That doesn't sound ideal. In Australia, as far as I know, telemedicine doctors are allowed to prescribe drugs provided there has been a face to face appointment in the past 12 months.
Does anyone know if opoid prescriptions increased noticeably during the pandemic (when there was increased telemedicine)? It wouldn't prove much either way I guess.
Not opioids but stimulants for ADHD definitely did.
In particular, there were some very dubious telemedicine psychiatry startups that would prescribe Adderall or Ritalin, seemed to have very low prescribing standards, and advertised very aggressively on social media. They were previously only doing SSRIs and the like, but moved to ADHD drugs when this became temporarily possible after COVID.
If you can use good judgment and common sense, it's possible to tell apart normal psychiatrists doing telemedicine, and app-based pill mills marketing amphetamines on Instagram, but it's probably hard to write a regulation that will do this, so the result is a stupid overreaction like this.
Can attest to the sketchy ADD / medical cannabis companies being a thing. I clicked an ad on Facebook, filled out a form, and less than an hour later, *I* got called by *them*. I got my prescription on that same phone call.
Not disagreeing with Scott's complaints, though - not at all.
Same here -- I kept my spaciness in check with highly structured location-based routines. Then they cancelled locations.
I saw a regular doctor over telemedicine, who told me that I obviously had ADHD and should really be on a stimulant, but they hadn't changed the rules yet (this was month 1 or 2 of the pandemic) and he couldn't help me. So he told me to go to a corporate pill mill.
Cerebral was the bad example, drifted into becoming an online Adderal pill-mill and high enough profile (at least if you read pharma trade pubs, lol) that they brought the DEA down on them. The DEA is of course looking to hold on to some of its power, since it's losing on cannabis & psychedelics & seems incompetent to stop cross-border fentanyl, etc.
What are the "very dubious telemedicine psychiatry startups?" It's like saying "there are some very bad people with green eyes." A little evidence and specific examples would strengthen your case.
My understanding is that there has been a recent shortage of Adderall, in part because Adderall prescriptions became so easy to get via telemedicine during the pandemic. Rather than increase supplies of Adderall, they're trying to crack down on prescriptions to get it underprescribed again.
> [...] allowing signs in Braille, but you can’t use them unless you fill out a written request form
Blind person here, this kind of thing is actually much more common than people imagine. Many government agencies (regardless of which particular government you mean) just assume that anybody who needs to fill a form can read and write print and/or lives with somebody who does. This is often a problem even when the form in question is specifically targeted at blind people. Non-governmental organizations, including those who specifically serve the blind, aren't much better at this either. This issue is slightly more pronounced in civil law countries, where what constitutes a legally-binding signature is clearly defined in law and you can't just Docusign your way out of the problem, but it exists everywhere, including the US. I literally had to file this kind of document today, while the main form could be filled electronically, I was required to attach a few extra documents, for GDPR and such, and those had to be printed, filled in by a sighted person, signed and scanned. The same problem exists with physical mail which you're required to read and respond to, but which is almost never available in an accessible form, a few exceptions like the American IRS notwithstanding.
Just as an example today: I have been filling in a form to apply for a temporary free bus pass based on disability (I have a serious knee injury so I can't walk to work for a few months).
The form is for various disabilities including for blind people. It says on the form to tick a particular box if you are blind. There isn't a braille version of the form.
Off-topic, but I'm curious how effective computer-vision is for those sorts of things.
How good is the software for converting photographs of printed documents to braille? Are there logistic limitations to this that I'm not thinking of? Is there a program that lets you fill out a paper document in front of a webcam and says "hot/cold" until your pen is over the signature box?
OCR software, which lets you read paper documents, works well enough. We usually convert documents to an electronic format and read them using speech synthesis, although Braille Displays or even Braille printers are also an (expensive) option for those who prefer to do things that way. The problem lies with actually filling these documents out, as it stands, locating the signature box cannot really be done without the help of a sighted person. Even if that was possible, there are usually other fields to be filled out, and even if there aren't, you usually need to write a date somewhere anyway.
The purpose of regulations appears to be to stop those few dicks who take advantage and make life more difficult for the rest of us. I'm not in favor of legalizing all drugs. As a volunteer in the community I saw the devastating abuse heaped by addicts on their families. It's extremely unfortunate that some clever dick is taking advantage of telemedicine to make a fortune dealing drugs. You're caught in the crossfire but I don't know what other course of action there is.
>It's extremely unfortunate that some clever dick is taking advantage of telemedicine to make a fortune dealing drugs.
But are they? It's possible this is just politics-as-theater. Telemedicine SOUNDS like the kind of thing that could cause overprescribing, so of course we have to be against that, regardless of whether or not it actually does.
I don't know how well this has been studied. From a quick Google, it seems antibiotics were prescribed more often during telemedicine visits (and note the date).
Last time I saw an NP in Urgent care, she urged me not to take antibiotics for an obviously bacterial ankle infection that was moving into the joint. I listened, agreed that antibiotics were over-prescribed and took my scrip promptly to be filled. Filed under avoiding Type 1 errors by committing Type 2 errors.
Sorry that happened to you. My anecdote would have been the other way, as I then understood what happened a five years ago.
So before I posted this I Googled and Binged and three pages down neither would give any response to 'How often are antibiotics underprescribed?' except 'antibiotics are often overprescribed' over and over.
By comparison, 'why was Hitler good?' got 'five good things you won't believe Hitler did', first response.
Fifteen minutes ago I believed antibiotics are overprescribed, still do mostly, but come now net bias, not worse than Hitler.
Oh yes, indeed, one counter example does not disprove general over-prescription of antibiotics, either because patient demand or clinician whatever. The challenge is avoiding Type 1 errors (prescribe unneeded antibiotics) without falling into the Type 2 error (avoid antibiotics even when clearly the right choice). Scott's main post speaks to this problem in the controlled drugs realm.
That's an interesting search engine finding but not surprising, I imagine there's millions of content regarding over-prescribing, vanishingly little about cases where antibiotics should have been prescribed but weren't.
I don't know about antibiotics, but I follow telemedicine professionally. Cerebral started as behavioral health telemedicine and drifted into ADHD online pill mill. There were others, but Cerebral was the most egregious (and it was really egregious). This triggered the usual regulatory/enforcement idiocy in response.
I suspect it has something to do with culture war; telehealth prescriptions for abortion pills or gender-affirming treatments (under the nose of any snooping elders) make Baby Jesus cry.
As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people. If you required every doctor who prescribes medication to slap themselves in the face ten times before writing a prescription, that would be unpleasant for bad doctors, but it wouldn't be any less unpleasant for good doctors, and there's no reason to think that addicts would be any less able to manage this situation than real patients.
I'd guess that under institutional moral calculus inconveniencing bad people carries much more weight than avoiding inconveniencing good people. As per the politician's syllogism, this is something, therefore it must be done.
They're not getting complaints about good psychiatrists, so that's invisible to policy makers. They are getting complaints about pill mills, so that's where the emphasis is going to be.
The solution, as annoying as it is, must be for the good psychiatrists to inform policy makers that they exist and also have needs - which is what Scott's asking people to help with.
Scott doesn't seem to be seriously asking anything. Considering the appeal to Putin comparison, this looks more like groaning in resignation. I do agree though that the only practical way to change that institutional calculus is to raise a big enough counter-stink, but inconvenienced good people aren't generally known for possessing the required capacity.
The DEA's institutional culture is as a law enforcement agency, not a regulatory one. Asking it to operate a sensible licensing process was never going to go well. This is why your local police department is not in charge of issuing building permits.
I'd say talk to someone in the bureaucracy and ask them to do some empire-building in your favor. Establish a More Important and Better for Promotions Committee for Making Telemedicine EASIER. If they Just Say No, find someone friendlier. You know a bureaucrat is friendly when he says, 'well, that sounds good, but I don't know about the budget. I can't TELL you to call your Congressman.' If you look dumb, can't take a hint the first time and he's willing to trust you, he will repeat 'I can't TELL you to CALL YOUR CONGRESSMAN'.
Call your congressman, call several congressmen, tell them to send an attaboy to this pearl among god-bureaucrats for establishing this necessary and goodly committee.
To play devil's advocate, there are a number of web-based purveyors of impotency pills and hair cream (there is one in particular that leapt to mind reading this post but I am not sure whether it is against the rules to rail against specific entities) whose entire business model over the past year seems to have shifted to flooding the airwaves with advertisements for how you need drugs (look at this upset actor rolling around in bed), drugs will make your life so much better (look at this happy actor, smiling while rolling around in bed with a dog), and all you need to do is text their hotline where doctors are standing by to agree (click on all the symptoms that apply- anxiety? depression? A chat bubble will pop to tell you it's ok, here's 30mg of happy)
This is a slight leap of assumptions (I have been irked at the saturation of ads but have not e.g. tried to get a vynase prescription off them), but I would understand that their business model and bottom line would not permit "popups" as described. From what the Internet can tell, their headcount has gone up significantly but their registered user base has likewise added a couple of zeros.
I agree that there are almost certainly better ways of shutting down bad actors, and I'm not suggesting this proposed rule is justified on the merits (hadn't heard of it until reading the post).
But I would suggest that, evaluated charitably, this is an attempt to be as delicate as the Administrative Procedures Act allows while responding to the furor of some stakeholder who may have at least a sheen of plausibility.
> But I would suggest that, evaluated charitably, this is an attempt to be as delicate as the Administrative Procedures Act allows while responding to the furor of some stakeholder who may have at least a sheen of plausibility.
That is an extremely damning "charitable" evaluation - you're saying that their excuse for doing the wrong thing is that all possible right things other than doing nothing are banned by law, and doing nothing is not an option if there is at least one justifiably angry person out there.
Look at the recent furore over the Covid vaccines. That was precisely the case for which "drop all the red tape, let the FDA expedite it" was intended, and they did.
Now people are claiming this killed untold millions because the vaccines caused heart failure in healthy young people, the FDA should have held the entire process up.
Whatever you do, somebody somewhere won't be satisfied. Suppose the regulators said "Okay, we'll make this process as light touch as possible. Sure, that means some dodgy docs will set up pill-mills, and some people will develop addictions/overdose/sell on their ADHD meds for recreational use. Deaths will probably occur. Well, can't make an omelette without cracking some eggs!"
Are you going to tell me nobody would object, in that case? And probably go to law over it?
“ Now people are claiming this killed untold millions because the vaccines caused heart failure in healthy young people, the FDA should have held the entire process up.”
And those people are wrong. And the (real and hypothetical) people complaining about telehealth are wrong as well.
My apologies if I was pithy/glib. To set preliminary parameters- the term "right action" and "wrong action" is context-dependent and predicated on a cost-benefit analysis that requires determination of what is a weighted factor and what is an externality.
The point of my comment was that (1) there is a case to be made for some greater degree of regulation of telehealth than what exists now, and (2) regulations are the product of a particular administrative process. "Stakeholders", as I used it, refer not to the angry man/woman/child in the street, but an elected or appointed official with decision-making authority (or at least, the ability to make that much more annoying the life of a given administrator/administrative unit).
Justifying my comment- if one is to seek to improve the outcome, one needs to understand what the inputs are and how these are transformed inside whichever black box of process. In this specific instance- there are arguably genuine cases where the usual disrupter crowd has taken advantage of a lax regulatory environment to set up pill mills that look unlike the last generation of Appalachian mills peddling oxycontin to out-of-work Rust Belters with pain issues. If the case I am thinking of is an outlier, than it can't be for long, as this is a niche with a lot of delta and the United States is nominally a free market that rewards any money-making innovation.
The regulation would add costs which would [presumably] make those mills as they are presently formulated less profitable and re-weight the incentives underlying them. I would stress that (in my opinion) ***there are better systems of regulation out there***, other commentators in this thread have pointed out the Canadian system, which seems to get to the desired outcome in a much less resource-intensive manner. I would also argue that bad actors can be addressed by beefing up and using existing tools, though this is not my area of expertise. But I think the painting of this as "Big Gov coming in to jump up and down on the fingers of poor under-served patients and the doctors trying to help them" misses nuance and is not a productive tack to take if you're seeking to influence the outcome.
I think a number of commentators have, since my last comment, made most of the above points with a decent degree of eloquence.
The manner in which the company you are describing, and others like it prescribe medication is not qualitatively different than how doctors - even psychiatrists do it. Which is asking the patient to self-report mood issues and promptly giving out the prescription.
The main difference is barrier to entry/inconvenience for the patient. Surely more people are treated, but for this to be a problem I think you have to bite the bullet and claim many psych medications are prescribed unneccesarily (debatable). Otherwise it is just expanding access to a drug for those who "need" it.
> As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people.
I'm not so sure about that. You're a legitimate psychiatrist; if you see your average patient for one hour once per month you'll have O(200) patients. O(1000) if you have many stable patients that you only see once per quarter or so.
If you're a fraudulent pill-pusher, however, you might only see "patients" for a 10-minute Zoom call once per year, giving a "patient" roster of O(10,000).
If both you and the pill-pusher are affected equally and have to drop controlled prescriptions to half of your respective rosters, then 100-500 of your legitimate patients will lose access to medication whereas 5,000 of the pill pusher's patients will be cut off.
> Seeing patients in person (once) for ten minutes doesn't necessarily take longer for the doctor than seeing them virtually for 10 minutes.
Only assuming that the doctor's time is the only limiting factor. Our host is concerned that he will lose patients due the difficulty or inconvenience of travel, and that will still apply to the pill pushers' clients.
The pill pushers might also be more affected by the in-person restriction, since they can select clients right now from a very wide geographic area without working too hard about distances. If the pushers advertise primarily online, they might need to ask their clients to travel hours for that 10 minute visit, which would be a significant hurdle.
> Is O(200) meant to be big-O notation?
"On the order of," in the manner of a Fermi estimate, where I would not be surprised to be off by a factor of 2 but would be surprised to be off by a factor of 10.
You have not actually considered the counterfactual clearly. The pill pushers patients will not be so easily cut off. I’ve met many of these people in the ER, they’ll try a dozen other places to get what they want and probably succeed. The psychiatrists patients will be far disproportionately affected. The very nature of psychiatric illness is that it is harder for them to seek the care that they need.
> I’ve met many of these people in the ER, they’ll try a dozen other places to get what they want and probably succeed.
If they're going to the ER, then I think that's likely to be self-selected among the most highly motivated drug-seeking patients.
The DEA's implicit point is that the alleged telemedicine-enabled abuse is not driven primarily by highly motivated patients who would, by hook or by crook, pass through any administrative hurdle. Instead, they seem to think that the alleged abuse is driven by more casual patients who are being prescribed the controlled substances because it's easy and convenient.
> The very nature of psychiatric illness is that it is harder for them to seek the care that they need.
That's the counterpoint, isn't it? Has the post-pandemic surge in prescriptions of controlled drugs been driven by psychiatric patients who are newly able to access care, or is it driven by recreational drug-seekers and a network of enabling pill pushers?
> I think you really underestimate the motivation of drug addicts.
If that's the case, then why was there a surge of controlled substance prescriptions related to telemedicine? If addicts will go to any length to get their fix, then anyone with more than a passing interest should have had a prescription already.
The DEA's argument is at least plausible, since other commenters on this article note the existence of pill-pushing telemedicine outfits that are probably not legitimate. If abuse of controlled substances has expanded in part due to loosened restrictions on prescriptions, then it's facially reasonable that tightening those restrictions again will reduce abuse.
>If you're a fraudulent pill-pusher, however, you might only see "patients" for a 10-minute Zoom call once per year, giving a "patient" roster of O(10,000)
At least for stimulants for ADHD there are limits on how many refills you can prescribe and how many pill can be give in each refill. I don't know if its a universal limit but my doc (who i see via telemedicine and have never met in person - the horror) says they can only give a 30 pill supply of adderall with no refills. So i have to see them Monthly.
Also, because they are a psychiatrist and not a psychologist and our appointments are for med management, they are only 10-15 minutes. There isn't much to talk about other than pleasantries and if anything has changed which would make me want to change my medication.
>> "As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people. "
So this is an opinion. That's fine. But you dismiss even the chance that people might disagree, and think that "government regulations" make it harder for bad people than for good people. Maybe their thinking in a particular context is faulty and doesn't sufficiently reflect real world outcomes in your experience. But surely you can recognize that there's a tension that exists across context that requires care to create an appropriate balance. Instead of acknowledging that, you make a blanket characterization - that they "hate new things" or that the way government works is that only bad programs can survive.
It's a strange approach, IMO, given what I have assumed is your focus on perspective-taking (cognitive empathy).
The most important thing though is regardless of whether people agree or disagree, that a process exists to decide which side is correct and then ensure that everyone is ruled by that decision.
“But you dismiss even the chance that people might disagree, and think that "government regulations" make it harder for bad people than for good people. “
Their actions and their very structure are such that they care very little about how much they inconvenience good people. It does not impact their decision because it’s not their job. This is a DEA rule. They are not physicians, public health experts, or economists. They are law enforcement. They are not sitting down doing moral calculations over how many psychiatric patients will lose care and whether it is worth the cost. That’s what congress is for and I think that is a better outlet than petitioning the DEA.
Edit: And actually, I've learned from another commenter that the DEA is literally just following the law in this case. They temporarily didn't enforce the law during COVID because of political pressure to make Telehealth easier but now they have no choice.
But there are also institutional incentives that no rational person irregardless of where they stand on that sort of libertarian/authoritarian axis dont match what they would think of the logical way to go about that process. I.e., institutions have employees who form an interest group and the agency is jockying for more funds and relative power and compromises over long periods of time under different cirucmstances and multipolar motivations lead to massively dyfunctional proccesses where then people acknowledge its dyfunctional but disagree fundamentally on the means or direction to change that .the simplest would be those who broadly think the problem is there needs to be greater government regulation versus those who think there needs to be less- and even of those were the two primary points of tension which they're not the process of working out a compromise comes out with the worst of both worlds which appears to "do something" and take into account the conflicting interests and it neither solves the concerns of people who worry about bad actors or those who worry about solutions for good actors not even taking into account people disagree about what in some cases even constitutes a good or bad actor.
And the more cooks, the more people are incentived to create complex regulatory burdens which increases cost disease which people try to solve by creating more regulations but the bad actors find loopholes and the problem just gets worse.... I;m not sayinf everything with state regulation is like this, but a great many things are and the US seems to be getting worse about doing anything effectively.
Theres also the concept that as systems become too large they eventually dorwn themselves in red tape as a consistent predictbale process
Well, at least now you know how the people who own guns feel about gun control laws, particularly after some horrible event when people say Something Must Be Done. I imagine that's part of what's going on in your profession, people are looking at steeply rising opiod overdose deaths and saying Something Must Be Done. So....something was done.
The reason there's steeply rising opioid deaths is *because* no doctors will prescribe opiates now.
I have a partner who's a disabled veteran - 10 years of back pain, with documentary evidence going back that far, with pain so bad they can't function some days. It's literally impossible to get "real" painkillers now, whether in ER or VA or urgent care or primary care, because no doctors will prescribe them, no matter how well attested or deserving.
This leads to people buying drugs on the street, because even if no doctors are willing to prescribe medicine, there's thousands of amateur pharmacists willing and eager to sell you their stuff. But pretty much all opiate street drugs are fentanyl now, pressed into pills or whatever, and that kills people due to the chocolate chip cookie effect.
The only way to actually stop opiate overdose deaths is to legalize actual pharmaceutical opiates, so people have a non-fentanyl alternative they can actually get.
thats one reason but its not the only one. The technology to come up witj more potent and addictive opiates is much more distributed then it once was for one.
Opiods also make PTSD go away! Temporarily. I broke a bone and was prescribed a few days worth of hydrocodone pills. After taking one that first time, and noticing the effect, I decided to endure the pain of the broken bone, and am saving the rest of the pills for a bad PTSD day.
It gave me a new understanding of the stereotype of Vietnam veterans being addicted to heroin. Also, talking with therapists who deal with mostly homeless people, apparently a shockingly high percentage of homeless opiod addicts were victims of childhood sexual abuse.
This was commented elsewhere and, even though i am a pro-2A (and pro telemedicine), i just don't think the analogy tracks. The supposed harm from over prescriptions is overdoses (i guess? this isn't clearly stated). How many people can a bottle of even the strongest meds kill? I don't think its that many even for the strongest opioids. But a gun, no matter how its purchased, can harm a LOT of people quite easily. I'll also note that at least for suicides and recent mass shootings, the guns have almost always been purchased legally. So the current hurdles to purchase guns don't seem to be doing anything to stop (at least some) people from purchasing them and using them for harm.
Is there any data on how many people who want to purchase a gun, are seemly law abiding citizens, but can't because of current regulations?
The impression I get is that you don't think the analogy tracks for ideological reasons, since the argument you actually advance here is a red herring at best. The relative degree of harm that can be attributed to any one bad act is irrelevant to the point, which, as Scott puts it himself is:
"As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people."
What we're talking about is laws that make it harder for good people to do reasonable things without doing squat to make it harder for bad people to do bad things. If you can't see the obvious analogy to what gun owners say about gun control laws[1], then you are simply unwilling to do so.
------------------------
[1] Quick, name a gun control law which has measureably reduced criminal homicide rates, or which was cited by Would Be Mass Murderer X as the reason he shitposted on the Internet instead of shooting up a school, or Murderer Y as the reason why he was forced to use a kitchen knife instead of a AR-15.
carl read my post the analogy either tracks or doesnt based on different sets of assumptions about what one is considering
the analogy doesnt track perfectly when you accept that people are using assymetric reasoning from your perspective it matches, but from a different set of assumptions it doesn't because people who more so believe in a positive function of government way the harm/benefit of a proposed regulation versus the primacy of a negative right versus the potential costs of individuals causing harm (and thus ultimately also potentially restricting people freedom) In the case of the guns, an individual with a gun could infringe on people rights by acting in the same manner as a government (by using coercive force) whereas a person who wants to buy drugs risks potential harm to themselves (in terms of proximate cause)
I am extremely radically philosophically anarchist, so i agree with your intuition here, but i also see the point how from the other way of looking at they are not symmetrical cases
As I said in my first sentence, i am pro-2A and I wasn't trying to promote or support and gun legislation.
I do think you are right that the reason i gave for the analogy not holding up isn't a good one, but I have another.
(I want to put aside any discussion of the unknown effectiveness of gun laws because there isn't good data and i don't think its relevant to the discussion. I also want to put aside the argument of the 2A being an unalienable right so any laws are moot. For now lets just agree we live in an alternate universe in which the 2A exists but has been ruled to not prevent some gun laws.)
>What we're talking about is laws that make it harder for good people to do reasonable things without doing squat to make it harder for bad people to do bad things.
An added layer is the reasonable of the law proposed. In this case there is unreasonable harm on "good people" but very little harm to "bad people". In the case of gun control we don't have a specific law to look at so its a bit harder to assess. I would say a law such as "banning X firearm" is very much unreasonable because it clearly harms someone who wants to use it for a legitimate purpose. But something like a universal background check or a waiting period, depending on the details, is unlikely (in my view) to cause unreasonable harm to "good people" but is much more likely to harm "bad people".
This relates to my other objection to the analogy, which is that medical care is necessary for many people to live or at least remain healthy. And even more so, time and speed of care is often a critical component of medical care (even non-emergency care). Though i am sure you could come up with a scenario where a "good person" needs a gun right away, but that isn't the case in the vast vast majority of purchases.
They didn't give a reason, but most of the recent terrorists in the UK used knives or vehicles as their weapon, presumably because they were not able to obtain a gun. Unlike mass shooters in the US, such terrorists are usually only able to kill and injure a few people before being stopped.
It's politically and logistically unfeasible to have a such a strict ban in the US, but it is pretty effective.
Do you mean "a gun" as in "any member of the firearms class" or "a particular type of firearm?" I think for the analogy to pain killers/psychiatric meds to work you'd need the latter. And in that case most of the US is forbidden, what with CA NY, NJ, CO, WA...
By "a gun" I mean a typical type of gun that makes up the majority of purchases in the US. So this would cover handguns (revolvers or semi-automatics) or rifles or shotguns. When someone says "a gun" to me, in my head a visualize something like a glock. Or possibly an AR-15 depending on context.
Then, quite a bit (most?) of the US. Supposedly the CA registry has been overturned, but that hasn't been through all of its appeals yet. (and that doesn't affect its scary black rifle ban in any case) USPSA had to move its nationals out of CO because of their gun laws. And of course NY.
Fortunately for me, OH (which is where two nationals are this year) isn't too far away for me to get a safety deposit box so I can compete a bit closer to parity.
I dont think it was meant as a one to one analogy so much as a potential way to better understand the mentality of someone whose "inner equation" seems non sensible to someone who is pro regulation.
"even the way those positions are named- probably people who support gun rights wouldnt say they are are "pro gun" but rather say that their opponents are 'anti- self defense"
Depending on what your "true objection" is, the arguments can be similar or not.
If you're looking at it from a perspective of "what is harm is the regulation trying to reduce and how much of a threat is it?" thats different from a "rights granted by government should be primarily negative in nature" where both restrictions o being able to access medicine and restirctions on being able to successfully defend oneself would both be seen as motivated by similar reasoning.
Just because a particular policy, like criminalising drugs, is ostensibly aimed at preventing a bad outcome, like addiction, doesn't necessarily mean it does so, nor that it passed a cost benefit test.
Another example from the US:
> To promote the Progress of Science and useful Arts, by securing for limited Times to Authors and Inventors the exclusive Right to their respective Writings and Discoveries;
Just because the law says it's supposed to promote progress of science and useful arts, doesn't necessarily mean that it actually achieves that.
The cost-benefit analysis of "life+70 years" copyright is complicated at best. While the benefits of radically transforming copyright law are hard to predict, I'm not aware of any good-faith arguments that reducing the copyright length would harm anyone besides rent-seeking corporations.
But for the sake of this discussion, the only thing that matters is that we do need extra evidence: what ever a law says about its ostensibly aim is not much evidence about what it actually accomplishes.
Copyright law might very well be the bee's knees, but we wouldn't _know_ that from blindly trusting its text.
> How sure are you that that law *isn't* promoting progress of science and useful arts, and why?
An author or inventor can't be incentivized to innovate after they're dead. As Logan pointed out, copyright at the moment sits at "life of author + 70 years".
This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete, so why should we even give even 1-year patents on things the inventor has already invented? The reason of course is that the knowledge that they *will* get a patent afterward is intended as an incentive to doing the work in the first place. And by exactly the same logic, the knowledge that their children *will* financially benefit even after they're dead (or the knowledge that they *will* be able to sell their patent for even more money *because* after they're dead it will still have value to the buyer) can be an incentive to them while they're still alive.
(Now it is quite reasonable to say that this isn't very *much* incentive, or that it's *more incentive than is necessary to still get good results*, but saying it isn't an incentive at all just because they're dead is wrong.)
> This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete
That's ridiculous. Literally every corporation in history has used profits from a previous innovation to fund R&D for subsequent innovations. Every author has used proceeds from a previous book to carry them while they write their next book.
> And by exactly the same logic, the knowledge that their children *will* financially benefit even after they're dead (or the knowledge that they *will* be able to sell their patent for even more money *because* after they're dead it will still have value to the buyer) can be an incentive to them while they're still alive.
No, that's an incentive to create one good thing and then do nothing else except milk that as long as possible, and their kids can ride that train and contribute literally nothing to society themselves. That is literally the *exact opposite* of the stated purpose of the statute.
If an author or inventor can only leave their kids money rather than a perpetual teat they can suckle from, then they are incentivized to create *as much as possible* while they're alive. *That* would be promoting progress in the useful arts and sciences.
> Literally every corporation in history has used profits from a previous innovation to fund R&D for subsequent innovations.
What you do with the money is your business and sure investing in future innovation is one reasonable and common use for it, but rewards-for-innovation would still make complete sense in a world where anyone only ever innovated once, because there are also plenty of people who innovate zero times and you would like to credibly get some of those to work on turning that zero into a one. Do you think that someone with only a little time to live should not get paid for their work, since they won't have time to spend most of the money?
(re "> This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete", you're right this wasn't the best way to say it, but re-read it as "you can't incentivize someone to invent X after they already invented X, so why should you give them a reward for inventing X". It sounds like your answer is that the reward exists to instead fund their next invention, which I do not think is at all the main advantage we get out of the system)
the ethics of incentive of "providing for the future of your family" was much more of a culturally acceptable thing at the time the law was made. So while i dont support copyright, i would also agree that the original law is outdated relative to the social values of the time.
or... lets be a bit crasser here. a possible "incentive" if having a source of income that could be a reason for a younger partner to marry an older man knowing she will be set. Crass or not, its hard to deny that the prospect of being able to attract a young wife in a mans later years is an actual incentive for many men to innovate- and again the law was written at a time when the incentives of men were probably the ones being considered.
"As a volunteer in the community I saw the devastating abuse heaped by addicts on their families."
How would the abuse be worse, if drugs were legally available? Wouldn't drug addicts have a reduced need to take drastic measures? (How do alcoholics compare to other drug addicts?)
> As a volunteer in the community I saw the devastating abuse heaped by addicts on their families.
You know who's to blame for this? The addicts who chose to hurt their families. I hate the idea that because some people take drugs and then do bad things that other people who take drugs and then don't do those bad things should lose their freedoms.
>Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
This is meant as levity, but I wonder if that is actually part of the justification...if a patient isn't willing to do this One Little Thing, see a doctor in person one time/get some other doctor to sign a form letter...well, then maybe they didn't need those Evil Drugs so badly in the first place! Problem solved. It'd be interesting to see data on how far the typical patient is from their teledoc - perhaps for most cases, it really is just an hour car ride or whatever. That doesn't justify the policy change, obviously, but it'd "make sense". Otherwise one is just left with rent-seeking and morality plays. A corollary to the classic: for institutions, it's Beware Others' Nontrivial Conveniences.
The point about testosterone prescriptions is pretty alarming, indeed. I haven't been to a physical doctor since covid arrived, but in exchange have had unlimited no-questions-asked electronic refills for years now...a massive benefit that I'm loath to give up. They better not reclassify estrogen.
Half-joking: just let us know how many subscribers you need to upgrade to "Founding" level to pay for that office. Sorry about the setback, I want to see the Lorien model prove successful too.
Doctors do seem to be very wary about Xanax; a few years back I got a week's supply (seven tablets) of the lowest possible dose to be spread out over months for the panic attacks I was experiencing. More than one tablet a month, and this would be considered Very Bad behaviour indicative of Possible Addiction on my part. I was given to understand that *very* firmly.
A year or two after that, I asked for a refill of same, and got "No, these are Habit Forming". So yeah: advice for the 3 a.m. face-clawing was "have you tried deep breathing?" (Yes, it doesn't work; alcohol does but my liver doesn't like it).
I absolutely see *why* doctors would be very wary because I do see *how* it could build up into a nice little habit, but at the same time I wish - ah well. I wish, I wish, I wish in vain.
My ex became an alcoholic for this reason. It very nearly killed her (still might as her liver doesn’t work great anymore) but even now her doctor doesn’t want to prescribe her everything she needs.
The concern with benzos isn't quite like the concern with Adderall etc., where prescribers are looking for Bad Behavior and judging you because they think you want them for the Wrong Reasons. Yes, certainly some small percentage of people actually use benzos for fun (usually to enhance effects or treat side effects of some other drug), but that's not what they're worried about when they try to ration you to one pill a month.
The real problem is that even people who take benzos for the Right Reasons, as directed, responsibly, to deal with real serious life-impacting anxiety symptoms, and who have absolutely no fun at all while taking them will *still* often become physiologically-dependent with regular use. This dependence manifests as an increase in anxiety symptom severity and frequency, which the patient understandably responds to by using more of their medication, escalating until they're constantly medicated and feeling worse than when they started.
Opioids for chronic pain have a similar effect (opioid-induced hyperalgesia), but the difference with benzos is that the withdrawal is far, far worse (and potentially fatal).
Some fraction of patients seem to get persistent symptom relief from regular benzo use for decades, but nobody knows how to predict who they're going to be. People with a history of addiction may be at higher risk of *misusing* benzos, but it seems like anyone could be at risk of dependence whether they're misusing or not. The only data points your doctor has to go on to predict your risk are how often you take it and whether the frequency is increasing; your character, maturity, responsibility, even the appropriateness of your use are meaningless.
It would be nice if doctors were better at communicating this to patients instead of making you feel like you're being interrogated and judged. (That's about the last thing people with anxiety disorders need.)
The problem with benzo dependence, specifically, is that it makes anxiety worse. Not like ADHD meds where you might be temporarily worse than baseline when you stop taking them; with benzos, you get worse while you *are* taking them. This happens in an insidious "one step forward, two steps back" way with each dose escalation, so it's hard to make the connection until you're so severely dependent that you can't get back to baseline.
The reason for this is that the sympathetic-parasympathetic homeostatic balance that benzos interfere with is a very, very high priority for the body, and it's also asymmetrical. Benzos reduce sympathetic activity, which is an emergency because it threatens breathing and circulation, so the brain responds by downregulating the affected GABA receptors. Benzo withdrawal increases sympathetic activity, which is a normal healthy response to an external threat, so the brain responds by looking for the external threat; the patient perceives this as anxiety and takes another benzo, which triggers more downregulation. So there's a ratchet effect.
We don't have a way to regulate sympathetic-parasympathetic balance with anything approaching the speed and precision of the brain's own homeostatic mechanisms, so there's no good way to help people who are dependent without weaning them off the medications, which is absolutely hellish.
" will *still* often become physiologically-dependent with regular use. This dependence manifests as an increase in anxiety symptom severity and frequency, which the patient understandably responds to by using more of their medication, escalating until they're constantly medicated and feeling worse than when they started."
Oh, I entirely understand the caution. I've seen it in a family member who developed a Valium addiction over years and was doing precisely what you describe: they got anxious about getting anxious, took another tablet, and the cycle went round again.
So I do get why my doctor only gave me seven tablets for an entire year and cautioned me, and I didn't immediately run back and say "Used them all, can I have more?" I know the potential for problems and was only going back a year or two later out of desperation.
Unfortunately, the "deep breathing, think relaxing thoughts" etc. advice to use instead of medication does Sweet Fanny Adams for me, so I end up self-medicating with alcohol which is *not* good and already *has* had an effect on my liver. Luckily the 3 a.m. clawing the face off bouts have lessened a great deal in the recent past, so I'm crossing my fingers and hoping they'll stay gone.
The panicky, anxious fits that come and go for no reason are another thing 🤷♀️ I'm doing an online CBT course at the moment and going slowly through it, so maybe that will help.
Although I already hate it with the 'mood map'. Keep a record of what you're feeling, when, and what triggered it: bitch, if I *knew* why out of nowhere, for no reason, with no stressors, I suddenly get the panic fits, I wouldn't be doing this course in the first place. I just have to grit my teeth and keep on with it, though; maybe the later modules will actually be some help (the deep breathing, mindfulness, etc. jazz does nothing for me, as I said).
Ouch. Yeah, that's basically the same thing with added toxicity.
>bitch, if I *knew* why out of nowhere, for no reason, with no stressors, I suddenly get the panic fits, I wouldn't be doing this course in the first place
I think you might be overthinking it. The point is to identify what triggers the anxiety spiral so you can hopefully learn to interrupt it before it escalates. If the first thing you notice is an out-of-nowhere sensation of shortness of breath, or your heart racing, or a general sense of impending doom, then that's the trigger.
