Adults who do NOT have ADHD

[Mass Effect]

Yeah that does happen sometimes, usually the young ones are pretty new grads full of "I'm going to save the world from evil controlled substances". That tends to get smoothed out with time.

That said, always have the patient call their PCP to make sure they're OK taking over.

I usually reach out to the PCP myself. I find it's better coordination that way and things don't get missed/mistaken for other things.

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[tr]

You can always punt your stable ADHD patients back to us in primary care. Most of us will gladly take that, especially if you've done the evaluation and initial treatment parts.

Really, I feel like a lot of PCPs just aren't that comfortable with amphetamine and pretty much don't want to do these refills. Either they will punt to psychiatry or sometimes they create really intense monitoring regimens (substance use contract, q month Utox) for people who don't have any history of SUD, seemingly intended to make the whole thing so burdensome that the patient will find someone else to prescribe.
I'm fine with managing amphetamines if primary care doesn't want to do it.

Agreed on that front, as well. Unless they have a really hard time tolerating stimulants, most are a couple of follow-ups and then I have no reason to see the pt again except to fulfill controlled sub prescribing requirements. It's maybe the one time I wish I had a midlevel I could use for all of the follow-ups and the mounting volume of monthly refill requests.

Yes the frequent refills/prior auths are so onerous and caused such havoc in my current arrangement where I have lots of cross-coverage from other MDs for non-clinic days, so I'm now requiring people on amphetamines to do a 15-minute appointment every month for the refill. I'm pretty clear that this is about managing the refill burden and has nothing to do with medically necessary care.

 

[hallowmann]

Most PCPs will and thank you for that. But I have run into some PCPs who insist prescription of controlled subs are beyond their scope of practice (we're talking highly educated, young MDs here) and will just put in another psych referral to some other psychiatrist. I had a PCP do this recently. The patient was a college student with ADHD dx since 3rd grade, taking Adderall XR 20 mg, tolerating fine, no issues. No co-mobridities. No hx of or present substance abuse. Patient was transitioning from peds to adult PCP and the adult PCP sent this patient to me for eval. I confirmed the diagnosis and sent back. PCP wants a psychiatrist to follow this patient just to refill.

That sounds ridiculous. PCPs here have no problem continuing stimulants and even making slight dose adjustments. Dual agents for adults or increasing doses for kids is usually something they will send to psych for reeval, but its definitely within the PCP wheelhouse to continue stabilized psych meds.

The more I hear and see the more it seems like there are just a lot of people that decide they don't want to do something less based on their training and more on their decision that they don't want to deal with it or are uninterested. That's fine, I don't think people should be forced to do stuff they don't feel comfortable doing, but as a PCP, you are doing the same exact thing for meds in other fields.

 

[psychacad]

Frankly better for them to be weary of controlled subs. than prescribe Xanax like candy.

 

[Mass Effect]

Frankly better for them to be weary of controlled subs. than prescribe Xanax like candy.

Extremes either way are never good.

 

[VA Hopeful Dr]

Extremes either way are never good.

I feel like a "no xanax ever no exceptions" extreme might be the exception that proves that rule.

 

[Mass Effect]

I feel like a "no xanax ever no exceptions" extreme might be the exception that proves that rule.

Even Xanax has its place.

 

[VA Hopeful Dr]

Even Xanax has its place.

Disagree

 

[birchswing]

Disagree

It made for a great song by Billie Eilish.

Never used it, so I can't compare it to any other benzo, but on paper it doesn't seem to have any particularly special qualities. High potency, short to intermediate half life, intermediate onset. Seems like a dime a dozen benzo. From what I can tell the thing people like most about it is the shape it comes in.

 

[cbrons]

Even Xanax has its place.

Only time I give this drug is to hospice patients.

 

[Mass Effect]

Disagree

I give it for short flights. I think it has its place.

 

[Mass Effect]

Only time I give this drug is to hospice patients.

Why Xanax over other options for hospice patients?

 

[birchswing]

Only time I give this drug is to hospice patients.

I don't understand the mystique of various benzodiazepines.

I could make an argument for why Ativan would be marginally better than Xanax for hospice patients, but for the general population, what does it really matter? They're both deleterious.

It seems like each benzodiazepine had its moment of being "the good one." For a while Xanax was the good one because it helped anxious people sleep but because it wore off quickly wouldn't make them "depressed" in the daytime (so the advertising went). Klonopin seemed to have a moment of resurgence where it was considered safer because it was somewhat biologically distinct from other benzodiazepines, which is partially true (serotonergic properties), but did not in fact make it safer. I've been around the block with this for decades so I've seen the drug reps and the doctors and have seen the spinning wheel of this whole thing (the spinning wheel changed with the opiate epidemic—people like to forget that before the opiate epidemic benzos were not regarded as they are now). The bottomline is that they're all benzodiazepines, and none of them is a good long-term treatment. Why any of them has a particularly bad rap, I am not sure, except that I've seen it circle around before and I guess it is still now.

