>Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists.
This is very on-point. So often, people defend a status quo system by reference to what it is ostensibly intended to do, without regard to the completely bullshit way it actually behaves. It's a kind of magical thinking. There is some worry (overprescription, addiction, whatever), and the rituals are intended to address that worry, therefore the rituals must be respected.
Part of what religion does is define the purpose of human life, which includes the purpose of the human body. That, in turn, determines what counts as health and what counts as harm, which has a huge effect on what constitutes correct medical care. In addition to this, there's a competitor called medical science, which isn't a religion, and tries to define health and harm without much of a strong idea of the purpose of the human life, and so it wobbles a good deal; see Canada and MAID for an example of contemporary political trouble stemming from this confusion.
I think a good number of these stories of poor medical care coming from ideologically-motivated doctors are symptoms of patients of one religion seeing a doctor of another. I don't have any recommendation other than that we should recognize that health and harm (and thus, any judgment of good vs bad medical care) aren't actually separable from religion, or some other purpose-granting worldview filling the role of a religion.
I used one of the pill mills. She instead prescribed me an anti depressant that worked so well I became manic after five days so I dropped it. In her defense I was definitely depressed but it was the middle of winter in the PNW during the final(ish?) Covid lockdown so if I wasn’t depressed then something would be wrong with me.
I then went to my doctor who tried to prescribe me a different antidepressant.
Finally I went to the super nurse my friend used to get his adderall prescriptions from. She gave me the same test as the others but highlighted the “correct” answers on the criteria sheet she had me fill out. She also asked me to answer sans my coping mechanisms which I don’t think is standard but should be.
I switched to another pill mill when I left the state then to another super nurse via telemedicine when I moved again.
As far as I can tell I actually have ADHD but because I coped well enough in childhood I’m considered sus. My apparently permanent gut issues from the stress I heaped on myself to function for 30 years doesn’t seem to be diagnostically relevant.
Btw it’s a bitch to get adderall regularly if you’re nomadic. But that’s one of a hundred issues with nomadism and modern bureaucracy so it isn’t especially bad.
Compete speculation, but I think that per appointment telepsychiatry is likely slightly worse than in person, but the benefits of ease of access are worth it.
I definitely have a sense that the body language etc cues are muted on zoom, which probably ever so slightly changes the likelihood of particular diagnoses being missed. My psychiatrist has also mentioned that it's harder to evaluate patients on long term antipsychotics for movement disorders.
However, I personally have found ease of access and continuity of care to be huge upsides to telepsychiatry. On my work from home days, I can block out exactly half an hour on my calendar for my half hour appointment and it's much more discreet than blocking out an hour and a half to commute to a office. Also, my doctor has added some evening appointment slots because she doesn't need to follow the building hours of her practice. There's much less of a barrier to frequent appointments when needed.
Continuity of care is also a big factor. I moved 2 hours away within the same state as my doctor. I sought out a new local doctor at one point, but found the hassle of finding a good fit and getting to know a new doc was not worth it. I have bipolar 1 and also ADHD/a generally chatty/hyperthymic personality. It was difficult to have a new doc learn what the line is between my normal personality and an unusual mood elevation. My telepsychiatry doc has known me for several years and has seen me through a lot of different mood states and I trust that she has a good feel for what my mood episodes look like vs my normal peppiness.
Devil’s advocate argument: if you compared the population of controlled substance users who get their prescriptions via in-person visits to people who get them via telemedicine, you’d probably find that the telemedicine users have significantly less compelling justifications for their use. Sure, they all have cleared the bar of “get a doctor to say you need a controlled substance”, but the bar is undoubtedly lower in telemedicine versus in-person medicine for what qualifies as a “need”.
Based on that logic, it’s reasonable to seek to accomplish the policy goal of reducing the amount of controlled substances being prescribed by seeking to convert some amount of telemedicine patients into in-person patients. Those people with strong justifications, and therefore strong incentives, will be more strongly incentivize to jump through the hoop than those people with weak justifications.
I think this entire discussion would be more fruitful if it focused on alternative pathways to achieve a policy goal of reduction in the total number of prescribed controlled substances, rather than just pointing out the flaws in this particular manifestation of that goal - which every plan will have, of course.
(A) The term “valid prescription” means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by—
(i) a practitioner who has conducted at least 1 in-person medical evaluation of the patient; or
What's the base rate we should expect for governmental competence in 'emerging' technology + medicine in the US?
Sounds like the new rule is *slightly* better than Australia's, but probably worse than Canada's. But then, it doesn't sound like the government is creating a central database of prescriptions that it then mines for use in a campaign of domestic surveillance so ... it could be worse?
What's worse than government neglect? Government scrutiny.
"If for some reason that doesn’t work, go to a different psychiatrist and try again. You don’t have to tell them you already tried, and HIPAA bans psychiatrists from communicating about this kind of thing among themselves."
Scott, to the best of my knowledge, this isn't right - as far as I know, only records for substance use-disorder treatment and separately maintained therapy notes have special restrictions on them (the former via another law). Generally, providers can communicate with one another freely for coordination of care without a patient release. See the link below from the HHS website that does a decent job of explaining what the rules are.
