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Comment by reureu | Hacker News Reader

Two that I'm comfortable sharing are:

Cerebral (cerebral.com): first, their whole business model is about being a pill farm for controlled substances. So, out of the gate that's pretty concerning (but, yes, you can make a lot of money by providing easy access to adderall and ativan). Beyond that, they're having a hell of time recruiting providers and so their lead time for appointments is pretty high. They're still taking customers on a subscription basis, but can't provide appointments. I think it's just a matter of time before that whole mess collapses.

One Medical (onemedical.com): in early 2021, they were caught letting people skip the line for covid vaccines. The house select committee on coronavirus investigated them and released a pretty damning report back in December, and their SEC filings have indicated that they're under further investigations by some various organizations. Based on this information and other chatter I've heard, I don't think that's the only questionable thing they've done.

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> first, their whole business model is about being a pill farm for controlled substances

Before COVID, you couldn’t get a prescription for controlled substances without first meeting a provider in person.

This law was enacted years ago because pill mills were popping up everywhere and dispensing controlled substances to people in exchange for $200+ phone calls. They’d do a minimal 5 minute call with anyone who signed up, speedrun through a prepared script, and then send the patient their controlled substance prescription of choice. You then made a follow-up appointment the next month for your refill, which was an even shorter phone call.

They didn’t accept insurance because no sane insurance company would deal with them. Their target audience only wanted to pay their way to prescriptions and didn’t mind.

And this is exactly what Cerebral is doing all over again. The COVID exceptions for in-person prescribing will theoretically expire at some point, but until they do there are several companies like Cerebral trying to cash in as much as possible with Instagram and TikTok ad campaigns to convince as many people as possible to sign up for literal Adderall pay-for-prescription subscriptions.

Before anyone rushes off to sign up, keep in mind that these controlled substance prescriptions will be logged in your state’s prescribing database and doctors everywhere are catching on to these pill mills. If you show up to a real doctor later asking for a prescription, they might check your prescribing history and think twice after seeing that you were getting prescriptions from known pill mills nowhere near you.

Pharmacies are also getting fed up with the sudden influx of prescriptions from remote doctors for scheduled substances.

I really hope this business model gets crushed ASAP, because if it’s allowed to continue then we’re going to see a crackdown on ADHD diagnoses and prescribing in the same way that pain management has become exceedingly difficult to come by (for true pain patients) in the wake of the opioid pill mill epidemic.

Is there any evidence to suggest adverse affects from all these excess scripts?

Because if there's not... Then it sounds like the easiest & best solution would be to reschedule the drugs and make them (mostly) OTC.

I can think of dozens of OTC drugs in Mexico that are a PITA to get in states due to unnecessary healthcare visits...

The most commonly prescribed medication for ADHD is pharmacologically essentially the same as meth. It affects us ADHD people differently than the rest of the population.

...and even for us, there are side effects. Concerta made me irritable and I wouldn't eat anything. I know someone who was on Focalin for a while and they suffered from awful mood swings and depression. I've been on the same dose of Vyvanse for 10 years and I still get occasional mood swings.

I'm not on anything, and I get occasional mood swings too. ;)

My point: For many of these substances, I'm perfectly capable of managing my own dosing, side-effects, and knowledge resources without a government-mandated overseer. Maybe the solution is to deregulate & facilitate access to knowledge providers, but not enforce more regulation.

I think we should get rid of the Controlled Substances Act and the DEA. Everything should be available over the counter from a pharmacist on request. (I'd still involve the pharmacist because they're a professional at identifying drug interactions and such, but you shouldn't require a scrip to get access to medication.)

But in your original comment you asked if there is any evidence that there is adverse effects from excess prescriptions. And, well, there's plenty of adverse effects from meth use (source: every trailer park in small town America). And studies have shown that the amphetamines commonly prescribed for ADHD produce an indistinguishable high amongst recreational users.

So if you made these drugs unscheduled and available over the counter, you'd basically just replace drug cartels and your local dealer with the Pharma industry and your local CVS. Which don't get me wrong, is a massive fucking improvement! I'm all for that. But you'd certainly also have a heck of a lot of meth-heads wrecking their lives with over-the-counter meds.

