> Also ridiculous but only tangentially related: Psychiatrists (or similar functions) cannot send prescriptions for ADHD drugs (Adderall / Amphetamines etc) to pharmacies (by any method). You need to pick up the physical prescription from the health care provider, then take it to any pharmacy. The pharmacy may not even have the medication, and certainly will need some time to fill it on the spot.

This is not true, at least in California. I take a certain ADHD medicine that’s a Schedule 2 drug. So I’m limited to 30 day prescriptions with no refills (so my doctor sends in 3 at a time), but my doctor can most definitely send them direct to my pharmacy.

That's odd that you can't get a 90-day supply. I'm also on a Schedule 2 drug for ADHD in California and have gotten a 90-day supply with Kaiser.

Granted, when I was seeing an individual psychiatrist prior to having Kaiser, she said I could only get a 30-day supply as well and would just send 3 at a time too. I feel like there is a way to do a 90-day supply that many providers either don't want to do or don't know about.

Edit - It might be something that's possible with electronic scripts and not possible with paper.

With Kaiser at least, if a doctor sends an Rx to the pharmacy the pharmacy can likely see the history. If the doctor sends a 90 day Rx and the last fill date was around 90 days prior, it's plain from that data the abuse is unlikely. They can also easily ping the doctor to verify the Rx and after so many Rx'es would flat the Rx as ok for 90 day supplies. But that's just me spitballing.

Some random pharmacy can't see the fulfillment history from other pharmacies. They only way they could see abuse would be after the fact. They don't want to set themselves up for a lawsuit or criminal investigation so they just limit their Rx amounts.

It can also be related to your insurance and employer's choices when setting up the benefits.

I don't think insurance will allow you to triple fill something and don't prescriptions for controlled substances expire?

You don't triple fill all at once. The doctor calls in one prescription for, say January, then one prescription for February, then one for March. You have to go to the pharmacy each month, but the doctor only 4 times a year. Basically the doctor can prescribe a prescription that doesn't start until a certain time. So the start time on the three prescriptions differs.

That's how it's done in FL for non-opioid schedule II. None of our Dr's can call or transmit Schedule II Rx, they have to be hand carried paper scripts.

Opioids are limited to a 3 day supply tho (with some tight exceptions, for those patients that can afford a PM Dr).

It varies state-to-state. In Michigan it is as op described. You have to go in person to get a physical prescription. A few years ago it changed briefly but it changed back. Since COVID the rules have been relaxed at least in MI.

Yep. For a long time in Michigan it was physical prescription only, but they could write you two additional 30 day scripts at the time, or you could get a longer script if you were going to be out traveling. But you still have to take it to the pharmacy yourself every 30 days in most cases. (again, much of this has been relaxed.)

My gut says that a lot of this is because of all of the regulations around handling and amount-on-hand rules in MI. There is one not-terrible side effect to the resulting process however; Since typically you'd just wait to get it filled (or pick it up ASAP,) It limits the risk of an electronic fill sitting around and getting 'lost'.

For healthcare purposes, a fax is usually considered a "paper copy" (unlike, say, an email) so it is quite likely that this is in fact legal.

I’m in Minnesota and take both a stimulant and testosterone. You can pick up the prescription from the doctor and deliver it to the pharmacy, or they can mail it in. They can’t use their online system, which I would think would actually be the most secure out of those three options. 30 days only for the stims, 90 days for testosterone.

My psychiatric nurse practitioner certainly wanted to reduce her own possible COVID-19 exposure here in the Seattle area but stressed that she could not call or send in the prescriptions for Adderall because of government regulations. Unclear who that regulating body is however.

My GP doc in WA sends electronic prescriptions of Adderall. When I was using a solo psychiatrist, he would give 3 mos of (1 per month) printed hardcopy prescriptions.

Note, getting the scrip from my GP requires an annual HIPAA privacy waiver and random piss tests. Privacy waiver is because they share medical records of patients prescribed controlled substances with law enforcement or any other local or federal government agency that wants to take a peek.

What are they testing for? To make sure you’re taking the ADHD meds or to make sure you aren’t taking other meds?

I just realized I didn't answer your question.

They are testing for abusive behavior to identify drug abusers, re-sellers, or negligent providers (over prescribing).

I have read some people complaining that their provider will not prescribe the drug they need if THC comes up in the test. That is not universal, it probably depends on the individual provider or the health provider system.

