Bad ADHD, two coronary stents, would you give a stimulant?

[whopper]

I got a guy with ADHD, he smokes, he has two coronary stents, he's obese and his ADHD was not effectively controlled with Wellbutrin.

An odd thing (though I've noticed it happening in actually quite a few ADHD patients) is that when his ADHD is not under control, he has symptoms of an anxiety disorder, more specifically GAD and Panic Disorder. When the ADHD is treated the anxiety goes away. I know this because another psychiatrist treated the guy with Adderall 90 mg a day (yes, 30 mg over the manufacturer's limit and the other guy never once explained to the guy the potential cardiac problems with the guy.).

I've already tried Wellbutrin with no success, and it did not curb his smoking. I figure there's pretty much no point in trying Strattera. It also has cardiac problems as a reason for caution and I've actually had quite a few patients on Strattera show cardiac problems with it. If I'm so worried about heart problems, why even try Strattera when I know the Adderall works for the guy?

I've already informed him that stimulants could increase his risk of cardiac problems if not outright cause fatality, he's already not in a good category (obese, smoker, coronary stents). I didn't start him on Adderall XR until we got an EKG and an okay from his cardiologist who reviewed the EKG. The cardiologist is actually being collegial and professional and keeping in good contact with him and I.

We've increased the Adderall, and I figure we'll have to do it some more so long as the cardiologist agrees with each step of the process, an EKG during each dosage increase. My hope is that with appropriate stimulant treatment he I can wean him off of his SSRI and benzodiazepine (remember this guy's anxiety goes away when his ADHD is treated), it could cause him to lose weight, and I'm planning on getting him to stop smoking as a requirement if I'm going to give him stimulants. I've also informed him that I want his wife to come to interviews so long as it's okay with him because I'm concerned about his physical health and I want her to understand too what's going on.

Anyone want to critique me on what I may be missing or doing wrong? Any suggestions?

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[billypilgrim37]

If you're THIS thoughtful about anything you do, you're probably doing all right.

I'm not so sure I entirely agree with your reasoning on Strattera. It sounds like my cousin who reads the side of the nicotine patch box and sees all the side effects, and decides she's afraid it's going to kill her, so instead she keeps smoking a lot. Any of these medications that increase catecholamines can create some cardiac issues, and I'm pretty sure Strattera would still be a relatively "safer" option, but your argument that you know Adderall works for him sounds fairly convincing.

I'm also not sure about the condition that he quit smoking in order to receive the stimulant. And by not sure, I mean I'm not sure. On one hand, when giving the cardiotoxic drug, it makes sense to address all modifiable risk factors. On the other hand, it's an addiction, and there's no good smoking test other than sniffing him when he walks in, and I really don't know if you'd just be increasing his resistance to quitting.

If he's passed your very thorough sniff tests to this point and isn't a high abuse potential sort of guy, and you have this cardiologist who sounds like the sort of cardiologist we'd like to clone and distribute through the country for his willingness to appropriately engage this question, then it sounds like this a cool case, and you're doing things well above the standards of community practice.

 

[Chimed]

You're doing exactly the right thing. If you had just asked, "Is it OK to start a stimulant in someone with 2 stents", I would have recommended exactly what you're doing--being in contact with the pt's cardiologist. I would have done the same thing and prescribed as long as the cardiologist gave their blessing.

You probably already know this, but the warning for sudden cardiac death has been much debated since the study in 2006 from Villalaba came out. The issue is that the death rate of sudden death in kids taking Stims are not higher then the rate of sudden death in the general population. The recommendations by AACAP are that routine cardiac evaluations are only needed in someone who has a pre-exisiting cardiac condition or symptoms of cardiac disease. They recommend consulting with a cardiologist if there is concern, which is what you did.

 

[whopper]

I'm not so sure I entirely agree with your reasoning on Strattera.

