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.
> [...] 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.
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.
>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.
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!
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
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.
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.
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.
We should approach things from a sensible standpoint. The whole system of prescriptions is founded on the basis of doctors knowing what they are doing, so you have to get a prescription for some things. That, by itself, is supposed to be the sanity check to prevent abuse.
But, of course, not ALL doctors, nor all psychiatrists, are on the up-and-up. So how do you put in a check on them? It sounds like this policy, as you say, only makes things harder, and doesn't in any way select for shady physicians.
I'm a software developer, not a doctor. But it seems like the way to go would be to audit at least a sample of prescriptions to make sure they were properly prescribed. The records are all there. You have to assign government employees to performing the audit, and then investigating instances that look fishy, and removing licenses and prosecuting doctors found to be bad actors.
Why would they choose the approach they are doing instead of something like this? For one, it's certainly cheaper (for the government) to simply pass a law than to implement a new bureaucracy. It's simpler (for the government). It takes less thought (for the government). And it "shows they're doing something about it".
Another commenter said "the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act."
Despite this, I still would consider that you Scott (and other doctors in similar situations) should talk to your congressperson. As in, calling them up, explaining the issue, and possibly scheduling an appointment to talk with a staffer at their local office. Congresspeople really do try to serve their constituents. Even though the proposed regulation is not a law, so Congress can't directly stop it, still better to keep it on their radar. Will have more impact than posting an internet comment (although admittedly, much higher effort). If the AMA is on your side, so much the better.
PS: Don't call it a "law" ("rule" or "regulation" should work). It's not a law, and it makes a difference (e.g. because lobbying Congress would have less direct impact). Also, I know you have beef with medical regulators in general, but if this is a DEA rule, just call them the DEA not "medical regulators". Maybe they are de facto medical regulators, but (at least outside of the medical field) not many people think of them that way. Seems like you are not exactly painting the right picture here, and bringing in your unrelated beef with the FDA.
This is an overresponse to the adderall shortage. There was an uptick in prescriptions over the pandemic and this was blamed on Cerebral and the like. Judging by Cerebral's advertising, I'm not surprised they're being branded a pill-mill; they definitely look like one. I'm currently seeing a telemedicine psych for adhd because I couldn't find an in-person psych during the pandemic, but when I saw Cerebral's adds, I figured I should avoid them.
This bill is obviously not narrowly tailored to this goal, but the goal seems pretty obvious. If there is a pill mill that only operates because they can reach hundreds of patients online with limited overhead, it will be more difficult for that group to operate if they have to meet in person. Adding in-person visits will make many of these online-only groups impossible to run. Having an option for a third-party doctor to review in person helps because that third-party doctor will presumably not endorse prescriptions for someone who has no need, or even the requirement might weed out people who never would have gotten the pills prior to telemedicine existing.
Whether this will work more in practice than it harms legitimate doctors is a good question. Personally, I think this will weed out some of the worst offenders quite effectively, but at a cost to the healthcare industry that strongly outweighs the savings from shutting down these offenders.
Isn't there clearly an issue with the DEA cap on stimulants? Even if there are "pill mills" prescribing them to people that don't actually need them, doesn't that mean that even these bogus cases are still getting bogus diagnosis? Wouldn't this mean that the DEA is refusing to adjust their cap in accordance with the number of ADHD diagnosis (legitimate or otherwise)? edited for spelling
Not quite the same thing, but...I was at a healthcare-related conference last week for work where one topic for discussion was imminent restrictions on telehealth services billed to Medicare and Medicaid, because the OIG had determined there had been a massive amount of fraud in this area over the last three years. Here's the fraud alert OIG put out on the subject last year:
Unfortunately, I couldn't tell you what makes telehealth Medicare fraud easier to pull off than regular Medicare fraud. The issue doesn't affect me personally, so I quit paying attention at some point.
I think the situation is worse for pain management doctors and patients. For many years, physicians have been at great legal peril if they prescribe opioid medications to patients deemed not to need them, or in quantities deemed excessive, even without reference to telemedicine. But, this wasn't restrictive enough, so the DEA, based on their medical expertise, has been reducing the allowable quantities.
But, even this wasn't restrictive enough, so several years ago, the DEA started threatening pharmacies that dispensed improper prescriptions. In response, one of the national chains stopped dispensing my wife's medication. The one we switched to would dispense the medication, but would not dispense refills until the day before the old prescription was used up. In addition, the pharmacist is required to personally review each prescription and validate that the quantity and frequency of medications are appropriate. If the DEA determines the pharmacist was wrong, she can lose her license and face criminal prosecution.
But, even this wasn't restrictive enough, so the DEA has started threatening insurance companies if they facilitate improper prescriptions. In December, our Pharmacy Benefits Administrator (PBA_ notified us that the new policy would limit coverage to 2 pills per day, regardless of strength. (It is common in pain management to prescribe 2 extended-release pills per day, plus smaller immediate-release pills for breakthrough pain.) The doctor could submit a justification for higher quantities.
But, even this wasn't restrictive enough, so our PBA added another automated check: if a patient presents a prescription, and another prescription for any amount was filled in the past 23 days, the quantity is further restricted. This limitation is too complicated to explain, so the PBA didn't explain it to either the insurer, or patients, or doctors, or pharmacies. In January, my wife got a prescription for 11 days' supply to last until her next doctor's appointment, when she got a new prescription for 30 days' supply which met the 2 pill per day limit. This triggered the automatic check, so her prescription wasn't covered. No explanation, just "not covered".
This is a knee-jerk reaction to a handful of sensationalized reports about online “pill mills” overprescribing amphetamines. But ultimately, this is about DC bureaucrats who want to protect their political careers. These non-doctor bureaucrats saw the opioid crisis originate with too many painkiller prescriptions, and irrespective of any differences between opioids and amphetamines, they are hell-bent on putting up as many roadblocks as possible in the misguided effort to prevent another prescription drug crisis. And once the herd in DC decides to move in one direction, everyone smart enough to understand their folly is also smart enough to know their is no upside (and lots of downside) to speaking out against the herd.
The AMA (American Medical Association) is a lobbying group that pushes for whatever keeps doctor salaries artificially high. The govt does what the AMA wants. It is always done under the pretext of helping patients, ofcourse
Does this help explain this situation with tele-medicine ? Or is something else is in play here?
I'm not entirely ready to just accept as fact that "pill mills" are a thing that is so super bad that they must be reflexively stamped-out of existence.
Then again, I know other people not only disagree with me, but want Public Health to ban all badthing mills like burger mills (Mickey D's), cigarette mills (convenience stores), fossil fuel mills (ditto), gun mills, porn mills, puppy mills...
I think the steelman argument against telemedicine in SOME situations is that you're restricting the physician's access to important information. For example, it seems very plausible to me that it's harder to detect psychosis over Zoom. I've taught online before and hated it because so much human nuance is lost, and I think that could be true for medicine too. That said, in many many use cases I think telemedicine is fine.
Of course, the bigger issue is that prescription stimulants have a lot of benefits and some drawbacks for all kinds of people. Some of them have ADHD. A lot of them don't. The question is whether we're cool with this. It appears the government is not.
Not to write a blanket defense of government regulations. And not to dismiss the very real problems you address in this post, but, much of the rhetoric in this post, I'd say, isn't particularly helpful for addressing the problems. Binary thinking is counterproductive:
>>"...Medical regulators hate new things, so for its first decade they ensured telemedicine was hard and inconvenient."
Just a bad faith take. Medical regulators have valid reasons to scrutinize "new things." Of course there are elements of group think or unreasonable resistance to change. But it's not that they (or at least all of them as a class) "hate new things." Government regulators are people to, and largely operate from the same basic cognitive and psychological constructs that YOU operate from! Just as you are likely to be open to change, you're also likely to be resistant to change.
>>"They yelled at the regulators, and the regulators grudgingly agreed to temporarily make telemedicine easy and convenient."
Again, what a bad faith take. Yes, openness to change can look "grudging." But it can also look like a role of applying appropriate scrutiny.
>>"They say “nothing is as permanent as a temporary government program”, but this only applies to government programs that make your life worse. Government programs that make your life better are ephemeral and can disappear at any moment. "
Oy. There are plenty of long-standing government programs that makes people's lives better, and plenty of government programs that "'make your life work" are ended after they prove to do so.
>>"So a few months ago, the medical regulators woke up, realized the pandemic was over, and started plotting ways to make telemedicine hard and inconvenient again."
This kind of bad faith motivation-impugning doesn't serve you well. It strikes me as antithetical to what I understand as some of your foundational principles. I understand that you are likely frustrated by what you see as obstacles to providing care to those in need. But this kind of unrealistic standard being applied against institutions of public health will not likely, IMO, lead to improvement in the long run, but more likely lead to a more impoverished role for public health in our society. Critique is critical, but it should be done with utmost care.
I am reading this after I finished my virtual meeting with my kid's psychiatrist who have extreme ADHD due to the underlying genetic disease. She has never seen him in person, but when we were establishing his diagnosis, I sent her a ton of video recordings of him in different social encounters: here he pushes other kids at a playground, and this is me trying to read him a book and he ignores and just skips through the pages; and this is him at a speech therapy constantly trying to get distracted but the teacher redirects him back.
If we went in person she would have seen him jumping on and off the chair but otherwise she would still rely on the data I as a parent would provide anyway.
We have a pediatrician though that requires we come in person and I can't come alone even if I'm just inquiring about the new lab work he needs. So I have to take him out of school in the morning, waste time driving and I yet can't have a thoughtful conversation with the doctor because the kid is noisy and continuously interrupts us. I leave the appointment, realize I forgot to ask about his folate being so low, and I can't even send an email to the practice. I have to call to pass my question and they only work Mon-Thu 9-4 with the lunch break. There's no way to leave your message if you called outside these hours. I can't wait for telemedicine to disrupt this!
As a long-term methylphenidate patient, I don’t really understand the concerns about pill mills for ADHD-grade stimulants. Couldn’t you essentially buy amphetamines over the counter in the 50s? And we made awesome cars and went to the moon.
