Table Of Contents:

1: Isn’t drug addiction is very bad?
2: Is telemedicine is worse than regular medicine?
3: What about “pill mills”?
4: Do people force the blind to fill out forms before they can access Braille?
5: Was I unfairly caricaturing Christian doctors?
6: Which part of the government is responsible for this regulation?
7: How do other countries do this?

1: Comments About How Drug Addiction Is Very Bad

Some people countered that drug addiction was very bad, and preventing it is worth some inconvenience. For example, Michael van der Ruyt:

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.

Lela Markham:

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.

I hope my point didn’t come across as “addiction doesn’t matter”. My point was - well, suppose the DEA passes a regulation saying that, because addiction matters so much, from now on only doctors with ground-floor offices can prescribe medication. You might ask questions like “Are doctors with ground-floor offices really better at controlling addiction than doctors with higher-up offices?” or “If there are bad doctors overprescribing meds, can’t they get ground-floor offices and keep doing that?” or “Doesn’t this just inconvenience everyone with a one-time office relocation fee, without shifting patients from worse to better doctors?”. These are the same questions I wanted people to ask about the telemedicine regulations, not “is addiction really bad?”

Also, for Lela, see eg here, here, and here: most research suggests that childhood use of ADHD medication decreases future risk of substance abuse; a minority of studies find no effect, but AFAIK no credible ones find an increase. ADHD treatment is correlated with substance abuse, because ADHD itself increases risk, but it’s not a causal relationship.

2: Comments Debating If Telemedicine Is Worse Than Regular Medicine

Some people did try to argue that telemedicine is worse than regular medicine, either along some axis related to addiction risk, or some other axis. For example, Freddie deBoer:

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.

Orson Smelles writes:

Adding some anecdata without taking a strong stance on the underlying claim: I recently had a one-off telehealth appointment with my therapist after a few months of in-person meetings, and I noticed that I felt like I had a lot more discretion over how visibly emotive or agitated I was.

An in-person session is a hotseat: I'm outside of my home, wearing actual clothes and shoes, sharing a room with a whole physical human whose space it is and who can see and hear everything I can, and I can't fidget imperceptibly under the desk or tab over to news/Reddit/ACX on another monitor. It's not just that they can see more of me or see more detail, it's that I feel less mental slack to perform "normal" if that's not what I'm actually experiencing.

In the event, this was actually mostly a positive because it gave me some space to marshal thoughts that I had had a hard time expressing in person before, but that benefit was totally dependent on noticing that slack and choosing to use it to communicate better. I think if instead I had been trying to conceal some incipient crisis or disturbed state, that would have been pretty easy to do compared to a face-to-face meeting.

Lela Markham again:

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.

In response to Freddie, I wrote that I’m face-blind and bad at body language, so maybe I’m missing some kind of really subtle cues that other people can notice, but to me seeing a good image of a person’s face and upper body captures 99% of what I would get from seeing a patient in person. There are very few psychiatric signs happening in a patient’s feet! (yes, ankle clonus for serotonin syndrome, very nice, I bet you aced your USMLEs). I’m not in person has no value, just that “drive a hundred miles and pay more so that I can get the extra 1% information” is a pretty big ask.

Belobog writes:

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.

I will never get tired of citing this tweet:

Steven Kaas @stevenkaas

Why idly theorize when you can JUST CHECK and find out the ACTUAL ANSWER to a superficially similar-sounding question SCIENTIFICALLY?

9:56 PM ∙ Dec 19, 2011

---

189Likes69Retweets

There are many studies of telemedicine, which mostly find it’s as good or better than regular medicine. See for example here, here, here, etc.

These suffice to get a vague sense that telemedicine is usually good and not bad, which I think is accurate. But nobody knows how well a study showing telemedicine is good at one thing in one specialty translates to being good at another thing in another specialty. For example, consider this study showing that telemedicine improves care in opioid use disorder. The clearest way it improved care was by patients being more likely to attend their appointments and continue care. This led to various other good things, like lower risk of overdose. Did doctors deliver equally good care per appointment? We don’t know. If you’re sure you won’t miss any of your appointments, will teleheath be better or worse for you than in-person? We don’t know. Does “telemedicine treats opioid use better” generalize to “telemedicine treats ADHD equally well?” I don’t know. Is the sample size large enough to notice if telehealth doctors did 1% worse at treating some specific easy-to-miss but dangerous condition? I don’t know. Does telehealth increase addiction risk in other patients who aren’t already addicted? I don’t know.

Certainly nobody has ever done studies on the point relevant to this particular regulation: whether making patients see a doctor in person once before receiving controlled substance prescriptions from them decreases addiction rates. It wouldn’t even make sense to study this, since part of the effect would be from patients self-selecting into the treatment population to begin with.

In the future, if you want to know whether I know of studies in some area, please just ask me nicely. You don’t have to speculate on which of my personal failures have caused me to hate Science and Evidence.

3: Comments About “Pill Mills”:

Some people express concerns about “pill mills”, unscrupulous companies that hire doctors to prescribe to anyone who asks. These are pretty common for Adderall in particular. Michael:

There were some very dubious telemedicine psychiatry startups that would prescribe Adderall or Ritalin, seemed to have very low prescribing standards, and advertised very aggressively on social media. They were previously only doing SSRIs and the like, but moved to ADHD drugs when this became temporarily possible after COVID.