About 1/3 of the patients I've put on is had some type of significant change on an EKG. E.g. one of my patients, within 48 hours, her HR went from 80 to 140. Yes it stayed up. It wasn't a fluke HR taken after she ran a mile. I could just be an outlier with bad luck with that medication, but since that event, I've ordered EKGs on any patient before or after Strattera use.

 

[Chimed]

About 1/3 of the patients I've put on is had some type of significant change on an EKG. E.g. one of my patients, within 48 hours, her HR went from 80 to 140. Yes it stayed up. It wasn't a fluke HR taken after she ran a mile. I could just be an outlier with bad luck with that medication, but since that event, I've ordered EKGs on any patient before or after Strattera use.

Yeah, Strattera can do that. I'm not sure what the relationship is to the stimulants, but agree that you might as well use a stimulant if you're going to use Strattera.

 

[firedoor]

There is a case report of an atomoxetine-induced MI in a 20 y/o female in the February 2011 Southern Medical Journal.

 

[Manicsleep]

How is he sleeping?

 

[whopper]

Poor sleep, only about 4-5 hours a night.

While we're on the this guy, has anyone else noticed that there appears to be a class of ADHD patients with enough criteria to meet an anxiety disorder, but when you give them a stimulant the anxiety goes away? I'm finding this happening with a lot of ADHD patients. I'm also finding a lot of these patients no longer needing anxiety meds once their ADHD is under control.

Makes sense to me. After all anxiety is often the byproduct of a sense of lack of control. If you can't focus, you likely don't feel like you have control over your life. I just never saw much if anything about this in the textbooks or from my training.

I've had 4 ADHD patients so far in the last year who came to me on several meds just for anxiety, they were never diagnosed with ADHD, turned out psychological testing backed they had ADHD, they got on an ADHD med that worked for them, and they went from a med regimen of several anti-anxiety meds to just 1 ADHD med.

agree that you might as well use a stimulant if you're going to use Strattera.

That's been my experience with this medication. Actually it's not surprising when you consider pretty much all the NRI mechanism meds can increase BP and it is affecting norepinephrine. In the case I mentioned above, thank God it happened in the hospital, where we could get immediate EKG results and monitor the person. It's the point where I am even wondering if I should even factor in Strattera in the early stages of treatment where I try to use a non-addictive medication first. I'm usually starting with Wellbutrin. Effexor is also an NRI, has data backing it's use for ADHD, and it's cheaper than Strattera.

 

[Chimed]

That's been my experience with this medication. Actually it's not surprising when you consider pretty much all the NRI mechanism meds can increase BP and it is affecting norepinephrine. In the case I mentioned above, thank God it happened in the hospital, where we could get immediate EKG results and monitor the person. It's the point where I am even wondering if I should even factor in Strattera in the early stages of treatment where I try to use a non-addictive medication first. I'm usually starting with Wellbutrin. Effexor is also an NRI, has data backing it's use for ADHD, and it's cheaper than Strattera.

I'd have to go back through some of the literature, but I believe the effect size for Strattera may be slightly better then Wellbutrin and is better then Effexor for adults with ADHD. And this is factoring in that as a whole, the effect size for non-stimulants is poor compared to stimulants. At least in kids, Strattera has more evidence compared to Wellbutrin and Wellbutrin has shown pretty modest results. For kids, I don't even bother with Wellbutrin in ADHD.

Regarding anxiety, it is comorbid in about 1/3rd of patients with ADHD so it comes up often. I'm not sure how often I've seen anxiety decrease with stimulants, but what you're saying makes sense. I have noticed sleep improve with stimulants, which can be counterintuitive. There are some studies supporting Strattera use ADHD and comorbid anxiety, but I'm not aware of stimulants being studied for this directly.

 

[nitemagi]

Poor sleep, only about 4-5 hours a night.

While we're on the this guy, has anyone else noticed that there appears to be a class of ADHD patients with enough criteria to meet an anxiety disorder, but when you give them a stimulant the anxiety goes away? I'm finding this happening with a lot of ADHD patients. I'm also finding a lot of these patients no longer needing anxiety meds once their ADHD is under control.

