to place healthcare technology where it is most needed. By building awareness, partnerships and targeting resources, it will be possible to bridge the digital divide and ensure that all communities have access to healthcare technology.

Here are some specific steps that can be taken:

• Conduct a comprehensive needs assessment in underserved communities to understand their unique healthcare challenges, cultural context and technological requirements. A needs assessment can involve surveys, interviews and focus group discussions with community members, healthcare providers and other stakeholders.

• Engage community members, healthcare professionals, and technology experts in a co-design approach. This means collaborating with the community to design and develop healthcare technology solutions that align with its needs, preferences and capabilities.  

• Adopt a user-centered design approach to make sure healthcare technology is user friendly.  Involve people from underserved communities in testing and interface design to ensure the technology is accessible, culturally appropriate and easy to operate.

• Consider the affordability and sustainability of healthcare technology by addressing cost barriers. ensuring compatibility with low-resource settings, and developing tools that can operate with limited infrastructure or connectivity.

• Provide training and support for people to utilize healthcare technology effectively. The training should include digital literacy programs, capacity-building workshops, and ongoing technical assistance.  

By involving underserved communities in the design process, healthcare technology can be tailored to their specific needs, leading to increased adoption and improved healthcare outcomes. It is crucial to prioritize the needs of these communities to ensure that they are included in the design and development of healthcare technology. By doing so, we can create more effective and sustainable solutions that genuinely address the healthcare challenges faced by underserved communities.

I am grateful for the opportunity to talk to patients, providers and caregivers in Arizona, thanks to a grant from HealtheVoices, Respond & Rescue, KB Companies and the International Pain Foundation. I look forward to continuing to gather feedback from underserved communities nationwide. By listening to patients and understanding their unique healthcare challenges, we can work towards creating meaningful solutions that improve access to care and overall health outcomes. 

Barby Ingle is a reality TV personality living with multiple rare and chronic diseases. She is a chronic pain educator, patient advocate, motivational speaker, and best-selling author on pain topics. You can follow Barby at www.barbyingle.com. 

DEA Considering More Changes to Telehealth Prescribing Rules

By Pat Anson, PNN Editor

The U.S. Drug Enforcement Administration will hold two public hearings next month – what it calls “listening sessions” – to consider if providers should continue prescribing controlled substances through telehealth without first requiring patients to have an in-person medical evaluation.

Patients are currently allowed to get a controlled medications without visiting their doctor under emergency telehealth rules adopted three years ago at the start of the Covid-19 pandemic. Controlled substances include many opioids, stimulants, sedatives, steroids, and addiction treatment medications such as methadone and buprenorphine (Suboxone).

“DEA recognizes the importance of telemedicine in providing Americans with access to needed medications, and DEA has been, and remains, committed to expanding access to telemedicine in a way that puts patients — and their safety — first, is simple to understand and apply, reflects technological advancements, and is consistent with lessons learned during the COVID–19 PHE and the ongoing opioid epidemic,” the agency said in a statement.

Rules that are “simple to understand and apply” may be the key issue. In March, the DEA proposed changing the telehealth rules to reimpose “guardrails” on Schedule II opioids such as oxycodone and hydrocodone. For those medications, a patient would first be required to have an in-person meeting with a doctor, with refills then allowed via telehealth. Other drugs that are classified as Schedule III, IV or V substances could initially be prescribed for 30 days via telehealth, but any refills would require an in-person meeting.

The proposed rule changes are so confusing and drew so much opposition that the DEA delayed implementing them until this November. Next month’s public hearings are another sign the agency is still uncertain what to do.

In a notice published in the Federal Register, the DEA said it was open to creating a special registration process that would allow providers to continue prescribing “some controlled substances” without seeing patients in-person. The agency didn’t specific which controlled substances it is referring to.

“DEA is open to considering — for some controlled substances — implementation of a separate Special Registration for telemedicine prescribing for patients without requiring the patient to ever have had an in-person medical evaluation at all,” the DEA notice said.

“DEA also observes that making permanent some telemedicine flexibilities on a routine and large-scale basis would potentially create a new framework for medicine that fundamentally expands access to controlled substances in a way that warrants a new framework for accountability based, in part, on increased data collection and visibility into prescription practices in order to ensure patient safety and prevent diversion in near-real-time.”