Panic disorder exists at the intersection of psychology, neurology, and pulmonology, where a disruption in the mind, the sympathetic nervous system, or the arterial blood gas balance can throw all three into a positive feedback loop with each other. Some people's triggers are obviously "psychological" - people with PTSD may have panic attacks in response to reminders of their trauma - but many panic patients are reacting to physiological sensations. (There's some lack of clarity on whether it's "normal responses to abnormal stimuli" or "abnormal hypersensitivity to normal stimuli," but it's not that important for treatment.)
>deep breathing
The common "deep breathing" advice may actually be counterproductive. It's good for generalized anxiety but often bad for panic attacks.
The body uses CO2 as a proxy for blood oxygenation. Either high or low CO2 can provoke a feeling of shortness of breath. The extreme anxiety that distinguishes panic disorder from other anxiety disorders is driven by a real, physiological signal of suffocation that is very literally not in your head. You can't think your way out of it directly any more than you can think your way out of the panic of real suffocation; you have to stop the signal.
The evidence of blood gas involvement in panic attack onset is mixed, probably reflecting heterogeneity in the disorder. Some patients have low blood CO2 at baseline, which suggests hypersensitivity to blood CO2 such that normal levels may trigger panic attacks ; others seem to be normal at baseline, but low immediately before a panic attack triggered by psychological stimuli; others have normal levels at baseline and panic in response to low levels; still others have normal levels at baseline and panic in response to high levels; and there may be some people for whom CO2 doesn't play an important role. That's why there's so much variation in responses to breathing techniques for prevention/early intervention. Some people can stop a panic attack before it starts with deep breathing.
But during a panic attack, patients are almost always hypocapnic (low blood CO2) as a result of hyperventilation. Hyperventilation in a medical sense just means that you're breathing more than you need to for your current level of metabolic activity; it can take the stereotypical form of short rapid breaths, but it can also be accomplished by deep breathing. (For example, the measured deep breathing of a distance swimmer doesn't *look* like hyperventilation, but it removes far more carbon dioxide than you can generate sitting on your couch having a panic attack.)
So once you're already panicking, the breathing interventions you're looking for are ones that *increase* blood CO2: slow breathing, breathe-hold-slow exhale, the old paper bag trick.
You can also kill two birds with one stone by holding your breath and immersing your face in cold water (under 50F/10C) to activate the diving reflex https://en.m.wikipedia.org/wiki/Diving_reflex. This will both increase your blood CO2 and downregulate the sympathetic overactivity that's driving the hyperventilation.
"Where a disruption in the mind, the sympathetic nervous system, or the arterial blood gas balance can throw all three into a positive feedback loop with each other
The body uses CO2 as a proxy for blood oxygenation. Either high or low CO2 can provoke a feeling of shortness of breath. The extreme anxiety that distinguishes panic disorder from other anxiety disorders is driven by a real, physiological signal of suffocation that is very literally not in your head. You can't think your way out of it directly any more than you can think your way out of the panic of real suffocation; you have to stop the signal."
Thank you for this, this answer is a lot more helpful to me than anything my doctor has said - they do seem to treat it all as psychological rather than physiological, and I do notice breathing problems/feeling like I'm gasping for air as one of the lovely, lovely symptoms when I'm freaking out 😁
>they do seem to treat it all as psychological rather than physiological
They do that 😠
I think the problem, besides the hammer/nail phenomenon, is that panic disorder has some superficial similarities with health anxiety (hypochondria). If you tell someone with health anxiety that there might be something physically wrong with them, you're reinforcing their fears, and they tend to get worse; I think there's an assumption that the same is true in panic disorder. So the standard of care is to emphasize that there's nothing physically wrong with you, you're going to be fine, your symptoms are purely psychological, and the treatment is therapy to correct your maladaptive thought/behavior patterns.
That does seem to work for a lot of people. But it doesn't work for everyone. Some people respond much better to the nuanced understanding that there *is* something measurably abnormal going on with your physiology, but it's not dangerous; it's just triggering a false alarm in a system evolved to keep you alive in low-oxygen/low-CO2 environments, and the treatment is still therapy, but the goal of therapy is to learn to recognize the false alarm early and stop your instinctive response to it.
I suspect that people who hang out here are more likely to be in that second group.
From the past experience as a low-level government minion: surprisingly, this is not because most regulators are Dolores Umbridge and wake up in the morning wondering what new and special ways they can make life miserable. (Some of 'em do it anyway, but it's not out of malice, it's because they have lovely shiny top-down policies that won't work in practice at the coalface, and they resolutely will not listen to the front-facing low-level minions about how it won't work and this is why, but that's a different argument).
It's down to bad actors. It's the people who will abuse telemedicine to feed a habit, and the pill-mills that will set up to take advantage of it, and the dodgy imports that others will set up to provide for the pill-mills to prescribe. One case of an addict who dies because a shady operator prescribed them something that came from China and was cut with all kinds of shit*, and there will be media coverage of the sobbing parents/partner and cute kid, grave thinkpieces online, and probably some current affairs hour-long documentary about the scourge of online telemedicine and how the government is doing nothing about it. Then come the ambulance chaser lawyers egging on the family to sue the relevant authorities for $$$$$$$.
Cue politicians freaking the hell out about upcoming elections in their constituency where the person comes from/died, and you get regulations like this.
Scott is legitimate, scrupulous, and knows what he's doing. On the other hand, you have Dr. Teetus Deletus out there practicing medicine:
Tangential to all this, I am envious: you can get your doctor (or some medical professional) to speak to you on video call and prescribe medicine? I am currently remembering when I got Covid; my GP told me that if it got bad, I could go to the emergency department of the regional hospital and get Paxlovid.
One bout of coughing so bad that I had to get a ride in the ambulance down there later, the ED told me "Yeah, there's nothing we can do for you". What about Paxlovid, you ask? Wot dat? But they did give me a chest x-ray, told me that was fine, then packed me off home to get better on my own 😁 I think the oxygen I got via nasal cannula during the ambulance ride down helped more than anything.
So yeah - all I can do is gape, awe-struck, at the advances in American medicine, even with the shackles of government regulation weighing it down!
Of Moloch it is written, "He always and everywhere offers the same deal: throw what you love most into the flames, and I can grant you power." We think of Moloch as huge and terrible, with giant "fingers of armies" and you have to look up and squint to see his "skyscraper-window eyes"
But Moloch is small, and he's a multitude - he's a tiny little parasite that sucks on your soul at a rate you can barely notice, and we're like those deer you see sometimes, late in the summer, so covered in ticks that their skin sags and they can't see and they stumble to the puddle for a small drink, just enough to keep them alive. Awe-struck indeed we should all be, at the strength and determination of humanity as it struggles mightily to put one foot in front of the other. Fuck disease and obesity, the biggest killers? Fuck depression and anxiety, the biggest miseries? Fuck poverty and war, the biggest injustices? Nah, fuck moloch and all the rest falls easily away.
I’d argue the Dolores Umbridge comparison is actually apt. Umbridge doesn’t want to make life difficult for everyone. Only the naughty children that deserve it, and she doesn’t care about the cross fire. Regulators only want to punish naughty people and they similarly don’t care about the cross fire.
We have no proof in from the text exactly what they did to her; it was unlikely to be that. But whatever it was it seems to have traumatized her pretty well, at least for a while.
The forms must be obeyed. It is still a children's book series, so it's not spelled out explicitly on the page in graphic detail (because if it was just stated, you'd say that wasn't proof because the character saying it could be lying or mistaken), but it's a classical allusion as clear as any.
Hmm… I can’t help but think centaurs would think that humans are too “gross” so they prefer other ways to punish them without having to profane themselves with that kind of human contact.
Meanwhile, the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act.
Don't worry, though - the DEA has said about this proposed rule that it feels this will be 'less burdensome' for providers than any kind of special registration, so it feels it has discharged its legal responsibility to create a special registration process.
I am a psychiatrist having to deal with this idiocy with my patients too, and renting an office temporarily is not going to cut it. So I am going the letter route. I will probably a lose a reasonable chunk of patients I was prescribing controlled substances to. The only possible saving grace is that PCPs in this country are used to being asked to sign and complete all kinds of nonsense forms and documents so probably most of them will just do it with minimal fuss.
I'm more concerned with the new requirement that all telemedicine scripts now have to be recorded by the prescriber with the date and time they were written, the PHYSICAL ADDRESS of the prescriber and patient at the time of the telehealth encounter, and have an explicit note on them that they are telemedicine prescriptions. I am less concerned about PCPs balking at writing an idiotic referral than I am skittish pharmacists refusing to fill scripts that they might interpret as being labeled equivalently to FAKE SCRIPT FOR DRUGSEEKERS
Bureaucracies just deciding not to do what the legislature tells them to do is why I can't agree with those who argue for the legitimacy of the delegated administrative state on the basis of those agencies being authorized by said legislature.
one would imagine that doctors who want to prescribe controlled substances remotely would have standing to sue the DEA for failing to promulgate a regulation. i wonder why this has not been done
the administrative procedures act waives sovereign immunity with respect to agency actions (5 USC §702), including "failure to act." a rule is an agency action (5 USC §551) so it seems to me like not making a rule they were supposed to is judicually reviewable. but I'm not a lawyer and dont really know anything about law, so idk
I think the real issue is that the best possible outcome for the one filing suit would be a court order to comply with the law and promulgate a regulation. This would be somewhat satisfying from a moral standpoint, but probably wouldn't result in an actual regulation.
It's a complicated problem with no easy answer. If chemists get trained that the new regulations require this level of detail, that may help. Part of the problem is trying to disentangle legitimate prescribers like yourself from the dodgy pill-mills, and that's not easy.
Unless the government throws up its hands, say "to hell with it, Adderall for everyone!" and doesn't put any control on such substances at all, there is always going to be the fumbling attempts to strike a balance.
"Compared to studies examining the prevalence and correlates of nonmedical ADHD drug use, fewer studies have specifically examined dimensions of access and motivation for NMU of ADHD medications. McCabe et al. reported that in a sample of middle and high school students in the Midwest, over 23% of those with a prescription for an ADHD medication were approached to sell, trade, or give away their medications. This finding is confirmed in the 2005 NSDUH, which found that most persons who used prescription stimulants (excluding methamphetamine) nonmedically in the past year received them from friends or relatives for free. Some studies have examined associations between NMU and psychological factors, including ADHD status to identify possible motivations for use. For example, a clinical case-control study by Wilens and colleagues based on ADHD diagnosis (N = 186) found that 36% of the sample reported use for self-medication, 25% used ADHD medications to get high, and 39% had unknown motivation. A community-based study at a single university found that nearly 25% of those with ADHD reported use of their medications for recreational purposes. Yet, much of the literature points to NMU of prescription stimulants for performance enhancement. Teter et al., in a study at a large, midwestern university, found that prescription stimulants were used primarily for performance enhancement, although use for feelings of euphoria (e.g., getting high) also was noted. These studies, while primarily limited to regional populations, suggest that peers are a common source of diverted medications and that performance enhancement or self-medication are important motivations for NMU."
'Just ring this number and answer a few simple questions and our qualified doctors will write you a prescription, sight unseen' is only exacerbating that. It's not even people trying to source party fun substances that, to me, seems to be the huge problem; it's a society where "unless I'm drugged up to the gills I can't concentrate enough for the study I need to do in school or the focus I need for the productivity demands of my job".
We talk about the Asian grind schools where kids spend hours upon hours doing homework and extra study for years to get into the universities to get the good jobs, but American society seems to be every bit as grinding, only with added chemical enhancement.
Well, that's actually pretty much my position. I feel that the "war on drugs" has done more damage to society than the drugs ever did. Make all (non-antibiotic) drugs available for purchase (at least for adults), and have "truth in labeling " laws with teeth in them that are actually enforced. You'll have lots of damage from improper use of drugs, but, I believe, less than the regulations have caused.
It's a pretty clear supply and demand issue: the *reason* opiate deaths have skyrocketed is *because* pretty much all doctors refuse to prescribe them now, driving people to amateur street pharmacists, all of which have fentanyl contaminated products.
This is a demand issue - the demand for strong painkillers will literally never go away. Further, addict's demand is famously inelastic too. That demand is a particularly personally motivating demand too, so people in actual pain or addicts aren't just going to give up when you make all safe and pharmaceutically pure opiates impossible to get.
There would be nearly zero opiate deaths if addicts and people in pain could buy trusted pharmaceutical pills, wether due to legalization or due to doctors actually being willing to hand them out.
But people are morally panicked about what people do to their own bodies, and regulators have stepped on doctors to drastically restrict scrips, which has led to people in actual pain and addicts turning to illegal drugs and dying in droves. There's a very obvious solution, but people can't stand the idea of people in pain and addicts actually getting what they want, so they'd rather (indirectly) kill them.
I think the difference between Asian Grind culture and USA education culture is the USA has a smaller "grind" population - if your parents are the sort who wait years on a waiting list to get you into the right preschool, you're on the Ivy League track and need Asian Grind level of commitment plus chemical enhancement.
But if you're just a regular Joe, and are planning on community college or state school, or even no college, then it really doesn't matter, and you're free to eschew homework and chemical enhancement if you want.
I'd imagine the split is probably 80/20 or 90/10 in the USA (Ivy is less than 1%, but it's really more the mindset of the parents, and I'd bet at least 20% of US parents are on that bandwagon).
Having lived in various Asian countries for years, I'd estimate the Asian Grind % to be something like a third to a half, so call it 40%. Thus Asia has 2-4x the "grind %" of the USA, as a high pass estimate, but those 10-20% who have to grind in the USA generally end up chemically enhanced just to compete, because the field is generally very chemically enhanced, much like Tour de France competitors prior to the Armstrong scandal.
The AMA has been pushing fairly hard for an easier telehealth registration process for many years now. They are also quite vociferously opposed to this proposed rule.
Doctors can be as venal and rent-seeking as anyone but this is very much coming from the DEA. It makes physicians' lives significantly harder.
If telemedicine becomes routine you will get insurance providers saying "it doesn't cost you as much to see a patient using Zoom, we won't reimburse you as much."
Followed by "If it's over Zoom we don't see why it takes a doctor to do it."
I admit that seems to be an alliance (conspiracy?) between the AMA and the DEA (and all the other 3-letters...)
On second thought both "alliance" and "conspiracy" are too strong in terms of indicating intent. Call it "aligned interests" - which makes it much harder to prove wrongdoing in court, yet is more effective in ensuring people continue to act.
telemedicine still requires a doctor, so no doctors are cut out of the process. if you want to make a medical rent seeking argument, i think it should go something like this:
if you are the only doctor in town, you have significant market power; you can charge higher prices for the same quality of service. traditional providers have to actually live near the town they are serving, so it is not so easy for competitors to enter your geographically segmented market and start offering lower prices/better care. but telemedicine providers can live anywhere, so they can compete with doctors in any market. having to live near the town is a costly (but not necessarily financially costly) barrier to entry; removing this barrier potentially weakens doctors' market power.
i don't know if i believe this story. another commenter notes that the AMA favors telemedicine, and anyway i havent fully thought through the model i describe above, but that's what comes to mind
Agreed. The AMA exists for the purpose of maximizing its members' income. Look for them (and the bar associations) to push back *hard* against any use of AI for diagnosis.
In my province (Canada) we have lots of telemedicine but no prescribing restrictions. However, all scripts for controlled drugs are copied to a central prescription monitoring programme, via one part of a triplicate prescription pad, and if you prescribe a lot to a patient, escalating amounts to a patient, or the drugs to more patients than other doctors in your speciality, you will get, first, a warning with a request for an explanation. Then follows a practice assessment where your records are examined to check appropriateness of prescription and whether you follow guidelines for alternative treatments, used patient contracts etc. If you are felt to be abusing your prescribing privileges, this then escalates to a complaint to the licensing body and usually you lose the right to prescribe narcotics after that, and have to place a notice of humiliation in your waiting room saying yo cannot prescribe these drugs.
It sounds intrusive, but it is actually easy and extremely effective at making us think before prescribing.
That sounds like the thing you'd actually need to do to tell the blatant pill-mills from the legitimate doctors: allow them to do their thing for a while, and then observe what they do. So, from your experience, this works well?
Yes, but it would be best to also track the patients that get the same prescription from multiple doctors. No sure what you should do when you'd found the "abusers" though.
This is absolutely tracked, at least in most US states, and doctors and pharmacies can pull up a score of how likely a patient is to be an abuser.
Unfortunately sometimes people get flagged by the system for the wrong reasons (legitimate hard-to-diagnose chronic pain also results in going to lots of different doctors and asking for pain meds) and then no one will prescribe to them because their score is high.
Yes, it does. The triplicate prescription can be mailed to a patient, but cannot be phoned in to a pharmacy. I didn't say it, but patients are tracked too, and it's not uncommon to get a warning that you have prescribed to a patient with an abnormal profile. No consequences flow to the physician unless they keep prescribing to someone who is either abusing or, more likely, selling on. That generally happens via an ER visit, when a stranger comes in with a painful complaint and sees a doc he has never seen before and fools him for one script. At the time I retired, the programme kept track of all narcotic/opiate scripts, barbiturates, and stimulants. Not benzodiazepines though.
Here in Ohio, perhaps the whole US, all registered substance perscriptions have to be made via a centralized computer system. Further, by law your prerscriber must check this database before prescribing such meds. Si, the government does have a centralized database of such perscriptions without needing a time consuming paper records recording and searching step.
We have a database like that - in California it's called CURES. I've never heard of people getting in trouble for overprescribing on it, but that could either be because they don't monitor or because I haven't tripped their alert yet.
I do something get letters from insurance companies asking if I really meant to prescribe X and Y drugs together. They are 90% dumb but sometimes they actually catch something.
I've been to three psychiatrists in Alberta and haven't been able to get a trial of Adderall. I supposed that this had something to do with The System but had no way of getting any information about how The System works. I am certain I have ADHD, but I can only get atomoxetine for it (which doesn't work).
I am wondering if every new psychiatrist decreases my chances of diagnosis and treatment (including the one that seemed to have a strong dislike for all medications as a rule, and scolded me for having daytime naps, and the one who said that I needed nonexistent proof from my childhood report cards in order to be diagnosed ... the third one said I "had the symptoms of ADHD" but didn't give a diagnosis for whatever reason.)
Will each new one be able to see my history and say "well the last N doctors didn't diagnose you, so clearly you don't have ADHD"?
Posted my comment on this proposed rule because my telemedicine doc just ended her relationship with me over this rule (she evidentally had concerns re maintaining her license and felt pressured given she has some longtime patients and is transitioning her practice) and I'm scrambling to find something local that I can even remotely afford. It's doubly frustrating because if the issue is docs who overprescribe, with scheduled drugs that's already tracked, the government doesn't need to dun the patients to suss out who these uncareful docs might be. Plus we all know this is about opiates/opioids, not drug abusing psych and weight loss patients, two groups that benefit highly from the access to telemedicine. Anyhoo, comment made. Would that our government overlords who I can't vote out of office weren't drunk with their own power and would actually listen.
I agree that this probably isn't a good or useful regulation. But I found myself more concerned about the way that you assume that there is nothing that you will learn from your patients in person that you are not learning from them over zoom. I find that I learn much more about people in person than I do over zoom and I expect that for a trained and professional observer of people that the delta is much larger.
I can certainly see how this law can be inconvenient and potentially damaging to you or your patients, but it also seems that there is an opportunity to be seized to learn more about your patients if you don't regard these visits as simply a perfunctory checking of boxes. If you think that the regulation is a bad regulation then you are right to fight it, but don't get so distracted by it that you miss the advantages that do come to you.
This would be true in general, but California still requires that doctors and patients both wear masks throughout an in-person appointment. A video call is actually better for seeing someone's facial expression.
No it doesn't. I've been to my physician a few times recently, and nobody wore masks. Pretty sure she's careful to stay on the right side of the law, too.
Wow remember when Cali seemed like the future instead of the past? Strange days.
Anyway, I think that the point still stands though certainly becomes more debatable. Body language and context awareness I suspect still make more complete observations in person reasonable.
For many people the choice isn't to see their doc on zoom OR go into an office. Its see their doc on zoom or NOT see a doctor at all (for a variety of reasons). For these patients, the doctor would learn nothing from seeing them in person because the patient wouldn't be there.
How did these people see doctors before the pandemic? Have they become so enfeebled in 3 years? Has all of the social support that was previously relied on fallen apart? If so, why?
There are many possible reasons someone wouldn't see a doctor in person but would via telemedicine:
They didn't have the condition until telemedicine was available
They live far away from a doctors office
Scheduling an in person appointment is difficult given family, work, or other responsibilities, but a telemedicine appointment is easier to schedule
Their condition makes scheduling any type of appointment difficult but telemedicine is much easier. This applies to many psychological disorders.
They don't have access to reliable transportation to get to an appointment on time.
These are just a few i thought of when typing this response. But the general point is we can't know all the reasons people do things and there will always be people who have difficulty accessing medical care. Why should we create unnecessary hurdles for them to access it?
The suggestion that there is no solutions but this one available is clearly not true though. People have been solving this problem without telemedicine for a long time. You said that the choice was telemedicine or go without medical care, I think that you are backing down from that as hyperbole. So my work here seems to be done.
How did these people get help before the pandemic when there were similar restrictions? To suggest that something is indispensable, that no alternative exists, to something which has only been in place for three years, strains credulity.
PS If you don't want psychiatrists and liberals in general to be accused of an unreasoning hatred towards Christianity you should probably be more judicious in your use of antiChristian tropes when describing everyone who is skeptical of mind-altering drugs.
I’ve been a primary care nurse practitioner in the Bible Belt for 20yrs and not once have I even heard of a provider telling a patient they should substitute religion for psychiatric (or any) medication. It’s so easy for some people to throw around these tropes as if Christianity is some exotic, weird tribe with horrifying anthropological traits.
-been told by my PCP not to get an IUD because it carries "a significant risk of causing infertility or death"
-had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient
-been told by a therapist to discontinue the SSRI a different provider had prescribed and just trust in the man of the house
the PCP wasn't even particularly Christian herself, but since all of her patients are she hadn't updated on IUDs since the scare back in the 70s. Our horrifying anthropological traits become everyone's problem--it might be worth listening to those who "throw around these tropes" so you can understand what they have to deal with
Once you get people hating you for a legitimate reason, they stop being careful about other reasons that agree with their feelings.
And there are LOT of people with legitimate reasons to hate "Christians". That was in quotes, because though the term was used to describe them, they do not fit my idea of what the character described in the synoptic gospels would consider appropriate for a follower. Unfortunately, that characterization applies to most of those who loudly proclaim that they are Christians.
Well yeah anybody who hates a group of people thinks it’s justified. That’s the whole thing. So the target group can reply, and then others can debate the rational basis of the hate, and we go on commenting. Welcome to this particular instance.
A lot of people feel that they’re justified in being prejudiced against certain ethnicities or races due to their experiences and various statistics. Are you arguing that they are being quite reasonable—the only thing wrong with their argument is that objectively ‘most’ of the group they hate doesn’t uphold their prejudice? In that case, if it was pointed out to you that the very loud groups you point to do not constitute ‘most Christians’ but rather the ones that the media chooses to highlight, would you admit that your position is ill-considered?
Or, on second thought, might you consider that prejudice is actually *inherently* wrong, even if some stereotypes have a kernel of truth?
There’s two roads to go down here and retain some dignity to this conversation, rather than continuing to gather momentum to go down the low road where specific prejudices are approved.
if a prejudice ia a prejudgement based on someone holding ideologival beliefs you disagree with, then no.
For example, police officers beleve it is justified to threaten people's lives to enforce the laws the state has passed and be paid to regularly do so. That is an inherent part of the job description of being a police officer. Since think such a person who acts and such on beliefs is committed to actions I consider fundamentally unethical, then no, judging them for such is not inherently wrong.
This applies to any set of beliefs someone has where a person in is fundamental disagreement. Depending on which side of the abortion debate one is one (simplifying to two sides for the sake of argument) then one judges the other side as either promoting the murder of infants, or on the other side, seeing abortion doctors killers as murders instead of heroes. Again, based on your ethical priors, these judgements are fair if you truly believe the actions they lead to are unethical.
Prejudice is nothing more than a heuristic *you* don't like. If you want to ban heuristics, you are insane. If you merely want to ban only the heuristics you don't like, you are insane. If you expect me to believe you operate in the world without heuristics, you are insane. If you want me to operate in the world without heuristics, either give me a palantír, or fuck yourself.
For some general orientation, you can park my assertion next to Sailer's: "political correctness is a war on noticing".
A Christian is by definition a failure- a Sinner saved by undeserved Grace. Bad behavior is implied. So the stereotypes have some legitimacy. Actually a stereotype is the classic example of the wisdom of the crowd, which perhaps suggests why the current trend of croqdsourcing said wisdom has pitfalls that its eager adopters haven't considered.
But social Christianity was the dominant ideology of this country for two hundred years and attracted the sorts of people who are always attracted to the dominant ideology. It will be interesting to see what happens to the purity of the church and Christian morals as we transition from an establishment religion to a persecuted religion
I disagree. There are certainly a lot of churches that promote that doctrine, but I don't believe that it is implicit in the synoptic gospels. If you want to say instead "a Christian admits that he has (in the past) failed, I'd agree, but that's a very different statement. The idea of "undeserved Grace" is something that was not implicit. Perhaps the Grace was deserved? Who are we to say. Even saying it was Grace isn't implicit. If I fix a program, I don't consider that I'm gracing it. I'm fixing it for my own reasons.
Actually, I'm not a Christian. There have been too many instance of people calling themselves Christians while in the midst of doing horrible things, and being approved of by the "Christian" community, so I can't stomach identifying with them. But as long as folks act in harmony with the synoptic gospels, and don't consider individuals or groups "godly" who do horrible things while calling themselves Christian, I have no real qualm about liking them ... if they're willing to shut up about how great Christianity is.
So your doctor told you that medicine has possible complications that you disagree with the doctor about, and a therapist encouraged you to deal with interpersonal problems without the use of medications. If you want us to see these as horror stories we need a little more detail. These seem pretty ok. Now I do think that a pharmacist should fill a prescription unless there is a chemical or statutory reason not to, but i can't say that I am hugely knowledgeable about that.
I certainly wouldn’t say it doesn’t happen, because there are quacks everywhere. I will say that neglecting spiritual health (any kind of spirituality) can be a problem for any average human but as a Christian among many such providers there’s a pretty dark line between practice and prayer, so to speak. Doing a spiritual assessment in a health crisis can make sense but it should be done very objectively.
Surely something as simple as referring an alcoholic to AA, for example, wouldn’t fall under this You Just Need Jesus accusation?
yes it does, because AA doesnt actually deserve its stellar reputations for many reasons, including they dont keep any records, so their success stories are cherry picked and tautologically, anyone who wasnt helped by AA wasnt "ready"
A treatment plan that calls itself the most successful but discounts the failures as not being the responsibility of the treatment plan is problematic.
Furthermore, the twelve steps are logically inconsistent. One has to admit one is powerless over their addictions, but take personal responsibility.
If one is powerless how can they also be personally responsible? why is belief in a higher power a precondition of success?
In fact, the histtory of AA, it was NOT founded to treat addicts but as a means of converting people to christianity. It was only later on that the "higher power" wasnt specifically the christian God. Originally it meant "any form of christianity is legitimate" but was explicitly desinged as a missionary program and part of it strategy was to insist on tis members declaring it to be the "one and only true way"
We just cant compare whether secular programs or other interventions are equally effective because the only available data come sfrom promoters of AA and has vague definitions for failure as people had to be "ready" or they couldnt succeed
Actually the primary literature says they don’t have the market cornered on treatment. Also I know many atheists who are sober in AA. There was a study on 12 Step outcomes within the last few years but you’d have to look it. Success rates among low bottom addicts and alcoholics are pretty dismal so as a “last house on the block” option it seems to have usefulness. The point is spiritual solutions are not unheard of.
Does it seem necessary to needle Christians in particular in order to make your point or could you have made the same point while only needling the group of people who believe that psychiatry isn’t real?
well... its kind fo an obvious one. A psychiatrist who suggest the answers to yor problems isnt medication or therapy but to convert to their religion seems to be very much doing malpractice.
If you want to make an argument that your religion is the answer to psychiatric and psychological problems, fine, your free to do do, but dont claim to be a psychiatrist and do it under such auspices where the person was expecting a secular analysis and treatment in accordance with the principles of modern psychiatrist.
imagine you went to doctor for panic attacks and he told your problem was you were being punished by Allah for being a infidel and you needed to repent and follow the one true god and he prescribed daily prayers to Mecca
I would imagine you would not be happy if that was the guy youre insurance sent you and that was his "psychiatric" advice
I thought so too. Scott is a devotee of pharmaceutically assisting mental problems and has a right to complain about his experiences with people who disagree with and make his life inconvenient.
But there are certainly plenty of reasons to be suspicious of 'better mental health through pills'. I look around and notice that we havent arrived in the Golden Age of Sanity and Happy People despite several decades of mass medication and a hundred years of psychiatry.
I would have thought that in San Francisco the particular reason that Scott called out for rejection of psych meds would be one of the less common ones he would hear. It certainly came across to me as a signal of the antireligious and particularly antichristian bias that psychiatrists are always accused of and usually deny. Maybe Scott is comfortable with that bias and would not deny it. I don't know, he is a pretty unique guy.
There have been obviously millenia of Judaeochristian thought. That is the control. About 100 years of psychiatry, 30 years of SSRIs, 10 of crosssex hormone availability. Those are the experimental cohorts. Are the experimental interventions improving mental health? Haven't we had them long enough to do some cost-benefit analysis?
Tbh, it seems more significant to me that people are reacting so strongly to an off the cuff example of a thing that does sometimes happen even if it is not representative of the majority of christian doctors
So common in tech-y West Coast circles. My firm is the same.
Most of these unpleasantness land just barely on the side of being insults, but insults that could be defended as “I meant the *crazy* kind of Christians.” (The anti-abortion types, or the people who have revivals, or something.) So you don’t really get an apology as the person insulting you feels justified in what they’re saying.
Of course, if you place it in another context that wouldn’t fly: a sophisticated person would never defend an insult of e.g., women by saying, “Oh, I didn’t mean you, I meant the *crazy* kind of women.” (The kind who protest, or something.)
To which you are expected to smile and separate yourself from the crazy types, which of course I (seem to) do. It’s my career at stake, I’m not going to fight a losing battle with HR. I suppose I should document this stuff in case I ever get laid off, but that just seems vicious.
but women are a biological category of person and christians are people with beliefs and ideologies. thats apples an oranges.
Judging someone on immutable biological circumstances of their birth is different from judging them on their beliefs and values and the actions and attitudes that result.
If they were judging my group on our belief in God, rather than some other accessory beliefs or behaviors that they impute through guilt by association, that might even be ‘fair,’ even if it’s textbook prejudice.
Certainly I think the values in this country promote tolerance and diversity of thought, and therefore people should not pride themselves on being prejudiced in ways that are acceptable or fashionable.
This is a shameful position, in my opinion, but if you sleep fine on it, sure.
'And that’s the best case scenario! The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else. '
What is the correct way for Scott to report on his patient's experiences with such physicians without being "anti-Christian"? Or do you think talking about these experiences is inherently problematic? Genuine question.
I think this is a case where Christians are reading it as "this this one source of this" whereas i think people like me are seeing it as a stand in for any thing like "Psych Drugs arent real because you just need to meditate" or "Psych drugs arent real because you need to clear your engrams"
Which of course raises the question: if this simply signifies all irrational reasoning, why is Christianity singled out by name?
Would you dismiss this as ‘just an example’ if the context was picking out, say, Jews? Or would you say that singling them out was unnecessary and inflammatory?
It's also the kind of language policing and offence-seeking that in other contexts in this readership would see people complaining of wokism. Not necessarily the same people who are complaining here of course.
again though, i dont see how "prejudices" are wrong if they are about people;s beliefs and the thought processes that derive from such beliefs and morals
I'm skeptical that he has heard that from another medical provider. I believe he is deriding everyone who is skeptical of psychiatric medication for whatever reason under a hate inducing trope.
If Scott would like to share a nonprivileged/anonymized instance where that happened in a nonprejudicial way I think a lot of people would be interested in reading it.
I think it interesting that someone happy to write about "the Men in Skirts" with "their perversion and corruption" is now come over all faint at the idea of hate inducing tropes. Man up.
I am not ashamed of what I said. The men in skirts are revealed over and over as child abusers, as destroyers of women, as borderline personalities. My statements are fact based. That group has an absurdly high rate of violence and hate. I hate the hateful and destructive.
Being disparaging to everyone who disagrees with mind altering drugs as the solution to interpersonal problems is not equivalent. False equivalence is a shield used to make good men and women do nothing in the face of evil.
Those are one of those tropes that usually bother me but that for some reason didn't when I read Scott's post. (In fact, I had to read onto the subthread to remind myself of what had been said in the post.)
But now that you (and Mike) bring it up, I agree with the general point, even though I take Scott's use of that trope to be a throwaway humorous line. I work in an academic-adjacent field in which it's very acceptable to casually make fun of or denigrate Christians. (Not all Christians, of course. Just the ones who decline to observe a Christianity that takes no political or cultural stances that disagrees with my colleagues.)
That rankles me. I grew up in a religious environment, even though I no longer really profess Christianity. I still feel defensive when I hear those types of tropes. Maybe I shouldn't. I realize that in the US in general, Christians aren't really an oppressed group, even if they're largely unwelcome in certain work environments like mine. And even if I can't help being defensive, I'll cop to being able to shake it off and deal with it. It's a medium deal, not a big deal.
That defensiveness when you hear those tropes is a good thing. It's a reminder that the people around you are willing to be mean to others who don't meet an ideological purity test. As time and the prevailing moods in academia shift, I would not be surprised if some portion of the people around you end up not agreeing with the group ideologically anymore--and that portion may include you. I'm glad that for the moment it doesn't--being shunned for ideological reasons in the workplace (especially in academia) is awful. Good luck and I hope it remains a medium deal for you.
We should approach things from a sensible standpoint. The whole system of prescriptions is founded on the basis of doctors knowing what they are doing, so you have to get a prescription for some things. That, by itself, is supposed to be the sanity check to prevent abuse.
But, of course, not ALL doctors, nor all psychiatrists, are on the up-and-up. So how do you put in a check on them? It sounds like this policy, as you say, only makes things harder, and doesn't in any way select for shady physicians.
I'm a software developer, not a doctor. But it seems like the way to go would be to audit at least a sample of prescriptions to make sure they were properly prescribed. The records are all there. You have to assign government employees to performing the audit, and then investigating instances that look fishy, and removing licenses and prosecuting doctors found to be bad actors.
Why would they choose the approach they are doing instead of something like this? For one, it's certainly cheaper (for the government) to simply pass a law than to implement a new bureaucracy. It's simpler (for the government). It takes less thought (for the government). And it "shows they're doing something about it".
There's also a jurisdictional quagmire here. Physicians are licensed and generally regulated by states, since nothing in the Constitution enables Congress to pass law on the subjecct, but the Federal government has long since arrogated to itself a right to regulate drugs via some creative interpretation of the Commerce Clause[1], which is why the Federal DEA is involved here. But since the two regulatory agencies are far apart -- in location, approach, motivations, identity and goals of their overlords, et cetera -- it means the kind of close cooperation that would produce a more flexible, informed, and fast-acting regulatory regime is difficult.
except prescriptions for psychiatric drugs is much more of an art then the system would like to admit, and there is a clear standard one can use to judge "properly prescribed" especially because of how idiosyncractic people's responses will be to different drugs and how treatment resistant many conditions are.