 

[calvnandhobbs68]

Most PCPs will and thank you for that. But I have run into some PCPs who insist prescription of controlled subs are beyond their scope of practice (we're talking highly educated, young MDs here) and will just put in another psych referral to some other psychiatrist. I had a PCP do this recently. The patient was a college student with ADHD dx since 3rd grade, taking Adderall XR 20 mg, tolerating fine, no issues. No co-mobridities. No hx of or present substance abuse. Patient was transitioning from peds to adult PCP and the adult PCP sent this patient to me for eval. I confirmed the diagnosis and sent back. PCP wants a psychiatrist to follow this patient just to refill.

We've also had a huge issue with that here. Basically PCPs acting as there's a blanket restriction on them prescribing stimulants. Also a different issue with PCPs basically telling patients they have ADHD but they don't prescribe controlled substances when the patient asks for Adderall, so then send them to us, I say "you don't have a strong history of this and you're toasting your brain with vaping MJ daily which also coincides with your inattention, so lets get a handle on that first" and then they go back to the PCP who says "I don't get why they didn't prescribe you Vyvanse!!".

Like we absolutely expect peds to manage uncomplicated ADHD but suddenly when they turn 18 their adult PCP is "oh sorry I don't do that".

 

[calvnandhobbs68]

That sounds ridiculous. PCPs here have no problem continuing stimulants and even making slight dose adjustments. Dual agents for adults or increasing doses for kids is usually something they will send to psych for reeval, but its definitely within the PCP wheelhouse to continue stabilized psych meds.

The more I hear and see the more it seems like there are just a lot of people that decide they don't want to do something less based on their training and more on their decision that they don't want to deal with it or are uninterested. That's fine, I don't think people should be forced to do stuff they don't feel comfortable doing, but as a PCP, you are doing the same exact thing for meds in other fields.

I think this is part of it. They just don't want to deal with it and a lot of hospital systems now are making people sign "contracts" for stimulants and have UDS multiple times a year and stuff. I mean I don't care about a bunch of easy ADHD med refills but it's a pain for the patients to have to get into psychiatry for that.

 

[VA Hopeful Dr]

I think this is part of it. They just don't want to deal with it and a lot of hospital systems now are making people sign "contracts" for stimulants and have UDS multiple times a year and stuff. I mean I don't care about a bunch of easy ADHD med refills but it's a pain for the patients to have to get into psychiatry for that.

Psh, that's easy. Have a standard form that your nurses fill out and have them collect the urine sample before they're put in the exam room to see me.

I don't do either for ADHD, but that's what I do if forced to.

We've also had a huge issue with that here. Basically PCPs acting as there's a blanket restriction on them prescribing stimulants. Also a different issue with PCPs basically telling patients they have ADHD but they don't prescribe controlled substances when the patient asks for Adderall, so then send them to us, I say "you don't have a strong history of this and you're toasting your brain with vaping MJ daily which also coincides with your inattention, so lets get a handle on that first" and then they go back to the PCP who says "I don't get why they didn't prescribe you Vyvanse!!".

Like we absolutely expect peds to manage uncomplicated ADHD but suddenly when they turn 18 their adult PCP is "oh sorry I don't do that".

I can't speak for everyone, but my only issue is diagnosing ADHD in adults. If they've been on meds since they were 7, that's a no brainer.

 

[FlowRate]

High potency, short to intermediate half life, intermediate onset.

I was really interested in why Xanax is so different from lorazepam even though they have apparently similar onsets and half-lives. The hidden information is the less discussed kinetic properties of absorption and distribution rate. Xanax is more quickly absorbed AND more quickly distributed than lorazepam. That means it hits a higher peak effective plasma concentration and then quickly distributes into other tissues. So the half life is time to elimination of the amount in your body, not the time to reduce blood concentration (which is what causes the clinical effect.) Lorazepam, on the other hand, is slightly more slowly absorbed and also more slowly distributed. Hence the longer duration of effect but similar half life.

I had to dig up Anesthesia literature from the 60's to figure this out.

 

[tr]

There seems to be some kind of mythology around Xanax. I'm not sure where it comes from. Personally I avoid benzos as much as possible, but I'm not less likely to give Xanax than Ativan or Klonopin. The rapid onset is often helpful for treating panic attacks.

