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. [1] 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?

[1] 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.

By 2 November, 2010.    Uncategorized   



9 Comments

  1. Reforming what the doctors are taught to believe about certain drugs (and the patients who ask for them) is what I usually think would help. But that goes so deep, not just what they learn in medical school, but on-the-job stereotyping and media stories about the horrible things that happen to people who take drug such-and-such. I don’t mind the doctors being the ones holding the prescription pad, but I do mind being asked stupid question about addiction by doctors who obviously don’t have a clear picture of what said addiction would even look like, and doctors who refuse to treat my pain symptoms on the simple grounds that Narcotics Are Bad.

  2. I’d like to see prescription refill limits relaxed. When I was on stimulants for ADHD, I had to get a new prescription every month, because stimulants are a controlled substance. I always thought it was ridiculous that they expected people with ADHD to make the arrangements to get a new prescription every month. I hear strong painkillers are treated similarly.

    It annoys me that I have to see a gynecologist and a gastroenterologist every year in order to refill my birth control and my IBS medication respectively. I wish I could just call and say “no change in my condition, thanks” and have them renew the prescription refills for another year. (I know others have discussed the idea that women MUST have a gynecological exam every year in order to get their birth control refilled, and the problems with that system.) At the moment I’m pretty content with my psychological meds as well, so what I’d like is a system where I keep getting refills UNLESS I call my doctor and ask for a new appointment to discuss a medication change. That still wouldn’t solve the problem of having to go through the whole ordeal every time you have to change doctors, though.

    I really just wish we had a national health care system. It would solve so many problems.

  3. I agree with much of this post, and you articulate very well both the frustration I feel with the paternalism of the prescription pad as well as its necessity.

    I also, though, agree with Diana. Doctors are the adult of the species; the juvenile is the med student and tends to be a people-pleaser. They are more likely than many to simply accept the received wisdom of the older generation of doctors, whether it makes sense or not. Given that most of the older generation of doctors come from privilege, it’s very clear that our doctors imbibe that privilege with the coffee they drink to cram for exams on kidney anatomy. It leads to unacceptable attitudes toward PWDs and other oppressed groups, which then gets reflected in they way they treat those groups. The prescription pad is one of the strongest weapons in that arsenal: doctors’ willingness to prescribe meds is heavily influenced by their “gut feel” about the trustworthiness of the patient, and that feel usually reflects how well their patient conforms to the kyriarchal ideal. PoC? You get fewer narcotics. Female? It’s just hysteria/depression. Fat? If you’d just lose weight, the problem would go away–why prescribe a drug?

    I noticed this immediately with my new GP. As a patient with pain and fatigue issues, I was acutely aware coming in of the dangers of being labeled a drug-seeker and refused for months to ask for anything stronger than an NSAID, despite out-of-control pain levels. But when I begged for something to help with fatigue, I think my doctor was willing to prescribe a stimulant because I didn’t “seem like” a drug seeker because of my comparative privilege. Doctors sometimes treat medication, particularly controlled substances, as a privilege for a compliant, privileged patient rather than a right for any patient who needs it. And that’s just plain not acceptable.

  4. Another consideration in a regulatory scheme where some but not all non-doctors can write prescriptions for themselves (say, after demonstrating some sort of knowledge or after a certain period of time) is how to handle situations where the non-doctor is actually obtaining the prescription for a third person or reselling it. There could be criminal penalties, but we may not always want to subject the person in question to criminal penalties; doctors are subject to state licensing boards, whereas non-doctors wouldn’t be. I doubt that’s an insurmountable issue, but it does raise questions about whether we’d need some kind of new regulatory discipline mechanism that falls short of actual criminal sanctions.

  5. I don’t know if I agree that people should be allowed to prescribe for themselves for the reason that Katie posted, but I sure would like it if stimulants (which I use) and narcotics were able to be refilled. There’s no reason why I should have to see a psychiatrist every month for a condition that is not going to change for a drug regimen that has also not changed considerably since diagnosis. (And in fact, when I don’t have health insurance that’s the thing that keeps me from getting treatment for my ADHD, stimulant meds are cheap but psych visits are expensive.) If doctors don’t feel their patients are trustable*, or they’ll only probably need one bottle of painkillers (like if they’re taking them after dental surgery), then they can choose to mark “0 refills.” But I don’t see how forcing me to see a doctor every month supposedly protects me from myself, and I also don’t understand how it keeps a lid on prescription drug dealers, who aren’t getting their product through normal medical channels anyway. Hell, there could still be a way to prevent me from refilling my Ritalin before a full month has elapsed, just write a law saying that pharmacists can’t fill it until then! But seeing as how Prop 19 couldn’t even pass, I doubt there is anyone out there lobbying to make Schedule II drugs easier to obtain.

