Over prescribe much?

March 2, 2010 11:13 PM

Oregon is set to become the third state in the US to allow psychologists (with no medical training) to write prescriptions. Senate Bill 1046 (PDF version on Google Docs) will become law by next July unless the Governor vetoes it. One funny twist: during public hearings on the bill, it was revealed that an out-of-state expert (who was temporarily licensed in Oregon so he could give recommendations on the panel) happened to run a school that trained psychologists to prescribe meds, which would directly benefit from the bill's passage.
posted by mathowie (81 comments total)

It just kind of astounds me this bill passed through the legislature given that both the Oregon Medical Association and the Oregon Psychiatric Association opposed it. Must have been a shit ton of drug company lobbying going on...
posted by mathowie at 11:15 PM on March 2, 2010 [4 favorites]

Get your own blog ... oh, nevermind!
posted by zippy at 11:25 PM on March 2, 2010 [9 favorites]

I see this as part of the inexorable slide to crap care in this country. I'd guess more than 50% of my past 20 prescriptions were from non-doctors (physicians' assistants, the "highly trained nurses" in the first link). And in my experience they are not exactly savants when it comes to knowing medications and their interactions.

So, what's the harm in letting yet another non-expert class in on the action?

Weeps for the America that could have been, with moonbases and excellent health care for all.
posted by zippy at 11:33 PM on March 2, 2010 [3 favorites]

Another thing that kind of surprised me was there is no requirement of doctor oversight like there is in the other two states that passed this, just a nod that psychologists should "collaborate" with medical professionals.
posted by mathowie at 11:33 PM on March 2, 2010

So, what's the harm in letting yet another non-expert class in on the action?

Nurses, physician assistants, etc all had at least some biology, anatomy, and medical-type class training on the way to getting their position.

Think about what it takes to get a psychology counselor degree these days. You can skip math and most all science on your way to being an expert in abnormal personality. There's nothing in the background of most psychologists about drug interactions, drug reactions, and other dangerous stuff.
posted by mathowie at 11:36 PM on March 2, 2010 [3 favorites]

Psychiatric nurse practitioners can write prescriptions in most states.
posted by JackFlash at 11:40 PM on March 2, 2010

Last year, I was nearly poisoned by an overdose of my migraine medication. It turns out that the physician assistant had prescribed far too much, and I'm still recovering a year later. I feel that I can be confident in saying that the only person who should be prescribing anything is a highly trained professional who understands drug interaction and how to prescribe heavy-duty medications properly. Giving prescription pads to unqualified people so they can give out psychiatric medications seems like a recipe for disaster.
posted by pecknpah at 11:41 PM on March 2, 2010

On the upside, maybe pharmacists could refuse to fill the scrips on moral grounds...
posted by Mister Moofoo at 11:44 PM on March 2, 2010 [5 favorites]

Psychiatric nurse practitioners can write prescriptions in most states.

Right, but this law was for allowing psychologists with no med school training to write them as well.
posted by mathowie at 11:48 PM on March 2, 2010 [1 favorite]

*insists on referendum, votes NO*
posted by Cranberry at 11:52 PM on March 2, 2010

I wonder if they'll any get pushback from the DEA wrt the Schedule II stimulants?
posted by ryanrs at 11:52 PM on March 2, 2010

On the upside, maybe pharmacists could refuse to fill the scrips on moral grounds...

That would be cool, if by "moral" you mean that, regardless of the law, the pharmacist would refuse to fill a prescription issued by someone without proper training according to a database of doctors who meet the training criteria of the AMA.
posted by pracowity at 12:09 AM on March 3, 2010 [1 favorite]

The bill would create a committee that would develop a formulary -- a list of drugs -- that the certificated psychologists would be permitted to prescribe. So, it wouldn't be all drugs, it would be limited to drugs on the formulary. A lot would depend upon what was on the list.

I don't have strong feelings on this. Most psychiatric drugs are currently prescribed by non-psychiatrists (e.g. primary care physicians), and generally there isn't some complicated bio-medical analysis that goes into prescribing anti-depressants (whether or not that's a good or bad thing, that's the state of affairs). On the other hand, there are really complicated issues with some medications, such as combinations, anti-psychotics, tranquilizers, lithium, depakote, lamictal, etc., which really do require expertise. In those cases, a primary care doctor without a lot of extra experience/training might say, should say, "that's too complicated for me," and refer the person to a specialist, and I would hope that a psychologist would do the same thing. I guess one concern would be whether psychologists would try to take on prescribing cases that are too complicated.
posted by ClaudiaCenter at 12:12 AM on March 3, 2010 [1 favorite]

Wait, guys... but psychologists have PhDs! (ok, or PsyDs.) They have years of training (including math and science), and even do residencies etc.

And the bill, "...limits eligibility to psychologists with doctoral degrees -- a late concession won by the bill's critics." So none of the newfangled masters degree-wielding psychologists* will even be able to prescribe.

Also: "Yet the bottom line here is who gets to play doctor with people's brains, and under what circumstances."

I'd much rather have psychologists prescribing psychotropic medication than PCPs. I think it makes much more sense to allow trained experts in psychology to determine which psychotropic medications patents need, than it does to allow PCPs to do so. I've encountered so many people whose PCPs (or even psychiatrists!) just wrote them scripts for an antidepressant or anti-anxiety pill with a bunch of refills, and sent them on their merry way. At least psychs are going to have a better idea of the psychological need for the medication, and understand the necessity of therapy in conjunction with drugs. Maybe I'm being too idealistic, but I can't imagine a psychologist wouldn't do the adequate research and consultation, or training, to be able to ensure s/he's not prescribing the wrong drug.

*Can you even call yourself a psychologist (legally) if you don't have a PsyD or Phd?
posted by sentient at 12:26 AM on March 3, 2010 [8 favorites]

Last year, I was nearly poisoned by an overdose of my migraine medication.

Stories like that are why I long ago started reading the info sheet on every med I'm prescribed, including dosing instructions. I also put everything into my Google Health profile so that new prescriptions get checked for drug-drug interaction with all my other prescriptions and over the counter meds.

As for the relative proficiency of doctors, phys. assistants, and nurse-practitioners, I've met individuals from all three categories who I wouldn't trust prescribing out of their specialty. My current PCP I would trust to fully understand absolutely any prescription he writes, but I'm not sure I trust that he has the time to spend looking at my chart or following up adequately. Sometimes an NP with more time to spend on you might do a better job than a Dr with time constraints. In any case, always double check everything. Statistically, in medicine, something like 1/200 decisions are erroneous.

