NCIL Member Center

Protect Access to Opioids for People with Chronic Pain: Barriers to Accessing Prescriptions and Telemedicine

November 29, 2023

Dear Secretary Becerra, Administrator Milgram, Attorney General Garland, and Assistant Secretary Delphin-Rittmon,

We write this letter on behalf of the undersigned disability rights organizations. As organizations that advocate for the civil and human rights of people with disabilities, we are deeply concerned about access to prescription medication via telemedicine.

Along with the Association for Programs for Rural Independent Living (APRIL) and the Centers for Independent Living (CILs) and Statewide Independent Living Councils (SILCs) represented by NCIL, we urge the Department of Health and Human Services to collaborate with the DEA on a final rule that keeps existing pandemic telehealth flexibilities in place.

As the COVID-19 emergency expires, the Drug Enforcement Agency has proposed rolling back pandemic-era flexibilities in prescribing controlled substances through virtual visits. NCIL provided comment to the Drug Enforcement Administration on the proposed rule, emphasizing disproportionate impact on our membership. We thank the DEA for extending the final rule until 2024, in response to comments from our organization and many others.

During the COVID-19 pandemic, we were heartened to see DEA expand access to telemedicine for Americans with chronic medical conditions. Flexible rules during the pandemic emergency not only improved care for individuals at high risk for COVID-19, they also improved longstanding inequities for individuals with substance use disorder, neurological conditions such as ADHD and seizures, and physical disabilities including chronic pain. All of these populations suffered from extremely limited access to care even before the pandemic, due to stigmatized diagnoses or physical inaccessibility of health care services [1, 2].

People with disabilities in rural areas face disproportionate barriers due to transportation and travel time [3], scarcity of providers [4], and wait times even longer than the 26-day average wait in large metropolitan areas [5]. Over 130 million Americans live in areas with a shortage of mental health providers. In those areas, only 28% (on average) of the demand for mental health care is met, with 6,600 new providers still needed to meet current needs [6]. Rural areas in particular do not have enough specialists in addiction medicine, psychiatry, or pain management to handle increased workload from a new in-person requirement; for example, only 45% of U.S. counties have a practicing psychiatrist [7, 8]. If practitioners are required to schedule all of their telemedicine patients for at least one in-person visit, those appointments will take up time that could have gone to new patients in critical need of care.

Even allowing for qualifying referrals, the narrow exceptions in the proposed rule are insufficient given that people of color and people with disabilities face inequities in access to care. A recent NBC News story highlights this disparity, quoting a patient who called more than 150 doctors before finding one who would accept her [9].

People with disabilities include individuals with opioid use disorder (OUD), less than 23% of whom received lifesaving medication as of 2022 [10]. Racial disparities in access are pronounced; among overdose decedents in Black, Hispanic, and American Indian/Alaska Native racial groups, only 8-10% previously accessed addiction treatment with medication [11].

Our members also include trans people, who have new and urgent need for inter-state prescribing due to state prohibitions on gender-affirming care. The proposed rule would require practitioners to become DEA-licensed in multiple states, a requirement that also affects people with chronic pain and rare disease. According to the National Pain Advocacy Center, “[p]eople with limited mobility, those with various stigmatized conditions, and those living in rural areas often rely on telemedicine relationships with geographically distant practitioners simply because they either lack access to nearby practitioners or there are no qualified nearby practitioners that will provide them with care.”

Individuals with neurological or psychiatric conditions may have disabilities in executive function that affect their ability to schedule appointments and navigate hurdles at the pharmacy. Some of our members with ADHD report that DEA’s telemedicine expansion finally enabled them to access helpful medication for the first time in their lives. For newly diagnosed patients, as well as long-term patients establishing care with a new provider, the proposed rule would erase these gains.

