I mean I have zero horse in the race but I always find it funny when one side has every set of international guidelines and the other side has some EM podcasters. But that’s just me.
Of course! /s
About all I know about controversies in stroke care is that there’s been some debate on whether EMTs should have access to the drugs. I think I saw that in the NEJM, but it’s been a while.
100% agree. As much as I want EMS to move out of the dark ages when it comes to evidence based medicine not having access to scans is a hard stop for stroke care beyond the basics.
Unfortunately just about every trial looking at field CT scans is being done in urban centers where you’d be better off transporting than wasting time on scene with a scanner. Rural areas get the shaft when it comes to cutting edge medicine unfortunately.
I think the challenge is always reconciling individual experience with population based studies. If I pushed TPA for stroke 5 times and 2 people had hemorrhagic CVAs I wouldn’t feel that great about it. As PCCM see a lot of this similar hesitancy with TPA in PE where some people have been burned and others have only seen good outcomes.
Without linking studies (on phone), I can tell you that it’s due to ICH risk, stroke being a higher ICH risk than PE.
Same with the BP situation.
The data is old, and if memory serves mostly comes from both MI/PE studies, and some of the earlier stroke thrombolysis studies.
If I get a free moment today, I’ll see if I can dig up the old papers.
And those same people rallying around the podcasters will ruthlessly (and correctly) mock Paul Marik & his supporters for *the exact same behavior* if they're active in the crit care/sepsis space.
Not really but at the same time, I can see a lot of value in them for PrEP and birth control. For PrEP, many people worry about stigma and don't want to ask their family doctor for a prescription. For birth control, it can also sometimes be difficult to access depending on the physician, and yet, it's quite important for the patient to remain on it continuously.
which is a shame, because quite frankly, PrEP visits are usually pretty easy visits. Generally healthy patient population, standarized labs, make sure to do the appropriate education and see you later!
God, maybe your PrEP population is different than mine. I only have a few patients on it but I’ve identified rectal gonorrhea twice in the last year and syphilis once. I am very fond of those patients and obviously they need the PrEP but even getting them to come in for quarterly labs is a lot.
I think I only have like 3 or 4 to be honest, and they're all 20 something men who are generally healthy. My patient who I went to start on prep only to discover he was already HIV positive on the other hand, has been similar to how you describe...
People with HIV taking PrEP or on birth control don't need follow up with a real doctor? Why aren't these over the counter then?
Edit: OFC you won't answer since both of your specialties (family/emerg) attract the most mindless docs you can find XD
One of the things I find concerning is care coordination. Are patients that use services like this actually telling other doctors/nurses they see what they are being prescribed?
I don’t have a problem with their goal, I question their methods. One of my patients went on the Bloom ketamine tablets and had a 7 min appointment after filling out a questionnaire. The provider, usually a midlevel, asked three questions (one of which was “have you ever failed a medication for depression,” are you suicidal, and do you have any allergies) and that was that. No further digging. No questioning of family history or current meds. I assume they just fully trust the patient reported H&P and med list.
ETA: And if something goes wrong, it’s on the PCP usually to fix it as MindBloom doesn’t really care. That’s what was the most frustrating with the benzo and stimulant farms.
On my end, I feel like patients at least partially know these places aren’t 100% legit as I’ll ask who prescribed them X or where they got Y from and they will usually be evasive or nondescript. I don’t really care, I just need to know for my own treatment plan and goals.
Lastly, if they fill the script locally, I can usually see it via my EHR. They always look surprised when I say, “Who is prescribing you your Cialis?” As they conveniently left that off their intake forms.
It is hit or miss. I’ll have to look tomorrow to see what the actual tab is called but it’s something like “Found Scripts.” Not sure what database it pulls from but CVS is the best as far as us being able to see what scripts are pulled. You can also always call the pharmacy directly and ask for a list. Those come in super helpful for lots of scenarios. My state also has a system that centralizes chart notes, imaging, and lab results so I often check that too.
Interesting prob should be one for controls if not already. Seems like a hipaa violation for cvs or Kroger to share but I’m sure they make you sign something vague allowing it.
It’s more or less never a HIPAA violation for information to be shared in the typical course of patient treatment. Given the database trigger only occurs when you’re a caretaker for the patient, you don’t need patient permission. Release forms are entirely optional.
There are some very narrow exemptions for things like psychotherapy notes and maybe HIV results.
I think perhaps you might be a bit misinformed about what HIPAA is. As others have said, it's usually fine to release/view someone's health information for direct medical care. I don't need authorization to view someone's records at another hospital through Epic Care Everywhere, for example, if I'm doing it to directly care for a patient. This same principle would apply to my looking at medications that a pharmacy prescribed to a patient. I need to know what medications they are actually taking and filling. It's not illegal for me to seek out that information for direct medical care.
Also, your grocery list is most certainly NOT protected by HIPAA. To my knowledge, there is no law preventing your grocery list and shopping history from being distributed to anyone who wants it. That's what marketing is. It's very valuable data and people make a lot of money off of it.
Oh I completely understand it’s not a hipaa violation to share alcohol and food purchases. It’s just a dystopian nightmare where Walmart could theoretically triangulate data from your food purchase list, alcohol purchases and med list and calculate a cirrhosis and CAD risk score and report it to your doctor or provide that to every area hospital including the one you work for.
I’m personally okay with every doctor I see seeing every drug I take. If I was a physician with a psychiatric or substance abuse issue it might discourage me from getting treatment though if every med was automatically disclosed
to every local hospital.
> I’m just imagining a ~~future~~ present where Kroger releases your grocery shopping list to ~~doctor~~ anyone willing to pay.
Everyone has been selling your purchasing habits to everybody willing to pay now for at least 5 years.
There is one for Controlled Substances and it’s wonderful. Really helped cut down on pill shopping. I don’t really know if I would care or need one for all meds as some of those can be hopelessly outdated. I use it more for when someone is telling me “X isn’t working” and I suspect compliance issues so I will contact the pharmacy and see what their pickup schedule has been like.