Psychologists as a whole should not be trusted with this without extensive additional training.
posted by BrotherCaine at 1:13 AM on March 3, 2010

So, as long as someone thinks things suck presently, and are wrong, it's all good to move further in that wrong direction, seeing as how it all sucks?

Not quite... My point was (supposed to be) that lots of people seem to prescribe irresponsibly, and that psychiatrists seem to have a lot of characteristics that would make them prescribe less irresponsibly. So there would be less net sucking if people switched from Psychiatrists only or PCPs only to Psychologists only.

The ideal case is probably when people on medications see a psychiatrist (or PCP) in addition to a psychologist. But as long as this isn't happening, it seems to me that seeing only a (prescribing) psychologist might well be better than seeing only a psychiatrist (or PCP).
posted by sentient at 1:21 AM on March 3, 2010 [1 favorite]

I probably need to read further before I ask, but I'll ask anyways: is there a limitation on what they prescribe? Under this new legislation, can a non-doctor mere psychologist prescribe narcotic painkillers?

Given the way the DEA has been throwing completely legitimate doctors who actually specialize in pain management in jail for writing prescriptions it would be seriously risky to try, even if they were legally allowed.

Anyway, I'm not really sure what the problem is with this. There are a lot of drugs which are not that dangerous. Just write those drugs on a big list and allow people with less training to write those scripts, and require a referral to a 'real' doctor or even a specialist to get a prescription to a more dangerous drug. And it sounds like that's what they're going to do:

The bill would create a committee that would develop a formulary -- a list of drugs -- that the certificated psychologists would be permitted to prescribe. So, it wouldn't be all drugs, it would be limited to drugs on the formulary. A lot would depend upon what was on the list.

And, I don't know if you've noticed, but a lot of people in this country don't have health insurance, that means that doesn't mean that their perscriptions will be written by well qualified doctors, it means their prescriptions won't be written by anyone at all. This could be especially problematic for people with Adult ADD, for example, who might have trouble holding down a job with health insurance because of their ADD, but can't get treatment because they don't have insurance.

So um, yeah I don't really see what the problem is. If you're worried about, then make sure you get your prescriptions from a doctor.

One way to reduce health care costs is to allow less well trained people to perform the routine task, rather then doctors. That's why you have "nurse practitioners" and so on.

As for the "These people are too stupid" argument, like I said, that's why you limit their ability to prescribe to drugs that are relatively safe.
posted by delmoi at 1:32 AM on March 3, 2010 [2 favorites]

So, as long as someone thinks things suck presently, and are wrong, it's all good to move further in that wrong direction

Someone didn't take their irony supplement today.
posted by zippy at 1:44 AM on March 3, 2010 [1 favorite]

I also put everything into my Google Health profile so that new prescriptions get checked for drug-drug interaction with all my other prescriptions and over the counter meds.

Predictions, anyone? How long until Google itself is put in charge of prescribing medications? (Based on a sophisticated analysis of a combination of your health profile and browsing habits, of course.) I'm betting on the year 2019, but then I'm an optimist...
posted by fairmettle at 2:04 AM on March 3, 2010 [1 favorite]

...both the Oregon Medical Association and the Oregon Psychiatric Association opposed it.

Heh, reminds me of how liquor stores are always against propositions that would allow supermarkets and gas stations to sell beer and wine. [/cynicism]

Also, the second article mentions the organization, "Psychologists Opposed to Prescription Privileges for Psychologists." Interesting to see that perspective. (And they've got quite a URL.)
posted by sentient at 2:11 AM on March 3, 2010

psychologists have PhDs! (ok, or PsyDs.) They have years of training (including math and science), and even do residencies etc.

Yes, but they've never been able to prescribe drugs before. So they probably don't have any training experience in doing that as well. Why would a residency program teach you to do something you would never be able to do? Most medical residents spend a lot of time discussing drug prescriptions and interactions with their attending physicians. It doesn't sound like the psychologists in Oregon will be required to go through additional training (at least it didn't say so in the article, but will they? is that why that out-of-state guy has his prescription med school?).
posted by bluefly at 2:22 AM on March 3, 2010

And, I don't know if you've noticed, but a lot of people in this country don't have health insurance, that means that doesn't mean that their perscriptions will be written by well qualified doctors, it means their prescriptions won't be written by anyone at all.

Well, that's the the strongest rationale for SB 1046 - to improve access to psychiatric medication prescribing, especially in rural areas.

One way to reduce health care costs is to allow less well trained people to perform the routine task, rather then doctors. That's why you have "nurse practitioners" and so on.

But as that opinion piece explains, the debate is precisely over who should be considered "well-trained"?

Physicians complete substantial premedical science training, then two more years of preclinical science instruction followed by two years of clinical training, and additional residency training (four years for psychiatry). Nurse practitioners and physician assistants also have undergraduate science requirements, receive several years of full-time training and varying amounts of continued supervision. How can we expect psychologists to safely prescribe without comparable training?

Indeed without medical training why would they be needed at all? If the drugs are so medically safe, sell them over the counter.

Regardless of what the legislature does it's gonna be the malpractice insurance that sets the limits on what a psychologists in Oregon (and in every other state) are practically able to do. From an insurance company's point of view, this easier access looks like a bad bet.
posted by three blind mice at 2:35 AM on March 3, 2010 [1 favorite]

That's pretty much what I was referring to re: Schedule II drugs. Amphetamines are one of the most commonly prescribed ADD medications. But given the current meth abuse issues, I think amphetamine prescriptions by non-medically trained psychologists won't fly.

From a financial standpoint, I think you'll find the drugs cost significantly more than the psychiatrist visit, even for many generics.
posted by ryanrs at 3:26 AM on March 3, 2010

Indeed without medical training why would they be needed at all? If the drugs are so medically safe, sell them over the counter.

Well first of all the FDA controls what can and can't be sold over the counter, not state governments.

Secondly, why does it have to be an 'either or' thing?

I mean, you need a prescription to get eye glasses presumably not all ophthalmologists know everything there is to know about 'science' and basic biology. Yet, they are still able to do it, because glasses are probably not going to cause someone a lot of damage if you get the prescription wrong. Maybe you get a headache at worst.