Opioid Diversion Rare

Contrary to popular belief, opioid diversion is rare. Using data gathered from prescription drug monitoring programs (PDMPs), pharmacies, hospitals and others in the drug supply chain, the DEA’s most recent estimate is that less than one percent of oxycodone (0.3%) and hydrocodone (0.42%) is lost, stolen or diverted to someone they were not prescribed to.

Opioid prescriptions are also harder to obtain and there are chronic opioid shortages around the country, so few pain patients are willing to part with their legally prescribed medications. Counterfeit medications and other street drugs made with illicit fentanyl are the real problem, which the DEA “listening sessions” won’t address.

The public hearings will be held on September 12 and 13 at DEA headquarters in Arlington, Virginia. Medical practitioners, patients, pharmacists, drug makers, distributors, law enforcement, and other interested parties can express their views either in-person or by video teleconference. The public hearings will also be streamed live online.

The DEA is seeking input on these key questions:

• Should telemedicine prescribing of Schedule II medications be permitted without an in-person medical evaluation?  If it is permitted, what safeguards would you recommend to ensure patient safety and prevent diversion?

• If telemedicine prescribing of Schedule III–V medications is permitted without an in-person medical evaluation, what safeguards and data should be collected for those substances? 

To register as a speaker, click here. The deadline for registering is August 21.

DEA Ending Lenient Telehealth Rules in November

By Arielle Zionts, KFF Health News

Federal regulators want most patients to see a health care provider in person before receiving prescriptions for potentially addictive medicines through telehealth — something that hasn’t been required in more than three years.

During the COVID-19 public health emergency, the Drug Enforcement Administration allowed doctors and other health care providers to prescribe controlled medicine during telehealth appointments without examining the patient in person. Controlled medications include many stimulants, sedatives, opioid painkillers, and anabolic steroids.

The emergency declaration ended May 13, and in February, the agency proposed new rules that would require providers to see patients at least once in person before prescribing many of those drugs during telehealth visits.

Regulators said they decided to extend the current regulations — which don’t require an in-person appointment — until Nov. 11 after receiving more than 38,000 comments on the proposed changes, a record amount of feedback. They also said patients who receive controlled medications from prescribers they’ve never met in person will have until Nov. 11, 2024, to come into compliance with the agency’s future rules.

The public comments discuss the potential effects on a variety of patients, including people being treated for mental health disorders, opioid addiction, or attention-deficit/hyperactivity disorder. Thousands of commenters also mentioned possible impacts on rural patients.

Opponents wrote that health care providers, not a law enforcement agency, should decide which patients need in-person appointments. They said the rules would make it difficult for some patients to receive care.

Other commenters called for exemptions for specific medications and conditions.

Supporters wrote that the proposal would balance the goals of increasing access to health care and helping prevent medication misuse.

Special Referrals for Rural Patients

Zola Coogan, 85, lives in Washington, Maine, a town of about 1,600 residents northeast of Portland. Coogan has volunteered with hospice patients and said it’s important for very sick and terminally ill people in rural areas to have access to opioids to ease their pain. But she said it can be hard to see a doctor in person if they lack transportation or are too debilitated to travel.

Coogan said she supports the DEA’s proposed rules because of a provision that could help patients who can’t travel to meet their telehealth prescriber. Instead, they could visit a local health care provider, who then could write a special referral to the telehealth prescriber. But she said accessing controlled medications would still be difficult for some rural residents.

“It could end up being a very sticky wicket” for some patients to access care, she said. “It’s not going to be easy, but it sounds like it’s doable.”

Some health care providers may hesitate to offer those referrals, said Stefan Kertesz, a physician and professor at the University of Alabama at Birmingham whose expertise includes addiction treatment. Kertesz said the proposed referral process is confusing and would require burdensome record-keeping.

Ateev Mehrotra, a physician and Harvard professor who has studied telehealth in rural areas, said different controlled drugs come with different risks. But overall, he finds the proposed rules too restrictive. He’s worried people who started receiving telehealth prescriptions during the pandemic would be cut off from medicine that helps them.