I don't see this as an objection to a prescription audit. If a questionable prescription has a second set of eyes determine it is worth investigating, then the reason the doctor prescribed it would be brought into question. If that reason is it had a chance of a favorable patient outcome, then the matter is settled. If it is found to be for nefarious purposes, then the judicial system can handle it.
Another commenter said "the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act."
Despite this, I still would consider that you Scott (and other doctors in similar situations) should talk to your congressperson. As in, calling them up, explaining the issue, and possibly scheduling an appointment to talk with a staffer at their local office. Congresspeople really do try to serve their constituents. Even though the proposed regulation is not a law, so Congress can't directly stop it, still better to keep it on their radar. Will have more impact than posting an internet comment (although admittedly, much higher effort). If the AMA is on your side, so much the better.
PS: Don't call it a "law" ("rule" or "regulation" should work). It's not a law, and it makes a difference (e.g. because lobbying Congress would have less direct impact). Also, I know you have beef with medical regulators in general, but if this is a DEA rule, just call them the DEA not "medical regulators". Maybe they are de facto medical regulators, but (at least outside of the medical field) not many people think of them that way. Seems like you are not exactly painting the right picture here, and bringing in your unrelated beef with the FDA.
Yeah, I agree - "medical regulators" weakens the force of the argument a lot, because it lets the specific agency responsible for the dumb rule off the hook. If I'm putting someone in my bad books, I want it to be the actual bad guys.
a regulation is by ans sensible definition a law. if you violete it it has the same consequences of violating a law, penalties backed by the threat of coercive force.
This is an overresponse to the adderall shortage. There was an uptick in prescriptions over the pandemic and this was blamed on Cerebral and the like. Judging by Cerebral's advertising, I'm not surprised they're being branded a pill-mill; they definitely look like one. I'm currently seeing a telemedicine psych for adhd because I couldn't find an in-person psych during the pandemic, but when I saw Cerebral's adds, I figured I should avoid them.
I saw three different psychs via telemedicine for ADHD. The worst one, by far, was the one from a traditional practice that had many offices in my area. They were also by far the most expensive. Maybe they were good in person, who knows, but the two i got via AheadADHD (now closed) were/have been great (saw one then moved to a different state so had to switch).
This bill is obviously not narrowly tailored to this goal, but the goal seems pretty obvious. If there is a pill mill that only operates because they can reach hundreds of patients online with limited overhead, it will be more difficult for that group to operate if they have to meet in person. Adding in-person visits will make many of these online-only groups impossible to run. Having an option for a third-party doctor to review in person helps because that third-party doctor will presumably not endorse prescriptions for someone who has no need, or even the requirement might weed out people who never would have gotten the pills prior to telemedicine existing.
Whether this will work more in practice than it harms legitimate doctors is a good question. Personally, I think this will weed out some of the worst offenders quite effectively, but at a cost to the healthcare industry that strongly outweighs the savings from shutting down these offenders.
I feel like they should be able to make stricter prescription requirements without requiring an in-person meeting. For example, they could require that there be at least two meetings a month apart for some prescriptions. Or, for adhd drugs at least, require that the drugs be provided alongside therapy.
The problem is the ability for people to lie, convincingly, about having met up with someone. You just put down on your patient log that you did indeed meet up with Bob twice in February. Who's going to say otherwise? I guess with in-person you could lie as well, but maybe they have a signature requirement or could at least prove that wrong somehow (like the person lives two states away and was at work when the meeting was supposed to happen). Not likely to be checked up on either, but it's an additional liability if missed.
I suppose you could increase the documentation necessary in prescribing medications to include what tests were run, the reasoning required, whatever. This again has pitfalls as pill mills copy and paste the standard language for every patient and real doctors painstakingly write out the new requirements.
I don't know that it's possible to have a good system to weed out pill mills that doesn't hurt real doctors more. It's easy to identify a pill mill when you see it, but hard to define in a way that wouldn't be Goodharted by the pill mills quite effectively.
If they are going to make a regulation about it they could at least attack it head on. If they want people to not prescribe lots of pills, then limit the number of scrips a doctor can write in a month or the number of patients they can have (there are clear down sides to these strategies!). But this rule puts most of the pain on the patients who need help and not the doctors who have financial reasons to comply and put in more efforts.
well, i had a telemedicine thing where the software actually has to register that you physically saw the person to auhorize the prescription going through.
I didnt have a camera on my computer and i had to buy one to make the process work even though the doctor was find with just hearing me (long time patient)
I guess I'm failing to see whats the big deal about letting people have access to drugs they want to have access to. Why is this considerded such an important thing to stop?
Isn't there clearly an issue with the DEA cap on stimulants? Even if there are "pill mills" prescribing them to people that don't actually need them, doesn't that mean that even these bogus cases are still getting bogus diagnosis? Wouldn't this mean that the DEA is refusing to adjust their cap in accordance with the number of ADHD diagnosis (legitimate or otherwise)? edited for spelling
Not quite the same thing, but...I was at a healthcare-related conference last week for work where one topic for discussion was imminent restrictions on telehealth services billed to Medicare and Medicaid, because the OIG had determined there had been a massive amount of fraud in this area over the last three years. Here's the fraud alert OIG put out on the subject last year:
Unfortunately, I couldn't tell you what makes telehealth Medicare fraud easier to pull off than regular Medicare fraud. The issue doesn't affect me personally, so I quit paying attention at some point.
I think the situation is worse for pain management doctors and patients. For many years, physicians have been at great legal peril if they prescribe opioid medications to patients deemed not to need them, or in quantities deemed excessive, even without reference to telemedicine. But, this wasn't restrictive enough, so the DEA, based on their medical expertise, has been reducing the allowable quantities.
But, even this wasn't restrictive enough, so several years ago, the DEA started threatening pharmacies that dispensed improper prescriptions. In response, one of the national chains stopped dispensing my wife's medication. The one we switched to would dispense the medication, but would not dispense refills until the day before the old prescription was used up. In addition, the pharmacist is required to personally review each prescription and validate that the quantity and frequency of medications are appropriate. If the DEA determines the pharmacist was wrong, she can lose her license and face criminal prosecution.
But, even this wasn't restrictive enough, so the DEA has started threatening insurance companies if they facilitate improper prescriptions. In December, our Pharmacy Benefits Administrator (PBA_ notified us that the new policy would limit coverage to 2 pills per day, regardless of strength. (It is common in pain management to prescribe 2 extended-release pills per day, plus smaller immediate-release pills for breakthrough pain.) The doctor could submit a justification for higher quantities.
But, even this wasn't restrictive enough, so our PBA added another automated check: if a patient presents a prescription, and another prescription for any amount was filled in the past 23 days, the quantity is further restricted. This limitation is too complicated to explain, so the PBA didn't explain it to either the insurer, or patients, or doctors, or pharmacies. In January, my wife got a prescription for 11 days' supply to last until her next doctor's appointment, when she got a new prescription for 30 days' supply which met the 2 pill per day limit. This triggered the automatic check, so her prescription wasn't covered. No explanation, just "not covered".
Is this the government working to protect you or is this the product of your (1) insurer, (2) doctor's clinic, or (3) pharmacy's risk department determining that they will take the most conservative route to avoid having to determine whether a prescription is proper or improper?
Not to diminish the suffering and stress this causes, but per the description there are a lot of decisions made at varying levels contributing to this quagmire.
Yes, there are a lot of decisions made at varying levels, but all are driven by one of two things:
1. Explicit regulatory rules (limits on total medicine that may be prescribed) - these primarily affect doctors, who have at least gotten clear rules.
2. Vague threats of dire consequences to anyone not sufficiently vigilant - these affect the pharmacies and insurers. There are no clear rules for the pharmacies or insurers, but they can nevertheless face ruinous consequences if they make the "wrong" judgment.
Either way, it's the DEA making life hard on everyone in a mostly vain attempt to protect people who don't want to be protected.
This is a knee-jerk reaction to a handful of sensationalized reports about online “pill mills” overprescribing amphetamines. But ultimately, this is about DC bureaucrats who want to protect their political careers. These non-doctor bureaucrats saw the opioid crisis originate with too many painkiller prescriptions, and irrespective of any differences between opioids and amphetamines, they are hell-bent on putting up as many roadblocks as possible in the misguided effort to prevent another prescription drug crisis. And once the herd in DC decides to move in one direction, everyone smart enough to understand their folly is also smart enough to know their is no upside (and lots of downside) to speaking out against the herd.
The AMA (American Medical Association) is a lobbying group that pushes for whatever keeps doctor salaries artificially high. The govt does what the AMA wants. It is always done under the pretext of helping patients, ofcourse
Does this help explain this situation with tele-medicine ? Or is something else is in play here?
>lobbying group that pushes for whatever keeps doctor salaries artificially high.
I think its more accurate to say they lobby for things that mostly maintain the status quo and may lead to higher salaries.
For some doctors - like Scott- telemedicine can drastically raise their salaries. For others, who dont want to adapt, it will lower them. Its much easier to "see" the harm to the second doctor instead of the invisible potential harm to telemedicine doctors.
I'm not entirely ready to just accept as fact that "pill mills" are a thing that is so super bad that they must be reflexively stamped-out of existence.
Then again, I know other people not only disagree with me, but want Public Health to ban all badthing mills like burger mills (Mickey D's), cigarette mills (convenience stores), fossil fuel mills (ditto), gun mills, porn mills, puppy mills...
Half of the journalists in Brooklyn have their legal meth, but me and my buddies on the hot line have to make do with yerba, cold brew, and just a lil coke as a treat. Can't let the working class folks have the real drugs, we're too dumb and irresponsible to be trusted with em
I don't think the reasons why people might want to dose their brain with drugs so it feels good needs a lot of exploration, any more than we need to do a Phase III clinical trial for $250 million exploring whether people in general do, or don't, enjoy sex and rock 'n' roll.
Beyond that, why should I give a damn about the motivations of drug-seeking people? I don't really care, so long as their self-destructive habits don't interfere with my life. It's only when they start stealing to support their habit, or driving high or drunk, that it does, and then I support efforts to punish them severely enough that they stop doing that. I don't really care what it costs them to figure out how to not be an antisocial asshole, or why they felt like being that way in the first place.
Sure, about rats. Humans are not rats. They need not live in the way that some God-like experimenter compels them to live, they have choice and agency, more than any other animal. I've never yet met an addict who didn't have about 500 peers who all had exactly his disadvantages and yet did not turn into addicts. If mere poverty and bad luck and absent/abusive parents, or shitty experiences as a kid, were sufficient to turn a free man into a hopeless criminal addict, despite his best efforts and will, about a quarter of the world ought to be lost that way. They're not.
I've met my share of addicts who used their experiences and environment as an excuse, of course. It's always easier to blame "society" or "my wretched luck" than the face in the mirror that keeps making dumfuk decisions. Which is why it's often so valuable to put them into a 12 step where other ex-addicts who have stopped making excuses can call them on their bullshit.
I think the steelman argument against telemedicine in SOME situations is that you're restricting the physician's access to important information. For example, it seems very plausible to me that it's harder to detect psychosis over Zoom. I've taught online before and hated it because so much human nuance is lost, and I think that could be true for medicine too. That said, in many many use cases I think telemedicine is fine.
Of course, the bigger issue is that prescription stimulants have a lot of benefits and some drawbacks for all kinds of people. Some of them have ADHD. A lot of them don't. The question is whether we're cool with this. It appears the government is not.
The trade off is not between telemedicine and in person medicine. The trade off is between telemedicine and many or most of these people not getting care at all.
As you've written Freddie, this is also a reflection of too many people at all levels who don't see psychological and psychiatric illnesses as real illnesses. So much flows from that...
That's absolutely true. But in those cases, the professionalism of the physician should take over and they elect not to proceed with further treatment until they are evaluated in-person.
I'm face-blind, I'm not getting the human nuance anyway.
Seriously, I really have trouble figuring out what this means. Assuming the camera is set far enough away for me to see the patient's body language, what could I possibly be missing? Their feet? I know everyone says this, so it must be true for some people, I just can't model it.
Adding some anecdata without taking a strong stance on the underlying claim: I recently had a one-off telehealth appointment with my therapist after a few months of in-person meetings, and I noticed that I felt like I had a lot more discretion over how visibly emotive or agitated I was.
An in-person session is a hotseat: I'm outside of my home, wearing actual clothes and shoes, sharing a room with a whole physical human whose space it is and who can see and hear everything I can, and I can't fidget imperceptibly under the desk or tab over to news/Reddit/ACX on another monitor. It's not just that they can see more of me or see more detail, it's that I feel less mental slack to perform "normal" if that's not what I'm actually experiencing.
In the event, this was actually mostly a positive because it gave me some space to marshal thoughts that I had had a hard time expressing in person before, but that benefit was totally dependent on noticing that slack and choosing to use it to communicate better. I think if instead I had been trying to conceal some incipient crisis or disturbed state, that would have been pretty easy to do compared to a face-to-face meeting.
(Freddie specifically mentioning psychosis also makes me wonder on a practical level: how do you tell whether a patient is interacting with a real or hallucinatory stimulus when everyone has background noise cancellation? Ask them to show you around the room? Focus on other indicators of mental status?)
Another point I'll add is that during in-person therapy, it's much less likely for one or both of the people involved to "freeze" in mid-sentence because of a bad internet connection.
Edited to add: Sorry, I realize that response was kind of glib. There's much to be said for giving people access to telehealth, and for some, it's a lot better. I have my preferences for in-person telehealth. And yes, in ways I find it difficult to articulate (and therefore I don't have an answer to Scott's question), I believe in-person is superior. There's much to be gained from in-person visits, both for the health care professional and the client. That said, others have different needs and even if I'm right, sometimes the less good option of telehealth is better than the what I see as the "best" option of in-person sessions.
Not to write a blanket defense of government regulations. And not to dismiss the very real problems you address in this post, but, much of the rhetoric in this post, I'd say, isn't particularly helpful for addressing the problems. Binary thinking is counterproductive:
>>"...Medical regulators hate new things, so for its first decade they ensured telemedicine was hard and inconvenient."
Just a bad faith take. Medical regulators have valid reasons to scrutinize "new things." Of course there are elements of group think or unreasonable resistance to change. But it's not that they (or at least all of them as a class) "hate new things." Government regulators are people to, and largely operate from the same basic cognitive and psychological constructs that YOU operate from! Just as you are likely to be open to change, you're also likely to be resistant to change.
>>"They yelled at the regulators, and the regulators grudgingly agreed to temporarily make telemedicine easy and convenient."
Again, what a bad faith take. Yes, openness to change can look "grudging." But it can also look like a role of applying appropriate scrutiny.
>>"They say “nothing is as permanent as a temporary government program”, but this only applies to government programs that make your life worse. Government programs that make your life better are ephemeral and can disappear at any moment. "
Oy. There are plenty of long-standing government programs that makes people's lives better, and plenty of government programs that "'make your life work" are ended after they prove to do so.
>>"So a few months ago, the medical regulators woke up, realized the pandemic was over, and started plotting ways to make telemedicine hard and inconvenient again."
This kind of bad faith motivation-impugning doesn't serve you well. It strikes me as antithetical to what I understand as some of your foundational principles. I understand that you are likely frustrated by what you see as obstacles to providing care to those in need. But this kind of unrealistic standard being applied against institutions of public health will not likely, IMO, lead to improvement in the long run, but more likely lead to a more impoverished role for public health in our society. Critique is critical, but it should be done with utmost care.
Saying "medical regulators hate new things" is not a bad faith take. It's a rephrasing of the very real incentives placed on those people who are selected into those jobs. Delaying/forbidding something good preserves the status quo and also preserves one's pay/benefits/retirement. Approving something bad draws negative attention to oneself and risks one's reputation and employment. Many (most?) government agencies (at least in the US) are specifically designed to be adversarial. The DEA is there to oppose recreation drug use. The ATF is there to curtail the second amendment as well as reduce alcohol and tobacco use. The FDA is there to keep "bad" manufacturers out of the market. To think that such organizations would attract and advance people with a mindset of "everything not permitted is forbidden" is hardly bad faith.
I read Scott's post without thinking of that, but your points ring true to me. I wouldn't go so far as to call the rhetoric "bad faith," but I do agree there's something not right about it.
That's both for the reasons you cite and also because I'm a (low to mid level) bureaucrat and have had low-level jobs where I had to enforce rules that either were stupid or were arguably good but couldn't help but seem stupid to the ones who were affected by them. I was sometimes accused of being one of those time-serving people whose goal in life was to inconvenience others. Scott, of course, is not talking about people like me. He's speaking of a specific policy that by his account does almost no good and at least a little harm.
Generally bureaucrats, particularly government ones, have strong incentives not to "allow" something if all the rules arent followed to the letter (they could suffer consequences) but litle incentive to to actually help people.
since in a broad sense the government doesnt want to give away money, bureaucrats are a wealth transfer from the people who are supposed to be helped to people whose job it is to make it harder for people to get help which they get payed for.
So the actual value of a bureaucrats job is to make less money go to people who are the ones who are theoretically being sevred by the program and that is the "value" they add.
While your goal may not have been to inconvenice others, you choose to do the job and have to take responsibility.
And I'm sorry, but its not just "inconvenciing people" its often "not getting the medicine they need to prevent their immune system from attacking their own body and going mad from months of followjng contradictory rules that after you followed them are changed"
i aslo speak from personal experience here and yes, i absolutey hold people like you personally responsible because no one held a gun to your head and made you take the job.
By your own admission, you enforce rules that you know are stupid and you actively choose to do this in exchange for money.
Receiving money for something isnt a moral justification for your actions.
I am reading this after I finished my virtual meeting with my kid's psychiatrist who have extreme ADHD due to the underlying genetic disease. She has never seen him in person, but when we were establishing his diagnosis, I sent her a ton of video recordings of him in different social encounters: here he pushes other kids at a playground, and this is me trying to read him a book and he ignores and just skips through the pages; and this is him at a speech therapy constantly trying to get distracted but the teacher redirects him back.
If we went in person she would have seen him jumping on and off the chair but otherwise she would still rely on the data I as a parent would provide anyway.
We have a pediatrician though that requires we come in person and I can't come alone even if I'm just inquiring about the new lab work he needs. So I have to take him out of school in the morning, waste time driving and I yet can't have a thoughtful conversation with the doctor because the kid is noisy and continuously interrupts us. I leave the appointment, realize I forgot to ask about his folate being so low, and I can't even send an email to the practice. I have to call to pass my question and they only work Mon-Thu 9-4 with the lunch break. There's no way to leave your message if you called outside these hours. I can't wait for telemedicine to disrupt this!
As a long-term methylphenidate patient, I don’t really understand the concerns about pill mills for ADHD-grade stimulants. Couldn’t you essentially buy amphetamines over the counter in the 50s? And we made awesome cars and went to the moon.
Maybe, but they did so without an environmental impact study, no DEIB plan, and without even considering how their colonialist efforts perpetuated social inequities!
I have struggled with motivation and executive function my whole life, and actually tried to get ADHD treatment through one of those "pill mill" online sites that are technically legal because you get screened, but pretty much exist just to sell you adderall or something. I'm not 100% sure I have ADHD but people keep telling me I do and I definitely struggle. So I got screened online by a clinician. I was honest but not, like, scrupulously, stupidly honest. I tried to answer the questions in the spirit in which they were intended, etc. I wasn't trying to scam anyone but I was trying to get meds.
Result? The clinician was like, idk, I can't really say whether you have ADHD or not. No meds. So I think sometimes even those sites are not quite as pill-milly as one might expect (or desire).
Too many are most sensitive to potential costs to their careers wrt cost to those they regulate. In addition, they see very little benefit to their careers from gray area decisions.
I can see this, but it does not seem to explain everything and is most relevant at the level of the individual decision maker. Take FDA's resistance to letting people develop quick and dirty screening tests for COVID. In some sense, just not taking any (blocking) action would not seem highly risky to anyone's career. [I don't want to try to understand this decision per se; it just seems like a good test of the "timid bureaucrat" hypothesis]
Sadly, I won't even say Timid Bureaucrat, rather, given the Iron Laws of Bureaucracy it is career wise The Sensative Bureaucrat.
A major question in political structure is, I have heard, how does one incentive more risk taking in bureaucracies without such changes enabling more corruption .
Can any of the deep thinkers on Scott's blog provide some insights on How To Build More Effective Bureaucracies Without Enabling More Corruption?
A. Someone develops a test. It causes something wrong (too many false results, either positive or negative). Bad things happen. "Why didn't you regulate this? You're supposed to do so." Bad publicity.
B. Someone develops a test without regulation, then someone says "We don't need the FDA, see?" Bad for empire-building.
i think in todays modern era, we could have competing private versions of the fda where reputational accuracy would be the value and people would learn to trust the ratings of some agencies more then others.
yes, some would take money to give good reviews, but eventually people would fvor the honest ones.
the agencies could get their funding through advertising on their review sites
> I’m probably going to rent an office somewhere in Oakland for the month for a few thousand dollars. [...] I’ll have to charge them a bit more, to recoup the cost of the office.
I agree that this whole situation is terrible, but aren't there more economically efficient solutions here? Does it matter whether your patients drive to Oakland or to another place with far lower real estate prices?
Hell, I know several doctors (including a psychiatrist) whose “office” is just an easily accessible room in their private residence. (Though, I don't live in the US so there might be some more regulatory issues I'm overlooking, and of course you will have to be comfortable giving patients your private address.)
Yeah, I don't want to give my patients my private address, although I trust each specific one I can think of, it just seems like a dangerous thing to do in psychiatry.
An excellent illustration of Conquest's First Law ("Everyone is conservative about what he knows best"). Hopefully it helps illustrate why many of us despise and resent government regulation for social engineering purposes.
By definition it's a bad faith take. Indeed, as in your follow-on comment, it eliminates any "charity," any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking.
I am not suggesting that critique isn't critical. But I don't think this kind of critique, imo in a Manichean framework, incorporating a kind of fundamental attribution error, is constructive in the long run. The net effect, imo, in balance, is just to tear down public health. We're on that track as a society, and I find it concerning.
"any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking."
First: incentives may be 'conflicting or even opposing' but they are not random. The whole process of self- and organizational- selection imposes a directionality on them and to deny this is to deny reality. No one is required by the laws of charity to consider the possibility of unobtanium. nor the angelic nature of humans nor the idea that government employees are crafted from a finer clay than mere mortals. Calling out the net effect of a complex process isn't uncharitable, it just is. Especially when the net effect is consistently in one direction and has been since someone forgot to check on the difference between enantiomerically pure and racemic mixtures of a drug back in 1957.
Second: even if we assume that "'crafting' a 'balance'" is something to be desired, whether or not it is difficult or complicated is irrelevant as to whether or not a system is biased and even more so when the results of the decisions cause other actions involving people with guns. I don't give cops any slack because their jobs are "complex" not do I care about how difficult it is to try and "craft a balance" between shooting a bad guy and not shooting an innocent person. Nor is it bad faith to notice if the shoot/no shoot decisions are biased in a particular way.
Third: since this was obviously written from a very particular POV, claiming that it needed to take other perspectives into consideration is as much a category error as anything else.
I'm happy to have a discussion about things I actually said but see no point in discussing absurd viewpoints you invented and then argued against. You don't need me for that discussion - you can just have it with yourself.
Yes, Scott is usually a Mistake Theorist, and it’s disconcerting to see him slip into “the people I disagree with are bad and want innocents to suffer!” Conflict Theorist mode.
i dont think its that the individual people involved want people to suffer but rather the systems work on perverse incentives. No one person inside the system wants people to suffer but the people following their ow incentives at all levels including orgazational incentives creata a moloch situation that trends towards predictable outcomes
I'm sympathetic to your arguments about telemedicine, but the intro was very disappointing. I understand your frustration with the new law, but to start off by claiming that the motivation behind its creation is that regulators hate new things and want to inconvenience people is just lazy writing and bad rhetoric.
Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
The reason the software industry really took off in India is it took govt bureaucrats a really long time to figure out exactly what software was (in order to regulate it). By then it had taken off.
> Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
Indeed - it always backfires with me. At least until someone can describe their mechanism for ESP mind-probing, it's a bad sign. And I havent seen anyone describe a plausible mind-probing technique as of yet, especially for a whole class of people let alone a particular individual.
Fraud is already illegal, and, physical injuries aside, I doubt tricking a doctor via deepfake would be any easier than faking symptoms in person, so as far as psychiatric pharmaceuticals go, this is the same as the original problem.
I think it's probably more accurate to describe that second step as "this will hurt a group of people who are more likely to be trans than the general population", which seems like a pretty sound reason for a trans-issues publication to highlight it in that context.
Simple rule of thumb: designing broad based rules to prevent outlier events never works out well. The majority end up suffering from the rule and the ones that the rule is designed to catch know how to game whatever rule is put in place.
I’m not sure that what Scott wrote is even completely accurate. I have a relative who is an MD in this space, and it seems that the underlying problem is not the DEA but an actual law passed by Congress. Aren’t telemedicine regulations limited with respect to controlled substances by the Ryan Haight Act of 2008 U.S.C. § 829(e)… there may be interpretations of this act by the DEA and other agencies, but, where controlled substances are prescribed by means of the Internet, the general requirement is that the prescribing Practitioner must have conducted at least one in-person medical evaluation of the patient.
It seems like a colossal overreach to ask an Executive Branch agency to overrule the plain text of the act. There are some exceptions, which Scott noted. A different way of looking at things was that the Executive Branch was highly responsive to the emergency situation of Covid. Now that it’s not an emergency, they are obligated to return to the legal framework that exists. Congress needs to change the law, not the DEA.
The *data* from covid should be used as part of a cost-benefit analysis to determine whether it is reasonable to regulate telemedicine, and, if so, what regulations might address whatever problems arose.
Son of a gun. I snarked earlier about how Congress never does anything that specific, instead fobbing off all the details to the bureaucrats, but I see on congress.gov that you are completely right, this is entirely and specifically Congress’s doing. I stand corrected.
It’s still stupid, but it’s a different kind of stupid.
Actually, Scott is even more off-base than I thought in my initial post. Apparently the DEA & DOJ are already proposing new changes to the 2008 Act (which seem like they violate the clear text of the act), but the act and the changes are summarized here:
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. Congress was attempting to fight opioid pill-mills. At the time of passage, I am willing to bet that ≈0% of patients were “Telehealth” using videoconferencing. More like phone calls and email a few times to get drugs.
The law should have been amended, and it hasn’t been, but it is far from clear that it was a crazy law in the first place.
Oh, Scott really needs to read this comment. This really needs a petition to Congress not the DEA. And contrary to popular belief, Congress actually does do stuff. It just years of concerted effort, public comments, debate, lobbying etc. This is what is necessary whether one likes it or not.
This seems correct to me (the name is also a hint, as the DEA describes: "The Ryan Haight Act was named for a California high school student who died in 2001 from a drug poisoning resulting from a controlled prescription medication he obtained from a rogue online pharmacy. That rogue online pharmacy allowed customers, like Ryan and others, to obtain controlled medications without an in-person medical evaluation by the prescriber.") The whole goal was to make that not happen, hence the name and the requirement for in-person visits.
Though they do seem to be relying on a provision of the law which allows them to come up with some alternate procedures under very limited circumstances, with the concurrence of the HHS secretary and the AG.
Btw, when I traveled out of state and requested a telemedicine appointment with an internist in my state, the software they have at the clinic did not work. They have strange clunky software but this happened because they're designed to NOT work out of state. Wish they'd use Google meet or Zoom or something ordinary like that. That's what concierge medicine doctors seem to use - they cut out the red tape.
I got the impression that typical commercial remote software, like Zoom, don't meet the data security requirements implied by federal patient privacy rules and enforced by the feds.
As I understand it, thus I'm not saying I'm certain, it's the government health beurocracy interpretation of HIPAA and other federal and state privacy rules. Further, this interpretation was put in abeyance during Covid...
Sorry, I don't know, I use a special medical conferencing program. But I've seen UCSF use Zoom, and they're big and formal enough that I'd be surprised if they didn't know HIPAA, so I assume it's okay.
See my comment that answers this question. It has nothing to do with data security.
“The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 and Drug Enforcement Administration's (DEA) implementing regulations, after a patient and a practitioner have had an in-person medical evaluation, that practitioner may use telehealth to prescribe that patient any prescription for a controlled medication that the practitioner deems medically necessary.”
All your points are valid ones, but there's this other issue, where there are some doctors who have overprescribed a huge variety of drugs (opiods being the most common example), even though I'm sure most doctors are responsible with meds. Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing. OK, of course, as with most regulations, the in-person requirement doesn't address this problem very well, as it has loopholes that make the regulation more of an inconvenience than a ban. But, when did that ever matter when it comes to a hot story that can be done in a way to inflame readers and (even better!) embarrass regulators! Which is probably some of the explanation why it's so hard for you to get the voice of reason heard.
One quibble with what you say. Comparing our health care regulators to Putin! How American. What you're talking about is on the level of inefficiency and in many cases, let's say, inconvenience for Dr. and patient alike, because of the loopholes in the regs that you mention. I like my fellow Americans do highly value making things convenient and efficient. But hey, it's a bad look to suggest requiring a second doctor to vouch for medications prescribed on line, in the context of some highly publicized abuses of that practice, is like... Putin's Russia. Unless the goal is to contribute to the bonfire that's American political discourse these days.
>Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing.
What if a rise is prescriptions is just a reflection of the many people who needed medication but were not able to get it because of the regulations? Do you have anyway of figuring out who group a individual is in and crafting a law that doesn't harm the "good" patient but does punish the "bad" one? We can't make laws based on what COULD happen in our dreams, we have to make them on what actually does happen in real life and in this case what does happen is people who really need medications but are too sick to go in person to a doctor aren't able to get the medications they need.
Sorry if I wasn't clear. I agree with Scott's points as far as they go, and your point is a good one, but I think the regulators are often more concerned with how things play in the press, which as I see it, would be eager to make a scandal out of things like "excessive on line prescription writing" even if as you say, it very well might not be a real problem. I'm suggesting why as Scott said, it's likely comments won't prevent this reg.
I generally like your writing and ideas, hell, I just re-uped for a year.
However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else."
In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time.
Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors.
Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking.
I do wonder if the cheap shot was actually intended at another religion popular on the west coast that also thinks of psychiatry as bunk, but is much more litigious (and much less safe to make fun of).
I'm thinking of the one where you go on a Cruise, a galactic one...
From a headline and PR standpoint, really need to develop and distinguish a different term than "controlled substance" if possible. Many people will only read the headline and think about law enforcement, prescription drug abuse, and problems stemming from something like opioid addiction/meth.
Notably absent from this post: any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. I genuinely don't want to be rude here; the temptation to isolated demands for rigor is greatest in fields where you consider yourself an expert.
Why didn't I link these studies that supported my point? Mostly because they don't exactly address the one thing I'm talking about - telemedicine with forcing the patient to see the doctor once, vs. telemedicine without doing that. That's because nobody has any plausible reason why the former would be good, and so nobody has ever bothered to study it.
(there are also some reasons why opioid use is an unusual case, and why I'm not sure how to measure outcomes, but the paragraph above is the main reason)
That data is also absent from the DEAs background on this action. In part it reads:
>The Ryan Haight Act intended to address the threat to public health and safety caused by physicians who prescribed controlled medications via the internet without establishing a valid doctor-patient relationship through such fundamental steps as performing an in-person medical evaluation of a patient. Prior to the enactment of the Ryan Haight Act, the internet was being exploited to facilitate the unlawful distribution of controlled substances through rogue websites. These rogue websites fueled the misuse of controlled prescription medications, such as hydrocodone and oxycodone, thereby contributing to increased drug poisonings and other harmful health, social, and economic consequences.
The original act was passed in 2001. It doesn't appear it has done anything to reduce or slow drug overdoses:
Accusing the guy who literally wrote the isolated demands for rigor post of isolated demands for rigor seems uncharitable.
Less confrontational wording: "This seems like an isolated demand for rigor since I don't see any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. Given that you're known for writing all those "Much More Than You Wanted To Know" series of excessively in-depth fact posts, this seems to me to be out of character for you; what am I missing?"
"Did I mention that if you come off of some of them too quickly, you can literally die?"
I once had the opposite problem. I had severe epilepsy, but the dosage of the most-likely-to-be-helpful medication, Lamictal, had to be increased veeery slowly, otherwise it could cause a potentially-deadly skin rash.
That one just stuck with me because it was so random. An anticonvulsant, that causes a skin rash, that's so bad you might die. I didn't even know it was POSSIBLE for rashes to be lethal.
The smallpox analogy occurred to me, but I assume that that kills you in the end because your body is overwhelmed with viral agents. Whereas here it's more like... a bad allergic reaction? Or something? There's no viruses or bacteria running amok.
Obviously I mourn the 100,000 people a year that die from opioids, but the negative toll on the people that don’t abuse opioids but need them is a very big price to pay for their abuse. This war on opioids harms many people caught up in the crossfire that need a drug that has been used since the beginning of human history!
Well, clearly we have to do domething about this telemedicine thing then (said sardonically (right word?)).
It's amazing how way too many people and organizations (I don't think you as I think you were being sardonic (right word?)) bring climate change as a supposed golden reason for everything even when Hollywood big shots generate far more CO2 while jetting to climate summits...
I imagine this is like putting "blockchain" in your IT startup proposal. It gets attention and funding from people who have control, but not knowledge.
Would it fulfill the letter of the law to have a patient go to an Urgent Care facility to get that letter signed? At least then it means minimal waiting and even the out-of-pocket costs tend to be low.
True, dumb, and pointless yes, but how else can an incompetent bureaucracy respond to the demands of commercial real estate owners? When trying to also forget every single lesson and ‘go back to work’ to monitor, control, and force people to waste money on transport and commercial real estate…they’re all out of ideas and revert to fascistic practices of stupid rules to force people to comply.
There is a fairly real existential threat to the financiers, banks, and wealthy land owners who wish to do continue to do nothing and be paid enormous sums of money for the service of simply owning things they didn’t build while holding us all hostage to their MAD style scheme to send the economy into a Great Depression 2.0 if their terms are not met.
This knee jerk and too little too late series of spasmodic reactions and planned obsolescence of anything disadvantageous to them may be part of this, along with the general trend of everything getting worse and all your favourite tv shows, brands, products, foods, restaurants, and government rules being inexplicably cancelled.
It may sound outlandish or conspiratorial to some, but it truly is what motivates the upper and powerful classes. The demands of enormously wealthy landlords and the even larger financial system behind them are always heard via all their legalised bribes of all kinds to politicians and senior staff in every single agency and regulator who get donations, speaking fees, and highly paid ‘jobs’. Regardless of the veneer of democracy, these groups in studies almost always get their way or erode things to get their way over time after populist movements’ brief attention span of a year or two ends.
Even the neocons could only squeeze and divert a hundred billion or so into their latest proxy war, but the banks were able to get 2 trillion plus of money printing done pretty much overnight because they asked for it.
And they are freaking out about commercial real estate and the collapse of the banking system. A broad demand to end all kinds of work from home is happening and that includes things like telemedicine. I doubt the elites behind this push would know, care, or be personally affected by this specific rule change.
But that’s how incredible power works and long chains of people interpreting their marching orders operate, quickly asking how high to jump when told to do so. Years and decades of activism and sensible modern policies by huge movements can be undone if one of our invisible aristocracies even so much as sneezes. And that’s just an unintended drive for compliance to their a near absolute demands. That’s the true power structure. And they are right, the economy has been built on glass support beams and will go into a terrible depression if we do see a continued lack of demand and turnover for 70% of commercials real estate into a non-free debt environment of 5% or more fed funding rates.