So, in some cases you can have a drug which is pretty safe, and you don't need someone who has a deep science background to make decisions about it. But you do at least want someone who understand the issues that the drug is supposed to treat.

I think it's silly to say either the drug is so safe that people should be able to buy it over the counter and take it without talking to someone or the drug is so dangerous that it can't be taken without supervision by someone who's spent years studying biology and human physiology.

There is obviously a middle ground of drugs that are not too dangerous, but might not be useful or appropriate to take for their condition, so you want to have someone who's at least somewhat knowledgeable working with them.
posted by delmoi at 3:32 AM on March 3, 2010 [1 favorite]

you need a prescription to get eye glasses

No you don't. Walk into a Lenscrafters and tell them the relevant specifications and they'll make you a pair, no questions asked!
posted by ryanrs at 3:41 AM on March 3, 2010 [1 favorite]

So, in some cases you can have a drug which is pretty safe, and you don't need someone who has a deep science background to make decisions about it. But you do at least want someone who understand the issues that the drug is supposed to treat.

That's why there are physician assistants in psychiatry. If psychologists want to get that certification, it seems like an appropriate level of experience to dispense your pretty safe drugs.
posted by BrotherCaine at 4:05 AM on March 3, 2010

I'd have much less of a problem with this plan if the psychologists were required to have additional training and certification before prescribing drugs. And I've got just the ticket: pharmacy school. A standard four year pharmacy program would certainly fill in any gaps in a psychologist's understanding of chemistry, physiology, pharmacology, and toxicology. The two fields actually complement each other quite well.

The downside is that requiring an additional four years of school would probably negate the purpose of this legislation. But making psychopharmacology easy is probably not within the means of the Oregon legislature. (Not that it will stop them trying.)
posted by ryanrs at 4:11 AM on March 3, 2010 [1 favorite]

Wow, I thought MeFites would think this is a good thing.

It's no surprise there would be opposition by the Oregon Medical Association - whose mission is "serving and supporting physicians" - and the Oregon Psychiatric Association ("an organization of physicians"). These are the lobbying groups for the profession most likely to suffer as a result - medical doctors. They are serving their constituency.

When prescription-writing ability is removed from the monopoly power of medical doctors, suddenly the services of medical doctors become less valuable. It's fair to assume that if the bill basses psychiatrists would have to lower their prices or increase their service level, or both, to compete with the suddenly expanded field of professionals.

If you live in Oregon and still want to go to a medical doctor because it makes you feel more comfortable with the prescription you get, you are free to. Nothing will change. The only difference, it seems, is that if you feel comfortable with a psychologist (maybe even the one you've been going to already for years), you no longer need to go to a second appointment for access to medicine that could help you. The increase in supply would also be a great benefit for uninsured or out-of-pocket payors.

Will there be crummy psychologists who misdiagnose? Sure, just like there are crummy doctors who misdiagnose. Make them carry insurance, regulate and monitor their licensure status, and make sure you are informed when you go to choose a doctor.
posted by AgentRocket at 4:16 AM on March 3, 2010 [6 favorites]

That's why there are physician assistants in psychiatry. If psychologists want to get that certification, it seems like an appropriate level of experience to dispense your pretty safe drugs.

Well, obviously other people disagree. I'm not sure what point you are trying to make here. Yes, anyone can prescribe drugs if they go to med school and graduate and become M.Ds. The question is whether or not we want to expand the number of people who can do so for certain drugs.

I mean, even OTC drugs have some risk. Why not ban them and make everyone get a scrip for ibuprofen?
posted by delmoi at 4:24 AM on March 3, 2010

What are the other 2 states and what has their experience been?
posted by Obscure Reference at 5:07 AM on March 3, 2010

I just returned from Mexico, where it appears you can buy pretty much any drug over the counter without a prescription. Maybe antibiotic resistant bacteria and valium addicted zombies lurk around every corner, but I didn't notice them.
posted by digsrus at 5:08 AM on March 3, 2010 [2 favorites]

They are serving their constituency.

Which also means standing up on behalf of their members for professional standards.

I mean, even OTC drugs have some risk. Why not ban them and make everyone get a scrip for ibuprofen?

demoi, you're asking a question you've already answered.

There is obviously a middle ground of drugs that are not too dangerous, but might not be useful or appropriate to take for their condition, so you want to have someone who's at least somewhat knowledgeable working with them.

Yeah, obviously all drugs have some risk. It seems to me that the question here is whether or not the drugs involved are sufficiently medically safe as to be suitable to be prescribed by someone with no medical training. I'm guessing that maybe the answer is maybe no? To quote Alice, "the ones mother gives you don't do anything at all."
posted by three blind mice at 5:09 AM on March 3, 2010 [1 favorite]

demoi, you're asking a question you've already answered.

Uh, right. I was asking it rhetorically. If it's true that some drugs are safe for people decide to take on their own, how can it be that all other drugs are too unsafe to be prescribed without spending years studying biology?

Yeah, obviously all drugs have some risk. It seems to me that the question here is whether or not the drugs involved are sufficiently medically safe as to be suitable to be prescribed by someone with no medical training.

Seems like a question that needs to be answered on a per drug basis which is what they are going to do

I'm guessing that maybe the answer is maybe no?

Uh why? A quote from Alice in wonderland is supposed to prove your point? Why don't you think they are safe enough to be prescribed by someone with no medical training? What's the actual reason?

Right now there are two groups of drugs, some you can get without a prescription, and some that you need a doctor or medical professional's to sign off. All this bill is doing is creating a third class from the second group that requires less supervision, but not no supervision.

If it's possible for the first group to exist, then it's obviously possible for the third group to also exist.
posted by delmoi at 5:20 AM on March 3, 2010 [1 favorite]

Just do away with prescriptions and let everybody buy their own damn drugs. Why do I have to sit in a doctor's office for three hours to get antibiotics when I know I have an effing ear infection?
posted by dortmunder at 5:29 AM on March 3, 2010

There's nothing in the background of most psychologists about drug interactions, drug reactions, and other dangerous stuff.

and

I'd have much less of a problem with this plan if the psychologists were required to have additional training and certification before prescribing drugs.

Well, YEAH, that's why completion of a psychopharmacology certification program will be necessary before psychologists will be able to prescribe. Which that now-California psychologist heads. The one who's on the task force in Oregon. Which might be a conflict of interest. Which was the point of the original post.