I admit my comment was poorly phrased and I apologize for offending with my tone. To clarify my point, I'm not really all that interested in the object level question about telemedicine, I'm asking about what you consider the rules to be about when and what types of evidence are needed. Certainly I may be missing something that's clear to others, but to me the approach you took to, say, Ivermectin is markedly different than what you took toward telemedicine, where evidence either way didn't even get mentioned. (not that I disagree with any of your conclusions on these topics!). So, I could imagine your position being, at least looking at the first post:
1. There is no good evidence about this regulation, so we have to do the best we can without it until it can be had.
2. This regulation is the sort of thing that there can't ever be strong evidence about either way, so we have to find some other way to think about it permanently.
3. Government regulation generally has a high burden of proof, so any regulation can/should be repealed if the evidence in favor of it is weak or ambiguous.
4. Your experience and people's general common sense is so clear and overwhelming on this topic that looking for scientific support would be redundant.
I think any of those are plausible, I'm just surprised, given the rest of your corpus, that none of them got a mention.
> the most severe ADHD patients get distracted and fail to jump through the hoops and then I have to decide if I really want to deny them medication on that basis or not.
This is darly ironic in the actually-ironic sense, at least for the amphetamine case. They want prescriptions written to "legitimate" patients and not "abusers", but the patients that most need the drug are least able to jump through bureaucratic hoops. Hence, not only do the regs fail to disproportionately inconvenience pill pushers over honest doctors, they also disproportionately hurt legit patients over fakers. It might reduce the absolute number of abusers, but it will probably *increase* their relative proportion.
(source: personal experience. It took me years to navigate the system sufficiently to get dexedrine, even once I'd decided to get medicated. Today I keep an emergency reserve for prescription hoop-jumping -- because I need the meds to maintain the executive function required to *get* the meds. Life would feel less precarious if they were available non-prescription from behind the counter, like working decongestants are)
I don't know a good solution for this. There may not be one. It seems like a problem inherent to any condition where the patients are bureaucratically-impaired and the treatment has a secondary recreational use.
I'm a psychotherapist who for years did therapy with people via video, phone, and email before Covid hit, when all of us had to do that.
I can't speak to the prescription drug angle of this, but I can say from lots of clinical experience in person and remote using a variety of technologies, that it's helpful if people add "for whom?" when they ask about whether telehealth is better or worse. The research before Covid already told us that it's better for some people and some situations and perhaps not as good for some others, but that overall outcomes are close enough to in-person that we ought to think of remote, technology-mediated mental healthcare as on par with in-person.
There are 24 states in the US that have passed "parity laws" requiring private insurance companies to cover telehealth just as they do in-person -- and part of that is in recognition of the research showing it's just as effective and accounting for the importance of increasing healthcare access to people who face impediments (geography, mobility, schedule, childcare, etc).
Back when I mostly met with people in-person, the portion of my patient population with ADHD were much more likely to miss appointments. During Covid, that changed because it was much easier for a person to not miss an appointment even if they forgot all the way up until the time of the appointment. To my mind, that's a good thing.
Patients of mine with more social anxiety, introversion, and a variety of other concerns do better meeting using remote technology. That obviously may not apply for extroverts or a whole range of other people. The cool thing about telehealth parity is that patients increasingly have the right to choose the format for meeting that best meets their needs, whatever the mix of factors is for them. And they can change their minds and move from one way of doing it to another as their preferences or circumstances change. This increased flexibility for patients seems a good thing to me.
I don't have trouble reading faces in the way Scott describes and I find the different mix of information that comes through phone, video, and text is differently but equally rich as meeting in-person. There's research showing the online disinhibition effect can enable people to bring more things into the clinical encounter when it's technology-mediated than they would in person. Again, that doesn't mean it's the best option for everybody, but it's really good in my mind that it's more and more an option for those who find it beneficial.
I think there's a pretty straightforward argument about why telemedicine is more helpful for pill mills than for normal doctors. I don't know if that argument is _true_, but I think it clearly exists. The argument is that telemedicine makes it easier for patients to match with a doctor of their choice, which lets bad patients find bad doctors.
Let's say that without telemedicine, most people only have one or two choices of psychiatrist who are convenient enough to get to in person, covered by their insurance, and moderately qualified to deal with their issue. If you're a patient who 90% of doctors will agree should get an Adderall prescription, the odds that at least one of those doctors will prescribe you Adderall is 90-99%. If you're a patient who 10% of doctors would agree should get an Adderall prescription, the odds that at least one doctor will prescribe you Adderall is only 10-19%.
If you allow telemedicine, maybe that means that each person now has access to 100 doctors or 1000 doctors. Now, even if only 10% of doctors would give you a prescription, the odds of at least one doctor giving you a prescription is basically 100%. And if you allow doctors/mental health startups to advertise on the internet, it's not even going to be hard to find that one doctor who would prescribe you Adderall, because they'll tell you who they are.
Maybe this isn't an issue for hardcore addicts, because those people will go to whatever lengths are necessary to find a pill mill doctor anyway. But it might be a pretty serious issue when it comes to people who want to be able to pull 16 hour days working with spreadsheets and think they might benefit from a little boost. That person might be told about side affects and dissuaded from trying stimulants if they have to talk to their local doctor, who's probably a reasonable person (assuming most doctors are reasonable people), but might go for it if they get a targeted ad online that directs them to a doctor who prescribes everyone Adderall.
