Both cannabis and buprenorphine have been used to treat opiate addiction, and both have been prescribed or recommended for this purpose via telemedicine during the pandemic. However, only buprenorphine may remain eligible for this type of streamlined access after cannabis is rescheduled, which is alarming to many healthcare advocates. Here’s why.
The DEA has temporarily extended COVID prescribing flexibilities while it considers new regulations to loosen restrictions for buprenorphine prescriptions. This plays out as federal regulators consider a directive by the Biden administration to "expeditiously" review the classification of cannabis as a Schedule 1 drug.
Cannabis's reclassification will have far-reaching unintended consequences on already established state medical marijuana markets. We can reduce this chaos by implementing self-enacting regulations that will foresee and forestall these potential disruptions.
Meanwhile, in anticipation of the end of the federal emergency, SAMHSA is proposing that buprenorphine be excepted from the in-person medical evaluation requirements of the Ryan Haight Act. If passed, this regulation will squeak into effect just as the public health emergency exceptions for COVID end.
This is excellent forward-thinking on the part of regulators as opiate addiction treatment prevents deaths due to overdose. This proposal has met with caution, however, because despite its therapeutic value, buprenorphine results in hundreds to thousands of overdose deaths per year and is frequently abused. Thus, regulators, activists and addiction industry stakeholders feared that the loosening of telemedicine restrictions would result in an increase in buprenorphine overdose deaths.
Fortunately, a recent study found no increase in buprenorphine overdoses between 2019 and 2021, despite the allowance of telemedicine for first-time buprenorphine patients. The study reaffirms the safety of telemedicine as a tool for delivering addiction treatment. It's a huge win for telemedicine in general—and evidence that telemedicine for cannabis is safe as well.
With recent advances in video telemedicine platforms, record-keeping and monitoring, healthcare practitioners operate in a completely different environment than they did during Ryan Haight's tragic and regrettable death. Telemedicine now massively increases access to quality medical treatment for patients who have mobility difficulties, need isolation due to illness or live in underserved areas.
As regulators unveil their proposed adjustments to controlled substance and telemedicine rules, activists are attempting to force federal foot-draggers to remove cannabis from its Schedule 1 status via lawsuit, appeal and any other action that has a remote chance of making lawmakers and regulators see reason. The general push seems to be in favor of any improvement, whether the substance is descheduled or merely rescheduled. But many are unaware of just how disruptive rescheduling cannabis to Schedule 2 will be.
Currently, state lawmakers aren't subjecting cannabis regulations to the same restrictions that apply to other drugs on the schedule because it's recommended in most states rather than prescribed. This is done as a "workaround" due to the plant's illicit status.
But it stands to reason that cannabis will be subject to prescription requirements should it become a Schedule 2 drug with (finally) recognized medical benefits. Rescheduling may also subject cannabis to the telemedicine prohibitions of the Ryan Haight Act.
This would have a profound and damaging effect on the millions of Americans who currently access their medical cannabis via telemedicine. It would push some patients back into the black market. Or worse, will it push patients toward prescriptions known to cause fatalities, even though cannabis works perfectly for them already. This is the very opposite of harm reduction. It's why we need to take every action possible to reasonably ease restrictions on access to cannabis specialists.
SAMHSA's recent regulatory proposal also includes an explanation for why it did not include the option of audio-only telemedicine for methadone: "SAMHSA is not extending this change to the use of audio-only telehealth platforms in assessing new patients who will be treated with methadone because methadone, in comparison to buprenorphine, holds a higher risk profile for sedation in patients presenting with mild somnolence which may be easier to identify through an audio-visual telehealth platform."
It's commendable that regulators are taking the risk factors of these treatments into consideration when deciding the type of distance medicine that should be allowed. It's the right approach for replacement therapies with a high-risk profile.
Under the same reasoning, cannabis recommendations via audio-only evaluations should be allowed with federal legalization because cannabis alone causes even fewer deaths from respiratory depression than buprenorphine—arguably zero, compared to hundreds. So it stands to reason that cannabis shouldn't be subjected to video requirements any more than buprenorphine should.
This is not to say that cannabis has never been associated with fatalities as a contributory factor or harm. Drug interactions and negative reactions do happen. Patients using medical cannabis for serious illnesses should be carefully monitored and guided.
But this is yet another reason we should make the telemedicine administration of this treatment as accessible as possible. Telemedicine applications already make it possible to carefully evaluate and guide at-risk patients who would otherwise turn to the unguided black market simply because it's more convenient and accessible.
The outdated prejudices against cannabis and telemedicine present a tough hurdle to overcome, and legislative and regulatory processes make snails seem to move at light speed. When the administration finally stands on the right side of history and acknowledges the medical benefits of cannabis, they will likely reschedule it instead of deschedule it. We need to take steps to reduce unintended harm caused by regulatory red tape that will result.
One solution is to create self-enacting regulations that apply the same telemedicine exemptions for cannabis as SAMHSA is currently proposing for buprenorphine. Forward-thinking regulatory actions like this will vastly reduce the chaos that is destined with the upcoming changes in cannabis scheduling.
As society comes to the collective realization that technological advances make telemedicine a legitimate tool for vastly improved healthcare access, we must leave the deadly double standards and prejudice surrounding cannabis and telemedicine behind.
Deb Tharp is a legal and policy researcher at NuggMD, a platform for patients seeking medical cannabis prescriptions in 22 states.