Most psychiatrists have a list of drugs that are antidepressants, or antipsychotics, or stimulants for ADHD, etc. and they look up possible interactions and side effects in The Big Book and use good old trial and error when they prescribe. They are not, for the most part, drawing on their extensive medical school background in physiology.

And yes, of course there will be a limited list of medications that psychologists can prescribe.

I think the biggest problem with this is that psychologists will become "body" people and start to think that people become depressed and anxious because of "a chemical imbalance." It's the dumbing down of the profession of psychology that I fear most. (not that... never mind)
posted by DMelanogaster at 5:30 AM on March 3, 2010 [4 favorites]

I'm not sure how I feel about this bill overall (I think it depends wildly on the psychologist), but I find AgentRocket's argument that nothing will change for those who are happy with existing relationships a bit pollyannaish. Do you really think insurance companies will continue to pay for higher-cost psychiatrists AND psychologists if they can get away with just paying psychologists?

To me, this seems to be the heart of conservative free market arguments and their fundamental flaw; this notion that nothing will change for the worse in a freer market -- because really, that's what this is in certain ways -- but everything will change for the better is disingenuous.

Please note that I don't think AgentRocket meant this in that sense, and I certainly don't want to be accused of calling him/her a conservative (especially if s/he considers that a pejorative), but at the same time, I think taking an overly-positive view of the fundamental nature of corporations (in this case, insurance companies) is a dangerous thing.

I do admit that I haven't read the bill, so if there's a provision to protect the insured from their insurers, I will humbly accept edification.
posted by JMOZ at 5:42 AM on March 3, 2010 [1 favorite]

A quote from Alice in wonderland is supposed to prove your point?

Not Carroll, Jefferson Airplane (the song White Rabbit):

One pill makes you larger
And one pill makes you small
And the ones that mother gives you
Don't do anything at all
Go ask Alice
When she's ten feet tall

The point being pharma that alters your head is not useful if it does not do something. The ones that are harmless - prescribed by mother - are useless.
posted by three blind mice at 5:53 AM on March 3, 2010

Wow, I thought MeFites would think this is a good thing.

Metafilter, favorably disposed toward markets in healthcare? HAHAHAHAHAH.

In all seriousness, though, this isn't a taxicab medallion situation. The drugs in question are heavily regulated, and most people believe for good reason. Since this isn't about recreational drug use and personal autonomy etc., we can set that aside. Is it worth creating a dual or multi-track (beyond what already exists) system for prescribing drugs? I don't have a good answer for that, but I can imagine that fixing others' prescribing mistakes would be a headache for better-trained psychiatrists.
posted by Inspector.Gadget at 6:03 AM on March 3, 2010

Most psychiatrists have a list of drugs that are antidepressants, or antipsychotics, or stimulants for ADHD, etc. and they look up possible interactions and side effects in The Big Book and use good old trial and error when they prescribe. They are not, for the most part, drawing on their extensive medical school background in physiology.

In my experience, this isn't true at all. They have a list of drugs in their head, that they learned in their extensive medical school and training background, and is updated constantly by experience and continuing education, and that they know backwards and forwards regarding interactions, side effects, and intended effects, down to a ridiculous level. Yes, there is trial and error involved to see how each individual reacts to each specific drug, but they know the intended effects, probable side effects, and drug interactions before prescribing anything. Yes, they have to consult drug reference books for less common drugs, but the way you've stated it makes it sound like they're making wild guesses with most prescriptions.

Full disclosure: my partner is a psychiatrist, although most of my exposure to psychiatry has been at a hospital-based psychiatry level, instead of general outpatient care. It will be interesting to ask him over lunch what he thinks of this bill.
posted by This Guy at 6:09 AM on March 3, 2010

Well, YEAH, that's why completion of a psychopharmacology certification program will be necessary before psychologists will be able to prescribe.

That specific language was present in the bill as introduced, but was removed before passage. The version passed by the Oregon Senate is less specific with regard to the training and certification requirements.
posted by ryanrs at 6:11 AM on March 3, 2010 [1 favorite]

If the formulary is put together in a conservative way, count me among those who see this as a good thing.

It simply has to be easier to take a trained psychologist who spends more than one fifteen-minute session with a patient and give them enough training to apply the formulary responsibly than it is to give a GP or family physician an equivalent/good-enough training in psychology and somehow force them to spend an hour a week with the patient.
posted by ROU_Xenophobe at 6:13 AM on March 3, 2010 [2 favorites]

Based on my experience, MDs charge too much and know too little about these drugs. They spend too little time with the patient, who usually has no relationship with them before they come for pills, and, because of the cost of followup visits, don't see much of the patient afterwards. There are, of course, many exceptions, but this is the rule.
posted by Obscure Reference at 6:14 AM on March 3, 2010 [2 favorites]

it was revealed that an out-of-state expert (who was temporarily licensed in Oregon so he could give recommendations on the panel) happened to run a school that trained psychologists to prescribe meds, which would directly benefit from the bill's passage

I'm not sure why you think this is relevant. Legislative hearings don't usually involve disinterested Solomons who don't give a crap whether the bill passes or fails. They usually involve interested parties with a direct stake in the matter, most commonly interested parties screaming bloody murder about how the bill (or continued lack of a bill) will hurt their bottom line.
posted by ROU_Xenophobe at 6:16 AM on March 3, 2010

There is a term for patients being on too many drugs: polypharmacy. When patients are as loaded up with medications as many whose reports I see daily are, drug interactions are rampant. Many, many people are now taking medications to counteract the side effects of other drugs. And when those medications cause interaction problems, along come more drugs. It is quite common to see patients on more than ten prescriptions at once, many having highly contradictory effects. And these prescriptions are coming from fully trained, licensed, Board-certified physicians who should know better.

Sadly, the health care system is so badly broken, it really does not behoove doctors to actively pursue true healing, with the goal of getting patients OFF medications. Doctors are allotted precious little time with each patient, and the expedient way of coping is to drug, drug, drug. Depressed? Take Zoloft (forget counseling, your insurance doesn't cover it). Got a stuffy nose? Use nasal steroids ('cause allergy testing isn't covered by your policy). Having stomach trouble? Use AcipHex (forget dietary counseling, you can't afford it).

This latest from Oregon is just one more step down the same path.
posted by kinnakeet at 6:17 AM on March 3, 2010 [1 favorite]

OK, is there anything in the links that actually shows this is a terrible thing, or is outrage at anything connected to psychiatric medicine just a given and we don't even have to make a token attempt to justify it anymore?