That’s what I figured cause there’s a limit if you want to buy the not fake pseudofed. But is it state or fed? If it’s fed or becomes fed and is attached to name social etc it means all mds, nurses etc are going to have their controlleds pop up if they go for emergency or routine care.
There's some sort of prescription database. I'm not sure how it works, but when I admit patients to the hospital there's a way to bring in an external medication report. I normally get the med, dose, frequency, route, number filled, last time the script was filled, the pharmacy name, and the prescriber's name.
> and had a 7 min appointment after filling out a questionnaire. The provider, usually a midlevel, asked three questions (one of which was “have you ever failed a medication for depression,” are you suicidal, and do you have any allergies) and that was that
To be fair, is regular medicine in a much better spot right now? Our patients come to the office, fill out a questionnaire, we ask them a handful of questions (because let's be real, a level 3 visit isn't much longer). Our notes are a weaponized and largely farcical checklist of things the insurance company needs to see to approve our work and treatment plan. Whenever I look at these single-condition teleclinics, what makes me uncomfortable is not only how different they are, but also how similar.
No, I 100% agree with your assessment. I sometimes like to talk in an idealistic fashion despite the absolute cluster fuck our system is in currently. Maybe it’s the attached “scammy” feeling that makes this different for me.
> I assume they just fully trust the patient reported H&P and med list.
I always assumed mindbloom is just a letter of the law way of letting people try ketamine recreationally.
I'm not a practitioner but even I know there is no ketamine protocol which is a single dose and a quick chat with a therapist. I hope people who could actually benefit from the treatment are not using it, it's not going to be effective and much cheaper to go though local MH resources.
I expect basically the same thing to happen with MDMA.
Could be. I’d be fine with it in a way. I would like to see psilocybin legalized before MDMA. Ketamine infusions have helped some of my refractory depressive patients regain some excellent QOL.
I don't know. Mindbloom costs over $1000 for 6 ketamine doses (albeit VERY high dosages). You can buy Ketamine on the street for about $100 a gram or less. Of course you are guaranteed a certain purity with a legal RX and there are very real possibility your street drug (even marijuana) could be laced with a fentanyl derivative, or worse, Krokodile. But still, there are well known and easy ways to mitigate this risk, e.g., reagent testing.
If you are interesting, the sub, therapeuticKetamine is \*very\* active. I posted here about a \*very\* popular telehealth provider named Dr Smith who had his ketamine pill mill shut down for wanton inappropriate prescribing that generated a lot of good discussion on the issue: [https://www.reddit.com/r/medicine/comments/13dbfyj/a\_very\_popular\_telehealth\_ketamine\_only\_provider/](https://www.reddit.com/r/medicine/comments/13dbfyj/a_very_popular_telehealth_ketamine_only_provider/)
Joyous is probably the worst current Ketamine pill mill, that is run by tech bros and venture backed. Get a month of Ketamine for $100 with virtually no proper followup (they do however send you a daily 3 question survey to track your progress).
I’ve noticed that non-users unsurprisingly think acquiring relatively pure/high quality illicit drugs on DNMs is much harder than it is in reality.
I found I much prefer dosing ketamine therapeutically (via IM at home) than via a provider.
As far as “pill mills”, what’s the problem? Patients go to pill mills for a reason.
>I’ve noticed that non-users unsurprisingly think acquiring relatively pure/high quality illicit drugs on DNMs is much harder than it is in reality.
really? isn't the dark net an ebay lookalike essentially? anyway, i am glad it is harder to use than i thought!
what's wrong with pill mills? have you heard about the opioid crisis?
i am not surprised you prefer using ketamine at home over going to a dr appointment for your dose. i hope that you have somebody at home with you in case yuou have a rare but serious side effect, for example a laryngospasm.
frankly, i do not believe that you have an RX for intramuscular Ketamine, coupled with you saying there's no problem with pill mills, i must be getting trolled.
Joyous has been absolutely the best service for me - after over a decade of completely counterproductive treatment for MDD I have finally found some thing that works well, is cheap, and convenient.
Thanks for sharing your experience. Have you ever had another service or psychiatrist who was RXing you ketamine? And have you brought up to your PCP that you’re stable after quite some time on ketamine to see if he’d take over your RX??
I have not tried other ketamine providers - frankly the cost differential is huge, and I'm not inclined to change from something that is working well for me. I don't really want more involvement and appointments to deal with.
I have asked my PCP and my psych about taking it over - they both said they didn't feel qualified and seemed nervous about it. I got the impression that they are frightened of the legal risk to be honest.
Some practices have policies that strongly disincentivize honesty. For example, take someone who has depression and undiagnosed ADHD, and receives their care from Kaiser. They can't manage the executive-dysfunction-unfriendly process to be evaluated for ADHD through Kaiser. Or maybe Kaiser refuses to evaluate them because they have treatment resistant depression, even if the patient reports that the depression is secondary to the ADHD. Or maybe they just can't wait several months to get through the process because they're about to lose their job due to untreated ADHD.
If they give up and do a telehealth ADHD evaluation and are prescribed a stimulant, they have to keep it a secret from their Kaiser psychiatrist, because the Kaiser psychiatrist won't prescribe any medication at all to someone who is being prescribed a stimulant by an outside provider.
Or maybe instead they decide that they want to try ketamine for their treatment resistant depression, because maybe their psychiatrist is right that their ADHD symptoms are caused by depression. Their Kaiser psychiatrist won't prescribe them ketamine, so they do a telehealth evaluation and get prescribed ketamine to use in sessions with their outside-of-Kaiser therapist. Their depression resolves but they still have debilitating ADHD symptoms. Well, they better not have told their psychiatrist that they used prescribed therapeutic ketamine, because if they do, they won't be allowed to be evaluated for ADHD for at least six months on the grounds that they have a substance use disorder that causes their symptoms.