The best part is that law enforcement can review the records at will (as long as they can articulate an official reason which is a very low bar.)

> The best part is that law enforcement can review the records at will (as long as they can articulate an official reason which is a very low bar.)

True, but a positive test wouldn't be enough to arrest someone for drug possession. I doubt it would even be enough to get a search warrant with.

It is a general drug abuse screen, referred to as: PAIN MANAGEMENT PANEL 4 RFLX

It tests for dozens of drugs, including THC.

All patients prescribed a controlled substance have to take it.

Here is a link to a random lab describing it: https://etd.paml.com/etd/display.php?id=8412

>All patients prescribed a controlled substance have to take it.

I was told that I "may need to" take this test at some point. I never have and have been taking adderall for many years.

I guess I did overstate it. I was thinking about the health system I use.

I assume the drug testing requirements may depend on the state or the provider. It benefits the provider/health system by providing evidence they are taking reasonable precautions to limit abuse.

Also, I don't know if psychiatrists in WA are held to a different reporting standard than general practitioners. When I used a solo psychiatrist, no testing or privacy waiver required. When my insurance changed, I lost that psychiatrist and went to a regular doc in a large health system (UW Physicians). They require the testing and waiver.

But the law was changing when I made the change, so it may apply to psychiatrists now, too.

UW is a special case. By law they have to accept everyone in the state and medicare has special requirements for some medications. To avoid discrimination they have everyone take the same tests.

Super valuable info. Thanks for that.

> requires an annual HIPAA privacy waiver... Privacy waiver is because they share medical records of patients prescribed controlled substances with law enforcement or any other local or federal government agency that wants to take a peek.

So, how good is a regulation if you need to waive it for something as basic as getting your medication?

Makes me respect GDPR even more.

Yes, it totally sucks, and it almost caused me harm trying to avoid it. I am sure I was not the only one. I imagine some poor souls got into some real trouble even suicide.

The American Medical Association, et al., sold out their patients in exchange for not being held accountable for the US opioid crisis. (my opinion of course.)

My doc didn't think it was any big deal, she said I was her first patient to question it. She thought the waiver had some limitations, I showed her that it did not have any limitations except that access had to be for official use (which is not much of a limitation.) The records are stored in an electronic registry that various local or federal government agencies can access without warrants or notice.

As a lawyer I cannot imagine voluntarily entering into such an agreement against the interest of my clients. I still find it shocking.

I had a similar issue with refusing to give a podiatrist I saw one time my SSN.

The rationale was, prior to getting a surgery once, I was asked in pre-op to review my EMR information by the nurse. The info was completely wrong and very dated. I asked the nurse where the info was from since I had never been to that hospital chain before. Her comment was an affiliated urgent care I went to years ago was in their medical system. But the brand name was different because they were acquired. I was pissed. What if I had been rolled in unconscious and that EMR record was meaningfully inaccurate against my wellbeing?

So now it raises eyebrows but I refuse to provide any nonlegally required info. And to OPs point the response is one of almost mocking surprise. But the counter argument is, why would I trust you to not sell my data going forward? What if I'm wheeled into a hospital unconscious and your medical records from 20 years ago somehow cause me harm? Absolutely no way.

IANAL

So I looked it up because that is very perculiar, and my quick skimming of the laws seem to imply that Schedule II through V drugs can be sent electronically:[0]

> (1) Information concerning a prescription for a controlled substance included in Schedules II through V, or information concerning a refill authorization for a controlled substance included in Schedules III through V, may be electronically communicated to a pharmacy of the patient's choice pursuant to the provisions of this chapter if the electronically communicated prescription information complies with the following:

> ...

[0]: https://app.leg.wa.gov/RCW/default.aspx?cite=69.50.312

Thanks for checking! :) I'll bring it up with her.

I think all of us agree that the paper prescriptions are ridiculous, especially at this time.

I wonder if we have the same practitioner. I'm having the same issue with mine; she's part of a couple, they practice in Redmond.

I doubt this is an issue specific to the NP. Regardless, we have different providers.

Maybe it's a lowly nurse practitioner vs deeply trusted MD issue?

My understanding is that an NP is considered as autonomous as a physician. I know several of my friends who are PAs and they're lobbying to be treated the same as NPs, as they feel that some of their restrictions are unnecessary and bureaucratic, logistical issues only, rather than based on patient care.