FUCKIN PROZAC! SUX YEAH! FUCKIN PSYCOTOGISTZ! FUCKIN BIG PHARMA LOL!
posted by edheil at 6:21 AM on March 3, 2010

Huh? Did you even read the thread? If you're looking for uninformed knee-jerk outrage, look no further than your own comment.
posted by ryanrs at 6:28 AM on March 3, 2010 [2 favorites]

My concern would be if the psychiatric symptoms are based on something physiological.

What if my depression is fatigue based on a thyroid problem? Perhaps many psychiatrists would say 'bring on the paxil!, but they might also be somewhat curious - and be able to run some tests on whether my presenting symptoms are a result of sleep apnea, anemia, etc.

In short, currently everyone else who can prescribe meds (NPs, PAs, MDs) at least have the ability to review a person's medical history, assign and review medical tests, and consider the whole body in a way that it doesn't seem psychologists can. (Whether they do or not, is a different story).

I think psychologists are an important part of the health care universe - on the whole, the ones I know have been much more willing to look at social/cultural/etc. factors as a cause for some of the presenting issues of anger, depression, etc. What's a shame is that too many psychiatrists aren't more like psychologists.

Overall, while I can see why people have issues with the pharma industry and psychiatrists (too many of which haven't met a pill they didn't like), I don't see how opening up the field to what could possibly be a population less able to consider the body/mind connection when assessing symptoms is a good idea.
posted by anitanita at 6:33 AM on March 3, 2010 [1 favorite]

Just a thought, but perhaps "people" aren't the best able to prescribe meds, but rather we could let programs do it for the uninsured. Simply enter the lab results, as needed, and if the software deems it worth a monitored risk, then a prescription is given. Nobody gets sued because it was free and voluntary, and people can take responsibility for doing the research on the internet. Patients give feedback and, if necessary, a doctor with now more time on their hands can always get involved. I'm simply acknowledging that Marcus Welby M.D. is a fantasy today, and probably always was.
posted by Brian B. at 6:36 AM on March 3, 2010

Nobody gets sued because it was free and voluntary

*snicker*
posted by ryanrs at 6:39 AM on March 3, 2010

If it's possible for the first group to exist, then it's obviously possible for the third group to also exist.

Shush, before you get our first group taken away. It includes drugs that can cause liver damage, gastritis and stomach bleeding, seizures, comas, deaths... if there wasn't a grandfather clause in the public consciousness, I don't know if you'd be able to so much as treat a headache without seeing a $100/hr licensed professional first.
posted by roystgnr at 7:05 AM on March 3, 2010

Things like this put me in an uncomfortable position. Given that I'm for legalization of pretty much anything you want to put into your body (except antibiotics) it pretty much follows that I think you should be able to buy over the counter whatever drugs these guys are going to be allowed to prescribe. And yet this whole thing stinks to high heaven of drug lobbying.

But I guess it would be a little weird to think it should be legal to buy pot or heroin but not antidepressants. So, whatever, let them eat prozac.
posted by Justinian at 7:09 AM on March 3, 2010

The conflict of interest here is accurate, but I still feel it's a little misleading. Yes, the person lancing this bill may be the same one who runs the school for certification of psychologists to dispense drugs. But what is the alternative? You can't have one without the other without removing the certification requirement.

Perhaps I'm just biased. I've been more than a handful of psychiatrists who have known less about the drugs they've prescribed me than I knew from having taken undergraduate biology and behaviour classes and read Wikipedia articles.
posted by tybeet at 7:11 AM on March 3, 2010

Having met a number of certified masters-level psych health professionals, I really don't have a huge problem with this. I see how much continuing education they do, etc. They're staying on top of the field.

Yes, care needs to be taken -- but that's true of *any* med. I don't care if you have a Ph.D, a Psych.D or an MS -- if you don't do the basics, you can do great harm.
posted by eriko at 7:20 AM on March 3, 2010

Not to derail, but this:

I mean, you need a prescription to get eye glasses presumably not all ophthalmologists know everything there is to know about 'science' and basic biology. Yet, they are still able to do it, because glasses are probably not going to cause someone a lot of damage if you get the prescription wrong. Maybe you get a headache at worst.

You're talking about optometrists. Their training consists of optometry school (after a regular college bachelor's degree program). Ophthalmologists do medical school, then four years of residency, and then usually several years of specialized fellowship training in addition to that. (Full disclosure: my spouse is a pediatric ophthalmologist -- an eye surgeon -- who spent roughly 13 years in med school/residency/fellowship.)

But in a way, your point may stand: I would not want an optometrist doing surgery on my retina, or even diagnosing my retinal problem, I would want to be evaluated by an ophthalmologist who specializes in the retina, simply due to the fact that it is her job to be more knowledgeable and skilled in how to treat it. Likewise, I would be hesitant to seek a prescription from a therapist/aide who might not be trained or experienced enough to know enough about what could possibly go wrong.
posted by mothershock at 7:33 AM on March 3, 2010

It simply has to be easier to take a trained psychologist who spends more than one fifteen-minute session with a patient and give them enough training to apply the formulary responsibly than it is to give a GP or family physician an equivalent/good-enough training in psychology and somehow force them to spend an hour a week with the patient.

This is the crux of the matter. A fantastic take on the situation. Which would all of you think is easier? Teach PhDs basic pharmacology, or teach MDs advanced psychology? Even if you choose the latter, they do not have the time to dedicate, so it is moot.

And regardless of how health care reform shakes out, simple demographics, of both patients and providers, will make it such that less and less of your care over the next 20 years will be performed by MDs. America needs to prepare for this. Med schools right now are not graduating docs at replacement rate for retiring baby boomers. Primary care is being completely abandoned to midlevels and foreign trained imports.
posted by discountfortunecookie at 7:38 AM on March 3, 2010 [1 favorite]

1. It is entirely incorrect to state that prescribing psychologists would have no medical training. All of the laws passed to date (Louisiana, New Mexico, Guam, Oregon) require psychologists who want to prescribe to get a whole 'nother Master's degree in psychopharm. This requires a hell of a lot of extra work and expense for people who already spent 5-7 years in a Psy.D. or Ph.D. program.