Makes sense to me. After all anxiety is often the byproduct of a sense of lack of control. If you can't focus, you likely don't feel like you have control over your life. I just never saw much if anything about this in the textbooks or from my training.

I've had 4 ADHD patients so far in the last year who came to me on several meds just for anxiety, they were never diagnosed with ADHD, turned out psychological testing backed they had ADHD, they got on an ADHD med that worked for them, and they went from a med regimen of several anti-anxiety meds to just 1 ADHD med.

I think there's a lot of theories floating around that since stimulants stimulate the whole brain, they're also stimulating the frontal/prefrontal lobes, increasing the ability to inhibit unwanted thoughts, etc. This may then lessen things like anxiety symptoms in some patients.

I'd say the evidence goes against using strattera in this case since it's less likely to work in someone who has already tried stimulants. But I always use it earlier, if for no other reason than to prescribe less controlled substances.

As for your case in particular, any illicits on board? Tested for OSA? I try to go conservative whenever possible, so if there's a suspicion of OSA as a contributor, could also try empirically provigil if he isn't willing to get a sleep study or try CPAP.

 

[OldPsychDoc]

I think there's a lot of theories floating around that since stimulants stimulate the whole brain, they're also stimulating the frontal/prefrontal lobes, increasing the ability to inhibit unwanted thoughts, etc. This may then lessen things like anxiety symptoms in some patients.
.

I wouldn't underestimate the amount of social anxiety/low self-esteem that develops over time in an ADD-er, either. Stims can improve confidence in those situations where the anxiety is rooted in cognitive experience as much as with sympathetic overflow.

 

[Lauraaa]

"What if I look totally stupid when I say this speech?"
"Are they going to not like me if it sucks?"
"Oh my gosh... he yawned... does that mean my talk is boring?"

It seems like with all the distractions in the form of these questions that pop up in social anxiety disorder that assistance in focusing on the subject at hand and the ability to ignore all the other distracting thoughts woud be much appreciated.

 

[markglt]

lauraaa..haaaa, good to see somebody remembers that show..it needs to come back...

adderall is the last drug this guy needs to be on, regardless of what cardio said. playing with fire,
switch that guy to ssri's and benzos pronto

 

[NJWxMan]

What's on this guy's tox screen? I'm sorry, but I'm just not buying this guy's story. I think this guy has anxiety; obviously, wellbutrin would have been the worst thing for him (plus, few people with ADHD respond to wellbutrin in the first place). We see guys like this all the time on the detox floor ("Doc, only adderall help with my ADHD").

 

[Manicsleep]

I think there's a lot of theories floating around that since stimulants stimulate the whole brain, they're also stimulating the frontal/prefrontal lobes, increasing the ability to inhibit unwanted thoughts, etc. This may then lessen things like anxiety symptoms in some patients.

I'd say the evidence goes against using strattera in this case since it's less likely to work in someone who has already tried stimulants. But I always use it earlier, if for no other reason than to prescribe less controlled substances.

As for your case in particular, any illicits on board? Tested for OSA? I try to go conservative whenever possible, so if there's a suspicion of OSA as a contributor, could also try empirically provigil if he isn't willing to get a sleep study or try CPAP.

Obese male with CAD who is on benzos, ssris and smokes while sleeping 4-5 hours a night.

It may not be OSA but a sleep study may be helpful to you nonetheless. I would guess that if you give him the STOP questionnaire he would be at a high risk for OSA.

S: Do you snore loudly?
T: Do you often feel tired, fatigued or sleepy during daytime?
O: Has anyone observed you stop breathing during sleep?
P: Do you have or are you being treated for high blood pressure?

The acronym is dumb but very easy. 2 or more and you have a high risk.

 

[Lauraaa]

I wish there was a study on stimulants in the context of social anxiety disorder; I think that would be super interesting...