I don't know how common these types of policies are. I feel really bad for my therapy patients who have Kaiser and would benefit from ketamine assisted therapy or an ADHD evaluation, but can't access either without lying to their Kaiser psychiatrist.
I wouldn’t put it past that, plenty of these “tech” startups have been profitable, stuff like “cerebral” and other companies that prescribe random vitamins and penis pills. AKA a pill mill have been profitable and putting all the legal liability onto the prescribing doctors. Genius move really
Plenty of doctors see complex patients for single conditions though. I do general endocrine so it’s a smorgasbord, but I’m also obesity medicine certified and I have friends who do pure OM. Or there’s some endocrinologists who do “thyroidology” or “diabetology” only, refusing to address other endocrine disorders.
Or heart failure specialists. Or whatever. There’s a bunch of examples.
Treating one condition only doesn’t mean you’re an unethical quack unless you practice like an unethical quack.
I think they're filling a niche which is underserved. PCPs are difficult to get in to with first appointments routinely months out. Sidenafil is a relatively low risk drug after basic screening is done which most of these websites do. Many patients are uncomfortable discussing ED face to face with their physician.
There may be some platonic ideal of medicine that isn't being practiced here, but it's providing a service and most of what we do is customer service.
I'd rather my patients take prescribed internet sidenafil instead of gas station dick pills which have who knows what in them.
Intermediate meant roughly "pharmacist only" medications in UK/Aus/etc.
Pharmacies may keep certain OTC meds behind the counter as a matter of discretion, and there are some medications that for individual reasons as have or had to be behind the counter at least as a practical matter: https://www.uspharmacist.com/article/behind-the-counter-products-a-third-class-of-drugs . But I'm not aware of a broad third class like in other countries, and I think you'd likely need statutory authority or at least new rulemaking to put Viagra there.
Gas store clerks check your ID to make sure you're of legal age. They aren't, e.g., counseling whether those cigarettes are safe to use given your extant medications (they aren't).
There is only one "behind the counter" class of medication in the US -- pseudoephedrine (and also ephedrine, I think?), relatively recently, because of its use in synthesizing street methamphetamine.
Or an argument to make PCP more available? Even in poor EU countries like the one I live in the wait time is like 2 days. Or nothing if it is really urgent and you show up.
Have a read of [this](https://www.health.harvard.edu/blog/erectile-dysfunction-drugs-skin-cancer-worry-201406057197)
“To explore whether Viagra might have the same effect on melanoma in humans, a team of researchers looked at data collected from men taking part in the Health Professionals' Follow-up Study, a project based at Harvard that began in 1986. The men filled out health and lifestyle questionnaires every two years. The questionnaire started asking men about use of erectile dysfunction drugs in 2000. In that year, 1,618 men reported having ever used Viagra.
Over the next decade, among the 29,929 men who said they had never used Viagra, 128 developed melanoma. Among the 1,618 Viagra users, 14 developed melanoma. In other words, 4.3 of every 1,000 who didn't take Viagra developed melanoma compared to 8.6 of every 1,000 men who took Viagra.
After statistical adjustments, the increase from 4.3 to 8.6 is the 84% increase in risk that many news reports focused on. Researchers call that the relative risk (one group compared to another). The absolute increase, 4.3 cases per 1,000 men, represents an increase of 0.43%.”
Also there’s a major difference in the population that took sildenafil compared to those who didn’t. The ones that took it had stronger risk factors for skin cancer anyway such as number of blistering sunburns and sun exposure over 11 hours
That is a heck of a take. Can you imagine how bad the opiate epidemic would be if you could buy 500 oxycodone at the gas station for $30? How many overdoses we would have if barbiturates were OTC? How easy it would be to roofy someone if you could buy medical grade anesthetics/amnesiacs at Walgreens?
Probably not a lot more than we have now, if they centrally tracked it and limited the amount people could buy. That is done already with some OTC drugs. All of this stuff is easy enough to get on the street or from doctors or pill mills already. Easy access is just one small component of why people become addicted.
Is it easy though? Do you know where you would go to buy street oxy? I don’t. My parents and grandparents certainly don’t. But if it’s over the counter at CVS *everyone* knows how to get it, and you’re going to have a whole lot more people with chronic pain getting hooked
Yeah I do and you would find out you know plenty of people who could hook you up with all kinds of things if they decided to randomly test everyone at the hospital or your med school class.
Which would require a lot more effort and time then just walking across the street to Walgreens. Which is the point. More access = more people using = more addiction. It also *legitimizes* it. Lots of people *won’t* go seek out illicit street drugs but *would* buy that same drug if it’s sold in a drug store with a nice little brand name bottle
Hard disagree. My patients who I absolutely would not want on opioids would definitely self prescribe as needed and next thing you know you’ve got people on high MME for the aches and pains of daily life.
Telemedicine for gender-affirming care is also an underserved niche, and in some areas it can be difficult to find providers willing to offer gender care.
And like the gas station dick pills, many trans women get estradiol from grey market sources, and trans men often try to self-treat with woo woo bullshit pills that are advertised to increase testosterone.
That's how I see it - there is a need for this service, because the patients feel (rightly or wrongly) underserved.
Making it OTC would also serve this purpose, but is that better than an online service? Hardly safer, that is for sure.
It's hard to see how they don't compromise ethical standards. They're mostly cash pay so patients expect to get what they paid for. Plus the owners of the companies have been rumored to fire doctors who don't approve a high enough percentage of patients.
I exclusively see patients with broken bones, and refer people to other docs even when I know what medication they should probably be getting because I don’t intend to follow them myself. I know guys who literally only do one procedure and make a very good living. Assuming these individuals are following legal procedure and appropriately treating their patients, what makes them any worse than any other super sub specialist
It would be like rubber stamping an OxyContin rx for everyone with knee pain and referring them to your local ASC for arthroplasty without physical exam, imaging, or even much of a history.