2. Morgan Sammons is probably the most qualified person to testify in front of any legislature about this issue. He's one of the original 10 DoD prescribing psychologists who went through the PDP. Look it up. He runs a school more or less because he IS Morgan Sammons. There's no real way to get around the fact that there aren't a lot of people qualified to (a) run a school and (b) testify on this issue.

3. For all of you people whining about "let them eat prozac" -- One major point of this effort is so prescribing psychologists will already be PSYCHOLOGISTS, with a settled professional identity as non-pill-pushers. Quite a few of us in the clinical psych field are sick to death of cleaning up the messes left behind by psychiatrists, or, much more commonly, by family practice docs who know basically nothing about human behavior (maybe have a six-week psych rotation under their belts from internship year, if that) but prescribe about 75% of the psychiatric drugs now prescribed. Prescription privileges would let us start to fix the "let em eat Prozac" problem. I think Morgan's the one I heard say, in a talk, "The power to prescribe is the power to un-prescribe." Everyone in the room knew how valuable that would be.

3a. There's a fair argument to be made, however, that prescribing psychologists could turn into pill dispensers with legs, just like the psychiatrists did in the 1980s and '90s. We will just have to see how that turns out. I suspect that will not happen, however. It sure hasn't happened to Morgan or to the other handful of RxP psychologists I know.
posted by PsychoTherapist at 7:39 AM on March 3, 2010 [8 favorites]

Matt-This is a bit provincial, but do you have a handy link to the vote? This seems like a horrible idea, and I would like to know who voted for it, and who voted against it. One of the things I like about Oregon is that politics is still at the retail level, somewhat (DeFazio works out at my gym, for example) and I would like to know how the vote went in case I run into one of those folks.

Fuck it, in less time than it took for me to write the above, I found it. It's amazing, the bi-partisanship of it all.
posted by Danf at 7:39 AM on March 3, 2010

BTW, and I speak as someone in favor of RxP, the whole rural access thing is bullshit. The entire reason the P.A. license was created was to solve that problem. Guess what? Physician's assistants like to live in big cities just like practically everyone else. Psychologists aren't any more likely to set up shop in the ass end of nowhere -- probably less so. So I don't think RxP would really lead to increased rural access, even though that was the original rationale (all the way back in Hawai`i when Sen. Inouye started this push) and continues to be part of the argument.
posted by PsychoTherapist at 7:49 AM on March 3, 2010

One funny twist: during public hearings on the bill, it was revealed that an out-of-state expert (who was temporarily licensed in Oregon so he could give recommendations on the panel) happened to run a school that trained psychologists to prescribe meds, which would directly benefit from the bill's passage.

Hahahaha..... wait a minute. That's not funny at all.

People should lose their license over unethical shit like this.
posted by graventy at 7:56 AM on March 3, 2010

Ok, I've got a plan. I get a psychologist, a pharmacist, a bunch of pills, and an ice cream truck that is modified to play "I Want A New Drug," and cruise around Oregon, raking in the cash.
posted by chambers at 8:10 AM on March 3, 2010

Likewise, I would be hesitant to seek a prescription from a therapist/aide who might not be trained or experienced enough to know enough about what could possibly go wrong.

This doesn't really make much sense to me unless you think that psychiatrists or other physicians routinely deduce problematic drug interactions and side effects from first principles and their knowledge of the molecular structure of the drugs. Otherwise, they're reading about the interactions from materials that describe the interactions and side effects.

I put it to you that someone who has successfully obtained a social science PhD can probably read well enough to read those same materials, and probably has a memory functional enough to retain that information. For that matter, it seems well within the realm of the possible to simply create a flowchart or checklist to rule out problematic drug interactions and side effects.
posted by ROU_Xenophobe at 8:28 AM on March 3, 2010 [2 favorites]

Hahahaha..... wait a minute. That's not funny at all.

People should lose their license over unethical shit like this.

Again, there's nothing remotely unethical about asking or subpoena-ing interested parties to give testimony at a hearing. People with a stake in the matter either way are who you want to hear from.
posted by ROU_Xenophobe at 8:32 AM on March 3, 2010 [2 favorites]

I'm not a mental health professional, but I work solely with clients with mental illness (IAAL). I often have to talk to psychiatrists and therapists about my clients' disabilities and I routinely find that the psychiatrists are barely familiar with their patients. The therapists--those with phd's and those who "only" have masters--are always much more knowledgeable. If psychologists get some training in prescribing and are limited to a formulary, I think this is a potentially great thing. I just don't see my clients getting that much out of their relationships with their psychiatrists beyond a 15 min appt every month and some pills. Maybe the solution would be to change the nature of psychiatric treatment, but I don't see that happening.
posted by Mavri at 10:03 AM on March 3, 2010 [1 favorite]

This doesn't really make much sense to me unless you think that psychiatrists or other physicians routinely deduce problematic drug interactions and side effects from first principles and their knowledge of the molecular structure of the drugs. Otherwise, they're reading about the interactions from materials that describe the interactions and side effects.

Side effects interact with a person's organic medical problems as well as their mental problems. Physicians do think about medical problems and drug action in terms of systems. It's true that some are black-box, but many have a rationale.

I'm pretty much in favor of this, with the caveat that patients should be evaluated for medical problems before coming to a diagnosis.
posted by a robot made out of meat at 10:14 AM on March 3, 2010 [1 favorite]

I don't think they'd be any less conscientious about it than PCPs. I have the drugs I'm on now because I told the doc-in-a-box that's what I'd taken before. I mean, sure, I'd filled out a form on a previous visit were I'd said I wasn't on any other medications, but he didn't do any deep investigation. I mean, I'm grateful, because if I can't get what I need, I'll take what I can get, but it's not exactly hard to get a scrip for antidepressants anyway. If a law like this meant I could find someone to help me, I'd be all for it.

(And yes, three years later, still no solution.)
posted by Karmakaze at 10:18 AM on March 3, 2010

Just do away with prescriptions and let everybody buy their own damn drugs. Why do I have to sit in a doctor's office for three hours to get antibiotics when I know I have an effing ear infection?

If you have to sit in the office for three hours, there's a problem with your medical system, but the solution is not to start selling all drugs over the counter like candy. I guarantee that the lines would get much longer if all drugs became OTC.

1. When people take antibiotics for no good reason -- something they would ignorantly do in huge numbers if they could get antibiotics like they get aspirin -- they would develop all sorts of drug-resistant strains of diseases that we now have under control. That's a huge public health risk, not just a risk you would take with your personal health.

