Why Can’t I Just Prescribe for Myself?
I recently changed my health insurance provider, which means I changed doctors and medical systems, which means I have to re-set up all of my care. (That must sound so funny to people with nationalized health care systems!) This mainly means I have to get new prescriptions. I was able to get a three month supply from my previous doctor to give myself time to jump through all of the hoops necessary before I can get them. A lot of annoying, time consuming hoops. And so I was considering – why can’t I just prescribe for myself?
Well, there’s a bunch of different policies that prevent me from doing so. First, there’s a federal law that prohibits anyone from selling me the drug without a prescription. Then there’s the policies my health care provider has created about how I can get a prescription. With my new provider, I have to go to an intake appointment with a therapist before I can get a referral to a psychiatrist. Then I have to have an appointment with a psychiatrist before I get a prescription.
So if I were allowed to prescribe to myself, it’d be a lot easier for me. And, as I’m filling out the 19th form required before my intake appointment, it seems obvious! I mean, I know exactly what drugs I want, the dosages, I’ve been taking exactly the same thing for like 6 years, and having me do an intake appointment where I review my whole history just to get a referral is a waste of everyone’s time. I mean, really!
But let’s think about this from a more objective perspective than I use when I’m extremely impatient and bored of filling out forms. Presumably there must be some benefits to prescription laws or we wouldn’t have any in the first place. And whether those benefits are outweighed by the costs of these policies – including the monumental cost of my annoyance – can’t be determined until we know what the benefits actually are. So who do those laws protect? Or, what policy goals are advanced?
1. The goal that people take medication for “legitimate” ends.
I put “legitimate” in quotations because it’s defined differently by different people, but one of the clear goals of the current prescription policy is that people should take prescription medications only when those medications address a genuine medical need. Part of this – the part of which I’m skeptical and that is motivating my use of quotation marks – is the “war on drugs” mentality that insists we need prescription controls on any medication that could create dependency or be abused or have any real street value. That portion is based on the assumption that we cannot trust adults to make logical and rational decisions about their use of these substances and so have to protect them from themselves, basically.
But even putting that extremely problematic goal aside, there are other components to the policy goal of restricting medication use.  With antibiotics, for example, taking them when they’re not medically indicated reduces their effectiveness in the future – not only for the person misusing antibiotics, but for anyone else infected with that now antibiotic-resistant strain. While the potential negative impact to me of someone taking a narcotic pain medication for fun instead of for pain management is both small and indirect, the potential negative impact of antibiotic misuse is significantly higher.
This goal also protects the interests of another major player in health care decisions – the insurer. Their insurance policy is a gamble that I will incur less in health care costs than the amount I pay them for the insurance policy, so every cost I incur is a danger to their bottom line. They want to make sure they are paying only for medication that addresses a “legitimate” medical need – using quotes again because insurers’ definitions of “legitimate” are often arbitrary and constrained, even compared to a doctor’s medical recommendations.
Looking at those subgoals, we could imagine a policy that dumped some or all of the restrictions on all drugs that don’t have the dangers of misuse that antibiotics have – although such a policy would make insurance companies unhappy and likely have big effects on the way they insured prescription coverage. Short of that, we might say that people with recorded diagnoses can purchase prescriptions in the drug classes appropriate for that diagnosis – so my bipolar diagnosis would allow me to buy antidepressants and mood stabilizers, but not blood pressure medication or cream for skin rashes. This would satisfy the insurer’s need while allowing me to buy the only kinds of prescriptions I really care about. (It would still create problems about ability to get diagnosed, though.)
2. Protecting people who take prescriptions.
The requirement that prescriptions come from doctors forces the person taking the medication to have an ongoing relationship with a doctor. This serves several goals – ensuring someone is monitoring the patient’s ongoing health and the course of their medical condition, ensuring someone is monitoring the patient’s response to the medication, and ensuring someone with education and licensing is evaluating all the potential medications and exercising their professional judgment in determining which medication is appropriate. Given the extreme information imbalance between patients and doctors, that makes some sense. I consider myself an extremely well informed health care consumer – I’ve read the full inserts that come with the medications, even – but I would be hard pressed to tell you the difference between lithium and Depakote, two types of mood stabilizers, or to say why one is more appropriate than the other for me other than it was the one my doctor decided to put me on years ago. If i did not speak English or didn’t have the education and free time to read up on all these issues, it would be even more necessary for me to rely on my doctor’s judgment and recommendations. And while I’m not getting a ton of benefit from having the ongoing course of my medical condition monitored, I do rely on my psychiatrist to order the blood tests and review the results to make sure I don’t have toxic blood levels of lithium.
It’s difficult to imagine how we could have a policy that allowed people who “really knew what they were doing” to prescribe for themselves while having doctors prescribe for everyone else, because of the impossibility of determining who “really knew what they were doing.” The only modification I imagine would be for people who had been taking the same medication for a period of time – 2 years? 5 years? – to be able to purchase ongoing refills without ongoing prescriptions. Although with such a policy, I’m not sure through what mechanism my doctor could get me to go get the necessary blood tests done, which I believe is an important component of the policy.
There are a few other issues – like the interest of the patient of having their medical history documented, for things like disability applications – both those two broad policy goals provide the bulk of the motivation for current prescription rules. And while in my irritated-at-forms-and-delays states, it seems obvious that I should be able to write my own prescriptions for the drugs I’ve taken for 10 years that will not harm others if misused, it’s difficult for me to articulate an alternate prescription policy that both serves my interests and the interests of people who are not me.
Some final thoughts: Our current policy relies heavily on the professionalism of doctors – perhaps attempting to enforce those professional standards would be more helpful to individual patients than reforming prescription policy itself? Can you articulate an alternate prescription policy that would address these goals and subgoals?
 It’s important to remember that there are a separate set of prescription issues relevant to trans people, based not only on overall health care discrimination against the trans community, but also specifically in the discrimination and harassment that takes place around hormone prescriptions. This discussion does not address those issues, but you can read more at Bird of Paradox and at Kiri’s tumblr.