(Thanks to Dinah at Shrinkrap for pointing me to http://www.telementalhealth.info.)
Let me start with "health." Good word. Wrong context. We are talking about psychiatry here. Mental ILLNESS, not mental health. Doctors treat diseases, illnesses, sick people. They're already off on the wrong foot -- or word.
Telemental. Define it, please. You can't, can you? Used as "telemental health" telemental is an adjective. It modifies health. So telemental health is a kind of health, right? Apparently not. What is it?
Whoever came up with this travesty has butchered the English language. We could try application of algebra:
Tele (mental health)
or Tele Mentalhealth, Tele Mental-health?
Face it. It does not work. Even if telemental can be defined, which I doubt, the term fails to name what it is intended to name and should be abandoned forever in favor of something like telepsychiatry.
The folks in Maryland should stick to making soft shell crabs, and leave inventing new words to someone else.
Tuesday, February 9, 2010
Bipolar: Overdiagnosis or Misdiagnosis
When I ask a patient psychiatric or substance use disorders in blood relatives, Bipolar disorder increasingly comes up. I think, "Yeah, right." This is just one of many adverse consequences of the Bipolar overdiagnosis epidemic.
So I was glad to see in JCP I received yesterday:
Psychiatric Diagnoses in Patients Previously Overdiagnosed With Bipolar Disorder (Zimmerman et al J Clin Psychiatry 71:1, January 2010)
However, I will quibble with the terminology: One cannot "over" diagnose a patient. Then it becomes misdiagnosis (which my spell checker recognizes, unlike overdiagnosis). One can certainly overdiagnose 2 or more patients, while one can misdiagnose any number of patients.
So I was glad to see in JCP I received yesterday:
Psychiatric Diagnoses in Patients Previously Overdiagnosed With Bipolar Disorder (Zimmerman et al J Clin Psychiatry 71:1, January 2010)
However, I will quibble with the terminology: One cannot "over" diagnose a patient. Then it becomes misdiagnosis (which my spell checker recognizes, unlike overdiagnosis). One can certainly overdiagnose 2 or more patients, while one can misdiagnose any number of patients.
Sunday, February 7, 2010
DEA Suboxone Audits: The Video
Read the script below.
Hello. I’m the owner & editor of BehaveNet.com
Today I want to talk to you about an initiative by the Drug Enforcement Administration that threatens patient access to buprenorphine, also known by the Trade names Suboxone and Subutex.
These drugs were made available in the US, as an alternative to methadone, for treatment of addiction to heroin and pharmaceutical opiates like Oxycontin early in 2003.
Starting as early as the summer of 2009 DEA agents started making unannounced and unscheduled visits to physician practices to audit records related to prescribing and dispensing buprenorphine.
These audits needlessly disrupt medical practices, threaten patient privacy, and waste taxpayer money and the agents’ time which could be better devoted to investigating diversion and illegal prescribing of dangerous opiates like Oxycontin.
I don’t object to the audits themselves which may result in stopping inappropriate practices by some physicians.
But physicians qualified to treat addiction with buprenorphine know to expect the audits, so DEA will not likely catch anyone red handed. I have already heard stories of agents wasting their time – and taxpayer money.
In one case agents appeared at a doctor’s office 3 times when they could not perform the audit because the doctor was absent.
In another case agents appeared at a doctor’s office when a staff Halloween costume party was in full swing but the physician was absent. I can just imagine the agent’s response at the reception desk:
"No, this is not a costume. I really am a DEA agent."
Surely agents have better things to do with their time. And taxpayer money.
If you are a patient, even if you are not treated with buprenorphine, you may find yourself sharing your doctor’s waiting room with a DEA agent who lives or works in your community and may recognize you.
I wrote a letter to my local DEA field office offering a time when I would be available for my audit. No one even responded.
Doctors have to jump through too many hoops already to provide this life-saving treatment. The disruption of practices that results from unscheduled audits will discourage physicians from providing buprenorphine treatment, resulting in increased illicit drug use. Maybe it is not just a coincidence that this will also increase job security for DEA employees.
I hope you will join me in demanding that DEA immediately begin scheduling all buprenorphine audits. In protest I have also made a decision to stop accepting new patients for buprenorphine treatment in my practice until my audit is completed. I hope other physicians will do the same and let it be known.
Contact your elected representatives, local medical associations, your local DEA field office, the Substance Abuse and Mental Health Services Administration, Dr. Westley Clark at the Center for Substance Abuse Treatment and Gil Kerlikowske at the Office of National Drug Control Policy. The American Civil Liberties Union may also be interested in your privacy concerns.
Physicians can coordinate efforts at the CSAT buprenorphine forum and the Behavenet opinion blog. Just search for “DEA Suboxone audit.”
Thank you, and stay clean.
Hello. I’m the owner & editor of BehaveNet.com
Today I want to talk to you about an initiative by the Drug Enforcement Administration that threatens patient access to buprenorphine, also known by the Trade names Suboxone and Subutex.
