When access becomes excess: the rise of opportunistic ADHD telehealth companies in the United States

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The loosening of Drug Enforcement Administration (DEA) regulations in an effort to expand telemedicine amid the COVID-19 pandemic has paved the way for the emergence of opportunistic, profit-driven telehealth start-ups that focus on the treatment of attention deficit hyperactivity disorder (ADHD). These companies are thought to be implicated in the recent years’ accelerated rise in stimulant prescriptions and the critical medication shortage.

In a recent publication for the Washington Journal of Law, Technology & Arts, Kaitlin Campanini argues that “the DEA’s sparse regulatory structure for telehealth companies has fostered an environment where ADHD telehealth companies can overprescribe controlled substances with impunity” and use aggressive advertising techniques on social media platforms to recruit and mislead consumers.

Despite the numerous challenges and sheer human loss brought by the COVID-19 pandemic, the crisis served as a catalyst for change in multiple realms of society. In healthcare, we have seen a dramatic increase in the use of telemedicine. Telemedicine has clear benefits in increasing accessibility, especially for those who live in rural and underserved communities without local providers. During the COVID-19 pandemic, federal and state governments loosened regulations to promote the use of telemedicine. By implementing an exception to the Ryan Haight Act of 2008, the DEA ultimately allowed providers to practice and prescribe controlled substances across state lines without the requirement of an in-person visit. This is especially relevant to the behavioral health sector, where decreased obstacles in some areas of telemedicine have offered more danger than equity, namely in the treatment of ADHD.

Companies like DoneADHD and Cerebral utilize a direct-to-consumer (DTC) telehealth delivery model, providing a convenient virtual option to receive an ADHD diagnosis and medications mailed directly to your door. The DTC telehealth model was initially designed to treat minor conditions. Campanini claims that the co-optation of this treatment model by companies like DoneADHD and Cerebral for the management of more complex, chronic conditions like ADHD highlights “two interconnected flaws with the DTC telemedicine model for ADHD treatment: overprescribing of addictive stimulants and predatory advertisements that mislead patients.”

Overprescribing

Campanini claims that overprescribing is tied to how these DTC telemedicine companies operate.

“They screen out patients who cannot take the medications they offer, rather than investigating the best possible treatment for that patient’s particular medical needs.”

This implicit promotion of pharmacologic management of ADHD as the initial and only treatment conflicts with the evidence-based recommendation for a multidimensional treatment approach to managing ADHD.

Additionally, these DTC telemedicine companies provide insufficient time for clinicians to conduct a thorough medical history, typically requiring only a short questionnaire and a thirty-minute virtual interview. This risks clinician misdiagnosis or overlooking what might be an alternative, actual cause of a patient’s symptoms. Without a thorough health history or physical exam, clinicians are also placed at increased risk of prescribing stimulants to a patient for which it may be contraindicated due to an underlying medical condition.

Campanini also provides accounts of clinicians feeling pressure from the company to provide a diagnosis and prescription during their visits. This may be tied to these companies’ financial interests in retaining customers who pay monthly for their subscriber-based services. This is supported by claims made last year by Matthew Truebe, Cerebral’s former Vice President, alleging the company told its providers their goal is to prescribe stimulants to 100% of their ADHD patients because it increased retention among customers.

Advertising

Campanini outlines the use of problematic advertising techniques on social media platforms.

“These companies utilize viral trends and memes to increase the effectiveness of the advertisements and target younger audiences,” and language that oversimplifies complex ADHD symptoms and misleads consumers into thinking they have ADHD. “According to one past provider on Cerebral, the advertisements will ask things like, ‘Have you ever felt overwhelmed?’ or ‘Do you ever not want to do your homework?’, which she described as ‘very basic and universal’ things to which people without ADHD can relate.”

Campanini notes how this method of marketing could lead patients to diagnose themselves with ADHD and seek treatment with a set view of what medications are right for them, which ultimately places more pressure on the clinician and can strain the doctor-patient relationship.

Additionally, Campanini argues that the use of this language in their advertising and the targeting of a student and young working professional demographic contributes to a culture of using stimulant medication to “focus” during exams and bolsters their misconception as “smart pills.” It is crucial to note abuse is especially common in the young adult population.

Among 18 to 25-year-olds, 7.4% report stimulant misuse, and 5% to 35% of college students report non-prescribed stimulant use. This misuse has been tied to beliefs that stimulants will produce academic enhancement, productivity, and improvements in cognitive performance in those without ADHD.

Regulation

Despite these dangerous advertising and prescribing practices, DTC telemedicine companies have been able to evade regulatory oversight. Campanini attributes this to outdated laws that were unprepared for the evolution of DTC telemedicine.

“Done and Cerebral currently evade the advertising regulations that pharmaceutical companies are subject to because they are not pharmaceutical companies, and they are technically marketing only medical services.”

She calls for DTC telehealth advertising to be subjected to the same FDA oversight used for pharmaceutical companies. Additionally, she categorizes the need for specific guidelines from the DEA regarding DTC telemedicine’s 1) appointment length, 2) release of medical information, and 3) provider training for prescribing controlled substances through telehealth services. These measures can prevent overprescribing, misdiagnosis, and fragmented or overlapping care in the management of ADHD through a DTC telehealth model.

Telehealth’s expansion is particularly relevant to the behavioral health sector. Without definitive or prerequisite biological markers, psychiatric diagnoses, like ADHD, are especially vulnerable to inflation and exploitation by economic interests.

Telemedicine has effectively addressed healthcare gaps and expanded access to care, notably during the pandemic. However, as the growth of telehealth continues, quality of care mustn’t be superseded by convenience or economic interests. For the protection of patients and a more responsible growth of telehealth, specific guidelines for DTC telehealth are needed to ensure compliance with the same high standard of care that traditional models demand when managing complex conditions like ADHD.

 

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Campanini, K. (2023). “TikTok Told Me I Have ADHD”: Regulatory Outlook for the Telehealth Revolution. Washington Journal of Law, Technology & Arts, 18(4), 3. (Link)

 

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.