Of course, the exact same argument means that telemedicine is really important for people with rare, hard-to-diagnose problems, or people who only work well with a handful of therapists, or anyone else who benefits from having a variety of choices for their doctor. And, likewise, telemedicine is really important for doctors who are ethical, good, people with an approach to medicine that is unusual. But the restriction "you are only allowed to ask one doctor for a diagnosis, and you don't get to pick that doctor" is a lot more obviously restrictive of pill mills than "you have to go to the doctor naked" or "doctors must have first-floor offices" or any other arbitrary bureaucratic restrictions. Restricting telemedicine isn't exactly the same as "you don't get to pick your doctor" but it is reasonably close.
This isn't to say that I think this is a _good_ rule, because I completely accept your account of the harms from this rule. But it is to say that it's a rule that seems like it's plausibly targeted against a real problem to a greater degree than you're giving it credit for.
"Everyone has a vague sense that if they overprescribe controlled substances, according to some inscrutable criterion, something bad will happen to them."
Pharmacists too. If you overdispense controlled substances as a percentage of total prescriptions dispensed, your WHOLESALER (not the DEA) says "no more controlled substances for you." But they won't tell you how much is too much.
I honestly have mixed feelings about pill mills too.
On the one hand, it just feels ... bad. I don't believe in legalizing most drugs (but I'm consistent! if we could beat the lobbies, tobacco would be out) and while I don't know enough to make the call on ADHD type drugs, I lean towards "maybe they should be restricted yeah?"
On the other hand, I've had a friend who was able to get their antidepressants basically from a pill mill and it has had a clear positive effect on her quality of life. So, it also seems like maybe some people who are miserable and don't qualify for an official med, but would otherwise probably deteriorate/kill themselves, now have the easier access that at least 50/50 works and the "bad 50%" isn't going to make things that much worse.
idk. If only things were clear and simple
Also, I just sort of hate technology and especially hate video calls, so I won't deny that that influences my opinion.
It's one thing to create new regulations if the statute calls for it. It's another to thing for those regulations to explicitly negate or nullify the clear text and intent of the law.
Because, and I don't think anyone disputes this, the original law clearly and intentionally required an in-person meeting. And what's being asked for is for the DEA to create new regulations which ensure that no in-person meeting will be required again, effectively negating the original law. Not stretch it, not enhance or clarify or modify it, to de facto negate it. Regardless of whether it's the right decision for patients, that's not something the DEA should do.
> had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient
And on the flip side, one time I was picking up my abortion pill prescription (for a miscarriage that wasn't clearing out on its own) and was asked by the pharmacist if I was pregnant, because if so I shouldn't use this ulcer drug, which causes a pregnancy to abort. Pharmacists are all *kinds* of people.
Telemed does end up being really frustrating as a pharmacist inasmuch as Corresponding Responsibility is pretty threateningly explicit about being on the watch for anything we think -might not be- wholly legitimate and even in the proper case, knowing someone got their controlled substance Rx after just calling "a doctor" -feels- pretty dicey.
“Left handedness used to be about 2% of the US population. Now it's about 12%.
While it could be that somehow we've got an epidemic of left-handedness that blossomed in the 1920s, what's much more likely is that we've gotten more accommodating and understanding of left handed people, so there was less incentive to fit the mold of right handed folks.
Seems a tad defensive. For which I would not blame you! It's annoying when a bunch of unlettered yokels criticize, without having done their homework, without being aware of the complexity of the issues, without assuming that simple solutions have already been tried and there's some good reason they were rejected, et cetera.
...which should help illustrate why the virologists reacted rather snappishly to the suggestion that ivermectin might be a miracle drug.
I'm surprised that blind people are still having problems filling out government forms, as over the last 25 years they have spent a lot on making all their forms accessible. There are even groups that sue government agencies that have non compliant forms.
Random unscientific data point related to "Is telemedicine worse than regular medicine?":
During COVID lockdowns, I had a series of telemedicine appointments for *physical* therapy.
On the surface, telemedicine appointments for physical therapy did not seem likely to be good replacements for in-person appointments. My in-person appointments tended to have a significant amount of "hands on" activity. Zoom appointments… don't have that.
Overall though? Still worked. And the quality difference between in-person and virtual was less than the difference between various in-person providers I've seen.
And the convenience factor is significant. In-person appointments meant spending 30 minutes traveling to the appointment, 15 minutes in the waiting room, 45 minutes at the appointment, and then another 30 minutes returning to the office. Zoom appointments cut the time cost in half.
Given that virtual appointments are viable for physical therapy, where physical contact is *important*, it certainly seems like they should be viable for psychiatry.
Economically, in a semi-socialized medicine state where the pool for paying out to telemedicine is the same pool as national services, telemedicine is winning big (and is made of private companies being paid by the state.) Exempli gratia, here in Sweden, the first-level health clinics and ERs have been gutted by cuts, and oddly these same politicians that spurred this were partial investors in telemed companies.
What happens is that a telemed visit is paid the same amount as a doctor visit. While a normal doctor visit might be discouraged for sniffles or the sort of "take and advil and wait it out" type of advice (which, honestly was a lot of Swedish med advice: "walk it off!"), that's all encouraged by the telemedicine world, so massive amounts of money are going out to the companies whose doctors are saying "take an advil" or "here's some allergy meds". When there's something actually difficult, the telemed docs can't actually do anything, so the onus goes back to the physical health care system, they get all the costly and difficult cases, meanwhile the bulk of the money is still being funneled more to telemed. The result is that doctors in physical locales are quitting, moving, etc, (in ten years here, I've had eight primary care physicians, none of them lasted. My last doc told me he had 1400 patients assigned to him. The result for me is continuous med prescription with nobody monitoring results. Telemed can't help at this point.)