For all of our members in the disability community, the regulatory environment for prescribing controlled substances is very different than it was in 2008 when the Ryan Haight Online Pharmacy Consumer Protection Act was enacted. Today, every controlled substance prescription is subject to multiple controls from state and federal agencies, as well as prior authorizations and pharmacy policies. In addition to CDC guidelines and Medicare/Medicaid rules, the U.S. Food and Drug Administration identified 526 new state laws and policies targeting opioid prescribing between 2016-2018 alone, with many more added since then [12]. As a result, opioid prescribing for pain has declined 44% to 1993 levels (per capita) [13]. Meanwhile, CDC data shows deaths related to illicit fentanyl have spiked by over 1000% between 2013-2021, while deaths related to prescribed opioids stayed roughly constant [14]. Not only have restrictions on prescribing failed to lower overdose rates, studies suggest that laws to limit prescribing may, inadvertently, result in more illicit drug use and more overdose events [15, 16].

Even more recent studies have found that expanded access to telehealth, rather than increasing harms from drug diversion, actually lowered overdose risk by allowing more patients with substance use disorders to start and sustain treatment [17, 18]. The text of the DEA rule acknowledges that psychiatry can be delivered effectively by telemedicine. Even in primary care, quality outcomes from telemedicine are similar to in-person [19].

In this context, stricter controls on prescribing via telemedicine are unwarranted, and the Biden Administration can save more lives by allowing telemedicine rules to continue as they have been through the pandemic emergency.

We thank you for considering these concerns and recommendations of the disability community. Any questions or comments may be directed to Jessica Podesva, Director of Advocacy and Public Policy (jessica@ncil.org).

Sincerely,

Jessica Podesva, J.D.
Director of Advocacy and Public Policy, National Council on Independent Living

Theotis Braddy
Executive Director, National Council on Independent Living

Brandon Brown
Executive Director, Association of Programs for Rural Independent Living

End Notes:

  1. Lagisetty PA, Healy N, Garpestad C, Jannausch M, Tipirneni R, Bohnert ASB. Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids. 
  2. Gloria L. Krahn, Deborah Klein Walker, and Rosaly Correa-De-Araujo,2015: Persons With Disabilities as an Unrecognized Health Disparity Population, American Journal of Public Health 105, S198_S206.
  3. Suntai Z, Won CR, Noh H. Access Barrier in Rural Older Adults’ Use of Pain Management and Palliative Care Services: A Systematic Review. Am J Hosp Palliat Care. 2021 May;38(5):494-502.
  4. Health Resources and Services Administration, Health Workforce Shortage Areas.
  5. “AMN Healthcare Survey: Physician Appointment Wait Times Up 8% from 2017, Up 24% from 2004.”
  6. “Where the behavioral health crisis is at its worst” Behavioral Health Business.
  7. James R. Langabeer, et al., “Geographic Proximity to Buprenorphine Treatment Providers in the U.S.” Drug and Alcohol Dependence (2020).
  8. “Mapping Supply of the U.S. Psychiatric Workforce,” School of Public Behavioral Health Workforce Research Center, University of Michigan. October 2018.
  9. CDC’s new opioid guidelines are too little, too late for chronic pain patients, experts say, (March 13, 2023).
  10. Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health.
  11. Kariisa M, Davis NL, Kumar S, et al. Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics – 25 States and the District of Columbia, 2019-2020. MMWR Morb Mortal Wkly Rep 2022;71:940-947.
  12. “Methods for Evaluating the Opioid Analgesic Risk Evaluation and Mitigation Strategy,” Center for Drug Evaluation and Research, Food and Drug Administration, December 11, 2020.
  13. Woods C. Prescription opioid utilization patterns in the U.S. FDA public workshop on opioid prescriber education. October 13, 2021.
  14. See CDC National Vital Statistics.
  15. See Lee., B. et al., Systematic Evaluation of State Policy Interventions Targeting the U.S. Opioid Epidemic, 2007-2018. 
  16. Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LM, Lyden J, Xu S, Narwaney KJ. The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study. Drug Alcohol Depend. 2020 Dec 1;217:108248.
  17. Jones CM, Shoff C, Hodges K, et al. Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2022;79(10):981–992.
  18. Wang, L., et al. Telemedicine increases access to buprenorphine initiation during the COVID-19 pandemic. Journal of Substance Abuse Treatment. January 15, 2021.
  19. Baughman DJ, Jabbarpour Y, Westfall JM, et al. Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System. JAMA Netw Open.2022;5(9):e2233267.