I have struggled with motivation and executive function my whole life, and actually tried to get ADHD treatment through one of those "pill mill" online sites that are technically legal because you get screened, but pretty much exist just to sell you adderall or something. I'm not 100% sure I have ADHD but people keep telling me I do and I definitely struggle. So I got screened online by a clinician. I was honest but not, like, scrupulously, stupidly honest. I tried to answer the questions in the spirit in which they were intended, etc. I wasn't trying to scam anyone but I was trying to get meds.
Result? The clinician was like, idk, I can't really say whether you have ADHD or not. No meds. So I think sometimes even those sites are not quite as pill-milly as one might expect (or desire).
> I’m probably going to rent an office somewhere in Oakland for the month for a few thousand dollars. [...] I’ll have to charge them a bit more, to recoup the cost of the office.
I agree that this whole situation is terrible, but aren't there more economically efficient solutions here? Does it matter whether your patients drive to Oakland or to another place with far lower real estate prices?
Hell, I know several doctors (including a psychiatrist) whose “office” is just an easily accessible room in their private residence. (Though, I don't live in the US so there might be some more regulatory issues I'm overlooking, and of course you will have to be comfortable giving patients your private address.)
An excellent illustration of Conquest's First Law ("Everyone is conservative about what he knows best"). Hopefully it helps illustrate why many of us despise and resent government regulation for social engineering purposes.
By definition it's a bad faith take. Indeed, as in your follow-on comment, it eliminates any "charity," any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking.
I am not suggesting that critique isn't critical. But I don't think this kind of critique, imo in a Manichean framework, incorporating a kind of fundamental attribution error, is constructive in the long run. The net effect, imo, in balance, is just to tear down public health. We're on that track as a society, and I find it concerning.
I'm sympathetic to your arguments about telemedicine, but the intro was very disappointing. I understand your frustration with the new law, but to start off by claiming that the motivation behind its creation is that regulators hate new things and want to inconvenience people is just lazy writing and bad rhetoric.
Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
Simple rule of thumb: designing broad based rules to prevent outlier events never works out well. The majority end up suffering from the rule and the ones that the rule is designed to catch know how to game whatever rule is put in place.
I’m not sure that what Scott wrote is even completely accurate. I have a relative who is an MD in this space, and it seems that the underlying problem is not the DEA but an actual law passed by Congress. Aren’t telemedicine regulations limited with respect to controlled substances by the Ryan Haight Act of 2008 U.S.C. § 829(e)… there may be interpretations of this act by the DEA and other agencies, but, where controlled substances are prescribed by means of the Internet, the general requirement is that the prescribing Practitioner must have conducted at least one in-person medical evaluation of the patient.
It seems like a colossal overreach to ask an Executive Branch agency to overrule the plain text of the act. There are some exceptions, which Scott noted. A different way of looking at things was that the Executive Branch was highly responsive to the emergency situation of Covid. Now that it’s not an emergency, they are obligated to return to the legal framework that exists. Congress needs to change the law, not the DEA.
The *data* from covid should be used as part of a cost-benefit analysis to determine whether it is reasonable to regulate telemedicine, and, if so, what regulations might address whatever problems arose.
Btw, when I traveled out of state and requested a telemedicine appointment with an internist in my state, the software they have at the clinic did not work. They have strange clunky software but this happened because they're designed to NOT work out of state. Wish they'd use Google meet or Zoom or something ordinary like that. That's what concierge medicine doctors seem to use - they cut out the red tape.
All your points are valid ones, but there's this other issue, where there are some doctors who have overprescribed a huge variety of drugs (opiods being the most common example), even though I'm sure most doctors are responsible with meds. Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing. OK, of course, as with most regulations, the in-person requirement doesn't address this problem very well, as it has loopholes that make the regulation more of an inconvenience than a ban. But, when did that ever matter when it comes to a hot story that can be done in a way to inflame readers and (even better!) embarrass regulators! Which is probably some of the explanation why it's so hard for you to get the voice of reason heard.
One quibble with what you say. Comparing our health care regulators to Putin! How American. What you're talking about is on the level of inefficiency and in many cases, let's say, inconvenience for Dr. and patient alike, because of the loopholes in the regs that you mention. I like my fellow Americans do highly value making things convenient and efficient. But hey, it's a bad look to suggest requiring a second doctor to vouch for medications prescribed on line, in the context of some highly publicized abuses of that practice, is like... Putin's Russia. Unless the goal is to contribute to the bonfire that's American political discourse these days.
I generally like your writing and ideas, hell, I just re-uped for a year.
However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else."
In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time.
Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors.
Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking.
From a headline and PR standpoint, really need to develop and distinguish a different term than "controlled substance" if possible. Many people will only read the headline and think about law enforcement, prescription drug abuse, and problems stemming from something like opioid addiction/meth.
Notably absent from this post: any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. I genuinely don't want to be rude here; the temptation to isolated demands for rigor is greatest in fields where you consider yourself an expert.
"Did I mention that if you come off of some of them too quickly, you can literally die?"
I once had the opposite problem. I had severe epilepsy, but the dosage of the most-likely-to-be-helpful medication, Lamictal, had to be increased veeery slowly, otherwise it could cause a potentially-deadly skin rash.
Obviously I mourn the 100,000 people a year that die from opioids, but the negative toll on the people that don’t abuse opioids but need them is a very big price to pay for their abuse. This war on opioids harms many people caught up in the crossfire that need a drug that has been used since the beginning of human history!
Would it fulfill the letter of the law to have a patient go to an Urgent Care facility to get that letter signed? At least then it means minimal waiting and even the out-of-pocket costs tend to be low.
True, dumb, and pointless yes, but how else can an incompetent bureaucracy respond to the demands of commercial real estate owners? When trying to also forget every single lesson and ‘go back to work’ to monitor, control, and force people to waste money on transport and commercial real estate…they’re all out of ideas and revert to fascistic practices of stupid rules to force people to comply.
There is a fairly real existential threat to the financiers, banks, and wealthy land owners who wish to do continue to do nothing and be paid enormous sums of money for the service of simply owning things they didn’t build while holding us all hostage to their MAD style scheme to send the economy into a Great Depression 2.0 if their terms are not met.
This knee jerk and too little too late series of spasmodic reactions and planned obsolescence of anything disadvantageous to them may be part of this, along with the general trend of everything getting worse and all your favourite tv shows, brands, products, foods, restaurants, and government rules being inexplicably cancelled.
It may sound outlandish or conspiratorial to some, but it truly is what motivates the upper and powerful classes. The demands of enormously wealthy landlords and the even larger financial system behind them are always heard via all their legalised bribes of all kinds to politicians and senior staff in every single agency and regulator who get donations, speaking fees, and highly paid ‘jobs’. Regardless of the veneer of democracy, these groups in studies almost always get their way or erode things to get their way over time after populist movements’ brief attention span of a year or two ends.
Even the neocons could only squeeze and divert a hundred billion or so into their latest proxy war, but the banks were able to get 2 trillion plus of money printing done pretty much overnight because they asked for it.
And they are freaking out about commercial real estate and the collapse of the banking system. A broad demand to end all kinds of work from home is happening and that includes things like telemedicine. I doubt the elites behind this push would know, care, or be personally affected by this specific rule change.
But that’s how incredible power works and long chains of people interpreting their marching orders operate, quickly asking how high to jump when told to do so. Years and decades of activism and sensible modern policies by huge movements can be undone if one of our invisible aristocracies even so much as sneezes. And that’s just an unintended drive for compliance to their a near absolute demands. That’s the true power structure. And they are right, the economy has been built on glass support beams and will go into a terrible depression if we do see a continued lack of demand and turnover for 70% of commercials real estate into a non-free debt environment of 5% or more fed funding rates.
We are seeing bureaucratic panic, which will inevitably not ‘solve’ the problem of most offices being unnecessary and will hurt many vulnerable powerless people in a myriad of ways. Is this 100% the total answer to why this specific rule change is happening? Of course it isn’t, but it is a significant structural factor in how choices, all choices get made by powerful controlling systems.
Or we can be naive and pretend power somehow doesn’t continue to operate as it has for millennia.
I'm one of those "bad" people who thinks potentially addictive meds should require in-person evaluation. I worked for a psychiatric and social work agency for 15 years. Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today.
Telemedicine for an earache or my son's psoriosis -- okay. An antibiotic, some cream for his outbreaks. Fine. But I've done telemed a few times since covid and it is not like seeing a doctor in person. Yeah, the antibiotic -- on the third call -- fixed my sinus infection, but my swollen knee -- well, no. Doc gave me a prescription for painkillers and a steroid based on my camera angle. It didn't fix it. But I didn't take the painkillers, because I know they're addictive (and they generally make me puke). I asked for a referral to a physical therapist to actually fix my knee. "After you've done this for a while. In the meantime, put your feet up" and get out of shape and make the problem worse. Fortunately, I rain into a friend who is a PT and she gave me "advice" that included going to the gym and getting my knee back in shape. I stopped taking the steriod. I'll report to the doctor when I go for my annual -- IF I go for my annual because telemed isn't really medical care.
Hey everyone; sorry for posting randomly on here. I'm undergoing psychiatric treatment myself. I have a rough situation up here in Canada, since there's a massive shortage of psychiatrists (https://www.thestar.com/news/canada/2022/01/15/psychiatrist-burnout-why-covid-weary-doctors-are-taking-a-mental-health-break.html): "These departures are leaving Ontario with an acute shortage of psychiatrists, says Villela. The number per capita was already declining before the pandemic, according to the Canadian Medical Association. And with half of all Canadian practitioners over the age of 55, that shortage is likely to accelerate."
I have a whole ton of questions about psychiatry and it's really frustrating. I don't know who to ask. I sometimes randomly email researchers but that only works once in a blue moon.
What's the best place online to get answers to certain questions? Like the most basic one I have is whether it's possible for a patient to simply be some kind of weird outlier who needs high doses of certain medications; such a patient is in a tough spot because someone might not want to prescribe high doses for them. What legal issues arise when psychiatrists go outside the bounds of the guidelines? I assume that psychiatrists wouldn't ever do so if doing so invites legal danger.