This is all leading to a steep decline in any sort of personal health care or monitoring of medical results. It's gonna get even better when AI is the telemed doc, right?
>End of the day, this should be modified by Congress, not the agencies. Everyone should remember that the law was written in 2008. That’s 1 year after the very first iPhone and 2 years before the first iPad. Zoom didn’t exist (2011). None of the other technologies for video conferencing existed.
I know I'm nitpicking on ProfessorE's comment, and that it does not really change anything in a meaningfull way, but I want to point out that Skype was released in 2003, and was somewhat commonly used by PC enthusiasts in late 00s. There was certainly a video call feature by 2008, for a few years even. So the technology was already there. It just was not common enough for the telemed purposes
I work in psych. Telemedicine is SUPERiOR to in person for psych. This is because anyone can dress up/put up make up for 30 minutes. Being able to see the patient’s chaotic home environment because they laid in bed all day with no motivation gives a truer picture.
"In response to Freddie, I wrote that I’m face-blind and bad at body language, so maybe I’m missing some kind of really subtle cues that other people can notice, but to me seeing a good image of a person’s face and upper body captures 99% of what I would get from seeing a patient in person."
This is an amazing assertion to me, and comes under the header of general amazement at the common assertion that zoom is practically equivalent to in-person... On a sheer bandwidth perspective it's not even close, eg for visual and auditory; there are whole sensory channels (smell! Touch!) not present; not to mention the social dynamics mentioned in one quoted comment... Which can go very deep indeed. Huge differences!
It may be for some people, eg Scott, that they are unaware of significant differences; it may be that tele- is sufficient for some interactions, telemedicine or otherwise, but on the whole I find this kind of assertion astonishing.
There's a big industry building in healthcare right now: Calling people and cajoling them into attending their appointments and taking their meds. There are a lot of chronic conditions that are relatively easily (and cheaply) managed, IF a patient actually, say, attends all their appointments and take their meds, that get incredibly expensive (and incrementally deadlier) if they don't. As a rule, if you don't stay treated, it gets harder to remain treated (because it's harder to do all that stuff if you feel like crap).
I think it is actually fair to lump ADHD in there. Make your appointments, stay on your meds, and you stay pretty functional. If your functionality stops dropping because you aren't taking your meds, then it becomes harder to make your appointment to get your meds, and let this go on for a little while and maybe you're unemployed now, and no longer on insurance, and now you can't afford your medications, and if you have literally any other health issues, those are going to go untreated or undertreated, and now your ADHD is a serious health risk. Okay, theory raised. Let's do an internet search aaaaand yep ADHD has a pretty high risk profile for other causes of early death.
I'm increasingly in camp "Give everybody who wants them medication to help improve their executive function"
“I’m not exactly sure who to be angry at, but I think “the government” is a fair albeit vague target”
While anger is a fair response, I would argue that Congress was shockingly progressive here allowing telemedicine prescriptions of controlled substances in the 2000s. Healthcare policy and controlled substances are extremely contentious in the best of times. Skype videoconferencing was still in beta then and Congress is not known for being tech savvy.
It’s annoying that they haven’t fixed the rules but I’m sure you are aware of how difficult it is to pass legislation through a bicameral presidential system. This is what lobbying and organizing is for. It takes time, money and effort but it can be done.
This comment could have been written about almost any industry/profession... “You have to understand, there’s more [fill in the blank] law than any human can read, and [most people] don’t have the skills to know where it is or how to interpret it. So the regulatory state mostly rules by fear. ” And to be clear, I’m not defending telemedicine regulation, but encouraging more skepticism of regulation generally.
I mentioned this in the prior thread but maybe its worth examining bad actors to try and put yourself in government and critics perspective. In the prior I mention Paul LeRoux who ran online/telemedicine pill mills, known as RX Limited and think that would be an interesting case (book the Mastermind). However there are a multitude of other bad actors like the Sacklers and there company Purdue, who in the book "Empire of Pain" are described as sort of the stereotypical jewish ellis island immigrant success story who got rich of Valium, then Oxycontin and the resulting consequences for America have been dire. Other good books are "Dopesick" and "Dreamlands".
Life expectancy in the US is tanking because of ODs from addicts, so it may be worth reflecting on how the US has arrived here.
I'm late to this, but prescription drug monitoring programs (PDMPs) exist in most states. They can even flag bad prescribing. I'm certainly not an expert, but I'm under the impression that the problem is that physicians are basically never punished for flagrantly violating the rules / standard of care on prescribing as long as they jump through the required bureaucratic hoops. See this paper and the shockingly low number of DEA enforcement actions against pill mills: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4266020
Typo in the first sentence: "Isn't drug addiction is very bad?"
The first two bullet points are grammatically incorrect
"1: Isn’t drug addiction is very bad?
2: Is telemedicine is worse than regular medicine?"
>Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists.
This is very on-point. So often, people defend a status quo system by reference to what it is ostensibly intended to do, without regard to the completely bullshit way it actually behaves. It's a kind of magical thinking. There is some worry (overprescription, addiction, whatever), and the rituals are intended to address that worry, therefore the rituals must be respected.