We are seeing bureaucratic panic, which will inevitably not ‘solve’ the problem of most offices being unnecessary and will hurt many vulnerable powerless people in a myriad of ways. Is this 100% the total answer to why this specific rule change is happening? Of course it isn’t, but it is a significant structural factor in how choices, all choices get made by powerful controlling systems.
Or we can be naive and pretend power somehow doesn’t continue to operate as it has for millennia.
I'm one of those "bad" people who thinks potentially addictive meds should require in-person evaluation. I worked for a psychiatric and social work agency for 15 years. Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today.
Telemedicine for an earache or my son's psoriosis -- okay. An antibiotic, some cream for his outbreaks. Fine. But I've done telemed a few times since covid and it is not like seeing a doctor in person. Yeah, the antibiotic -- on the third call -- fixed my sinus infection, but my swollen knee -- well, no. Doc gave me a prescription for painkillers and a steroid based on my camera angle. It didn't fix it. But I didn't take the painkillers, because I know they're addictive (and they generally make me puke). I asked for a referral to a physical therapist to actually fix my knee. "After you've done this for a while. In the meantime, put your feet up" and get out of shape and make the problem worse. Fortunately, I rain into a friend who is a PT and she gave me "advice" that included going to the gym and getting my knee back in shape. I stopped taking the steriod. I'll report to the doctor when I go for my annual -- IF I go for my annual because telemed isn't really medical care.
"Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today."
Were these people getting their pills from telemedicine or in-person?
I'm not denying lots of people abuse drugs and it's bad. I'm denying that requiring everyone see a doctor once in person has any bearing on this question. "Give kids Ritalin because Mom and the teacher can't abide normal play" is unfortunately very standard now. Punishing telemedicine docs in particular for this won't change anything.
I could see an argument that goes something like "we are creating a situation where 30% of society is on ADHD medication, because parents don't like their children's natural limitations, and then we need lifelong medication for these people because they have chosen careers that their unmedicated minds are not suited for. Might it not be better to start paring back access to this medication so we can slowly return to a more natural balance?
You are not wrong! Somehow, we need to get to that point. It's unfortunate that doctors don't do that for themselves (first do no harm comes to mind), but they don't.
They were getting their pills in person back then. I would suggest they'd be much more likely to be prescribed pills through telemed. To think that wouldn't be true is to ignore an important component of human nature. As Tempo says below "It allows more doctor-shopping...."
Hey everyone; sorry for posting randomly on here. I'm undergoing psychiatric treatment myself. I have a rough situation up here in Canada, since there's a massive shortage of psychiatrists (https://www.thestar.com/news/canada/2022/01/15/psychiatrist-burnout-why-covid-weary-doctors-are-taking-a-mental-health-break.html): "These departures are leaving Ontario with an acute shortage of psychiatrists, says Villela. The number per capita was already declining before the pandemic, according to the Canadian Medical Association. And with half of all Canadian practitioners over the age of 55, that shortage is likely to accelerate."
I have a whole ton of questions about psychiatry and it's really frustrating. I don't know who to ask. I sometimes randomly email researchers but that only works once in a blue moon.
What's the best place online to get answers to certain questions? Like the most basic one I have is whether it's possible for a patient to simply be some kind of weird outlier who needs high doses of certain medications; such a patient is in a tough spot because someone might not want to prescribe high doses for them. What legal issues arise when psychiatrists go outside the bounds of the guidelines? I assume that psychiatrists wouldn't ever do so if doing so invites legal danger.
I found this (https://astralcodexten.substack.com/p/oh-the-places-youll-go-when-trying) super interesting but I still have questions. Regarding escitalopram, what exact risk do you face if you go up to like 50mg, 60mg, 70mg? And why are people seeking to declare that nobody (not even outliers) can benefit from high-dose escitalopram if indeed that's what their saying?
And why would a patient need so much escitalopram (or guanfacine for that matter...imagine a patient who needs 10mg guanfacine XR in order to get a good treatment effect)? Is a patient who's an outlier (when it comes to needing high doses) unusual pharmacodynamically or pharmacokinetically?
Another weird thing is what if a patient swears up and down that they experience very powerful effects from a medication within seconds or within a couple minutes? We can say that it's just placebo, but what in our science sets a hard limit on how quickly a molecule could reach the brain or affect the brain? The difficulty here is that it seems like you have to (1) identify all possible pathways through which a non-placebo effect could occur, (2) rule out the possibility that there's another pathway that you're unfamiliar with, and (3) rule out that any of the possible pathways could allow for such a fast non-placebo reaction.
I'll try to answer these as best I can, they're not medical advice.
The most likely reason someone would need very high doses of medication is that they're a fast metabolizer; ie their liver shreds medication very fast and so it's hard to build up a high level in the blood. The second most likely reason is something something the brain - we don't understand the brain as well as the liver and can't necessarily predict what this would be.
Another (very common) reason is that the patient has developed tolerance to normal doses of the medication. In this case, giving higher ones isn't likely to help (they'll just develop tolerance to those too) and it will just make the problem worse.
Another reason is that the medication just doesn't work for the patient, you're trying to hammer a nail in with a screwdriver, and you have to hammer really really hard to get anywhere at all.
The main reason doctors don't like giving very high doses of medication is that just because you're undersensitive to the beneficial effects doesn't mean you'll be undersensitive to the side effects, and so if you need 10x the normal dose of Lexapro to get any antidepressant effect, you'll get 10x the normal side effects, which will be really bad. Sometimes doctors have a specific side effect in mind when they worry about this, other times they're just worried nobody has studied that dose and proven it doesn't have terrible side effects.
In psychiatry, a lot of drugs at very very high doses will turn you into an emotionless zombie. This often solves your problems - emotionless zombies aren't depressed, anxious, or violent - but it's a bad outcome. People often aren't able to describe being an emotionless zombie very well, or even necessarily notice right away, which makes psychiatrists nervous about "this extra high dose of this drug solved all my problems!"
I think it's very very unlikely to get effects within minutes from an oral medication - it hasn't even made it out of the stomach and into the bloodstream by then. Whatever galaxy-brained mechanism someone is thinking of for why this might happen, I think placebo effects are more likely. Luckily this should be easy to test.
Thanks so much; I appreciate these excellent answers.
The reason could be: (1) "their liver shreds medication very fast and so it's hard to build up a high level in the blood"; (2) "the patient has developed tolerance to normal doses...giving higher ones isn't likely to help"; or (3) "the medication just doesn't work for the patient". But how do you tell which it is? I guess that you could check blood levels to see if (1) is the case, correct? Is there literature on discerning between the three of these options?
I wasn't sure about the difference between (3) and (2), actually; regarding (3) do you just mean that it *does* indeed work but requires a high dose?
Also, I'm very curious about the science behind how often a higher dose will "stick" even after tolerance terminated the treatment effect at the lower doses; is there good literature on the rate at which something "sticks" and why exactly that sometimes happens? I agree of course that climbing up the dose ladder is a dubious proposition if it's just going to lead to more tolerance and disappointment; the trick is to be able to predict what the ultimate outcome will be.
You said this: "just because you're undersensitive to the beneficial effects doesn't mean you'll be undersensitive to the side effects". I suppose that the issue is what the statistics say on what the risk of increasing the dose is *given* the patient's situation. I'm sure you have at least one excellent post on this topic already, but there's a problem with statistics where you read in the news that (e.g.) eating bacon daily gives you a 20% risk of developing heart disease. The problem (I assume; correct me if I'm mistaken here) is that the person reading about the bacon thing might be in a special subset (e.g., the subset of people who have no heart disease in their family tree or something) and that makes the statistic irrelevant. Same with the patient who might experience bad side effects at a high dosage; there are various things about the patient (maybe they've had zero side effects so far in response to this medication, for example, but maybe they also have other traits) that might make the generalized statistics irrelevant.
And of course, there's also the issue that the patient could be vigilant (regarding side effects); regarding nefazodone it seems to be the case that you can get your liver checked in a way that makes it very unlikely (or even impossible?) that anything terrible will happen to you liver-wise.
I'd love to read to a pro-medical-regulator person steelman this, and be able to have it withstand these criticisms, and the kinds of criticisms this forum can bring to bear. I mean, I doubt its possible, but I would love to read the attempt.
So, as a factual question, is this primarily the law as written preventing telemedicine of controlled substances or is it the DEA choosing to make it difficult?
Because "regulator" is kind of being used in a general way with specifying whether this is, at core, the fault of DEA administrators making a policy decision or of the Senate/Congress making a bad law. Let me clarify, from the Federal Register link provided (1):
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As indicated above, in 21 U.S.C. 829(e), the Ryan Haight Act generally requires an in-person medical evaluation prior to the prescription of controlled substances. Section 829(e), however, also provides an exception to this in-person medical evaluation requirement where the practitioner is “engaged in the practice of telemedicine” [17] within the meaning of the Ryan Haight Act (21 U.S.C. 802(54)).
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The DEA release makes several references to the Ryan Haight Act, which you can read here (2), having a clear intent to prevent controlled substances from being prescribed without an in-person evaluation. The statutory authority doesn't appear to be anywhere within the core of the law but instead...basically a loophole buried in paragraph of a subsection.
Because, if the law was clearly written to do X, and we want to pressure the DEA to use a loophole to achieve the opposite of X, because they allowed the opposite of X in a global emergency, that has...several obvious concerns.
But I don't know enough to make the specific argument that "no, this is Congress' fault, the DEA is faithfully fulfilling the law as written". So, for people with either more legal experience of more practical medical regulatory experience than me, what was the intent of the Ryan Haight Act, how much discretion does the DEA have here, and who is ultimately responsible?
While we are talking about stupid bureaucratic requirements, can we pretty please acknowledge that fax machines are over and adjust our talmudic interpretations of HIPAA accordingly? This is very small bore compared to telemedicine, and so probably less likely to happen, but really.... So stupid.
I'm actually slightly optimistic about this for selfish reasons. I have been on stimulants for ADHD for 20+ years. This will make getting a prescription for said meds very difficult.
However, due to the FDA limit on stimulant manufacturer, for the past 6 months I haven't been able to get ANY medication WITH a prescription. Every pharmacy is out of every stimulant.
So. If demand drops, and I have to work harder, but can eventually actually obtain the meds I need to not be fired from my job...
Well, it's way better for me than the current situation.
When my patients have had this problem I've had some success switching them to modafinil - it only works about 50% as well, but for some of them that's enough not to get fired. If you can't get modafinil, even Sabroxy might be better than nothing.
(Sorry, I was just going to make a quick comment about Intuniv and then I ended up writing a little reflection on my treatment.)
I wrote about my experience with Intuniv 3mg here: https://join.substack.com/p/is-this-the-biggest-thing. Some of the science might be incorrect, but I did put caveats in the piece explaining that I hadn't vetted the science. I have absolutely no idea why I had a "miracle week"; I guess that nobody knows. If only I could've maintained that effect.
I take notes on my psychiatric treatment; I often look back on my notes and it's super interesting to read because the notes will say things about how incredible and wonderful and functional my current brain state is and how my life will be great if I can only maintain this brain state. I haven't gotten any of these "miracle" states to "stick" yet, unfortunately; it's interesting to read my notes and try to re-inhabit the really good treatment effects that I've experienced.
On the one hand, everyone's brain is always changing and is always in flux, right? But on the other hand, I feel like a life like mine is freakishly and ultra-abnormally fragmented in terms of how many brain states I've inhabited. I think that a person with a stable brain has some consistency over time that I completely lack. I wonder what the "instability" is in terms of brain science, though.
23k comments and climbing. In a search for "good", I found mostly comments about it "doing more harm than good", but in a search for "thank you", buried among the "...for your time" is at least one comment that seems to have a sincere appreciation for one effect of such a regulation, specifically that it should reduce accessibility of euthenasia drugs, which is a moral stance that I think is honest and worthy of consideration. In my opinion though it doesn't counterbalance the overwhelming deluge of negative comments, including official responses from nonprofit providers saying that this will be especially bad for them.
>The problem here is that the DEA is trying to catch evil overprescribers by filtering for whether a doctor can see a patient one time in person, which is uncorrelated with whether they’re an evil overprescriber or not. It’s just an extra hurdle that’s inconvenient for everyone
Scott, do you remember the Lesswrong post "beware trivial inconveniences"?
I would be very surprised if this requirement did *not* discourage a significant number of overprescribers. (Consider that "overprescriber" may contain elements of fraud and not just be "otherwise legitimate psychiatrist who prescribes too much". And that drug abusers are poor and/or lazy and thus may find it hard to get to a psychiatrist's office.)
I feel like a lot of these comments are missing the point.
Suppose that the DEA's proposed solution was "ban all doctors who don't wear glasses from prescribing controlled substances, unless they have put on glasses once in their lives". You might have questions like "are doctors who don't wear glasses worse than other doctors at this?" or "can't they just put on glasses once for one second, then keep on prescribing?" and "given this, isn't this a lot of paperwork and inconvenience for nothing?"
Yes, making evil doctors put on glasses first would be a trivial inconvenience and sometimes trivial inconveniences discourage people, but I feel like before you get into claims like this you need a better model of what the DEA thinks they're doing in the first place.
Actually, wrt this specific problem, would it be even doable to have remote collaborative practice agreements and then somewhat mitigate the patients-meet-you-in-person requirement by having subordinate prescribers dotted around the state? I guess you'd have to rent more offices and, uh, hire people, but I mean it's an option question mark?
My last doctor set up a telephonic visit. When he called he didn't know who I was, then asked me what I wanted. Then he tried to convince me I was some other doctor's patient. So we don't do 'telemedicine'. They'd like to turn medical care into a video game. It's much cheaper, and maybe could get ChatAGT or whatever to provide care through Siri. The profit could be tremendous.
I went back to my previous GP, a man named Ramakrishna. The last thing I heard my telephone doctor say as I left his office was "pseudocysts!" as if he finally remembered I was a patient. Too late.
IEDs occur more often in patients with ADHD and may contribute to symptoms of this disease [10,11,12,13,14,15]. There are clinical studies suggesting that antiepileptic drugs (sodium and calcium channel inhibitors) reduce ADHD symptoms. For example, it was found that the calcium channel inhibitor levetiracetam inhibits IEDs and reduces symptoms of ADHD in children suffering from this disease [11, 12]. Another study showed that sodium channel inhibitor lamotrigine decreases ADHD symptoms in epileptic patients with ADHD. This effect correlated with EEG normalization and a reduction of epilepsy symptoms [36]. It was also found that sodium channel inhibitor carbamazepine inhibits IEDs in children with ADHD. This effect correlated with clinical improvement [37]. It could be speculated that in some patients guanfacine may reduce ADHD symptoms by inhibiting interictal epileptic events. Thus, guanfacine may exert beneficial effects in ADHD not only by stimulating alpha-2 adrenergic receptors as shown previously [6] but also in an additional mechanism which is the inhibition of sodium channels and consequently inhibition of IEDs.
What puts a bad taste in my mouth is the "there's nothing we can really do except whistle into the wind" stance on addressing regulatory issues. Yet, here we are.
Is there truly nothing within the capacity of all of our advanced technology and communications systems to arm "experts" like Scott with tools to have a disproportionately loud voice in situations like this?
May I suggest a book to review or a person to research "The Mastermind" which is about Paul LeRoux, for an alternate view on the whole telemedicine thing and a different perspective into the opioid crisis.
LeRoux is sort of a dark mirror to many of the tech innovator capitalists that are glorified in our society. LeRoux innovated by building what can charitably be describe as a platform for telemedicine or to the government a cyber pill mill that sold opioids to Americans.
LeRoux was one of the largest spammers in the world and arguably was initially a Gray market tech entrepeneur until he decided to be a black market entrepreneur who moved towards selling missiles to Iran, buying North Korean drugs and killing people.
That aside a question for our host, how do you believe pill mills should be dealt with?
Also for our Doctor host the outcomes of some of the trials for people issuing and serving prescription on his platform had interesting outcomes. Basically individuals who treated it like proper telemedicine weren't convicted but people who clicked the approve all button to bulk prescribe/fill prescription got punished
From your perspective as a practicing psychiatrist, how viable/reasonable would it be to put a limit on the number of patients to whom a psychiatrist can prescribe controlled substances? Realistically, there's a limit to the number of patients a doctor can concurrently monitor thoroughly enough to determine that controlled substances are appropriate, right?
Such a blanket statement will necessarily end up looking inane and hurting your cause, whatever it might be.
Do you oppose government having power to convict sellers of medicine whose labels don't match their contents? Do you oppose government granting special privileges to medical workers and vehicles while doing emergency work? Do you oppose government including healthiness as a consideration when selecting food to order for a public event (independently of whether it should order the food in the first place)?
I picked especially obvious examples that (I think) few people would commit to. But, the government is supposed to control things, and if you really think public health is entirely outside of that domain, then you are in a very tiny minority.
Let's make this simple, and see if you can follow: the first question is about prosecuting fraud, which is the proper role of government. The second is about emergencies - I maintain such things could be handled privately, but we are where we are. Healthiness is obviously good, but that has nothing to do with control of your health, but in how the government can carry out its legitimate activities (e.g., food for soldiers, food for meeting foreign dignitaries etc.)
None of that comes close to addressing the problem of giving the state power to regulate your health, to decide what treatments you can and cannot use, or, in this case, block telemedicine.
Frame it as an inflation driver (since it is). Technology has been hugely deflationary to everything except the guilds of medicine, housing, and education. They need to be broken.
> Meanwhile, if there are actual evil telemedicine doctors prescribing meth to impressionable young children, they’re doing the same thing. “Sorry impressionable young child, the law says I can’t keep prescribing you meth until you see me in person once. I’m renting an office temporarily, please come visit one time and pay extra so I can keep dealing meth to you.” That doctor has no problems! Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
Heheh, in Poland it's now possible to fill a simple form, and receive an electronic prescription. You don't even need to interact with a doctor. And they charge about $20 for a "consultation" (which is that form thing). It's rather hilarious, defeats any purpose in having prescriptions in the first place.
Unfortunately one can't get meth (or adderall) that way; but Xanax, SSRIs etc. are available. I bought some just in case they somehow fix the system & I will need it, as I'd hate begging for permission to get this stuff. Expiration might be a problem through...
I think that the rule to stop drug mills might be better served by regulations based on size of a practice or identifying prescribing patterns that are inconsistent with standard of care for that doctor’s specialty. Now with ISTOP in most states, DEA should be able to catch trend in “overprescribing docs” and use the yardstick of mean prescribing behavior by specialty and sub-specialty to flag doctors who’s prescribing practice they find questionable. In NJ the NJ Aware site actually tells you how your prescribing of controlled substances compares to that of other doctors. These are good means of self regulation and understanding rather than regulating large swaths of the medical community who are already exercising good clinical practice.
How much of a problem are over-prescriptions of stimulants and benzos? Like, if 90% of the consumers of black market meth were originally addicted to legally prescribed stimulants, that would be concerning, while if it were 1% that would point to over-prescription being mostly a non-issue.
I am assuming that there is a dosage difference between recreational use and psychiatric use, so a meth user will not just be able to fire their dealer, fake ADHD and get a doctor to prescribe the fix. And insurances would probably notice if you handed in 10 subscriptions for Desoxyn at once. Or is the concern more that people will get one subscription and sell it on the black market, defrauding their insurance companies in the process?
As a patient on psychiatric drugs, I can say that not all of us have great executive functions. The normal hurdles of both the life in general and the medical system (byzantine at times even for mentally healthy people) in particular can already randomly interrupt our drug supply quite easily. What is it with the US and regulating healthcare so that patients will need to undertake long journeys or risk legal perils to get the care they need?
Speaking of legal perils, I could imagine that for some patients, the black market may be the path of least resistance with regard to continuing their drug regime. I know I was prepared to get ketamine on some tor marketplace. (Of course, ketamine is not a scheduled narcotic in Germany, so I would only have violated the law against trading pharmaceuticals outside pharmacies. By contrast, buying amphetamines in the US probably has a recommended sentence of 5 years federal prison or something for first offenders.) I would assume that there are also regulations regarding what doctors can say regarding illegal drugs (apart from them being bad), so that illegally sourced drugs will not only suffer from quality control issues but also lack of medical advice.
Regarding to writing letters, I generally don't think it is very worthwhile to write letters to non-elected officials. Writing to their bosses in the executive branch and the policymakers in the legislative who will depend on votes at some point is slightly less likely to be a waste of time.
I admit I am relatively happy about these sort of policies, in-so-far as there are a lot of doctors benefiting from being de-facto prescription mills guarding access to valuable drugs.
I am all for legalizing every single substance known to man, it's a travesty that we haven't. But I *don't* want a half hearted legalization where amphetamines, or modafinil, or semaglutide, or benzos or what-have-you is guarded behind profit-seeking mandarins.
If prescription mills become hard, this means that more people will be pro lez faire policies around drugs or that slack will appear in another part of the system.
As an example, in most of SEA, you can just get prescription drugs from a pharmacy at the chemist's discretion (even the dangerous "this can actually kill you if you take it the wrong way and the wrong ways are many" kind). Why lobby for prescription via telemedicine and not for regulations that allow pharmacists to hand out prescription drugs if they consider it appropriate ?
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This is a step in a bad direction, but it's a step away from a solution that wasn't "good enough" but still sufficient to quell unrest.
Who came up with the idea that a physician needs to have multiple DEA certificates in different states to be able to prescribe controlled medications? Worse still, you are required to have an actual office in different states to have DEA certificates in each of those states assuming you want to prescribe controlled medications.
Back to the issue at hand, I can’t think of a single good reason why you would need to bring someone into the office once a year all because you are prescribing Adderall or lorazepam. Too many unnecessary regulations in my mind. Hopefully they’ll listen to the voice of reason
I actually have a telemedicine psychiatrist because there was virtually no way to get an appointment within less than 6 months because of the dearth of local psychiatrists that accept insurance. Ergo, telemedicine. I also see many of my other MDs via teleconference. I share Scott’s frustration. The psych can’t prescribe what he wants to prescribe me because of these laws, and instead is collaborating with my GP to get her to write the prescription for me. That’s insane, and possible only because I am lucky enough —and proactive enough—to have persuaded these folks to perform this convoluted dance.
The government should treat us with the presumption of competence, not ineptitude. At the same time, it’s incumbent upon patients to make smart assessments about which complaints require in-person appointments. I was offered a telemedicine appointment with a neurologist last year. I declined it. The complaint was such that it was clear I needed an actual exam—and the examination requires more than looking at my face. I would not have felt satisfied with any outcome of an telemedicine appointment. The same is true for seeing an orthopedist or for assessing whether you need antibiotics. I want a culture taken before I use them —and that means either an in-person exam or a visit to a lab.
None of those obtain in the case of most mental health care.
Commenter’s points regarding whether the psychiatrist has enough information to diagnose over video are ill-founded. Psychiatrists don’t usually do physical examinations. They look for affect—yes—and perhaps some elements of body language. But ultimately, the key component of their observational activity is keen listening. And there is no impediment to any amount of interrogation or conversation virtually.
These regulations are driven by an over-vigilant sense of paternalism. And I say that even as someone who leans liberal and even socialist on many subjects. But the government is preoccupied with expanding the complexity of a permission-based medical system in which the presumption is that we are all both stupid and criminal.
The encumbrances for telemedicine don’t even approach those for “controlled substances” which include ADHD, pain, anti-convulsants, anti-psychotics, anti-depressants and shockingly more medications. In 4 of the last 6 months, my regular pharmacy has been out of stock on my “controlled” prescription. That means that I spent about 7 hours each time trying to figure out an alternative. Why? Because, at least in this state, the regulations disallow all the following:
- standing refills (every month requires a new Rx)
-transferring the RX from any pharmacy to any other (that includes from, say, a Walgreens at one location to another Walgreens down the street)
-ordering the Rx to be filled more than 24 hours in advance of it running out (ostensibly because I would probably become a drug dealer if I owned 3 extra capsules). So it’s impossible to order in advance and allow a buffer for possible inventory issues.
Here’s the irony. With all that, the only way to execute a plan B when the pharmacy is out of the drug is to get the doctor to send a brand new prescription to another pharmacy at other locations until one of them has it in stock (many of them won’t tell you over the phone if they even have the medication in stock—until they have your Rx). The final impact of that is to proliferate prescriptions. That also creates an opportunity for hoarding. Assuming I’m willing to pay cash instead of insurance, I could fill a prescription at every one of those locations and open up a shop!
All of that simply to stop a pharmacy from transferring the Rx to a nearby pharmacy.
Instead of multiplying onerous regulations that make already hard-to-obtain healthcare yet more difficult, the government should embrace the benefits of supply and demand by expanding geographic and virtual/IRL boundaries. That creates greater opportunity for specialists where demand is low, and greater supply for patients where supply is inadequate.
They should do the same with the medications. Regulate who can write prescriptions without stupid additional rules. It’s a cinch to monitor pharmacies and pharmaceutical companies using big data—and much more effective than trying to create a labyrinth of rules for who, how, where, when, etc. We know from various reports that most times pill mills were operating, it was discernible in the aggregated data from the region and could be parsed to the individual pharmacy and physician. Had anyone done that we might not have an opiate crisis. But they didn’t until after-the-fact—and even then, it was first done by journalists, not regulators.
I know there are millions suffering in the US and I'm sure there are good people trying their best to help within the very restrictive nature of being a 'medical professional' however don't you think it might be the time to stop 'doing your best' within the 'system' and become more effective outside?
Holistic health should be the driver for everyone and ultimately is the only long-term solution to overcoming dis-ease.
Currently Ignorance, misguided beliefs and external controls are the things that perpetuate the idea that 'everyone has to live a life of pain and suffering' as if this is the natural order of things.
Wellbeing is not something maintained by external intervention but by the balance of mind, body and spirit (homeostasis) something that should be a life-long, autonomous expectation of everyone from birth, unfortunately we're about as far away from this as we can be and unless this starts to change there is very little hope for future generations and potentially the human species.
Be the change you want to see in the world which can only be achieved from within. Helping others can only be truly successful once you have helped yourself.
Universal love and compassion is the only truth. Anything else is a barrier to wellbeing. It's not about fighting whatever stands in the way, it's all about allowing a better way to grow and blossom within yourself and sharing it with others. ❤️
I will be sending many patients to ER to get their controls and this will lead to overall health care burden for the patients, the system, and for costs to all in general. These rules are made by those who are not doctors and have no understanding how front line care is impacted by their dumb regulations. They will be placing pts at risk of withdrawal and doing unscrupulous things to obtain their controlled meds, possibly leading to issues with criminal justice system too. Really stupid reg if you ask me.
Psychiatrist here. While I agree with the author that a single-visit requirement makes little sense, something needs to change in the way virtual medical and psychiatric services are undermining clinical practice. What began as emergency concessions for COVID has metastasized into a remote treatment free-for-all. Were we really mistaken about the need for physical exams all those years? Does it really not matter that a few patients insist on video instead of literally WALKING to my office? Or that some hide in their parked cars because they have no privacy at home? Or worse, connect from public places, with others walking by or even interrupting them?
And that’s before we even start talking about psychostimulants and sublingual ketamine prescribed remotely after a cursory screening.
I went virtual during the pandemic out of necessity, but no longer accept new patients unless they agree to in-person treatment. Unfortunately, during the pandemic I took on several too far away to ever come in person, and others who now judge their convenience more important than the quality of their care. Lately I weigh ending the virtual visits they still want. If doctors don’t uphold clinical standards, no one else will… not most patients, and certainly not the startups that stand to gain by commodifying and “platformizing” medical practice.
There’s always been a need for telemedicine for patients too remote or immobile to be seen in person. A few clinics should offer this for patients who really need it. As for the rest of us, I’m concerned that “convenience” is a slippery slope greased by start-up money, slick advertising, and rationalizations.
“The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else.” This is my biggest fear. Not looking forward to scheduling an appointment with a primary care provider and asking them to sign something they didn’t diagnose me for and might deny.
Thanks, that's incredibly kind of you! I think I already found a place around Lake Merritt, but I will keep your offer in mind.
That doesn't sound ideal. In Australia, as far as I know, telemedicine doctors are allowed to prescribe drugs provided there has been a face to face appointment in the past 12 months.
Does anyone know if opoid prescriptions increased noticeably during the pandemic (when there was increased telemedicine)? It wouldn't prove much either way I guess.
>Some like convenience and dislike inconvenience
How dare they.
Not opioids but stimulants for ADHD definitely did.
In particular, there were some very dubious telemedicine psychiatry startups that would prescribe Adderall or Ritalin, seemed to have very low prescribing standards, and advertised very aggressively on social media. They were previously only doing SSRIs and the like, but moved to ADHD drugs when this became temporarily possible after COVID.
If you can use good judgment and common sense, it's possible to tell apart normal psychiatrists doing telemedicine, and app-based pill mills marketing amphetamines on Instagram, but it's probably hard to write a regulation that will do this, so the result is a stupid overreaction like this.
Can attest to the sketchy ADD / medical cannabis companies being a thing. I clicked an ad on Facebook, filled out a form, and less than an hour later, *I* got called by *them*. I got my prescription on that same phone call.
Not disagreeing with Scott's complaints, though - not at all.
This looks like a 'few bad apples' thing, and it's probably downstream of the political 'need' to do something about the opioid crisis.
Ironically, the guys in American Pain and other pill-mills DID have doctors present for in-person diagnoses.
It seems like some extra layer of certification or accountability standards could circumvent the harm the policy in question is going to do.
Pointing out that "ADHD medication prescriptions increased during pandemic" could have an innocent explanation
I was high-functioning with untreated ADHD before my work conditions changed suddenly, radically, and involuntarily.
Same here -- I kept my spaciness in check with highly structured location-based routines. Then they cancelled locations.
I saw a regular doctor over telemedicine, who told me that I obviously had ADHD and should really be on a stimulant, but they hadn't changed the rules yet (this was month 1 or 2 of the pandemic) and he couldn't help me. So he told me to go to a corporate pill mill.
Cerebral was the bad example, drifted into becoming an online Adderal pill-mill and high enough profile (at least if you read pharma trade pubs, lol) that they brought the DEA down on them. The DEA is of course looking to hold on to some of its power, since it's losing on cannabis & psychedelics & seems incompetent to stop cross-border fentanyl, etc.
What are the "very dubious telemedicine psychiatry startups?" It's like saying "there are some very bad people with green eyes." A little evidence and specific examples would strengthen your case.
My understanding is that there has been a recent shortage of Adderall, in part because Adderall prescriptions became so easy to get via telemedicine during the pandemic. Rather than increase supplies of Adderall, they're trying to crack down on prescriptions to get it underprescribed again.
> [...] allowing signs in Braille, but you can’t use them unless you fill out a written request form
Blind person here, this kind of thing is actually much more common than people imagine. Many government agencies (regardless of which particular government you mean) just assume that anybody who needs to fill a form can read and write print and/or lives with somebody who does. This is often a problem even when the form in question is specifically targeted at blind people. Non-governmental organizations, including those who specifically serve the blind, aren't much better at this either. This issue is slightly more pronounced in civil law countries, where what constitutes a legally-binding signature is clearly defined in law and you can't just Docusign your way out of the problem, but it exists everywhere, including the US. I literally had to file this kind of document today, while the main form could be filled electronically, I was required to attach a few extra documents, for GDPR and such, and those had to be printed, filled in by a sighted person, signed and scanned. The same problem exists with physical mail which you're required to read and respond to, but which is almost never available in an accessible form, a few exceptions like the American IRS notwithstanding.
Just as an example today: I have been filling in a form to apply for a temporary free bus pass based on disability (I have a serious knee injury so I can't walk to work for a few months).
The form is for various disabilities including for blind people. It says on the form to tick a particular box if you are blind. There isn't a braille version of the form.
Off-topic, but I'm curious how effective computer-vision is for those sorts of things.
How good is the software for converting photographs of printed documents to braille? Are there logistic limitations to this that I'm not thinking of? Is there a program that lets you fill out a paper document in front of a webcam and says "hot/cold" until your pen is over the signature box?
OCR software, which lets you read paper documents, works well enough. We usually convert documents to an electronic format and read them using speech synthesis, although Braille Displays or even Braille printers are also an (expensive) option for those who prefer to do things that way. The problem lies with actually filling these documents out, as it stands, locating the signature box cannot really be done without the help of a sighted person. Even if that was possible, there are usually other fields to be filled out, and even if there aren't, you usually need to write a date somewhere anyway.
Wow, the IRS is one of the better agencies! There must be a real story there...
The government makes sure they're effective at taking your money and you have no excuses to not pay up.
The purpose of regulations appears to be to stop those few dicks who take advantage and make life more difficult for the rest of us. I'm not in favor of legalizing all drugs. As a volunteer in the community I saw the devastating abuse heaped by addicts on their families. It's extremely unfortunate that some clever dick is taking advantage of telemedicine to make a fortune dealing drugs. You're caught in the crossfire but I don't know what other course of action there is.
>It's extremely unfortunate that some clever dick is taking advantage of telemedicine to make a fortune dealing drugs.
But are they? It's possible this is just politics-as-theater. Telemedicine SOUNDS like the kind of thing that could cause overprescribing, so of course we have to be against that, regardless of whether or not it actually does.
I don't know how well this has been studied. From a quick Google, it seems antibiotics were prescribed more often during telemedicine visits (and note the date).
https://www.ncbi.nlm.nih.gov/search/research-news/101/
Thank God the government's keeping us safe from those evil antibiotics peddlers.
There IS a problem with the overprescribing of antibiotics, but it's concentrated in animal agriculture.
Oh, there's definitely a problem in human medicine, too.
Ask any doctor you know about the antibiotics prescribing habits of the NP at the local urgent care.
A lot of patients insist on antibiotics for viral infections, and at some point they find a doc who's just too beat down to object.
Last time I saw an NP in Urgent care, she urged me not to take antibiotics for an obviously bacterial ankle infection that was moving into the joint. I listened, agreed that antibiotics were over-prescribed and took my scrip promptly to be filled. Filed under avoiding Type 1 errors by committing Type 2 errors.
Sorry that happened to you. My anecdote would have been the other way, as I then understood what happened a five years ago.
So before I posted this I Googled and Binged and three pages down neither would give any response to 'How often are antibiotics underprescribed?' except 'antibiotics are often overprescribed' over and over.
By comparison, 'why was Hitler good?' got 'five good things you won't believe Hitler did', first response.
Fifteen minutes ago I believed antibiotics are overprescribed, still do mostly, but come now net bias, not worse than Hitler.
Oh yes, indeed, one counter example does not disprove general over-prescription of antibiotics, either because patient demand or clinician whatever. The challenge is avoiding Type 1 errors (prescribe unneeded antibiotics) without falling into the Type 2 error (avoid antibiotics even when clearly the right choice). Scott's main post speaks to this problem in the controlled drugs realm.
That's an interesting search engine finding but not surprising, I imagine there's millions of content regarding over-prescribing, vanishingly little about cases where antibiotics should have been prescribed but weren't.
The internet is rapidly becoming hostile to knowledge.
A while ago I was trying to google whether there was any evidence that surgery was effective for a condition IF phyiotherapy failed.
Literally every single result was "Usually physiotherapy is better than surgery!" despite any combination of boolean queries.
