Managing Medications

Q: Can I Get My ADHD Medication Refilled Out of State?

Snowbirds and college students alike have long struggled to get prescription refills of ADHD medications deemed controlled substances. However, a recent DEA rule change has lifted the requirement for face-to-face doctors’ appointments for refills, paving the way for more efficient telemedicine.

An RV road trip

Q: “I live full time in my RV and travel the country.  My residency is in Vermont, but I’m presently residing in Arizona and it seems I need to become a resident of Arizona to get a prescription — at least at some clinics. Given that my ADHD medication is a controlled substance, I can’t get a script from my PCP back in Vermont because it requires a face-to-face appointment. Do you have any advice for long-term travelers or college students with ADHD who need to get their prescriptions while away from home?” — Michael

Dear Michael,

The short answer is that the Drug Enforcement Administration (DEA) rules changed permanently in March 2020 and, so long as the initial evaluation was done face-to-face, your original prescriber can continue to prescribe for you based on contacts by phone, Internet, and video conferences such as Zoom. This is a permanent rule change, and it is huge since change at the DEA is usually measured in decades.

The long answer is much more complicated because it keeps changing monthly due to the many different and evolving responses to the pandemic being launched by hundreds of state and federal regulators.

The regulator the really matters is the DEA. No one in any state can prescribe controlled substances unless they have a national DEA certificate. If a clinician loses their DEA certificate, they are out of business. This is because whatever would cause the loss of the DEA certificate would also jeopardize state medical licenses, hospital privileges, liability insurance, etc. as well.

Your doctor in Vermont still has to deal with state regulations. Interestingly enough, they are not going to affect you that much because Vermont’s regulations are concerned with dispensing controlled substances going into Vermont, but not out of Vermont.

[Click to Read: Can You Stock Up on ADHD Medications During a Crisis?]

The DEA’s sole concern as far as doctors and patients are concerned is verifying that there is a real doctor-patient relationship. The DEA wants to prevent “pill mills” in which the person with prescriptive authority is just selling prescriptions that will be abused. A doctor-patient relationship requires that the clinician and patient have met in person — usually for the initial assessment, but the follow-up can now be done virtually (more about this below). The doctor must keep records and must obtain objective measures of whether the controlled substance is being used safely. In the case of all of the medications used in ADHD, this is achieved by taking a baseline blood pressure and heart rate measurement before starting the medications and then repeated determinations on the medication every 90 days to document that:

  • with stimulants the diastolic pressure (the bottom or 2nd number) has not increased more than 10 points over the baseline reading and that the pulse rate is not over 100.
  • with alpha agonists (clonidine and guanfacine) that the BP and pulse rate have not decreased below a systolic (the 1st or upper number) of 90 or a pulse rate of 60 bpm.
  • No lab tests or ECG are routinely needed.

The DEA and most states require that only 90 days of a controlled medication can be prescribed at one time before the clinician and patient have to check in with one another again but now, for the first time, this check-in can be done virtually.

The DEA does not regulate the dose of medications or the amount that can be dispensed at one time.

[Read: ADHD Medications for Adults and Children Overview –ADD Stimulants, Nonstimulants & More]

At this time, just four states will not honor controlled prescriptions from other states:

  • New York
  • Texas
  • California
  • Hawaii

Two other states are constantly changing their regulations so you and your doctor would have to check every time:

  • Michigan
  • Massachusetts

Mail order pharmacies will ship controlled substances to all 50 states, but there must be a physical address (no P.O. Boxes) and someone must be physically present to sign for the package. (This is usually the requirement that keeps this from working for college students)

Telemedicine has been possible for more than 20 years but had limitations on it that made its use very difficult. The biggest restriction came from the refusal of insurance companies to pay for it. The second was the face-to-face requirement from the DEA that was just recently lifted. It meant that pain patients who needed analgesic medications had to painfully get to the doctor’s office every 90 days at a minimum in order to get their pain medications.

Face-to-face meetings were a hard-and-fast rule… until the pandemic. Suddenly, 20 years of restrictions that prevented remote medicine/telemedicine disappeared in a matter of days.

There were two big changes on January 31, 2020:

1. The U.S. Secretary of Health and Human Services has declared a public health emergency. HHS Secretary, Alex Azar, declared such a public health emergency with regard to the pandemic on January 31, 2020. For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation. For now, doing the evaluation by telemedicine or some meeting software app (ex. ZOOM) is enough. This will change back to the original requirement for face-to-face meetings as soon as the national state of emergency is lifted.

2. If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared by the Secretary of Health and Human Services, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. In addition, for the prescription to be valid, the practitioner must comply with any applicable State laws.

I cannot over-emphasize how important it is for the clinician to document, document, document. The existence of an ongoing real doctor-patient relationship must be documented every time a prescription is written for any controlled substance. The clinician sending a bill to you or your insurance is not good enough.

Be ready to give your clinician a blood pressure and heart rate at your telemedicine appointment. This may take some searching because the automatic cuffs that have been available at most pharmacies have been removed to prevent transmission. The upper arm automatic BP cuffs are adequate, but the wrist cuffs are too highly variable.

Finally, most clinicians are not aware of the DEA rule change. Sometimes, even when they know of the change, they are still uncomfortable with the change and may refuse to write a prescription without a face-to-face meeting. This is entirely appropriate and within their rights as prescribers.

Telemedicine: Next Steps

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