Part of what religion does is define the purpose of human life, which includes the purpose of the human body. That, in turn, determines what counts as health and what counts as harm, which has a huge effect on what constitutes correct medical care. In addition to this, there's a competitor called medical science, which isn't a religion, and tries to define health and harm without much of a strong idea of the purpose of the human life, and so it wobbles a good deal; see Canada and MAID for an example of contemporary political trouble stemming from this confusion.
I think a good number of these stories of poor medical care coming from ideologically-motivated doctors are symptoms of patients of one religion seeing a doctor of another. I don't have any recommendation other than that we should recognize that health and harm (and thus, any judgment of good vs bad medical care) aren't actually separable from religion, or some other purpose-granting worldview filling the role of a religion.
I used one of the pill mills. She instead prescribed me an anti depressant that worked so well I became manic after five days so I dropped it. In her defense I was definitely depressed but it was the middle of winter in the PNW during the final(ish?) Covid lockdown so if I wasn’t depressed then something would be wrong with me.
I then went to my doctor who tried to prescribe me a different antidepressant.
Finally I went to the super nurse my friend used to get his adderall prescriptions from. She gave me the same test as the others but highlighted the “correct” answers on the criteria sheet she had me fill out. She also asked me to answer sans my coping mechanisms which I don’t think is standard but should be.
I switched to another pill mill when I left the state then to another super nurse via telemedicine when I moved again.
As far as I can tell I actually have ADHD but because I coped well enough in childhood I’m considered sus. My apparently permanent gut issues from the stress I heaped on myself to function for 30 years doesn’t seem to be diagnostically relevant.
Btw it’s a bitch to get adderall regularly if you’re nomadic. But that’s one of a hundred issues with nomadism and modern bureaucracy so it isn’t especially bad.
Compete speculation, but I think that per appointment telepsychiatry is likely slightly worse than in person, but the benefits of ease of access are worth it.
I definitely have a sense that the body language etc cues are muted on zoom, which probably ever so slightly changes the likelihood of particular diagnoses being missed. My psychiatrist has also mentioned that it's harder to evaluate patients on long term antipsychotics for movement disorders.
However, I personally have found ease of access and continuity of care to be huge upsides to telepsychiatry. On my work from home days, I can block out exactly half an hour on my calendar for my half hour appointment and it's much more discreet than blocking out an hour and a half to commute to a office. Also, my doctor has added some evening appointment slots because she doesn't need to follow the building hours of her practice. There's much less of a barrier to frequent appointments when needed.
Continuity of care is also a big factor. I moved 2 hours away within the same state as my doctor. I sought out a new local doctor at one point, but found the hassle of finding a good fit and getting to know a new doc was not worth it. I have bipolar 1 and also ADHD/a generally chatty/hyperthymic personality. It was difficult to have a new doc learn what the line is between my normal personality and an unusual mood elevation. My telepsychiatry doc has known me for several years and has seen me through a lot of different mood states and I trust that she has a good feel for what my mood episodes look like vs my normal peppiness.
Devil’s advocate argument: if you compared the population of controlled substance users who get their prescriptions via in-person visits to people who get them via telemedicine, you’d probably find that the telemedicine users have significantly less compelling justifications for their use. Sure, they all have cleared the bar of “get a doctor to say you need a controlled substance”, but the bar is undoubtedly lower in telemedicine versus in-person medicine for what qualifies as a “need”.
Based on that logic, it’s reasonable to seek to accomplish the policy goal of reducing the amount of controlled substances being prescribed by seeking to convert some amount of telemedicine patients into in-person patients. Those people with strong justifications, and therefore strong incentives, will be more strongly incentivize to jump through the hoop than those people with weak justifications.
I think this entire discussion would be more fruitful if it focused on alternative pathways to achieve a policy goal of reduction in the total number of prescribed controlled substances, rather than just pointing out the flaws in this particular manifestation of that goal - which every plan will have, of course.
The telemedicine law referred to is 21 USC § 829(e), https://www.law.cornell.edu/uscode/text/21/829#e
In particular:
(A) The term “valid prescription” means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by—
(i) a practitioner who has conducted at least 1 in-person medical evaluation of the patient; or
What's the base rate we should expect for governmental competence in 'emerging' technology + medicine in the US?
Sounds like the new rule is *slightly* better than Australia's, but probably worse than Canada's. But then, it doesn't sound like the government is creating a central database of prescriptions that it then mines for use in a campaign of domestic surveillance so ... it could be worse?
What's worse than government neglect? Government scrutiny.
"If for some reason that doesn’t work, go to a different psychiatrist and try again. You don’t have to tell them you already tried, and HIPAA bans psychiatrists from communicating about this kind of thing among themselves."
Scott, to the best of my knowledge, this isn't right - as far as I know, only records for substance use-disorder treatment and separately maintained therapy notes have special restrictions on them (the former via another law). Generally, providers can communicate with one another freely for coordination of care without a patient release. See the link below from the HHS website that does a decent job of explaining what the rules are.
https://www.hhs.gov/hipaa/for-professionals/faq/3007/when-does-hipaa-allow-hospital-notify-individuals-family-friends-caregivers-patient-hospitalized-psychiatric-hold-been-admitted-discharged/index.html
I admit my comment was poorly phrased and I apologize for offending with my tone. To clarify my point, I'm not really all that interested in the object level question about telemedicine, I'm asking about what you consider the rules to be about when and what types of evidence are needed. Certainly I may be missing something that's clear to others, but to me the approach you took to, say, Ivermectin is markedly different than what you took toward telemedicine, where evidence either way didn't even get mentioned. (not that I disagree with any of your conclusions on these topics!). So, I could imagine your position being, at least looking at the first post:
1. There is no good evidence about this regulation, so we have to do the best we can without it until it can be had.
2. This regulation is the sort of thing that there can't ever be strong evidence about either way, so we have to find some other way to think about it permanently.