These drugs were made available in the US, as an alternative to methadone, for treatment of addiction to heroin and pharmaceutical opiates like Oxycontin early in 2003.
Starting as early as the summer of 2009 DEA agents started making unannounced and unscheduled visits to physician practices to audit records related to prescribing and dispensing buprenorphine.
These audits needlessly disrupt medical practices, threaten patient privacy, and waste taxpayer money and the agents’ time which could be better devoted to investigating diversion and illegal prescribing of dangerous opiates like Oxycontin.
I don’t object to the audits themselves which may result in stopping inappropriate practices by some physicians.
But physicians qualified to treat addiction with buprenorphine know to expect the audits, so DEA will not likely catch anyone red handed. I have already heard stories of agents wasting their time – and taxpayer money.
In one case agents appeared at a doctor’s office 3 times when they could not perform the audit because the doctor was absent.
In another case agents appeared at a doctor’s office when a staff Halloween costume party was in full swing but the physician was absent. I can just imagine the agent’s response at the reception desk:
"No, this is not a costume. I really am a DEA agent."
Surely agents have better things to do with their time. And taxpayer money.
If you are a patient, even if you are not treated with buprenorphine, you may find yourself sharing your doctor’s waiting room with a DEA agent who lives or works in your community and may recognize you.
I wrote a letter to my local DEA field office offering a time when I would be available for my audit. No one even responded.
Doctors have to jump through too many hoops already to provide this life-saving treatment. The disruption of practices that results from unscheduled audits will discourage physicians from providing buprenorphine treatment, resulting in increased illicit drug use. Maybe it is not just a coincidence that this will also increase job security for DEA employees.
I hope you will join me in demanding that DEA immediately begin scheduling all buprenorphine audits. In protest I have also made a decision to stop accepting new patients for buprenorphine treatment in my practice until my audit is completed. I hope other physicians will do the same and let it be known.
Contact your elected representatives, local medical associations, your local DEA field office, the Substance Abuse and Mental Health Services Administration, Dr. Westley Clark at the Center for Substance Abuse Treatment and Gil Kerlikowske at the Office of National Drug Control Policy. The American Civil Liberties Union may also be interested in your privacy concerns.
Physicians can coordinate efforts at the CSAT buprenorphine forum and the Behavenet opinion blog. Just search for “DEA Suboxone audit.”
Thank you, and stay clean.
Friday, February 5, 2010
Flush the drugs, man! The feds're comin'.
Expired drugs in the office? How do you get rid of them correctly before those nasty DEA agents invade your office looking for contraband buprenorphine?
"I emailed a local agent who replied thus, "...you are allowed to dispose of the controlled substances yourself - with at least one witness. This activity must be recorded on a DEA Form-41."
This sounded good, particularly after the aspersions I have cast at DEA in the past few months, but then I read Form 41, and I wrote back:
"Form 41 is confusing:
Signature of applicant or authorized agent: Who is that?
"Destroyed by": Is that me, or does someone at DEA sign that after destroying the drug?
The instructions imply I should send the drugs to DEA rather than destroy, except one indication of "destroyed as indicated and the remainder forwarded tape-sealed after verifying contents." What does that mean? This comes after the blank for how many packages have been received. Received by DEA? by me?
I have 56 tabs of 200 mg modafinil. Please advise. Is the form correctly completed?"
So should I put the pills in a bottle full of wet coffee grounds or mail them to the DEA field office. Has anyone done this and avoided the gas chamber?
"I emailed a local agent who replied thus, "...you are allowed to dispose of the controlled substances yourself - with at least one witness. This activity must be recorded on a DEA Form-41."
This sounded good, particularly after the aspersions I have cast at DEA in the past few months, but then I read Form 41, and I wrote back:
"Form 41 is confusing:
Signature of applicant or authorized agent: Who is that?
"Destroyed by": Is that me, or does someone at DEA sign that after destroying the drug?
The instructions imply I should send the drugs to DEA rather than destroy, except one indication of "destroyed as indicated and the remainder forwarded tape-sealed after verifying contents." What does that mean? This comes after the blank for how many packages have been received. Received by DEA? by me?
I have 56 tabs of 200 mg modafinil. Please advise. Is the form correctly completed?"
So should I put the pills in a bottle full of wet coffee grounds or mail them to the DEA field office. Has anyone done this and avoided the gas chamber?
Skypiatry
Another med management visit today. This is like a virtual house call. I actually did a couple real ones when I practiced in Manhattan in the 80's. You get a little more feel for the patient, and you may get to meet the pets when you see the home, even the office.
I recommend routine "visits" to very stable patients the first time you try this, and this kind of visit serves another needed purpose. Many patients I treat have been and will be taking the same medication for years. As far as I'm concerned I one visit per year should suffice, but my malpractice risk managers recommend more frequent visits. For example, you should always make sure to have patients come in the day before a suicide attempt. This really is risk management mentality, and of course in an ideal world we would do that, but the patients I describe will not likely try to hurt themselves, and have the sense to call if things start to fall apart, or they just want to talk about a change in treatment.