Any such legalization and normalization would require active community support and intervention to help substance abusers too.

If we do that we should also outlaw drug advertising. That would turn into a serious shit show taking advantage of people

My only resistance to that idea is this: Passing that law would invariably result in some deaths.

Sure, it would primarily be the people who had no control over themselves in the face of their addictions, but making all drugs legal would cause many, many people to either overdose or to keep taking the drugs until they died from secondary effects.

If that could be mediated, I am all for full legalization of all drugs, including "hard" drugs like cocaine and heroin.

Other countries have done similar things and found a decrease in usage among both new and previous users, a decrease in overall drug-related deaths, a decrease in drug-related crime, and an increase in rehabilitation.

I may not approve of using drugs myself, but I think what I do with myself is my business and what others do with themselves is their business. I would prefer for things to be as good as they can be with the goal of getting better, and broad scale legalization has strong potential to be a step in the right direction.

Not passing that law has already resulted in needless deaths (lookup the history of HIV antivirals and the FDA to see what I mean). Don't forget to account for the opportunity cost of inaction.

I can't quite classify it but I feel that there is an ethical line between the deaths that are occurring because of a person's flaunting of a law and the deaths that would occur because of a law being changed.

As a terrible analogy, if we made it against the law to wear seat belts, some people would die who would not otherwise die.

Most people would continue to wear seat belts anyway as they are aware that wearing a seat belt is far safer than not wearing a seat belt.

Further, it makes sense that a large portion of those people who would die would be the ones that weren't wearing seat belts to begin with regardless of the law, but it stands to reason that some percentage of people who die would be people who would have worn seat belts but chose not to because it was no longer illegal to drive without a seat belt.

I feel there would be a similar outcome to mass drug legalization. Most people would have no change in their lives. Some people who were subconsciously mid-drug induced suicide would continue on and die quicker thanks to the ease of access and legalization, but there would be some people who, without the legal issues and difficulty of obtaining the drugs being an inhibitor would then choose to indulge, and some fraction of those people may overdose or otherwise harm themselves where they would have been protected by the current status quo.

It's hard to navigate mentally but I feel confident in the statement even if it is not fully formed.

I'm also on Vyvanse. Side effects are thankfully minimal compared to some of the horror stories I've heard. But I do have trouble sleeping, routinely rub my tongue raw from bruxism, and if I accidentally have any caffeine I feel like my heart is going to explode. But it is way better than being off medication.

> The most commonly prescribed medication for ADHD is pharmacologically essentially the same as meth.

I'm not sure about that. If I remember correctly, the most prescribed medication for ADHD is Adderall, and Adderall is amphetamine salts. Amphetamine and methamphetamine are not the same, though they are close. Also, the difference between a therapeutic dose of amphetamine or methamphetamine and what the regular drug abuser uses is huge.

I'm not at my home computer so I'm not able to pull up citations, but there is a paper I have read in which they gave meth addicts amphetamine-based ADHD medication vs typical equivalent street doses of meth in a double-blind study, and the meth addicts reported them as basically equivalent. I say "basically equivalent" because they were not indistinguishable due to different formulations having noticeably different durations of effect, but the high they produced and the side effects were basically the same. This study was a pretty big deal because it demolished the widespread assumption that the methyl- group makes methamphetamine more neurologically potent.

So yeah, aphetamine (Adderall et al) and meth are basically the same, pharmacologically. The anticipated differences between them in their effect on the body and mind largely aren't real.

Most studies I've seen of methamphetamine for ADHD treatment use 20-40mg doses, sometimes but not necessarily split in two. A google search seems to claim that abusers take up to 50mg at a time. That's not a lot higher than the prescribed dose.

I've seen the same thing as you for methamphetamine and amphetamine being "basically equivalent" but it was a study in rats. However, patients usually rate desoxyn (which is methamphetamine) higher (~10% higher) than either adderall or dexedrine (another amphetamine), and methamphetamine is supposed to be better at crossing the blood brain barrier. I'm not sure if I would call it equivalent/the same but they're very close. Especially this part:

> The anticipated differences between them in their effect on the body and mind largely aren't real.