3. Government regulation generally has a high burden of proof, so any regulation can/should be repealed if the evidence in favor of it is weak or ambiguous.
4. Your experience and people's general common sense is so clear and overwhelming on this topic that looking for scientific support would be redundant.
I think any of those are plausible, I'm just surprised, given the rest of your corpus, that none of them got a mention.
> the most severe ADHD patients get distracted and fail to jump through the hoops and then I have to decide if I really want to deny them medication on that basis or not.
This is darly ironic in the actually-ironic sense, at least for the amphetamine case. They want prescriptions written to "legitimate" patients and not "abusers", but the patients that most need the drug are least able to jump through bureaucratic hoops. Hence, not only do the regs fail to disproportionately inconvenience pill pushers over honest doctors, they also disproportionately hurt legit patients over fakers. It might reduce the absolute number of abusers, but it will probably *increase* their relative proportion.
(source: personal experience. It took me years to navigate the system sufficiently to get dexedrine, even once I'd decided to get medicated. Today I keep an emergency reserve for prescription hoop-jumping -- because I need the meds to maintain the executive function required to *get* the meds. Life would feel less precarious if they were available non-prescription from behind the counter, like working decongestants are)
I don't know a good solution for this. There may not be one. It seems like a problem inherent to any condition where the patients are bureaucratically-impaired and the treatment has a secondary recreational use.
I'm a psychotherapist who for years did therapy with people via video, phone, and email before Covid hit, when all of us had to do that.
I can't speak to the prescription drug angle of this, but I can say from lots of clinical experience in person and remote using a variety of technologies, that it's helpful if people add "for whom?" when they ask about whether telehealth is better or worse. The research before Covid already told us that it's better for some people and some situations and perhaps not as good for some others, but that overall outcomes are close enough to in-person that we ought to think of remote, technology-mediated mental healthcare as on par with in-person.
There are 24 states in the US that have passed "parity laws" requiring private insurance companies to cover telehealth just as they do in-person -- and part of that is in recognition of the research showing it's just as effective and accounting for the importance of increasing healthcare access to people who face impediments (geography, mobility, schedule, childcare, etc).
Back when I mostly met with people in-person, the portion of my patient population with ADHD were much more likely to miss appointments. During Covid, that changed because it was much easier for a person to not miss an appointment even if they forgot all the way up until the time of the appointment. To my mind, that's a good thing.
Patients of mine with more social anxiety, introversion, and a variety of other concerns do better meeting using remote technology. That obviously may not apply for extroverts or a whole range of other people. The cool thing about telehealth parity is that patients increasingly have the right to choose the format for meeting that best meets their needs, whatever the mix of factors is for them. And they can change their minds and move from one way of doing it to another as their preferences or circumstances change. This increased flexibility for patients seems a good thing to me.
I don't have trouble reading faces in the way Scott describes and I find the different mix of information that comes through phone, video, and text is differently but equally rich as meeting in-person. There's research showing the online disinhibition effect can enable people to bring more things into the clinical encounter when it's technology-mediated than they would in person. Again, that doesn't mean it's the best option for everybody, but it's really good in my mind that it's more and more an option for those who find it beneficial.
I think there's a pretty straightforward argument about why telemedicine is more helpful for pill mills than for normal doctors. I don't know if that argument is _true_, but I think it clearly exists. The argument is that telemedicine makes it easier for patients to match with a doctor of their choice, which lets bad patients find bad doctors.
Let's say that without telemedicine, most people only have one or two choices of psychiatrist who are convenient enough to get to in person, covered by their insurance, and moderately qualified to deal with their issue. If you're a patient who 90% of doctors will agree should get an Adderall prescription, the odds that at least one of those doctors will prescribe you Adderall is 90-99%. If you're a patient who 10% of doctors would agree should get an Adderall prescription, the odds that at least one doctor will prescribe you Adderall is only 10-19%.
If you allow telemedicine, maybe that means that each person now has access to 100 doctors or 1000 doctors. Now, even if only 10% of doctors would give you a prescription, the odds of at least one doctor giving you a prescription is basically 100%. And if you allow doctors/mental health startups to advertise on the internet, it's not even going to be hard to find that one doctor who would prescribe you Adderall, because they'll tell you who they are.
Maybe this isn't an issue for hardcore addicts, because those people will go to whatever lengths are necessary to find a pill mill doctor anyway. But it might be a pretty serious issue when it comes to people who want to be able to pull 16 hour days working with spreadsheets and think they might benefit from a little boost. That person might be told about side affects and dissuaded from trying stimulants if they have to talk to their local doctor, who's probably a reasonable person (assuming most doctors are reasonable people), but might go for it if they get a targeted ad online that directs them to a doctor who prescribes everyone Adderall.
