Telehealth ADHD care tied to small rise in substance diagnoses; risk concentrated in adults 26–34
New University of Michigan study finds a slight increase in substance use disorder diagnoses after starting stimulant treatment via telehealth, with persistent risk for adults aged 26–34. (150 characters)
A newly released University of Michigan study found that people who began stimulant treatment for ADHD through telehealth had a marginally higher rate of a subsequent substance use disorder diagnosis than those who started treatment in person, a finding that could shape imminent policy decisions about telehealth ADHD care. The analysis tracked 77,153 patients aged 12 to 64 who initiated stimulant prescriptions in 2021 and compared one-year outcomes between telehealth and in-person starts. While the overall difference narrowed after accounting for psychiatric comorbidities, a distinct elevated risk remained for adults aged 26 to 34, prompting calls for targeted screening and monitoring.
Study finds a small overall increase in substance diagnoses after telehealth starts
Researchers reported that 3.7% of patients who began stimulant therapy through telehealth received a substance use disorder (SUD) diagnosis within a year, compared with 3.2% of those who started in person. After adjusting for differences in baseline psychiatric diagnoses—conditions such as anxiety and depression that are independently associated with SUD—the overall increased risk between telehealth and in-person groups largely disappeared. The authors emphasize that the unadjusted difference was modest but measurable, and that comorbidity patterns explain much of the gap.
Elevated risk persists for adults aged 26 to 34
The study identified adults aged 26 to 34 as the only subgroup with a statistically significant higher SUD risk after adjustment for psychiatric conditions and other factors. Investigators suggest the transition out of parental insurance coverage at age 26 and greater independence in obtaining and managing prescriptions may contribute to this pattern. The authors contend this age cohort warrants special attention in any telehealth ADHD care model because of its distinct clinical and social circumstances.
Scope and methods: insurance records for 77,153 patients
Analysts used de-identified private insurance and Medicaid claims to assemble a cohort of 77,153 people who had not received stimulant medication or an SUD diagnosis in the previous year and who initiated stimulants in 2021. More than 21,000 patients began treatment via telehealth; the remainder started with an in-person visit. The team adjusted for demographic factors and documented psychiatric diagnoses and then followed patients’ records for one year to identify new SUD diagnoses.
Clinical prescribing environment for stimulants and oversight gaps
Stimulant medications used for ADHD are regulated as controlled substances and generally require prescribers to be registered with the Drug Enforcement Administration and to consult state prescription drug monitoring programs. Despite these safeguards, the study notes the absence of specific, standardized guidelines for initial screening of SUD risk or for ongoing monitoring tied to stimulant prescribing. The paper also points out that several telehealth-first companies emerged during the pandemic-era loosening of telemedicine requirements, and some have faced regulatory action over concerns about oversight.
Regulatory timing and policy debate ahead of telehealth rule expirations
Federal telehealth flexibilities that expanded virtual behavioral health access during the COVID-19 pandemic are set to expire at the end of the calendar year, and the study arrives as lawmakers and regulators debate their future. Investigators say the results are directly relevant to that policy conversation because they quantify risk differences tied to the mode of initiation and identify an age group with sustained vulnerability. Policymakers will need to balance access benefits from telehealth ADHD care against potential harms and consider whether additional guardrails are warranted.
Recommendations for screening, monitoring and provider guidance
Based on their findings, the researchers recommend that screening for addiction risk and structured follow-up be integrated into telehealth ADHD care models, with particular emphasis on young adults early in independent treatment. They advocate for clear provider guidance on baseline risk assessment, use of prescription monitoring tools, and scheduled reassessments to detect emerging misuse or diversion. The study authors argue that combining access with standardized safety practices can preserve telehealth’s benefits while mitigating preventable harms.
This analysis underscores a nuanced picture: telehealth ADHD care expanded access to stimulant treatment for many patients, but it may require tailored safety measures to address subgroup risks and psychiatric comorbidity. As regulators decide whether to extend pandemic-era telehealth flexibilities, clinicians and policymakers should consider targeted screening, enhanced monitoring, and age-specific interventions to ensure that increased access does not come at the expense of patient safety.
