Substance use treatment, gender-affirming care, and more at risk under proposed DEA rules

Dr. Kimberly Sue, the medical director of Harm Reduction Coalition, spent over a year using remote tools like FaceTime to treat patients for opioid use disorder. Through telehealth appointments that did not require in-person visits, she prescribed buprenorphine, a medication used to manage pain and opioid dependence. In a Twitter thread, Sue said people were grateful for this flexibility because it expanded access to “life-saving medication” for those who don’t have transportation or nearby health care facilities. New proposed rules from the Drug Enforcement Administration (DEA) could soon change that. 

The DEA published proposed rules on March 1 that would require practitioners to see patients in person at least once before they prescribe many controlled substances. This includes medications like Adderall, Valium, and testosterone. People who’ve only ever seen their doctor via telehealth appointments may soon have to go into the office to continue receiving their medication. The proposed rules were developed with the U.S. Department of Health and Human Services and in close coordination with the U.S. Department of Veterans Affairs. The DEA gave the public until March 31 to submit comments, and the agency will soon issue final regulations.

The DEA wrote that its proposed rules aim to provide guardrails for telehealth prescriptions. However, physicians and patients say the rules could hinder treatment to people with opioid use disorder; poor, disabled, or trans patients; and those in rural areas.

The American Psychiatric Association responded to the DEA’s proposed rules, writing that the requirement for in-person evaluations, “penalizes patients with unmet health related social needs including uninsurance or underinsurance, mobility and transportation challenges, and geographic disparity.”

Telehealth visits boomed in the first year of the COVID-19 pandemic when the federal government declared a public health emergency, which allowed doctors to prescribe controlled substances without an in-person visit. The Department of Health and Human Services also waived some restrictions, allowing Medicare to cover the costs for more extensive telehealth options. With the public health emergency coming to an end on May 11, these provisions aren’t guaranteed to remain in place. Data from the Centers for Disease Control and Prevention found that 37% of adults used telehealth services in 2021.

The DEA’s proposed restrictions for buprenorphine would mean that anyone who started treatment via telemedicine would have to see a physician in person within 30 days to renew their prescription. Currently, the average wait time to see a new primary care provider is around 26 days. Sue wrote on Twitter that this change would present “a major barrier to life-saving meds.”

“It is a sad fact that buprenorphine is already wildly inaccessible in the U.S. to people that need it and would benefit from it,” she wrote on Twitter. “We lost 108,000 people last year alone. And now the DEA is rolling back a provision that has and could continue to expand this [medication] for so many vulnerable folks.”

According to a February 2023 report from the National Association of Community Health Centers, more than 100 million Americans face barriers to accessing primary care in part because of rural hospital closures and a primary care provider shortage. Rivr Rayn lives two hours away from their established doctors, so telehealth has been their primary method of receiving care for the past three years. 

“Even prior to the pandemic, I would use telehealth as a means of convenience,” they said, noting that the cost of Ubers and taxis adds up quickly. “But now it’s the primary way I see my medical professionals. It’s allowed me to safely stay home and free up more time in the day. As an autistic person, it really helps ease a lot of anxiety, allowing me to be more succinct and collected with doctors.”

Rayn cited the rollback of mask mandates in health care facilities as another major barrier for access. 

“My household is an immunosuppressed one, so we can’t risk anyone getting sick because it could easily take us all out,” they told Prism. Rayn added that around 1 in 4 Americans is disabled. “[W]hile not every disability constitutes a weakened immune system, many do. Even people who’ve avoided COVID thus far are at risk of catching it and developing long COVID.” 

Kimberly Vered Shashoua, a gender-affirming therapist and Licensed Clinical Social Worker operating in Texas and North Carolina, transitioned to a fully online practice in 2020. Since then, they’ve used telehealth as both a patient and a provider. Vered Shashoua said patients have appreciated that they can discuss difficult topics in the comfort of their own home, and the therapist said they also favor telehealth appointments during a symptom flare. 

Vered Shashoua’s website is clear about the catalyst for the shift to telehealth. The top of the landing page reads, “In-person suspended until further notice. Thanks, COVID-19.” 

“Sick people, vulnerable people, these are the people who are in healthcare facilities,” Vered Shashoua said. “I can see an argument for increasing risk around people of varying levels of health, but there is no argument to be made for increasing risk for sick people in the places where sick people are and have to go. We’re on our own. Even if we mask, take an air filter, etc., we have to worry about our health. There are material, emotional, and cognitive barriers to getting care where masks aren’t worn.” 

Both Vered Shashoua and Rayn referred to the U.S. government’s response to the pandemic as “eugenics.” 

 “[These policies] are disabling people and then giving them nowhere to turn,” Rayn said. “It’s forced death and being sold as freedom.”

For some, these risks are enough to consider going without care. 

Jennifer Brown and her partner are deaf, and they rely on telehealth to get their mental health medications because they can ensure an interpreter will be available. Brown, a yoga teacher who lives in Baltimore and doesn’t drive, would otherwise have to coordinate rideshares to see multiple specialists in person. They also rely on a community health system that sees a lot of turnover, meaning they would have to schedule in-office appointments for every new psychiatrist. This year Brown has already had two doctors, and her partner is on his third. 

These factors, coupled with the risk of contracting COVID-19, have prompted Brown to consider whether getting their prescriptions is worth it. 

“A lot of people who are very concerned about this new situation with the DEA are high-risk and already avoiding health care in many situations because of the risk that ending mask mandates poses to their health, me included,” Brown said in an email. “I am considering—or I do consider—how much value these medications that make my life manageable and even keep me alive are worth when there are so many barriers to getting them.”

The DEA’s proposal has also drawn criticism for its potential to limit access to testosterone, which is a Schedule III controlled substance. Vered Shashoua said many of their rural transmasculine patients would have to drive hours to find a medical center that would prescribe hormone replacement therapy. 

“They would have to find new providers, which can be difficult,” they said. “You have to find a provider who takes your insurance or you can afford, who is competent at their job and you feel comfortable with. There’s a huge emotional and cognitive burden involved in changing providers.”

Trans patients are more likely to utilize video telehealth services. The National Transgender Discrimination Survey found that 19% of the more than 6,400 people surveyed reported being refused care because of their gender identity, and half of participants said they had to teach their doctors about transgender care. Telehealth allows trans patients to bypass these barriers to access the care they need.

Legislators have proposed nearly 500 anti-trans bills in 2023, and Rayn sees the DEA’s proposal as more of the same.

“My feminizing hormone treatment is not a controlled substance, but for [transmasculine people] testosterone is,” she said. “By forcing in-person visits, we are once again limiting gender-affirming care for consenting adults and putting them at greater risk of harm from multiple avenues.” 

Rayn and Sue, the doctor who treats patients recovering from opioid addiction, urged their Twitter followers to respond to the proposed rule changes during the DEA’s public comment period that ended March 31. 

“These changes are security theater,” Vered Shashoua said. “With rural hospitals closing at rapid rates, America needs to maintain or expand telehealth. Texas has had mental health crises for decades, with few providers and fewer accessible locations. We’ve known and documented these deficits in accessibility. We need to make positive changes instead of increasing inequalities in access.”

Ash Peterson (she/they) is a freelance writer and illustrator with a particular interest in environmental and disability issues. They are based in Northwest Georgia, where she received two awards from...