From the pandemic, a direct healthcare boom was born.
Lockdowns and social distancing created a market for pharmacy delivery, video appointments, and home testing kits. But of these new ventures, the most opportunistic are companies selling prescriptions for stimulants, like Adderall and Ritalin, over the internet. As a lawyer who counsels companies on regulations, I know that the FDA’s classifies stimulants as Schedule II drugs, meaning they have a high potential for abuse. So, I am shocked to see web ads for online ADHD treatment alongside ads for shoes and candy.
The companies that sell stimulant prescriptions online - Done, Health Piper, Good Rx, Circle Medical, and others - are taking advantage of a COVID-related exception to the Controlled Substances Act. The Act prohibits the prescription of Schedule II drugs online. But the law has a built-in exception, triggered when the Secretary of Health and Human Services declares a public health emergency, which is what happened in January 2020 during the pandemic. Now, getting legal stimulants is as easy as opening up a laptop and connecting to Wi-Fi.
And this should terrify us. Misuse of prescription stimulants is widespread. Although the drugs can be prescribed to treat conditions like attention deficit disorder, binge eating disorder, and narcolepsy, many use the drugs to get a competitive edge. Stimulants increase alertness, enhance focus, and curb hunger. Students pop Vyvanse to cram before exams. Workers use the drugs to get through long shifts. Dieters take pills to suppress their appetites. In response to a 2018 study, over 5 million Americans admitted misuse.
Misuse presents a danger because prescription stimulants are addictive, just as are non-legal stimulants, like cocaine and methamphetamine. Prolonged use can result in dependency, a sense that users need the drugs in order to function normally. Comorbid with dependency is a host of psychological and physiological side effects, including social impairment, loss of productivity, and cardiovascular abnormalities. Withdrawal from stimulants can cause dysphoric mood (the opposite of euphoria), fatigue, disturbing dreams, and increased appetite. After prolonged stimulant use, users may build up a tolerance - as the drugs lose efficacy, higher doses are required to achieve the same effects, which risks a fatal overdose.
Previously, the in-person diagnosis requirement served as a small hurdle one must clear to score a prescription. A patient would show up to a healthcare provider’s office and answer a series of questions. Based on the answers, the provider would decide whether to make a diagnosis and write prescription. The process was gameable, as it was fairly obvious what responses would yield a diagnosis. But the hassle of making a trip to an office and the discomfort of responding to diagnostic questions in-person (sometimes to a primary care provider with which the patient has built a rapport) served as a possible deterrent to those wanting stimulants for non-medical reasons. But with that safeguard removed, stimulants are a click away. In the case of one company, Done, a customer must simply fill-out an online questionnaire and attend a video call to receive a diagnosis and a prescription.
Another worrisome aspect of the emerging business model is that many of the companies not only write prescriptions, they also fill them. The conflict strikes me as a major legal red flag. The companies have a financial incentive to make diagnoses, which is at odds with the interests of patients.
It’s unclear if the internet stimulant trade is here to stay. Afterall, the exception to the Controlled Substance Act should expire at the end of the public health emergency. Yet, these businesses may seek a loophole or lobby to enable their continued operation. But, regulators should intervene to protect patients and crack-down on the capitalization of the demand for productivity pills.
If they do not, the dawn of the next prescription drug epidemic is near.
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