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.
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.