    *Which, of course, is problematic in itself since certain groups are more likely to be considered trustable than certain other groups… but ideally this trust would be based on objective means like how long a patient has been taking the drug, their abuse history, etc.

  6. just to be clear – i don’t think what i wrote advocates for lifting all restrictions on prescriptions and allowing people to prescribe anything and everything for themselves. in fact, i had a hard time articulating an alternative prescription policy that would remove some of the barriers while still accomplishing the important policy goals identified in the post!

  7. One thing I think hasn’t been considered is a move to “behind the counter” for more medications. Right now we use this for only handful of medications that are deemed to ‘risky’ for OTC use but too important for RX only — emergency contraceptives and certain nasal decongenstants. If we moved the vast majority of medications into this class I think it would be a good thing for society. Assuming EC doesn’t move to full OTC status, it helps de-stigmatizes asking for it. And I think that a lot of people — both lay people and the people making laws — assume is going on, but often isn’t, when they say “it’s important that people get an RX for these drugs” is cross checking for reactions, making sure the patient isn’t “over medicated” (I HATE that term), and making sure that one drug isn’t the cause of the other conditions. A lot of doctors don’t bother, and the current medical system isn’t actually set up to let a lot of pharmacists and pharmacy techs do much more than “get RX, call insurance, count, print, fill” (I know there is more than that, but the limitations of of “i filled this one at cvs, this at riteaid, 3 at medco, 4 at caremark last year” throws off a lot).

    Patients with various levels of expertise could be relied on to make informed decisions if there was a expectation that 1) at any given pharmacy, a patient could give a pharmacist access to their medical records for the purpose of reviewing their current medications and counseling them on interactions and side effects. 2) the information in that record was current 3) the patient could revoke access to that information on their own without any technical skill.

    There are some medications, I think, that will require a doctor’s supervision to take until such a time that that the blood tests are DIY, and those will probably continue to require the complete doctor RX access gate even in such a modified system — any kind of medication where you’re looking at regular blood work for toxicity is likely on that list, as are medication where you need to regularly monitor for liver or kidney failure.

  8. The no-refills thing annoys me too, although I have it better than some here (my husband gets a three-month prescription with three refills once a year, I get a no-refill prescription every three months). The psychiatrist I’m using won’t go any longer without seeing a patient, and since he’ll fax in the script for me (insurance requires mail-order), it’s not really a problem. Still, since I’m taking them long-term, it does get frustrating to have to go through a gatekeeper, especially if for some reason I’m having trouble getting a prescription on time, as happened the beginning of last year when the mail-order thing started (I wound up going a week without meds as a result).

  9. Katie – i have big concerns about shifting the responsibility for checking for medication interactions and such to the patient. while i agree that doctors don’t always spend much (if any!) time and effort on this step, and i have yet to have a pharmacist even attempt to check for these things, i’d argue that the better reform is to ensure doctors and pharmacists actually do this. i consider myself an extremely well informed consumer of health care, and i have the educational background to read package inserts and understand what a controlled double-blind test with placebos is and evaluate the likelihood of experiencing the potential side effects, etc, and even i get a bit overwhelmed with more than two medications. imagining people with limited english proficiency, relatively limited education, and a whole lot of other things to do besides reading and evaluating those printouts trying to make sense of that information doesn’t seem like an optimal way to make sure those issues are adequately looked at.

    this is what makes things particularly difficult with this policy issue – you’ve got such a wide range of consumers with such a wide range of needs. people like us, who take the same sets of medications over long periods of time and are likely more educated on our health issues and how medications work, need much less oversight and gatekeeping. but there are lots of people who don’t have the capabilities to perform those oversight and gatekeeping functions themselves – and the policy has to address both those groups of people. it’s enormously tricky.