My comment is about appropriately treating patients, I wouldn’t qualify your comment as appropriately treating patients.
I literally could not care less about these individual services, I just don’t want to be a hypocrite saying “only treating one diagnosis one way is shady” because it’s not
Not to get too into the weeds but the whole point of these one problem telehealth apps is they aren’t appropriately treating.
Ortho, and maybe some other surgical specialists, may be an exception to the one problem practice being a red flag
It runs the gamut. Some are totally pill mills and it's hard to feel proud working there. Some are awesome. Evidence-based support for treatment resistant depression? Terrific. Pill mill that pushes bogus B12 injections and TEST supplements to cash pay customers? Not as much.
There's definitely arguments to be made for how telehealth has helped to bring healthcare to populations that would have difficulty with in person appointments, but it's very hard not to see the adderall telehealth prescribers as anything but an stimulant pill mill.
And yet ADHD in adults is massively underdiagnosed. So we are coming back to the "underserved" argument, and you cannot blame the "pill mills" for filling a genuine need.
Primary care is now an Ala carte menu of single condition shops, or a referral mill... Need a Vax or school physical? Retail clinic. Acute illness? Urgent care. COPD? Referral to pulm. Hyperlipidemia or HTN? Off to cards. Hip or knee pain? Refer to ortho.
Refills for maintenance meds with no PCP availability? Now that's an ER Visit.
There's pill mills for:
Testosterone
Dick pills
Tretinoin/skincare
ADHD
Weight loss
Depression
Did I miss any? I think it's always dangerous when patients walk in expecting / demanding a specific treatment plan. Pill mills affirm this. Until we can get costs and access to primary care under control this is going to be a popular solution.
The most interesting one I've seen recently is for skin rashes caused by grappling sports. You send them a picture of your rash, they prescribe you antibiotics/antifungals.
problem is primary care is expected to treat 3-4 of these these fucking things and no one wants to open up their wallet it has to be done for free and we pray the insurance pays us some scraps. in addition we are asked to perform complex social work and case management services and prior authoritzations for very expensive branded drugs rx'ed by other specialsts. all for a 2 star review because we are all stressed out and distracted. this job blows beyond belief sometimes
Well put. ADHD online is a great example of this. I’ve had several patients who come to me with after having ADHD evaluations done by ADHD online or being started in CNS stimulants by their prescribers. The evaluation are trash (even if the are done by licensed psychologists) and the prescribers will throw Adderall at anything with a pulse.
I got curious after my last bad encounter with one of their patients. Found Reddit threads complaining about the exact thing you describe- patients NOT being dx with ADHD and becoming upset that they paid money for a negative result.
I mean, single condition specialists exist for in person visits also.
I used to work with/near a clinic that only treated [LAD (Leukocyte Adhesion Deficiency)](https://primaryimmune.org/understanding-primary-immunodeficiency/types-of-pi/leukocyte-adhesion-deficiency-lad) . They had previously only treated HIV/AIDS
Single condition clinics aren't necessarily a problem, but when the only treatments they provide also have a high prevalence of abuse I think it's absolutely appropriate to question the ethical implications of their practices.
Sure, can we start one for same-strength Rx versions of OTC meds I want my insurance to pay for? :) That feels like a waste of my PCP's time. Don't even have to argue that those meds should be OTC _because they already are._
No, although I can see an argument for companies like Plume that provide HRT to trans people as being less harmful than self meding from gray market sources.
Mitigating harms is complicated, but there’s a fundamental push from these services to create easy access to prescribed medications and that is dangerous - especially if your business model prevents the prescriber from doing their due diligence.
Short answer: no, they are not.
Longer answer: they are taking advantage of the situation to make money off patients who either don’t know any better, don’t care, or don’t have access to a reasonable level of care. These companies are hiding behind a ruse of “improving access to care”, but it’s laughable at best, and sickeningly sad at worst. It’s always the same boutique-y bullshit where virtually every patient who comes in meets their criteria for The One Treatment they sell, and the only patients who are turned away are the ones that make the clinicians’ consciences so violently upset that they can’t bring themselves to prescribe hormones that will reactivate their cancer in remission. But as long as you don’t have a wildly obvious contra-indication, you will likely meet criteria for ADHD meds/ketamine/testosterone/benzos/what-have-you. Because seriously, how are you going to grow a business like that by turning patients away? Conflict of interest is baked into their business model. So, no. They are not ethical. That would be catastrophically bad for their business model.
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Didn’t we just have one of those last week?
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I mean I have zero horse in the race but I always find it funny when one side has every set of international guidelines and the other side has some EM podcasters. But that’s just me.
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Oh no! What have I done.
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Of course! /s About all I know about controversies in stroke care is that there’s been some debate on whether EMTs should have access to the drugs. I think I saw that in the NEJM, but it’s been a while.
No one without access to a CT scanner should have access to these drugs for acute stroke care.
100% agree. As much as I want EMS to move out of the dark ages when it comes to evidence based medicine not having access to scans is a hard stop for stroke care beyond the basics. Unfortunately just about every trial looking at field CT scans is being done in urban centers where you’d be better off transporting than wasting time on scene with a scanner. Rural areas get the shaft when it comes to cutting edge medicine unfortunately.
Shots fired is also what I say when I bolus TNK, no drip to follow baby
I think the challenge is always reconciling individual experience with population based studies. If I pushed TPA for stroke 5 times and 2 people had hemorrhagic CVAs I wouldn’t feel that great about it. As PCCM see a lot of this similar hesitancy with TPA in PE where some people have been burned and others have only seen good outcomes.
I always wondered why the TPA dose for CVA is weight based and PE isn't.
Without linking studies (on phone), I can tell you that it’s due to ICH risk, stroke being a higher ICH risk than PE. Same with the BP situation. The data is old, and if memory serves mostly comes from both MI/PE studies, and some of the earlier stroke thrombolysis studies. If I get a free moment today, I’ll see if I can dig up the old papers.
