Telehealth Prescribing of ADHD Medications: Improving Access Without Sacrificing Safety

During the COVID-19 pandemic, psychiatric care delivered via telemedicine increased significantly, and so did the prescription of ADHD medications, particularly stimulants.  Now well beyond the pandemic, telemedicine continues to be an important component of delivering care.  While some see this as an important step in improving access for patients who previously faced barriers to care, others have expressed concern that easier access to stimulants may also lead to increased risks for misuse or substance use disorders (SUDs).

In a recent study published in the American Journal of Psychiatry, Vinod Rao, MD PhD, Medical Director of the Ambulatory Psychiatry Clinic and West End Clinic at Massachusetts General Hospital, and colleagues examined whether stimulant prescriptions provided via telehealth carry a different risk profile compared to prescriptions initiated in person. They focused on two key questions:

1. Does receiving an initial stimulant prescription from a provider whom the patient has never seen in person increase the risk for developing a substance use disorder?
2. Does receiving the initial stimulant prescription during a telehealth versus in-person visit change the risk of developing a substance use disorder (SUD) or stimulant use disorder (stimUD)?

Study Design and Key Findings

Researchers conducted a retrospective cohort study using electronic health record data from an academically affiliated health system in Boston. They included patients ages 12 and older with ADHD who received their first stimulant prescription between March 1, 2020 (at the beginning of the COVID pandemic) and August 25, 2023. Patients with a SUD diagnosis (other than nicotine) at the time of their initial prescription were excluded.

The final sample included 7,944 patients. Outcomes were tracked to determine onset of SUD or stimulant use disorder following the receipt of the initial prescription of a stimulant.

Question 1: In-Person Relationship with Prescriber Compared to Telehealth-Only

A total of 7,224 patients (91%) had at least one in-person visit with their prescriber before or at the time of their first prescription; 389 (5.4%) later developed an SUD, and 16 (0.2%) developed stimUD.  In the 720 patients (9%) who had only telehealth visits with their prescriber, 43 (6.0%) later developed an SUD, and three (0.4%) developed stimUD.

After adjusting for confounders, exclusively telehealth-based care was not associated with increased risk for SUD or stimUD.

Question 2: Type of Appointment (In-Person vs.Telehealth) at the First Stimulant Prescription

A total of 3,963 (46%) received their first prescription during an in-person visit.  In this cohort, 165 (4.2%) developed an SUD, and two (0.05%) developed stimUD.  Among the 3,981 patients (54%) who had received their first prescription during a telehealth visit, 267 (6.7%) developed an SUD, and 17 (0.4%) developed stimUD.

Adjusted analyses showed no significant difference in risk for SUD between groups. However, patients prescribed stimulants during a telehealth visit were at higher risk for developing stimUD (adjusted odds ratio=6.18, 95% CI=1.34, 28.46).

In this video, Dr. Vinod discusses the findings of the study:

Clinical Implications

Overall, the study found that telehealth prescribing of stimulants for ADHD does not increase the general risk of developing a substance use disorder compared to in-person care. Importantly, an ongoing in-person relationship with the prescriber did not lower the risk of SUD or stimUD.

Although absolute rates of stimulant use disorder were very low (0.04%–0.4%), patients who received their initial prescription via telehealth were more likely to later develop a stimUD. The authors note that this finding may reflect unmeasured patient characteristics, rather than an inherent risk of telehealth itself, and thus this finding should be interpreted with caution.

Limitations of the study include the single health system setting, lack of substantial racial/ethnic diversity in the sample, and potential missing data from care received outside the system. The authors also note that given that the sample exhibited low rates of developing stimUD, the finding that initiating stimulants through telehealth is associated with a higher rate of developing stimUD requires replication in larger samples with adequate power to better quantify meaningful differences in risk.

Despite these limitations, the study supports the use of telehealth as a safe and effective option for initiating ADHD treatment with stimulants—while highlighting the need for ongoing research.  There is a large body of medical research indicating that  forgoing treatment of ADHD carries significant risks. When weighing concerns about stimulant prescribing, particularly through telehealth, it is important to consider the risks of leaving ADHD untreated. Untreated ADHD has been consistently linked to poorer academic and occupational outcomes, difficulties with relationships, higher rates of accidental injury, and increased risk for mood, anxiety, and substance use disorders. 

For many patients, especially adolescents and young adults, timely access to effective treatment can help reduce these long-term negative outcomes. Thus, while careful prescribing and monitoring of stimulant medications remain essential, the potential benefits of treatment should be considered alongside the relatively small risks observed in this study.

As Dr. Timothy Wilens, coauthor and Chief of the Division of Child and Adolescent Psychiatry at Mass General, noted: “Our study supports the use of telehealth for ADHD stimulant therapy in clinical settings. The vast majority of the data show no increase in substance use disorder developing when patients exclusively use telehealth.”

Rao V, Lanni S, Yule AM, McCabe SE, Veliz PT, Schepis TS, Wilens TE. Telehealth Prescribing of Stimulants for ADHD and Associated Risk for Later Stimulant and Substance Use Disorders. Am J Psychiatry. 2025 Aug 1;182(8):779-788.