Mehrotra said he hasn’t seen clear evidence that every patient needs an in-person appointment before receiving controlled medicine through telehealth. He said it’s also not clear whether providers are less likely to write inappropriate prescriptions after in-person appointments than after telehealth ones.

Mehrotra described the proposed rules as “a situation where there’s not a clear benefit, but there are substantial harms for at least some patients,” including many in rural areas.

Beverly Jordan, a family practice doctor in Alabama and a member of the state medical board, supports the proposed rule, as well as a new Alabama law that requires annual in-person appointments for patients who receive controlled medications. Jordan prescribes such medications, including to rural patients who travel to her clinic in the small city of Enterprise.

“I think that once-a-year hurdle is probably not too big for anybody to be able to overcome, and is really a good part of patient safety,” Jordan said.

Jordan said it’s important for health care practitioners to physically examine patients to see if the exam matches how the patients describe their symptoms and whether they need any other kind of treatment.

Jordan said that, at the beginning of the pandemic, she couldn’t even view most telehealth patients on her computer. Three-fourths of her appointments were over the phone, because many rural patients have poor internet service that doesn’t support online video.

The proposed federal rules also have a special allowance for buprenorphine, which is used to treat opioid use disorder, and for most categories of non-narcotic controlled substances, such as testosterone, ketamine, and Xanax.

Providers could prescribe 30 days’ worth of these medications after telehealth appointments before requiring patients to have an in-person appointment to extend the prescription. Tribal health care practitioners would be exempt from the proposed regulations, as would Department of Veterans Affairs providers in emergency situations.

Many people who work in health care were surprised by the proposed rules, Kertesz said. He said they expected the DEA to let prescribers apply for special permission to provide controlled medicine without in-person appointments. Congress ordered the agency to create such a program in 2008, but it has not done so.

Agency officials said they considered creating a version of that program for rural patients but decided against it.

Denise Holiman disagrees with the proposed regulations. Holiman, who lives on a farm outside Centralia, Missouri, used to experience postmenopausal symptoms, including forgetfulness and insomnia. The 50-year-old now feels back to normal after being prescribed estrogen and testosterone by a Florida-based telehealth provider. Holiman said she doesn’t think she should have to go see her telehealth provider in person to maintain her prescriptions.

“I would have to get on a plane to go to Florida. I’m not going to do that,” she said. “If the government forces me to do that, that’s wrong.”

Holiman said her primary care doctor doesn’t prescribe injectable hormones and that she shouldn’t have to find another in-person prescriber to make a referral to her Florida provider.

Holiman is one of thousands of patients who shared their opinions with the DEA. The agency also received comments from advocacy, health care, and professional groups, such as the American Medical Association.

The physicians’ organization said the in-person rule should be eliminated for most categories of controlled medication. Even telehealth prescriptions for drugs with a higher risk of misuse, such as Adderall and oxycodone, should be exempt when medically necessary, the group said.

State Laws Burden Patients

Some states already have laws that are stricter than the DEA’s proposed rules. Amelia Burgess said Alabama’s annual exam requirement, which went into effect last summer, burdened some patients. The Minnesota doctor works at Bicycle Health, a telehealth company that prescribes buprenorphine.

Burgess said hundreds of the company’s patients in Alabama couldn’t switch to in-state prescribers because many weren’t taking new patients, were too far away, or were more expensive than the telehealth service. So Burgess and her co-workers flew to Alabama and set up a clinic at a hotel in Birmingham. About 250 patients showed up, with some rural patients driving from five hours away.

Critics of the federal proposal are lobbying for exemptions for medications that can be difficult to obtain due to a lack of specialists in rural areas.

Many of the public comments focus on the importance of telehealth-based buprenorphine treatment in rural areas, including in jails and prisons.

Rural areas also have shortages of mental health providers who can prescribe controlled substances for anxiety, depression, and ADHD. Patients across the country who use opioids for chronic pain have trouble finding prescribers.

It also can be difficult to find rural providers who prescribe testosterone, a controlled drug often taken by transgender men or people with various medical conditions, such as menopause. Controlled medications are also used to treat seizures, sleep disorders, and other conditions.

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

DEA to Reimpose ‘Guardrails’ on Telehealth Opioids

By Pat Anson, PNN Editor

The U.S. Drug Enforcement Administration plans to reimpose rules that require doctors to meet face-to-face with patients before they are prescribed opioids and other controlled substances.