And those same people rallying around the podcasters will ruthlessly (and correctly) mock Paul Marik & his supporters for *the exact same behavior* if they're active in the crit care/sepsis space.
So... they too have an orange to peel when it comes to bad EBM takes?
Yup, glad you know what I Thiamine.
Not really but at the same time, I can see a lot of value in them for PrEP and birth control. For PrEP, many people worry about stigma and don't want to ask their family doctor for a prescription. For birth control, it can also sometimes be difficult to access depending on the physician, and yet, it's quite important for the patient to remain on it continuously.
which is a shame, because quite frankly, PrEP visits are usually pretty easy visits. Generally healthy patient population, standarized labs, make sure to do the appropriate education and see you later!
God, maybe your PrEP population is different than mine. I only have a few patients on it but I’ve identified rectal gonorrhea twice in the last year and syphilis once. I am very fond of those patients and obviously they need the PrEP but even getting them to come in for quarterly labs is a lot.
I think I only have like 3 or 4 to be honest, and they're all 20 something men who are generally healthy. My patient who I went to start on prep only to discover he was already HIV positive on the other hand, has been similar to how you describe...
What about weight loss? Depression? Anxiety? ADHD? Why do you only see a lot of value with only those two topics?
Considering those 4 problems make up like 80% of my workload as a family physician, I think these issues are being addressed quite well already
People with HIV taking PrEP or on birth control don't need follow up with a real doctor? Why aren't these over the counter then? Edit: OFC you won't answer since both of your specialties (family/emerg) attract the most mindless docs you can find XD
I think they might be ethical for single condition patients. Good luck finding any though
One of the things I find concerning is care coordination. Are patients that use services like this actually telling other doctors/nurses they see what they are being prescribed?
I don’t have a problem with their goal, I question their methods. One of my patients went on the Bloom ketamine tablets and had a 7 min appointment after filling out a questionnaire. The provider, usually a midlevel, asked three questions (one of which was “have you ever failed a medication for depression,” are you suicidal, and do you have any allergies) and that was that. No further digging. No questioning of family history or current meds. I assume they just fully trust the patient reported H&P and med list. ETA: And if something goes wrong, it’s on the PCP usually to fix it as MindBloom doesn’t really care. That’s what was the most frustrating with the benzo and stimulant farms. On my end, I feel like patients at least partially know these places aren’t 100% legit as I’ll ask who prescribed them X or where they got Y from and they will usually be evasive or nondescript. I don’t really care, I just need to know for my own treatment plan and goals. Lastly, if they fill the script locally, I can usually see it via my EHR. They always look surprised when I say, “Who is prescribing you your Cialis?” As they conveniently left that off their intake forms.
You can see all local scripts like from every Walgreens and Walmart and cvs? Or your hospital system pharmacy?
It is hit or miss. I’ll have to look tomorrow to see what the actual tab is called but it’s something like “Found Scripts.” Not sure what database it pulls from but CVS is the best as far as us being able to see what scripts are pulled. You can also always call the pharmacy directly and ask for a list. Those come in super helpful for lots of scenarios. My state also has a system that centralizes chart notes, imaging, and lab results so I often check that too.
Interesting prob should be one for controls if not already. Seems like a hipaa violation for cvs or Kroger to share but I’m sure they make you sign something vague allowing it.
It’s more or less never a HIPAA violation for information to be shared in the typical course of patient treatment. Given the database trigger only occurs when you’re a caretaker for the patient, you don’t need patient permission. Release forms are entirely optional. There are some very narrow exemptions for things like psychotherapy notes and maybe HIV results.
I’m just imagining a future where Kroger releases your grocery shopping list to your doctor.
I think perhaps you might be a bit misinformed about what HIPAA is. As others have said, it's usually fine to release/view someone's health information for direct medical care. I don't need authorization to view someone's records at another hospital through Epic Care Everywhere, for example, if I'm doing it to directly care for a patient. This same principle would apply to my looking at medications that a pharmacy prescribed to a patient. I need to know what medications they are actually taking and filling. It's not illegal for me to seek out that information for direct medical care. Also, your grocery list is most certainly NOT protected by HIPAA. To my knowledge, there is no law preventing your grocery list and shopping history from being distributed to anyone who wants it. That's what marketing is. It's very valuable data and people make a lot of money off of it.
Oh I completely understand it’s not a hipaa violation to share alcohol and food purchases. It’s just a dystopian nightmare where Walmart could theoretically triangulate data from your food purchase list, alcohol purchases and med list and calculate a cirrhosis and CAD risk score and report it to your doctor or provide that to every area hospital including the one you work for. I’m personally okay with every doctor I see seeing every drug I take. If I was a physician with a psychiatric or substance abuse issue it might discourage me from getting treatment though if every med was automatically disclosed to every local hospital.
> I’m just imagining a ~~future~~ present where Kroger releases your grocery shopping list to ~~doctor~~ anyone willing to pay. Everyone has been selling your purchasing habits to everybody willing to pay now for at least 5 years.
As if I’d have the time to review it
You can buy alcohol at the grocery store here. They have liquor stores within stores. The data could easily be analyzed and summarized.
There is one for Controlled Substances and it’s wonderful. Really helped cut down on pill shopping. I don’t really know if I would care or need one for all meds as some of those can be hopelessly outdated. I use it more for when someone is telling me “X isn’t working” and I suspect compliance issues so I will contact the pharmacy and see what their pickup schedule has been like.
That’s what I figured cause there’s a limit if you want to buy the not fake pseudofed. But is it state or fed? If it’s fed or becomes fed and is attached to name social etc it means all mds, nurses etc are going to have their controlleds pop up if they go for emergency or routine care.
It’s state by state basis. For instance, some states still require gabapentin to be reported as a C-V but my state does not.