I found this (https://astralcodexten.substack.com/p/oh-the-places-youll-go-when-trying) super interesting but I still have questions. Regarding escitalopram, what exact risk do you face if you go up to like 50mg, 60mg, 70mg? And why are people seeking to declare that nobody (not even outliers) can benefit from high-dose escitalopram if indeed that's what their saying?
And why would a patient need so much escitalopram (or guanfacine for that matter...imagine a patient who needs 10mg guanfacine XR in order to get a good treatment effect)? Is a patient who's an outlier (when it comes to needing high doses) unusual pharmacodynamically or pharmacokinetically?
Another weird thing is what if a patient swears up and down that they experience very powerful effects from a medication within seconds or within a couple minutes? We can say that it's just placebo, but what in our science sets a hard limit on how quickly a molecule could reach the brain or affect the brain? The difficulty here is that it seems like you have to (1) identify all possible pathways through which a non-placebo effect could occur, (2) rule out the possibility that there's another pathway that you're unfamiliar with, and (3) rule out that any of the possible pathways could allow for such a fast non-placebo reaction.
I'd love to read to a pro-medical-regulator person steelman this, and be able to have it withstand these criticisms, and the kinds of criticisms this forum can bring to bear. I mean, I doubt its possible, but I would love to read the attempt.
So, as a factual question, is this primarily the law as written preventing telemedicine of controlled substances or is it the DEA choosing to make it difficult?
Because "regulator" is kind of being used in a general way with specifying whether this is, at core, the fault of DEA administrators making a policy decision or of the Senate/Congress making a bad law. Let me clarify, from the Federal Register link provided (1):
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As indicated above, in 21 U.S.C. 829(e), the Ryan Haight Act generally requires an in-person medical evaluation prior to the prescription of controlled substances. Section 829(e), however, also provides an exception to this in-person medical evaluation requirement where the practitioner is “engaged in the practice of telemedicine” [17] within the meaning of the Ryan Haight Act (21 U.S.C. 802(54)).
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The DEA release makes several references to the Ryan Haight Act, which you can read here (2), having a clear intent to prevent controlled substances from being prescribed without an in-person evaluation. The statutory authority doesn't appear to be anywhere within the core of the law but instead...basically a loophole buried in paragraph of a subsection.
Because, if the law was clearly written to do X, and we want to pressure the DEA to use a loophole to achieve the opposite of X, because they allowed the opposite of X in a global emergency, that has...several obvious concerns.
But I don't know enough to make the specific argument that "no, this is Congress' fault, the DEA is faithfully fulfilling the law as written". So, for people with either more legal experience of more practical medical regulatory experience than me, what was the intent of the Ryan Haight Act, how much discretion does the DEA have here, and who is ultimately responsible?
While we are talking about stupid bureaucratic requirements, can we pretty please acknowledge that fax machines are over and adjust our talmudic interpretations of HIPAA accordingly? This is very small bore compared to telemedicine, and so probably less likely to happen, but really.... So stupid.
I'm actually slightly optimistic about this for selfish reasons. I have been on stimulants for ADHD for 20+ years. This will make getting a prescription for said meds very difficult.
However, due to the FDA limit on stimulant manufacturer, for the past 6 months I haven't been able to get ANY medication WITH a prescription. Every pharmacy is out of every stimulant.
So. If demand drops, and I have to work harder, but can eventually actually obtain the meds I need to not be fired from my job...
Well, it's way better for me than the current situation.
23k comments and climbing. In a search for "good", I found mostly comments about it "doing more harm than good", but in a search for "thank you", buried among the "...for your time" is at least one comment that seems to have a sincere appreciation for one effect of such a regulation, specifically that it should reduce accessibility of euthenasia drugs, which is a moral stance that I think is honest and worthy of consideration. In my opinion though it doesn't counterbalance the overwhelming deluge of negative comments, including official responses from nonprofit providers saying that this will be especially bad for them.
>The problem here is that the DEA is trying to catch evil overprescribers by filtering for whether a doctor can see a patient one time in person, which is uncorrelated with whether they’re an evil overprescriber or not. It’s just an extra hurdle that’s inconvenient for everyone
Scott, do you remember the Lesswrong post "beware trivial inconveniences"?
I would be very surprised if this requirement did *not* discourage a significant number of overprescribers. (Consider that "overprescriber" may contain elements of fraud and not just be "otherwise legitimate psychiatrist who prescribes too much". And that drug abusers are poor and/or lazy and thus may find it hard to get to a psychiatrist's office.)
My last doctor set up a telephonic visit. When he called he didn't know who I was, then asked me what I wanted. Then he tried to convince me I was some other doctor's patient. So we don't do 'telemedicine'. They'd like to turn medical care into a video game. It's much cheaper, and maybe could get ChatAGT or whatever to provide care through Siri. The profit could be tremendous.
I went back to my previous GP, a man named Ramakrishna. The last thing I heard my telephone doctor say as I left his office was "pseudocysts!" as if he finally remembered I was a patient. Too late.
IEDs occur more often in patients with ADHD and may contribute to symptoms of this disease [10,11,12,13,14,15]. There are clinical studies suggesting that antiepileptic drugs (sodium and calcium channel inhibitors) reduce ADHD symptoms. For example, it was found that the calcium channel inhibitor levetiracetam inhibits IEDs and reduces symptoms of ADHD in children suffering from this disease [11, 12]. Another study showed that sodium channel inhibitor lamotrigine decreases ADHD symptoms in epileptic patients with ADHD. This effect correlated with EEG normalization and a reduction of epilepsy symptoms [36]. It was also found that sodium channel inhibitor carbamazepine inhibits IEDs in children with ADHD. This effect correlated with clinical improvement [37]. It could be speculated that in some patients guanfacine may reduce ADHD symptoms by inhibiting interictal epileptic events. Thus, guanfacine may exert beneficial effects in ADHD not only by stimulating alpha-2 adrenergic receptors as shown previously [6] but also in an additional mechanism which is the inhibition of sodium channels and consequently inhibition of IEDs.
What puts a bad taste in my mouth is the "there's nothing we can really do except whistle into the wind" stance on addressing regulatory issues. Yet, here we are.
Is there truly nothing within the capacity of all of our advanced technology and communications systems to arm "experts" like Scott with tools to have a disproportionately loud voice in situations like this?
May I suggest a book to review or a person to research "The Mastermind" which is about Paul LeRoux, for an alternate view on the whole telemedicine thing and a different perspective into the opioid crisis.
LeRoux is sort of a dark mirror to many of the tech innovator capitalists that are glorified in our society. LeRoux innovated by building what can charitably be describe as a platform for telemedicine or to the government a cyber pill mill that sold opioids to Americans.
LeRoux was one of the largest spammers in the world and arguably was initially a Gray market tech entrepeneur until he decided to be a black market entrepreneur who moved towards selling missiles to Iran, buying North Korean drugs and killing people.
That aside a question for our host, how do you believe pill mills should be dealt with?
From your perspective as a practicing psychiatrist, how viable/reasonable would it be to put a limit on the number of patients to whom a psychiatrist can prescribe controlled substances? Realistically, there's a limit to the number of patients a doctor can concurrently monitor thoroughly enough to determine that controlled substances are appropriate, right?
Frame it as an inflation driver (since it is). Technology has been hugely deflationary to everything except the guilds of medicine, housing, and education. They need to be broken.
> Meanwhile, if there are actual evil telemedicine doctors prescribing meth to impressionable young children, they’re doing the same thing. “Sorry impressionable young child, the law says I can’t keep prescribing you meth until you see me in person once. I’m renting an office temporarily, please come visit one time and pay extra so I can keep dealing meth to you.” That doctor has no problems! Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
Heheh, in Poland it's now possible to fill a simple form, and receive an electronic prescription. You don't even need to interact with a doctor. And they charge about $20 for a "consultation" (which is that form thing). It's rather hilarious, defeats any purpose in having prescriptions in the first place.
Unfortunately one can't get meth (or adderall) that way; but Xanax, SSRIs etc. are available. I bought some just in case they somehow fix the system & I will need it, as I'd hate begging for permission to get this stuff. Expiration might be a problem through...
I think that the rule to stop drug mills might be better served by regulations based on size of a practice or identifying prescribing patterns that are inconsistent with standard of care for that doctor’s specialty. Now with ISTOP in most states, DEA should be able to catch trend in “overprescribing docs” and use the yardstick of mean prescribing behavior by specialty and sub-specialty to flag doctors who’s prescribing practice they find questionable. In NJ the NJ Aware site actually tells you how your prescribing of controlled substances compares to that of other doctors. These are good means of self regulation and understanding rather than regulating large swaths of the medical community who are already exercising good clinical practice.
How much of a problem are over-prescriptions of stimulants and benzos? Like, if 90% of the consumers of black market meth were originally addicted to legally prescribed stimulants, that would be concerning, while if it were 1% that would point to over-prescription being mostly a non-issue.
I am assuming that there is a dosage difference between recreational use and psychiatric use, so a meth user will not just be able to fire their dealer, fake ADHD and get a doctor to prescribe the fix. And insurances would probably notice if you handed in 10 subscriptions for Desoxyn at once. Or is the concern more that people will get one subscription and sell it on the black market, defrauding their insurance companies in the process?
As a patient on psychiatric drugs, I can say that not all of us have great executive functions. The normal hurdles of both the life in general and the medical system (byzantine at times even for mentally healthy people) in particular can already randomly interrupt our drug supply quite easily. What is it with the US and regulating healthcare so that patients will need to undertake long journeys or risk legal perils to get the care they need?
Speaking of legal perils, I could imagine that for some patients, the black market may be the path of least resistance with regard to continuing their drug regime. I know I was prepared to get ketamine on some tor marketplace. (Of course, ketamine is not a scheduled narcotic in Germany, so I would only have violated the law against trading pharmaceuticals outside pharmacies. By contrast, buying amphetamines in the US probably has a recommended sentence of 5 years federal prison or something for first offenders.) I would assume that there are also regulations regarding what doctors can say regarding illegal drugs (apart from them being bad), so that illegally sourced drugs will not only suffer from quality control issues but also lack of medical advice.
Regarding to writing letters, I generally don't think it is very worthwhile to write letters to non-elected officials. Writing to their bosses in the executive branch and the policymakers in the legislative who will depend on votes at some point is slightly less likely to be a waste of time.
