Oregon Prescribing Bill Awaits Governor's Decision

Legislation to create a panel within the Oregon Medical Board to make recommendations for training psychologists in Oregon to prescribe medication was awaiting Gov. Ted Kulongoski's decision as Psychiatric News went to press.

On March 29, Kulongoski (D) issued a “notice of possible intent to veto” the bill, a protocol in the state whereby the governor signals to legislators his dissatisfaction with a bill and his possible intent to veto it in five days. But the notice prompted heated lobbying by pro-prescribing psychologists and equally vigorous counter efforts by opponents of the bill—who include some psychologists as well as psychiatrists.

John McCulley, executive director of the Oregon Psychiatric Association, told Psychiatric News that the governor would be meeting with proponents and opponents of the bill in the first full week of April and had a deadline of April 8 to make a decision.

In addition to the content of the bill and its possible effect on patient safety, McCulley said the governor has had concerns about the process by which the bill was brought to fruition. “He realizes this bill has had no public hearing and was pieced together in an effort to salvage earlier legislation that had failed,” he said.

McCulley said that supporters of the bill are claiming that psychologist prescribing will ameliorate access-to-care problems in the state and are also making the novel argument that primary care physicians—who prescribe the majority of psychotropic medications—are not adequately trained to treat mental illness.

“On average there are less than four psychiatrists per 100,000 residents in rural parts of our country,” said Oregon Sen. Monnes Anderson, speaking on behalf of the bill in the state legislature. “That means the majority of mental health patients are getting treated by nonpsychiatric physicians. We do not have enough psychiatrists, which has left it to primary care providers to do diagnosis and prescribing for mental health patients.... We need people who are well trained and whose focus is in mental health to meet the needs of the mentally ill.”

If approved, SB 1046 would establish within the Oregon Medical Board the seven-member Committee on Prescribing Psychologists charged with making recommendations to the board on “educational requirements, clinical training requirements, standards, examinations, and continuing education for prescribing psychologists.” The committee would also be charged with making recommendations to the board regarding the formulary for psychologist prescribing and annual formulary revisions.

Somewhat confusingly, the bill also creates a six-member task force to make similar recommendations about prescribing to the legislature. “No one is quite certain how the two separate panels would work together,” said McCulley, who added that the confusion around the functioning of the two panels is also a concern of the governor's.

However, it appears that the six-member panel making recommendations to the legislature would be temporary and cease to exist after its report. The seven-member committee within the Oregon Medical Board would be permanent. This committee would consist of four psychologists, including one who is a member of the State Board of Psychologist Examiners and who would serve as chair of the committee, and three licensed physicians, including one psychiatrist.

The bill passed easily in the state's legislature, which has a history of scope-of-practice expansion. In 2009 the legislature approved a bill to allow naturopaths to prescribe any drug, and another to permit podiatrists to assist with any surgery.

The issue of prescriptive authority for psychologists has come up in the Oregon legislation four times in the past—2003, 2005, 2007, and 2009. The 2009 bill was appended to language creating the work group that came up with the 2010 bill.

But the governor has heard vocal opposition from APA, the AMA, Oregon Psychiatric Association, Oregon Medical Association, and Oregon Council of Child and Adolescent Psychiatry, as well as some psychologists in the state. In a letter to Kulongoski, APA Medical Director James H. Scully Jr., M.D., said the bill “puts patients' lives at risk by creating a dangerous, substandard level of care.”

He wrote, “Psychotropic medications used to treat mental illnesses are among the most powerful in modern medicine.... These medications have potentially disabling and deadly side effects if improperly prescribed and can cause convulsions, epilepsy, heart arrhythmia, blood disease, seizures, coma, stroke, and death.”

Also, Scully said that many patients receiving psychotropic medications have comorbid medical conditions, for which they may be receiving medication, that require the prescribing clinician to monitor general medical health and potentially hazardous drug interactions.

“Under no circumstances are psychologists trained to understand, assess, and monitor a patient's medical condition as a whole,” Scully wrote to the governor.

Michael Maves, M.D., M.B.A., executive vice president and CEO of the AMA, echoed those concerns in a March 18 letter to the governor: “The simple fact is that psychologists have not undergone the rigorous medical education and training that licensed psychiatrists and other physicians receive before having the ability to independently prescribe psychotropic medications that are used to treat mental illness and are among the most powerful in modern medicine.”

Scully and Maves both drew attention to the fact that the bill calls for a “collaborative” relationship between a prescribing psychologist and a “health care professional” who oversees a patient's medical care—but does little else to clarify that relationship and does not give a physician supervisory authority to overrule the prescribing psychologist.

The bill states only that this collaboration shall be maintained to ensure that necessary medical examinations are conducted, that the prescribed drug is appropriate for the patient's medical condition, and that the prescribing psychologist and health care professional discuss “in a timely manner any significant changes in the patient's medical or psychological condition.”

Scully wrote, “As defined, the collaborative requirement that this bill envisions would occur between psychologists and physicians and assigns no supervisory authority, veto power, or direction to the physician. Who decides, for example, whether a prescribed drug ‘is appropriate’ for a patient? Physicians may never have the opportunity to conduct a medical differential diagnosis or appropriate patient assessment before being asked to validate these medication orders.

“Indeed, there is nothing in the bill to ensure that the physician will ever lay eyes on the patient,” Scully continued. “As a result, the bill raises rather than answers profound questions of adequate care. We believe there is a serious potential for harm as a result.”

In a letter drafted March 31, as Kulongoski was weighing arguments for and against the bill, child psychiatrist Ajit Jetmalani, M.D., president of the Oregon Council of Child and Adolescent Psychiatry, told the governor that the “lack of regard for the safety of children in this entire process [by which the bill was written] reflects how dangerous and poorly conceived this bill remains.”

Jetmalani emphasized these points in urging the governor to reject the bill:

Some psychologists in the state have weighed in against the bill. “I and several of my Oregon psychologist colleagues are actively lobbying the governor to veto [the bill],” Ronald Glaus, Ph.D., told Psychiatric News. “Many psychologists in Oregon do not support psychologist prescribing. This is not about physicians versus psychologists in Oregon, no matter how the prescribing proponents try to paint it that way.”

Glaus retired in 2009 as chief of the Psychology Department at Oregon State Hospital and from the U.S. Army Reserves for which he had been a psychologist serving troops in Iraq. He said he seeks to encourage the profession of psychology to “abandon this quest to become medical providers and to appropriately place its focus on behavior—research, understanding, interpretation and intervention.”