Exactly. Lots of MDs are of course frustrated because they spent more time and money on education.

The focus should absolutely be on patient care.

Doubtful and she works with a MD.

I have many friends in the medical field. This MD vs NP hatred needs to stop.

NPs can be specialized and have great knowledge and experience in their particular field.

And my NP visit is cheaper - absolutely worth it to me.

I think you misunderstood the parent comment. The commenter is not saying NPs are a problem, they are pointing out that NPs aren't treated with due respect. The sarcastic use of "lowly NP" gives it away.

Can confirm!

Sarcasm comes across poorly in online communication, so I should probably use it less :)

This is exactly what my doctor in Oregon does. I've never had to deal with a handwritten prescription.

If they imposed this in California you'd see mass exodus of Adderall addicted techies leaving.

Every month I end up playing the game of "will they have my medicine?" and regularly have to drive around different pharmacies to find one that can fill the prescription that day (because they only fill one every thirty days, and there is exactly a thirty day supply given, so there is zero buffer).

This becomes far more problematic if I have to travel for work (which was very common pre-COVID) and I'd literally have to drive an hour to a 24hr pharmacy and wait until 12.01am on the day of my flight, then wait half an hour to get the prescription filled, drive an hour home, then leave at 5.30am to get my morning flight.

And if the refill date occurs when I am away, I'm SOL - CA won't take a prescription from WA for a controlled substance. I usually have to ask my wife to go in early to pick it up, then spend a ton of money to overnight the medicine to my hotel.

There needs to be a system that allows for people who have been taking the same stuff for years to have SOME kind of buffer or slight flexibility. The current system is bullshit.

This is an insidious predicament to be in, having once been through this myself. I take it you are also forced to make the decision to burn meds to be able to function while driving to and from pharmacies or face life altering withdrawals to conserve your 30 day supply while you are navigating this BS pharmacy refill circus act we find ourselves subjected to when filling a script we've been on for years, yet met with disdain or a watchful eye meant to keep tabs on a suspected criminal/drug seeker by an overworked and grossly understaffed pharmacy tech who acts as a gatekeeper to getting it filled and will give you a hard time if you are from out of town.

We aren't opioid addicts abusing the system and putting a strain on tax payers, we need this stuff to be a functional and contributing member of society because our brains don't produce enough dopamine for myriad reasons. Why subject us to this hell every 30 days, we need medical reform NOW!

> Every month I end up playing the game of "will they have my medicine?" and regularly have to drive around different pharmacies to find one that can fill the prescription that day (because they only fill one every thirty days, and there is exactly a thirty day supply given, so there is zero buffer)

This is an utterly absurd situation - surely the people coming up with this stuff must realise this?

If anything, stupidity like this could actually cause more people to go to the black market.

It is deeply annoying for me.

What is genuinely enraging however, is when my son runs out and we can’t get him his medicine. His symptoms are honestly pretty bad and he is aware of them but can’t do anything about it. Hearing him ask “daddy, why can’t I have my medicine?” is both heartbreaking and enraging.

In the end, we asked the doctor, who agreed to issue us a slightly different prescription for him a few days after we filled the first one. This let us get the second prescription Refilled immediately so we thankfully have a small buffer for him now.

Laws like this are bullshit.

This reminds me of Gabe Newell's famous quote, "Piracy is a service problem." If you could buy your medicine illegally as easily as people pirate digital goods, you absolutely would.

I have seriously considered buying a buffer quantity on one of the various TOR-based markets.

If you don't mind me asking, what's the drug/medication?

For me, just adderall. I won’t die if I don’t get it but I have fairly bad symptoms if I miss a dose.

Why do they have to make this such a pain in the ass? They are trying so hard to restrict abusers that it makes it almost impossible to get treatment if you actually have ADHD. Do you know what people with ADHD do? Forget to make appointments because they got distracted. Essentially the system is set up to be hostile to ADHD sufferers to actually get help . I ended up having to pay concierge mental health to consistently be able to fill this script. The doctors would sometimes refuse to see me because of this diagnosis, and the pharmacies would lie to me that they were out of the medication and to come back on x date. If I do this they just repeat the same statement and choose a different random day. This was so much trouble that I spent years without treatment and it affected my life terribly. I did things like cause 10s of thousands of dollars in damages to apartments due to Inattention, almost getting myself fired, driving extremely poorly, almost failing out of school. This condition is preventing me from doing things I really want to do with my life because theres a wall of motivation I have to get over, even for things I enjoy.