You're totally right about that. People associate methamphetamine with drug abuse and amphetamine with people taking adderall, but I think it's a case where the dose makes the poison.

For the abusers parts, I've found Simon et al, 2001 "A comparaison of patterns of methamphetamine and cocaine use", that would indicate doses of 500 mg, usually snorted instead of "eaten". As an anecdote, a friend that used to abuse amphetamine consumed around 300 mg a day.

I'm a physician who's prescribed medications for many ADHD adults. Methamphetamine (MA) is legal to prescribe for ADHD and indeed a few patients had best results with it. MA isn't "stronger" than D-amphetamine but may be better tolerated. AIUI the main reason MA is the dominant street amphetamine-type drug is that it's easier to synthesize in clandestine labs vs. classic amphetamine. At equivalent doses the effects are similar.

In any case you're right that there's a big difference in street drug use vs. therapeutic doses. For street drug user a typical daily dose is on the order of 1000mg whereas prescribed doses are with few exceptions 1-2 orders of magnitude below that. MA in particular is in the lower end of the range, I'd say 10-20mg/day (partly due to it being a very expensive pharmaceutical product if in fact it's even being manufactured at present).

Only a small portion of methamphetamine users are using a full gram in a single dose. Perhaps spread over a day or two, but most recreational doses are closer to 100mg

Wow, this is a depressing read.

https://www.bloomberg.com/news/features/2022-03-11/cerebral-...

https://archive.ph/aKcMK

Cerebral (read: Uber for drugs)

SoftBank is a huge Uber investor and also threw $300 million into their latest round.

Asking for a friend, but is the secret to receiving Softbank capital just to be either a scam or a highly misleading business? I still can't work out why they ever invested so much in WeWork.

At the very least SoftBank money is a good indicator of something fishy.

If get an answer so, let me know. A friend of could use some SoftBank millions as well!

This is the best write-up of the Softbank business model:

https://www.readmargins.com/p/softbank-robinhood-and-a-margi...

In short, the background of Softbank founders is in plumbing of the financial system. They intentionally bid up dubious companies into obviously unsustainable valuations, with the aim to make them highly illiquid. Faced with illiquid stocks, many of the assumptions behind trading models break down, and obscurities of the financial plumbing come to fore - the water Softbank knows really well. Eventually, index funds include a portion of the bid-up companies on their balance sheets, FOMO investors roll in - that's when Softbank unloads their bags

Is this like a- preemptive vulture fund?

That article is incredibly damning.

The "TikTok-ification" of medicine is pretty frightening as well.

> One ADHD content creator, Reece Palamar, has posted about a half-dozen Cerebral-related videos to his almost 600,000 TikTok followers. (https://www.tiktok.com/@reeceisrandom?lang=en)

> In [another ad] a woman is asked: “Yo, bro, who got you smiling like that?” She then begins dancing with a box of prescription pills. (https://www.tiktok.com/@samanthaswanson1?lang=en)

Do either of these creators look like they're qualified to provide medical advice? They're getting millions of views to dance around and convince people that they have ADHD and need amphetamines. Why? Because they have trouble keeping their lives organized in an age of smartphones and constant media bombardment. But doesn't everyone?

> Some ads suggest that symptoms as common as difficulty with multitasking, focusing, and stress, as well as poor planning, procrastination, and disorganization can all be symptoms of ADHD. (They can also, as one former Cerebral nurse says, “simply be attributed to being an adult in 2022.”)

While this article is particular to Cerebral, they are not the only offenders. There is a whole cottage industry around convincing people with mild organizational problems that they have ADHD, even in "traditional" psychiatry. It's happened to family members and friends of mine.

I was diagnosed with ADHD and went through an Adderall -> Vyvanse -> Ritalin pipeline. I eventually settled on using half of the smallest available dose of Ritalin (5mg/2 = 2.5mg) and that is plenty for me. It's scary how many people I know who are dependent on regular doses of 30+mg of amphetamines.

> It's scary how many people I know who are dependent on regular doses of 30+mg of amphetamines.