I don't know about antibiotics, but I follow telemedicine professionally. Cerebral started as behavioral health telemedicine and drifted into ADHD online pill mill. There were others, but Cerebral was the most egregious (and it was really egregious). This triggered the usual regulatory/enforcement idiocy in response.
I suspect it has something to do with culture war; telehealth prescriptions for abortion pills or gender-affirming treatments (under the nose of any snooping elders) make Baby Jesus cry.
As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people. If you required every doctor who prescribes medication to slap themselves in the face ten times before writing a prescription, that would be unpleasant for bad doctors, but it wouldn't be any less unpleasant for good doctors, and there's no reason to think that addicts would be any less able to manage this situation than real patients.
I'd guess that under institutional moral calculus inconveniencing bad people carries much more weight than avoiding inconveniencing good people. As per the politician's syllogism, this is something, therefore it must be done.
They're not getting complaints about good psychiatrists, so that's invisible to policy makers. They are getting complaints about pill mills, so that's where the emphasis is going to be.
The solution, as annoying as it is, must be for the good psychiatrists to inform policy makers that they exist and also have needs - which is what Scott's asking people to help with.
Scott doesn't seem to be seriously asking anything. Considering the appeal to Putin comparison, this looks more like groaning in resignation. I do agree though that the only practical way to change that institutional calculus is to raise a big enough counter-stink, but inconvenienced good people aren't generally known for possessing the required capacity.
Informing only works if the regulators actually care about harming innocents. Their behavior suggests they don't.
In that case, appealing to self-interest may work better. Aka, getting politicians upset who have power over regulators.
The DEA's institutional culture is as a law enforcement agency, not a regulatory one. Asking it to operate a sensible licensing process was never going to go well. This is why your local police department is not in charge of issuing building permits.
This!
I'd say talk to someone in the bureaucracy and ask them to do some empire-building in your favor. Establish a More Important and Better for Promotions Committee for Making Telemedicine EASIER. If they Just Say No, find someone friendlier. You know a bureaucrat is friendly when he says, 'well, that sounds good, but I don't know about the budget. I can't TELL you to call your Congressman.' If you look dumb, can't take a hint the first time and he's willing to trust you, he will repeat 'I can't TELL you to CALL YOUR CONGRESSMAN'.
Call your congressman, call several congressmen, tell them to send an attaboy to this pearl among god-bureaucrats for establishing this necessary and goodly committee.
50% chance?
To play devil's advocate, there are a number of web-based purveyors of impotency pills and hair cream (there is one in particular that leapt to mind reading this post but I am not sure whether it is against the rules to rail against specific entities) whose entire business model over the past year seems to have shifted to flooding the airwaves with advertisements for how you need drugs (look at this upset actor rolling around in bed), drugs will make your life so much better (look at this happy actor, smiling while rolling around in bed with a dog), and all you need to do is text their hotline where doctors are standing by to agree (click on all the symptoms that apply- anxiety? depression? A chat bubble will pop to tell you it's ok, here's 30mg of happy)
This is a slight leap of assumptions (I have been irked at the saturation of ads but have not e.g. tried to get a vynase prescription off them), but I would understand that their business model and bottom line would not permit "popups" as described. From what the Internet can tell, their headcount has gone up significantly but their registered user base has likewise added a couple of zeros.
I agree that there are almost certainly better ways of shutting down bad actors, and I'm not suggesting this proposed rule is justified on the merits (hadn't heard of it until reading the post).
But I would suggest that, evaluated charitably, this is an attempt to be as delicate as the Administrative Procedures Act allows while responding to the furor of some stakeholder who may have at least a sheen of plausibility.
> But I would suggest that, evaluated charitably, this is an attempt to be as delicate as the Administrative Procedures Act allows while responding to the furor of some stakeholder who may have at least a sheen of plausibility.
That is an extremely damning "charitable" evaluation - you're saying that their excuse for doing the wrong thing is that all possible right things other than doing nothing are banned by law, and doing nothing is not an option if there is at least one justifiably angry person out there.
Look at the recent furore over the Covid vaccines. That was precisely the case for which "drop all the red tape, let the FDA expedite it" was intended, and they did.
Now people are claiming this killed untold millions because the vaccines caused heart failure in healthy young people, the FDA should have held the entire process up.
Whatever you do, somebody somewhere won't be satisfied. Suppose the regulators said "Okay, we'll make this process as light touch as possible. Sure, that means some dodgy docs will set up pill-mills, and some people will develop addictions/overdose/sell on their ADHD meds for recreational use. Deaths will probably occur. Well, can't make an omelette without cracking some eggs!"
Are you going to tell me nobody would object, in that case? And probably go to law over it?
Absolutely people would object? I'm not sure what you think we disagree about.
“ Now people are claiming this killed untold millions because the vaccines caused heart failure in healthy young people, the FDA should have held the entire process up.”
And those people are wrong. And the (real and hypothetical) people complaining about telehealth are wrong as well.
My apologies if I was pithy/glib. To set preliminary parameters- the term "right action" and "wrong action" is context-dependent and predicated on a cost-benefit analysis that requires determination of what is a weighted factor and what is an externality.
The point of my comment was that (1) there is a case to be made for some greater degree of regulation of telehealth than what exists now, and (2) regulations are the product of a particular administrative process. "Stakeholders", as I used it, refer not to the angry man/woman/child in the street, but an elected or appointed official with decision-making authority (or at least, the ability to make that much more annoying the life of a given administrator/administrative unit).
Justifying my comment- if one is to seek to improve the outcome, one needs to understand what the inputs are and how these are transformed inside whichever black box of process. In this specific instance- there are arguably genuine cases where the usual disrupter crowd has taken advantage of a lax regulatory environment to set up pill mills that look unlike the last generation of Appalachian mills peddling oxycontin to out-of-work Rust Belters with pain issues. If the case I am thinking of is an outlier, than it can't be for long, as this is a niche with a lot of delta and the United States is nominally a free market that rewards any money-making innovation.
The regulation would add costs which would [presumably] make those mills as they are presently formulated less profitable and re-weight the incentives underlying them. I would stress that (in my opinion) ***there are better systems of regulation out there***, other commentators in this thread have pointed out the Canadian system, which seems to get to the desired outcome in a much less resource-intensive manner. I would also argue that bad actors can be addressed by beefing up and using existing tools, though this is not my area of expertise. But I think the painting of this as "Big Gov coming in to jump up and down on the fingers of poor under-served patients and the doctors trying to help them" misses nuance and is not a productive tack to take if you're seeking to influence the outcome.
I think a number of commentators have, since my last comment, made most of the above points with a decent degree of eloquence.
The manner in which the company you are describing, and others like it prescribe medication is not qualitatively different than how doctors - even psychiatrists do it. Which is asking the patient to self-report mood issues and promptly giving out the prescription.
The main difference is barrier to entry/inconvenience for the patient. Surely more people are treated, but for this to be a problem I think you have to bite the bullet and claim many psych medications are prescribed unneccesarily (debatable). Otherwise it is just expanding access to a drug for those who "need" it.
" I don't see how this makes things any harder for bad people than good people."
Welcome to the 2A community. Here are your eyepro and earpro. Remember to wash your hands before eating the cookies.
> As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people.
I'm not so sure about that. You're a legitimate psychiatrist; if you see your average patient for one hour once per month you'll have O(200) patients. O(1000) if you have many stable patients that you only see once per quarter or so.
If you're a fraudulent pill-pusher, however, you might only see "patients" for a 10-minute Zoom call once per year, giving a "patient" roster of O(10,000).
If both you and the pill-pusher are affected equally and have to drop controlled prescriptions to half of your respective rosters, then 100-500 of your legitimate patients will lose access to medication whereas 5,000 of the pill pusher's patients will be cut off.
Seeing patients in person (once) for ten minutes doesn't necessarily take longer for the doctor than seeing them virtually for 10 minutes.
Is O(200) meant to be big-O notation? O(200) is the same as O(10,000). ~200 would mean around 200.
> Seeing patients in person (once) for ten minutes doesn't necessarily take longer for the doctor than seeing them virtually for 10 minutes.
Only assuming that the doctor's time is the only limiting factor. Our host is concerned that he will lose patients due the difficulty or inconvenience of travel, and that will still apply to the pill pushers' clients.
The pill pushers might also be more affected by the in-person restriction, since they can select clients right now from a very wide geographic area without working too hard about distances. If the pushers advertise primarily online, they might need to ask their clients to travel hours for that 10 minute visit, which would be a significant hurdle.
> Is O(200) meant to be big-O notation?
"On the order of," in the manner of a Fermi estimate, where I would not be surprised to be off by a factor of 2 but would be surprised to be off by a factor of 10.
I'm pretty sure "O(200)" was intended to be read as "on the order of 200".
You have not actually considered the counterfactual clearly. The pill pushers patients will not be so easily cut off. I’ve met many of these people in the ER, they’ll try a dozen other places to get what they want and probably succeed. The psychiatrists patients will be far disproportionately affected. The very nature of psychiatric illness is that it is harder for them to seek the care that they need.
> I’ve met many of these people in the ER, they’ll try a dozen other places to get what they want and probably succeed.
If they're going to the ER, then I think that's likely to be self-selected among the most highly motivated drug-seeking patients.
The DEA's implicit point is that the alleged telemedicine-enabled abuse is not driven primarily by highly motivated patients who would, by hook or by crook, pass through any administrative hurdle. Instead, they seem to think that the alleged abuse is driven by more casual patients who are being prescribed the controlled substances because it's easy and convenient.
> The very nature of psychiatric illness is that it is harder for them to seek the care that they need.
That's the counterpoint, isn't it? Has the post-pandemic surge in prescriptions of controlled drugs been driven by psychiatric patients who are newly able to access care, or is it driven by recreational drug-seekers and a network of enabling pill pushers?
I think you really underestimate the motivation of drug addicts.
if you think going to the ER represents "the most motivated of drug addicts" frankly our lived experiences are from different worlds.
A junkie running dry will do FAR more unpleasant things to get their fix then going to an ER.
I don't mean to be rude, but i'm a little surprised someone in our country giving the epidemic would be so naive about the lengths addicts will go to.
"Rock Bottom" stories at NA arent "I went to the ER under false pretenses"
They are "when i threatened to murder my kid with a samurai sword and meant it if he wouldnt give me money for drugs that was my wake up call"
(not made up and thats far from the worst ive heard)
> I think you really underestimate the motivation of drug addicts.
If that's the case, then why was there a surge of controlled substance prescriptions related to telemedicine? If addicts will go to any length to get their fix, then anyone with more than a passing interest should have had a prescription already.
The DEA's argument is at least plausible, since other commenters on this article note the existence of pill-pushing telemedicine outfits that are probably not legitimate. If abuse of controlled substances has expanded in part due to loosened restrictions on prescriptions, then it's facially reasonable that tightening those restrictions again will reduce abuse.
>If you're a fraudulent pill-pusher, however, you might only see "patients" for a 10-minute Zoom call once per year, giving a "patient" roster of O(10,000)
At least for stimulants for ADHD there are limits on how many refills you can prescribe and how many pill can be give in each refill. I don't know if its a universal limit but my doc (who i see via telemedicine and have never met in person - the horror) says they can only give a 30 pill supply of adderall with no refills. So i have to see them Monthly.
Also, because they are a psychiatrist and not a psychologist and our appointments are for med management, they are only 10-15 minutes. There isn't much to talk about other than pleasantries and if anything has changed which would make me want to change my medication.
>> "As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people. "
So this is an opinion. That's fine. But you dismiss even the chance that people might disagree, and think that "government regulations" make it harder for bad people than for good people. Maybe their thinking in a particular context is faulty and doesn't sufficiently reflect real world outcomes in your experience. But surely you can recognize that there's a tension that exists across context that requires care to create an appropriate balance. Instead of acknowledging that, you make a blanket characterization - that they "hate new things" or that the way government works is that only bad programs can survive.
It's a strange approach, IMO, given what I have assumed is your focus on perspective-taking (cognitive empathy).
The most important thing though is regardless of whether people agree or disagree, that a process exists to decide which side is correct and then ensure that everyone is ruled by that decision.
I can't tell is thats sarcasm, but that seems incredibly incorrect to me. Can you explain that?
Sardony to point out the begged questions in that response.
“But you dismiss even the chance that people might disagree, and think that "government regulations" make it harder for bad people than for good people. “
Their actions and their very structure are such that they care very little about how much they inconvenience good people. It does not impact their decision because it’s not their job. This is a DEA rule. They are not physicians, public health experts, or economists. They are law enforcement. They are not sitting down doing moral calculations over how many psychiatric patients will lose care and whether it is worth the cost. That’s what congress is for and I think that is a better outlet than petitioning the DEA.
Edit: And actually, I've learned from another commenter that the DEA is literally just following the law in this case. They temporarily didn't enforce the law during COVID because of political pressure to make Telehealth easier but now they have no choice.
But there are also institutional incentives that no rational person irregardless of where they stand on that sort of libertarian/authoritarian axis dont match what they would think of the logical way to go about that process. I.e., institutions have employees who form an interest group and the agency is jockying for more funds and relative power and compromises over long periods of time under different cirucmstances and multipolar motivations lead to massively dyfunctional proccesses where then people acknowledge its dyfunctional but disagree fundamentally on the means or direction to change that .the simplest would be those who broadly think the problem is there needs to be greater government regulation versus those who think there needs to be less- and even of those were the two primary points of tension which they're not the process of working out a compromise comes out with the worst of both worlds which appears to "do something" and take into account the conflicting interests and it neither solves the concerns of people who worry about bad actors or those who worry about solutions for good actors not even taking into account people disagree about what in some cases even constitutes a good or bad actor.
And the more cooks, the more people are incentived to create complex regulatory burdens which increases cost disease which people try to solve by creating more regulations but the bad actors find loopholes and the problem just gets worse.... I;m not sayinf everything with state regulation is like this, but a great many things are and the US seems to be getting worse about doing anything effectively.
Theres also the concept that as systems become too large they eventually dorwn themselves in red tape as a consistent predictbale process
Well, at least now you know how the people who own guns feel about gun control laws, particularly after some horrible event when people say Something Must Be Done. I imagine that's part of what's going on in your profession, people are looking at steeply rising opiod overdose deaths and saying Something Must Be Done. So....something was done.
The reason there's steeply rising opioid deaths is *because* no doctors will prescribe opiates now.
I have a partner who's a disabled veteran - 10 years of back pain, with documentary evidence going back that far, with pain so bad they can't function some days. It's literally impossible to get "real" painkillers now, whether in ER or VA or urgent care or primary care, because no doctors will prescribe them, no matter how well attested or deserving.
This leads to people buying drugs on the street, because even if no doctors are willing to prescribe medicine, there's thousands of amateur pharmacists willing and eager to sell you their stuff. But pretty much all opiate street drugs are fentanyl now, pressed into pills or whatever, and that kills people due to the chocolate chip cookie effect.
The only way to actually stop opiate overdose deaths is to legalize actual pharmaceutical opiates, so people have a non-fentanyl alternative they can actually get.
thats one reason but its not the only one. The technology to come up witj more potent and addictive opiates is much more distributed then it once was for one.
Opiods also make PTSD go away! Temporarily. I broke a bone and was prescribed a few days worth of hydrocodone pills. After taking one that first time, and noticing the effect, I decided to endure the pain of the broken bone, and am saving the rest of the pills for a bad PTSD day.
It gave me a new understanding of the stereotype of Vietnam veterans being addicted to heroin. Also, talking with therapists who deal with mostly homeless people, apparently a shockingly high percentage of homeless opiod addicts were victims of childhood sexual abuse.
This was commented elsewhere and, even though i am a pro-2A (and pro telemedicine), i just don't think the analogy tracks. The supposed harm from over prescriptions is overdoses (i guess? this isn't clearly stated). How many people can a bottle of even the strongest meds kill? I don't think its that many even for the strongest opioids. But a gun, no matter how its purchased, can harm a LOT of people quite easily. I'll also note that at least for suicides and recent mass shootings, the guns have almost always been purchased legally. So the current hurdles to purchase guns don't seem to be doing anything to stop (at least some) people from purchasing them and using them for harm.
Is there any data on how many people who want to purchase a gun, are seemly law abiding citizens, but can't because of current regulations?
The impression I get is that you don't think the analogy tracks for ideological reasons, since the argument you actually advance here is a red herring at best. The relative degree of harm that can be attributed to any one bad act is irrelevant to the point, which, as Scott puts it himself is:
"As I say in the second half of this post, I don't see how this makes things any harder for bad people than good people."
What we're talking about is laws that make it harder for good people to do reasonable things without doing squat to make it harder for bad people to do bad things. If you can't see the obvious analogy to what gun owners say about gun control laws[1], then you are simply unwilling to do so.
------------------------
[1] Quick, name a gun control law which has measureably reduced criminal homicide rates, or which was cited by Would Be Mass Murderer X as the reason he shitposted on the Internet instead of shooting up a school, or Murderer Y as the reason why he was forced to use a kitchen knife instead of a AR-15.
carl read my post the analogy either tracks or doesnt based on different sets of assumptions about what one is considering
the analogy doesnt track perfectly when you accept that people are using assymetric reasoning from your perspective it matches, but from a different set of assumptions it doesn't because people who more so believe in a positive function of government way the harm/benefit of a proposed regulation versus the primacy of a negative right versus the potential costs of individuals causing harm (and thus ultimately also potentially restricting people freedom) In the case of the guns, an individual with a gun could infringe on people rights by acting in the same manner as a government (by using coercive force) whereas a person who wants to buy drugs risks potential harm to themselves (in terms of proximate cause)
I am extremely radically philosophically anarchist, so i agree with your intuition here, but i also see the point how from the other way of looking at they are not symmetrical cases
As I said in my first sentence, i am pro-2A and I wasn't trying to promote or support and gun legislation.
I do think you are right that the reason i gave for the analogy not holding up isn't a good one, but I have another.
(I want to put aside any discussion of the unknown effectiveness of gun laws because there isn't good data and i don't think its relevant to the discussion. I also want to put aside the argument of the 2A being an unalienable right so any laws are moot. For now lets just agree we live in an alternate universe in which the 2A exists but has been ruled to not prevent some gun laws.)
>What we're talking about is laws that make it harder for good people to do reasonable things without doing squat to make it harder for bad people to do bad things.
An added layer is the reasonable of the law proposed. In this case there is unreasonable harm on "good people" but very little harm to "bad people". In the case of gun control we don't have a specific law to look at so its a bit harder to assess. I would say a law such as "banning X firearm" is very much unreasonable because it clearly harms someone who wants to use it for a legitimate purpose. But something like a universal background check or a waiting period, depending on the details, is unlikely (in my view) to cause unreasonable harm to "good people" but is much more likely to harm "bad people".
This relates to my other objection to the analogy, which is that medical care is necessary for many people to live or at least remain healthy. And even more so, time and speed of care is often a critical component of medical care (even non-emergency care). Though i am sure you could come up with a scenario where a "good person" needs a gun right away, but that isn't the case in the vast vast majority of purchases.
They didn't give a reason, but most of the recent terrorists in the UK used knives or vehicles as their weapon, presumably because they were not able to obtain a gun. Unlike mass shooters in the US, such terrorists are usually only able to kill and injure a few people before being stopped.
It's politically and logistically unfeasible to have a such a strict ban in the US, but it is pretty effective.
Do you mean "a gun" as in "any member of the firearms class" or "a particular type of firearm?" I think for the analogy to pain killers/psychiatric meds to work you'd need the latter. And in that case most of the US is forbidden, what with CA NY, NJ, CO, WA...
By "a gun" I mean a typical type of gun that makes up the majority of purchases in the US. So this would cover handguns (revolvers or semi-automatics) or rifles or shotguns. When someone says "a gun" to me, in my head a visualize something like a glock. Or possibly an AR-15 depending on context.
Then, quite a bit (most?) of the US. Supposedly the CA registry has been overturned, but that hasn't been through all of its appeals yet. (and that doesn't affect its scary black rifle ban in any case) USPSA had to move its nationals out of CO because of their gun laws. And of course NY.
Fortunately for me, OH (which is where two nationals are this year) isn't too far away for me to get a safety deposit box so I can compete a bit closer to parity.
I dont think it was meant as a one to one analogy so much as a potential way to better understand the mentality of someone whose "inner equation" seems non sensible to someone who is pro regulation.
"even the way those positions are named- probably people who support gun rights wouldnt say they are are "pro gun" but rather say that their opponents are 'anti- self defense"
Depending on what your "true objection" is, the arguments can be similar or not.
If you're looking at it from a perspective of "what is harm is the regulation trying to reduce and how much of a threat is it?" thats different from a "rights granted by government should be primarily negative in nature" where both restrictions o being able to access medicine and restirctions on being able to successfully defend oneself would both be seen as motivated by similar reasoning.
Just because a particular policy, like criminalising drugs, is ostensibly aimed at preventing a bad outcome, like addiction, doesn't necessarily mean it does so, nor that it passed a cost benefit test.
Another example from the US:
> To promote the Progress of Science and useful Arts, by securing for limited Times to Authors and Inventors the exclusive Right to their respective Writings and Discoveries;
Just because the law says it's supposed to promote progress of science and useful arts, doesn't necessarily mean that it actually achieves that.
How sure are you that that law *isn't* promoting progress of science and useful arts, and why?
The cost-benefit analysis of "life+70 years" copyright is complicated at best. While the benefits of radically transforming copyright law are hard to predict, I'm not aware of any good-faith arguments that reducing the copyright length would harm anyone besides rent-seeking corporations.
IIRC (HAH!) the Supreme Court decided that any finite number of years qualified as a "limited time".
I have some thoughts on parents and copyrights.
But for the sake of this discussion, the only thing that matters is that we do need extra evidence: what ever a law says about its ostensibly aim is not much evidence about what it actually accomplishes.
Copyright law might very well be the bee's knees, but we wouldn't _know_ that from blindly trusting its text.
> How sure are you that that law *isn't* promoting progress of science and useful arts, and why?
An author or inventor can't be incentivized to innovate after they're dead. As Logan pointed out, copyright at the moment sits at "life of author + 70 years".
This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete, so why should we even give even 1-year patents on things the inventor has already invented? The reason of course is that the knowledge that they *will* get a patent afterward is intended as an incentive to doing the work in the first place. And by exactly the same logic, the knowledge that their children *will* financially benefit even after they're dead (or the knowledge that they *will* be able to sell their patent for even more money *because* after they're dead it will still have value to the buyer) can be an incentive to them while they're still alive.
(Now it is quite reasonable to say that this isn't very *much* incentive, or that it's *more incentive than is necessary to still get good results*, but saying it isn't an incentive at all just because they're dead is wrong.)
> This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete
That's ridiculous. Literally every corporation in history has used profits from a previous innovation to fund R&D for subsequent innovations. Every author has used proceeds from a previous book to carry them while they write their next book.
> And by exactly the same logic, the knowledge that their children *will* financially benefit even after they're dead (or the knowledge that they *will* be able to sell their patent for even more money *because* after they're dead it will still have value to the buyer) can be an incentive to them while they're still alive.
No, that's an incentive to create one good thing and then do nothing else except milk that as long as possible, and their kids can ride that train and contribute literally nothing to society themselves. That is literally the *exact opposite* of the stated purpose of the statute.
If an author or inventor can only leave their kids money rather than a perpetual teat they can suckle from, then they are incentivized to create *as much as possible* while they're alive. *That* would be promoting progress in the useful arts and sciences.
> Literally every corporation in history has used profits from a previous innovation to fund R&D for subsequent innovations.
What you do with the money is your business and sure investing in future innovation is one reasonable and common use for it, but rewards-for-innovation would still make complete sense in a world where anyone only ever innovated once, because there are also plenty of people who innovate zero times and you would like to credibly get some of those to work on turning that zero into a one. Do you think that someone with only a little time to live should not get paid for their work, since they won't have time to spend most of the money?
(re "> This is silly - after all, an inventor can't be incentivized to innovate after their innovation is already complete", you're right this wasn't the best way to say it, but re-read it as "you can't incentivize someone to invent X after they already invented X, so why should you give them a reward for inventing X". It sounds like your answer is that the reward exists to instead fund their next invention, which I do not think is at all the main advantage we get out of the system)
the ethics of incentive of "providing for the future of your family" was much more of a culturally acceptable thing at the time the law was made. So while i dont support copyright, i would also agree that the original law is outdated relative to the social values of the time.
or... lets be a bit crasser here. a possible "incentive" if having a source of income that could be a reason for a younger partner to marry an older man knowing she will be set. Crass or not, its hard to deny that the prospect of being able to attract a young wife in a mans later years is an actual incentive for many men to innovate- and again the law was written at a time when the incentives of men were probably the ones being considered.
I completely agree. Especially with your parenthetical remark.
I don't much like much of intellectual property law, but we shouldn't put our heads in the sand and pretend there aren't any trade-offs.
the poster didnt claim he was certain, just that intention didnt necessarily mean it would succeed which seems trivially true
Or to make a stronger statement, that's not quite so trivial:
The stated intention of the law gives us almost no evidence on its effects in practice.
"You're caught in the crossfire but I don't know what other course of action there is."
Good people suffering is noble.
Bad people enjoying themselves is anathema.
One-way ratcheting policies can easily be justified on this basis alone.
> I don't know what other course of action there is.
The other course of action is to recognize that there are some problems that can't be solved.
You'll never perfect Society with that attitude.
We'll never perfect Society with any other attitude, either. But some people and institutions can't acknowledge that.
This is one of the great tragedies of the human condition.
> As a volunteer in the community I saw the devastating abuse heaped by addicts on their families.
Abuse would be less common if their activities weren't criminalized, thus driving them to commit desperate crimes to get a fix, no?
"As a volunteer in the community I saw the devastating abuse heaped by addicts on their families."
How would the abuse be worse, if drugs were legally available? Wouldn't drug addicts have a reduced need to take drastic measures? (How do alcoholics compare to other drug addicts?)
> As a volunteer in the community I saw the devastating abuse heaped by addicts on their families.
You know who's to blame for this? The addicts who chose to hurt their families. I hate the idea that because some people take drugs and then do bad things that other people who take drugs and then don't do those bad things should lose their freedoms.
>Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
This is meant as levity, but I wonder if that is actually part of the justification...if a patient isn't willing to do this One Little Thing, see a doctor in person one time/get some other doctor to sign a form letter...well, then maybe they didn't need those Evil Drugs so badly in the first place! Problem solved. It'd be interesting to see data on how far the typical patient is from their teledoc - perhaps for most cases, it really is just an hour car ride or whatever. That doesn't justify the policy change, obviously, but it'd "make sense". Otherwise one is just left with rent-seeking and morality plays. A corollary to the classic: for institutions, it's Beware Others' Nontrivial Conveniences.
The point about testosterone prescriptions is pretty alarming, indeed. I haven't been to a physical doctor since covid arrived, but in exchange have had unlimited no-questions-asked electronic refills for years now...a massive benefit that I'm loath to give up. They better not reclassify estrogen.
Half-joking: just let us know how many subscribers you need to upgrade to "Founding" level to pay for that office. Sorry about the setback, I want to see the Lorien model prove successful too.
Doctors do seem to be very wary about Xanax; a few years back I got a week's supply (seven tablets) of the lowest possible dose to be spread out over months for the panic attacks I was experiencing. More than one tablet a month, and this would be considered Very Bad behaviour indicative of Possible Addiction on my part. I was given to understand that *very* firmly.
A year or two after that, I asked for a refill of same, and got "No, these are Habit Forming". So yeah: advice for the 3 a.m. face-clawing was "have you tried deep breathing?" (Yes, it doesn't work; alcohol does but my liver doesn't like it).
I absolutely see *why* doctors would be very wary because I do see *how* it could build up into a nice little habit, but at the same time I wish - ah well. I wish, I wish, I wish in vain.
My ex became an alcoholic for this reason. It very nearly killed her (still might as her liver doesn’t work great anymore) but even now her doctor doesn’t want to prescribe her everything she needs.
The concern with benzos isn't quite like the concern with Adderall etc., where prescribers are looking for Bad Behavior and judging you because they think you want them for the Wrong Reasons. Yes, certainly some small percentage of people actually use benzos for fun (usually to enhance effects or treat side effects of some other drug), but that's not what they're worried about when they try to ration you to one pill a month.
The real problem is that even people who take benzos for the Right Reasons, as directed, responsibly, to deal with real serious life-impacting anxiety symptoms, and who have absolutely no fun at all while taking them will *still* often become physiologically-dependent with regular use. This dependence manifests as an increase in anxiety symptom severity and frequency, which the patient understandably responds to by using more of their medication, escalating until they're constantly medicated and feeling worse than when they started.
Opioids for chronic pain have a similar effect (opioid-induced hyperalgesia), but the difference with benzos is that the withdrawal is far, far worse (and potentially fatal).
Some fraction of patients seem to get persistent symptom relief from regular benzo use for decades, but nobody knows how to predict who they're going to be. People with a history of addiction may be at higher risk of *misusing* benzos, but it seems like anyone could be at risk of dependence whether they're misusing or not. The only data points your doctor has to go on to predict your risk are how often you take it and whether the frequency is increasing; your character, maturity, responsibility, even the appropriateness of your use are meaningless.
It would be nice if doctors were better at communicating this to patients instead of making you feel like you're being interrogated and judged. (That's about the last thing people with anxiety disorders need.)
The problem with benzo dependence, specifically, is that it makes anxiety worse. Not like ADHD meds where you might be temporarily worse than baseline when you stop taking them; with benzos, you get worse while you *are* taking them. This happens in an insidious "one step forward, two steps back" way with each dose escalation, so it's hard to make the connection until you're so severely dependent that you can't get back to baseline.
The reason for this is that the sympathetic-parasympathetic homeostatic balance that benzos interfere with is a very, very high priority for the body, and it's also asymmetrical. Benzos reduce sympathetic activity, which is an emergency because it threatens breathing and circulation, so the brain responds by downregulating the affected GABA receptors. Benzo withdrawal increases sympathetic activity, which is a normal healthy response to an external threat, so the brain responds by looking for the external threat; the patient perceives this as anxiety and takes another benzo, which triggers more downregulation. So there's a ratchet effect.
We don't have a way to regulate sympathetic-parasympathetic balance with anything approaching the speed and precision of the brain's own homeostatic mechanisms, so there's no good way to help people who are dependent without weaning them off the medications, which is absolutely hellish.
" will *still* often become physiologically-dependent with regular use. This dependence manifests as an increase in anxiety symptom severity and frequency, which the patient understandably responds to by using more of their medication, escalating until they're constantly medicated and feeling worse than when they started."
Oh, I entirely understand the caution. I've seen it in a family member who developed a Valium addiction over years and was doing precisely what you describe: they got anxious about getting anxious, took another tablet, and the cycle went round again.
So I do get why my doctor only gave me seven tablets for an entire year and cautioned me, and I didn't immediately run back and say "Used them all, can I have more?" I know the potential for problems and was only going back a year or two later out of desperation.
Unfortunately, the "deep breathing, think relaxing thoughts" etc. advice to use instead of medication does Sweet Fanny Adams for me, so I end up self-medicating with alcohol which is *not* good and already *has* had an effect on my liver. Luckily the 3 a.m. clawing the face off bouts have lessened a great deal in the recent past, so I'm crossing my fingers and hoping they'll stay gone.
The panicky, anxious fits that come and go for no reason are another thing 🤷♀️ I'm doing an online CBT course at the moment and going slowly through it, so maybe that will help.
Although I already hate it with the 'mood map'. Keep a record of what you're feeling, when, and what triggered it: bitch, if I *knew* why out of nowhere, for no reason, with no stressors, I suddenly get the panic fits, I wouldn't be doing this course in the first place. I just have to grit my teeth and keep on with it, though; maybe the later modules will actually be some help (the deep breathing, mindfulness, etc. jazz does nothing for me, as I said).
You may want to investigate psychedelic-assisted psychotherapy treatment options.
Not a doctor. Don't take medical advice from just me.
“To help you remain tranquil in the face of almost certain death, smooth jazz will be deployed in 3… 2… 1…”
>self-medicating with alcohol
Ouch. Yeah, that's basically the same thing with added toxicity.
>bitch, if I *knew* why out of nowhere, for no reason, with no stressors, I suddenly get the panic fits, I wouldn't be doing this course in the first place
I think you might be overthinking it. The point is to identify what triggers the anxiety spiral so you can hopefully learn to interrupt it before it escalates. If the first thing you notice is an out-of-nowhere sensation of shortness of breath, or your heart racing, or a general sense of impending doom, then that's the trigger.
Panic disorder exists at the intersection of psychology, neurology, and pulmonology, where a disruption in the mind, the sympathetic nervous system, or the arterial blood gas balance can throw all three into a positive feedback loop with each other. Some people's triggers are obviously "psychological" - people with PTSD may have panic attacks in response to reminders of their trauma - but many panic patients are reacting to physiological sensations. (There's some lack of clarity on whether it's "normal responses to abnormal stimuli" or "abnormal hypersensitivity to normal stimuli," but it's not that important for treatment.)
>deep breathing
The common "deep breathing" advice may actually be counterproductive. It's good for generalized anxiety but often bad for panic attacks.
One of the systems that's malfunctioning in panic disorder is the regulation of blood gases: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937087/
The body uses CO2 as a proxy for blood oxygenation. Either high or low CO2 can provoke a feeling of shortness of breath. The extreme anxiety that distinguishes panic disorder from other anxiety disorders is driven by a real, physiological signal of suffocation that is very literally not in your head. You can't think your way out of it directly any more than you can think your way out of the panic of real suffocation; you have to stop the signal.
The evidence of blood gas involvement in panic attack onset is mixed, probably reflecting heterogeneity in the disorder. Some patients have low blood CO2 at baseline, which suggests hypersensitivity to blood CO2 such that normal levels may trigger panic attacks ; others seem to be normal at baseline, but low immediately before a panic attack triggered by psychological stimuli; others have normal levels at baseline and panic in response to low levels; still others have normal levels at baseline and panic in response to high levels; and there may be some people for whom CO2 doesn't play an important role. That's why there's so much variation in responses to breathing techniques for prevention/early intervention. Some people can stop a panic attack before it starts with deep breathing.
But during a panic attack, patients are almost always hypocapnic (low blood CO2) as a result of hyperventilation. Hyperventilation in a medical sense just means that you're breathing more than you need to for your current level of metabolic activity; it can take the stereotypical form of short rapid breaths, but it can also be accomplished by deep breathing. (For example, the measured deep breathing of a distance swimmer doesn't *look* like hyperventilation, but it removes far more carbon dioxide than you can generate sitting on your couch having a panic attack.)
So once you're already panicking, the breathing interventions you're looking for are ones that *increase* blood CO2: slow breathing, breathe-hold-slow exhale, the old paper bag trick.
You can also kill two birds with one stone by holding your breath and immersing your face in cold water (under 50F/10C) to activate the diving reflex https://en.m.wikipedia.org/wiki/Diving_reflex. This will both increase your blood CO2 and downregulate the sympathetic overactivity that's driving the hyperventilation.
"Where a disruption in the mind, the sympathetic nervous system, or the arterial blood gas balance can throw all three into a positive feedback loop with each other
One of the systems that's malfunctioning in panic disorder is the regulation of blood gases: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937087/
The body uses CO2 as a proxy for blood oxygenation. Either high or low CO2 can provoke a feeling of shortness of breath. The extreme anxiety that distinguishes panic disorder from other anxiety disorders is driven by a real, physiological signal of suffocation that is very literally not in your head. You can't think your way out of it directly any more than you can think your way out of the panic of real suffocation; you have to stop the signal."