The rules were suspended in 2020 in the early stages of the Covid-19 pandemic so that doctors and patients could connect remotely via telehealth – also known as telemedicine --  to get medications prescribed without an in-person meeting.

But when the federal government ends the Covid public health emergency on May 11, the DEA plans to restore “appropriate safeguards” on medications it considers addictive. Patients will still be able to get prescriptions for antibiotics, statins, insulin and other common medications through telehealth, without a physical examination or meeting with a doctor.

“DEA is committed to ensuring that all Americans can access needed medications,” said DEA Administrator Anne Milgram said in a statement.  “The permanent expansion of telemedicine flexibilities would continue greater access to care for patients across the country, while ensuring the safety of patients. DEA is committed to the expansion of telemedicine with guardrails that prevent the online overprescribing of controlled medications that can cause harm.”  

Under the DEA’s proposed rules, Schedule II controlled substances such as oxycodone and hydrocodone cannot be prescribed without first having an in-person meeting. Refills would then be allowed via telehealth.

Other drugs that are classified as Schedule III, IV or V substances – such as Xanax (alprazolam) and Suboxone (buprenorphine) could still be prescribed for 30 days via telehealth, but any refills will require an in-person meeting.

The DEA rules were developed in conjunction with the Department of Health and Human Services (HHS) and the Department of Veterans Affairs. Public comments on the rules can be submitted through the Federal Register by clicking here.

“Improved access to mental health and substance use disorder services through expanded telemedicine flexibilities will save lives,” said HHS Secretary Xavier Becerra. “We still have millions of Americans, particularly those living in rural communities, who face difficulties accessing a doctor or health care provider in-person.”

Drug overdoses rose sharply during the pandemic, with nearly 107,500 drug deaths reported in the 12-month period ending in August, 2022. About 70% of the fatal overdoses involved illicit fentanyl and other street drugs, not prescribed medications.

Coping With Pain and Isolation During the Pandemic

By Alexa Mikhail, The 19th

Originally published by The 19th

Even before the pandemic, Sabra Thomas ordered her groceries. The 33-year-old has not been able to push a cart and her walker at the same time for years, and she can’t pick up heavy cases like water. 

It’s the pain — the invisible enemy she faces daily.  

In March 2020, when the pandemic set in and grocery orders surged, Thomas was never able to get hers delivered in time. She had to start placing orders five weeks ahead, and they kept getting canceled. 

“I desperately needed food,” said Thomas, who has lived alone for the bulk of the pandemic. “And because of my chronic pain and feeling like food options were limited, I was rationing out my meals. Many days I had to figure out how to balance taking meds and how much to eat.” 

Tasks that seem quotidian to so many have brought Thomas anxiety for years. At age 12, Thomas was diagnosed with Ehlers Danlos — a degenerative chronic pain condition affecting connective tissue, primarily the skin, joints and blood vessel walls. 

She suspected, and later confirmed, that she was having hip dislocations all through childhood, which were constantly dismissed by doctors when she was younger, she said. When she finally received her diagnosis, she was told the disease would only progress as she got older. In high school, she was able to be more active, but the plays Thomas used to act in, the basketball and dance that defined her when she was growing up, have become nearly impossible activities now. The former dance instructor hasn’t danced in over a year. 

On a good day prior to the pandemic, Thomas might go dance for a few hours with friends — though she would pay for it the next day. On a bad day, she was completely bedridden, usually waking up with joint dislocation, a migraine, vertigo or a combination of the three. The pain is always hidden.

“With a chronic pain condition, it’s like ‘OK, you look normal.’ I used to hate when people said that. What the heck does that mean, I look normal?” Thomas said. “I don’t feel normal.” 

Now, Thomas lives in an apartment alone in Birmingham, Alabama, so she can be closer to family. Before moving, she hadn’t seen her family for a year. After pandemic-induced isolation and struggling to secure medical appointments, Thomas is tired. As a Black woman with chronic pain, she’s had to be her own medical advocate, she said. 

“I’m here by myself. All I can focus on is my pain and the loneliness,” Thomas said. “I was feeling trapped, hopeless in all facets of my life.” 