If you can use good judgment and common sense, it's possible to tell apart normal psychiatrists doing telemedicine, and app-based pill mills marketing amphetamines on Instagram, but it's probably hard to write a regulation that will do this, so the result is a stupid overreaction like this.

Serimachi:

Can attest to the sketchy ADD / medical cannabis companies being a thing. I clicked an ad on Facebook, filled out a form, and less than an hour later, *I* got called by *them*. I got my prescription on that same phone call.

Astine:

This is an overresponse to the adderall shortage. There was an uptick in prescriptions over the pandemic and this was blamed on Cerebral and the like. Judging by Cerebral's advertising, I'm not surprised they're being branded a pill-mill; they definitely look like one. I'm currently seeing a telemedicine psych for adhd because I couldn't find an in-person psych during the pandemic, but when I saw Cerebral's adds, I figured I should avoid them.

I agree that these pill mills exist and Cerebral is one of them, but I have trouble figuring out how to think about them.

As I wrote here, the official definition of ADHD is so fuzzy as to be meaningless. It requires a patient to meet five vague criteria off a list with items like “often has difficulty sustaining attention” and “is often easily distracted”.

Some doctors diagnose with a gestalt impression: they take a history, they hear things that seem to satisfy those criteria, and they diagnose with ADHD. Others use questionnaires that ask “on a scale of 1-5, how much trouble would you have paying attention in such-and-such a situation?”. A few use sophisticated video-game-style tests, but these are expensive, inconvenient, and probably less than 20% of diagnoses, plus they come with big warnings saying NOT TO BE USED TO DIAGNOSE ADHD, YOU CAN ONLY DO THAT BASED ON WHETHER THEY FIT THE CRITERIA.

I bet pill mills like Cerebral spend thirty seconds asking patients “Do you often have difficulty sustaining attention?”, and the patients say yes. Maybe they even give a questionnaire. So in a purely formal sense, there’s nothing that good doctors are doing that they’re not. You would hope that the good doctors dig deeper, try to make sure they’re understanding the situation and telling the truth - but the exact amount to do that is a judgment call. As I discuss here, I usually err on the side not making them jump through too many hoops - most of the hoops are security theater, and the most severe ADHD patients get distracted and fail to jump through the hoops and then I have to decide if I really want to deny them medication on that basis or not. So the difference between good doctors and pill mills here is really thin.

Or to put it another way: even in a world without any pill mills or telepsychiatrists, you will always be able to get Adderall through the following process:

• Read what the symptoms of ADHD are. Go to a psychiatrist and say you have them.

• Go through whatever security theater the psychiatrist puts up.

• If for some reason that doesn’t work, go to a different psychiatrist and try again. You don’t have to tell them you already tried, and HIPAA bans psychiatrists from communicating about this kind of thing among themselves.

Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists.

See also my old post Bureaucracy As Active Ingredient. The security theater doesn’t work because it’s effective. It works because it’s inconvenient enough to weed out the less motivated fakers, and some of the remaining fakers get cold feet about lying to a nice sincere psychiatrist who seems to be trying to help them. Pill mills remove the inconvenience, and seem to be nod-and-wink cooperating with liars, so the theater stops working. The only solution is to inject some inconvenience and shame back into the process somewhere, which the DEA has chosen to do by restricting telepsychiatry. They could accomplish the same goal by making you attend your appointments naked, but I guess clothing companies have better lobbyists than telepsychiatrists do.

4: Comments About Forcing Blind People To Fill Out Forms Before They Can Access Braille

I analogized forcing patients to see an in-person doctor before they could access a teledoctor to forcing blind people to fill out forms before they could access Braille. Several blind people and their friends pitched in to say this was a real problem. For example, Mikolysz:

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.

5: Comments About My Caricature Of A Doctor Who Refuses To Prescribe Psych Drugs Because People Just Need Jesus

Jon Cutchins writes:

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 anti-Christian tropes when describing everyone who is skeptical of mind-altering drugs.

Mike writes:

I’ve been a primary care nurse practitioner in the Bible Belt for 20yrs and not once have I even heard of a provider telling a patient they should substitute religion for psychiatric (or any) medication. It’s so easy for some people to throw around these tropes as if Christianity is some exotic, weird tribe with horrifying anthropological traits.

On the other hand, fluxe writes:

I am a young Christian--in my life, I have

-been told by my PCP not to get an IUD because it carries "a significant risk of causing infertility or death"

-had a pharmacist refuse to fill an old, male family friend's ulcer medication because it's also an abortifacient

-been told by a therapist to discontinue the SSRI a different provider had prescribed and just trust in the man of the house

the PCP wasn't even particularly Christian herself, but since all of her patients are she hadn't updated on IUDs since the scare back in the 70s. Our horrifying anthropological traits become everyone's problem--it might be worth listening to those who "throw around these tropes" so you can understand what they have to deal with

Unfortunately I only mention this possibility because it’s happened to several of my patients. The best I can offer in terms of being unbiased and apolitical is to signal-boost posts like this one about overly woke therapists being another big problem.