Thank you for this, this answer is a lot more helpful to me than anything my doctor has said - they do seem to treat it all as psychological rather than physiological, and I do notice breathing problems/feeling like I'm gasping for air as one of the lovely, lovely symptoms when I'm freaking out 😁
>they do seem to treat it all as psychological rather than physiological
They do that 😠
I think the problem, besides the hammer/nail phenomenon, is that panic disorder has some superficial similarities with health anxiety (hypochondria). If you tell someone with health anxiety that there might be something physically wrong with them, you're reinforcing their fears, and they tend to get worse; I think there's an assumption that the same is true in panic disorder. So the standard of care is to emphasize that there's nothing physically wrong with you, you're going to be fine, your symptoms are purely psychological, and the treatment is therapy to correct your maladaptive thought/behavior patterns.
That does seem to work for a lot of people. But it doesn't work for everyone. Some people respond much better to the nuanced understanding that there *is* something measurably abnormal going on with your physiology, but it's not dangerous; it's just triggering a false alarm in a system evolved to keep you alive in low-oxygen/low-CO2 environments, and the treatment is still therapy, but the goal of therapy is to learn to recognize the false alarm early and stop your instinctive response to it.
I suspect that people who hang out here are more likely to be in that second group.
From the past experience as a low-level government minion: surprisingly, this is not because most regulators are Dolores Umbridge and wake up in the morning wondering what new and special ways they can make life miserable. (Some of 'em do it anyway, but it's not out of malice, it's because they have lovely shiny top-down policies that won't work in practice at the coalface, and they resolutely will not listen to the front-facing low-level minions about how it won't work and this is why, but that's a different argument).
It's down to bad actors. It's the people who will abuse telemedicine to feed a habit, and the pill-mills that will set up to take advantage of it, and the dodgy imports that others will set up to provide for the pill-mills to prescribe. One case of an addict who dies because a shady operator prescribed them something that came from China and was cut with all kinds of shit*, and there will be media coverage of the sobbing parents/partner and cute kid, grave thinkpieces online, and probably some current affairs hour-long documentary about the scourge of online telemedicine and how the government is doing nothing about it. Then come the ambulance chaser lawyers egging on the family to sue the relevant authorities for $$$$$$$.
*https://www.reuters.com/article/uk-china-pharmaceuticals-idUKBRE87R0OE20120828
Cue politicians freaking the hell out about upcoming elections in their constituency where the person comes from/died, and you get regulations like this.
Scott is legitimate, scrupulous, and knows what he's doing. On the other hand, you have Dr. Teetus Deletus out there practicing medicine:
https://www.facebook.com/drsidhbhgallagher/videos/teetus-deletus-my-new-fav-term-i-cant-take-credit-this-was-from-alexx_kpopstan-o/2681426892072067/
Tangential to all this, I am envious: you can get your doctor (or some medical professional) to speak to you on video call and prescribe medicine? I am currently remembering when I got Covid; my GP told me that if it got bad, I could go to the emergency department of the regional hospital and get Paxlovid.
One bout of coughing so bad that I had to get a ride in the ambulance down there later, the ED told me "Yeah, there's nothing we can do for you". What about Paxlovid, you ask? Wot dat? But they did give me a chest x-ray, told me that was fine, then packed me off home to get better on my own 😁 I think the oxygen I got via nasal cannula during the ambulance ride down helped more than anything.
So yeah - all I can do is gape, awe-struck, at the advances in American medicine, even with the shackles of government regulation weighing it down!
That sounds like regulators take the most risk averse position given their options.
Oh, wonderful pun. The opposite of malloc is free. :D
Still some C programmers around I see. :)
Motto: collect your own garbage!
Why would you expect anything else? There is no praise, only blame.
Of Moloch it is written, "He always and everywhere offers the same deal: throw what you love most into the flames, and I can grant you power." We think of Moloch as huge and terrible, with giant "fingers of armies" and you have to look up and squint to see his "skyscraper-window eyes"
But Moloch is small, and he's a multitude - he's a tiny little parasite that sucks on your soul at a rate you can barely notice, and we're like those deer you see sometimes, late in the summer, so covered in ticks that their skin sags and they can't see and they stumble to the puddle for a small drink, just enough to keep them alive. Awe-struck indeed we should all be, at the strength and determination of humanity as it struggles mightily to put one foot in front of the other. Fuck disease and obesity, the biggest killers? Fuck depression and anxiety, the biggest miseries? Fuck poverty and war, the biggest injustices? Nah, fuck moloch and all the rest falls easily away.
I’d argue the Dolores Umbridge comparison is actually apt. Umbridge doesn’t want to make life difficult for everyone. Only the naughty children that deserve it, and she doesn’t care about the cross fire. Regulators only want to punish naughty people and they similarly don’t care about the cross fire.
I like the happy ending where she gets raped by a herd of centaurs. I sometimes read that when I'm annoyed at regulatory agencies.
We have no proof in from the text exactly what they did to her; it was unlikely to be that. But whatever it was it seems to have traumatized her pretty well, at least for a while.
The forms must be obeyed. It is still a children's book series, so it's not spelled out explicitly on the page in graphic detail (because if it was just stated, you'd say that wasn't proof because the character saying it could be lying or mistaken), but it's a classical allusion as clear as any.
Hmm… I can’t help but think centaurs would think that humans are too “gross” so they prefer other ways to punish them without having to profane themselves with that kind of human contact.
Glad to see my senator (Warner) on the right side of this.
Meanwhile, the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act.
Don't worry, though - the DEA has said about this proposed rule that it feels this will be 'less burdensome' for providers than any kind of special registration, so it feels it has discharged its legal responsibility to create a special registration process.
I am a psychiatrist having to deal with this idiocy with my patients too, and renting an office temporarily is not going to cut it. So I am going the letter route. I will probably a lose a reasonable chunk of patients I was prescribing controlled substances to. The only possible saving grace is that PCPs in this country are used to being asked to sign and complete all kinds of nonsense forms and documents so probably most of them will just do it with minimal fuss.
I'm more concerned with the new requirement that all telemedicine scripts now have to be recorded by the prescriber with the date and time they were written, the PHYSICAL ADDRESS of the prescriber and patient at the time of the telehealth encounter, and have an explicit note on them that they are telemedicine prescriptions. I am less concerned about PCPs balking at writing an idiotic referral than I am skittish pharmacists refusing to fill scripts that they might interpret as being labeled equivalently to FAKE SCRIPT FOR DRUGSEEKERS
Bureaucracies just deciding not to do what the legislature tells them to do is why I can't agree with those who argue for the legitimacy of the delegated administrative state on the basis of those agencies being authorized by said legislature.
one would imagine that doctors who want to prescribe controlled substances remotely would have standing to sue the DEA for failing to promulgate a regulation. i wonder why this has not been done
Sovereign immunity largely means that you cannot sue the federal government unless the federal government consents to be sued.
the administrative procedures act waives sovereign immunity with respect to agency actions (5 USC §702), including "failure to act." a rule is an agency action (5 USC §551) so it seems to me like not making a rule they were supposed to is judicually reviewable. but I'm not a lawyer and dont really know anything about law, so idk
I think the real issue is that the best possible outcome for the one filing suit would be a court order to comply with the law and promulgate a regulation. This would be somewhat satisfying from a moral standpoint, but probably wouldn't result in an actual regulation.
It's a complicated problem with no easy answer. If chemists get trained that the new regulations require this level of detail, that may help. Part of the problem is trying to disentangle legitimate prescribers like yourself from the dodgy pill-mills, and that's not easy.
Unless the government throws up its hands, say "to hell with it, Adderall for everyone!" and doesn't put any control on such substances at all, there is always going to be the fumbling attempts to strike a balance.
And even back in 2007 this study found:
https://substanceabusepolicy.biomedcentral.com/articles/10.1186/1747-597X-2-32
"Compared to studies examining the prevalence and correlates of nonmedical ADHD drug use, fewer studies have specifically examined dimensions of access and motivation for NMU of ADHD medications. McCabe et al. reported that in a sample of middle and high school students in the Midwest, over 23% of those with a prescription for an ADHD medication were approached to sell, trade, or give away their medications. This finding is confirmed in the 2005 NSDUH, which found that most persons who used prescription stimulants (excluding methamphetamine) nonmedically in the past year received them from friends or relatives for free. Some studies have examined associations between NMU and psychological factors, including ADHD status to identify possible motivations for use. For example, a clinical case-control study by Wilens and colleagues based on ADHD diagnosis (N = 186) found that 36% of the sample reported use for self-medication, 25% used ADHD medications to get high, and 39% had unknown motivation. A community-based study at a single university found that nearly 25% of those with ADHD reported use of their medications for recreational purposes. Yet, much of the literature points to NMU of prescription stimulants for performance enhancement. Teter et al., in a study at a large, midwestern university, found that prescription stimulants were used primarily for performance enhancement, although use for feelings of euphoria (e.g., getting high) also was noted. These studies, while primarily limited to regional populations, suggest that peers are a common source of diverted medications and that performance enhancement or self-medication are important motivations for NMU."
'Just ring this number and answer a few simple questions and our qualified doctors will write you a prescription, sight unseen' is only exacerbating that. It's not even people trying to source party fun substances that, to me, seems to be the huge problem; it's a society where "unless I'm drugged up to the gills I can't concentrate enough for the study I need to do in school or the focus I need for the productivity demands of my job".
We talk about the Asian grind schools where kids spend hours upon hours doing homework and extra study for years to get into the universities to get the good jobs, but American society seems to be every bit as grinding, only with added chemical enhancement.
Well, that's actually pretty much my position. I feel that the "war on drugs" has done more damage to society than the drugs ever did. Make all (non-antibiotic) drugs available for purchase (at least for adults), and have "truth in labeling " laws with teeth in them that are actually enforced. You'll have lots of damage from improper use of drugs, but, I believe, less than the regulations have caused.
Maybe I'd agree to this for non opioid drugs if we also get to execute all the heroin and fentanyl dealers. 100,000 overdoses last year. It must end.
It's a pretty clear supply and demand issue: the *reason* opiate deaths have skyrocketed is *because* pretty much all doctors refuse to prescribe them now, driving people to amateur street pharmacists, all of which have fentanyl contaminated products.
This is a demand issue - the demand for strong painkillers will literally never go away. Further, addict's demand is famously inelastic too. That demand is a particularly personally motivating demand too, so people in actual pain or addicts aren't just going to give up when you make all safe and pharmaceutically pure opiates impossible to get.
There would be nearly zero opiate deaths if addicts and people in pain could buy trusted pharmaceutical pills, wether due to legalization or due to doctors actually being willing to hand them out.
But people are morally panicked about what people do to their own bodies, and regulators have stepped on doctors to drastically restrict scrips, which has led to people in actual pain and addicts turning to illegal drugs and dying in droves. There's a very obvious solution, but people can't stand the idea of people in pain and addicts actually getting what they want, so they'd rather (indirectly) kill them.
also legalizing ibogaine might help
I think the difference between Asian Grind culture and USA education culture is the USA has a smaller "grind" population - if your parents are the sort who wait years on a waiting list to get you into the right preschool, you're on the Ivy League track and need Asian Grind level of commitment plus chemical enhancement.
But if you're just a regular Joe, and are planning on community college or state school, or even no college, then it really doesn't matter, and you're free to eschew homework and chemical enhancement if you want.
I'd imagine the split is probably 80/20 or 90/10 in the USA (Ivy is less than 1%, but it's really more the mindset of the parents, and I'd bet at least 20% of US parents are on that bandwagon).
Having lived in various Asian countries for years, I'd estimate the Asian Grind % to be something like a third to a half, so call it 40%. Thus Asia has 2-4x the "grind %" of the USA, as a high pass estimate, but those 10-20% who have to grind in the USA generally end up chemically enhanced just to compete, because the field is generally very chemically enhanced, much like Tour de France competitors prior to the Armstrong scandal.
why is the "drugs for those who want them" such an unacceptable thing?
Thank you for alerting us to this shitty legislative development. I commented, though I share your skepticism that it will do any good.
It's not technically a "legislative development" as it's the DEA rather than the legislature making this decision.
Are *any* decisions actually made by the legislature any more?
Symbolic resolutions :)
...and how much of this regulation is the AMA lobbying to keep doctors doing everything?
The key is that "That'll be $200 please." This removes any incentive for doctors to make things easier.
The AMA has been pushing fairly hard for an easier telehealth registration process for many years now. They are also quite vociferously opposed to this proposed rule.
Doctors can be as venal and rent-seeking as anyone but this is very much coming from the DEA. It makes physicians' lives significantly harder.
If telemedicine becomes routine you will get insurance providers saying "it doesn't cost you as much to see a patient using Zoom, we won't reimburse you as much."
Followed by "If it's over Zoom we don't see why it takes a doctor to do it."
I admit that seems to be an alliance (conspiracy?) between the AMA and the DEA (and all the other 3-letters...)
On second thought both "alliance" and "conspiracy" are too strong in terms of indicating intent. Call it "aligned interests" - which makes it much harder to prove wrongdoing in court, yet is more effective in ensuring people continue to act.
telemedicine still requires a doctor, so no doctors are cut out of the process. if you want to make a medical rent seeking argument, i think it should go something like this:
if you are the only doctor in town, you have significant market power; you can charge higher prices for the same quality of service. traditional providers have to actually live near the town they are serving, so it is not so easy for competitors to enter your geographically segmented market and start offering lower prices/better care. but telemedicine providers can live anywhere, so they can compete with doctors in any market. having to live near the town is a costly (but not necessarily financially costly) barrier to entry; removing this barrier potentially weakens doctors' market power.
i don't know if i believe this story. another commenter notes that the AMA favors telemedicine, and anyway i havent fully thought through the model i describe above, but that's what comes to mind
Agreed. The AMA exists for the purpose of maximizing its members' income. Look for them (and the bar associations) to push back *hard* against any use of AI for diagnosis.
In my province (Canada) we have lots of telemedicine but no prescribing restrictions. However, all scripts for controlled drugs are copied to a central prescription monitoring programme, via one part of a triplicate prescription pad, and if you prescribe a lot to a patient, escalating amounts to a patient, or the drugs to more patients than other doctors in your speciality, you will get, first, a warning with a request for an explanation. Then follows a practice assessment where your records are examined to check appropriateness of prescription and whether you follow guidelines for alternative treatments, used patient contracts etc. If you are felt to be abusing your prescribing privileges, this then escalates to a complaint to the licensing body and usually you lose the right to prescribe narcotics after that, and have to place a notice of humiliation in your waiting room saying yo cannot prescribe these drugs.
It sounds intrusive, but it is actually easy and extremely effective at making us think before prescribing.
"It sounds intrusive, but it is actually easy and extremely effective at making us think before prescribing."
I do not notice a contradiction.
That sounds like the thing you'd actually need to do to tell the blatant pill-mills from the legitimate doctors: allow them to do their thing for a while, and then observe what they do. So, from your experience, this works well?
Relevant enforcement agencies in the government already have all these prescribing data for controlled substances in the U.S., too.
Yes, but it would be best to also track the patients that get the same prescription from multiple doctors. No sure what you should do when you'd found the "abusers" though.
This is absolutely tracked, at least in most US states, and doctors and pharmacies can pull up a score of how likely a patient is to be an abuser.
Unfortunately sometimes people get flagged by the system for the wrong reasons (legitimate hard-to-diagnose chronic pain also results in going to lots of different doctors and asking for pain meds) and then no one will prescribe to them because their score is high.
Yes, it does. The triplicate prescription can be mailed to a patient, but cannot be phoned in to a pharmacy. I didn't say it, but patients are tracked too, and it's not uncommon to get a warning that you have prescribed to a patient with an abnormal profile. No consequences flow to the physician unless they keep prescribing to someone who is either abusing or, more likely, selling on. That generally happens via an ER visit, when a stranger comes in with a painful complaint and sees a doc he has never seen before and fools him for one script. At the time I retired, the programme kept track of all narcotic/opiate scripts, barbiturates, and stimulants. Not benzodiazepines though.
Here in Ohio, perhaps the whole US, all registered substance perscriptions have to be made via a centralized computer system. Further, by law your prerscriber must check this database before prescribing such meds. Si, the government does have a centralized database of such perscriptions without needing a time consuming paper records recording and searching step.
We have a database like that - in California it's called CURES. I've never heard of people getting in trouble for overprescribing on it, but that could either be because they don't monitor or because I haven't tripped their alert yet.
I do something get letters from insurance companies asking if I really meant to prescribe X and Y drugs together. They are 90% dumb but sometimes they actually catch something.
I've been to three psychiatrists in Alberta and haven't been able to get a trial of Adderall. I supposed that this had something to do with The System but had no way of getting any information about how The System works. I am certain I have ADHD, but I can only get atomoxetine for it (which doesn't work).
I am wondering if every new psychiatrist decreases my chances of diagnosis and treatment (including the one that seemed to have a strong dislike for all medications as a rule, and scolded me for having daytime naps, and the one who said that I needed nonexistent proof from my childhood report cards in order to be diagnosed ... the third one said I "had the symptoms of ADHD" but didn't give a diagnosis for whatever reason.)
Will each new one be able to see my history and say "well the last N doctors didn't diagnose you, so clearly you don't have ADHD"?
Please take all of these comments and this article and post it on the open comment period for the dea telemedicine rule on regulations.gov
He was white as a sheet
and he also made false teeth
Hah. Took me a moment. Well done.
Posted my comment on this proposed rule because my telemedicine doc just ended her relationship with me over this rule (she evidentally had concerns re maintaining her license and felt pressured given she has some longtime patients and is transitioning her practice) and I'm scrambling to find something local that I can even remotely afford. It's doubly frustrating because if the issue is docs who overprescribe, with scheduled drugs that's already tracked, the government doesn't need to dun the patients to suss out who these uncareful docs might be. Plus we all know this is about opiates/opioids, not drug abusing psych and weight loss patients, two groups that benefit highly from the access to telemedicine. Anyhoo, comment made. Would that our government overlords who I can't vote out of office weren't drunk with their own power and would actually listen.
I agree that this probably isn't a good or useful regulation. But I found myself more concerned about the way that you assume that there is nothing that you will learn from your patients in person that you are not learning from them over zoom. I find that I learn much more about people in person than I do over zoom and I expect that for a trained and professional observer of people that the delta is much larger.
I can certainly see how this law can be inconvenient and potentially damaging to you or your patients, but it also seems that there is an opportunity to be seized to learn more about your patients if you don't regard these visits as simply a perfunctory checking of boxes. If you think that the regulation is a bad regulation then you are right to fight it, but don't get so distracted by it that you miss the advantages that do come to you.
This would be true in general, but California still requires that doctors and patients both wear masks throughout an in-person appointment. A video call is actually better for seeing someone's facial expression.
No it doesn't. I've been to my physician a few times recently, and nobody wore masks. Pretty sure she's careful to stay on the right side of the law, too.
Wow remember when Cali seemed like the future instead of the past? Strange days.
Anyway, I think that the point still stands though certainly becomes more debatable. Body language and context awareness I suspect still make more complete observations in person reasonable.
For many people the choice isn't to see their doc on zoom OR go into an office. Its see their doc on zoom or NOT see a doctor at all (for a variety of reasons). For these patients, the doctor would learn nothing from seeing them in person because the patient wouldn't be there.
How did these people see doctors before the pandemic? Have they become so enfeebled in 3 years? Has all of the social support that was previously relied on fallen apart? If so, why?
There are many possible reasons someone wouldn't see a doctor in person but would via telemedicine:
They didn't have the condition until telemedicine was available
They live far away from a doctors office
Scheduling an in person appointment is difficult given family, work, or other responsibilities, but a telemedicine appointment is easier to schedule
Their condition makes scheduling any type of appointment difficult but telemedicine is much easier. This applies to many psychological disorders.
They don't have access to reliable transportation to get to an appointment on time.
These are just a few i thought of when typing this response. But the general point is we can't know all the reasons people do things and there will always be people who have difficulty accessing medical care. Why should we create unnecessary hurdles for them to access it?
The suggestion that there is no solutions but this one available is clearly not true though. People have been solving this problem without telemedicine for a long time. You said that the choice was telemedicine or go without medical care, I think that you are backing down from that as hyperbole. So my work here seems to be done.
Maybe words like "most" are hyperbolic, but there absolutely are people who would just never seek care in-person.
The point is why are we okay with an unelected arm of the state deciding that some routes to care are too convenient?
How did these people get help before the pandemic when there were similar restrictions? To suggest that something is indispensable, that no alternative exists, to something which has only been in place for three years, strains credulity.
PS If you don't want psychiatrists and liberals in general to be accused of an unreasoning hatred towards Christianity you should probably be more judicious in your use of antiChristian tropes when describing everyone who is skeptical of mind-altering drugs.
I’ve been a primary care nurse practitioner in the Bible Belt for 20yrs and not once have I even heard of a provider telling a patient they should substitute religion for psychiatric (or any) medication. It’s so easy for some people to throw around these tropes as if Christianity is some exotic, weird tribe with horrifying anthropological traits.
I am a young Christian--in my life, I have
-been told by my PCP not to get an IUD because it carries "a significant risk of causing infertility or death"
-had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient
-been told by a therapist to discontinue the SSRI a different provider had prescribed and just trust in the man of the house
the PCP wasn't even particularly Christian herself, but since all of her patients are she hadn't updated on IUDs since the scare back in the 70s. Our horrifying anthropological traits become everyone's problem--it might be worth listening to those who "throw around these tropes" so you can understand what they have to deal with
That’s a far cry from Psych Meds Aren’t Real You Just Need Jesus
Once you get people hating you for a legitimate reason, they stop being careful about other reasons that agree with their feelings.
And there are LOT of people with legitimate reasons to hate "Christians". That was in quotes, because though the term was used to describe them, they do not fit my idea of what the character described in the synoptic gospels would consider appropriate for a follower. Unfortunately, that characterization applies to most of those who loudly proclaim that they are Christians.
Well yeah anybody who hates a group of people thinks it’s justified. That’s the whole thing. So the target group can reply, and then others can debate the rational basis of the hate, and we go on commenting. Welcome to this particular instance.
A lot of people feel that they’re justified in being prejudiced against certain ethnicities or races due to their experiences and various statistics. Are you arguing that they are being quite reasonable—the only thing wrong with their argument is that objectively ‘most’ of the group they hate doesn’t uphold their prejudice? In that case, if it was pointed out to you that the very loud groups you point to do not constitute ‘most Christians’ but rather the ones that the media chooses to highlight, would you admit that your position is ill-considered?
Or, on second thought, might you consider that prejudice is actually *inherently* wrong, even if some stereotypes have a kernel of truth?
There’s two roads to go down here and retain some dignity to this conversation, rather than continuing to gather momentum to go down the low road where specific prejudices are approved.
Prejudices are just strong priors over socially sensitive categories; any apparent "inherent" wrongness is an artifact of current social consensus.
if a prejudice ia a prejudgement based on someone holding ideologival beliefs you disagree with, then no.
For example, police officers beleve it is justified to threaten people's lives to enforce the laws the state has passed and be paid to regularly do so. That is an inherent part of the job description of being a police officer. Since think such a person who acts and such on beliefs is committed to actions I consider fundamentally unethical, then no, judging them for such is not inherently wrong.
This applies to any set of beliefs someone has where a person in is fundamental disagreement. Depending on which side of the abortion debate one is one (simplifying to two sides for the sake of argument) then one judges the other side as either promoting the murder of infants, or on the other side, seeing abortion doctors killers as murders instead of heroes. Again, based on your ethical priors, these judgements are fair if you truly believe the actions they lead to are unethical.
Prejudice is nothing more than a heuristic *you* don't like. If you want to ban heuristics, you are insane. If you merely want to ban only the heuristics you don't like, you are insane. If you expect me to believe you operate in the world without heuristics, you are insane. If you want me to operate in the world without heuristics, either give me a palantír, or fuck yourself.
For some general orientation, you can park my assertion next to Sailer's: "political correctness is a war on noticing".
A Christian is by definition a failure- a Sinner saved by undeserved Grace. Bad behavior is implied. So the stereotypes have some legitimacy. Actually a stereotype is the classic example of the wisdom of the crowd, which perhaps suggests why the current trend of croqdsourcing said wisdom has pitfalls that its eager adopters haven't considered.
But social Christianity was the dominant ideology of this country for two hundred years and attracted the sorts of people who are always attracted to the dominant ideology. It will be interesting to see what happens to the purity of the church and Christian morals as we transition from an establishment religion to a persecuted religion
I disagree. There are certainly a lot of churches that promote that doctrine, but I don't believe that it is implicit in the synoptic gospels. If you want to say instead "a Christian admits that he has (in the past) failed, I'd agree, but that's a very different statement. The idea of "undeserved Grace" is something that was not implicit. Perhaps the Grace was deserved? Who are we to say. Even saying it was Grace isn't implicit. If I fix a program, I don't consider that I'm gracing it. I'm fixing it for my own reasons.
Actually, I'm not a Christian. There have been too many instance of people calling themselves Christians while in the midst of doing horrible things, and being approved of by the "Christian" community, so I can't stomach identifying with them. But as long as folks act in harmony with the synoptic gospels, and don't consider individuals or groups "godly" who do horrible things while calling themselves Christian, I have no real qualm about liking them ... if they're willing to shut up about how great Christianity is.
So your doctor told you that medicine has possible complications that you disagree with the doctor about, and a therapist encouraged you to deal with interpersonal problems without the use of medications. If you want us to see these as horror stories we need a little more detail. These seem pretty ok. Now I do think that a pharmacist should fill a prescription unless there is a chemical or statutory reason not to, but i can't say that I am hugely knowledgeable about that.
Interesting, I have had several patients describe this happening to them.
I certainly wouldn’t say it doesn’t happen, because there are quacks everywhere. I will say that neglecting spiritual health (any kind of spirituality) can be a problem for any average human but as a Christian among many such providers there’s a pretty dark line between practice and prayer, so to speak. Doing a spiritual assessment in a health crisis can make sense but it should be done very objectively.
Surely something as simple as referring an alcoholic to AA, for example, wouldn’t fall under this You Just Need Jesus accusation?
yes it does, because AA doesnt actually deserve its stellar reputations for many reasons, including they dont keep any records, so their success stories are cherry picked and tautologically, anyone who wasnt helped by AA wasnt "ready"
A treatment plan that calls itself the most successful but discounts the failures as not being the responsibility of the treatment plan is problematic.
Furthermore, the twelve steps are logically inconsistent. One has to admit one is powerless over their addictions, but take personal responsibility.
If one is powerless how can they also be personally responsible? why is belief in a higher power a precondition of success?
In fact, the histtory of AA, it was NOT founded to treat addicts but as a means of converting people to christianity. It was only later on that the "higher power" wasnt specifically the christian God. Originally it meant "any form of christianity is legitimate" but was explicitly desinged as a missionary program and part of it strategy was to insist on tis members declaring it to be the "one and only true way"
We just cant compare whether secular programs or other interventions are equally effective because the only available data come sfrom promoters of AA and has vague definitions for failure as people had to be "ready" or they couldnt succeed
Actually the primary literature says they don’t have the market cornered on treatment. Also I know many atheists who are sober in AA. There was a study on 12 Step outcomes within the last few years but you’d have to look it. Success rates among low bottom addicts and alcoholics are pretty dismal so as a “last house on the block” option it seems to have usefulness. The point is spiritual solutions are not unheard of.
Does it seem necessary to needle Christians in particular in order to make your point or could you have made the same point while only needling the group of people who believe that psychiatry isn’t real?
It’s illuminating to me that of all the possible manifestations of psychiatric malpractice that the mentioned scenario is the “worst case”.
well... its kind fo an obvious one. A psychiatrist who suggest the answers to yor problems isnt medication or therapy but to convert to their religion seems to be very much doing malpractice.
If you want to make an argument that your religion is the answer to psychiatric and psychological problems, fine, your free to do do, but dont claim to be a psychiatrist and do it under such auspices where the person was expecting a secular analysis and treatment in accordance with the principles of modern psychiatrist.
imagine you went to doctor for panic attacks and he told your problem was you were being punished by Allah for being a infidel and you needed to repent and follow the one true god and he prescribed daily prayers to Mecca
I would imagine you would not be happy if that was the guy youre insurance sent you and that was his "psychiatric" advice
I thought so too. Scott is a devotee of pharmaceutically assisting mental problems and has a right to complain about his experiences with people who disagree with and make his life inconvenient.
But there are certainly plenty of reasons to be suspicious of 'better mental health through pills'. I look around and notice that we havent arrived in the Golden Age of Sanity and Happy People despite several decades of mass medication and a hundred years of psychiatry.
I would have thought that in San Francisco the particular reason that Scott called out for rejection of psych meds would be one of the less common ones he would hear. It certainly came across to me as a signal of the antireligious and particularly antichristian bias that psychiatrists are always accused of and usually deny. Maybe Scott is comfortable with that bias and would not deny it. I don't know, he is a pretty unique guy.
„ I look around and notice that we havent arrived in the Golden Age of Sanity and Happy People despite several decades “ of religion
There have been obviously millenia of Judaeochristian thought. That is the control. About 100 years of psychiatry, 30 years of SSRIs, 10 of crosssex hormone availability. Those are the experimental cohorts. Are the experimental interventions improving mental health? Haven't we had them long enough to do some cost-benefit analysis?
to be fair, i dont think any religion that i know of promises it will bring earthly happiness to people
Tbh, it seems more significant to me that people are reacting so strongly to an off the cuff example of a thing that does sometimes happen even if it is not representative of the majority of christian doctors
What do you suppose it signifies?
So common in tech-y West Coast circles. My firm is the same.
Most of these unpleasantness land just barely on the side of being insults, but insults that could be defended as “I meant the *crazy* kind of Christians.” (The anti-abortion types, or the people who have revivals, or something.) So you don’t really get an apology as the person insulting you feels justified in what they’re saying.
Of course, if you place it in another context that wouldn’t fly: a sophisticated person would never defend an insult of e.g., women by saying, “Oh, I didn’t mean you, I meant the *crazy* kind of women.” (The kind who protest, or something.)
To which you are expected to smile and separate yourself from the crazy types, which of course I (seem to) do. It’s my career at stake, I’m not going to fight a losing battle with HR. I suppose I should document this stuff in case I ever get laid off, but that just seems vicious.
but women are a biological category of person and christians are people with beliefs and ideologies. thats apples an oranges.
Judging someone on immutable biological circumstances of their birth is different from judging them on their beliefs and values and the actions and attitudes that result.
If they were judging my group on our belief in God, rather than some other accessory beliefs or behaviors that they impute through guilt by association, that might even be ‘fair,’ even if it’s textbook prejudice.
Certainly I think the values in this country promote tolerance and diversity of thought, and therefore people should not pride themselves on being prejudiced in ways that are acceptable or fashionable.
This is a shameful position, in my opinion, but if you sleep fine on it, sure.
What are you referring to?
'And that’s the best case scenario! The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else. '
What is the correct way for Scott to report on his patient's experiences with such physicians without being "anti-Christian"? Or do you think talking about these experiences is inherently problematic? Genuine question.
Remove ‘because you just need Jesus’ and thus avoid the obvious prejudice of saying anti-empirical attitudes are all coming from one religion.
Removing unnecessary prejudices is not hard, dude.
I think this is a case where Christians are reading it as "this this one source of this" whereas i think people like me are seeing it as a stand in for any thing like "Psych Drugs arent real because you just need to meditate" or "Psych drugs arent real because you need to clear your engrams"
Which of course raises the question: if this simply signifies all irrational reasoning, why is Christianity singled out by name?
Would you dismiss this as ‘just an example’ if the context was picking out, say, Jews? Or would you say that singling them out was unnecessary and inflammatory?
It's also the kind of language policing and offence-seeking that in other contexts in this readership would see people complaining of wokism. Not necessarily the same people who are complaining here of course.
again though, i dont see how "prejudices" are wrong if they are about people;s beliefs and the thought processes that derive from such beliefs and morals
I'm skeptical that he has heard that from another medical provider. I believe he is deriding everyone who is skeptical of psychiatric medication for whatever reason under a hate inducing trope.
If Scott would like to share a nonprivileged/anonymized instance where that happened in a nonprejudicial way I think a lot of people would be interested in reading it.
I think it interesting that someone happy to write about "the Men in Skirts" with "their perversion and corruption" is now come over all faint at the idea of hate inducing tropes. Man up.
I am not ashamed of what I said. The men in skirts are revealed over and over as child abusers, as destroyers of women, as borderline personalities. My statements are fact based. That group has an absurdly high rate of violence and hate. I hate the hateful and destructive.
Being disparaging to everyone who disagrees with mind altering drugs as the solution to interpersonal problems is not equivalent. False equivalence is a shield used to make good men and women do nothing in the face of evil.
Those are one of those tropes that usually bother me but that for some reason didn't when I read Scott's post. (In fact, I had to read onto the subthread to remind myself of what had been said in the post.)
But now that you (and Mike) bring it up, I agree with the general point, even though I take Scott's use of that trope to be a throwaway humorous line. I work in an academic-adjacent field in which it's very acceptable to casually make fun of or denigrate Christians. (Not all Christians, of course. Just the ones who decline to observe a Christianity that takes no political or cultural stances that disagrees with my colleagues.)
That rankles me. I grew up in a religious environment, even though I no longer really profess Christianity. I still feel defensive when I hear those types of tropes. Maybe I shouldn't. I realize that in the US in general, Christians aren't really an oppressed group, even if they're largely unwelcome in certain work environments like mine. And even if I can't help being defensive, I'll cop to being able to shake it off and deal with it. It's a medium deal, not a big deal.
If they are oppressed in your particular local environment isn't it reasonable that oppression in other localities is more extensive than you suspect?
That defensiveness when you hear those tropes is a good thing. It's a reminder that the people around you are willing to be mean to others who don't meet an ideological purity test. As time and the prevailing moods in academia shift, I would not be surprised if some portion of the people around you end up not agreeing with the group ideologically anymore--and that portion may include you. I'm glad that for the moment it doesn't--being shunned for ideological reasons in the workplace (especially in academia) is awful. Good luck and I hope it remains a medium deal for you.
We should approach things from a sensible standpoint. The whole system of prescriptions is founded on the basis of doctors knowing what they are doing, so you have to get a prescription for some things. That, by itself, is supposed to be the sanity check to prevent abuse.
But, of course, not ALL doctors, nor all psychiatrists, are on the up-and-up. So how do you put in a check on them? It sounds like this policy, as you say, only makes things harder, and doesn't in any way select for shady physicians.
I'm a software developer, not a doctor. But it seems like the way to go would be to audit at least a sample of prescriptions to make sure they were properly prescribed. The records are all there. You have to assign government employees to performing the audit, and then investigating instances that look fishy, and removing licenses and prosecuting doctors found to be bad actors.
Why would they choose the approach they are doing instead of something like this? For one, it's certainly cheaper (for the government) to simply pass a law than to implement a new bureaucracy. It's simpler (for the government). It takes less thought (for the government). And it "shows they're doing something about it".
There's also a jurisdictional quagmire here. Physicians are licensed and generally regulated by states, since nothing in the Constitution enables Congress to pass law on the subjecct, but the Federal government has long since arrogated to itself a right to regulate drugs via some creative interpretation of the Commerce Clause[1], which is why the Federal DEA is involved here. But since the two regulatory agencies are far apart -- in location, approach, motivations, identity and goals of their overlords, et cetera -- it means the kind of close cooperation that would produce a more flexible, informed, and fast-acting regulatory regime is difficult.