I admit I am relatively happy about these sort of policies, in-so-far as there are a lot of doctors benefiting from being de-facto prescription mills guarding access to valuable drugs.
I am all for legalizing every single substance known to man, it's a travesty that we haven't. But I *don't* want a half hearted legalization where amphetamines, or modafinil, or semaglutide, or benzos or what-have-you is guarded behind profit-seeking mandarins.
If prescription mills become hard, this means that more people will be pro lez faire policies around drugs or that slack will appear in another part of the system.
As an example, in most of SEA, you can just get prescription drugs from a pharmacy at the chemist's discretion (even the dangerous "this can actually kill you if you take it the wrong way and the wrong ways are many" kind). Why lobby for prescription via telemedicine and not for regulations that allow pharmacists to hand out prescription drugs if they consider it appropriate ?
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This is a step in a bad direction, but it's a step away from a solution that wasn't "good enough" but still sufficient to quell unrest.
Who came up with the idea that a physician needs to have multiple DEA certificates in different states to be able to prescribe controlled medications? Worse still, you are required to have an actual office in different states to have DEA certificates in each of those states assuming you want to prescribe controlled medications.
Back to the issue at hand, I can’t think of a single good reason why you would need to bring someone into the office once a year all because you are prescribing Adderall or lorazepam. Too many unnecessary regulations in my mind. Hopefully they’ll listen to the voice of reason
I actually have a telemedicine psychiatrist because there was virtually no way to get an appointment within less than 6 months because of the dearth of local psychiatrists that accept insurance. Ergo, telemedicine. I also see many of my other MDs via teleconference. I share Scott’s frustration. The psych can’t prescribe what he wants to prescribe me because of these laws, and instead is collaborating with my GP to get her to write the prescription for me. That’s insane, and possible only because I am lucky enough —and proactive enough—to have persuaded these folks to perform this convoluted dance.
The government should treat us with the presumption of competence, not ineptitude. At the same time, it’s incumbent upon patients to make smart assessments about which complaints require in-person appointments. I was offered a telemedicine appointment with a neurologist last year. I declined it. The complaint was such that it was clear I needed an actual exam—and the examination requires more than looking at my face. I would not have felt satisfied with any outcome of an telemedicine appointment. The same is true for seeing an orthopedist or for assessing whether you need antibiotics. I want a culture taken before I use them —and that means either an in-person exam or a visit to a lab.
None of those obtain in the case of most mental health care.
Commenter’s points regarding whether the psychiatrist has enough information to diagnose over video are ill-founded. Psychiatrists don’t usually do physical examinations. They look for affect—yes—and perhaps some elements of body language. But ultimately, the key component of their observational activity is keen listening. And there is no impediment to any amount of interrogation or conversation virtually.
These regulations are driven by an over-vigilant sense of paternalism. And I say that even as someone who leans liberal and even socialist on many subjects. But the government is preoccupied with expanding the complexity of a permission-based medical system in which the presumption is that we are all both stupid and criminal.
The encumbrances for telemedicine don’t even approach those for “controlled substances” which include ADHD, pain, anti-convulsants, anti-psychotics, anti-depressants and shockingly more medications. In 4 of the last 6 months, my regular pharmacy has been out of stock on my “controlled” prescription. That means that I spent about 7 hours each time trying to figure out an alternative. Why? Because, at least in this state, the regulations disallow all the following:
- standing refills (every month requires a new Rx)
-transferring the RX from any pharmacy to any other (that includes from, say, a Walgreens at one location to another Walgreens down the street)
-ordering the Rx to be filled more than 24 hours in advance of it running out (ostensibly because I would probably become a drug dealer if I owned 3 extra capsules). So it’s impossible to order in advance and allow a buffer for possible inventory issues.
Here’s the irony. With all that, the only way to execute a plan B when the pharmacy is out of the drug is to get the doctor to send a brand new prescription to another pharmacy at other locations until one of them has it in stock (many of them won’t tell you over the phone if they even have the medication in stock—until they have your Rx). The final impact of that is to proliferate prescriptions. That also creates an opportunity for hoarding. Assuming I’m willing to pay cash instead of insurance, I could fill a prescription at every one of those locations and open up a shop!
All of that simply to stop a pharmacy from transferring the Rx to a nearby pharmacy.
Instead of multiplying onerous regulations that make already hard-to-obtain healthcare yet more difficult, the government should embrace the benefits of supply and demand by expanding geographic and virtual/IRL boundaries. That creates greater opportunity for specialists where demand is low, and greater supply for patients where supply is inadequate.
They should do the same with the medications. Regulate who can write prescriptions without stupid additional rules. It’s a cinch to monitor pharmacies and pharmaceutical companies using big data—and much more effective than trying to create a labyrinth of rules for who, how, where, when, etc. We know from various reports that most times pill mills were operating, it was discernible in the aggregated data from the region and could be parsed to the individual pharmacy and physician. Had anyone done that we might not have an opiate crisis. But they didn’t until after-the-fact—and even then, it was first done by journalists, not regulators.
I know there are millions suffering in the US and I'm sure there are good people trying their best to help within the very restrictive nature of being a 'medical professional' however don't you think it might be the time to stop 'doing your best' within the 'system' and become more effective outside?
Holistic health should be the driver for everyone and ultimately is the only long-term solution to overcoming dis-ease.
Currently Ignorance, misguided beliefs and external controls are the things that perpetuate the idea that 'everyone has to live a life of pain and suffering' as if this is the natural order of things.
Wellbeing is not something maintained by external intervention but by the balance of mind, body and spirit (homeostasis) something that should be a life-long, autonomous expectation of everyone from birth, unfortunately we're about as far away from this as we can be and unless this starts to change there is very little hope for future generations and potentially the human species.
Be the change you want to see in the world which can only be achieved from within. Helping others can only be truly successful once you have helped yourself.
Universal love and compassion is the only truth. Anything else is a barrier to wellbeing. It's not about fighting whatever stands in the way, it's all about allowing a better way to grow and blossom within yourself and sharing it with others. ❤️
I will be sending many patients to ER to get their controls and this will lead to overall health care burden for the patients, the system, and for costs to all in general. These rules are made by those who are not doctors and have no understanding how front line care is impacted by their dumb regulations. They will be placing pts at risk of withdrawal and doing unscrupulous things to obtain their controlled meds, possibly leading to issues with criminal justice system too. Really stupid reg if you ask me.
Psychiatrist here. While I agree with the author that a single-visit requirement makes little sense, something needs to change in the way virtual medical and psychiatric services are undermining clinical practice. What began as emergency concessions for COVID has metastasized into a remote treatment free-for-all. Were we really mistaken about the need for physical exams all those years? Does it really not matter that a few patients insist on video instead of literally WALKING to my office? Or that some hide in their parked cars because they have no privacy at home? Or worse, connect from public places, with others walking by or even interrupting them?
And that’s before we even start talking about psychostimulants and sublingual ketamine prescribed remotely after a cursory screening.
I went virtual during the pandemic out of necessity, but no longer accept new patients unless they agree to in-person treatment. Unfortunately, during the pandemic I took on several too far away to ever come in person, and others who now judge their convenience more important than the quality of their care. Lately I weigh ending the virtual visits they still want. If doctors don’t uphold clinical standards, no one else will… not most patients, and certainly not the startups that stand to gain by commodifying and “platformizing” medical practice.
There’s always been a need for telemedicine for patients too remote or immobile to be seen in person. A few clinics should offer this for patients who really need it. As for the rest of us, I’m concerned that “convenience” is a slippery slope greased by start-up money, slick advertising, and rationalizations.
“The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else.” This is my biggest fear. Not looking forward to scheduling an appointment with a primary care provider and asking them to sign something they didn’t diagnose me for and might deny.
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.
> [...] 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.
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.
>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.
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!
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
Thank you for alerting us to this shitty legislative development. I commented, though I share your skepticism that it will do any good.
...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.
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.
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
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.
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.
We should approach things from a sensible standpoint. The whole system of prescriptions is founded on the basis of doctors knowing what they are doing, so you have to get a prescription for some things. That, by itself, is supposed to be the sanity check to prevent abuse.
But, of course, not ALL doctors, nor all psychiatrists, are on the up-and-up. So how do you put in a check on them? It sounds like this policy, as you say, only makes things harder, and doesn't in any way select for shady physicians.
I'm a software developer, not a doctor. But it seems like the way to go would be to audit at least a sample of prescriptions to make sure they were properly prescribed. The records are all there. You have to assign government employees to performing the audit, and then investigating instances that look fishy, and removing licenses and prosecuting doctors found to be bad actors.
Why would they choose the approach they are doing instead of something like this? For one, it's certainly cheaper (for the government) to simply pass a law than to implement a new bureaucracy. It's simpler (for the government). It takes less thought (for the government). And it "shows they're doing something about it".
Another commenter said "the DEA was instructed by law in -2008- to develop a special registration process for telemedicine to allow providers to prescribe controlled substances remotely. The DEA has simply failed to do so in that time, despite repeated Congressional demands to act."
Despite this, I still would consider that you Scott (and other doctors in similar situations) should talk to your congressperson. As in, calling them up, explaining the issue, and possibly scheduling an appointment to talk with a staffer at their local office. Congresspeople really do try to serve their constituents. Even though the proposed regulation is not a law, so Congress can't directly stop it, still better to keep it on their radar. Will have more impact than posting an internet comment (although admittedly, much higher effort). If the AMA is on your side, so much the better.
PS: Don't call it a "law" ("rule" or "regulation" should work). It's not a law, and it makes a difference (e.g. because lobbying Congress would have less direct impact). Also, I know you have beef with medical regulators in general, but if this is a DEA rule, just call them the DEA not "medical regulators". Maybe they are de facto medical regulators, but (at least outside of the medical field) not many people think of them that way. Seems like you are not exactly painting the right picture here, and bringing in your unrelated beef with the FDA.
This is an overresponse to the adderall shortage. There was an uptick in prescriptions over the pandemic and this was blamed on Cerebral and the like. Judging by Cerebral's advertising, I'm not surprised they're being branded a pill-mill; they definitely look like one. I'm currently seeing a telemedicine psych for adhd because I couldn't find an in-person psych during the pandemic, but when I saw Cerebral's adds, I figured I should avoid them.