I’m actually very worried about where this is heading. We had a cohort of mentees come through a mentorship program I help with who ended up recommending Cerebral to each other and getting prescriptions together. I didn’t catch on until later when they started talking about regrets, but I was stunned at how easily they were prescribed excessive doses in exchange for cash payments.

Once the initial euphoria of a medically unnecessary or otherwise excessive amphetamine prescription wears off (and it will), some people end up in a rather unhealthy place. There is no free lunch.

Well, it's "move fast, break things" mentality. Just the thing you are breaking are actual people and their minds.

I use onemedical because it's easy to find providers in my area with them but I recently got notified of a class action lawsuit against them for... misleading people into thinking they need a membership to use their facilities? I'm still confused on whether this means I actually need this membership in order to book appointments etc.

https://www.onemedicalsettlement.com/

You can still book and have appointments without a membership, but you have to call the office instead of being able to use the app. It's totally undocumented but I'm guessing it's some legal continuing-care thing as to why they have to offer it

Very strange that Simone Biles (the olympic gymnast) is Chief Impact Officer at Cerebral, front and center on the homepage.

Serious question: what the hell is a chief impact officer? Isn't former prince Harry also one for some startup? Is it basically just an celebrity spokesperson?

When I see stuff like that, I instantly take the company less seriously or ignore them unless the person in charge is someone eccentric like Elon. At least he is capable of running his company in a ruthlessly effective way even with wonky titles and shenanigans.

Chief Impact Officer at SpaceX would be an entirely different role I feel. :)

When I see someone endorse Elon Musk, I instantly take them less serious and avoid getting into into discussions with them, unless they own a Model X. At least it means they're capable of purchasing low-quality luxury goods....?

Yes, that's what it is.

I don't know what a Chief Impact Officer is.

However, Harry is not a "former" prince - he is still Prince Harry, Duke of Sussex, and sixth in line to the throne.

Didn't he have to give up royal titles when he abdicated? Why do I even know this...

He didn’t abdicate (nor can he). He just became a “non active” family member. The title is conferred by birth not by job - so he is very much still Prince Harry!

I feel like people stopped giving credibility to celebrity endorsement in the traditional form because they know celebrities are just getting paid to read a script, so companies had to come up with something that signals a deeper relationship with the brand, and that something is this phony C-level position. The celebrities also benefit from being able to add "entrepreneur" to their Instagram bios. I believe this trend started with Intel and it's "Chief Innovation Officer" (or something like that) Will.i.am a couple of years ago

A way to give a C-suite job to someone who was "homeschooled", has a degree from an online school she is a "brand ambassador" for, and zero professional experience.

"chief X officer" seems to be the new "director" or "VP" type title.

I personally know one of those!

Not to sound silly - but how is it strange? They offered her 6+ figures to use her name and then they used her name… seems relatively straightforward. Mayim Bialik is hocking “brain pills”; Matt Damon, Snoop, and every other celebrity is hocking crypto currencies. Most celebrities will put their names on almost anything if the price is right.

Those are commercials, those companies aren't lying to people that celebrities are actually involved with the companies.

If they give her a nominal position, seems like they probably aren’t lying here?

I mean, can anyone without looking it up, say exactly what the typical job responsibilities for the Chief Impact Officer in a typical company is?

I would guess that her "job" is to have a recognizable name and face that they can put on her advertising, and probably to not go around committing crimes or doing things that would make her name less valuable to the public at large in the process.

https://www.3dsystems.com/press-releases/3d-systems-appoints...

Worked at one softbank backed company for a short time and the amount of money and heads they dumped at any problem was incredible. Literally they tried to grow and scale at all costs.

That doesn't work for mental health though. Money can't buy more therapists to meet patient demand.

Edit: more importantly I would never trust my mental health with a company that takes money from Khashoggi's murderers.

https://en.m.wikipedia.org/wiki/Public_Investment_Fund

https://en.m.wikipedia.org/wiki/Assassination_of_Jamal_Khash...

I worked at one SB company and yeah, they had basically unlimited money to throw at problem, but their main competitors had too, from what I heard.