As far as comparisons of addictive potential among benzos, I've never seen anything too convincing and any differences seem likely to be related to availability and acculturation among the SUD population, but none of them finger Xanax as particularly worse than any other benzo. If anything Valium has the worst track record.

Relative abuse liability of different benzodiazepines in drug abusers - PubMed

There is a convergence of data from various sources suggesting that there are meaningful differences among the benzodiazepines with respect to their attractiveness as drugs of abuse for drug abusers. Laboratory studies of subjective and reinforcing effects in drug abusers, interviews with drug...

pubmed.ncbi.nlm.nih.gov

Addictive behaviors and benzodiazepines: 2. Are there differences between benzodiazepines in potential for physical dependence and abuse liability? - PubMed

This paper examines data on the question of possible differences between benzodiazepines in abuse liability and potential for causing physical dependence. The data on potential for causing physical dependence indicates that all benzodiazepines cause physical dependence and there is little...

pubmed.ncbi.nlm.nih.gov

 

[FlowRate]

There seems to be some kind of mythology around Xanax. I'm not sure where it comes from. Personally I avoid benzos as much as possible, but I'm not less likely to give Xanax than Ativan or Klonopin. The rapid onset is often helpful for treating panic attacks.

As far as comparisons of addictive potential among benzos, I've never seen anything too convincing and any differences seem likely to be related to availability and acculturation among the SUD population, but none of them finger Xanax as particularly worse than any other benzo. If anything Valium has the worst track record.

Relative abuse liability of different benzodiazepines in drug abusers - PubMed

There is a convergence of data from various sources suggesting that there are meaningful differences among the benzodiazepines with respect to their attractiveness as drugs of abuse for drug abusers. Laboratory studies of subjective and reinforcing effects in drug abusers, interviews with drug...

pubmed.ncbi.nlm.nih.gov

Addictive behaviors and benzodiazepines: 2. Are there differences between benzodiazepines in potential for physical dependence and abuse liability? - PubMed

This paper examines data on the question of possible differences between benzodiazepines in abuse liability and potential for causing physical dependence. The data on potential for causing physical dependence indicates that all benzodiazepines cause physical dependence and there is little...

pubmed.ncbi.nlm.nih.gov

I was always taught that the main downside to Xanax (in the context of panic disorder or other one-time use) is the rebound anxiety, although I don't have solid research to back up that concern on hand.

 

[Stagg737]

I don't understand the mystique of various benzodiazepines.

I could make an argument for why Ativan would be marginally better than Xanax for hospice patients, but for the general population, what does it really matter? They're both deleterious.

It seems like each benzodiazepine had its moment of being "the good one." For a while Xanax was the good one because it helped anxious people sleep but because it wore off quickly wouldn't make them "depressed" in the daytime (so the advertising went). Klonopin seemed to have a moment of resurgence where it was considered safer because it was somewhat biologically distinct from other benzodiazepines, which is partially true (serotonergic properties), but did not in fact make it safer. I've been around the block with this for decades so I've seen the drug reps and the doctors and have seen the spinning wheel of this whole thing (the spinning wheel changed with the opiate epidemic—people like to forget that before the opiate epidemic benzos were not regarded as they are now). The bottomline is that they're all benzodiazepines, and none of them is a good long-term treatment. Why any of them has a particularly bad rap, I am not sure, except that I've seen it circle around before and I guess it is still now.

They should all have a relatively bad reputation, but some are just worse than others. If I'm going to prescribe a benzo for an anxiety disorder, other than a few other unique circumstances, I like Klonopin because of the serotonergic effects and smoother onset and elimination. There's also some data showing that Klonopin when used for PD can help improve symptoms long-term while the data for other benzos isn't there. With one exception I do not prescribe benzos for PD (or really anxiety disorders at all), but when I have to I either try and taper or switch to Klonopin or occasionally valium.

Edited for correction (previously said PTSD instead of PD).

I was really interested in why Xanax is so different from lorazepam even though they have apparently similar onsets and half-lives. The hidden information is the less discussed kinetic properties of absorption and distribution rate. Xanax is more quickly absorbed AND more quickly distributed than lorazepam. That means it hits a higher peak effective plasma concentration and then quickly distributes into other tissues. So the half life is time to elimination of the amount in your body, not the time to reduce blood concentration (which is what causes the clinical effect.) Lorazepam, on the other hand, is slightly more slowly absorbed and also more slowly distributed. Hence the longer duration of effect but similar half life.

I had to dig up Anesthesia literature from the 60's to figure this out.