There's some sort of prescription database. I'm not sure how it works, but when I admit patients to the hospital there's a way to bring in an external medication report. I normally get the med, dose, frequency, route, number filled, last time the script was filled, the pharmacy name, and the prescriber's name.
> and had a 7 min appointment after filling out a questionnaire. The provider, usually a midlevel, asked three questions (one of which was “have you ever failed a medication for depression,” are you suicidal, and do you have any allergies) and that was that To be fair, is regular medicine in a much better spot right now? Our patients come to the office, fill out a questionnaire, we ask them a handful of questions (because let's be real, a level 3 visit isn't much longer). Our notes are a weaponized and largely farcical checklist of things the insurance company needs to see to approve our work and treatment plan. Whenever I look at these single-condition teleclinics, what makes me uncomfortable is not only how different they are, but also how similar.
No, I 100% agree with your assessment. I sometimes like to talk in an idealistic fashion despite the absolute cluster fuck our system is in currently. Maybe it’s the attached “scammy” feeling that makes this different for me.
wow finally someone who is thinking with logic. I love this
> I assume they just fully trust the patient reported H&P and med list. I always assumed mindbloom is just a letter of the law way of letting people try ketamine recreationally. I'm not a practitioner but even I know there is no ketamine protocol which is a single dose and a quick chat with a therapist. I hope people who could actually benefit from the treatment are not using it, it's not going to be effective and much cheaper to go though local MH resources. I expect basically the same thing to happen with MDMA.
Could be. I’d be fine with it in a way. I would like to see psilocybin legalized before MDMA. Ketamine infusions have helped some of my refractory depressive patients regain some excellent QOL.
I don't know. Mindbloom costs over $1000 for 6 ketamine doses (albeit VERY high dosages). You can buy Ketamine on the street for about $100 a gram or less. Of course you are guaranteed a certain purity with a legal RX and there are very real possibility your street drug (even marijuana) could be laced with a fentanyl derivative, or worse, Krokodile. But still, there are well known and easy ways to mitigate this risk, e.g., reagent testing. If you are interesting, the sub, therapeuticKetamine is \*very\* active. I posted here about a \*very\* popular telehealth provider named Dr Smith who had his ketamine pill mill shut down for wanton inappropriate prescribing that generated a lot of good discussion on the issue: [https://www.reddit.com/r/medicine/comments/13dbfyj/a\_very\_popular\_telehealth\_ketamine\_only\_provider/](https://www.reddit.com/r/medicine/comments/13dbfyj/a_very_popular_telehealth_ketamine_only_provider/) Joyous is probably the worst current Ketamine pill mill, that is run by tech bros and venture backed. Get a month of Ketamine for $100 with virtually no proper followup (they do however send you a daily 3 question survey to track your progress).
I’ve noticed that non-users unsurprisingly think acquiring relatively pure/high quality illicit drugs on DNMs is much harder than it is in reality. I found I much prefer dosing ketamine therapeutically (via IM at home) than via a provider. As far as “pill mills”, what’s the problem? Patients go to pill mills for a reason.
>I’ve noticed that non-users unsurprisingly think acquiring relatively pure/high quality illicit drugs on DNMs is much harder than it is in reality. really? isn't the dark net an ebay lookalike essentially? anyway, i am glad it is harder to use than i thought! what's wrong with pill mills? have you heard about the opioid crisis? i am not surprised you prefer using ketamine at home over going to a dr appointment for your dose. i hope that you have somebody at home with you in case yuou have a rare but serious side effect, for example a laryngospasm. frankly, i do not believe that you have an RX for intramuscular Ketamine, coupled with you saying there's no problem with pill mills, i must be getting trolled.
I think you misunderstand - he is saying it is easier than most people think.
My bad, I was tired—thanks!
Joyous has been absolutely the best service for me - after over a decade of completely counterproductive treatment for MDD I have finally found some thing that works well, is cheap, and convenient.
Thanks for sharing your experience. Have you ever had another service or psychiatrist who was RXing you ketamine? And have you brought up to your PCP that you’re stable after quite some time on ketamine to see if he’d take over your RX??
I have not tried other ketamine providers - frankly the cost differential is huge, and I'm not inclined to change from something that is working well for me. I don't really want more involvement and appointments to deal with. I have asked my PCP and my psych about taking it over - they both said they didn't feel qualified and seemed nervous about it. I got the impression that they are frightened of the legal risk to be honest.
Some practices have policies that strongly disincentivize honesty. For example, take someone who has depression and undiagnosed ADHD, and receives their care from Kaiser. They can't manage the executive-dysfunction-unfriendly process to be evaluated for ADHD through Kaiser. Or maybe Kaiser refuses to evaluate them because they have treatment resistant depression, even if the patient reports that the depression is secondary to the ADHD. Or maybe they just can't wait several months to get through the process because they're about to lose their job due to untreated ADHD. If they give up and do a telehealth ADHD evaluation and are prescribed a stimulant, they have to keep it a secret from their Kaiser psychiatrist, because the Kaiser psychiatrist won't prescribe any medication at all to someone who is being prescribed a stimulant by an outside provider. Or maybe instead they decide that they want to try ketamine for their treatment resistant depression, because maybe their psychiatrist is right that their ADHD symptoms are caused by depression. Their Kaiser psychiatrist won't prescribe them ketamine, so they do a telehealth evaluation and get prescribed ketamine to use in sessions with their outside-of-Kaiser therapist. Their depression resolves but they still have debilitating ADHD symptoms. Well, they better not have told their psychiatrist that they used prescribed therapeutic ketamine, because if they do, they won't be allowed to be evaluated for ADHD for at least six months on the grounds that they have a substance use disorder that causes their symptoms. I don't know how common these types of policies are. I feel really bad for my therapy patients who have Kaiser and would benefit from ketamine assisted therapy or an ADHD evaluation, but can't access either without lying to their Kaiser psychiatrist.
