Today, Explained - Adderall via Instagram

Episode Date: June 9, 2022

The mental health startup Cerebral benefited from pandemic-era changes to federal telehealth laws. But its easy-to-get prescriptions for tightly regulated stimulants — heavily promoted on social media — have sparked a Department of Justice investigation. This episode was produced by Tori Dominguez, edited by Matt Collette, fact-checked by Laura Bullard, engineered by Paul Mounsey, and hosted by Sean Rameswaram. Transcript at vox.com/todayexplained   Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

Big tech wants to help? With your telephone? With your transportation? With your food delivery? With your entertainment? With your photos? With your news? With your blood?

That didn't go very well. Miss Grace Theranos, founder and CEO, found guilty on 4 of 11 counts in her landmark Silicon Valley fraud case. With your brain? In the case of Cerebral, that's also not going very well. Making this late night video is a general PSA to anyone who is thinking about joining Cerebral.

Do not walk, but f***ing run. Adderall via Instagram. The rise and sort of stumbly fall of Cerebral. Coming up on Today Explained. Get groceries delivered across the GTA from Real Canadian Superstore with PC Express. Shop online for super prices and super savings. Try it today and get up to $75 in PC Optimum Points.

Visit superstore.ca to get started. My name is Rolf Winkler. I'm a reporter at The Wall Street Journal. And I'm Sean Ramos-Verm, hosted today, explained from Vox. Rolf is here to tell us about Cerebral. Cerebral is an online mental health company that, after launching two short years ago, January 2020, has exploded to a $5 billion valuation and is treating tens of thousands of patients for mental health conditions. It's one of the fastest growing mental health companies online today. But there is a but. A controversy has ensued. Correct. The controversy is over their prescriptions of controlled substances, in particular Adderall and stimulants, to treat ADHD. I was able to get in and see a clinician and get on medication within like two weeks. And their advertising. Therefore, it's dangerous to have ads that highlight very general symptoms,

being spacey or forgetful or chatty as you potentially having a mental health condition. There was advertising that was criticized as inappropriate. Instagram took it down. The company admitted mistakes in its advertising, said it would form a new review board to look at it. They were doing ads that, you know, connected obesity and ADHD. Are you overeating? Maybe you have ADHD. Come and get treatment, which people thought was over the line. And on the other side of it, there are

concerns, and we reported a lot on this, about nurse practitioners on the platform, the people who prescribe the medication. Ones we spoke to said they had felt pressured by the company to prescribe stimulants for people who came in saying that they had ADHD. And of course, a large number of them do have ADHD and need treatment and stimulants are the best treatment for that. That's agreed on by psychiatrists. On the other hand, a lot of other people were coming in to seek this medication, the nurses said, and they would have to do battle with them. Basically, you are just sort of seeking this stimulant and I'm not going to give it to you. And the company would pressure them to provide stimulants, to go ahead and prescribe them

because that would keep people paying their subscription fee. That's what the nurses said, that they felt that pressure. Now, the company, of course, says, we don't pressure any nurses, we trust their clinical judgment, and we've never punished anybody for not prescribing medication. So let's wind back a little bit and talk about how this company got started. What's its origin story? It started in January 2020. The original idea for the business was they were going to prescribe medication for mental health concerns. At the time, a lot of the online mental health

services would provide therapy. Support for the show today comes from BetterHelp. They wanted to do for mental health, for depression and anxiety, something similar to what HIMSS and Roman did for erectile dysfunction and hair loss. Roman makes it simple and convenient to take care of ED. So when the moment's right, you're ready. Roman Ready. Let's make it easy to prescribe and get people access to the medication that could help them for these issues. Its co-founder, former co-founder, but he's no longer with the company, had been at HIMSS.