Yep, Xanax stays in your system just as long but has a much shorter duration of clinical effect. I've wondered if that's part of why patients seem to have so many more dependency problems with Xanax than other benzos (quick onset + lasting presence possibly leading to metabolic tolerance). Idk if that’s true, but seems logical at least.

There seems to be some kind of mythology around Xanax. I'm not sure where it comes from. Personally I avoid benzos as much as possible, but I'm not less likely to give Xanax than Ativan or Klonopin. The rapid onset is often helpful for treating panic attacks.

As far as comparisons of addictive potential among benzos, I've never seen anything too convincing and any differences seem likely to be related to availability and acculturation among the SUD population, but none of them finger Xanax as particularly worse than any other benzo. If anything Valium has the worst track record.

Relative abuse liability of different benzodiazepines in drug abusers - PubMed

There is a convergence of data from various sources suggesting that there are meaningful differences among the benzodiazepines with respect to their attractiveness as drugs of abuse for drug abusers. Laboratory studies of subjective and reinforcing effects in drug abusers, interviews with drug...

pubmed.ncbi.nlm.nih.gov

Addictive behaviors and benzodiazepines: 2. Are there differences between benzodiazepines in potential for physical dependence and abuse liability? - PubMed

This paper examines data on the question of possible differences between benzodiazepines in abuse liability and potential for causing physical dependence. The data on potential for causing physical dependence indicates that all benzodiazepines cause physical dependence and there is little...

pubmed.ncbi.nlm.nih.gov

That’s actually really interesting. Will have to read those later. I’ve always thought that in addition to was Flow said, that Xanax is seen as the worst because patients can easily feel the effects kick in and when it’s wearing off. Older attendings have told me this is part of why they hated triazolam so much. Anecdotally, of my patients who clutch on to their benzos, Xanax is by far the most common one patients have problems tapering or even switching to something else.

 

[Mass Effect]

I don't understand the mystique of various benzodiazepines.

I could make an argument for why Ativan would be marginally better than Xanax for hospice patients, but for the general population, what does it really matter? They're both deleterious.

It seems like each benzodiazepine had its moment of being "the good one." For a while Xanax was the good one because it helped anxious people sleep but because it wore off quickly wouldn't make them "depressed" in the daytime (so the advertising went). Klonopin seemed to have a moment of resurgence where it was considered safer because it was somewhat biologically distinct from other benzodiazepines, which is partially true (serotonergic properties), but did not in fact make it safer. I've been around the block with this for decades so I've seen the drug reps and the doctors and have seen the spinning wheel of this whole thing (the spinning wheel changed with the opiate epidemic—people like to forget that before the opiate epidemic benzos were not regarded as they are now). The bottomline is that they're all benzodiazepines, and none of them is a good long-term treatment. Why any of them has a particularly bad rap, I am not sure, except that I've seen it circle around before and I guess it is still now.

I was always taught that the main downside to Xanax (in the context of panic disorder or other one-time use) is the rebound anxiety, although I don't have solid research to back up that concern on hand.

What FlowRate said. Rebound anxiety with Xanax. I give Klonopin for panic disorder or for scheduled use. I find it works better and don't have to up the dose usually (I don't prescribe for long-term daily use).

 

[Mass Effect]

They should all have a relatively bad reputation, but some are just worse than others. If I'm going to prescribe a benzo for an anxiety disorder, other than a few other unique circumstances, I like Klonopin because of the serotonergic effects and smoother onset and elimination. There's also a little data showing that Klonopin when used for PTSD can help improve symptoms long-term while the data for other benzos isn't there. With one exception I do not prescribed benzos for PTSD (or really anxiety disorders at all), but when I have to I either try and taper or switch to Klonopin or occasionally valium.

Can you link that data? I don't use any benzo for PTSD.

 

[Stagg737]

Can you link that data? I don't use any benzo for PTSD.

Nope, because I was having a brain fart and thinking of panic disorder. I may have seen something on panic symptoms in patients with concurrent PTSD, but the long-term improvements were seen in the panic symptoms. Thanks for that catch. I also don't use benzos for PTSD.

 

[birchswing]

Nope, because I was having a brain fart and thinking of panic disorder. I may have seen something on panic symptoms in patients with concurrent PTSD, but the long-term improvements were seen in the panic symptoms. Thanks for that catch. I also don't use benzos for PTSD.

I thought I remembered hearing that if you gave a benzodiazepine immediately after a trauma it could be helpful, but when I look it up now it seems that thought is very controversial.

It seems like it would make sense at a theoretical level. It would be like the equivalent of anesthesia for a surgery, which without amnesia would be very traumatic. I wonder if it's too difficult to assess the possibility because you would need to have the medicine available almost instantly, which probably never happens. Any delay and you'd not stop memory formation, you'd maybe just cloud the processing of the trauma.

