Click Here for Adderall: Fixing Telehealth Advertising and Services To Prevent Stimulant Misuse

Introduction

Prescription stimulant consumption in the United States has increased significantly in recent years. These medications treat a range of conditions, the most common being attention deficit hyperactivity disorder (ADHD), a medical condition characterized by inattentiveness, hyperactivity, and impulsivity. In patients both with and without ADHD, the medication may improve concentration and productivity, leading many to seek out stimulant drugs without a legitimate medical need. In the past couple of decades, consumption of stimulant medication has surged, following a pattern similar to the opioid epidemic. Increases in consumption of stimulant medications continued during the COVID-19 pandemic, when some telehealth companies took advantage of loosened regulations to offer prescriptions for stimulants with little medical oversight or appropriate care. However, despite increases in the consumption and availability of stimulant medications, stimulant misuse and overprescription face less scrutiny than other Schedule II controlled substances, such as opioids.

During the COVID-19 pandemic, policymakers rightly removed barriers to seeking mental health treatment via telehealth services. Telehealth services allowed patients to seek medical care remotely, such as from their home or workplace, and enabled patients to more easily obtain prescription stimulant medications. While many health care providers began offering telehealth services during the pandemic, or expanded existing operations, there have also been a number of new telehealth companies that have used these new telehealth policies to offer prescription stimulants to individuals even when not medically necessary. Individuals seeking these drugs can easily find online telehealth providers that offer remote medical treatment for ADHD, making it possible to obtain prescription stimulants with only a few clicks. These providers not only endanger the health and safety of individuals who obtain these drugs for non-medical purposes, but also threaten to delegitimize valid uses of telehealth services for mental health.

Moreover, many telehealth companies have used advertising loopholes to aggressively market stimulant medications to users on social media without the typical disclosures found in pharmaceutical ads. For example, companies offering stimulant medications for ADHD treatment have advertised on social media platforms with pictures or videos extolling the benefits of ADHD medications. The advertisements suggest that medication is the key to resolving symptoms common to the general population, including “being able to have a quiet mind” or “being able to focus,” that may not necessarily be indicative of ADHD. While these advertisements may lead some ADHD patients to seek out an evaluation and receive an accurate diagnosis, they do not disclose potential risks of taking these medications.

Telehealth companies can post advertisements for prescription drugs without including any warnings or information about side effects due to technicalities in pharmaceutical advertising laws and regulations. There are generally three types of prescription drug advertisements: product claim advertisements, reminder advertisements, and help-seeking advertisements. The Food and Drug Administration (FDA), alongside the Federal Trade Commission (FTC) in certain circumstances, regulates product claim advertisements and reminder advertisements, and requires both to adhere to strict content standards depending on their nature. However, if an advertisement simply references a condition but does not suggest a specific drug, it is considered a help-seeking advertisement and falls under the purview of the Federal Trade Commission . As such, help-seeking ads are subject to the FTC’s truth-in-advertising laws instead of the FDA’s pharmaceutical advertising regulations, and do not have to contain the same disclosures or elements as other prescription drug advertisements.

Many telehealth companies have turned to help-seeking advertisements to market their mental health services, including writing prescriptions for medications that can treat certain conditions. The advertisements often feature or discuss medication to mitigate the symptoms of ADHD without naming a specific drug. Stimulant medications are a well-known treatment for ADHD, so advertisements for ADHD medications or treatment do not necessarily have to name a specific drug to draw interest in a prescription for stimulant medications. Telehealth companies’ use of help-seeking advertisements for ADHD medications essentially allows them to promote access to prescription stimulant medications without making viewers aware of the associated side effects or risks.

Moreover, should a telehealth company post an advertisement violating the FDA’s regulations, the agency’s ability to pursue legal action is limited by its narrow scope. Federal law regulates advertisements from packers, distributors, and other actors responsible for producing medication. Telehealth companies do not fall under the definition of a regulated entity because they are typically structured as technology platforms that connect patients with medical providers. As such, they are not held to the same advertising standards as many others.

Both federal and state policymakers have enacted various mechanisms to monitor prescription drug trends, retail sales of stimulant medications, and drug misuse; however, these mechanisms do not provide policymakers with comprehensive or timely data to quickly combat drug misuse. On a federal level, the U.S. Drug Enforcement Administration (DEA) publishes quarterly reports of retail sales of stimulant medications in the ARCOS database. However, the DEA only reports the amount of stimulants sold. The reported data does not show the number of prescriptions, dosage amounts, or prescriber information. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) also conducts an annual survey, known as the National Survey on Drug Use and Health (NSDUH), to collect data on drug misuse, including misuse of stimulant medications.

State Prescription Drug Monitoring Program (PDMPs) databases collect more information. PDMPs track prescriptions for controlled substances at an individual level, allowing for prescribers to review a patient’s prescription history before issuing a prescription for stimulant medications. Some states allow patients to apply for and review their prescription histories; however, further public disclosure of the data to policymakers, researchers, and other designated medical providers or officials is limited. Through PDMPs, state authorities can monitor prescribing trends across the population and inform efforts to improve public health.

Telehealth enables the provision of medical care to patients who may otherwise not receive treatment and policymakers should support this mission. To that end, policymakers should both make permanent many of the COVID-19 era policies that allow medical providers to see patients remotely; and enact provisions allowing for the practice of telemedicine over state lines. However, policymakers should take further steps to ensure that telehealth providers offer and abide by the same standard of care as in-person treatment. Delays in data reporting and a lack of interoperability between state and federal databases make it difficult to know the effect of some companies’ mental telehealth services on prescription stimulant drug misuse or overprescription. Policymakers and medical researchers need better data to truly know the extent of this problem. In pursuit of this objective, state policymakers should standardize and improve data collection and reporting efforts by requiring prescribers to check a patient’s PDMP before prescribing any Schedule II medication and entering into data-sharing agreements with other states. States should also conduct regular reviews of PDMP data to identify telehealth providers with higher prescription rates than their peers and require that they receive additional education and training. On the federal level, policymakers should revise the NSDUH survey to include questions on malingering, or the feigning of symptoms to obtain a lawful prescription. The survey could then provide a more comprehensive picture of unnecessary stimulant medication consumption in the United States.

Further, federal policymakers should close advertising loopholes by disallowing telehealth platforms and third-party actors from advertising medications without disclosing the side effects and nature of treatment. Finally, the DEA, the Department of Health and Human Services’ Office of the Inspector General, and state law enforcement agencies should conduct random audits of telehealth companies to ensure that they are not operating as digital pill mills by providing patients with medically unnecessary controlled substances.

Read the full report. (PDF)