The funding world is _weird_ and I really wonder when the music will stop. I thought (hoped? against my short-time self-interest) that COVID will be such a crisis that will make people reconsider all these crazy spendings, but, apparently not!

YOLO I guess

> I would never trust my mental health with a company that takes money from Khashoggi's murderers.

It's interesting that Khashoggi's assassination is what seems to bother people most about the Saudis. Not the invasion of Yemen that has killed over a hundred thousand civilians or the littany of other crimes.

Because Khashoggi's murder is so well covered and so just blatantly bold. The war in Yemen doesn't bother people that much because a) who knows where Yemen actually is b) Yemen is a poor and mostly muslim country c) Saudi is buying western weapons and selling us oil d) Saudi is hosting the Formula 1.

Considering what Saudi Arabia is doing in Yemen, with implicit support from NATO countries, and what Russia is doing in Ukraine we (as in Europe and the "West") should have stopped all business relationships with Saudi quite a while ago.

Saudi's actions bother me so, up to the point I refuse to work as much as possible with them, for them or with money from them. Luckily, for now at least, that is made easy since (to my knowledge) my employer isn't funded by Saudi blood money. It is funded by Chinese money so, which poses an interesting dilemma.

He was related to CIA, so media told everyone it was outrage time.

It's the mental image of a sedative plunge, plea to breathe by an asthmatic, and rapid dismemberment in a plastic wrapped room by a hit squad of private jet flown high level Saudis. He was going to get marriage paperwork completed. The callus calculation left an impression.

It doesn't diminish the deaths of 100k civilians. No whataboutism debate necessary, both are barbaric. One was top of mind, neither is mutually exclusive.

The common denominator between Saudis and Russia is oil and lack of conscience or moral compass. Absolute power corrupts absolutely.

As someone with a long-standing Vyvanse prescription, I find the concept of ADHD pill mills horrifying.

These drugs develop dependencies in long-term users (I would know). They can have pretty nasty side effects, and even the more benign options can still cause mood swings and appetite issues (again, I would know). For most people, it can take years before tolerances stabilize (I got lucky). They probably have long-term effects on your brain that we don't know about yet, but meth gives us a good guess.

My employer gives us OneMedical. I can’t say I really understand what it is. I concluded its a concierge service for some tests and procedures. Given the location of their offices, not surprised about the trouble they got themselves into. They seem like another in the pile of companies who provide enterprise scale HR services, billed at scale. Calm, too (the idea of celebrity voices leading meditations seems orthogonal to my mind).

In fairness to One Medical, there's fraud like Theranos where the core conceit of what they're selling isn't actually _real_, and there's shady activities that are going to get them what I would hope is a pretty serious fine and some consequences (but who knows, America) like engineering some line cutting for vaccines, or the class action wherein they very significantly downplay that anyone can book an appointment manually without paying the fee.

At its core, One Medical is still offering actual healthcare services. I use them and appreciate the convenience of the app and integrated EMR that they offer. I'm not pleased about the shadiness here, obviously, but it's still so wildly better an experience of primary care that I'm not going to switch over it.

That's true - One Medical is definitely responding to a real need (lack of easy access to primary care). I don't think they'll outright collapse like the other examples, but I would think/hope there's a major shake up in their leadership.

They've done a good job at creating a real loyal base of customers, but they've also painted themselves into a corner with their business model. On one hand, they sell memberships en masse to self-insured employers claiming they lower total cost of care so can save them money. On the other hand, they're building partnerships with large healthcare systems, where the partners view One Medical as a source of insured patients that will eventually need specialty services. But large healthcare systems are notorious for being expensive. So, their two main business models are in conflict with each other. I think some of the things we're seeing are a reflection of this lack of a coherent strategy, and some of the flailing that comes with different arms of the business having opposing needs.

It's interesting you mention their integrated EMR. One Medical builds their own medical record system and patient app. My understanding is it doesn't use any of the standards the rest of the health tech world uses, which is why (last I heard) they weren't offering HealthKit integration -- not that there's not a demand for it (with such a tech focused user based, I imagine it's a common request), but rather they couldn't deliver on it quickly because their infrastructure just isn't set up that way.

I just signed up with Cerebral yesterday and have an appointment in half an hour...