 

[Mass Effect]

I thought I remembered hearing that if you gave a benzodiazepine immediately after a trauma it could be helpful, but when I look it up now it seems that thought is very controversial.

That was the old way. They'd give Valium immediately after. But not anymore. Giving any benzo following trauma is thought to increase risk of PTSD and is not routinely done for that reason. Although never say never.

 

[meow1985]

Thanks for this! A couple questions: 1) what objective metric do you use (and have friends/family use)? 2) how do you do collateral? Do you schedule a family visit? Do you call family? (Trying to figure out how I would work this into my workday/workweek.

I used to do Adult ADHD questionnaire and Wender Utah. Or I would call collateral, but then realized it was too much work.

Now, I changed to the BAARS-IV per the advice of our department neuropsychologist. There's a version for the patient that goes over childhood symptoms and present symptoms, and a version for the collateral source - parents for childhood, present partner/roommate/etc for adulthood. I had my staff put together a bunch of packets that simply get mailed to the patients on request. The envelopes got pre-stuffed, I keep them in my office, and if I want one mailed out I put a sticky note with the MRN on the envelope and give it to the front desk. If the patients were coming in in person, I'd give them the paperwork and have them mail/fax/mychart/drop it off back to me.

To everyone else, no one is withholding stimulants. I'm just working to confirm the diagnosis. ADHD is not an emergency unless there are safety concerns, in which case I do truncate my process. Also in theory, people could be very good liars/actors and research/ask people in the medical field what to say and how to act to convincingly project ADHD and get a stimulant. In my practice, the severe case of ADHD where a person can't even string a sentence together and has no other confounding diagnoses or potential contraindications is very rare, whereas liars and embellishers abound. I also think a lot of the "spacey" ADHD sorts will give vague and overly general answers to most questions, which is why surveys are important to get a more precise handle on the problem.

In more moderate/clear cut cases, I literally tell people - ok, how fast can you get these surveys back to me? When you get them back to me, we can start a stimulant. Those who care get them back in a week.

OP, another tip I have to make your interview more concrete and help define treatment goals is to ask about practical things - how's your driving? are you someone who constantly needs their phone/keys/wallet/ID replaced? how often do you double book yourself? are others frustrated with your behaviors and if so which? are there financial or other "costs" to your forgetfulness? If there are a lot of "no" answers to the above, it may help people realize things aren't so bad and themselves question if they need a med.

 

[Mass Effect]

To everyone else, no one is withholding stimulants. I'm just working to confirm the diagnosis. ADHD is not an emergency unless there are safety concerns, in which case I do truncate my process. Also in theory, people could be very good liars/actors and research/ask people in the medical field what to say and how to act to convincingly project ADHD and get a stimulant. In my practice, the severe case of ADHD where a person can't even string a sentence together and has no other confounding diagnoses or potential contraindications is very rare, whereas liars and embellishers abound. I also think a lot of the "spacey" ADHD sorts will give vague and overly general answers to most questions, which is why surveys are important to get a more precise handle on the problem.

In more moderate/clear cut cases, I literally tell people - ok, how fast can you get these surveys back to me? When you get them back to me, we can start a stimulant. Those who care get them back in a week.

OP, another tip I have to make your interview more concrete and help define treatment goals is to ask about practical things - how's your driving? are you someone who constantly needs their phone/keys/wallet/ID replaced? how often do you double book yourself? are others frustrated with your behaviors and if so which? are there financial or other "costs" to your forgetfulness? If there are a lot of "no" answers to the above, it may help people realize things aren't so bad and themselves question if they need a med.

The issue is that while you think ADHD isn't a significant enough to be an emergency, it can drastically change someone's life. They don't have to be failing out of school or be totaling their car every other day to feel the effects and benefit from a stimulant. If a patient is having trouble and they meet criteria, I never try to convince them things aren't so bad and maybe they don't need a med.

I think we need to stop teaching residents stimulants=wrong. Stimulants can be life-changing and the vast majority of patients are not going to abuse them. The fear that residents/new attendings have is overblown imo.

 

[WisNeuro]

Dunno about "vast majority" depending on how you define it. Some past surveys suggested something like 14-20% of people prescribed it have abused their script. That's still A LOT of people.

 

[Mass Effect]

Dunno about "vast majority" depending on how you define it. Some past surveys suggested something like 14-20% of people prescribed it have abused their script. That's still A LOT of people.