Disparities in Pain Care

In the United States, 70 percent of people struggling with some form of chronic pain are women, despite 80 percent of studies on pain involving either men or mice. It’s a common pitfall of medical research that experts say could be because it is harder to get women of childbearing age to participate in studies. While research on pain is difficult given the ambiguous factors involved in feeling it, women report experiencing higher levels of pain than men, according to a study in Scientific American magazine. 

There are vast disparities across both racial and gender lines when it comes to the validation of pain and getting treatment. Black patients are 40 percent less likely to receive medication for acute pain compared to White patients, and 34 percent less likely to be prescribed opioids, according to an analysis by the American Journal of Emergency Medicine. 

That’s become even more difficult in the pandemic, experts say.

Thomas has long felt like she’s screaming to an empty auditorium when it comes to her checkups. Even when she was seeing doctors in-person, she seldom felt truly believed. In 2018, she waited months to see a top gynecologist for the excessive bleeding and pain she was having. Knowing her diagnosis, she thought the doctor, who was a White man, would surely run tests. He insisted it was her job — at the time she worked in social security as a customer service representative — that was making her stressed. 

“I just felt very deflated,” Thomas said. “I felt like he was making me question myself.” 

When Thomas went to get a second opinion by a doctor, a woman of color, she immediately found out she had to go into emergency surgery for eight inflamed fibroids linked to her Ehlers Danlos. 

Now, Thomas is hardly able to secure in-person appointments because of a backlog from the pandemic. Virtually it’s much harder for her to show a physician her pain and explain her experience, she said. 

The ambiguity around how people express their pain, coupled with ingrained biases and stereotypes, makes it hard for the most marginalized people to be taken seriously when explaining their pain, said Janice Sabin, a researcher on implicit bias in medicine at the University of Washington. This notion of “it’s all in your head” or “you’re crazy,” dates back a century when it comes to women and women of color experiencing chronic pain, Sabin said.

“The lived experience of discrimination is incredibly damaging. It is an emotional burden, but it’s also something that can be tapped intergenerationally,” Sabin said. “Women were considered to be in the 1950s, for example, ‘hysterical’ — just that legacy of not believing women and women being looked at as weak.”

Being Your Own Advocate

Having to be your own advocate is the hardest, Thomas said. And especially during a pandemic, it is nearly impossible to stay on top of your own appointments and procedures. Typically, Thomas sees a specialist once a month and a therapist once a week. This year, Thomas tried to get into a new primary care doctor. She called to schedule in February for an appointment, and the earliest opening was in July. For someone in her level of constant pain, the wait is excruciating, forcing her to take her care into her own hands, doing her own medical research and reaching out to countless experts for advice and help. 

“I had so much medical documentation,” Thomas said. “I could have made my own library.”

Telehealth skyrocketed at the beginning of the pandemic. Between June 26 and November 6, of 2020, 30.2 percent of weekly health center visits occurred via telehealth, according to the Centers for Disease Control and Prevention. Telehealth has made it easier for those in rural areas or for people who have children at home to get appointments, and experts say it’s here to stay: 83 percent of patients expect to use virtual appointments after the pandemic. 

On the flip side, it is more difficult for those like Thomas to feel completely understood. Vulnerable pain patients can be seen as seeking unneeded drugs when they simply need any remedy to get them out of bed, said Shoshana Aronowitz, a researcher of racial disparities in pain medications and the opioid crisis at the University of Pennsylvania. In the pandemic, the limited access to pain doctors affects those most marginalized, specifically women, people of color and LGBTQ+ people who may have previously experienced discrimination in treatment. 

“We’ve gotten into the situation where people, especially Black Americans, have less access to pain care, and then also have less access to substance use disorder treatment. If people don’t have access to other types of treatment, that’s not OK,” Aronowitz said. 

She advocates for a system in which the most marginalized are prioritized for a holistic approach to care that includes both telehealth and in-person therapy and remedies post-pandemic. There are a handful of pain centers across the country that view pain in this way, but with waitlists and costs for initial evaluation, they remain very inaccessible, experts said. 