I sometimes forget to take my ADHD medication on several days and only realize after the fact that I was very unproductive. My friends will also notice that my mind was more cluttered again. I dive from tangentially related thing to the next, only connected in my mind by emotion. Eventually I reach a stack overflow - I'll have no idea how the conversation started or what the real topic or task were.

It isn't very effective if it allows you to forget to take it.

You can still suffer from the same, every day normal forgetting of things on ADHD medication. It doesn't instantly make you superhuman. You still need systems to remember things effectively, ADHD or not.

that's like saying pain medication isn't very effective if you just hurt again afterwards.

it is somewhat ironic that you have to remember to take something that helps you remember to do things.

Why would doctors and pharmacists refuse to serve you? What's their incentive?

Legal liability or the general threat of having to expose themselves to additional scrutiny of government agents.

If a government agent determines that the doc is over-prescribing they can get into big trouble.

It is because of the US Opioid crisis, but the regulations are directed toward all controlled substances, not just oxycodone.

It’s funny 90% the time people throw out the claim “blockchain is a good solution for this”, what they really have in mind is just an append-only database controlled by trusted parties. (Before someone tells me the story of Coca Cola’s supply chain, thanks, I’ve heard dozens of times.)

What is this Coca Cola supply chain story?

Yeah, the 'decentralized' part of blockchain seems to slip people's minds a lot.

A centralized ledger database is the right solution sometimes.

I don't know if it's because you're talking about a psychiatrist or not, but my wife takes Vyvanse for ADHD, prescribed by her family doctor. Ours just retired, and while he wasn't allowed to do more than give her a paper prescription to pick it up each month, the NEW doctor can, because she is set up to send it electronically.

Most other prescriptions he could call in, but I think in WA there's a special system you have to get set up with to do it yourself.

Now my wife doesn't need to physically pick it up anymore. If it would be useful to you, I can find out from my doctor's office what system they had to be part of to allow them to call in prescriptions like that.

Uh what? This seems like the kind of thing solvable with routine electronic authenticated messages from doctor to pharmacy. The problem there is mandating the dubious paper method as the only way.

> ...with routine electronic authenticated messages from doctor to pharmacy.

These are professions that still use fax machines. The concept of sending scrips between random doctors and pharmacies over electronic means is too daunting (HIPPA, privacy lawsuits, child protection laws etc). They would rather stick them in envelopes. Giving it to the post office won't get them sued.

Perhaps for some, but for the last 5-10 years all my doctors have had me specify a pharmacy and the prescriptions gets sent their directly without me having to hold anything physical.

This isn’t true in Washington. My psychiatrist has been sending my ADHD meds for digitally for a few years now.

https://www.addcenterofbellevue.com/ If you’re interested in a new doc.

This isn't the case in NY from my understanding as I've seen psychiatrists send ADHD prescriptions digitally to both physical pharmacies and delivery pharmacies (Capsule). So it might be a restriction imposed by your state.

They actually must be sent electronically now in NY, or at least that’s how my doctor explained it to me.

I’d assumed that was for all prescriptions, but it could just be controlled substances.

This makes sense because information about controlled substance prescriptions are stored in a central registry so law enforcement or other government agents can review them easily. The federal regs only apply to controlled substances, so the e-script systems 'probably' direct controlled substance scrips to the DEA registry. But, the health providers, insurance companies, health systems, pharmacies networks/chains, and so on, are probably keeping a copy of everything.

I was recently told by a pharmacist that this applies to _all_ prescriptions in NY. YMMV, though.

Interesting! Maybe it's a Washington State thing then.

So from my understanding, most prescriptions are handled over the phone/fax, and regulated drugs require some kind of verifiable signature that a fax does not comply with. I believe mail works fine though, as none of this makes sense.

There is an e-signing program that I think lets the pharmacy watch the signature being made or something that is now fixing this issue, but I hear it is both expensive and rather difficult to use.

Look for a pharmacy that offers delivery, they can make the trip to your doctors office for you as again these regulations are ridiculous.

Physical signatures are nearly worthless a digital signature ensures that the prescription is valid unless the doctors computer or the pharmacies is compromised.

This would presumably be no worse than keeping people from forging paper prescriptions.

It would logically be based on a public private key pair like gpg.