That's fear-mongering (and I'd be interested to see that survey). Does a surgeon withhold pain meds? You treat the disorder and stimulants are a first-line medication for ADHD. To not prescribe it in someone because "Oh no! A stimulant!" is as wrong as withholding Zoloft or Abilify.

 

[WisNeuro]

That's fear-mongering (and I'd be interested to see that survey). Does a surgeon withhold pain meds? You treat the disorder and stimulants are a first-line medication for ADHD. To not prescribe it in someone because "Oh no! A stimulant!" is as wrong as withholding Zoloft or Abilify.

Didn't say don't treat it, just that abuse is a real thing that should be considered.

Abuse of Medications Employed for the Treatment of ADHD: Results From a Large-Scale Community Survey

The objective is to assess abuse of prescription and illicit stimulants among individuals being treated for attention-deficit/hyperactivity disorder (ADHD).A survey was distributed to patients enrolled in an ADHD treatment center. It included questions ...

www.ncbi.nlm.nih.gov

This is just one, quick search and you'll find a lot of these over the years.

 

[Mass Effect]

Didn't say don't treat it, just that abuse is a real thing that should be considered.

Abuse of Medications Employed for the Treatment of ADHD: Results From a Large-Scale Community Survey

The objective is to assess abuse of prescription and illicit stimulants among individuals being treated for attention-deficit/hyperactivity disorder (ADHD).A survey was distributed to patients enrolled in an ADHD treatment center. It included questions ...

www.ncbi.nlm.nih.gov

This is just one, quick search and you'll find a lot of these over the years.

I mean, I don't know of anyone prescribing stimulants who doesn't consider it. But the point is that it should not change your prescribing practices unless your patient is abusing/diverting. The vast majority will not abuse the stimulant. The vast majority will benefit greatly from it.

This line of posts began due to this statement: "I'd say the only reason why stimulants would be first line for me is if someone's literally unsafe due to their ADHD symptoms"

That is bad medicine. Fear of abuse is not a reason not to treat.

 

[calvnandhobbs68]

I mean, I don't know of anyone prescribing stimulants who doesn't consider it. But the point is that it should not change your prescribing practices unless your patient is abusing/diverting. The vast majority will not abuse the stimulant. The vast majority will benefit greatly from it.

This line of posts began due to this statement: "I'd say the only reason why stimulants would be first line for me is if someone's literally unsafe due to their ADHD symptoms"

That is bad medicine. Fear of abuse is not a reason not to treat.

I mean I don’t think stimulants are as bad as opioids in any way but that kind of thinking is what led to our current problem with opioids. You could have made the exact same statement about pain and many people did. Remember how OxyContin was “low risk” for abuse?

At first you say “show me the paper that says people abuse their stimulants” and then you basically don’t response when the paper is shown to you. Fear of abuse SHOULD be a reason to very carefully consider the risks and benefits of a medication.

 

[Mass Effect]

I mean I don’t think stimulants are as bad as opioids in any way but that kind of thinking is what led to our current problem with opioids. You could have made the exact same statement about pain and many people did. Remember how OxyContin was “low risk” for abuse?

At first you say “show me the paper that says people abuse their stimulants” and then you basically don’t response when the paper is shown to you. Fear of abuse SHOULD be a reason to very carefully consider the risks and benefits of a medication.

I did want to see the paper. I didn't respond to the paper because I didn't have time to read the paper because I'm, you know, seeing patients. I also don't necessarily need to reply to the paper. I wanted to see it, not dissect it. And the reason wasn't because I didn't believe there was abuse potential, but I did want a citation of the number being that high.

I will still make the argument about stimulants AND pain meds. You don't withhold pain meds because some may abuse them, unless the patient you're treating is the one abusing them. It's just bad medicine. You treat the disorder and if, down the line, you suspect abuse, that's when you deal with it. You don't prophylactically withhold meds that are evidence-based treatments for specific indications.

 

[hamstergang]

This line of posts began due to this statement: "I'd say the only reason why stimulants would be first line for me is if someone's literally unsafe due to their ADHD symptoms"

Unless I'm looking at the wrong post, I don't see this being said. Can you quote that statement?

 

[Mass Effect]

Unless I'm looking at the wrong post, I don't see this being said. Can you quote that statement?

Post is one of the first ones in the thread. #32

 

[calvnandhobbs68]

I did want to see the paper. I didn't respond to the paper because I didn't have time to read the paper because I'm, you know, seeing patients. I also don't necessarily need to reply to the paper. I wanted to see it, not dissect it. And the reason wasn't because I didn't believe there was abuse potential, but I did want a citation of the number being that high.