So that was January 2020. A key development was two months later, COVID hit, the pandemic. If you don't test, you don't have any cases. Then some of the guardrails around telehealth were lifted, including they made an exception to something called the Ryan Hate Act, which is a law that prohibits prescribing Schedule II medications without at least one in-person visit. In other words, if you want a schedule two med like Adderall or another stimulant, other meds in this category include Oxycontin and Vicodin. This is a DEA category, you know, the schedule. Schedule two includes substances that can be prescribed but have a high potential for abuse. They were now allowed to prescribe. So now all of a sudden you could treat ADHD online

and prescribe stimulants. So they moved pretty aggressively into that marketplace and it became a key growth area for them. How did they move aggressively? They spent a lot of money on advertising, for instance. Whether you struggle with anxiety, depression, ADHD, or you're just feeling unsure, Cerebral gives you access to a team of licensed therapists, counselors, and prescribers online. And their business model is not unlike my business model. I work at the Wall Street Journal. I'm at a

newspaper. We sell subscriptions. Our business is to write stories you want to read so that you keep paying your subscription fee every month, right? Cerebral is in a similar business. They're a subscription business, and a primary thing they sell you is called medication management. Come to us for the medication that you need to treat whatever conditions you have, whether it's depression, anxiety, insomnia, ADHD, and we'll give you medication. And you pay us every month, and we'll give you medication and you pay us every month and we'll manage that medication, including renewing your prescriptions for you to be renewed. What does their advertising look like? A lot of social media ads, a lot of ads on TikTok, a lot of ads on Instagram.

You might know this company also because they signed up Simone Biles to be their chief impact officer last fall after her very public battles with mental health during the Olympics. For me, Cerebral eases my anxiety. I choose to do weekly therapy. But if a licensed prescriber decides you need prescription medication, Cerebral can have it delivered to your door. Having the support and tools... So how does Cerebral's business do in the pandemic? Exploded. Remember, this is a company that launched January of 2020.

So start from zero. And by last year, when they're raising money, they're treating over 100,000 patients already. That's fast growth. That's fast growth. How does the service work? The way the business works is you're paying your subscription fee, which is roughly $80 a month for medication management. And the nurse practitioner is paid on the order of $40 to $50 for that initial assessment and then say $20, $25 per month thereafter for follow-up visits when they see you in person, when they do a follow-up visit. How does Cerebral's process at this point compare to say a regular traditional in-office diagnosis of ADHD and say, you know, prescription for Adderall? Sean, that is the key question because it's short. It's a much shorter appointment. They

did half-hour appointments to diagnose ADHD. And that is a lot shorter than your standard appointment. When we talk to experts, they say, look, the shortest ADHD appointments, they should run at least 90 minutes. And many of them can run, they can run three, four hours and have you fill out lots of information. And then the psychiatrist may, or the person evaluating you may interview your family. And so the cerebral appointment's much shorter at 30 minutes. And as you mentioned earlier, cerebrals allowed to do this thanks to the reversal of something called the Ryan Hate Act. The Ryan Hate Act is still a law that's on the books.

The young man from California was only 18 when he overdosed on painkillers that were illegally prescribed over the internet. But the public health emergency for COVID, which is continuing, has basically created an exception to that rule so that it's temporarily relaxed. COVID-19 might be getting all the headlines, but patients are still getting sick from other diseases and injuries, and that's left doctors looking for other ways to treat them while minimizing contact. Enter telemedicine. When the public health emergency ends, it's my understanding that the Ryan Haidt Act snaps back, and so you won't be able to do some of these controlled substances online anymore without an in-person appointment. How does Cerebral's sort of newfound ability to expedite this process of diagnosing mental illness

and prescribing medication for it start to land them in hot water? I think the questions that people started asking were around the quality of the diagnoses that the company's nurse practitioners were providing. Like, how much can they actually know in 30 minutes? And were there cases where patients maybe don't have ADHD but are getting the meds anyway? And the nurses said they felt pressure to prescribe these meds, including something that happened late last year that the nurses prescribed. And we saw documents that showed this process was something called auditing, where Cerebral's clinical quality team would pull charts, say.