I was a bit mistaken, the law requires a full written prescription, not just signature, and it can't be a copy. The system in place allows for electronically writing prescriptions so they will still comply with the written requirement.

There are more security requirements like what you describe, but much of this is about making a new standard comply with laws from the 70's.

This is what my doc told me, that prescriptions had to be via paper in my state. Another doc said he sent electronically but had to pay a high fee to set up a system to do it for him.

During covid, my doc all of a sudden started sending electronically.

I’m not sure if my doc was wrong, or lying, or just didn’t understand the stupid regulations around some meds.

Lots of small clinics that don't write lots of prescriptions use paper. (I do some IT for one.) It's not regulation, it's cost. As long as it's cheaper to buy the paper and take the time to print on it than to pay monthly fees to the appropriate online clearinghouses, some doctors will do exactly that.

Lots of prescriptions that don't see "abuse" can be communicated to the pharmacy with a phone call. Amphetamines are not such a drug.

I find this post interesting because the OP lept to blaming "The Feds" and specifically the FDA and DEA (two frequent targets of popular ire) even though subsequent replies make it clear the OP has no factual basis for any claims made.

This is not true anymore, Adderall can be sent electronically to the pharmacy. It makes things so much easier since I don’t have to find time to get into the office to pick up the paper prescription.

Since when? In Washington state it was still true 2 months ago.

I did a quick search and found that Washington State Senate Bill 5380 [0] that was signed into law in May of 2019 says that Schedule 2 substances can be prescribed electronically in 2019. There are exceptions to that and your prescriber may not participate in it.

[0] http://lawfilesext.leg.wa.gov/biennium/2019-20/Pdf/Bills/Sen...

I've been getting my adderall prescription sent electronically for the past 6 months, since I moved here.

Another post claims they've been getting it sent electronically for a few years: https://news.ycombinator.com/item?id=23215206

It definitely depends on the state. Something to possibly check into, if you have a primary care doctor you can ask them to conference with your psychiatrist so your primary can prescribe it through normal means. I don't know Washington regulations for that, so it might not help.

In PA, my doctor's only been able to send Adderall prescriptions directly to the pharmacy within the past couple years. If yours doesn't, check that it's not a rule from your insurance. My insurance makes me sign a form to choose the only pharmacy location I can use for those meds, amd I need an appointment with my doctor every 6 months.

It's hard to tell what's a federal law, a state law, or my insurance company judging me as a likely junkie.

I had a hell of a time when I chose that in PA and the pharmacy didn't have the medication in stock.

It was 2 months before I was able to finally get it, because I made the mistake of trying to change my pharmacy to one that had it in stock.

It would be enforced by the DEA, but as far as I remember, the requirement that only paper prescriptions are accepted for C-IIs is written into the law itself. So only Congress could change it.

There is actually a way to e-prescribe, but there are strict security requirements and I think it varies by state. IDK why blockchain is needed though, an ordinary digital signature ought to be enough and that's what the e-prescribing rule requires.

I don't understand why it has to be so complicated. In most of Europe you go to a pharmacy with your health insurance card and 30 seconds later you walk out with the drug you have been prescribed. On the rare occasions when it is out of stock you can come back later (usually it takes only a few hours) or go to another pharmacy around the corner where the chances are they will have it.

A odd, underdiscussed, difference I noticed between the US and Germany (and presumably other European countries) is around packaging. In Germany pretty much any medication comes packaged for retail in a cardboard box with tablets on one of these bubble sheets. Similar to most over the counter stuff in the US. In the US the pharmacist puts the tablets into an orange container with the precise counts requested by the prescription and with an individualized label. I wonder how much of the logistics issue in the US is from the individual packaging work required.

Yes, I have seen that in American sitcoms and films. In Europe, as you say, they come in cardboard boxes. The pharmacist will cut out and keep the barcode in the case of prescription drugs.

> I know it's a running joke to throw out the term Blockchain, but this really is where Blockchain might be a good solution.

Why so complicated? Most use cases for Blockchain could be solved by public-key cryptography, technically backed by using a national government issued, RFID capable ID card (drivers license, passport, whatever) and it's trust chain.

Meanwhile meth is ridiculously easy to get and can even be ordered on the dark web with little chance of getting caught.

The whole system is just shockingly stupid.

I know this is only dealing with a tiny portion of your comment, but why do people think digital prescriptions require a proof of work database, when matching a UDID and changing a 0 to a 1 would suffice?