I will still make the argument about stimulants AND pain meds. You don't withhold pain meds because some may abuse them, unless the patient you're treating is the one abusing them. It's just bad medicine. You treat the disorder and if, down the line, you suspect abuse, that's when you deal with it. You don't prophylactically withhold meds that are evidence-based treatments for specific indications.

Yeah you’re not the only one seeing patients on here but good for you (although apparently got enough time to post on SDN). Some of us can see patients and a paper both in one day!!

There have been major sweeping changes in the ways opioids have been prescribed compared to 10 years ago. So yes, I would say that people generally do change prescribing patterns because there’s the possibility people may abuse a certain class of medication.

 

[Mass Effect]

Yeah you’re not the only one seeing patients on here but good for you (although apparently got enough time to post on SDN). Some of us can see patients and a paper both in one day!!

There have been major sweeping changes in the ways opioids have been prescribed compared to 10 years ago. So yes, I would say that people generally do change prescribing patterns because there’s the possibility people may abuse a certain class of medication.

I post in between patients, in between meetings, in between phone calls. When I read a paper, I actually study it, I don't just skim the conclusion to declare victory.

Changing prescribing "patterns" with opiates is different from changing prescribing patterns for stimulants. You no longer prescribe opiates for extended periods of time. However, stimulants have always been used extended periods of time. Don't see that changing. The point is, if I go in to have my GB removed, I'm going to leave a script for pain meds. Doctors don't withhold pain meds because opiates can be addictive.

 

[Old&InTheWay]

Unless I'm looking at the wrong post, I don't see this being said. Can you quote that statement?

Check to see if you have "ignored" any users' content.

 

[Stagg737]

I mean I don’t think stimulants are as bad as opioids in any way but that kind of thinking is what led to our current problem with opioids. You could have made the exact same statement about pain and many people did. Remember how OxyContin was “low risk” for abuse?

There have been major sweeping changes in the ways opioids have been prescribed compared to 10 years ago. So yes, I would say that people generally do change prescribing patterns because there’s the possibility people may abuse a certain class of medication.

There is a huge difference between these situations historically though. When Oxycontin was considered "low risk" there was still poor data regarding outcomes with long-term use and imo it would normally be poor practice to regularly prescribe in that way without the data. Unfortunately, all the "fifth vital sign" nonsense was going on and the federal gov and lobbies were pushing for pain to be more directly addressed, so their obvious(ly wrong) solution was opiates. So the problem wasn't even really driven by physicians, it was driven by stupid government policies made by ignorant people who shouldn't be making any decisions on prescribing patterns. Now that we have more data, we know that was a terrible idea obviously prescribing guidelines had to be changed.

This is very different from stimulants which we have had mountains of data and research on for decades, have been using for around a century or more, and which we know are the most effective form of treatment we have for anything in psychiatry. They're even far more effective for ADHD than opioids are for literally anything they're prescribed for. The two really aren't comparable in regards to caution needed when prescribing.

There's also a difference between theoretical abuse potential versus actual abuse rates and adverse outcomes. Even if 15% of people "abuse" stimulants, if those people don't develop tolerance/dependence and they're not having significant adverse effects, why would you change your prescribing practices? On the other hand, if 50% of people become dependent or 5% of people who take it die, that's a completely different story.

 

[clausewitz2]

There's also a difference between theoretical abuse potential versus actual abuse rates and adverse outcomes. Even if 15% of people "abuse" stimulants, if those people don't develop tolerance/dependence and they're not having significant adverse effects, why would you change your prescribing practices? On the other hand, if 50% of people become dependent or 5% of people who take it die, that's a completely different story.

Turns out I did have more time than @Mass Effect to dissect that paper and, uh, it's not fantastic. I read it pretty thoroughly and I was totally unable to find any place where the paper defines what they mean by "abuse." I even read the supplementary materials for their survey at the end. I am sure there are other papers but this one ain't all that persuasive.

 

[Stagg737]

I read it pretty thoroughly and I was totally unable to find any place where the paper defines what they mean by "abuse."

Definitions are something that I always try and look out for as it's so easy to manipulate data with vague or absent definitions. Is abuse defined as regularly refilling too early? Using higher doses than prescribed? Taking more frequently than prescribed? Taking the correct amount but in the wrong schedule? You can vastly change the outcomes based on how metrics or even just words are defined and it's an unfortunately common problem I see in a lot of (maybe even most) studies.

Example: I have a patient who's prescribed Ativan 0.5mg BID PRN for panic attacks. He only uses it about once a week, but when he does he takes a full 1mg dose and sometimes an extra 0.5-1mg in an hour if anxiety is still severe. Technically you can argue he's abusing it because he's using it incorrectly at higher than prescribed doses. However, he's not dependent on it, he's not refilling early, he's technically taking it improperly but when total ingestion is considered using far less than what he is prescribed, and he's not having adverse effects and symptoms are gradually improving with less of the med. So realistically, where's the problem?