A nurse practitioner has a few hundred patients maybe, and they'll pull a few charts at random to see, are they prescribing the appropriate medication? And maybe they pull some ADHD patients and they discover, okay, you diagnosed ADHD, but you didn't prescribe a stimulant. And that's the preferred medication for ADHD. Why haven't you done that? You should either change your diagnosis or switch the medication. And some nurses looked at that and they said, hold on a minute. It's not the company's job to tell me what to prescribe. I prescribe the medication I feel that is appropriate. It's my prescribing license. That's my job. Now the company says they don't pressure anyone to prescribe medication, and they encourage nurses to follow their best clinical judgment and support them when they do. A lot has been happening after people wrote about the company's practices, in particular around its ADHD prescribing. One, we reported that some pharmacies had had issues with controlled

substance prescriptions coming from cerebral and similar companies that do this online. Sources telling the Wall Street Journal, Walmart, CVS, and Walgreens have all blocked or delayed prescriptions from certain telehealth providers. Then it came out that there was a DOJ investigation, that they were being investigated for possible violations of the Controlled Substances Act, which the company says, we haven't been accused of violating any laws, and they were going to cooperate fully.

And last, most recently, the CEO basically got fired by the board. More with Rolf in a minute on Today Explained. to help you save time and put money back in your pocket. Ramp says they give finance teams unprecedented control and insight into company spend. With Ramp, you're able to issue cards to every employee with limits and restrictions and automate expense reporting so you can stop wasting time at the end of every month. And now you can get $250 when you join Ramp. Thank you. Cards issued by Sutton Bank. Member FDIC. Terms and conditions apply. You're always taken care of with a sportsbook born in Vegas. That's a feeling you can only get with BetMGM. And no matter your team, your favorite player, or your style, there's something every NBA fan will love about BetMGM. Download the app today and discover why BetMGM is your basketball home for the season.

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or someone close to you, please contact Connex Ontario at 1-866-531-2600 to speak to an advisor free of charge. BetMGM operates pursuant to an operating agreement with iGaming Ontario. Whether you struggle with anxiety, depression, ADHD, or you're just feeling unsure, Cerebral gives you access to a team of licensed therapists, counselors, and prescribers online. Prescription medication delivered to you today. Today Explained, Sean Ramos for him back with Rolf Winkler from the Wall Street Journal,

who just told us about Cerebral's fast rise during the pandemic, which was followed by lots of questions about its practices and ethics, prescribing things like ADHD medication very quickly. Rolf, how does the federal government take an interest in Cerebral? We don't have full answers to that. We know that what they're doing is investigating potential violations of the Controlled Substances Act. And, you know, that's after the DEA has interviewed some nurse practitioners at Cerebral. So we're waiting to see.

Cerebral hasn't been accused of violating any laws. And they say they're fully cooperating. So that's yet to be determined what's going on there. Hmm. But this isn't the only problem Cerebral's having right now. Well, they had to shut down that ADHD business. They decided that was the best course of action. And the board voted out the CEO and replaced him with the company's existing CMO. And by the way, that has been quite a mess. The CEO said in a memo to the board that he feels like he's a scapegoat and the people you're replacing me with have been there the whole time. And the board knew everything, investors knew everything. You're just blaming me to try to effectively make a clean break. But is this really a clean break? That's a question for people to ask.

Executives now in charge who have been there for all of the relevant period. The CMO joined in February 2021. So that's a question is, how much of a break is it with the past? We wrote our story about people feeling pressure to prescribe back in late March. So a lot of this has happened pretty

quickly. How is Cerebral responding to all of this, Rolf? Cerebral has had a bunch of different responses. They say that they follow evidence-based best practices for all of their prescribing, that they never pressure nurse practitioners to prescribe. They say they provide high quality care. And they say, you know, above all, our mission is to expand access for mental health, right? It is a fact that there's more demand for mental health resources in this country than there is supply. You want to go see a psychiatrist, one, can you afford it? A lot of people can't afford that. And two, a lot of people may not have a psychiatrist near them who can see them, you know, anytime before three months from now. So Cerebral says, look, we are helping to expand access to behavioral health medication that people in this country need. You know, I asked you how Cerebral sort of responded to all the controversy. Wall Street Journal has done a lot of the reporting here. How have they responded

specifically to the reporting you all have done? They said it was a broad problem in the telehealth industry at the time we were reporting this. But the thing when we followed up was the telehealth industry doesn't broadly prescribe controlled substances. They said it was an industry-wide problem. And we had asked, well, who else in the industry is doing controlled substances? Because the top general telehealth players, Teladoc, MDLive, Doctor on Demand, these kinds of services, and also the other mental health companies, Lyra Health, Modern Health, Ginger, they don't do controlled substances. So Cerebral's defending their practices, but at the same time, they just got rid of their CEO. And ended a lot of their practices around ADHD and controlled substances.