“In primary care, integrated team care is a model that is being advanced,” Sabin said. “Sort of having this medical home all in one place, so people aren’t being sent to a counselor for this and somewhere else for that. The providers in that model can discuss patients together. Everything is in one spot.” 

Similar to chronic pain patients, many of whom struggle with undiagnosed ongoing medical problems, long-haul COVID patients face that same uncertain battle. With doctors spread thin working to address those with ongoing COVID-19 symptoms, Sabin hopes this is a turning point in which mysterious lingering chronic pain conditions can be looked at and appreciated in a new light. 

Thomas decided last month to leave her job as a customer service representative and apply for disability status. Taking the phone calls her job required all day, especially when her pain flared up, was just not doable. 

The pandemic pushed her to make changes that will help her take care of herself and the uncertainty of her condition. She still feels ashamed: That she can’t function to the extent she desires, that she has to endure the financial instability of a monthly check. She still hasn’t told many of her friends about quitting her job. When she has Zoom calls, she usually avoids the topic of work. 

But still, she said, she is now ready to own her reality.

“For us in chronic pain, we’re always like, ‘We just got to keep going.’ ‘We push through it.’ And then by the time we finally stop, our body’s completely broken,” Thomas said. “So I’m trying not to do that because I am 33. I’m not 103.” 

“Ironically, the pandemic gave me an out,” she added. “It was the catalyst to push me to make a change for myself, for the good of my health and well-being.” 

Most Patients Satisfied With Telehealth, But Some Exploited for Healthcare Fraud

By Pat Anson, PNN Editor

Telehealth has been a godsend for pain sufferers during the coronarvirus pandemic, with many patients discovering the ease and convenience of visiting with their doctors online or over the telephone. Some have even been able to get prescriptions written for opioid medication without an initial face-to-face meeting with their doctors – thanks to a DEA decision to relax some of the rules about prescribing controlled substances.  

Unfortunately, some providers are taking advantage of patients — and the pandemic — by filing billions of dollars in false medical claims.

Saving Time and Money

Most patients who use telehealth – also known as telemedicine – to connect with pain management specialists were highly satisfied with their experience, according to a new study presented at the annual meeting of the American Society of Anesthesiologists.

Last summer, researchers at UCLA’s Comprehensive Pain Center began giving patients the option of in-office visits or remote appointments via telehealth. Nearly 1,400 patients chose telehealth, resulting in nearly 3,000 virtual appointments before and during the pandemic, from August, 2019 to June, 2020.

“This era of contactless interactions and social distancing has really accelerated the adoption of telemedicine, but even before the pandemic, patient satisfaction was consistently high,” said lead author Laleh Jalilian, MD, an anesthesiologist at the Ronald Reagan UCLA Medical Center in Los Angeles.

“Patients who are being evaluated for new conditions may be better off having office visits initially. But once patients establish a relationship with providers, follow-up visits can occur efficiently with telemedicine, while maintaining patient rapport and quality outcomes. We believe 50 percent of our visits could be conducted via telemedicine.”

Asked about their experiences with telehealth, 92 percent of patients said they were satisfied. Many said they were happy to avoid the lengthy commutes and time spent in Los Angeles area traffic. On average, patients saved 69 minutes in traffic per visit and $22 in gas and parking fees.

For telehealth to be sustainable in a post-pandemic world, Jalilian says insurers should consider expanding reimbursement for providers to take into account the additional work and technology needed for telehealth visits. The Centers for Medicare & Medicaid Services (CMS) has waived many of the limits on telehealth visits during the pandemic and some private insurers have followed suit.

“Now that telemedicine is more widespread, it may become a valued part of care delivery in chronic pain practices,” said Jalilian. “Clearly many patients benefitted from remote consultations and follow-up appointments using telemedicine. We hope it will encourage policymakers and insurance providers to continue to support these platforms and inspire more innovation in this developing field of research and patient care.”

Telehealth Fraud Takedown

But as demand has grown for telehealth services, federal prosecutors say hundreds of healthcare providers have exploited the situation. In what’s being called the largest healthcare fraud and enforcement action in Department of Justice history, criminal charges were recently filed against 345 doctors, nurses and other providers for submitting over $6 billion in false and fraudulent claims to Medicare, Medicaid and private insurers. Some of the false claims were for COVID-19 testing.

