Pandemic-era rules around telemedicine have been a huge boost to efforts to prevent opioid overdoses in the US. But those rules are also how controversial startup companies like Cerebral were able to prescribe Adderall and Xanax to huge numbers of people — and efforts to stem that flood of prescriptions could sweep away overdose prevention efforts in the process.

Since 2020, doctors have been able to prescribe controlled substances after a telehealth visit without needing to see patients in person. But that’s a big umbrella: Adderall and Xanax are controlled substances. So are buprenorphine and methadone, which are used to treat people dependent on opioids. Opioid overdoses have reached epidemic proportions in the US, with tens of thousands of people dying every year.

Telehealth led to clear improvements in treatment access for people with opioid addiction or dependence, also known as opioid-use disorder. But the policies that led to those improvements aren’t guaranteed to stay in place. They could end, and the risk of them ending went up with the public backlash to practices of companies like Cerebral, which used those same telehealth policies to distribute huge numbers of prescriptions — including medications that are often misused. The COVID-19 public health emergency that enabled both is set to expire in October, though the Biden administration could extend it again. But it will end eventually, and when it does, policymakers will have to decide if they’re going to keep some of the relaxed public health rules or if they’ll revert to the pre-pandemic status quo.

“We’re already thinking about contingency plans, while at the same time trying to do whatever we can to show pretty much anyone who will listen that this is very beneficial,” says Shoshana Aronowitz, a health services researcher at the University of Pennsylvania who provides substance-use disorder treatment in Philadelphia and through the digital platform Ophelia Health. “It’s very easy for these things to kind of get grouped together in people’s minds and then also in policy.”

Prior to the pandemic, doctors weren’t able to prescribe controlled substances without at least one in-person visit. The Drug Enforcement Administration (DEA) waived the requirement in March 2020 as pandemic restrictions made it more difficult (and the pandemic made it potentially dangerous) for people to set up in-person appointments.

That waiver made it easier for people struggling with excessive opioid use to set up appointments and start treatment, research shows. The ability to use telehealth also helped create new types of innovative healthcare programs. The University of Pennsylvania, for example, set up a “bridge clinic” that lets people set up same-day telehealth visits (via phone or video) and get a same-day, short-term prescription for medication that can reduce the effects of opioid withdrawal and help them stop using more dangerous drugs like heroin. That would hold them over if there were a wait for an in-person appointment. “They could easily overdose and die in that time,” Aronowitz says. “Being able to bridge people for even a few days is huge. And you can’t do that if you’re not allowed to prescribe via telehealth.”

Getting more people connected to medication that can help them has clear benefits to fight the overdose epidemic in the United States, she says. “Medication for opioid-use disorder is really the best, most evidence-based thing to treat opioid-use disorder and prevent overdose.”

Even though offering these prescriptions via telehealth was legal under pandemic-era guidelines, Aronowitz says she still ran into some challenges with pharmacies — some of which wouldn’t fill prescriptions if they came from a telehealth visit. There’s stigma and misconceptions around using a drug to treat reliance on another drug, with some patients told they’re not actually sober if they use something like buprenorphine. Some pharmacies had been reluctant to fill the prescriptions if they were sent through telehealth from providers in different states.

That was even before the backlash started against companies like Cerebral — doctors for the company said they felt pressure to prescribe ADHD medication without proper evaluation, the US Department of Justice opened an investigation, and the company eventually said it would stop prescribing controlled substances.

In the face of that news, Walmart stopped filling prescriptions for controlled substances through telehealth. That policy didn’t differentiate between the various types of controlled substances, which are used for very different types of health conditions. (ADHD, for example, is different from opioid-use disorder.) Any blanket approach that groups every controlled substance together doesn’t account for the different types of care patients receive, Aronowitz says.

The focus for these types of decisions should be on the quality of the care, not the way the care is delivered. “I think the most important thing is — is there a real treatment relationship?” says Aaron Neinstein, the vice president for digital health at the University of California, San Francisco Health. “Does the doctor know who the patient is and understand enough the healthcare context to make a safe choice around the prescription?”

Telehealth does allow for health organizations to reach more people than they might be able to with in-person care. Patients don’t have to travel to a doctor’s office, and doctors can see more people in a day. A company that is overprescribing, then, might be able to get through more patients than it might if it had to add in the in-person component. But it’s still possible to establish a very real relationship between a patient and a provider via a digital health platform, Neinstein says. It’s also just as possible to prescribe drugs irresponsibly without a strong therapeutic relationship at an in-person clinic — in-person “pill mills” contributed to the start of the opioid crisis.

“We should be way more focused on what differentiates high quality from low quality healthcare, and not worry as much about whether it’s delivered virtually or not,” Neinstein says.

Aronowitz hopes that policymakers are able to understand that distinction. Some lawmakers have indicated they’re aware of the landscape — Sens. Rob Portman (R-OH) and Sheldon Whitehouse (D-RI) sent a letter to the DEA and the Department of Health and Human Services in April of this year asking them to allow opioid-use disorder treatment through telehealth to continue.

But other lawmakers have expressed worries that broader access to telehealth makes fraud more likely. Neinstein says he’s concerned lawmakers will pull back on access to telehealth once the public health emergency ends. “There’s a fear that it enables bad actors in the healthcare environment to practice bad healthcare,” he says. “And those fears are real, but I think it probably is helping more people than it’s hurting.”

So, for now, healthcare providers treating patients who use opioids via telehealth are in limbo. It’s frustrating to try to come up with innovative programs without being sure if they’ll be able to continue, Aronowitz says. She’s concerned about the repercussions if telehealth has to end; some patients might not be able to connect with treatment in any other way. But Aronowitz says she’s skeptical that decision-makers will really take those concerns, and all the work her field has done, into account.

“I don’t trust that all of the evidence means people will listen,” she says. “I think we’re really doing what we can to get that evidence out there and just keep treating as many people as possible so that it’s harder to make the argument that it’s beneficial to roll this back.”