Thursday, May 31, 2012

Zombie Drugs Defeat Policy

The sellers of Zombie Matter, perhaps the latest legal (so far) version of "synthetic" marijuana chose the right brand name. Every time DEA kills a cannabinoid by placing it in Schedule 1 a new version seems to spring to life. This new version may be more addictive and dangerous than good old fashioned "natural" pot, and undetected with drug screens currently in use. If you do not believe the negative test results on the product Web site it is probably only a matter of time before a patient reports using the drug and testing negative at home with a retail drug test.

I predict that DEA will soon identify the psychoactive compound or compounds in Zombie Matter and classify them as Schedule 1 too. Will another zombie drug then rise from the dead? Will its use lead to even more problems for those who use it than its predecessors?

Like the song asks, "When will they ever learn?" But for drug policy that seems to demonstrate its failure more every day would anyone have had an incentive to market these drugs? Let's demand drug policy that avoids giving new life to the very business it pretends to kill.

Thursday, May 24, 2012

When Independent Treatment Goes Dysfunctional

What does a psychiatrist, or even a primary care physician, do when she harbors doubts about the patient's psychotherapy? As I have opined previously I believe the advantages of independent psychotherapy and medication management (or other biological treatment, such as TMS) outweigh the disadvantages. But when the physician does not know the psychotherapist well because the patient chooses his psychotherapist or the physician does not know the psychotherapist well, problems can arise, for example when there is:
  • No sign of improvement after extended treatment.
  • Evidence of boundary violations or other impropriety in the relationship.
  • Failure of the psychotherapist to respond to phone calls or other attempts to establish or maintain contact for coordination of treatment.
  • Lack of evidence of effectiveness of the treatment approach for the patient's disorder.
or when:
  • The physician has a vague negative sense about the psychotherapist from past encounters.
  • The physician dislikes the psychotherapist.
  • The physician knows that the psychotherapist dislikes her.
One might expect to resolve some of these problems with a phone call, email, or other communication, but a persistently dysfunctional treatment team can ultimately harm the treatment. Which relationship should take precedence over the other, the medication management relationship in which the patient spends ten minutes with the psychiatrist every three months, or the psychotherapy relationship consisting of fifty minute meetings weekly? Medication may work the same regardless of how you feel about the person who prescribes it. This may not hold true for psychotherapy. At what point should the physician impose an ultimatum: Find a new psychotherapist, or find a new psychiatrist?

Saturday, May 12, 2012

Board Certification Patient Feedback May Be Unethical

According to the APA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry Section 1.1:

 “A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient.”

From an APA Ethics Opinion: Section 2-RR:

“Their consent, while ‘freely’ given, is likely to be heavily influenced by their transference feelings, the need to please you… suggests an exploitation of your patients for your personal gain that outweighs the potential benefit...”

And yet the American Board of Psychiatry and Neurology (ABPN) has apparently implemented plans to require psychiatrists who want to maintain board certification status to not only solicit evaluation by other health care providers, but also from their own patients. According to ABPN policy the patient would complete a feedback questionnaire and give it to the psychiatrist who would keep it on file. As I understand it, based on feedback from both other providers and patients, the psychiatrist would look for opportunities for improvement, plan and carry out steps to improve their practice, then measure improvement over time with follow up questionnaires. ABPN would conduct audits of selected psychiatrists to confirm compliance.

One can easily imagine problems with such an approach. Psychiatrists might agree to provide glowing reports to other psychiatrist who agreed to reciprocate. Patients might suggest that an increase in dose of Xanax or a few prescriptions of OxyContin might lead to a more favorable evaluation. At best such data would seem unreliable.

Even the patient who would never think of submitting a dishonest assessment of the psychiatrist might fear the consequences of submitting a critical report. As stated in the ethics excerpts above a physician should never put the patient in the position of having to make such a choice which could hardly be made freely.

Unless I am missing something here I would suggest that patients consider refusing to complete such assessments and even consider filing ethics complaints against physicians who asked them to do so. Let us see to what extent organized psychiatry will sacrifice ethical principles to create an illusion of superior ability has represented by a framed piece of paper hung on the wall.

Better yet I hope psychiatrists will refuse to participate.

Thursday, May 10, 2012

eRx Bogged Down

I started using electronic prescribing several years ago, and, despite flaws, which have diminished over time, I believe it to carry less risk of error and much greater efficiency. For a while it seemed that most pharmacies were moving toward adoption, but if anything it seems that some have reversed course. Almost all pharmacies accept electronic orders, but fewer seem to send requests for refill authorization electronically. In the past few weeks I have received electronic requests from Top Food Pharmacies and Rite-Aid. I have also received requests from Safeway, but they seem to have stopped. A pharmacist at one store in a chain may tell me the chain has not yet implemented eRx even though I have received such requests from other stores in the same chain. Can a chain really have implemented eRx on a store by store basis? More likely they have simply failed to educate their pharmacists.

The failure of most vendors to implement eRx of controlled substances continues to limit the overall efficiency of the technology despite approval by DEA as long ago as two years. I know of only one vendor having adopted this late last year, but mine, Practice Fusion, has not. This means I still need two separate systems to track and record prescriptions and refills. It also means I still must use paper prescriptions or telephone, both of which I believe to be more vulnerable to fraud and error.

My vendor has only recently implemented (apparently) formulary status check when using eRx. This could help avoid the shock of high copay or required prior authorization, but I have yet to try it.

Speaking of prior authorization, eRx could dramatically increase efficiency. Recently I pursued prior authorization from Medco involving numerous faxes. Ultimately it seems that reimbursement hinged only on whether I prescribed the drug for smoking cessation. Instead of all the faxes and finally a phone call, I should have been able to simply check a box during the initial order.

eRx is not perfect, but with so much potential we should aim for complete conversion in months, not years. Maybe if a large enough number of physicians simply blocked fax requests...

Thursday, May 3, 2012

The Genericebo Effect


Information No results found for "genericebo effect".

Does that mean I can claim to have coined the term?

genericebo effect

It seems like patients switching to generic preparations of drugs newly off patent increasingly report intolerable adverse effects or loss of efficacy. I intend the new term to capture the possibility that these apparent changes may originate from an expectation on the part of the patient, and possibly initiated by the prescriber, that generics, particularly those manufactured by certain pharmaceutical companies, must fall short of their branded predecessors.

Of course generics and even branded drugs can suffer from real manufacturing problems, so we must not assume these phenomena occur only in our patients' heads.