Of course, the exact same argument means that telemedicine is really important for people with rare, hard-to-diagnose problems, or people who only work well with a handful of therapists, or anyone else who benefits from having a variety of choices for their doctor. And, likewise, telemedicine is really important for doctors who are ethical, good, people with an approach to medicine that is unusual. But the restriction "you are only allowed to ask one doctor for a diagnosis, and you don't get to pick that doctor" is a lot more obviously restrictive of pill mills than "you have to go to the doctor naked" or "doctors must have first-floor offices" or any other arbitrary bureaucratic restrictions. Restricting telemedicine isn't exactly the same as "you don't get to pick your doctor" but it is reasonably close.
This isn't to say that I think this is a _good_ rule, because I completely accept your account of the harms from this rule. But it is to say that it's a rule that seems like it's plausibly targeted against a real problem to a greater degree than you're giving it credit for.
"Everyone has a vague sense that if they overprescribe controlled substances, according to some inscrutable criterion, something bad will happen to them."
Pharmacists too. If you overdispense controlled substances as a percentage of total prescriptions dispensed, your WHOLESALER (not the DEA) says "no more controlled substances for you." But they won't tell you how much is too much.
https://mattstoller.substack.com/p/the-monopolies-behind-the-adderall
I honestly have mixed feelings about pill mills too.
On the one hand, it just feels ... bad. I don't believe in legalizing most drugs (but I'm consistent! if we could beat the lobbies, tobacco would be out) and while I don't know enough to make the call on ADHD type drugs, I lean towards "maybe they should be restricted yeah?"
On the other hand, I've had a friend who was able to get their antidepressants basically from a pill mill and it has had a clear positive effect on her quality of life. So, it also seems like maybe some people who are miserable and don't qualify for an official med, but would otherwise probably deteriorate/kill themselves, now have the easier access that at least 50/50 works and the "bad 50%" isn't going to make things that much worse.
idk. If only things were clear and simple
Also, I just sort of hate technology and especially hate video calls, so I won't deny that that influences my opinion.
You are not alone, Scott. https://bhbusiness.com/2023/03/29/dea-faces-tsunami-of-criticism-in-comments-on-proposed-telehealth-controlled-substances-rules/
So, to make the case for the DEA:
It's one thing to create new regulations if the statute calls for it. It's another to thing for those regulations to explicitly negate or nullify the clear text and intent of the law.
Because, and I don't think anyone disputes this, the original law clearly and intentionally required an in-person meeting. And what's being asked for is for the DEA to create new regulations which ensure that no in-person meeting will be required again, effectively negating the original law. Not stretch it, not enhance or clarify or modify it, to de facto negate it. Regardless of whether it's the right decision for patients, that's not something the DEA should do.
> had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient
And on the flip side, one time I was picking up my abortion pill prescription (for a miscarriage that wasn't clearing out on its own) and was asked by the pharmacist if I was pregnant, because if so I shouldn't use this ulcer drug, which causes a pregnancy to abort. Pharmacists are all *kinds* of people.
Telemed does end up being really frustrating as a pharmacist inasmuch as Corresponding Responsibility is pretty threateningly explicit about being on the watch for anything we think -might not be- wholly legitimate and even in the proper case, knowing someone got their controlled substance Rx after just calling "a doctor" -feels- pretty dicey.
Comment from hn on a different post that I thought was interesting: https://news.ycombinator.com/item?id=35432043
“Left handedness used to be about 2% of the US population. Now it's about 12%.
While it could be that somehow we've got an epidemic of left-handedness that blossomed in the 1920s, what's much more likely is that we've gotten more accommodating and understanding of left handed people, so there was less incentive to fit the mold of right handed folks.
[…]”
Seems a tad defensive. For which I would not blame you! It's annoying when a bunch of unlettered yokels criticize, without having done their homework, without being aware of the complexity of the issues, without assuming that simple solutions have already been tried and there's some good reason they were rejected, et cetera.
...which should help illustrate why the virologists reacted rather snappishly to the suggestion that ivermectin might be a miracle drug.
Your response to 3 seems like a pretty strong argument to just sell these medications like we sell Tylenol.
I'm surprised that blind people are still having problems filling out government forms, as over the last 25 years they have spent a lot on making all their forms accessible. There are even groups that sue government agencies that have non compliant forms.
> Surely you would have the right to a jury trial first, right?
That's not how the regulatory state works.
Random unscientific data point related to "Is telemedicine worse than regular medicine?":
During COVID lockdowns, I had a series of telemedicine appointments for *physical* therapy.
On the surface, telemedicine appointments for physical therapy did not seem likely to be good replacements for in-person appointments. My in-person appointments tended to have a significant amount of "hands on" activity. Zoom appointments… don't have that.
Overall though? Still worked. And the quality difference between in-person and virtual was less than the difference between various in-person providers I've seen.
And the convenience factor is significant. In-person appointments meant spending 30 minutes traveling to the appointment, 15 minutes in the waiting room, 45 minutes at the appointment, and then another 30 minutes returning to the office. Zoom appointments cut the time cost in half.
Given that virtual appointments are viable for physical therapy, where physical contact is *important*, it certainly seems like they should be viable for psychiatry.
Economically, in a semi-socialized medicine state where the pool for paying out to telemedicine is the same pool as national services, telemedicine is winning big (and is made of private companies being paid by the state.) Exempli gratia, here in Sweden, the first-level health clinics and ERs have been gutted by cuts, and oddly these same politicians that spurred this were partial investors in telemed companies.