I realize that we take certain precautions when prescribing controlled substances, but at the end of the day the goal is to provide as much benefit to the patient while causing as little harm or distress as possible regardless of what the treatment is. Without understanding how we're actually determining what "harm" or "benefit" or any label/measure actually is, there's not really any meaning to arguments or guidelines regarding prescribing practices.

/steps off soapbox

TL;DR: We make too many arguments or decisions using "data" without actually understanding what the data actually means (if it's even defined).

 

[WisNeuro]

Turns out I did have more time than @Mass Effect to dissect that paper and, uh, it's not fantastic. I read it pretty thoroughly and I was totally unable to find any place where the paper defines what they mean by "abuse." I even read the supplementary materials for their survey at the end. I am sure there are other papers but this one ain't all that persuasive.

It is self-reported, but still fairly telling. Also telling that about 17% reported diversion of their script. It also references many other similar studies. It's not the be all, end all, but to have earlier claimed that the "vast majority" are only using as prescribed, is simply not true. I didn't comment on prescribing or not, just that perhaps people are willfully blind to the negatives.

 

[psychacad]

It is self-reported, but still fairly telling. Also telling that about 17% reported diversion of their script. It also references many other similar studies. It's not the be all, end all, but to have earlier claimed that the "vast majority" are only using as prescribed, is simply not true. I didn't comment on prescribing or not, just that perhaps people are willfully blind to the negatives.

Isn't 80% a "vast majority"? And yeah, that article is fairly laughable. Amazing what gets published out there.

I mean, not to get hung up on semantics here, but I think with the case of stimulants the benefits of prescribing clearly outweigh the risks in a confirmed case, as long as there is no history of substance use. Even then, it's debatable.

 

[WisNeuro]

Isn't 80% a "vast majority"? And yeah, that article is fairly laughable. Amazing what gets published out there.

I mean, not to get hung up on semantics here, but I think with the case of stimulants the benefits of prescribing clearly outweigh the risks in a confirmed case, as long as there is no history of substance use. Even then, it's debatable.

I wouldn't call it a vast majority, but YMMV. Also, what is laughable about the study? It's survey research.

 

[robellis]

Dunno about "vast majority" depending on how you define it. Some past surveys suggested something like 14-20% of people prescribed it have abused their script. That's still A LOT of people.

Do you prescribe stimulants?

 

[WisNeuro]

Do you prescribe stimulants?

What's the question behind the question?

 

[clausewitz2]

I wouldn't call it a vast majority, but YMMV. Also, what is laughable about the study? It's survey research.

None of the survey questions ask something like 'did you abuse your stimulant?'. They ask about a number of specific behaviors in separate questions but I have no idea which numbers they are adding together to get the overall 'abuse' figure and they don't define what this means in the context of the paper. Survey research has limitations for sure but if well done it is at least explicit about what it purports to measure!

 

[WisNeuro]

None of the survey questions ask something like 'did you abuse your stimulant?'. They ask about a number of specific behaviors in separate questions but I have no idea which numbers they are adding together to get the overall 'abuse' figure and they don't define what this means in the context of the paper. Survey research has limitations for sure but if well done it is at least explicit about what it purports to measure!

"Have you ever used your prescription stimulant for purposes other than its prescribed use (for example, snorted or injected it to get “high,” rather than using it as prescribed for the treatment of ADHD)? "

This one seems pretty clear.

 

[psychacad]

None of the survey questions ask something like 'did you abuse your stimulant?'. They ask about a number of specific behaviors in separate questions but I have no idea which numbers they are adding together to get the overall 'abuse' figure and they don't define what this means in the context of the paper. Survey research has limitations for sure but if well done it is at least explicit about what it purports to measure!

They don't even bother to discuss any of that in the discussion or give a half-assed attempt to define what they are measuring in the methods. so yes, sorry, I lol'ed.

 

[clausewitz2]

"Have you ever used your prescription stimulant for purposes other than its prescribed use (for example, snorted or injected it to get “high,” rather than using it as prescribed for the treatment of ADHD)? "

This one seems pretty clear.

Yeah but the paper doesn't actually say they are basing it on that question., which is a big problem. Under this definition if someone uses an extra IR due to a particular demanding day they have to say yes, and I lose zero sleep worrying about someone doing that. The definition of abuse is important because it gives us a sense of whether this is behavior that matters and has a meaningful negative impact or not