Alien on Earth writes:

I generally like your writing and ideas, hell, I just re-uped for a year.

However, in an otherwise near perfect post, you took a cheap shot at a steriotyped view of one religion thst is not popular amoungst coastal elites, that really detracts from your core point. "The worst-case is that you get one of those doctors who think that Psych Drugs Aren’t Real Because You Just Need Jesus, and then the patient has to keep looking until they find someone else."

In my experience, it is the new age(y), non-religious, doctors who are least likely to like prescribing psyc. meds or who tend to give them at too low a dose or for too short a time.

Certainly, I've found little correlation with their religion, if I even know it. The only correlation I've observed is that this perscription reluctance is, perhaps, slightly more common amongst middle career doctors.

Perhaps it is more common in deep red areas, I don't know. However, even there, I would suggest, it is less due to religion, per se, than to "old fashion" "grit your teeth and bear it" thinking.

I agree that there are many reasons people recommend against psychiatric drugs (a few are even good). Psychiatric drugs have lots of side effects and are clearly imperfect options, and I see people object to them more often when they think they have a perfect option as an alternative. Sometimes that option is Jesus. Other times it’s the trendy new somatic yoga reprocessing kundalini trauma dianetics therapy. Other times it’s LSD or ketamine or Dr. Bob’s 24-In-One Internet Nootropic. All of these work for some people, but not as much as the people pushing them think - which I guess is also true for psych drugs. I’m nervous about people who think they’ve found the answer and pressure people towards one alternative or another without presenting evidence. I’ve seen this happen enough in religious contexts that I think it was a fair thing to use as an example.

6: Comments About Which Part Of The Government Is Responsible For This Regulation

ProfessorE writes:

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.

Followed by:

Actually, Scott is even more off-base than I thought in my initial post. Apparently the DEA & DOJ are already proposing new changes to the 2008 Act (which seem like they violate the clear text of the act), but the act and the changes are summarized here:

https://www.legitscript.com/2023/03/27/proposed-changes-ryan-haight/

Sounds like government is aware of the issue. See

https://www.federalregister.gov/documents/2023/03/01/2023-04248/telemedicine-prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had

For the actual changes that are being proposed.

End of the day, this should be modified by Congress, not the agencies. Everyone should remember that the law was written in 2008. That’s 1 year after the very first iPhone and 2 years before the first iPad. Zoom didn’t exist (2011). None of the other technologies for video conferencing existed. Congress was attempting to fight opioid pill-mills. At the time of passage, I am willing to bet that ≈0% of patients were “Telehealth” using videoconferencing. More like phone calls and email a few times to get drugs.

The law should have been amended, and it hasn’t been, but it is far from clear that it was a crazy law in the first place.

I mostly accept this correction, although I’m still a bit confused - a lot of the analyses by lawyers I read said things like “Unquestionably, the DEA’s proposal is not what most industry stakeholders were anticipating. The initial reaction is the rules are more restrictive than necessary and impose concerning limitations and burdens on clinicians and the patients they treat”, and I’m confused why industry stakeholders weren’t anticipating it if the DEA had to do it in order to follow the law.

And JR writes:

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

Based on that comment and this, my best guess about what’s happening is:

• Congress passed restrictions on telemedicine in 2001, and asked the DEA to come up with a way that trusted providers could avoid those restrictions. Now that there is videoconferencing, etc, most people now believe those restrictions were too severe.

• The DEA enforced the restrictions, but didn’t create the workaround

• During the pandemic, the executive branch declared a state of emergency and the DEA lifted those restrictions.

• Now that the state of emergency is over, the DEA needs to decide how to re-implement those restrictions.

• Most people expected they would finally create the workaround Congress authorized them to make, allowing de facto easier telemedicine prescribing.

• Instead they proposed implementing restrictions pretty similar to the pre-pandemic ones, without the workaround.

I’m not exactly sure who to be angry at, but I think “the government” is a fair albeit vague target.

7: Comments About How Other Countries Do It

Coagulopath writes:

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.

A few years ago I was told this was how it worked in the US too. As far as I can tell, the currently proposed restrictions remove the 12 month requirement (if it even ever existed), which I think is a positive step.

Christopher Moss:

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 specialty, 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.

California has a centralized database of all controlled substance prescriptions (it’s called CURES). I don’t know how carefully the government monitors it. I often hear stories of doctors who overprescribe controlled substances getting in trouble, but I don’t know the details.

You have to understand, there’s more medical law than any human can read, and doctors don’t have the skills to know where it is or how to interpret it. So the regulatory state mostly rules by fear. Everyone has a vague sense that if they overprescribe controlled substances, according to some inscrutable criterion, something bad will happen to them. What counts as overprescription? How bad is the bad thing? Surely you would have the right to a jury trial first, right? Surely there isn’t some DEA Star Chamber where judges wearing expressionless masks condemn you to death via forced amphetamine overdose as a suitable yet ironic punishment, right?

These are among the many questions none of the doctors I’ve ever asked about this know the answers to.