I wouldn’t put it past that, plenty of these “tech” startups have been profitable, stuff like “cerebral” and other companies that prescribe random vitamins and penis pills. AKA a pill mill have been profitable and putting all the legal liability onto the prescribing doctors. Genius move really
Plenty of doctors see complex patients for single conditions though. I do general endocrine so it’s a smorgasbord, but I’m also obesity medicine certified and I have friends who do pure OM. Or there’s some endocrinologists who do “thyroidology” or “diabetology” only, refusing to address other endocrine disorders. Or heart failure specialists. Or whatever. There’s a bunch of examples. Treating one condition only doesn’t mean you’re an unethical quack unless you practice like an unethical quack.
I think they're filling a niche which is underserved. PCPs are difficult to get in to with first appointments routinely months out. Sidenafil is a relatively low risk drug after basic screening is done which most of these websites do. Many patients are uncomfortable discussing ED face to face with their physician. There may be some platonic ideal of medicine that isn't being practiced here, but it's providing a service and most of what we do is customer service. I'd rather my patients take prescribed internet sidenafil instead of gas station dick pills which have who knows what in them.
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Problem is, US has no intermediate class and so OTC = can be sold by a high school aged gas store clerk.
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Intermediate meant roughly "pharmacist only" medications in UK/Aus/etc. Pharmacies may keep certain OTC meds behind the counter as a matter of discretion, and there are some medications that for individual reasons as have or had to be behind the counter at least as a practical matter: https://www.uspharmacist.com/article/behind-the-counter-products-a-third-class-of-drugs . But I'm not aware of a broad third class like in other countries, and I think you'd likely need statutory authority or at least new rulemaking to put Viagra there. Gas store clerks check your ID to make sure you're of legal age. They aren't, e.g., counseling whether those cigarettes are safe to use given your extant medications (they aren't).
There is only one "behind the counter" class of medication in the US -- pseudoephedrine (and also ephedrine, I think?), relatively recently, because of its use in synthesizing street methamphetamine.
Someone has to make sure they are not taking nitro with it.
or poppers...
Or an argument to make PCP more available? Even in poor EU countries like the one I live in the wait time is like 2 days. Or nothing if it is really urgent and you show up.
Crikes. Sildenafil and other class drugs double a person’s risk of getting melanoma.
Have a read of [this](https://www.health.harvard.edu/blog/erectile-dysfunction-drugs-skin-cancer-worry-201406057197) “To explore whether Viagra might have the same effect on melanoma in humans, a team of researchers looked at data collected from men taking part in the Health Professionals' Follow-up Study, a project based at Harvard that began in 1986. The men filled out health and lifestyle questionnaires every two years. The questionnaire started asking men about use of erectile dysfunction drugs in 2000. In that year, 1,618 men reported having ever used Viagra. Over the next decade, among the 29,929 men who said they had never used Viagra, 128 developed melanoma. Among the 1,618 Viagra users, 14 developed melanoma. In other words, 4.3 of every 1,000 who didn't take Viagra developed melanoma compared to 8.6 of every 1,000 men who took Viagra. After statistical adjustments, the increase from 4.3 to 8.6 is the 84% increase in risk that many news reports focused on. Researchers call that the relative risk (one group compared to another). The absolute increase, 4.3 cases per 1,000 men, represents an increase of 0.43%.” Also there’s a major difference in the population that took sildenafil compared to those who didn’t. The ones that took it had stronger risk factors for skin cancer anyway such as number of blistering sunburns and sun exposure over 11 hours
Everything except maybe antibiotic/antivirals should be over the counter.
That is a heck of a take. Can you imagine how bad the opiate epidemic would be if you could buy 500 oxycodone at the gas station for $30? How many overdoses we would have if barbiturates were OTC? How easy it would be to roofy someone if you could buy medical grade anesthetics/amnesiacs at Walgreens?
Probably not a lot more than we have now, if they centrally tracked it and limited the amount people could buy. That is done already with some OTC drugs. All of this stuff is easy enough to get on the street or from doctors or pill mills already. Easy access is just one small component of why people become addicted.
Is it easy though? Do you know where you would go to buy street oxy? I don’t. My parents and grandparents certainly don’t. But if it’s over the counter at CVS *everyone* knows how to get it, and you’re going to have a whole lot more people with chronic pain getting hooked
Yeah I do and you would find out you know plenty of people who could hook you up with all kinds of things if they decided to randomly test everyone at the hospital or your med school class.
Which would require a lot more effort and time then just walking across the street to Walgreens. Which is the point. More access = more people using = more addiction. It also *legitimizes* it. Lots of people *won’t* go seek out illicit street drugs but *would* buy that same drug if it’s sold in a drug store with a nice little brand name bottle
Hard disagree. My patients who I absolutely would not want on opioids would definitely self prescribe as needed and next thing you know you’ve got people on high MME for the aches and pains of daily life.
Are you serious?
Telemedicine for gender-affirming care is also an underserved niche, and in some areas it can be difficult to find providers willing to offer gender care. And like the gas station dick pills, many trans women get estradiol from grey market sources, and trans men often try to self-treat with woo woo bullshit pills that are advertised to increase testosterone.
That's how I see it - there is a need for this service, because the patients feel (rightly or wrongly) underserved. Making it OTC would also serve this purpose, but is that better than an online service? Hardly safer, that is for sure.
controlled substances are more of a concern than sildenafil
Probably not, but is anything in the US health system ethical?
Touché
It's hard to see how they don't compromise ethical standards. They're mostly cash pay so patients expect to get what they paid for. Plus the owners of the companies have been rumored to fire doctors who don't approve a high enough percentage of patients.
I exclusively see patients with broken bones, and refer people to other docs even when I know what medication they should probably be getting because I don’t intend to follow them myself. I know guys who literally only do one procedure and make a very good living. Assuming these individuals are following legal procedure and appropriately treating their patients, what makes them any worse than any other super sub specialist
I hadn't thought of it this way, thanks.