And in regard to Bupropion and anxiety there have been some studies showing that looked at SSRIs compared to Bupropion that seemed to suggest that both lead to a comparable improvement in the treatment of anxiety symptoms (in patients with MDD w/ anxiety), time to see improvement, or severity in the residual anxiety symptoms remaining.

Here at my program we also had this general belief that for prominent anxiety symptoms you should stay away from giving bupropion, all other things being equal... but now it seems that more people at my program are starting to question this idea and are now prescribing Wellbutrin say for those with depression and anxiety who don't want to have the sexual side effects associated with SSRIs. And at least for those who I've treated with anxiety with Wellbutrin all have done well (but small N). And going back to social anxiety disorder, even in our anxiety clinic, the head believes through his practice and clinical experience that there are some people who can be treated well with Wellbutrin, and some that do well with stimulants... and his N is of course much bigger.

Going back to the patient in this case with ADHD I was curious about three things:

1.) Is he symptomatic from his CAD?

2.) How much beta blocker is he on?

3.) Do you know why his cardiologist wants him to get a ECG prior to starting and prior to dose increases? To see if there is a baseline arrthymia? Reason I'm asking is that I thought that the main danger with giving stimulants to patients with CAD was the potential increase in a cardivascuar event which could lead to ischemia if the heart can not tolerate the increase in sympathetic outflow. I assume that the cardiologist has him beta-blocked the heck out of him, so heart rate is well controlled and that heart rate would be taken at each visit and each dose change. If HR is well controlled, what ECG findings would result in a contraindication for him to be on Adderall?

 

[billypilgrim37]

And in regard to Bupropion and anxiety there have been some studies showing that looked at SSRIs compared to Bupropion that seemed to suggest that both lead to a comparable improvement in the treatment of anxiety symptoms (in patients with MDD w/ anxiety), time to see improvement, or severity in the residual anxiety symptoms remaining.

Very much agree with this, especially in younger folks and folks who I'm worried about some predisposition to bipolar disorder, given slightly lower risk of inducing manic symptoms. And with XL version being generic now and insurance companies no longer making me do prior auths, I have fewer reasons not to prescribe it.

 

[OldPsychDoc]

Here at my program we also had this general belief that for prominent anxiety symptoms you should stay away from giving bupropion, all other things being equal... but now it seems that more people at my program are starting to question this idea and are now prescribing Wellbutrin say for those with depression and anxiety who don't want to have the sexual side effects associated with SSRIs. And at least for those who I've treated with anxiety with Wellbutrin all have done well (but small N). And going back to social anxiety disorder, even in our anxiety clinic, the head believes through his practice and clinical experience that there are some people who can be treated well with Wellbutrin, and some that do well with stimulants... and his N is of course much bigger.
...

I try to train our residents and students to ask the follow-up question when there's a CC of "anxiety": "What is your anxiety LIKE? What do you mean by 'anxiety'? " Do this enough and you'll find a whole host of things that people call "anxiety"--situational worries, panic attacks, cannabis and alcohol withdrawal, social scrutiny, frank paranoia... One drug does not "fit all". (Though maybe Seroquel comes close... )

 

[Manicsleep]

One drug does not "fit all". (Though maybe Seroquel comes close... )

You could try seroquel + neurontin with prn horizant. You may have to use nuedexta for breakthrough symptoms.

 

[Lauraaa]

I try to train our residents and students to ask the follow-up question when there's a CC of "anxiety": "What is your anxiety LIKE? What do you mean by 'anxiety'? " Do this enough and you'll find a whole host of things that people call "anxiety"--situational worries, panic attacks, cannabis and alcohol withdrawal, social scrutiny, frank paranoia... One drug does not "fit all". (Though maybe Seroquel comes close... )

Thank you. I will rephrase to clarify the above to this statement: "Here at my program we also had this general belief that for prominent anxiety symptoms - after the clarification of what the patient meant by 'anxiety' for example, ruling out substance use, psychosis, etc - it was thought to be better to stay away from giving bupropion, all other things being equal... but now it seems that more people at my program are starting to question this idea and are now prescribing Wellbutrin say for those with depression and anxiety who don't want to have the sexual side effects associated with SSRIs with some good results."

