Telehealth for ADHD treatment associated with higher risk of substance use disorders

Telehealth for ADHD treatment associated with higher risk of substance use disorders

For nearly five years, people with attention-deficit/hyperactivity disorder have had the opportunity to have their stimulant medications prescribed and renewed by doctors who only see them through a computer screen, despite the risks that these stimulants can pose in drug abuse.

Given the expiration dates for the TELEHEACK rules that made this possible, a new study provides important evidence about the safety of virtual ADHD care that could inform policymakers.

Published in JournalHealth MattersBy a team at the University of Michigan, the study shows that people ages 12 to 64 who began receiving stimulant medications via telehealth over the next year were slightly more likely to develop substance use disorder (SUD, sometimes called addiction) than those who began receiving the medications via in-person care. The risk in these two groups was 3.7% versus 3.2%.

For the entire study population of 12- to 64-year-olds, the higher risk disappeared when taking into account the fact that people who used telehealth to start stimulant therapy were more likely to have mental illnesses such as depression. These conditions are strong risk factors for SUD.

However, the study finds one group — adults ages 26 to 34 who started their ADHD stimulants through telemedicine — had a higher risk of SUD even after accounting for mental health conditions.

“Although there appeared to be an increased risk of substance use disorder among patients who initiated their ADHD stimulant medication through telehealth, when we accounted for psychiatric diagnoses that also increased risk, the difference disappeared except for those aged 26 to 34,” said Joanne Constantin, Ph.D., the study’s lead author and a postdoctoral research fellow at the Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, based in the UM Department of Pediatrics at the Faculty of Medicine.

The fact that young adults after age 26 are largely no longer able to be covered by a parent's health insurance could play a role, Konstantin said. “Young adults are more independent when receiving their own medications without parental supervision, highlighting the importance of screening and monitoring in this age group.”

The researchers conclude that screening for addiction risk and monitoring signs of SUD may be important to include in future guidelines regarding telehealth-based ADHD care.

Current federal state rules allow behavioral health care without in-person visits until Dec. 31.

This is in addition to other policies designed to prevent the abuse and diversion of stimulants for ADHD, which are specifically regulated controlled substances. Such drugs, sold under names like Ritalin and Adderall, now carry strong warnings from the U.S. Food and Drug Administration about potential risks from abuse.

Telemedicine can be an essential way to access care. However, this study highlights an ongoing need to balance such access with protecting safety through guidelines for providers about screening and follow-up. “

Joanne Constantin, Ph.D., study lead author of the study

Konstantin collaborated with pediatrician and Michigan Medicine health researcher Kao-Ping Chua, MD, Ph.D., a member of Chear, on the study.

Current ADHD prescribing climate

To prescribe stimulants for ADHD, physicians must be licensed by the U.S. Drug Enforcement Administration and must often review the patient's prescription drug prescription records to see the patient's history of receiving medications that are controlled based on their risk of abuse.

However, there are no specific guidelines for screening for SUD risk factors at the start of treatment or monitoring patients for SUDs on an ongoing basis, beyond the FDA's "Black Box" warning.

This warning focuses not only on the potential risk of using ADHD stimulant medication in ways different from those prescribed, but also the risks to people without ADHD to whom the patient might give or sell their medication.

Several companies have been offering standalone ADHD care over the past five years after insurance requirements for virtual care became much more flexible due to the Covid-19 pandemic.

Some of these companies were investigations of criminal and non-criminal cases from state law enforcement agencies due to the alleged lack of oversight over how the stimulants are prescribed by their clinicians.

More about the study

The study used data from anonymous health insurance records from people with private insurance or Medicaid coverage. It included 77,153 people who had not received a stimulant ADHD medication or a SUD diagnosis in the past year and who started using a stimulant in 2021.

Researchers then examined records for the same people over the year after they received their first stimulant prescription to see whether they were diagnosed with an SUD of any type.

More than 21,000 patients began their stimulant medication via a telehealth visit, while the remainder began with an in-person visit. Those who started via Telegehealth were much more likely to also have a diagnosis of anxiety, depression, and/or another psychiatric condition in their records. Therefore, the researchers adjusted for this difference and other differences between the two populations in their analysis.

In addition to Konstantin and Chua, the study authors are Sean Estaban McCabe, Ph.D., and Emily Pasman, Ph.D., LMSW, of the UM School of Nursing, and Timothy Willens, MD, chief of Child and Adolescent Psychiatry and co-director of the Center for Addiction Medicine at Massachusetts General Hospital.

McCabe directs the UM Center for Drug, Alcohol, Smoking and Health Assessment, also called the Dash Center. McCabe and Chua are members of the UM Institute for Health Policy and Innovation.

Chua has consulted for the U.S. Department of Justice on unrelated matters.

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