This bill is obviously not narrowly tailored to this goal, but the goal seems pretty obvious. If there is a pill mill that only operates because they can reach hundreds of patients online with limited overhead, it will be more difficult for that group to operate if they have to meet in person. Adding in-person visits will make many of these online-only groups impossible to run. Having an option for a third-party doctor to review in person helps because that third-party doctor will presumably not endorse prescriptions for someone who has no need, or even the requirement might weed out people who never would have gotten the pills prior to telemedicine existing.
Whether this will work more in practice than it harms legitimate doctors is a good question. Personally, I think this will weed out some of the worst offenders quite effectively, but at a cost to the healthcare industry that strongly outweighs the savings from shutting down these offenders.
"Commenting seems almost pathetically innocent,"
Policy matters are determined by experts.
Commentators are not experts.
Therefore those commenting should stop wasting time and obey the experts.
Isn't there clearly an issue with the DEA cap on stimulants? Even if there are "pill mills" prescribing them to people that don't actually need them, doesn't that mean that even these bogus cases are still getting bogus diagnosis? Wouldn't this mean that the DEA is refusing to adjust their cap in accordance with the number of ADHD diagnosis (legitimate or otherwise)? edited for spelling
Not quite the same thing, but...I was at a healthcare-related conference last week for work where one topic for discussion was imminent restrictions on telehealth services billed to Medicare and Medicaid, because the OIG had determined there had been a massive amount of fraud in this area over the last three years. Here's the fraud alert OIG put out on the subject last year:
https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf
Unfortunately, I couldn't tell you what makes telehealth Medicare fraud easier to pull off than regular Medicare fraud. The issue doesn't affect me personally, so I quit paying attention at some point.
My understanding was the obstacles to telemedicine are to keep down costs. If you make people physically go to the doctor they go far less.
I think the situation is worse for pain management doctors and patients. For many years, physicians have been at great legal peril if they prescribe opioid medications to patients deemed not to need them, or in quantities deemed excessive, even without reference to telemedicine. But, this wasn't restrictive enough, so the DEA, based on their medical expertise, has been reducing the allowable quantities.
But, even this wasn't restrictive enough, so several years ago, the DEA started threatening pharmacies that dispensed improper prescriptions. In response, one of the national chains stopped dispensing my wife's medication. The one we switched to would dispense the medication, but would not dispense refills until the day before the old prescription was used up. In addition, the pharmacist is required to personally review each prescription and validate that the quantity and frequency of medications are appropriate. If the DEA determines the pharmacist was wrong, she can lose her license and face criminal prosecution.
But, even this wasn't restrictive enough, so the DEA has started threatening insurance companies if they facilitate improper prescriptions. In December, our Pharmacy Benefits Administrator (PBA_ notified us that the new policy would limit coverage to 2 pills per day, regardless of strength. (It is common in pain management to prescribe 2 extended-release pills per day, plus smaller immediate-release pills for breakthrough pain.) The doctor could submit a justification for higher quantities.
But, even this wasn't restrictive enough, so our PBA added another automated check: if a patient presents a prescription, and another prescription for any amount was filled in the past 23 days, the quantity is further restricted. This limitation is too complicated to explain, so the PBA didn't explain it to either the insurer, or patients, or doctors, or pharmacies. In January, my wife got a prescription for 11 days' supply to last until her next doctor's appointment, when she got a new prescription for 30 days' supply which met the 2 pill per day limit. This triggered the automatic check, so her prescription wasn't covered. No explanation, just "not covered".
This is your government at work to protect you.
This is a knee-jerk reaction to a handful of sensationalized reports about online “pill mills” overprescribing amphetamines. But ultimately, this is about DC bureaucrats who want to protect their political careers. These non-doctor bureaucrats saw the opioid crisis originate with too many painkiller prescriptions, and irrespective of any differences between opioids and amphetamines, they are hell-bent on putting up as many roadblocks as possible in the misguided effort to prevent another prescription drug crisis. And once the herd in DC decides to move in one direction, everyone smart enough to understand their folly is also smart enough to know their is no upside (and lots of downside) to speaking out against the herd.
The AMA (American Medical Association) is a lobbying group that pushes for whatever keeps doctor salaries artificially high. The govt does what the AMA wants. It is always done under the pretext of helping patients, ofcourse
Does this help explain this situation with tele-medicine ? Or is something else is in play here?
Actually they do pay attention to comments. You might try to suggest another way of addressing the problem they believe exists.
I'm not entirely ready to just accept as fact that "pill mills" are a thing that is so super bad that they must be reflexively stamped-out of existence.
Then again, I know other people not only disagree with me, but want Public Health to ban all badthing mills like burger mills (Mickey D's), cigarette mills (convenience stores), fossil fuel mills (ditto), gun mills, porn mills, puppy mills...
A pity that The War On Drugs is a sacred cow that is milked by many constituencies.
Rather than playing Whack-A-Mole chasing users and suppliers, we could be asking why so many people are so bound and determined to get high?
I think the steelman argument against telemedicine in SOME situations is that you're restricting the physician's access to important information. For example, it seems very plausible to me that it's harder to detect psychosis over Zoom. I've taught online before and hated it because so much human nuance is lost, and I think that could be true for medicine too. That said, in many many use cases I think telemedicine is fine.
Of course, the bigger issue is that prescription stimulants have a lot of benefits and some drawbacks for all kinds of people. Some of them have ADHD. A lot of them don't. The question is whether we're cool with this. It appears the government is not.
Scott -
Not to write a blanket defense of government regulations. And not to dismiss the very real problems you address in this post, but, much of the rhetoric in this post, I'd say, isn't particularly helpful for addressing the problems. Binary thinking is counterproductive:
>>"...Medical regulators hate new things, so for its first decade they ensured telemedicine was hard and inconvenient."
Just a bad faith take. Medical regulators have valid reasons to scrutinize "new things." Of course there are elements of group think or unreasonable resistance to change. But it's not that they (or at least all of them as a class) "hate new things." Government regulators are people to, and largely operate from the same basic cognitive and psychological constructs that YOU operate from! Just as you are likely to be open to change, you're also likely to be resistant to change.
>>"They yelled at the regulators, and the regulators grudgingly agreed to temporarily make telemedicine easy and convenient."
Again, what a bad faith take. Yes, openness to change can look "grudging." But it can also look like a role of applying appropriate scrutiny.
>>"They say “nothing is as permanent as a temporary government program”, but this only applies to government programs that make your life worse. Government programs that make your life better are ephemeral and can disappear at any moment. "
Oy. There are plenty of long-standing government programs that makes people's lives better, and plenty of government programs that "'make your life work" are ended after they prove to do so.
>>"So a few months ago, the medical regulators woke up, realized the pandemic was over, and started plotting ways to make telemedicine hard and inconvenient again."
This kind of bad faith motivation-impugning doesn't serve you well. It strikes me as antithetical to what I understand as some of your foundational principles. I understand that you are likely frustrated by what you see as obstacles to providing care to those in need. But this kind of unrealistic standard being applied against institutions of public health will not likely, IMO, lead to improvement in the long run, but more likely lead to a more impoverished role for public health in our society. Critique is critical, but it should be done with utmost care.
I am reading this after I finished my virtual meeting with my kid's psychiatrist who have extreme ADHD due to the underlying genetic disease. She has never seen him in person, but when we were establishing his diagnosis, I sent her a ton of video recordings of him in different social encounters: here he pushes other kids at a playground, and this is me trying to read him a book and he ignores and just skips through the pages; and this is him at a speech therapy constantly trying to get distracted but the teacher redirects him back.
If we went in person she would have seen him jumping on and off the chair but otherwise she would still rely on the data I as a parent would provide anyway.
We have a pediatrician though that requires we come in person and I can't come alone even if I'm just inquiring about the new lab work he needs. So I have to take him out of school in the morning, waste time driving and I yet can't have a thoughtful conversation with the doctor because the kid is noisy and continuously interrupts us. I leave the appointment, realize I forgot to ask about his folate being so low, and I can't even send an email to the practice. I have to call to pass my question and they only work Mon-Thu 9-4 with the lunch break. There's no way to leave your message if you called outside these hours. I can't wait for telemedicine to disrupt this!
As a long-term methylphenidate patient, I don’t really understand the concerns about pill mills for ADHD-grade stimulants. Couldn’t you essentially buy amphetamines over the counter in the 50s? And we made awesome cars and went to the moon.
I have struggled with motivation and executive function my whole life, and actually tried to get ADHD treatment through one of those "pill mill" online sites that are technically legal because you get screened, but pretty much exist just to sell you adderall or something. I'm not 100% sure I have ADHD but people keep telling me I do and I definitely struggle. So I got screened online by a clinician. I was honest but not, like, scrupulously, stupidly honest. I tried to answer the questions in the spirit in which they were intended, etc. I wasn't trying to scam anyone but I was trying to get meds.
Result? The clinician was like, idk, I can't really say whether you have ADHD or not. No meds. So I think sometimes even those sites are not quite as pill-milly as one might expect (or desire).
Is it time to read or reread Ivan Illich, Medical Nemesis? There may be some much deeper issues.
What do we think of an eye doctor, who says here is a prescription to get carrots delivered to your door every few weeks. See you in a year?
Pharmacology and the commodification of medicine is tricky business.
How about an RCT people who see psych
in person every 2 year (w/ w/out Rx) v.
in person once a year (w/ w/out Rx)v.
in person twice a year (w/ w/out Rx)v.
in person 4 times a year (w/ w/out Rx) v.
telemed every 2 year (w/ w/out Rx) v.
telemed once a year (w/ w/out Rx) v.
telemed twice a year (w/ w/out Rx) v.
telemed 4 times a year (w/ w/out Rx) v.
no treatment
Example # 1,369 of not using cost benefit analysis to make regulations.
> I’m probably going to rent an office somewhere in Oakland for the month for a few thousand dollars. [...] I’ll have to charge them a bit more, to recoup the cost of the office.