The other reason for more than once yearly visits: $. What I charge barely covers the cost of the visit, not to mention the med refills and liability that have become fixed costs per patient. My patients do not want to come see me every three months, much less pay for it, but with at least with a visit via Internet the inconvenience of the trip, and the attendant risks, disappear. I figure even after I get used to Skype I will want even the most stable patients to come to the office once a year, but if we can conduct 2 out of 4 or 3 out of 4 visits via Skype, I get adequate quarterly "dues," the risk managers can sleep at night, and I minimize inconvenience to the patient.
What were the risks attendant to office visits?
I recommend routine "visits" to very stable patients the first time you try this, and this kind of visit serves another needed purpose. Many patients I treat have been and will be taking the same medication for years. As far as I'm concerned I one visit per year should suffice, but my malpractice risk managers recommend more frequent visits. For example, you should always make sure to have patients come in the day before a suicide attempt. This really is risk management mentality, and of course in an ideal world we would do that, but the patients I describe will not likely try to hurt themselves, and have the sense to call if things start to fall apart, or they just want to talk about a change in treatment.
The other reason for more than once yearly visits: $. What I charge barely covers the cost of the visit, not to mention the med refills and liability that have become fixed costs per patient. My patients do not want to come see me every three months, much less pay for it, but with at least with a visit via Internet the inconvenience of the trip, and the attendant risks, disappear. I figure even after I get used to Skype I will want even the most stable patients to come to the office once a year, but if we can conduct 2 out of 4 or 3 out of 4 visits via Skype, I get adequate quarterly "dues," the risk managers can sleep at night, and I minimize inconvenience to the patient.
What were the risks attendant to office visits?
- Cost of gas, increased carbon footprint, global warming, climate change
- Risk of motor vehicle accident
- Risk of running into your neighbor in the psychiatrists office: "Joe, I didn't know you were mental!"
- Time missed from work
Thursday, February 4, 2010
Milestone: My First Patient Contact for Med Management via Skype
The connection dropped about halfway through, probably due to a connection problem for the patient's Internet, but we reconnected after a few minutes. The audio quality was excellent, video adequate.
This is good, clearly better than telephone. It may never completely replace in person contact, the advantages stack up pretty well.
Next I need to work out how to share screens with the patient. I hope this will enable us to simultaneously view random.org while we roll the die for a random drug screen.
Surprises:
I'm accustomed to scribbling notes on my Tablet PC in my lap, but for Skype the computer sits on the desk in front of me under the Web cam, so I can make brief notes with the keyboard during the visit with little or no disruption. This should make ordering prescriptions online or via fax easier, too, not to mention browsing for patient information documents online.
The informal protocol cues are missing: The patient alerting me she's in the waiting room, inviting her into the office, greeting my dog, escorting the patient out of the office at the end. I imagine new rituals will evolve.
It's not for every body or for every visit, but for the right ones the only disadvantage is the patient doesn't get the healing interactions with the pup.
This is good, clearly better than telephone. It may never completely replace in person contact, the advantages stack up pretty well.
Next I need to work out how to share screens with the patient. I hope this will enable us to simultaneously view random.org while we roll the die for a random drug screen.
Surprises:
I'm accustomed to scribbling notes on my Tablet PC in my lap, but for Skype the computer sits on the desk in front of me under the Web cam, so I can make brief notes with the keyboard during the visit with little or no disruption. This should make ordering prescriptions online or via fax easier, too, not to mention browsing for patient information documents online.
The informal protocol cues are missing: The patient alerting me she's in the waiting room, inviting her into the office, greeting my dog, escorting the patient out of the office at the end. I imagine new rituals will evolve.
It's not for every body or for every visit, but for the right ones the only disadvantage is the patient doesn't get the healing interactions with the pup.
Tuesday, February 2, 2010
Docs. Where have you been?
Twice in the past week I have talked to orthopedic surgeons who were clueless about buprenorphine (Suboxone). Well, not actually the surgeons themselves, but their "medical assistants." (All surgeons seem to do anymore is cut.) All jokes about the intellectual capacity of doctors in that specialty aside, maybe we should not expect them to completely grasp a concept like addiction that none of should claim to have mastered, but we all learned about opiate partial agonists in medical school. Even those of us for whom buprenorphine was not around way back then there were nalbuphine and pentazocine. Almost the same idea.
And it is not just the surgeons. ED docs often seem ignorant of the drug as well. Even when the patient produces a wallet card with an 800 number (which they don't bother to call) they ignore the drug's properties. They never call me either.
What will it take to get the rest of the medical profession up to speed on this drug?
And it is not just the surgeons. ED docs often seem ignorant of the drug as well. Even when the patient produces a wallet card with an 800 number (which they don't bother to call) they ignore the drug's properties. They never call me either.
What will it take to get the rest of the medical profession up to speed on this drug?
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