-------------------------
[1] Upheld by the Supreme Court in 2007 https://en.wikipedia.org/wiki/Gonzales_v._Raich
except prescriptions for psychiatric drugs is much more of an art then the system would like to admit, and there is a clear standard one can use to judge "properly prescribed" especially because of how idiosyncractic people's responses will be to different drugs and how treatment resistant many conditions are.
I don't see this as an objection to a prescription audit. If a questionable prescription has a second set of eyes determine it is worth investigating, then the reason the doctor prescribed it would be brought into question. If that reason is it had a chance of a favorable patient outcome, then the matter is settled. If it is found to be for nefarious purposes, then the judicial system can handle it.
How are prescriptions to psychiatric drugs an art? That's not my experience AT ALL
Another commenter said "the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act."
Despite this, I still would consider that you Scott (and other doctors in similar situations) should talk to your congressperson. As in, calling them up, explaining the issue, and possibly scheduling an appointment to talk with a staffer at their local office. Congresspeople really do try to serve their constituents. Even though the proposed regulation is not a law, so Congress can't directly stop it, still better to keep it on their radar. Will have more impact than posting an internet comment (although admittedly, much higher effort). If the AMA is on your side, so much the better.
PS: Don't call it a "law" ("rule" or "regulation" should work). It's not a law, and it makes a difference (e.g. because lobbying Congress would have less direct impact). Also, I know you have beef with medical regulators in general, but if this is a DEA rule, just call them the DEA not "medical regulators". Maybe they are de facto medical regulators, but (at least outside of the medical field) not many people think of them that way. Seems like you are not exactly painting the right picture here, and bringing in your unrelated beef with the FDA.
Yeah, I agree - "medical regulators" weakens the force of the argument a lot, because it lets the specific agency responsible for the dumb rule off the hook. If I'm putting someone in my bad books, I want it to be the actual bad guys.
those distinctions are largely semantical though.
a regulation is by ans sensible definition a law. if you violete it it has the same consequences of violating a law, penalties backed by the threat of coercive force.
This is an overresponse to the adderall shortage. There was an uptick in prescriptions over the pandemic and this was blamed on Cerebral and the like. Judging by Cerebral's advertising, I'm not surprised they're being branded a pill-mill; they definitely look like one. I'm currently seeing a telemedicine psych for adhd because I couldn't find an in-person psych during the pandemic, but when I saw Cerebral's adds, I figured I should avoid them.
I saw three different psychs via telemedicine for ADHD. The worst one, by far, was the one from a traditional practice that had many offices in my area. They were also by far the most expensive. Maybe they were good in person, who knows, but the two i got via AheadADHD (now closed) were/have been great (saw one then moved to a different state so had to switch).
This bill is obviously not narrowly tailored to this goal, but the goal seems pretty obvious. If there is a pill mill that only operates because they can reach hundreds of patients online with limited overhead, it will be more difficult for that group to operate if they have to meet in person. Adding in-person visits will make many of these online-only groups impossible to run. Having an option for a third-party doctor to review in person helps because that third-party doctor will presumably not endorse prescriptions for someone who has no need, or even the requirement might weed out people who never would have gotten the pills prior to telemedicine existing.
Whether this will work more in practice than it harms legitimate doctors is a good question. Personally, I think this will weed out some of the worst offenders quite effectively, but at a cost to the healthcare industry that strongly outweighs the savings from shutting down these offenders.
I feel like they should be able to make stricter prescription requirements without requiring an in-person meeting. For example, they could require that there be at least two meetings a month apart for some prescriptions. Or, for adhd drugs at least, require that the drugs be provided alongside therapy.
The problem is the ability for people to lie, convincingly, about having met up with someone. You just put down on your patient log that you did indeed meet up with Bob twice in February. Who's going to say otherwise? I guess with in-person you could lie as well, but maybe they have a signature requirement or could at least prove that wrong somehow (like the person lives two states away and was at work when the meeting was supposed to happen). Not likely to be checked up on either, but it's an additional liability if missed.
I suppose you could increase the documentation necessary in prescribing medications to include what tests were run, the reasoning required, whatever. This again has pitfalls as pill mills copy and paste the standard language for every patient and real doctors painstakingly write out the new requirements.
I don't know that it's possible to have a good system to weed out pill mills that doesn't hurt real doctors more. It's easy to identify a pill mill when you see it, but hard to define in a way that wouldn't be Goodharted by the pill mills quite effectively.
If they are going to make a regulation about it they could at least attack it head on. If they want people to not prescribe lots of pills, then limit the number of scrips a doctor can write in a month or the number of patients they can have (there are clear down sides to these strategies!). But this rule puts most of the pain on the patients who need help and not the doctors who have financial reasons to comply and put in more efforts.
well, i had a telemedicine thing where the software actually has to register that you physically saw the person to auhorize the prescription going through.
I didnt have a camera on my computer and i had to buy one to make the process work even though the doctor was find with just hearing me (long time patient)
I guess I'm failing to see whats the big deal about letting people have access to drugs they want to have access to. Why is this considerded such an important thing to stop?
"Commenting seems almost pathetically innocent,"
Policy matters are determined by experts.
Commentators are not experts.
Therefore those commenting should stop wasting time and obey the experts.
is this tongue in cheek? can't tell
Yes, and a reference to the official position here of "the experts are probably right and you should do what they say."
Isn't there clearly an issue with the DEA cap on stimulants? Even if there are "pill mills" prescribing them to people that don't actually need them, doesn't that mean that even these bogus cases are still getting bogus diagnosis? Wouldn't this mean that the DEA is refusing to adjust their cap in accordance with the number of ADHD diagnosis (legitimate or otherwise)? edited for spelling
Not quite the same thing, but...I was at a healthcare-related conference last week for work where one topic for discussion was imminent restrictions on telehealth services billed to Medicare and Medicaid, because the OIG had determined there had been a massive amount of fraud in this area over the last three years. Here's the fraud alert OIG put out on the subject last year:
https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf
Unfortunately, I couldn't tell you what makes telehealth Medicare fraud easier to pull off than regular Medicare fraud. The issue doesn't affect me personally, so I quit paying attention at some point.
My understanding was the obstacles to telemedicine are to keep down costs. If you make people physically go to the doctor they go far less.
I think the situation is worse for pain management doctors and patients. For many years, physicians have been at great legal peril if they prescribe opioid medications to patients deemed not to need them, or in quantities deemed excessive, even without reference to telemedicine. But, this wasn't restrictive enough, so the DEA, based on their medical expertise, has been reducing the allowable quantities.
But, even this wasn't restrictive enough, so several years ago, the DEA started threatening pharmacies that dispensed improper prescriptions. In response, one of the national chains stopped dispensing my wife's medication. The one we switched to would dispense the medication, but would not dispense refills until the day before the old prescription was used up. In addition, the pharmacist is required to personally review each prescription and validate that the quantity and frequency of medications are appropriate. If the DEA determines the pharmacist was wrong, she can lose her license and face criminal prosecution.
But, even this wasn't restrictive enough, so the DEA has started threatening insurance companies if they facilitate improper prescriptions. In December, our Pharmacy Benefits Administrator (PBA_ notified us that the new policy would limit coverage to 2 pills per day, regardless of strength. (It is common in pain management to prescribe 2 extended-release pills per day, plus smaller immediate-release pills for breakthrough pain.) The doctor could submit a justification for higher quantities.
But, even this wasn't restrictive enough, so our PBA added another automated check: if a patient presents a prescription, and another prescription for any amount was filled in the past 23 days, the quantity is further restricted. This limitation is too complicated to explain, so the PBA didn't explain it to either the insurer, or patients, or doctors, or pharmacies. In January, my wife got a prescription for 11 days' supply to last until her next doctor's appointment, when she got a new prescription for 30 days' supply which met the 2 pill per day limit. This triggered the automatic check, so her prescription wasn't covered. No explanation, just "not covered".
This is your government at work to protect you.
Is this the government working to protect you or is this the product of your (1) insurer, (2) doctor's clinic, or (3) pharmacy's risk department determining that they will take the most conservative route to avoid having to determine whether a prescription is proper or improper?
Not to diminish the suffering and stress this causes, but per the description there are a lot of decisions made at varying levels contributing to this quagmire.
Yes, there are a lot of decisions made at varying levels, but all are driven by one of two things:
1. Explicit regulatory rules (limits on total medicine that may be prescribed) - these primarily affect doctors, who have at least gotten clear rules.
2. Vague threats of dire consequences to anyone not sufficiently vigilant - these affect the pharmacies and insurers. There are no clear rules for the pharmacies or insurers, but they can nevertheless face ruinous consequences if they make the "wrong" judgment.
Either way, it's the DEA making life hard on everyone in a mostly vain attempt to protect people who don't want to be protected.
This is a knee-jerk reaction to a handful of sensationalized reports about online “pill mills” overprescribing amphetamines. But ultimately, this is about DC bureaucrats who want to protect their political careers. These non-doctor bureaucrats saw the opioid crisis originate with too many painkiller prescriptions, and irrespective of any differences between opioids and amphetamines, they are hell-bent on putting up as many roadblocks as possible in the misguided effort to prevent another prescription drug crisis. And once the herd in DC decides to move in one direction, everyone smart enough to understand their folly is also smart enough to know their is no upside (and lots of downside) to speaking out against the herd.
The AMA (American Medical Association) is a lobbying group that pushes for whatever keeps doctor salaries artificially high. The govt does what the AMA wants. It is always done under the pretext of helping patients, ofcourse
Does this help explain this situation with tele-medicine ? Or is something else is in play here?
>lobbying group that pushes for whatever keeps doctor salaries artificially high.
I think its more accurate to say they lobby for things that mostly maintain the status quo and may lead to higher salaries.
For some doctors - like Scott- telemedicine can drastically raise their salaries. For others, who dont want to adapt, it will lower them. Its much easier to "see" the harm to the second doctor instead of the invisible potential harm to telemedicine doctors.
Actually they do pay attention to comments. You might try to suggest another way of addressing the problem they believe exists.
I'm not entirely ready to just accept as fact that "pill mills" are a thing that is so super bad that they must be reflexively stamped-out of existence.
Then again, I know other people not only disagree with me, but want Public Health to ban all badthing mills like burger mills (Mickey D's), cigarette mills (convenience stores), fossil fuel mills (ditto), gun mills, porn mills, puppy mills...
A pity that The War On Drugs is a sacred cow that is milked by many constituencies.
Rather than playing Whack-A-Mole chasing users and suppliers, we could be asking why so many people are so bound and determined to get high?
Half of the journalists in Brooklyn have their legal meth, but me and my buddies on the hot line have to make do with yerba, cold brew, and just a lil coke as a treat. Can't let the working class folks have the real drugs, we're too dumb and irresponsible to be trusted with em
I don't think the reasons why people might want to dose their brain with drugs so it feels good needs a lot of exploration, any more than we need to do a Phase III clinical trial for $250 million exploring whether people in general do, or don't, enjoy sex and rock 'n' roll.
Beyond that, why should I give a damn about the motivations of drug-seeking people? I don't really care, so long as their self-destructive habits don't interfere with my life. It's only when they start stealing to support their habit, or driving high or drunk, that it does, and then I support efforts to punish them severely enough that they stop doing that. I don't really care what it costs them to figure out how to not be an antisocial asshole, or why they felt like being that way in the first place.
You don't find the Rat Park experiment at all instructive?
Funny you should bring that up! Scott wrote an article on the Rat Park on Slate Star Codex. Tl;dr some skepticism is warranted.
Sure, about rats. Humans are not rats. They need not live in the way that some God-like experimenter compels them to live, they have choice and agency, more than any other animal. I've never yet met an addict who didn't have about 500 peers who all had exactly his disadvantages and yet did not turn into addicts. If mere poverty and bad luck and absent/abusive parents, or shitty experiences as a kid, were sufficient to turn a free man into a hopeless criminal addict, despite his best efforts and will, about a quarter of the world ought to be lost that way. They're not.
I've met my share of addicts who used their experiences and environment as an excuse, of course. It's always easier to blame "society" or "my wretched luck" than the face in the mirror that keeps making dumfuk decisions. Which is why it's often so valuable to put them into a 12 step where other ex-addicts who have stopped making excuses can call them on their bullshit.
So background and environment have no bearing on anything in humans.
I'm sure that there were rats that didn't like the Kool-aid, FWIW.
I think the steelman argument against telemedicine in SOME situations is that you're restricting the physician's access to important information. For example, it seems very plausible to me that it's harder to detect psychosis over Zoom. I've taught online before and hated it because so much human nuance is lost, and I think that could be true for medicine too. That said, in many many use cases I think telemedicine is fine.
Of course, the bigger issue is that prescription stimulants have a lot of benefits and some drawbacks for all kinds of people. Some of them have ADHD. A lot of them don't. The question is whether we're cool with this. It appears the government is not.
The trade off is not between telemedicine and in person medicine. The trade off is between telemedicine and many or most of these people not getting care at all.
Truth
Bingo
As you've written Freddie, this is also a reflection of too many people at all levels who don't see psychological and psychiatric illnesses as real illnesses. So much flows from that...
That's absolutely true. But in those cases, the professionalism of the physician should take over and they elect not to proceed with further treatment until they are evaluated in-person.
I'm face-blind, I'm not getting the human nuance anyway.
Seriously, I really have trouble figuring out what this means. Assuming the camera is set far enough away for me to see the patient's body language, what could I possibly be missing? Their feet? I know everyone says this, so it must be true for some people, I just can't model it.
Adding some anecdata without taking a strong stance on the underlying claim: I recently had a one-off telehealth appointment with my therapist after a few months of in-person meetings, and I noticed that I felt like I had a lot more discretion over how visibly emotive or agitated I was.
An in-person session is a hotseat: I'm outside of my home, wearing actual clothes and shoes, sharing a room with a whole physical human whose space it is and who can see and hear everything I can, and I can't fidget imperceptibly under the desk or tab over to news/Reddit/ACX on another monitor. It's not just that they can see more of me or see more detail, it's that I feel less mental slack to perform "normal" if that's not what I'm actually experiencing.
In the event, this was actually mostly a positive because it gave me some space to marshal thoughts that I had had a hard time expressing in person before, but that benefit was totally dependent on noticing that slack and choosing to use it to communicate better. I think if instead I had been trying to conceal some incipient crisis or disturbed state, that would have been pretty easy to do compared to a face-to-face meeting.
(Freddie specifically mentioning psychosis also makes me wonder on a practical level: how do you tell whether a patient is interacting with a real or hallucinatory stimulus when everyone has background noise cancellation? Ask them to show you around the room? Focus on other indicators of mental status?)
Another point I'll add is that during in-person therapy, it's much less likely for one or both of the people involved to "freeze" in mid-sentence because of a bad internet connection.
Edited to add: Sorry, I realize that response was kind of glib. There's much to be said for giving people access to telehealth, and for some, it's a lot better. I have my preferences for in-person telehealth. And yes, in ways I find it difficult to articulate (and therefore I don't have an answer to Scott's question), I believe in-person is superior. There's much to be gained from in-person visits, both for the health care professional and the client. That said, others have different needs and even if I'm right, sometimes the less good option of telehealth is better than the what I see as the "best" option of in-person sessions.
Scott -
Not to write a blanket defense of government regulations. And not to dismiss the very real problems you address in this post, but, much of the rhetoric in this post, I'd say, isn't particularly helpful for addressing the problems. Binary thinking is counterproductive:
>>"...Medical regulators hate new things, so for its first decade they ensured telemedicine was hard and inconvenient."
Just a bad faith take. Medical regulators have valid reasons to scrutinize "new things." Of course there are elements of group think or unreasonable resistance to change. But it's not that they (or at least all of them as a class) "hate new things." Government regulators are people to, and largely operate from the same basic cognitive and psychological constructs that YOU operate from! Just as you are likely to be open to change, you're also likely to be resistant to change.
>>"They yelled at the regulators, and the regulators grudgingly agreed to temporarily make telemedicine easy and convenient."
Again, what a bad faith take. Yes, openness to change can look "grudging." But it can also look like a role of applying appropriate scrutiny.
>>"They say “nothing is as permanent as a temporary government program”, but this only applies to government programs that make your life worse. Government programs that make your life better are ephemeral and can disappear at any moment. "
Oy. There are plenty of long-standing government programs that makes people's lives better, and plenty of government programs that "'make your life work" are ended after they prove to do so.
>>"So a few months ago, the medical regulators woke up, realized the pandemic was over, and started plotting ways to make telemedicine hard and inconvenient again."
This kind of bad faith motivation-impugning doesn't serve you well. It strikes me as antithetical to what I understand as some of your foundational principles. I understand that you are likely frustrated by what you see as obstacles to providing care to those in need. But this kind of unrealistic standard being applied against institutions of public health will not likely, IMO, lead to improvement in the long run, but more likely lead to a more impoverished role for public health in our society. Critique is critical, but it should be done with utmost care.
Saying "medical regulators hate new things" is not a bad faith take. It's a rephrasing of the very real incentives placed on those people who are selected into those jobs. Delaying/forbidding something good preserves the status quo and also preserves one's pay/benefits/retirement. Approving something bad draws negative attention to oneself and risks one's reputation and employment. Many (most?) government agencies (at least in the US) are specifically designed to be adversarial. The DEA is there to oppose recreation drug use. The ATF is there to curtail the second amendment as well as reduce alcohol and tobacco use. The FDA is there to keep "bad" manufacturers out of the market. To think that such organizations would attract and advance people with a mindset of "everything not permitted is forbidden" is hardly bad faith.
Totally agree, Scott could've made all his arguments without that kind of rhetorical hack, which does a disservice to otherwise great article.
I read Scott's post without thinking of that, but your points ring true to me. I wouldn't go so far as to call the rhetoric "bad faith," but I do agree there's something not right about it.
That's both for the reasons you cite and also because I'm a (low to mid level) bureaucrat and have had low-level jobs where I had to enforce rules that either were stupid or were arguably good but couldn't help but seem stupid to the ones who were affected by them. I was sometimes accused of being one of those time-serving people whose goal in life was to inconvenience others. Scott, of course, is not talking about people like me. He's speaking of a specific policy that by his account does almost no good and at least a little harm.
except you are one of those people.
Generally bureaucrats, particularly government ones, have strong incentives not to "allow" something if all the rules arent followed to the letter (they could suffer consequences) but litle incentive to to actually help people.
since in a broad sense the government doesnt want to give away money, bureaucrats are a wealth transfer from the people who are supposed to be helped to people whose job it is to make it harder for people to get help which they get payed for.
So the actual value of a bureaucrats job is to make less money go to people who are the ones who are theoretically being sevred by the program and that is the "value" they add.
While your goal may not have been to inconvenice others, you choose to do the job and have to take responsibility.
And I'm sorry, but its not just "inconvenciing people" its often "not getting the medicine they need to prevent their immune system from attacking their own body and going mad from months of followjng contradictory rules that after you followed them are changed"
i aslo speak from personal experience here and yes, i absolutey hold people like you personally responsible because no one held a gun to your head and made you take the job.
By your own admission, you enforce rules that you know are stupid and you actively choose to do this in exchange for money.
Receiving money for something isnt a moral justification for your actions.
I think your assumptions that bureaucrats are also people is not universally shared.
I am reading this after I finished my virtual meeting with my kid's psychiatrist who have extreme ADHD due to the underlying genetic disease. She has never seen him in person, but when we were establishing his diagnosis, I sent her a ton of video recordings of him in different social encounters: here he pushes other kids at a playground, and this is me trying to read him a book and he ignores and just skips through the pages; and this is him at a speech therapy constantly trying to get distracted but the teacher redirects him back.
If we went in person she would have seen him jumping on and off the chair but otherwise she would still rely on the data I as a parent would provide anyway.
We have a pediatrician though that requires we come in person and I can't come alone even if I'm just inquiring about the new lab work he needs. So I have to take him out of school in the morning, waste time driving and I yet can't have a thoughtful conversation with the doctor because the kid is noisy and continuously interrupts us. I leave the appointment, realize I forgot to ask about his folate being so low, and I can't even send an email to the practice. I have to call to pass my question and they only work Mon-Thu 9-4 with the lunch break. There's no way to leave your message if you called outside these hours. I can't wait for telemedicine to disrupt this!
As a long-term methylphenidate patient, I don’t really understand the concerns about pill mills for ADHD-grade stimulants. Couldn’t you essentially buy amphetamines over the counter in the 50s? And we made awesome cars and went to the moon.
"And we made awesome cars and went to the moon."
Maybe, but they did so without an environmental impact study, no DEIB plan, and without even considering how their colonialist efforts perpetuated social inequities!
I have struggled with motivation and executive function my whole life, and actually tried to get ADHD treatment through one of those "pill mill" online sites that are technically legal because you get screened, but pretty much exist just to sell you adderall or something. I'm not 100% sure I have ADHD but people keep telling me I do and I definitely struggle. So I got screened online by a clinician. I was honest but not, like, scrupulously, stupidly honest. I tried to answer the questions in the spirit in which they were intended, etc. I wasn't trying to scam anyone but I was trying to get meds.
Result? The clinician was like, idk, I can't really say whether you have ADHD or not. No meds. So I think sometimes even those sites are not quite as pill-milly as one might expect (or desire).
Is it time to read or reread Ivan Illich, Medical Nemesis? There may be some much deeper issues.
What do we think of an eye doctor, who says here is a prescription to get carrots delivered to your door every few weeks. See you in a year?
Pharmacology and the commodification of medicine is tricky business.
How about an RCT people who see psych
in person every 2 year (w/ w/out Rx) v.
in person once a year (w/ w/out Rx)v.
in person twice a year (w/ w/out Rx)v.
in person 4 times a year (w/ w/out Rx) v.
telemed every 2 year (w/ w/out Rx) v.
telemed once a year (w/ w/out Rx) v.
telemed twice a year (w/ w/out Rx) v.
telemed 4 times a year (w/ w/out Rx) v.
no treatment
Example # 1,369 of not using cost benefit analysis to make regulations.
Too many are most sensitive to potential costs to their careers wrt cost to those they regulate. In addition, they see very little benefit to their careers from gray area decisions.
This is an iron law of all bureaucracies...
I can see this, but it does not seem to explain everything and is most relevant at the level of the individual decision maker. Take FDA's resistance to letting people develop quick and dirty screening tests for COVID. In some sense, just not taking any (blocking) action would not seem highly risky to anyone's career. [I don't want to try to understand this decision per se; it just seems like a good test of the "timid bureaucrat" hypothesis]
Sadly, I won't even say Timid Bureaucrat, rather, given the Iron Laws of Bureaucracy it is career wise The Sensative Bureaucrat.
A major question in political structure is, I have heard, how does one incentive more risk taking in bureaucracies without such changes enabling more corruption .
Can any of the deep thinkers on Scott's blog provide some insights on How To Build More Effective Bureaucracies Without Enabling More Corruption?
incentivise funding to outcomes? that might be a starting place
A. Someone develops a test. It causes something wrong (too many false results, either positive or negative). Bad things happen. "Why didn't you regulate this? You're supposed to do so." Bad publicity.
B. Someone develops a test without regulation, then someone says "We don't need the FDA, see?" Bad for empire-building.
Take your pick from A or B. Why not both?
i think in todays modern era, we could have competing private versions of the fda where reputational accuracy would be the value and people would learn to trust the ratings of some agencies more then others.
yes, some would take money to give good reviews, but eventually people would fvor the honest ones.
the agencies could get their funding through advertising on their review sites
> I’m probably going to rent an office somewhere in Oakland for the month for a few thousand dollars. [...] I’ll have to charge them a bit more, to recoup the cost of the office.
I agree that this whole situation is terrible, but aren't there more economically efficient solutions here? Does it matter whether your patients drive to Oakland or to another place with far lower real estate prices?
Hell, I know several doctors (including a psychiatrist) whose “office” is just an easily accessible room in their private residence. (Though, I don't live in the US so there might be some more regulatory issues I'm overlooking, and of course you will have to be comfortable giving patients your private address.)
Yeah, I don't want to give my patients my private address, although I trust each specific one I can think of, it just seems like a dangerous thing to do in psychiatry.
An excellent illustration of Conquest's First Law ("Everyone is conservative about what he knows best"). Hopefully it helps illustrate why many of us despise and resent government regulation for social engineering purposes.
By definition it's a bad faith take. Indeed, as in your follow-on comment, it eliminates any "charity," any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking.
I am not suggesting that critique isn't critical. But I don't think this kind of critique, imo in a Manichean framework, incorporating a kind of fundamental attribution error, is constructive in the long run. The net effect, imo, in balance, is just to tear down public health. We're on that track as a society, and I find it concerning.
"any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking."
First: incentives may be 'conflicting or even opposing' but they are not random. The whole process of self- and organizational- selection imposes a directionality on them and to deny this is to deny reality. No one is required by the laws of charity to consider the possibility of unobtanium. nor the angelic nature of humans nor the idea that government employees are crafted from a finer clay than mere mortals. Calling out the net effect of a complex process isn't uncharitable, it just is. Especially when the net effect is consistently in one direction and has been since someone forgot to check on the difference between enantiomerically pure and racemic mixtures of a drug back in 1957.
Second: even if we assume that "'crafting' a 'balance'" is something to be desired, whether or not it is difficult or complicated is irrelevant as to whether or not a system is biased and even more so when the results of the decisions cause other actions involving people with guns. I don't give cops any slack because their jobs are "complex" not do I care about how difficult it is to try and "craft a balance" between shooting a bad guy and not shooting an innocent person. Nor is it bad faith to notice if the shoot/no shoot decisions are biased in a particular way.
Third: since this was obviously written from a very particular POV, claiming that it needed to take other perspectives into consideration is as much a category error as anything else.
" .... nor the angelic nature of humans nor the idea that government employees are crafted from a finer clay than mere mortals"
I have no interest in engaging with straw men. Carry on.
But you are a fan of the drive-by insult.
I'm happy to have a discussion about things I actually said but see no point in discussing absurd viewpoints you invented and then argued against. You don't need me for that discussion - you can just have it with yourself.
Interesting. You demand something for yourself you are not willing to grant to Scott. Or to me.
Yes, Scott is usually a Mistake Theorist, and it’s disconcerting to see him slip into “the people I disagree with are bad and want innocents to suffer!” Conflict Theorist mode.
i dont think its that the individual people involved want people to suffer but rather the systems work on perverse incentives. No one person inside the system wants people to suffer but the people following their ow incentives at all levels including orgazational incentives creata a moloch situation that trends towards predictable outcomes
why do people equate "public health" with "government regulated health systems"? the two clearly dont have to be synonymous
Where are they not? the "public" seems to always have the same meaning that it does in "public schools" (US definition, not UK).
I'm sympathetic to your arguments about telemedicine, but the intro was very disappointing. I understand your frustration with the new law, but to start off by claiming that the motivation behind its creation is that regulators hate new things and want to inconvenience people is just lazy writing and bad rhetoric.
Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
It is generally true though.
The reason the software industry really took off in India is it took govt bureaucrats a really long time to figure out exactly what software was (in order to regulate it). By then it had taken off.
> Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
Indeed - it always backfires with me. At least until someone can describe their mechanism for ESP mind-probing, it's a bad sign. And I havent seen anyone describe a plausible mind-probing technique as of yet, especially for a whole class of people let alone a particular individual.
i think motivation is linked to frameworked premise. So a ssytem that operates on the presumptions of violence will lead to perverse incentives.
If the stupid "in person" rules do one thing, it's make it harder to deepfake.
Fraud is already illegal, and, physical injuries aside, I doubt tricking a doctor via deepfake would be any easier than faking symptoms in person, so as far as psychiatric pharmaceuticals go, this is the same as the original problem.
Have them.us managed to re-derive the concept of the general good from identity politics?
This will hurt people.
Some people are trans.
This will hurt trans people.
(It’s not logical necessity, but it’ll do)
I think it's probably more accurate to describe that second step as "this will hurt a group of people who are more likely to be trans than the general population", which seems like a pretty sound reason for a trans-issues publication to highlight it in that context.
Simple rule of thumb: designing broad based rules to prevent outlier events never works out well. The majority end up suffering from the rule and the ones that the rule is designed to catch know how to game whatever rule is put in place.
I’m not sure that what Scott wrote is even completely accurate. I have a relative who is an MD in this space, and it seems that the underlying problem is not the DEA but an actual law passed by Congress. Aren’t telemedicine regulations limited with respect to controlled substances by the Ryan Haight Act of 2008 U.S.C. § 829(e)… there may be interpretations of this act by the DEA and other agencies, but, where controlled substances are prescribed by means of the Internet, the general requirement is that the prescribing Practitioner must have conducted at least one in-person medical evaluation of the patient.
It seems like a colossal overreach to ask an Executive Branch agency to overrule the plain text of the act. There are some exceptions, which Scott noted. A different way of looking at things was that the Executive Branch was highly responsive to the emergency situation of Covid. Now that it’s not an emergency, they are obligated to return to the legal framework that exists. Congress needs to change the law, not the DEA.
The *data* from covid should be used as part of a cost-benefit analysis to determine whether it is reasonable to regulate telemedicine, and, if so, what regulations might address whatever problems arose.
Son of a gun. I snarked earlier about how Congress never does anything that specific, instead fobbing off all the details to the bureaucrats, but I see on congress.gov that you are completely right, this is entirely and specifically Congress’s doing. I stand corrected.
It’s still stupid, but it’s a different kind of stupid.
Actually, Scott is even more off-base than I thought in my initial post. Apparently the DEA & DOJ are already proposing new changes to the 2008 Act (which seem like they violate the clear text of the act), but the act and the changes are summarized here:
https://www.legitscript.com/2023/03/27/proposed-changes-ryan-haight/
Sounds like government is aware of the issue. See
https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had
For the actual changes that are being proposed.
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. Congress was attempting to fight opioid pill-mills. At the time of passage, I am willing to bet that ≈0% of patients were “Telehealth” using videoconferencing. More like phone calls and email a few times to get drugs.
The law should have been amended, and it hasn’t been, but it is far from clear that it was a crazy law in the first place.
Oh, Scott really needs to read this comment. This really needs a petition to Congress not the DEA. And contrary to popular belief, Congress actually does do stuff. It just years of concerted effort, public comments, debate, lobbying etc. This is what is necessary whether one likes it or not.
This seems correct to me (the name is also a hint, as the DEA describes: "The Ryan Haight Act was named for a California high school student who died in 2001 from a drug poisoning resulting from a controlled prescription medication he obtained from a rogue online pharmacy. That rogue online pharmacy allowed customers, like Ryan and others, to obtain controlled medications without an in-person medical evaluation by the prescriber.") The whole goal was to make that not happen, hence the name and the requirement for in-person visits.
Though they do seem to be relying on a provision of the law which allows them to come up with some alternate procedures under very limited circumstances, with the concurrence of the HHS secretary and the AG.
Btw, when I traveled out of state and requested a telemedicine appointment with an internist in my state, the software they have at the clinic did not work. They have strange clunky software but this happened because they're designed to NOT work out of state. Wish they'd use Google meet or Zoom or something ordinary like that. That's what concierge medicine doctors seem to use - they cut out the red tape.
I got the impression that typical commercial remote software, like Zoom, don't meet the data security requirements implied by federal patient privacy rules and enforced by the feds.
Scott Alexander?
Well, why are concierge medicine doctors okay with it then?
Every business in the country uses zoom now. Why can't doctors?
As I understand it, thus I'm not saying I'm certain, it's the government health beurocracy interpretation of HIPAA and other federal and state privacy rules. Further, this interpretation was put in abeyance during Covid...
Considering the security problems that Zoom had (admittedly they say they've fixed them), I can understand their reluctance.
Although I suspect it was more ignorance than caution. Correct result for the wrong reasons?
Sorry, I don't know, I use a special medical conferencing program. But I've seen UCSF use Zoom, and they're big and formal enough that I'd be surprised if they didn't know HIPAA, so I assume it's okay.
See my comment that answers this question. It has nothing to do with data security.
“The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 and Drug Enforcement Administration's (DEA) implementing regulations, after a patient and a practitioner have had an in-person medical evaluation, that practitioner may use telehealth to prescribe that patient any prescription for a controlled medication that the practitioner deems medically necessary.”
More in the post above. Congress needs to fix.
All your points are valid ones, but there's this other issue, where there are some doctors who have overprescribed a huge variety of drugs (opiods being the most common example), even though I'm sure most doctors are responsible with meds. Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing. OK, of course, as with most regulations, the in-person requirement doesn't address this problem very well, as it has loopholes that make the regulation more of an inconvenience than a ban. But, when did that ever matter when it comes to a hot story that can be done in a way to inflame readers and (even better!) embarrass regulators! Which is probably some of the explanation why it's so hard for you to get the voice of reason heard.
One quibble with what you say. Comparing our health care regulators to Putin! How American. What you're talking about is on the level of inefficiency and in many cases, let's say, inconvenience for Dr. and patient alike, because of the loopholes in the regs that you mention. I like my fellow Americans do highly value making things convenient and efficient. But hey, it's a bad look to suggest requiring a second doctor to vouch for medications prescribed on line, in the context of some highly publicized abuses of that practice, is like... Putin's Russia. Unless the goal is to contribute to the bonfire that's American political discourse these days.
>Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing.
What if a rise is prescriptions is just a reflection of the many people who needed medication but were not able to get it because of the regulations? Do you have anyway of figuring out who group a individual is in and crafting a law that doesn't harm the "good" patient but does punish the "bad" one? We can't make laws based on what COULD happen in our dreams, we have to make them on what actually does happen in real life and in this case what does happen is people who really need medications but are too sick to go in person to a doctor aren't able to get the medications they need.
Sorry if I wasn't clear. I agree with Scott's points as far as they go, and your point is a good one, but I think the regulators are often more concerned with how things play in the press, which as I see it, would be eager to make a scandal out of things like "excessive on line prescription writing" even if as you say, it very well might not be a real problem. I'm suggesting why as Scott said, it's likely comments won't prevent this reg.
I generally like your writing and ideas, hell, I just re-uped for a year.
However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else."
In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time.
Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors.
Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking.
I do wonder if the cheap shot was actually intended at another religion popular on the west coast that also thinks of psychiatry as bunk, but is much more litigious (and much less safe to make fun of).
I'm thinking of the one where you go on a Cruise, a galactic one...
From a headline and PR standpoint, really need to develop and distinguish a different term than "controlled substance" if possible. Many people will only read the headline and think about law enforcement, prescription drug abuse, and problems stemming from something like opioid addiction/meth.
Or you could do the version where you use jitsi instead of Zoom for a session, and agree that you'll both pretend that they visited you.
Notably absent from this post: any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. I genuinely don't want to be rude here; the temptation to isolated demands for rigor is greatest in fields where you consider yourself an expert.
That's because I don't really trust them.
The classic way to study this is through opioid use disorder. There have been a bunch of studies showing that telemedicine based treatment has higher retention rates and equally good outcomes compared to in-person, see eg https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800718 and https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2795953 .
Why didn't I link these studies that supported my point? Mostly because they don't exactly address the one thing I'm talking about - telemedicine with forcing the patient to see the doctor once, vs. telemedicine without doing that. That's because nobody has any plausible reason why the former would be good, and so nobody has ever bothered to study it.