I agree that this whole situation is terrible, but aren't there more economically efficient solutions here? Does it matter whether your patients drive to Oakland or to another place with far lower real estate prices?
Hell, I know several doctors (including a psychiatrist) whose “office” is just an easily accessible room in their private residence. (Though, I don't live in the US so there might be some more regulatory issues I'm overlooking, and of course you will have to be comfortable giving patients your private address.)
An excellent illustration of Conquest's First Law ("Everyone is conservative about what he knows best"). Hopefully it helps illustrate why many of us despise and resent government regulation for social engineering purposes.
By definition it's a bad faith take. Indeed, as in your follow-on comment, it eliminates any "charity," any recognition that "incentives" are complex and can run in different or even opposing directions, any acknowledgement that crafting a balance is complicated. It rests on motive- and incentive-impugning and lacks even an attempt at perspective taking.
I am not suggesting that critique isn't critical. But I don't think this kind of critique, imo in a Manichean framework, incorporating a kind of fundamental attribution error, is constructive in the long run. The net effect, imo, in balance, is just to tear down public health. We're on that track as a society, and I find it concerning.
I'm sympathetic to your arguments about telemedicine, but the intro was very disappointing. I understand your frustration with the new law, but to start off by claiming that the motivation behind its creation is that regulators hate new things and want to inconvenience people is just lazy writing and bad rhetoric.
Readers should always be cautions whenever someone proclaims to know an opponent's motivations as evil for evil's sake.
If the stupid "in person" rules do one thing, it's make it harder to deepfake.
Have them.us managed to re-derive the concept of the general good from identity politics?
This will hurt people.
Some people are trans.
This will hurt trans people.
(It’s not logical necessity, but it’ll do)
Simple rule of thumb: designing broad based rules to prevent outlier events never works out well. The majority end up suffering from the rule and the ones that the rule is designed to catch know how to game whatever rule is put in place.
I’m not sure that what Scott wrote is even completely accurate. I have a relative who is an MD in this space, and it seems that the underlying problem is not the DEA but an actual law passed by Congress. Aren’t telemedicine regulations limited with respect to controlled substances by the Ryan Haight Act of 2008 U.S.C. § 829(e)… there may be interpretations of this act by the DEA and other agencies, but, where controlled substances are prescribed by means of the Internet, the general requirement is that the prescribing Practitioner must have conducted at least one in-person medical evaluation of the patient.
It seems like a colossal overreach to ask an Executive Branch agency to overrule the plain text of the act. There are some exceptions, which Scott noted. A different way of looking at things was that the Executive Branch was highly responsive to the emergency situation of Covid. Now that it’s not an emergency, they are obligated to return to the legal framework that exists. Congress needs to change the law, not the DEA.
The *data* from covid should be used as part of a cost-benefit analysis to determine whether it is reasonable to regulate telemedicine, and, if so, what regulations might address whatever problems arose.
Btw, when I traveled out of state and requested a telemedicine appointment with an internist in my state, the software they have at the clinic did not work. They have strange clunky software but this happened because they're designed to NOT work out of state. Wish they'd use Google meet or Zoom or something ordinary like that. That's what concierge medicine doctors seem to use - they cut out the red tape.
All your points are valid ones, but there's this other issue, where there are some doctors who have overprescribed a huge variety of drugs (opiods being the most common example), even though I'm sure most doctors are responsible with meds. Now, let's say, the regulators withdraw the reg, and then we start seeing some very high profile cases of on line excessive abusive prescribing. OK, of course, as with most regulations, the in-person requirement doesn't address this problem very well, as it has loopholes that make the regulation more of an inconvenience than a ban. But, when did that ever matter when it comes to a hot story that can be done in a way to inflame readers and (even better!) embarrass regulators! Which is probably some of the explanation why it's so hard for you to get the voice of reason heard.
One quibble with what you say. Comparing our health care regulators to Putin! How American. What you're talking about is on the level of inefficiency and in many cases, let's say, inconvenience for Dr. and patient alike, because of the loopholes in the regs that you mention. I like my fellow Americans do highly value making things convenient and efficient. But hey, it's a bad look to suggest requiring a second doctor to vouch for medications prescribed on line, in the context of some highly publicized abuses of that practice, is like... Putin's Russia. Unless the goal is to contribute to the bonfire that's American political discourse these days.
I generally like your writing and ideas, hell, I just re-uped for a year.
However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else."
In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time.
Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors.
Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking.
From a headline and PR standpoint, really need to develop and distinguish a different term than "controlled substance" if possible. Many people will only read the headline and think about law enforcement, prescription drug abuse, and problems stemming from something like opioid addiction/meth.
Or you could do the version where you use jitsi instead of Zoom for a session, and agree that you'll both pretend that they visited you.
Notably absent from this post: any actual data on patient outcomes or rates of drug abuse with in-person vs telemedicine. I genuinely don't want to be rude here; the temptation to isolated demands for rigor is greatest in fields where you consider yourself an expert.
"Did I mention that if you come off of some of them too quickly, you can literally die?"
I once had the opposite problem. I had severe epilepsy, but the dosage of the most-likely-to-be-helpful medication, Lamictal, had to be increased veeery slowly, otherwise it could cause a potentially-deadly skin rash.
https://www.nhs.uk/medicines/lamotrigine/side-effects-of-lamotrigine/#:~:text=Skin%20rashes&text=It%20causes%20flu%2Dlike%20symptoms,dose%20is%20increased%20too%20quickly.
Obviously I mourn the 100,000 people a year that die from opioids, but the negative toll on the people that don’t abuse opioids but need them is a very big price to pay for their abuse. This war on opioids harms many people caught up in the crossfire that need a drug that has been used since the beginning of human history!
Don't forget the climate change implications of restricting telemedicine:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800850
The government is applying the precautionary principle. Just like you want them to do with AI.
"Ah, but here they are applying it stupidly." Right, just like they certainly would with AI.
Because it's the same government, operating according to the same bureaucratic logic. It doesn't suddenly get smart because nerds begin yelling at it.
Would it fulfill the letter of the law to have a patient go to an Urgent Care facility to get that letter signed? At least then it means minimal waiting and even the out-of-pocket costs tend to be low.
True, dumb, and pointless yes, but how else can an incompetent bureaucracy respond to the demands of commercial real estate owners? When trying to also forget every single lesson and ‘go back to work’ to monitor, control, and force people to waste money on transport and commercial real estate…they’re all out of ideas and revert to fascistic practices of stupid rules to force people to comply.
There is a fairly real existential threat to the financiers, banks, and wealthy land owners who wish to do continue to do nothing and be paid enormous sums of money for the service of simply owning things they didn’t build while holding us all hostage to their MAD style scheme to send the economy into a Great Depression 2.0 if their terms are not met.
This knee jerk and too little too late series of spasmodic reactions and planned obsolescence of anything disadvantageous to them may be part of this, along with the general trend of everything getting worse and all your favourite tv shows, brands, products, foods, restaurants, and government rules being inexplicably cancelled.
It may sound outlandish or conspiratorial to some, but it truly is what motivates the upper and powerful classes. The demands of enormously wealthy landlords and the even larger financial system behind them are always heard via all their legalised bribes of all kinds to politicians and senior staff in every single agency and regulator who get donations, speaking fees, and highly paid ‘jobs’. Regardless of the veneer of democracy, these groups in studies almost always get their way or erode things to get their way over time after populist movements’ brief attention span of a year or two ends.
Even the neocons could only squeeze and divert a hundred billion or so into their latest proxy war, but the banks were able to get 2 trillion plus of money printing done pretty much overnight because they asked for it.
And they are freaking out about commercial real estate and the collapse of the banking system. A broad demand to end all kinds of work from home is happening and that includes things like telemedicine. I doubt the elites behind this push would know, care, or be personally affected by this specific rule change.
But that’s how incredible power works and long chains of people interpreting their marching orders operate, quickly asking how high to jump when told to do so. Years and decades of activism and sensible modern policies by huge movements can be undone if one of our invisible aristocracies even so much as sneezes. And that’s just an unintended drive for compliance to their a near absolute demands. That’s the true power structure. And they are right, the economy has been built on glass support beams and will go into a terrible depression if we do see a continued lack of demand and turnover for 70% of commercials real estate into a non-free debt environment of 5% or more fed funding rates.
We are seeing bureaucratic panic, which will inevitably not ‘solve’ the problem of most offices being unnecessary and will hurt many vulnerable powerless people in a myriad of ways. Is this 100% the total answer to why this specific rule change is happening? Of course it isn’t, but it is a significant structural factor in how choices, all choices get made by powerful controlling systems.
Or we can be naive and pretend power somehow doesn’t continue to operate as it has for millennia.
I'm one of those "bad" people who thinks potentially addictive meds should require in-person evaluation. I worked for a psychiatric and social work agency for 15 years. Saw a lot of speed addicts on Ritalin, saw a lot of kids who were place on Ritalin because Mom or the teacher couldn't abide normal play behavior. Many of those kids are addicts cooking meth today.
Telemedicine for an earache or my son's psoriosis -- okay. An antibiotic, some cream for his outbreaks. Fine. But I've done telemed a few times since covid and it is not like seeing a doctor in person. Yeah, the antibiotic -- on the third call -- fixed my sinus infection, but my swollen knee -- well, no. Doc gave me a prescription for painkillers and a steroid based on my camera angle. It didn't fix it. But I didn't take the painkillers, because I know they're addictive (and they generally make me puke). I asked for a referral to a physical therapist to actually fix my knee. "After you've done this for a while. In the meantime, put your feet up" and get out of shape and make the problem worse. Fortunately, I rain into a friend who is a PT and she gave me "advice" that included going to the gym and getting my knee back in shape. I stopped taking the steriod. I'll report to the doctor when I go for my annual -- IF I go for my annual because telemed isn't really medical care.
Hey everyone; sorry for posting randomly on here. I'm undergoing psychiatric treatment myself. I have a rough situation up here in Canada, since there's a massive shortage of psychiatrists (https://www.thestar.com/news/canada/2022/01/15/psychiatrist-burnout-why-covid-weary-doctors-are-taking-a-mental-health-break.html): "These departures are leaving Ontario with an acute shortage of psychiatrists, says Villela. The number per capita was already declining before the pandemic, according to the Canadian Medical Association. And with half of all Canadian practitioners over the age of 55, that shortage is likely to accelerate."