 

[NJWxMan]

You could try seroquel + neurontin with prn horizant. You may have to use nuedexta for breakthrough symptoms.

Does Neurontin truly have much more than a placebo effect?

 

[jettavr6]

Whopper: you are spot on with your assessment and treatment of this patient. I don't like Strattera and have seen elevated LFT's on patients using it. While I would like to prescribe more Provigil, insurance will not pay. The next best and safest substitute is Adderall. Relatively safe in the elderly as well including those with underlying cardiac problems.

 

[markglt]

spot on, i dont think so.
go ahead and give him an 8ball while your at it.
have fun in court.

 

[caribbeanjp17]

I'm glad the patient's GP got him to the pyschiatrist so they can assess the guy instead of "Giving 8balls?"


jetta: question.. Have you had success in treating ADHD with Provigil or no experience due to insurance? Also, if insurance won't cover it I'm guessing its cousin Nuvigil is out of the question as well.. Would dexedrine have any benefit over adderall or no?

 

[caribbeanjp17]

jetta: question.. Have you had success in treating ADHD with Provigil? Also, if insurance won't cover it I'm guessing its cousin Nuvigil is out of the question as well.. Would dexedrine have any benefit over adderall or no?

 

[IAmAUser]

.

 

[Manicsleep]

spot on, i dont think so.
go ahead and give him an 8ball while your at it.
have fun in court.

YOu have to weigh risks vs benefits in all cases. We don't know this patient like whopper so to presume this is malpractice (saying have fun in court..is a little off base).

I understand where you are coming from however. I would be very hesitant to give someone like this opposing drugs (benzos and stims) at the same time at higher than approved doses with the history that is being presented.

 

[Manicsleep]

Does Neurontin truly have much more than a placebo effect?

I believe his post was sarcastic

Yup

 

[Mattchiavelli]

this is just a toss-in from a med student- what about Clonidine or Guanfacine?

 

[whopper]

adderall is the last drug this guy needs to be on, regardless of what cardio said. playing with fire,
switch that guy to ssri's and benzos pronto

Exactly why I'm a bit more touchy feely on this case. He's already been tried on several SSRIs, SNRIs and benzos. The benzos work, I didn't start him on them, and both he and I want him off of them because we know they're addictive and over time a person just builds a tolerance to them.

OSA? Yes he has it. I've already told him I will not give him meds to sedate him. He already tried a CPA machine and he can't sleep with all the noise. I told him he's really just going to have to lose the weight or live to learn with the machine.

Urine drug screen? Negative except for benzos, but he's already on benzos, he told me about it, and actually since he's been put on Adderall, he told me his anxiety is much less and he cut down his Valium use to 1/3 of what it was before I saw him.

Clonidine or Guanfacine?

I did consider using that. Ultimately I did not, but I still might give it a try. I've rarely seen success with those meds, and he's already jumped through plenty of hoops I put him through--e.g. I wanted several months of clean UDSs, an EKG, consultations with his cardiologist, psychological testing, a trial on 2 SSRIs, and Buspirone with no success, and he's already on several BP meds.

Mind you the psychological testing used was the TOVA test and the Wender Utah, the first is difficult to malinger, and the 2nd test has a way to figure out if someone is malingering on it. He was positive on both.

I do not give out stimulants unless 1) psychological testing backs the person has ADHD, 2) There's an EKG, 3) the person agrees to random drug tests and they are negative 4) after the stimulant has been started, the person tells me they feel a benefit from it. Otherwise it stops.

Have you had success in treating ADHD with Provigil? Also, if insurance won't cover it I'm guessing its cousin Nuvigil is out of the question as well.. Would dexedrine have any benefit over adderall or no?