They just stopped it all. So, yes, on the one hand, they're saying everything we're doing is great. We follow best practices. And our mission is a good one. And that's for everybody out there to decide, right? Which it seems like is a way of admitting that things weren't up to snuff. They've certainly owned up to mistakes. They've certainly admitted that they made mistakes in various areas, and they're going to try to do better.

So if they're not prescribing these controlled substances, how much of their business remains intact? A significant part of it, because a lot of what the company does is also prescribe SSRIs for depression, for instance. They'll prescribe non-controlled substances for depression, anxiety, insomnia. These are all large components of their business and the majority, really. So they still have a fairly sizable business there, for sure. I'm sure a lot of people listening to this can't help but think of a recent health startup controversy in this country that was recently turned into a tv show the world works in certain ways until a new great idea comes along and changes everything i think there's a movie

coming to uh grace theranos founder and ce, found guilty on four of 11 counts in her landmark Silicon Valley fraud case. Yeah. Do you draw any lines between the two? Their technology was, it was diagnostic. It was different. It was blood tests. It wasn't medication that you were putting in your body. In this case, with Cerebral, it hasn't been around nearly as long, only two years, so not as many people have heard of it. The CEO isn't a household name. On the other hand, it prescribes medication, right? So its impact on the daily lives of, again, tens of thousands of people is just very different. And to be clear, none of our reporting would suggest that most people going to cerebral aren't getting great care.

Do you think there's some larger problem here that maybe we move too fast, especially with something as serious as prescription medicine or mental health diagnoses? Should telehealth startups have sort of a different bar than, say, tech startups that help you, who knows, get some food delivered or, you know, book a car? So I think it's important to separate out the prescribing of online mental health, it should be said, is filling a need that is there in this country. A lot of people need help for mental health issues, especially during the pandemic. And it's hard that those resources just aren't widely available. So there are a lot of companies that are trying to make those resources

available. And I think everybody would agree that's something that's badly needed, right? And the question that knowledgeable people in this area have raised for me and the thing they've said to focus on is really the controlled substances aspect of this. So to your question about, you know, Silicon Valley getting into this, right? The question is, okay, if we're looking at controlled substances as the thing where you have to be really careful, I mean, we put guardrails around controlled substances for a reason, because they're prone to abuse. And so you ask yourself, okay, well, does the Silicon Valley direct-to-consumer playbook

where we spend tons of money to advertise, you bring people in, you make something easier for the client to get. That's the general idea, right? Is that appropriate for controlled substances? The sources I spoke to, the answer to that question, and really the challenge, is around the approach to the business

and treating the people who come in like clients who are customers who want to buy a product, right? The nurse practitioners we spoke to said, look, we're being evaluated like Uber drivers. We're getting rated on a scale of one to five. Who do you think are some of the people that give me a one? It's the people I don't give the medication to who want it. But I'm not an Uber driver. I'm supposed to be able to say no to you. our show today was made by victoria dominguez it's her first she was edited by matthew collette fact-checked by laura bullard and mixed and mastered by paulounsey. The rest of the Today Explained team includes Halima Shah,

Miles Bryan, Victoria Chamberlain, Hadi Mawagdi, and Avishai Artsy. Our supervising producer is Amna Alsadi. Our director of sound is Afim Shapiro. My co-host is Noel King. Our VP of audio at Vox is Liz Kelly Nelson.

We use music by Breakmaster Cylinder and sometimes Noam Hassenfeld, too. He hosts a show called Unexplainable, and they're launching a series this week on Lost Worlds. I'm Sean Ramos. From Today Explained is part of the Vox Media Podcast Network. We're on the radio across these United States in partnership with WNYC. Thank you.