I have a whole ton of questions about psychiatry and it's really frustrating. I don't know who to ask. I sometimes randomly email researchers but that only works once in a blue moon.
What's the best place online to get answers to certain questions? Like the most basic one I have is whether it's possible for a patient to simply be some kind of weird outlier who needs high doses of certain medications; such a patient is in a tough spot because someone might not want to prescribe high doses for them. What legal issues arise when psychiatrists go outside the bounds of the guidelines? I assume that psychiatrists wouldn't ever do so if doing so invites legal danger.
I found this (https://astralcodexten.substack.com/p/oh-the-places-youll-go-when-trying) super interesting but I still have questions. Regarding escitalopram, what exact risk do you face if you go up to like 50mg, 60mg, 70mg? And why are people seeking to declare that nobody (not even outliers) can benefit from high-dose escitalopram if indeed that's what their saying?
And why would a patient need so much escitalopram (or guanfacine for that matter...imagine a patient who needs 10mg guanfacine XR in order to get a good treatment effect)? Is a patient who's an outlier (when it comes to needing high doses) unusual pharmacodynamically or pharmacokinetically?
Another weird thing is what if a patient swears up and down that they experience very powerful effects from a medication within seconds or within a couple minutes? We can say that it's just placebo, but what in our science sets a hard limit on how quickly a molecule could reach the brain or affect the brain? The difficulty here is that it seems like you have to (1) identify all possible pathways through which a non-placebo effect could occur, (2) rule out the possibility that there's another pathway that you're unfamiliar with, and (3) rule out that any of the possible pathways could allow for such a fast non-placebo reaction.
Lastly, take a look at this interesting medication that I'd never heard of: https://www.reddit.com/r/Nefazodone/comments/1251z72/can_you_guys_help_me_learn_about_nefazodone/je32w77/.
I'd love to read to a pro-medical-regulator person steelman this, and be able to have it withstand these criticisms, and the kinds of criticisms this forum can bring to bear. I mean, I doubt its possible, but I would love to read the attempt.
So, as a factual question, is this primarily the law as written preventing telemedicine of controlled substances or is it the DEA choosing to make it difficult?
Because "regulator" is kind of being used in a general way with specifying whether this is, at core, the fault of DEA administrators making a policy decision or of the Senate/Congress making a bad law. Let me clarify, from the Federal Register link provided (1):
--
As indicated above, in 21 U.S.C. 829(e), the Ryan Haight Act generally requires an in-person medical evaluation prior to the prescription of controlled substances. Section 829(e), however, also provides an exception to this in-person medical evaluation requirement where the practitioner is “engaged in the practice of telemedicine” [17] within the meaning of the Ryan Haight Act (21 U.S.C. 802(54)).
--
The DEA release makes several references to the Ryan Haight Act, which you can read here (2), having a clear intent to prevent controlled substances from being prescribed without an in-person evaluation. The statutory authority doesn't appear to be anywhere within the core of the law but instead...basically a loophole buried in paragraph of a subsection.
Because, if the law was clearly written to do X, and we want to pressure the DEA to use a loophole to achieve the opposite of X, because they allowed the opposite of X in a global emergency, that has...several obvious concerns.
But I don't know enough to make the specific argument that "no, this is Congress' fault, the DEA is faithfully fulfilling the law as written". So, for people with either more legal experience of more practical medical regulatory experience than me, what was the intent of the Ryan Haight Act, how much discretion does the DEA have here, and who is ultimately responsible?
(1) https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had
(2) https://www.govinfo.gov/content/pkg/USCODE-2021-title21/pdf/USCODE-2021-title21-chap13-subchapI-partA-sec802.pdf
EDIT: Blarg! Should have read ProfessorE's comment below. I am genuinely curious though about who's ultimately at fault.
While we are talking about stupid bureaucratic requirements, can we pretty please acknowledge that fax machines are over and adjust our talmudic interpretations of HIPAA accordingly? This is very small bore compared to telemedicine, and so probably less likely to happen, but really.... So stupid.
I'm actually slightly optimistic about this for selfish reasons. I have been on stimulants for ADHD for 20+ years. This will make getting a prescription for said meds very difficult.
However, due to the FDA limit on stimulant manufacturer, for the past 6 months I haven't been able to get ANY medication WITH a prescription. Every pharmacy is out of every stimulant.
So. If demand drops, and I have to work harder, but can eventually actually obtain the meds I need to not be fired from my job...
Well, it's way better for me than the current situation.
23k comments and climbing. In a search for "good", I found mostly comments about it "doing more harm than good", but in a search for "thank you", buried among the "...for your time" is at least one comment that seems to have a sincere appreciation for one effect of such a regulation, specifically that it should reduce accessibility of euthenasia drugs, which is a moral stance that I think is honest and worthy of consideration. In my opinion though it doesn't counterbalance the overwhelming deluge of negative comments, including official responses from nonprofit providers saying that this will be especially bad for them.
>The problem here is that the DEA is trying to catch evil overprescribers by filtering for whether a doctor can see a patient one time in person, which is uncorrelated with whether they’re an evil overprescriber or not. It’s just an extra hurdle that’s inconvenient for everyone
Scott, do you remember the Lesswrong post "beware trivial inconveniences"?
I would be very surprised if this requirement did *not* discourage a significant number of overprescribers. (Consider that "overprescriber" may contain elements of fraud and not just be "otherwise legitimate psychiatrist who prescribes too much". And that drug abusers are poor and/or lazy and thus may find it hard to get to a psychiatrist's office.)
Ever consider hiring a pharmacist to help you wrangle prescriptions?
My last doctor set up a telephonic visit. When he called he didn't know who I was, then asked me what I wanted. Then he tried to convince me I was some other doctor's patient. So we don't do 'telemedicine'. They'd like to turn medical care into a video game. It's much cheaper, and maybe could get ChatAGT or whatever to provide care through Siri. The profit could be tremendous.
I went back to my previous GP, a man named Ramakrishna. The last thing I heard my telephone doctor say as I left his office was "pseudocysts!" as if he finally remembered I was a patient. Too late.
This is super random, but I found this paper absolutely fascinating (and it made me want to look into trying some antiepileptic drugs):
https://link.springer.com/article/10.1007/s43440-023-00458-4
IEDs occur more often in patients with ADHD and may contribute to symptoms of this disease [10,11,12,13,14,15]. There are clinical studies suggesting that antiepileptic drugs (sodium and calcium channel inhibitors) reduce ADHD symptoms. For example, it was found that the calcium channel inhibitor levetiracetam inhibits IEDs and reduces symptoms of ADHD in children suffering from this disease [11, 12]. Another study showed that sodium channel inhibitor lamotrigine decreases ADHD symptoms in epileptic patients with ADHD. This effect correlated with EEG normalization and a reduction of epilepsy symptoms [36]. It was also found that sodium channel inhibitor carbamazepine inhibits IEDs in children with ADHD. This effect correlated with clinical improvement [37]. It could be speculated that in some patients guanfacine may reduce ADHD symptoms by inhibiting interictal epileptic events. Thus, guanfacine may exert beneficial effects in ADHD not only by stimulating alpha-2 adrenergic receptors as shown previously [6] but also in an additional mechanism which is the inhibition of sodium channels and consequently inhibition of IEDs.
What puts a bad taste in my mouth is the "there's nothing we can really do except whistle into the wind" stance on addressing regulatory issues. Yet, here we are.
Is there truly nothing within the capacity of all of our advanced technology and communications systems to arm "experts" like Scott with tools to have a disproportionately loud voice in situations like this?
May I suggest a book to review or a person to research "The Mastermind" which is about Paul LeRoux, for an alternate view on the whole telemedicine thing and a different perspective into the opioid crisis.
LeRoux is sort of a dark mirror to many of the tech innovator capitalists that are glorified in our society. LeRoux innovated by building what can charitably be describe as a platform for telemedicine or to the government a cyber pill mill that sold opioids to Americans.
LeRoux was one of the largest spammers in the world and arguably was initially a Gray market tech entrepeneur until he decided to be a black market entrepreneur who moved towards selling missiles to Iran, buying North Korean drugs and killing people.
That aside a question for our host, how do you believe pill mills should be dealt with?
If anyone is interested, King of the Bro-Scientists, Derek of More Plates More Dates, discusses this new regulation here: https://www.youtube.com/watch?v=NQ1sXYwYyhs/
Hell on a flat Earth
From your perspective as a practicing psychiatrist, how viable/reasonable would it be to put a limit on the number of patients to whom a psychiatrist can prescribe controlled substances? Realistically, there's a limit to the number of patients a doctor can concurrently monitor thoroughly enough to determine that controlled substances are appropriate, right?
It's almost as though giving the government power to control your health is a Bad Idea.
https://open.substack.com/pub/thefrontierpsychiatrists/p/sxsw-dispatch-an-open-letter-to-ai?utm_source=direct&r=1ct8f&utm_campaign=post&utm_medium=web Pro tips on making regulations.gov comments
Frame it as an inflation driver (since it is). Technology has been hugely deflationary to everything except the guilds of medicine, housing, and education. They need to be broken.
> Meanwhile, if there are actual evil telemedicine doctors prescribing meth to impressionable young children, they’re doing the same thing. “Sorry impressionable young child, the law says I can’t keep prescribing you meth until you see me in person once. I’m renting an office temporarily, please come visit one time and pay extra so I can keep dealing meth to you.” That doctor has no problems! Meth addicts’ willingness to drive a few hours and pay a little extra is noticeably higher than real psychiatric patients’!
Heheh, in Poland it's now possible to fill a simple form, and receive an electronic prescription. You don't even need to interact with a doctor. And they charge about $20 for a "consultation" (which is that form thing). It's rather hilarious, defeats any purpose in having prescriptions in the first place.
Unfortunately one can't get meth (or adderall) that way; but Xanax, SSRIs etc. are available. I bought some just in case they somehow fix the system & I will need it, as I'd hate begging for permission to get this stuff. Expiration might be a problem through...