Didn't start it for the reason mentioned above. Insurance usually wont' pay for it.

 

[Manicsleep]

OSA? Yes he has it. I've already told him I will not give him meds to sedate him. He already tried a CPA machine and he can't sleep with all the noise. I told him he's really just going to have to lose the weight or live to learn with the machine.

Personally, I would use CPAP adherence/non adherence as a carrot (or stick) to make this guy sleep better. I see a lot of guys who 'prefer' provigil or adderral even though they aren't using their CPAP enough.

Poor sleep and ADHD symptoms or ADHD-like symptoms are very common. Hopefully his sleep doc is fellowship trained and can work with you from a behavioral standpoint.

 

[whopper]

Poor sleep and ADHD symptoms or ADHD-like symptoms are very common

Yes, another thing I'm seeing that isn't exactly emphasized in the books or I got from residency training. The usual clinical presentation I've seen is a patient that while trying to sleep feels scatterbrained and has "1000 things" going through their mind. Such a patient is often misdiagnosed as having bipolar disorder since poor sleep is often considered a red flag symptom for mania. Hyperactive ADHD patients often look like they have bipolar disorder, and treating a patient with a presentation that looks like both with a stimulant could be risky because it could drive the person into mania if it truly is bipolar disorder.

I have a guy who was diagnosed with major depressive disorder, generalized anxiety disorder, and panic disorder without agoraphobia. Each time I put him on an SSRI, buspirone augumentation or a benzo it only caused marginal improvement. The guy was also on a testosterone gel. Turned out his testerone levels were low and I believed that this was likely a side effect of his high dosages of an SSRI.

I gave the guy a Wender Utah test and his score was through the roof. It highly suggested he had ADHD. Wellbutrin didn't work well, but after trying him on a stimulant, I was able to wean him off of the other meds (Fluoxetine 80 mg QAM, Buspirone 30 mg QBID, Clonazepam 1 mg QTID and testosterone gel). He's just down now to 1 medication and it's a stimulant.

 

[caribbeanjp17]

YOu have to weigh risks vs benefits in all cases. We don't know this patient like whopper so to presume this is malpractice (saying have fun in court..is a little off base). .

Well Put!

 

[nitemagi]

I gave the guy a Wender Utah test and his score was through the roof. It highly suggested he had ADHD. Wellbutrin didn't work well, but after trying him on a stimulant, I was able to wean him off of the other meds (Fluoxetine 80 mg QAM, Buspirone 30 mg QBID, Clonazepam 1 mg QTID and testosterone gel). He's just down now to 1 medication and it's a stimulant.

I'd keep in mind that the Wender, like many ADHD measures, are self-reports and thus questionable.

Interestingly there's a subpopulation of kids diagnosed as ADHD as children that actually have sleep apnea.

Sleep deprive a kid and what happens? He's bouncing off the walls and can't pay attention.

Sleep deprive an adult and what happens? He's spacey, can't pay attention, may nod off, have trouble getting things done. Think about residency. I could easily have scored high on multiple ADHD scales during residency if I focused on the period of time during residency. Sad that I just wrote that.

Also too bad that insurance won't cover provigil for a guy with OSA. Manicsleep- any ideas on ways around that?

 

[whopper]

True.

The Wender, like the MMPI, (at least the version I've been using) has been loaded with bogus questions. While the test, as far as I know, never mathematically measured the mechanics of adding up the bogus numbers to see if someone is malingering the results, if one is going over the results of the exam, and almost every single answer is a 4 (bogus and real ones), it should cause concern.

One could also do a TOVA test as well. The test is hard to fake because all it involves is someone pressing a button in response to computer stimuli.

In Ohio, we got OARRS. It allows me to check up all the meds being prescribed to a patient by every single doctor.

 

[nitemagi]

A lot of patients I've seen just have an investment in being diagnosed as ADHD, and seem more in the symptom exaggeration camp than what they would acknowledge as outright lying/malingering.