FYI: Controlled substance prescriptions will be registered in your state’s controlled substance database. Any future provider will be able to see that you’ve gotten pills from a pill mill doctor if they care to look, at least until the records fall off.

This is basically the opioid epidemic being repeated with amphetamine.

If you believe you actually have ADHD, get a real appointment with a real doctor and build a real relationship that doesn’t involve a cash-only subscription to a pill mill. Using a pill mill will jeopardize your future doctor relationships and the pill mills will be shut down as soon as the COVID controlled prescribing exceptions expire.

Ugh stop trying to demonize this. I have a diagnosed problem which I used to take a controlled substance for from a psych who I had dedicated sessions with. Every time I went to the pharmacist, I had to put my name on a binder for the "controlled substances list" and got dark looks from the pharmacist every time I filled my prescription in. It was embarrassing enough at first admitting to friends and family that I sough mental health help. Attitudes like yours intimidate so many people who rely on controlled substances for living fulfilling everyday lives. With the help of my psych I left the controlled substance, but a significant factor was the stigma I'd face from friends, family, and the judgemental pharmacists who knew nothing about me.

Pill mill or not, let people find a way to live their best lives. Unless you're a doctor or healthcare professional, stop telling others how to live their lives.

I'm sorry, how are they "demonizing" it? Sounds more like a warning, and a pretty reasonable one.

If you let people find their own free way to best live their lives, they won't. Exposing the masses to strong, addictive and unhealthy drugs means getting more people hooked. What follows is crime, unemployment, heavier drugs, death.

Unless you understand that your use-case might not fit the public, stop implying substances are controlled for no reason.

In a country like the US where big pharma keeps lobbying to regulate as little as possible I would pause and think about why they're not OTC and how it would affect the general population if they were.

> If you let people find their own free way to best live their lives, they won't. Exposing the masses to strong, addictive and unhealthy drugs means getting more people hooked. What follows is crime, unemployment, heavier drugs, death.

Ah like the War on Drugs, got it.

> Unless you understand that your use-case might not fit the public, stop implying substances are controlled for no reason.

You're constructing a strawman. You're taking what I said ("whether it's a pill mill or not, let folks live their lives") and interpreting it in the weakest way possible ("implying substances are controlled for no reason".) This is not what I said. A "pill mill" (some pejorative used for institutions that folks disagree with apparently) is an institution that has some medical liability. It's not making every substances an unregulated one.

> Ah like the War on Drugs, got it.

Other than leading to the same thing they have nothing in common, and the reason there is a war on drugs is a complex, heated political topic. At no point did I say the war on drugs is a good thing.

You're constructing a strawman, You're taking what I said (leads to people's misery) and interpreting it in the weakest way possible (drugs are bad). This is not what I said, I said that exposing the masses to addictive drugs is a really bad idea. You tried giving opioids to everyone, everyone got hooked on opioids, rinse and repeat.

I'm not saying we should mistreat or lock up consumers of drugs, I'm saying it's a good idea to limit exposure in the first place. Drugs help people everywhere, they also ruin people everywhere.

There's no point at which you will be able to get those from a pill mill but not a doctor if they're actually medication for you

Crack dealer dot com definitely should be demonized

If appointments with local mental health experts weren't booked out months in advance, I wouldn't be here. I don't "believe" I have ADHD, I know it and have a diagnosis to that effect; but I have to speak to a psych in person (in the 'normal' system) for bullshit bureaucratic reasons to get meds restarted.

I'm elated this exists, and find your demonizing of it to be insensitive, hyperbolic and distasteful. Please mind your own business.

>This is basically the opioid epidemic being repeated with amphetamine.

No it isn't, it's a repeat of the previous American amphetamine epidemic, which has somehow been successfully memory-holed despite lasting multiple decades.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377281/

https://www.smithsonianmag.com/history/speedy-history-americ...

I'm happy for you. Hopefully they continue to offer you quick access to services. However, I'd encourage you to look on twitter and in the news for examples where Cerebral went radio silent on patients who were waiting for refills. Maybe consider savoring the prescriptions you get, since you don't know when/if the next one will arrive ;)

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