2. If a guy screws up his body with the wrong drugs, that's his (and his family's) problem, assuming that, because he was responsible for fucking himself up with the wrong drugs, he has to pay 100 percent of all subsequent medical treatment out of his own pocket. Bujt that's not he way it would work. The sick guy would get expensive, scarce medical care because he didn't know what he was doing.

3. It's not cool if people start killing their kids with well-meaning home remedies involving every possible drug manufactured in the world.

4. If a guy makes himself crazy, or fails to make himself sane, because he thinks he doesn't need a doctor but he has no idea what he's doing with piles of OTC psychoactive drugs, he's not just his own problem. He's driving the car behind you, or flying the plane above, or buying wall-piercing ammunition at the gun shop near you.

Sometimes people ought to be encouraged to see a doctor, even when the wait is a tad inconvenient.
posted by pracowity at 11:07 AM on March 3, 2010

The Big Nurse unavailable for comment.
posted by Smedleyman at 3:01 PM on March 3, 2010

Man, this is disappointing to see the amount of malice towards primary care around here. It's too bad people have had such bad experiences.

With that aside out of the way, I'm taking a wait and see approach to this issue. And I'm glad other states are doing it before mine.

The one hand:
Even in my progressive, open minded, relatively affluent city, it is damn difficult to get someone in for *any* mental health treatment and even harder for med management. If that person happens to live on the margins of society, -- ie uninsured, homeless, drug addicted, you know, the kind of people that really need psychiatric medications -- forget about it. I have literally had to tell psychotic, suicidal, and homeless people that they can make an appointment with a psychiatrist for 3 months from now and if they miss that appointment, then the community mental health clinic will drop them to the bottom of the waiting list. That's the desperate crisis that proposals like this come from. Primary care doctors have become the de-facto first line mental health professionals. I don't like having spend 30 minutes on a difficult mentally ill person that was scheduled for 15, trying to figure out how to keep him marginally sane, but I disagree strongly with the idea that family doctors are totally unqualified for this role. You can't spend years working long hours observing human behavior intimately and longitudinally, plus all the journal reading/licensing exams/lectures, not to mention being the ultimate legally responsible entity for what you prescribe and not know a great deal about mental health management.

In my federally funded clinic, we actually have a program designed to catch these people who fall through the cracks where we consult regularly with our staff psychiatrist who also provides a lot of educational and clinical back up for us and as a result I am doing some fairly complex medication management for psychiatric problems and, I think, with this kind of support, I do a reasonably competent job of it. I suspect a program with prescribing psychologists could work very similarly and help to fill (albeit imperfectly) a very significant gap we have in our health care system.

The other hand:
In medicine, so much harm is done by not recognizing when you're getting in over your head. I have no doubt you could train non-physicians to know dosing, side effects and interactions of the top 100 psychiatric medications; none of them are totally benign, but none of them are totally mysterious either. But I do think there is a lot to be said for the experiential knowledge that accumulates through med school and residency where you see things that go unexpectedly, or the one in a thousand guy who wound up in the hospital due to a life threatening reaction to some usually safe drug. You just develop a sense of when things are adding up and when they aren't and what to do about it when they aren't and your practice reflects this. I supervise a number of mid-level providers and for the 99% of patients with colds, they do fine. But there's always that 1%. And I fully acknowledge that just having an MD behind your name doesn't assure you'll catch that 1%, but I will tell you that my approach to medicine is profoundly shaped by the existence of that 1% when I've seen that person die during residency, or I know I'm the one that's going to get called to come to the hospital in the middle of the night to take care of that misdiagnosed person who's now in the ICU.

Then there's the really valid point that there's a shit load of medical illness that mimics or complicates mental illness and certainly we will see more of that being missed or unaddressed.

As a society, we've decided that we want the ease of access that PA's and nurse practitioners and have found ways to mitigate or accept any safety issues that arise. I myself don't know what the best answer is with this particular proposal; I do believe that psychology and medicine are fundamentally different disciplines. But I guarantee that the societal forces that have brought about this question for consideration will only intensify as the doctor shortage worsens.
posted by Slarty Bartfast at 4:17 PM on March 3, 2010 [3 favorites]

I support this.

I have no doubt that a psychiatrist knows more about drugs and their interactions then a psychologist. But psychiatrists have priced themselves out of the market. A psychiatrist's time is so precious and so limited, patients have no time to build a working relationship with one over the years it takes to treat a mental illness.

Training for doctoral-level psychologists is pretty rigorous (at least Ph.D.s, Psy.D.s can be gotten online). Training in statistics and experimental methods is probably more rigorous for psychologists than psychiatrists, so they should be able to read the journal articles on this stuff and draw conclusions that help them treat patients better.
posted by miyabo at 5:39 PM on March 3, 2010

At this rate, if you're depressed, just drink the tap water. There's going to be enough antidepressant in it to make you feel much better, I'm sure.
posted by Hildegarde at 7:25 PM on March 3, 2010

Why do I have to sit in a doctor's office for three hours to get antibiotics when I know I have an effing ear infection?

Public health (MRSA), and personal health (aplastic anemia).
posted by BrotherCaine at 7:53 PM on March 3, 2010 [1 favorite]

It's no surprise there would be opposition by the Oregon Medical Association ... and the Oregon Psychiatric Association ("an organization of physicians"). These are the lobbying groups for the profession most likely to suffer as a result - medical doctors.

I and all the other medical doctors I know have more than enough patients so that we aren't the least bit concerned about loss of revenue from this. Patients with mental health problems are time-consuming and I would be happy to have them get all their mental health care elsewhere. We do oppose psychologists' prescribing because we don't think psychologists are competent to safely prescribe the meds.
posted by neuron at 8:53 PM on March 3, 2010 [2 favorites]

I think this is a good thing. I get the impression that too many psychiatrists know hardly anything about psychology. I think it's silly to think that you can make the right decision about medication when you don't know much about your patient's psychological problem. Whoever writes the prescription needs more than a reference book of commonly classified disorders; in real life, patients are more complex than a DSM diagnosis.

The other option is to require psychiatrists to also be trained as clinical psychologists before they can write a prescription for a patient.
posted by Soupisgoodfood at 11:00 PM on March 3, 2010

Forgot to say: I think that anyone who isn't an M.D. should obviously have their prescriptions reviewed by an M.D. (probably the patient's GP) before being filled at the pharmacy. Or something to that effect.
posted by Soupisgoodfood at 11:10 PM on March 3, 2010

We were discussing this at a Oregon Psychological Association meeting a couple years ago and one of the main reasons people wanted to be able to do this was so they had the ability to manipulate prior prescriptions.