I think that the rule to stop drug mills might be better served by regulations based on size of a practice or identifying prescribing patterns that are inconsistent with standard of care for that doctor’s specialty. Now with ISTOP in most states, DEA should be able to catch trend in “overprescribing docs” and use the yardstick of mean prescribing behavior by specialty and sub-specialty to flag doctors who’s prescribing practice they find questionable. In NJ the NJ Aware site actually tells you how your prescribing of controlled substances compares to that of other doctors. These are good means of self regulation and understanding rather than regulating large swaths of the medical community who are already exercising good clinical practice.
I’ve submitted similar comments to DEA. Thank you for taking time to write this article. I hope common sense will win in the end!
How much of a problem are over-prescriptions of stimulants and benzos? Like, if 90% of the consumers of black market meth were originally addicted to legally prescribed stimulants, that would be concerning, while if it were 1% that would point to over-prescription being mostly a non-issue.
I am assuming that there is a dosage difference between recreational use and psychiatric use, so a meth user will not just be able to fire their dealer, fake ADHD and get a doctor to prescribe the fix. And insurances would probably notice if you handed in 10 subscriptions for Desoxyn at once. Or is the concern more that people will get one subscription and sell it on the black market, defrauding their insurance companies in the process?
As a patient on psychiatric drugs, I can say that not all of us have great executive functions. The normal hurdles of both the life in general and the medical system (byzantine at times even for mentally healthy people) in particular can already randomly interrupt our drug supply quite easily. What is it with the US and regulating healthcare so that patients will need to undertake long journeys or risk legal perils to get the care they need?
Speaking of legal perils, I could imagine that for some patients, the black market may be the path of least resistance with regard to continuing their drug regime. I know I was prepared to get ketamine on some tor marketplace. (Of course, ketamine is not a scheduled narcotic in Germany, so I would only have violated the law against trading pharmaceuticals outside pharmacies. By contrast, buying amphetamines in the US probably has a recommended sentence of 5 years federal prison or something for first offenders.) I would assume that there are also regulations regarding what doctors can say regarding illegal drugs (apart from them being bad), so that illegally sourced drugs will not only suffer from quality control issues but also lack of medical advice.
Regarding to writing letters, I generally don't think it is very worthwhile to write letters to non-elected officials. Writing to their bosses in the executive branch and the policymakers in the legislative who will depend on votes at some point is slightly less likely to be a waste of time.
I admit I am relatively happy about these sort of policies, in-so-far as there are a lot of doctors benefiting from being de-facto prescription mills guarding access to valuable drugs.
I am all for legalizing every single substance known to man, it's a travesty that we haven't. But I *don't* want a half hearted legalization where amphetamines, or modafinil, or semaglutide, or benzos or what-have-you is guarded behind profit-seeking mandarins.
If prescription mills become hard, this means that more people will be pro lez faire policies around drugs or that slack will appear in another part of the system.
As an example, in most of SEA, you can just get prescription drugs from a pharmacy at the chemist's discretion (even the dangerous "this can actually kill you if you take it the wrong way and the wrong ways are many" kind). Why lobby for prescription via telemedicine and not for regulations that allow pharmacists to hand out prescription drugs if they consider it appropriate ?
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This is a step in a bad direction, but it's a step away from a solution that wasn't "good enough" but still sufficient to quell unrest.
Who came up with the idea that a physician needs to have multiple DEA certificates in different states to be able to prescribe controlled medications? Worse still, you are required to have an actual office in different states to have DEA certificates in each of those states assuming you want to prescribe controlled medications.
Back to the issue at hand, I can’t think of a single good reason why you would need to bring someone into the office once a year all because you are prescribing Adderall or lorazepam. Too many unnecessary regulations in my mind. Hopefully they’ll listen to the voice of reason
I actually have a telemedicine psychiatrist because there was virtually no way to get an appointment within less than 6 months because of the dearth of local psychiatrists that accept insurance. Ergo, telemedicine. I also see many of my other MDs via teleconference. I share Scott’s frustration. The psych can’t prescribe what he wants to prescribe me because of these laws, and instead is collaborating with my GP to get her to write the prescription for me. That’s insane, and possible only because I am lucky enough —and proactive enough—to have persuaded these folks to perform this convoluted dance.
The government should treat us with the presumption of competence, not ineptitude. At the same time, it’s incumbent upon patients to make smart assessments about which complaints require in-person appointments. I was offered a telemedicine appointment with a neurologist last year. I declined it. The complaint was such that it was clear I needed an actual exam—and the examination requires more than looking at my face. I would not have felt satisfied with any outcome of an telemedicine appointment. The same is true for seeing an orthopedist or for assessing whether you need antibiotics. I want a culture taken before I use them —and that means either an in-person exam or a visit to a lab.
None of those obtain in the case of most mental health care.
Commenter’s points regarding whether the psychiatrist has enough information to diagnose over video are ill-founded. Psychiatrists don’t usually do physical examinations. They look for affect—yes—and perhaps some elements of body language. But ultimately, the key component of their observational activity is keen listening. And there is no impediment to any amount of interrogation or conversation virtually.
These regulations are driven by an over-vigilant sense of paternalism. And I say that even as someone who leans liberal and even socialist on many subjects. But the government is preoccupied with expanding the complexity of a permission-based medical system in which the presumption is that we are all both stupid and criminal.
The encumbrances for telemedicine don’t even approach those for “controlled substances” which include ADHD, pain, anti-convulsants, anti-psychotics, anti-depressants and shockingly more medications. In 4 of the last 6 months, my regular pharmacy has been out of stock on my “controlled” prescription. That means that I spent about 7 hours each time trying to figure out an alternative. Why? Because, at least in this state, the regulations disallow all the following:
- standing refills (every month requires a new Rx)
-transferring the RX from any pharmacy to any other (that includes from, say, a Walgreens at one location to another Walgreens down the street)
-ordering the Rx to be filled more than 24 hours in advance of it running out (ostensibly because I would probably become a drug dealer if I owned 3 extra capsules). So it’s impossible to order in advance and allow a buffer for possible inventory issues.
Here’s the irony. With all that, the only way to execute a plan B when the pharmacy is out of the drug is to get the doctor to send a brand new prescription to another pharmacy at other locations until one of them has it in stock (many of them won’t tell you over the phone if they even have the medication in stock—until they have your Rx). The final impact of that is to proliferate prescriptions. That also creates an opportunity for hoarding. Assuming I’m willing to pay cash instead of insurance, I could fill a prescription at every one of those locations and open up a shop!
All of that simply to stop a pharmacy from transferring the Rx to a nearby pharmacy.
Instead of multiplying onerous regulations that make already hard-to-obtain healthcare yet more difficult, the government should embrace the benefits of supply and demand by expanding geographic and virtual/IRL boundaries. That creates greater opportunity for specialists where demand is low, and greater supply for patients where supply is inadequate.
They should do the same with the medications. Regulate who can write prescriptions without stupid additional rules. It’s a cinch to monitor pharmacies and pharmaceutical companies using big data—and much more effective than trying to create a labyrinth of rules for who, how, where, when, etc. We know from various reports that most times pill mills were operating, it was discernible in the aggregated data from the region and could be parsed to the individual pharmacy and physician. Had anyone done that we might not have an opiate crisis. But they didn’t until after-the-fact—and even then, it was first done by journalists, not regulators.
The comments might help. I can still but Kratom at every independent gas station I walk into on the back of that kind of shit.
Couldn't agree more. Punitive and idiotic.
I know there are millions suffering in the US and I'm sure there are good people trying their best to help within the very restrictive nature of being a 'medical professional' however don't you think it might be the time to stop 'doing your best' within the 'system' and become more effective outside?
Holistic health should be the driver for everyone and ultimately is the only long-term solution to overcoming dis-ease.
Currently Ignorance, misguided beliefs and external controls are the things that perpetuate the idea that 'everyone has to live a life of pain and suffering' as if this is the natural order of things.
Wellbeing is not something maintained by external intervention but by the balance of mind, body and spirit (homeostasis) something that should be a life-long, autonomous expectation of everyone from birth, unfortunately we're about as far away from this as we can be and unless this starts to change there is very little hope for future generations and potentially the human species.
Be the change you want to see in the world which can only be achieved from within. Helping others can only be truly successful once you have helped yourself.
Universal love and compassion is the only truth. Anything else is a barrier to wellbeing. It's not about fighting whatever stands in the way, it's all about allowing a better way to grow and blossom within yourself and sharing it with others. ❤️
I will be sending many patients to ER to get their controls and this will lead to overall health care burden for the patients, the system, and for costs to all in general. These rules are made by those who are not doctors and have no understanding how front line care is impacted by their dumb regulations. They will be placing pts at risk of withdrawal and doing unscrupulous things to obtain their controlled meds, possibly leading to issues with criminal justice system too. Really stupid reg if you ask me.
Psychiatrist here. While I agree with the author that a single-visit requirement makes little sense, something needs to change in the way virtual medical and psychiatric services are undermining clinical practice. What began as emergency concessions for COVID has metastasized into a remote treatment free-for-all. Were we really mistaken about the need for physical exams all those years? Does it really not matter that a few patients insist on video instead of literally WALKING to my office? Or that some hide in their parked cars because they have no privacy at home? Or worse, connect from public places, with others walking by or even interrupting them?
And that’s before we even start talking about psychostimulants and sublingual ketamine prescribed remotely after a cursory screening.
I went virtual during the pandemic out of necessity, but no longer accept new patients unless they agree to in-person treatment. Unfortunately, during the pandemic I took on several too far away to ever come in person, and others who now judge their convenience more important than the quality of their care. Lately I weigh ending the virtual visits they still want. If doctors don’t uphold clinical standards, no one else will… not most patients, and certainly not the startups that stand to gain by commodifying and “platformizing” medical practice.
There’s always been a need for telemedicine for patients too remote or immobile to be seen in person. A few clinics should offer this for patients who really need it. As for the rest of us, I’m concerned that “convenience” is a slippery slope greased by start-up money, slick advertising, and rationalizations.
“The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else.” This is my biggest fear. Not looking forward to scheduling an appointment with a primary care provider and asking them to sign something they didn’t diagnose me for and might deny.