(there are also some reasons why opioid use is an unusual case, and why I'm not sure how to measure outcomes, but the paragraph above is the main reason)
That data is also absent from the DEAs background on this action. In part it reads:
>The Ryan Haight Act intended to address the threat to public health and safety caused by physicians who prescribed controlled medications via the internet without establishing a valid doctor-patient relationship through such fundamental steps as performing an in-person medical evaluation of a patient. Prior to the enactment of the Ryan Haight Act, the internet was being exploited to facilitate the unlawful distribution of controlled substances through rogue websites. These rogue websites fueled the misuse of controlled prescription medications, such as hydrocodone and oxycodone, thereby contributing to increased drug poisonings and other harmful health, social, and economic consequences.
The original act was passed in 2001. It doesn't appear it has done anything to reduce or slow drug overdoses:
https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
Accusing the guy who literally wrote the isolated demands for rigor post of isolated demands for rigor seems uncharitable.
Less confrontational wording: "This seems like an isolated demand for rigor since I don't see any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. Given that you're known for writing all those "Much More Than You Wanted To Know" series of excessively in-depth fact posts, this seems to me to be out of character for you; what am I missing?"
"Did I mention that if you come off of some of them too quickly, you can literally die?"
I once had the opposite problem. I had severe epilepsy, but the dosage of the most-likely-to-be-helpful medication, Lamictal, had to be increased veeery slowly, otherwise it could cause a potentially-deadly skin rash.
https://www.nhs.uk/medicines/lamotrigine/side-effects-of-lamotrigine/#:~:text=Skin%20rashes&text=It%20causes%20flu%2Dlike%20symptoms,dose%20is%20increased%20too%20quickly.
Oh yeah, so many Psych meds and anti-epileptics are scary in both directions.
That one just stuck with me because it was so random. An anticonvulsant, that causes a skin rash, that's so bad you might die. I didn't even know it was POSSIBLE for rashes to be lethal.
I imagine that most things where that happens it's no longer called just a "rash."
Look at smallpox. I'm not going to describe the end result, it's too gross. But the patient could die from extreme "rash".
The smallpox analogy occurred to me, but I assume that that kills you in the end because your body is overwhelmed with viral agents. Whereas here it's more like... a bad allergic reaction? Or something? There's no viruses or bacteria running amok.
The poxes grow enough that they join, and your skin falls off. It's hard to live without skin.
It is true that this is caused by disease as opposed to a drug reaction, but I was responding to the idea that a rash could not be fatal.
Luckily Lamictal isn't a controlled substance, that one's a huge mess to go on and off of.
Obviously I mourn the 100,000 people a year that die from opioids, but the negative toll on the people that don’t abuse opioids but need them is a very big price to pay for their abuse. This war on opioids harms many people caught up in the crossfire that need a drug that has been used since the beginning of human history!
Don't forget the climate change implications of restricting telemedicine:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800850
Well, clearly we have to do domething about this telemedicine thing then (said sardonically (right word?)).
It's amazing how way too many people and organizations (I don't think you as I think you were being sardonic (right word?)) bring climate change as a supposed golden reason for everything even when Hollywood big shots generate far more CO2 while jetting to climate summits...
I imagine this is like putting "blockchain" in your IT startup proposal. It gets attention and funding from people who have control, but not knowledge.
Oh JAMA, never change.
The government is applying the precautionary principle. Just like you want them to do with AI.
"Ah, but here they are applying it stupidly." Right, just like they certainly would with AI.
Because it's the same government, operating according to the same bureaucratic logic. It doesn't suddenly get smart because nerds begin yelling at it.
https://astralcodexten.substack.com/p/kelly-bets-on-civilization
Would it fulfill the letter of the law to have a patient go to an Urgent Care facility to get that letter signed? At least then it means minimal waiting and even the out-of-pocket costs tend to be low.
True, dumb, and pointless yes, but how else can an incompetent bureaucracy respond to the demands of commercial real estate owners? When trying to also forget every single lesson and ‘go back to work’ to monitor, control, and force people to waste money on transport and commercial real estate…they’re all out of ideas and revert to fascistic practices of stupid rules to force people to comply.
There is a fairly real existential threat to the financiers, banks, and wealthy land owners who wish to do continue to do nothing and be paid enormous sums of money for the service of simply owning things they didn’t build while holding us all hostage to their MAD style scheme to send the economy into a Great Depression 2.0 if their terms are not met.
This knee jerk and too little too late series of spasmodic reactions and planned obsolescence of anything disadvantageous to them may be part of this, along with the general trend of everything getting worse and all your favourite tv shows, brands, products, foods, restaurants, and government rules being inexplicably cancelled.
It may sound outlandish or conspiratorial to some, but it truly is what motivates the upper and powerful classes. The demands of enormously wealthy landlords and the even larger financial system behind them are always heard via all their legalised bribes of all kinds to politicians and senior staff in every single agency and regulator who get donations, speaking fees, and highly paid ‘jobs’. Regardless of the veneer of democracy, these groups in studies almost always get their way or erode things to get their way over time after populist movements’ brief attention span of a year or two ends.
Even the neocons could only squeeze and divert a hundred billion or so into their latest proxy war, but the banks were able to get 2 trillion plus of money printing done pretty much overnight because they asked for it.
And they are freaking out about commercial real estate and the collapse of the banking system. A broad demand to end all kinds of work from home is happening and that includes things like telemedicine. I doubt the elites behind this push would know, care, or be personally affected by this specific rule change.
But that’s how incredible power works and long chains of people interpreting their marching orders operate, quickly asking how high to jump when told to do so. Years and decades of activism and sensible modern policies by huge movements can be undone if one of our invisible aristocracies even so much as sneezes. And that’s just an unintended drive for compliance to their a near absolute demands. That’s the true power structure. And they are right, the economy has been built on glass support beams and will go into a terrible depression if we do see a continued lack of demand and turnover for 70% of commercials real estate into a non-free debt environment of 5% or more fed funding rates.
We are seeing bureaucratic panic, which will inevitably not ‘solve’ the problem of most offices being unnecessary and will hurt many vulnerable powerless people in a myriad of ways. Is this 100% the total answer to why this specific rule change is happening? Of course it isn’t, but it is a significant structural factor in how choices, all choices get made by powerful controlling systems.
Or we can be naive and pretend power somehow doesn’t continue to operate as it has for millennia.
I'm one of those "bad" people who thinks potentially addictive meds should require in-person evaluation. I worked for a psychiatric and social work agency for 15 years. Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today.
Telemedicine for an earache or my son's psoriosis -- okay. An antibiotic, some cream for his outbreaks. Fine. But I've done telemed a few times since covid and it is not like seeing a doctor in person. Yeah, the antibiotic -- on the third call -- fixed my sinus infection, but my swollen knee -- well, no. Doc gave me a prescription for painkillers and a steroid based on my camera angle. It didn't fix it. But I didn't take the painkillers, because I know they're addictive (and they generally make me puke). I asked for a referral to a physical therapist to actually fix my knee. "After you've done this for a while. In the meantime, put your feet up" and get out of shape and make the problem worse. Fortunately, I rain into a friend who is a PT and she gave me "advice" that included going to the gym and getting my knee back in shape. I stopped taking the steriod. I'll report to the doctor when I go for my annual -- IF I go for my annual because telemed isn't really medical care.
"Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today."
Were these people getting their pills from telemedicine or in-person?
I'm not denying lots of people abuse drugs and it's bad. I'm denying that requiring everyone see a doctor once in person has any bearing on this question. "Give kids Ritalin because Mom and the teacher can't abide normal play" is unfortunately very standard now. Punishing telemedicine docs in particular for this won't change anything.
It allows more doctor shopping and expands reach of addicts to seek out supply
I could see an argument that goes something like "we are creating a situation where 30% of society is on ADHD medication, because parents don't like their children's natural limitations, and then we need lifelong medication for these people because they have chosen careers that their unmedicated minds are not suited for. Might it not be better to start paring back access to this medication so we can slowly return to a more natural balance?
You are not wrong! Somehow, we need to get to that point. It's unfortunate that doctors don't do that for themselves (first do no harm comes to mind), but they don't.
They were getting their pills in person back then. I would suggest they'd be much more likely to be prescribed pills through telemed. To think that wouldn't be true is to ignore an important component of human nature. As Tempo says below "It allows more doctor-shopping...."
Hey everyone; sorry for posting randomly on here. I'm undergoing psychiatric treatment myself. I have a rough situation up here in Canada, since there's a massive shortage of psychiatrists (https://www.thestar.com/news/canada/2022/01/15/psychiatrist-burnout-why-covid-weary-doctors-are-taking-a-mental-health-break.html): "These departures are leaving Ontario with an acute shortage of psychiatrists, says Villela. The number per capita was already declining before the pandemic, according to the Canadian Medical Association. And with half of all Canadian practitioners over the age of 55, that shortage is likely to accelerate."
I have a whole ton of questions about psychiatry and it's really frustrating. I don't know who to ask. I sometimes randomly email researchers but that only works once in a blue moon.
What's the best place online to get answers to certain questions? Like the most basic one I have is whether it's possible for a patient to simply be some kind of weird outlier who needs high doses of certain medications; such a patient is in a tough spot because someone might not want to prescribe high doses for them. What legal issues arise when psychiatrists go outside the bounds of the guidelines? I assume that psychiatrists wouldn't ever do so if doing so invites legal danger.
I found this (https://astralcodexten.substack.com/p/oh-the-places-youll-go-when-trying) super interesting but I still have questions. Regarding escitalopram, what exact risk do you face if you go up to like 50mg, 60mg, 70mg? And why are people seeking to declare that nobody (not even outliers) can benefit from high-dose escitalopram if indeed that's what their saying?
And why would a patient need so much escitalopram (or guanfacine for that matter...imagine a patient who needs 10mg guanfacine XR in order to get a good treatment effect)? Is a patient who's an outlier (when it comes to needing high doses) unusual pharmacodynamically or pharmacokinetically?
Another weird thing is what if a patient swears up and down that they experience very powerful effects from a medication within seconds or within a couple minutes? We can say that it's just placebo, but what in our science sets a hard limit on how quickly a molecule could reach the brain or affect the brain? The difficulty here is that it seems like you have to (1) identify all possible pathways through which a non-placebo effect could occur, (2) rule out the possibility that there's another pathway that you're unfamiliar with, and (3) rule out that any of the possible pathways could allow for such a fast non-placebo reaction.
Lastly, take a look at this interesting medication that I'd never heard of: https://www.reddit.com/r/Nefazodone/comments/1251z72/can_you_guys_help_me_learn_about_nefazodone/je32w77/.
I'll try to answer these as best I can, they're not medical advice.
The most likely reason someone would need very high doses of medication is that they're a fast metabolizer; ie their liver shreds medication very fast and so it's hard to build up a high level in the blood. The second most likely reason is something something the brain - we don't understand the brain as well as the liver and can't necessarily predict what this would be.
Another (very common) reason is that the patient has developed tolerance to normal doses of the medication. In this case, giving higher ones isn't likely to help (they'll just develop tolerance to those too) and it will just make the problem worse.
Another reason is that the medication just doesn't work for the patient, you're trying to hammer a nail in with a screwdriver, and you have to hammer really really hard to get anywhere at all.
The main reason doctors don't like giving very high doses of medication is that just because you're undersensitive to the beneficial effects doesn't mean you'll be undersensitive to the side effects, and so if you need 10x the normal dose of Lexapro to get any antidepressant effect, you'll get 10x the normal side effects, which will be really bad. Sometimes doctors have a specific side effect in mind when they worry about this, other times they're just worried nobody has studied that dose and proven it doesn't have terrible side effects.
In psychiatry, a lot of drugs at very very high doses will turn you into an emotionless zombie. This often solves your problems - emotionless zombies aren't depressed, anxious, or violent - but it's a bad outcome. People often aren't able to describe being an emotionless zombie very well, or even necessarily notice right away, which makes psychiatrists nervous about "this extra high dose of this drug solved all my problems!"
I think it's very very unlikely to get effects within minutes from an oral medication - it hasn't even made it out of the stomach and into the bloodstream by then. Whatever galaxy-brained mechanism someone is thinking of for why this might happen, I think placebo effects are more likely. Luckily this should be easy to test.
Nefazodone is indeed interesting, see https://slatestarcodex.com/2015/04/25/nefarious-nefazodone-and-flashy-rare-side-effects/ for my thoughts on it.
Thanks so much; I appreciate these excellent answers.
The reason could be: (1) "their liver shreds medication very fast and so it's hard to build up a high level in the blood"; (2) "the patient has developed tolerance to normal doses...giving higher ones isn't likely to help"; or (3) "the medication just doesn't work for the patient". But how do you tell which it is? I guess that you could check blood levels to see if (1) is the case, correct? Is there literature on discerning between the three of these options?
I wasn't sure about the difference between (3) and (2), actually; regarding (3) do you just mean that it *does* indeed work but requires a high dose?
Also, I'm very curious about the science behind how often a higher dose will "stick" even after tolerance terminated the treatment effect at the lower doses; is there good literature on the rate at which something "sticks" and why exactly that sometimes happens? I agree of course that climbing up the dose ladder is a dubious proposition if it's just going to lead to more tolerance and disappointment; the trick is to be able to predict what the ultimate outcome will be.
You said this: "just because you're undersensitive to the beneficial effects doesn't mean you'll be undersensitive to the side effects". I suppose that the issue is what the statistics say on what the risk of increasing the dose is *given* the patient's situation. I'm sure you have at least one excellent post on this topic already, but there's a problem with statistics where you read in the news that (e.g.) eating bacon daily gives you a 20% risk of developing heart disease. The problem (I assume; correct me if I'm mistaken here) is that the person reading about the bacon thing might be in a special subset (e.g., the subset of people who have no heart disease in their family tree or something) and that makes the statistic irrelevant. Same with the patient who might experience bad side effects at a high dosage; there are various things about the patient (maybe they've had zero side effects so far in response to this medication, for example, but maybe they also have other traits) that might make the generalized statistics irrelevant.
And of course, there's also the issue that the patient could be vigilant (regarding side effects); regarding nefazodone it seems to be the case that you can get your liver checked in a way that makes it very unlikely (or even impossible?) that anything terrible will happen to you liver-wise.
I'd love to read to a pro-medical-regulator person steelman this, and be able to have it withstand these criticisms, and the kinds of criticisms this forum can bring to bear. I mean, I doubt its possible, but I would love to read the attempt.
So, as a factual question, is this primarily the law as written preventing telemedicine of controlled substances or is it the DEA choosing to make it difficult?
Because "regulator" is kind of being used in a general way with specifying whether this is, at core, the fault of DEA administrators making a policy decision or of the Senate/Congress making a bad law. Let me clarify, from the Federal Register link provided (1):
--
As indicated above, in 21 U.S.C. 829(e), the Ryan Haight Act generally requires an in-person medical evaluation prior to the prescription of controlled substances. Section 829(e), however, also provides an exception to this in-person medical evaluation requirement where the practitioner is “engaged in the practice of telemedicine” [17] within the meaning of the Ryan Haight Act (21 U.S.C. 802(54)).
--
The DEA release makes several references to the Ryan Haight Act, which you can read here (2), having a clear intent to prevent controlled substances from being prescribed without an in-person evaluation. The statutory authority doesn't appear to be anywhere within the core of the law but instead...basically a loophole buried in paragraph of a subsection.
Because, if the law was clearly written to do X, and we want to pressure the DEA to use a loophole to achieve the opposite of X, because they allowed the opposite of X in a global emergency, that has...several obvious concerns.
But I don't know enough to make the specific argument that "no, this is Congress' fault, the DEA is faithfully fulfilling the law as written". So, for people with either more legal experience of more practical medical regulatory experience than me, what was the intent of the Ryan Haight Act, how much discretion does the DEA have here, and who is ultimately responsible?
(1) https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had
(2) https://www.govinfo.gov/content/pkg/USCODE-2021-title21/pdf/USCODE-2021-title21-chap13-subchapI-partA-sec802.pdf
EDIT: Blarg! Should have read ProfessorE's comment below. I am genuinely curious though about who's ultimately at fault.
While we are talking about stupid bureaucratic requirements, can we pretty please acknowledge that fax machines are over and adjust our talmudic interpretations of HIPAA accordingly? This is very small bore compared to telemedicine, and so probably less likely to happen, but really.... So stupid.
I'm actually slightly optimistic about this for selfish reasons. I have been on stimulants for ADHD for 20+ years. This will make getting a prescription for said meds very difficult.
However, due to the FDA limit on stimulant manufacturer, for the past 6 months I haven't been able to get ANY medication WITH a prescription. Every pharmacy is out of every stimulant.
So. If demand drops, and I have to work harder, but can eventually actually obtain the meds I need to not be fired from my job...
Well, it's way better for me than the current situation.
When my patients have had this problem I've had some success switching them to modafinil - it only works about 50% as well, but for some of them that's enough not to get fired. If you can't get modafinil, even Sabroxy might be better than nothing.
(Sorry, I was just going to make a quick comment about Intuniv and then I ended up writing a little reflection on my treatment.)
I wrote about my experience with Intuniv 3mg here: https://join.substack.com/p/is-this-the-biggest-thing. Some of the science might be incorrect, but I did put caveats in the piece explaining that I hadn't vetted the science. I have absolutely no idea why I had a "miracle week"; I guess that nobody knows. If only I could've maintained that effect.
I take notes on my psychiatric treatment; I often look back on my notes and it's super interesting to read because the notes will say things about how incredible and wonderful and functional my current brain state is and how my life will be great if I can only maintain this brain state. I haven't gotten any of these "miracle" states to "stick" yet, unfortunately; it's interesting to read my notes and try to re-inhabit the really good treatment effects that I've experienced.
On the one hand, everyone's brain is always changing and is always in flux, right? But on the other hand, I feel like a life like mine is freakishly and ultra-abnormally fragmented in terms of how many brain states I've inhabited. I think that a person with a stable brain has some consistency over time that I completely lack. I wonder what the "instability" is in terms of brain science, though.
23k comments and climbing. In a search for "good", I found mostly comments about it "doing more harm than good", but in a search for "thank you", buried among the "...for your time" is at least one comment that seems to have a sincere appreciation for one effect of such a regulation, specifically that it should reduce accessibility of euthenasia drugs, which is a moral stance that I think is honest and worthy of consideration. In my opinion though it doesn't counterbalance the overwhelming deluge of negative comments, including official responses from nonprofit providers saying that this will be especially bad for them.
>The problem here is that the DEA is trying to catch evil overprescribers by filtering for whether a doctor can see a patient one time in person, which is uncorrelated with whether they’re an evil overprescriber or not. It’s just an extra hurdle that’s inconvenient for everyone
Scott, do you remember the Lesswrong post "beware trivial inconveniences"?
I would be very surprised if this requirement did *not* discourage a significant number of overprescribers. (Consider that "overprescriber" may contain elements of fraud and not just be "otherwise legitimate psychiatrist who prescribes too much". And that drug abusers are poor and/or lazy and thus may find it hard to get to a psychiatrist's office.)
I feel like a lot of these comments are missing the point.
Suppose that the DEA's proposed solution was "ban all doctors who don't wear glasses from prescribing controlled substances, unless they have put on glasses once in their lives". You might have questions like "are doctors who don't wear glasses worse than other doctors at this?" or "can't they just put on glasses once for one second, then keep on prescribing?" and "given this, isn't this a lot of paperwork and inconvenience for nothing?"
Yes, making evil doctors put on glasses first would be a trivial inconvenience and sometimes trivial inconveniences discourage people, but I feel like before you get into claims like this you need a better model of what the DEA thinks they're doing in the first place.
Sorry if this is annoying because you already saw the other comment, but the DEA actually has no agency here. They are simply following the law, in this case the Ryan Haight Act of 2008: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/ryan-haight-act
Changing the law is the purview of Congress not the DEA.
Ever consider hiring a pharmacist to help you wrangle prescriptions?
Actually, wrt this specific problem, would it be even doable to have remote collaborative practice agreements and then somewhat mitigate the patients-meet-you-in-person requirement by having subordinate prescribers dotted around the state? I guess you'd have to rent more offices and, uh, hire people, but I mean it's an option question mark?
Hell, does it even preclude prescribers traveling -to the patients-?
My last doctor set up a telephonic visit. When he called he didn't know who I was, then asked me what I wanted. Then he tried to convince me I was some other doctor's patient. So we don't do 'telemedicine'. They'd like to turn medical care into a video game. It's much cheaper, and maybe could get ChatAGT or whatever to provide care through Siri. The profit could be tremendous.
I went back to my previous GP, a man named Ramakrishna. The last thing I heard my telephone doctor say as I left his office was "pseudocysts!" as if he finally remembered I was a patient. Too late.
This is super random, but I found this paper absolutely fascinating (and it made me want to look into trying some antiepileptic drugs):
https://link.springer.com/article/10.1007/s43440-023-00458-4
IEDs occur more often in patients with ADHD and may contribute to symptoms of this disease [10,11,12,13,14,15]. There are clinical studies suggesting that antiepileptic drugs (sodium and calcium channel inhibitors) reduce ADHD symptoms. For example, it was found that the calcium channel inhibitor levetiracetam inhibits IEDs and reduces symptoms of ADHD in children suffering from this disease [11, 12]. Another study showed that sodium channel inhibitor lamotrigine decreases ADHD symptoms in epileptic patients with ADHD. This effect correlated with EEG normalization and a reduction of epilepsy symptoms [36]. It was also found that sodium channel inhibitor carbamazepine inhibits IEDs in children with ADHD. This effect correlated with clinical improvement [37]. It could be speculated that in some patients guanfacine may reduce ADHD symptoms by inhibiting interictal epileptic events. Thus, guanfacine may exert beneficial effects in ADHD not only by stimulating alpha-2 adrenergic receptors as shown previously [6] but also in an additional mechanism which is the inhibition of sodium channels and consequently inhibition of IEDs.
What puts a bad taste in my mouth is the "there's nothing we can really do except whistle into the wind" stance on addressing regulatory issues. Yet, here we are.
Is there truly nothing within the capacity of all of our advanced technology and communications systems to arm "experts" like Scott with tools to have a disproportionately loud voice in situations like this?
May I suggest a book to review or a person to research "The Mastermind" which is about Paul LeRoux, for an alternate view on the whole telemedicine thing and a different perspective into the opioid crisis.
LeRoux is sort of a dark mirror to many of the tech innovator capitalists that are glorified in our society. LeRoux innovated by building what can charitably be describe as a platform for telemedicine or to the government a cyber pill mill that sold opioids to Americans.
LeRoux was one of the largest spammers in the world and arguably was initially a Gray market tech entrepeneur until he decided to be a black market entrepreneur who moved towards selling missiles to Iran, buying North Korean drugs and killing people.
That aside a question for our host, how do you believe pill mills should be dealt with?
Also for our Doctor host the outcomes of some of the trials for people issuing and serving prescription on his platform had interesting outcomes. Basically individuals who treated it like proper telemedicine weren't convicted but people who clicked the approve all button to bulk prescribe/fill prescription got punished
If anyone is interested, King of the Bro-Scientists, Derek of More Plates More Dates, discusses this new regulation here: https://www.youtube.com/watch?v=NQ1sXYwYyhs/
Hell on a flat Earth
From your perspective as a practicing psychiatrist, how viable/reasonable would it be to put a limit on the number of patients to whom a psychiatrist can prescribe controlled substances? Realistically, there's a limit to the number of patients a doctor can concurrently monitor thoroughly enough to determine that controlled substances are appropriate, right?
That seems super logical from a regulatory standpoint.
It's almost as though giving the government power to control your health is a Bad Idea.
Such a blanket statement will necessarily end up looking inane and hurting your cause, whatever it might be.
Do you oppose government having power to convict sellers of medicine whose labels don't match their contents? Do you oppose government granting special privileges to medical workers and vehicles while doing emergency work? Do you oppose government including healthiness as a consideration when selecting food to order for a public event (independently of whether it should order the food in the first place)?
I picked especially obvious examples that (I think) few people would commit to. But, the government is supposed to control things, and if you really think public health is entirely outside of that domain, then you are in a very tiny minority.
Let's make this simple, and see if you can follow: the first question is about prosecuting fraud, which is the proper role of government. The second is about emergencies - I maintain such things could be handled privately, but we are where we are. Healthiness is obviously good, but that has nothing to do with control of your health, but in how the government can carry out its legitimate activities (e.g., food for soldiers, food for meeting foreign dignitaries etc.)
None of that comes close to addressing the problem of giving the state power to regulate your health, to decide what treatments you can and cannot use, or, in this case, block telemedicine.
https://open.substack.com/pub/thefrontierpsychiatrists/p/sxsw-dispatch-an-open-letter-to-ai?utm_source=direct&r=1ct8f&utm_campaign=post&utm_medium=web Pro tips on making regulations.gov comments
Frame it as an inflation driver (since it is). Technology has been hugely deflationary to everything except the guilds of medicine, housing, and education. They need to be broken.
> Meanwhile, if there are actual evil telemedicine doctors prescribing meth to impressionable young children, they’re doing the same thing. “Sorry impressionable young child, the law says I can’t keep prescribing you meth until you see me in person once. I’m renting an office temporarily, please come visit one time and pay extra so I can keep dealing meth to you.” That doctor has no problems! Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
Heheh, in Poland it's now possible to fill a simple form, and receive an electronic prescription. You don't even need to interact with a doctor. And they charge about $20 for a "consultation" (which is that form thing). It's rather hilarious, defeats any purpose in having prescriptions in the first place.
Unfortunately one can't get meth (or adderall) that way; but Xanax, SSRIs etc. are available. I bought some just in case they somehow fix the system & I will need it, as I'd hate begging for permission to get this stuff. Expiration might be a problem through...
I think that the rule to stop drug mills might be better served by regulations based on size of a practice or identifying prescribing patterns that are inconsistent with standard of care for that doctor’s specialty. Now with ISTOP in most states, DEA should be able to catch trend in “overprescribing docs” and use the yardstick of mean prescribing behavior by specialty and sub-specialty to flag doctors who’s prescribing practice they find questionable. In NJ the NJ Aware site actually tells you how your prescribing of controlled substances compares to that of other doctors. These are good means of self regulation and understanding rather than regulating large swaths of the medical community who are already exercising good clinical practice.
I’ve submitted similar comments to DEA. Thank you for taking time to write this article. I hope common sense will win in the end!
How much of a problem are over-prescriptions of stimulants and benzos? Like, if 90% of the consumers of black market meth were originally addicted to legally prescribed stimulants, that would be concerning, while if it were 1% that would point to over-prescription being mostly a non-issue.
I am assuming that there is a dosage difference between recreational use and psychiatric use, so a meth user will not just be able to fire their dealer, fake ADHD and get a doctor to prescribe the fix. And insurances would probably notice if you handed in 10 subscriptions for Desoxyn at once. Or is the concern more that people will get one subscription and sell it on the black market, defrauding their insurance companies in the process?
As a patient on psychiatric drugs, I can say that not all of us have great executive functions. The normal hurdles of both the life in general and the medical system (byzantine at times even for mentally healthy people) in particular can already randomly interrupt our drug supply quite easily. What is it with the US and regulating healthcare so that patients will need to undertake long journeys or risk legal perils to get the care they need?
Speaking of legal perils, I could imagine that for some patients, the black market may be the path of least resistance with regard to continuing their drug regime. I know I was prepared to get ketamine on some tor marketplace. (Of course, ketamine is not a scheduled narcotic in Germany, so I would only have violated the law against trading pharmaceuticals outside pharmacies. By contrast, buying amphetamines in the US probably has a recommended sentence of 5 years federal prison or something for first offenders.) I would assume that there are also regulations regarding what doctors can say regarding illegal drugs (apart from them being bad), so that illegally sourced drugs will not only suffer from quality control issues but also lack of medical advice.
Regarding to writing letters, I generally don't think it is very worthwhile to write letters to non-elected officials. Writing to their bosses in the executive branch and the policymakers in the legislative who will depend on votes at some point is slightly less likely to be a waste of time.
I admit I am relatively happy about these sort of policies, in-so-far as there are a lot of doctors benefiting from being de-facto prescription mills guarding access to valuable drugs.
I am all for legalizing every single substance known to man, it's a travesty that we haven't. But I *don't* want a half hearted legalization where amphetamines, or modafinil, or semaglutide, or benzos or what-have-you is guarded behind profit-seeking mandarins.
If prescription mills become hard, this means that more people will be pro lez faire policies around drugs or that slack will appear in another part of the system.
As an example, in most of SEA, you can just get prescription drugs from a pharmacy at the chemist's discretion (even the dangerous "this can actually kill you if you take it the wrong way and the wrong ways are many" kind). Why lobby for prescription via telemedicine and not for regulations that allow pharmacists to hand out prescription drugs if they consider it appropriate ?
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This is a step in a bad direction, but it's a step away from a solution that wasn't "good enough" but still sufficient to quell unrest.
Who came up with the idea that a physician needs to have multiple DEA certificates in different states to be able to prescribe controlled medications? Worse still, you are required to have an actual office in different states to have DEA certificates in each of those states assuming you want to prescribe controlled medications.
Back to the issue at hand, I can’t think of a single good reason why you would need to bring someone into the office once a year all because you are prescribing Adderall or lorazepam. Too many unnecessary regulations in my mind. Hopefully they’ll listen to the voice of reason
I actually have a telemedicine psychiatrist because there was virtually no way to get an appointment within less than 6 months because of the dearth of local psychiatrists that accept insurance. Ergo, telemedicine. I also see many of my other MDs via teleconference. I share Scott’s frustration. The psych can’t prescribe what he wants to prescribe me because of these laws, and instead is collaborating with my GP to get her to write the prescription for me. That’s insane, and possible only because I am lucky enough —and proactive enough—to have persuaded these folks to perform this convoluted dance.
The government should treat us with the presumption of competence, not ineptitude. At the same time, it’s incumbent upon patients to make smart assessments about which complaints require in-person appointments. I was offered a telemedicine appointment with a neurologist last year. I declined it. The complaint was such that it was clear I needed an actual exam—and the examination requires more than looking at my face. I would not have felt satisfied with any outcome of an telemedicine appointment. The same is true for seeing an orthopedist or for assessing whether you need antibiotics. I want a culture taken before I use them —and that means either an in-person exam or a visit to a lab.
None of those obtain in the case of most mental health care.
Commenter’s points regarding whether the psychiatrist has enough information to diagnose over video are ill-founded. Psychiatrists don’t usually do physical examinations. They look for affect—yes—and perhaps some elements of body language. But ultimately, the key component of their observational activity is keen listening. And there is no impediment to any amount of interrogation or conversation virtually.
These regulations are driven by an over-vigilant sense of paternalism. And I say that even as someone who leans liberal and even socialist on many subjects. But the government is preoccupied with expanding the complexity of a permission-based medical system in which the presumption is that we are all both stupid and criminal.
The encumbrances for telemedicine don’t even approach those for “controlled substances” which include ADHD, pain, anti-convulsants, anti-psychotics, anti-depressants and shockingly more medications. In 4 of the last 6 months, my regular pharmacy has been out of stock on my “controlled” prescription. That means that I spent about 7 hours each time trying to figure out an alternative. Why? Because, at least in this state, the regulations disallow all the following:
- standing refills (every month requires a new Rx)
-transferring the RX from any pharmacy to any other (that includes from, say, a Walgreens at one location to another Walgreens down the street)
-ordering the Rx to be filled more than 24 hours in advance of it running out (ostensibly because I would probably become a drug dealer if I owned 3 extra capsules). So it’s impossible to order in advance and allow a buffer for possible inventory issues.
Here’s the irony. With all that, the only way to execute a plan B when the pharmacy is out of the drug is to get the doctor to send a brand new prescription to another pharmacy at other locations until one of them has it in stock (many of them won’t tell you over the phone if they even have the medication in stock—until they have your Rx). The final impact of that is to proliferate prescriptions. That also creates an opportunity for hoarding. Assuming I’m willing to pay cash instead of insurance, I could fill a prescription at every one of those locations and open up a shop!
All of that simply to stop a pharmacy from transferring the Rx to a nearby pharmacy.
Instead of multiplying onerous regulations that make already hard-to-obtain healthcare yet more difficult, the government should embrace the benefits of supply and demand by expanding geographic and virtual/IRL boundaries. That creates greater opportunity for specialists where demand is low, and greater supply for patients where supply is inadequate.
They should do the same with the medications. Regulate who can write prescriptions without stupid additional rules. It’s a cinch to monitor pharmacies and pharmaceutical companies using big data—and much more effective than trying to create a labyrinth of rules for who, how, where, when, etc. We know from various reports that most times pill mills were operating, it was discernible in the aggregated data from the region and could be parsed to the individual pharmacy and physician. Had anyone done that we might not have an opiate crisis. But they didn’t until after-the-fact—and even then, it was first done by journalists, not regulators.
The comments might help. I can still but Kratom at every independent gas station I walk into on the back of that kind of shit.
Couldn't agree more. Punitive and idiotic.
I know there are millions suffering in the US and I'm sure there are good people trying their best to help within the very restrictive nature of being a 'medical professional' however don't you think it might be the time to stop 'doing your best' within the 'system' and become more effective outside?
Holistic health should be the driver for everyone and ultimately is the only long-term solution to overcoming dis-ease.
Currently Ignorance, misguided beliefs and external controls are the things that perpetuate the idea that 'everyone has to live a life of pain and suffering' as if this is the natural order of things.
Wellbeing is not something maintained by external intervention but by the balance of mind, body and spirit (homeostasis) something that should be a life-long, autonomous expectation of everyone from birth, unfortunately we're about as far away from this as we can be and unless this starts to change there is very little hope for future generations and potentially the human species.
Be the change you want to see in the world which can only be achieved from within. Helping others can only be truly successful once you have helped yourself.
Universal love and compassion is the only truth. Anything else is a barrier to wellbeing. It's not about fighting whatever stands in the way, it's all about allowing a better way to grow and blossom within yourself and sharing it with others. ❤️
I will be sending many patients to ER to get their controls and this will lead to overall health care burden for the patients, the system, and for costs to all in general. These rules are made by those who are not doctors and have no understanding how front line care is impacted by their dumb regulations. They will be placing pts at risk of withdrawal and doing unscrupulous things to obtain their controlled meds, possibly leading to issues with criminal justice system too. Really stupid reg if you ask me.
Psychiatrist here. While I agree with the author that a single-visit requirement makes little sense, something needs to change in the way virtual medical and psychiatric services are undermining clinical practice. What began as emergency concessions for COVID has metastasized into a remote treatment free-for-all. Were we really mistaken about the need for physical exams all those years? Does it really not matter that a few patients insist on video instead of literally WALKING to my office? Or that some hide in their parked cars because they have no privacy at home? Or worse, connect from public places, with others walking by or even interrupting them?
And that’s before we even start talking about psychostimulants and sublingual ketamine prescribed remotely after a cursory screening.
I went virtual during the pandemic out of necessity, but no longer accept new patients unless they agree to in-person treatment. Unfortunately, during the pandemic I took on several too far away to ever come in person, and others who now judge their convenience more important than the quality of their care. Lately I weigh ending the virtual visits they still want. If doctors don’t uphold clinical standards, no one else will… not most patients, and certainly not the startups that stand to gain by commodifying and “platformizing” medical practice.
There’s always been a need for telemedicine for patients too remote or immobile to be seen in person. A few clinics should offer this for patients who really need it. As for the rest of us, I’m concerned that “convenience” is a slippery slope greased by start-up money, slick advertising, and rationalizations.
“The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else.” This is my biggest fear. Not looking forward to scheduling an appointment with a primary care provider and asking them to sign something they didn’t diagnose me for and might deny.