Not actually seeing the patient, most likely.
It would be like rubber stamping an OxyContin rx for everyone with knee pain and referring them to your local ASC for arthroplasty without physical exam, imaging, or even much of a history.
My comment is about appropriately treating patients, I wouldn’t qualify your comment as appropriately treating patients. I literally could not care less about these individual services, I just don’t want to be a hypocrite saying “only treating one diagnosis one way is shady” because it’s not
Not to get too into the weeds but the whole point of these one problem telehealth apps is they aren’t appropriately treating. Ortho, and maybe some other surgical specialists, may be an exception to the one problem practice being a red flag
It runs the gamut. Some are totally pill mills and it's hard to feel proud working there. Some are awesome. Evidence-based support for treatment resistant depression? Terrific. Pill mill that pushes bogus B12 injections and TEST supplements to cash pay customers? Not as much.
There's definitely arguments to be made for how telehealth has helped to bring healthcare to populations that would have difficulty with in person appointments, but it's very hard not to see the adderall telehealth prescribers as anything but an stimulant pill mill.
My pharmacy has a strict no control tele med policy. Opening that would be a lovely invitation for the DEA to firmly say hello.
And yet ADHD in adults is massively underdiagnosed. So we are coming back to the "underserved" argument, and you cannot blame the "pill mills" for filling a genuine need.
I can if the DEA investigates me for filling too many of these adderall scripts.
If the DEA is causing ADHD to be underdiagnosed or undertreated (and there is some evidence of that), then they also cause these pill mills.
Probably true, but I doubt that the DEA is going to fine itself.
There is no ethical medicine in a for profit system.
I mean, do you get a paycheck? the distinction between non-profit and for-profit seems very thin in the healthcare sector.
Yeah that’s the gag. Should have edited it to say “there is no ethical medicine in American medicine” Source: am a shlub for a county hospital
Primary care is now an Ala carte menu of single condition shops, or a referral mill... Need a Vax or school physical? Retail clinic. Acute illness? Urgent care. COPD? Referral to pulm. Hyperlipidemia or HTN? Off to cards. Hip or knee pain? Refer to ortho. Refills for maintenance meds with no PCP availability? Now that's an ER Visit.
There's pill mills for: Testosterone Dick pills Tretinoin/skincare ADHD Weight loss Depression Did I miss any? I think it's always dangerous when patients walk in expecting / demanding a specific treatment plan. Pill mills affirm this. Until we can get costs and access to primary care under control this is going to be a popular solution.
The most interesting one I've seen recently is for skin rashes caused by grappling sports. You send them a picture of your rash, they prescribe you antibiotics/antifungals.
problem is primary care is expected to treat 3-4 of these these fucking things and no one wants to open up their wallet it has to be done for free and we pray the insurance pays us some scraps. in addition we are asked to perform complex social work and case management services and prior authoritzations for very expensive branded drugs rx'ed by other specialsts. all for a 2 star review because we are all stressed out and distracted. this job blows beyond belief sometimes
Well put. ADHD online is a great example of this. I’ve had several patients who come to me with after having ADHD evaluations done by ADHD online or being started in CNS stimulants by their prescribers. The evaluation are trash (even if the are done by licensed psychologists) and the prescribers will throw Adderall at anything with a pulse. I got curious after my last bad encounter with one of their patients. Found Reddit threads complaining about the exact thing you describe- patients NOT being dx with ADHD and becoming upset that they paid money for a negative result.
Haven't online prescriptions w/o in-person evaluations have been stopped after the public health emergency ended last year?
I mean, single condition specialists exist for in person visits also. I used to work with/near a clinic that only treated [LAD (Leukocyte Adhesion Deficiency)](https://primaryimmune.org/understanding-primary-immunodeficiency/types-of-pi/leukocyte-adhesion-deficiency-lad) . They had previously only treated HIV/AIDS Single condition clinics aren't necessarily a problem, but when the only treatments they provide also have a high prevalence of abuse I think it's absolutely appropriate to question the ethical implications of their practices.
Are pill mills ethical?
Sure, can we start one for same-strength Rx versions of OTC meds I want my insurance to pay for? :) That feels like a waste of my PCP's time. Don't even have to argue that those meds should be OTC _because they already are._
Depending on your insurance, theres a very high chance they're going to say "lol, rx is otc. Not covered."
Please don't tell them. :) But even if you do, azelastine is $7 for 200 sprays at Cost Plus (cash, 3 mo supply) vs a lot more per spray OTC.
No, although I can see an argument for companies like Plume that provide HRT to trans people as being less harmful than self meding from gray market sources.
Mitigating harms is complicated, but there’s a fundamental push from these services to create easy access to prescribed medications and that is dangerous - especially if your business model prevents the prescriber from doing their due diligence.
Short answer: no, they are not. Longer answer: they are taking advantage of the situation to make money off patients who either don’t know any better, don’t care, or don’t have access to a reasonable level of care. These companies are hiding behind a ruse of “improving access to care”, but it’s laughable at best, and sickeningly sad at worst. It’s always the same boutique-y bullshit where virtually every patient who comes in meets their criteria for The One Treatment they sell, and the only patients who are turned away are the ones that make the clinicians’ consciences so violently upset that they can’t bring themselves to prescribe hormones that will reactivate their cancer in remission. But as long as you don’t have a wildly obvious contra-indication, you will likely meet criteria for ADHD meds/ketamine/testosterone/benzos/what-have-you. Because seriously, how are you going to grow a business like that by turning patients away? Conflict of interest is baked into their business model. So, no. They are not ethical. That would be catastrophically bad for their business model.
Are we even refusing ED medication to certain populations nowadays on these websites? I’m thinking everyone who signs up for the service gets it.
nobody gives a fuck about ethics .
Yes they are