In the case of public health, you will often receive a new patient and he will have gone through multiple psychiatrists/PCP's and each has added their mark to the patient's perscriptions depending on their particular outlook.

Most psychologists wanted to wean them off of the various meds they were taking and now this gives the psychologists the option to do it. I really hope there will be some sort of training for this. I can't believe that was taken out of the bill.
posted by psycho-alchemy at 11:39 PM on March 3, 2010 [1 favorite]

delmoi wrote: "All this bill is doing is creating a third class from the second group that requires less supervision, but not no supervision."

In many other countries, that role is filled by the pharmacist, who does have training on drug dosing and interaction.

Makes a lot more sense than letting a talk therapist prescribe medication. I for one am glad my SO has an excellent psychiatric diagnostician writing her scrip, and a different doctor (a psychologist) to handle the psychotherapy aspect of her treatment.

If a psychologist would like to change a patient's drug regimen, perhaps they would be advised to discuss the case with the patient's psychiatrist. If that is not possible, the answer is not to allow psychologists to prescribe drugs. The answer is to solve the underlying communication problem.

And GPs prescribing psych meds? That's insanity, except as an emergency measure in certain cases. They shouldn't be prescribing antidepressants, for example, given how in many, if not most, cases, the first drug tried will cause significant side effects, like mania or suicidal ideation.

I suppose if the formulary were limited to drugs like Xanax and others which don't really do much in small doses, I can't see it hurting so long as they have training on interactions and the like, and if the duty of care is increased for pharmacists, so they can act as an actual second set of eyeballs.

I think more people probably need drugs than are getting them. I don't think the answer to that is to hand them out willy nilly, since they can often do more harm than good, and whether the balance is more to the harm side or the good side is entirely based on the individual. That's why I think a team of professionals is almost certainly required for the vast majority of psych cases out there.
posted by wierdo at 1:22 AM on March 4, 2010

So?
posted by telstar at 6:25 AM on March 4, 2010

The identified problem is that there are simply not enough psychiatrists to go around any more. Psychiatry is the physician specialty that makes the least amount of money, so it does not always attract the top talent, or the numbers, needed to sustain itself. This is acutely felt in many rural areas in the U.S. today, where only 1 or 2 psychiatrists may be available for a population of thousands. Similar to the problem with a lack of physicians entering primary care roles, we have the same issue with psychiatry.

Psychologists have been doing prescriptions for some time now, so it's apparently safe to allow them to do so.

But I fear that once you do so, psychologists will then focus more on medication management since they will quickly learn that it is more lucrative to do so. Want to double your salary overnight? Move from doing psychotherapy to medication management appointments only -- this is exactly what happened to psychiatry (which used to do a *lot* more psychotherapy than most psychiatrists do today). There's no reason to believe that capitalism won't eventually influence their work in this regard, and all this talk of wanting to provide a more consistent care experience will go out the door.

The good news is that it's taken a decade to just get 2 states on board with this. If that's the rate they're moving at, it'll be a century before they get prescription privileges in all 50 states. It comes up in one or two state legislatures every year, and every year, never gets passed (in virtually every case).
posted by docjohn at 7:04 AM on March 4, 2010

Oh, and with all due respect to the original poster, psychologists will indeed receive equivalent medical training before being allowed to prescribe.

As any psychiatrist will tell you (if they're being honest), 95% of what they learned in medical school is irrelevant to their daily psychiatry practice. Most of what psychiatrists learn that is relevant is done so in residency.

Or, to turn this on its head, psychiatrists generally receive either no or next to none psychotherapy training while in medical school (they get it in residency). Compare that to the typical psychologist which is trained extensively throughout their graduate school education on psychotherapy -- especially PsyDs. But psychiatrists still can do psychotherapy, despite the fact that their primary training in this area occurs after their formal schooling has ended.

This is very similar to the model being forwarded by psychologists for prescription privileges. The prescribing training is being learned in the equivalent of a "residency" for the psychologist.
posted by docjohn at 7:09 AM on March 4, 2010 [1 favorite]

Man, this is disappointing to see the amount of malice towards primary care around here. It's too bad people have had such bad experiences.

...

In medicine, so much harm is done by not recognizing when you're getting in over your head.

Shouldn't this mean that GPs and family-practice physicians should recognize when adequately treating someone's mental disorder is beyond their realistic means and refer them elsewhere instead of giving a prescription for $ANTIDEPRESSANT on the basis of a 15-minute appointment and sending them on their way?
posted by ROU_Xenophobe at 10:43 AM on March 4, 2010

I just heard back from my assemblywoman on this:

Thank you for writing; I'll answer your question here. In brief, the testimony supported these two determinations: a) it would increase access to (mental) health care for patients in some areas where there is not a psychiatrist, or it's very infrequent with a lengthy waiting period; and that b) patient safety would likely be increased, not decreased, since prescribers would have several hundred hours of very specific instruction and training, followed by a long supervised period (currently, psychologists rely on primary care physicians to write the prescriptions, although both lack that specific training).

From previous work on this, we learned that in many cases, patients who need treatment go for several months without medication while they are being shuffled between their psychologist and their doctor. Currently, primary care providers are acting as mental health providers, even though 50% of Oregonians live in Health Professional Shortage Areas and most primary care providers lack specialized mental health training.

The original bill, House Bill 2702, would have allowed the Board of Psychology to authorize certain licensed psychologists to issue prescriptions. That version of the bill had a number of requirements in order for a psychologist to be authorized to prescribe medicine, including additional training of over 800 hours of clinical supervised training and a prescribing psychologist to collaborate with a patient's primary care physician. This additional specialized training exceeds that of some of those who are currently allowed to prescribe psychotropic medications. The bill was developed with the input of psychiatrist, psychologist, family practice physicians, and nurse practitioners.

The bill that passed in February (Senate 18-11, House 48-9) creates a Committee on Prescribing Psychologists within the Oregon Medical Board. The committee will be responsible for, among other things, making recommendation to the OMB on educational requirements, clinical training requirements, standards, examinations and continuing education for prescribing psychologists.

Cordially,
Nancy Nathanson
posted by Danf at 4:04 PM on March 4, 2010 [1 favorite]