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Continued Decline in Youth Substance Abuse

Current illicit drug use among teens is continuing to decline, according to a new report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) released today. The study also shows positive signs that teens are seeing the dangers of abusing prescription drugs and methamphetamine and are pushing back. Among youth ages 12-17, the 2007 National Survey on Drug Use and Health (NSDUH), the Nation's largest substance use survey, shows that the significant decline in overall past month illicit drug use that began in 2002 continued through 2007, from 11.6 percent to 9.5 percent.

The survey, released at the start of the 19th Annual National Alcohol and Drug Addiction Recovery Month, shows that the reductions in youth drug use occurred for nearly every type of illicit drug including marijuana, cocaine, hallucinogens, LSD, and Ecstasy. The survey also shows dramatic declines in meth use, down by 67 percent (from 0.3% to 0.1%) and prescription drug abuse among teens, which declined overall by 18 percent, from 4 percent to 3.3 percent between 2002-2007.

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Responsible Telemedicine?

Columns - On the Web

Tuesday, 30 September 2003

It has happened again: clinicians providing medical care on the Web have had actions taken against their licenses. One physician in South Carolina, one in Minnesota, and one in Georgia have each received 60-day license suspensions from the North Carolina Medical Board. Each physician was providing Internet consultations for Virtualmedicalgroup.com (VMG), a small North Carolina company. Without examining the patients or forming a patient-physician relationship, these doctors wrote prescriptions for VMG’s customers. The Board found that this constituted an unauthorized practice of medicine within the state. It is unclear whether these physicians were licensed in North Carolina or whether the Board simply informed the states in which they are licensed.

VMG started up in 1999, building a national physician network and a mail-order pharmacy. VMG users choose the condition for which they desire treatment, then fill out an online questionnaire. The entered medical history is reviewed by a member physician and follow-up discussion takes place through secured Internet-based communications. The treatment plan often involves prescription of medication, which can then be ordered from the VMG-affiliated pharmacy. Narcotic drugs and other controlled substances are not prescribed. Insurance is not part of the process. The service treats what they call “lifestyle conditions” only. This includes treatment of allergies, arthritis, cold sores, impotence, depression, social anxiety, hair loss, and urinary tract infections.

VMG proudly notes that it is a founding member of the Council for Responsible Telemedicine. The mission of this council is “to serve the public interest by improving the quality and effectiveness of, and access to, healthcare in general and telemedicine in particular.” Available information regarding the Council indicates that there are only three members, AmeriMed Industries and Private Medical Group, both of Florida, and VMG. The Council indicates that any company joining must agree to treat only nonemergent conditions. A number of questions arise regarding this licensure action:

VMG is based in North Carolina. The doctors VMG works with are independent contractors from around the country. The customers of VMG are also from around the country. Most states have regulations that we’ve discussed here in the past, requiring physicians to be licensed within the state in which the patient is physically seen. Generally, though, the majority of companies which contract with physicians also require the physician to be licensed within the company’s home state, or at least within a state where the company has physical operations. For example, I have a contract to provide peer review for a Maryland-based company with a physical site in Massachusetts, where I live. The peer reviews I conduct often have nothing to do with anyone in Massachusetts, but since I am sitting in Massachusetts as I conduct the review, the company requires that I have a Massachusetts medical license. Did VMG require its physicians to have a license in North Carolina?
The Council for Responsible Telemedicine is a relatively new organization formed by three companies that have put together guidelines which appear relatively self-serving. The standard in the industry is the eRisk Working Group on Healthcare, a consortium of medical societies, professional liability carriers, and state medical board representatives. This working group has guidelines that are quite clear: “Online consultations should occur only within the context of a previously established doctor-patient relationship that includes a face-to-face encounter when clinically appropriate.” Obviously, this statement is also rather self-serving. The professional liability carriers are working to reduce risk, and there’s no question that eliminating online consultations would reduce risk (given the restrictions currently inherent within such communication). State medical board representatives are no doubt seeking to retain control of the practice of medicine within their own states, both for political and health-related reasons. Allowing doctors from outside their states to “practice” online on their population removes a level of control. So given the Council’s position in which online consultations are fine so long as only nonemergent conditions are treated, or the working group’s position that online consultations should not occur unless the patient has been seen in a live setting first, is there a happy medium?
Finally, define the practice of medicine for me. Let’s say that I, an addiction psychiatrist, lose my medical license. Can I open an office tomorrow in which I provide counseling services to clients, or does that constitute the practice of medicine? Let’s say I don’t perform physical exams and I don’t prescribe medicine, but I only provide therapy. In part, the answers are based upon the state in which I practice. Does the state require counselors to be licensed? How does the state define the practice of medicine? States are starting to look very closely at online activities with respect to patient care. If a non-medical clinician in Iowa is providing online services to a client in Connecticut, and if these services are deemed psychiatric in nature, it wouldn’t be difficult to fathom Connecticut taking this on as a “Practicing Medicine without a License” issue. Similarly, if an unlicensed clinician in one state does business with a client in another where similar clinicians must have a license, a licensure action could be taken despite the clinician not having a license. While there may be little immediate fallout for the clinician, difficulties could arise as a result later in his or her career.

Medical conditions, psychiatric conditions, and addictive disease are seen as three distinct entities by many federal and state regulations. Clinicians often perceive medical conditions as being a superset that includes the other two categories. Should there be different rules regarding these categories of illness in the online environment?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He will be speaking at the Psychiatric Congress in Orlando in November 2003.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2003, v.4, n.5, pp. 46-47.