Some telehealth firms are rethinking ADHD drugs

Bloomberg: The largest online mental health startup has tightened its prescription practices after criticism by medical professionals that its aggressive social-media marketing and workplace culture made some addictive medications too easy to get. And there are signs that scrutiny of mental telehealth is only intensifying.

SoftBank-financed Cerebral announced it would stop writing new prescriptions for drugs that treat attention deficit/hyperactivity disorder, such as Adderall and Ritalin. That announcement came after a recently departed executive alleged in a lawsuit that Cerebral’s chief medical officer had told employees the company’s goal was to prescribe stimulants to 100% of its ADHD patients as part of a plan to increase customer retention. The company has denied that contention.

Its rivals face challenges as well. At one, a former nurse practitioner recalls diagnosing a patient with obsessive-compulsive disorder and then being quizzed by her supervisor immediately afterward: Why hadn’t she also prescribed ADHD medication? That company, known as Ahead, announced last month that it would be closing.

A third startup, known as Done, has also stirred concern among clinicians by using a  2020 training manual that told them to consider prescribing addictive amphetamines even to patients who didn’t fit the official criteria for an ADHD diagnosis.

Online mental-health firms have been allowed to prescribe controlled medications, including those for ADHD, for a little over two years, thanks to a regulatory rollback that was meant to improve patients’ access to care during pandemic lockdowns. That rule change also spurred competition among the web-based platforms and a rush of advertising that promised quick diagnoses. Among the changes Cerebral announced this week was a plan to submit all social-media advertisements to an internal clinical review committee.

Agents from the Drug Enforcement Administration have spoken with at least two Cerebral employees about its handling of controlled substances, according to two people familiar with the conversations. A Cerebral spokesperson said that the company was “unaware” of any such conversations and said it has not been contacted by the DEA. A spokesperson for the agency said it “cannot confirm or comment on ongoing investigations.”

Since the new breed of companies began writing online prescriptions, national amphetamine sales have boomed, according to nationwide data from the DEA. In 2021, the amount of prescription amphetamines, such as Adderall, that were sold in the U.S. jumped by 1.37 million grams, or 1 ½ tons, over 2020, the DEA data show. It was the biggest annual gain since 2016. More than 41 million prescriptions for amphetamines were filled last year — an almost 16% increase over 2019, before the Covid-19 pandemic began, according to IQVIA, a clinical research and technology company.

The causes of that surge vary, but it’s being fed in part by online providers, which allow customer complaints — including that prescribers have been too stingy with drugs — to drive business decisions, former employees say. Nearly two-dozen current and former clinicians at the companies described a race to the bottom, in which executives pressured them to prescribe ADHD medicine in order to preserve or increase their firms’ market share.

Executives and spokespeople for the companies defend their approach to telemedicine at a time when the Covid-19 pandemic has stirred concern about mental health even as it limited opportunities for face-to-face treatment. And they reject any suggestion that they’ve put profits ahead of patient care.

“Our team is not incentivized to diagnose and treat any specific condition,” said Don Campbell, a spokesman for Cerebral, which has been valued at $4.8 billion. “Our singular goal is to help patients who are struggling with mental illness get access to clinicians who can carefully assess and provide a professional expert opinion on the best course of treatment.”

The firms say they’re broadening access to much-needed care through impactful advertising and patient-centered approaches — and they win plaudits from many customers who say their lives have improved. Yet some experts say their subscription-based business model — pay a monthly price for diagnosis, prescription and follow-up appointments — can imperil patient health.

“The direct-to-consumer model, supported by the pharmaceutical industry, is an inappropriate, potentially dangerous model,” says Omar Atiq, president-elect of the American College of Physicians, who co-authored a 2021 research paper that examined the role of profit in the U.S. healthcare system. “With the new technologies we have available, many vulnerable people, mostly young, could self-diagnose illnesses that they would not be qualified to diagnose.”

A more troubling concern stems from the ADHD medications that have been a focal point of much of the companies’ advertising. The drugs can be abused — the DEA puts them in the same risk category as cocaine and fentanyl — and are popular with recreational drug users and people looking to improve their focus. Bloomberg News interviewed 23 current and former clinicians for the online companies who said they fear the industry is fueling an inappropriate boom in ADHD-related prescriptions.

“Don’t miss out on your discounted ADHD diagnosis,” says an ad for Done, which was founded in December 2019 by former Facebook product designer Ruthia He and backed by investors including former San Francisco 49ers quarterback Joe Montana. The company now offers ADHD treatment in 25 states and the District of Columbia. A training manual provided to Done employees in 2020 suggested that clinicians consider prescribing ADHD medications even to patients who didn’t fully fit the diagnosis. “Still might be worth doing a medication trial,” the document stated.