What happens is that a telemed visit is paid the same amount as a doctor visit. While a normal doctor visit might be discouraged for sniffles or the sort of "take and advil and wait it out" type of advice (which, honestly was a lot of Swedish med advice: "walk it off!"), that's all encouraged by the telemedicine world, so massive amounts of money are going out to the companies whose doctors are saying "take an advil" or "here's some allergy meds". When there's something actually difficult, the telemed docs can't actually do anything, so the onus goes back to the physical health care system, they get all the costly and difficult cases, meanwhile the bulk of the money is still being funneled more to telemed. The result is that doctors in physical locales are quitting, moving, etc, (in ten years here, I've had eight primary care physicians, none of them lasted. My last doc told me he had 1400 patients assigned to him. The result for me is continuous med prescription with nobody monitoring results. Telemed can't help at this point.)
This is all leading to a steep decline in any sort of personal health care or monitoring of medical results. It's gonna get even better when AI is the telemed doc, right?
>End of the day, this should be modified by Congress, not the agencies. Everyone should remember that the law was written in 2008. That’s 1 year after the very first iPhone and 2 years before the first iPad. Zoom didn’t exist (2011). None of the other technologies for video conferencing existed.
I know I'm nitpicking on ProfessorE's comment, and that it does not really change anything in a meaningfull way, but I want to point out that Skype was released in 2003, and was somewhat commonly used by PC enthusiasts in late 00s. There was certainly a video call feature by 2008, for a few years even. So the technology was already there. It just was not common enough for the telemed purposes
I work in psych. Telemedicine is SUPERiOR to in person for psych. This is because anyone can dress up/put up make up for 30 minutes. Being able to see the patient’s chaotic home environment because they laid in bed all day with no motivation gives a truer picture.
"In response to Freddie, I wrote that I’m face-blind and bad at body language, so maybe I’m missing some kind of really subtle cues that other people can notice, but to me seeing a good image of a person’s face and upper body captures 99% of what I would get from seeing a patient in person."
This is an amazing assertion to me, and comes under the header of general amazement at the common assertion that zoom is practically equivalent to in-person... On a sheer bandwidth perspective it's not even close, eg for visual and auditory; there are whole sensory channels (smell! Touch!) not present; not to mention the social dynamics mentioned in one quoted comment... Which can go very deep indeed. Huge differences!
It may be for some people, eg Scott, that they are unaware of significant differences; it may be that tele- is sufficient for some interactions, telemedicine or otherwise, but on the whole I find this kind of assertion astonishing.
There's a big industry building in healthcare right now: Calling people and cajoling them into attending their appointments and taking their meds. There are a lot of chronic conditions that are relatively easily (and cheaply) managed, IF a patient actually, say, attends all their appointments and take their meds, that get incredibly expensive (and incrementally deadlier) if they don't. As a rule, if you don't stay treated, it gets harder to remain treated (because it's harder to do all that stuff if you feel like crap).
I think it is actually fair to lump ADHD in there. Make your appointments, stay on your meds, and you stay pretty functional. If your functionality stops dropping because you aren't taking your meds, then it becomes harder to make your appointment to get your meds, and let this go on for a little while and maybe you're unemployed now, and no longer on insurance, and now you can't afford your medications, and if you have literally any other health issues, those are going to go untreated or undertreated, and now your ADHD is a serious health risk. Okay, theory raised. Let's do an internet search aaaaand yep ADHD has a pretty high risk profile for other causes of early death.
I'm increasingly in camp "Give everybody who wants them medication to help improve their executive function"
“I’m not exactly sure who to be angry at, but I think “the government” is a fair albeit vague target”
While anger is a fair response, I would argue that Congress was shockingly progressive here allowing telemedicine prescriptions of controlled substances in the 2000s. Healthcare policy and controlled substances are extremely contentious in the best of times. Skype videoconferencing was still in beta then and Congress is not known for being tech savvy.
It’s annoying that they haven’t fixed the rules but I’m sure you are aware of how difficult it is to pass legislation through a bicameral presidential system. This is what lobbying and organizing is for. It takes time, money and effort but it can be done.
This comment could have been written about almost any industry/profession... “You have to understand, there’s more [fill in the blank] law than any human can read, and [most people] don’t have the skills to know where it is or how to interpret it. So the regulatory state mostly rules by fear. ” And to be clear, I’m not defending telemedicine regulation, but encouraging more skepticism of regulation generally.
I mentioned this in the prior thread but maybe its worth examining bad actors to try and put yourself in government and critics perspective. In the prior I mention Paul LeRoux who ran online/telemedicine pill mills, known as RX Limited and think that would be an interesting case (book the Mastermind). However there are a multitude of other bad actors like the Sacklers and there company Purdue, who in the book "Empire of Pain" are described as sort of the stereotypical jewish ellis island immigrant success story who got rich of Valium, then Oxycontin and the resulting consequences for America have been dire. Other good books are "Dopesick" and "Dreamlands".
Life expectancy in the US is tanking because of ODs from addicts, so it may be worth reflecting on how the US has arrived here.
I'm late to this, but prescription drug monitoring programs (PDMPs) exist in most states. They can even flag bad prescribing. I'm certainly not an expert, but I'm under the impression that the problem is that physicians are basically never punished for flagrantly violating the rules / standard of care on prescribing as long as they jump through the required bureaucratic hoops. See this paper and the shockingly low number of DEA enforcement actions against pill mills: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4266020