The fraud charges involve more than $4.5 billion connected to telemedicine, $845 million involving substance abuse treatment, and $806 million connected to illegal opioid distribution.

“This nationwide enforcement operation is historic in both its size and scope, alleging billions of dollars in healthcare fraud across the country,” said Acting Assistant Attorney General Brian Rabbitt.  “These cases hold accountable those medical professionals and others who have exploited health care benefit programs and patients for personal gain.” 

Prosecutors say telemedicine executives allegedly paid kickbacks to doctors and nurse practitioners to order unnecessary medical equipment, genetic and other diagnostic testing, and pain medications, either without any interaction with patients or after a brief telephone conversation with patients they had never met or seen. Medical equipment companies, genetic testing labs and pharmacies then purchased the orders in exchange for illegal kickbacks and bribes.

In addition to those charges, CMS announced that it had taken administrative action against 256 healthcare providers, revoking their Medicare billing privileges because of their involvement in telemedicine schemes. 

“Telemedicine can foster efficient, high-quality care when practiced appropriately and lawfully.  Unfortunately, bad actors attempt to abuse telemedicine services and leverage aggressive marketing techniques to mislead beneficiaries about their health care needs and bill the government for illegitimate services,” said HHS Deputy Inspector General Gary Cantrell. 

The charges against substance abuse treatment facilities -- known as “sober homes” – mostly involve illegal payments to patient recruiters for referring scores of patients to treatment facilities. The patients were then subjected to medically unnecessary drug testing – often billing thousands of dollars for a single test – and therapy sessions that were often not provided.

Some sober homes also allegedly prescribed medically unnecessary controlled substances and other medications to patients to entice them to stay at the facility.  Prosecutors say the patients were then often discharged and admitted to other treatment facilities, or referred to other labs and clinics, in exchange for more kickbacks.

9 Best Practices for Telehealth

By Barby Ingle, PNN Columnist

Telehealth can make life easier for chronic pain patients. We spend so much of our time and energy traveling to and from provider appointments, paying for gas or public transportation, and then sitting in waiting rooms for our appointments to begin.

Being able to talk with providers over the phone or online without leaving home is not only more convenient, the “virtual” visits greatly reduce the risk of exposure to COVID-19 and other communicable diseases – an important point for patients with compromised immune systems.

If you’re new to telehealth or wondering how to make use of it, here are nine best practices I’ve learned.

1. Be strategic in your appointment time slot. It is best if you can schedule it earlier in the day because providers are often less rushed and can spend more time with you.

2. Before your appointment, you should take time to assess your needs. Should a loved one or caregiver participate in the call? They could have some significant information about your health or have a question you didn’t think of.

3. If your appointment is online, your provider will send you a login link or they will call you through their online platform. Some doctors work with telehealth companies that provide their patients with health monitoring tools, such as blood pressure checks. Practice using the technology before your appointment.

4. If you will be on camera with your provider, do a test with a family member or friend. Make sure that you are in a well-lit, quiet location, and there is nothing in the background that is distracting or inappropriate.

5. Telehealth may seem a little less formal, but remember to stay focused on what your needs are, just as you would when visiting a doctor in their office.

6. Patients may benefit if they have access to their online patient portal information. I utilize this feature often with my primary care provider and his staff. During my last appointment, he said that he prefers that I text him directly if the situation is more urgent.

7. I have a thick case file and keep my health records organized. You should too. Make sure to keep track of your telehealth appointments, billing and insurance payments, just as you do with in-person visits.

8. If you struggle with new technology or this type of communication, be sure to let the provider know. Maybe your internet is not fast enough, your wi-fi not strong enough, or you don’t have the right app on your phone. Ask for help or other options.

9. Just in case the technology fails, have a backup plan. One of my providers was a little late and called me two minutes after our scheduled time. He apologized and said his last appointment went longer than expected. In those two minutes I realized I didn’t know what to do. Was I supposed to call him? Was he going to call me? Did he give me a link? Having that information on hand will save you some stress in an already stressful moment.

Not all healthcare needs can be addressed via telehealth. Some prescriptions, such as opioids, may require a visit to the office. So will some medical exams. A combination of in-person, phone and online appointments may be best for you.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website.