 

[michaelrack]

Also too bad that insurance won't cover provigil for a guy with OSA. Manicsleep- any ideas on ways around that?

I'm not Manicsleep, but I do have a few ideas... You could give the patient a coupon for a 30 day free supply of nuvigil (avail from your cephalon rep) if the patient does NOT have medicare/medicaid- the coupons don't work with gov insurance.

samples of nuvigil are still readily available

Most insur co will cover nuvigil for sleepiness due to osa despite being on cpap. Many don't strictly define what it means to be on cpap. get the pt to use cpap for a few nights and he may qualify (this assumes he still has the machine)

Also would consider in this case (as others have pointed out) that many of his ADHD syx are due to OSA (I am not familiar with the ability of psych testing to distinguish between the 2). You could just defer treatment of his adhd until his sleep apnea was effectively treated.

 

[michaelrack]

giving a stimulant to a cardiac pt with untreated osa (both increase the risk of cardiac dz) is medicolegally risky.

 

[nitemagi]

Also would consider in this case (as others have pointed out) that many of his ADHD syx are due to OSA (I am not familiar with the ability of psych testing to distinguish between the 2). You could just defer treatment of his adhd until his sleep apnea was effectively treated.

My point exactly.

 

[NJWxMan]

Maybe it's due in part to the fact that I am located in a busy inner city program, but we don't treat adult ADHD. Giving stimulants to adults is just asking for trouble. There are guys/gals that get admitted for Substance Induced Psychosis from injecting their prescribed stimulants. I could hear it now in court..."So, doctor. You believed that the benefits of having better concentration and less hyperactivity outweighed the high risk of causing death (after the guy drops dead from an arrhythmia)." Why put yourself at risk?

 

[Manicsleep]

Agree with Dr. Rack, provigil is covered with OSA and somnolence. Some of these guys who have had OSA for years just don't have a significant improvement in daytime somnolence even with good sleep.

However, this guy is only sleeping 4 hours or so...per his report. I would determine his AHI/RDI (measure of OSA severity) and his CPAP adherence plus effectiveness.

 

[heyjack70]

Not to be that guy, but I've got to ask this.

Is the patient working, living off of the government, or being supported in some other way? I think the stimulant is a risky intervention, and in my opinion, the only reason to go the stimulant route would be if he is working. If not, you're optimizing quality of life for a guy who is essentially a bump on a log, and you're giving him a potential heart attack in a pill. Now that I say that, I would be hesitant prescribing the stimulant even to the working man. I mean you don't want to kill this patient. A question I often ask myself is, "What would I do if this patient were my father?" It helps to clarify what I believe truly optimal care would look like. Would you risk giving your dad a heart attack to help relieve his anxiety/ADHD?

I'm also curious about this cardiology consult. Is the cardiologist essentially endorsing the prescription of the med to this patient, and if so is he effectively taking on the majority of the cardiac death liability? If I was a cardiologist, I don't think I would actually stick my neck out there like this.

Just food for thought.

 

[whopper]

Maybe it's due in part to the fact that I am located in a busy inner city program, but we don't treat adult ADHD

Same happened where I did training. In NJ we didn't have the OARRS system, and we did have a bunch of malingerers wanting meds for abuse. Add to the trouble, no one in the system where I did residency training ever directed me to use the Wender Utah, a TOVA, or anything that would have some ability to differentiate between a malingerer vs someone who truly had ADHD.

But the good thing I did get out of the experience was I did have one attending that used to work in the prison system and he taught me the tricks several patients pull in trying to get meds for the wrong reasons.

A problem with working in a setting with several drug abusers if the person may even need a stimulant, but then the patient is in a situation where the medication could still be used for nontherapeutic reasons simply because several factors such as the street value of the medication and the person may need the money. Many of the things that could be done to make sure the patient is compliant are even harder in an inner-city setting such as clean urine drug screens because in some areas it's literally almost everyone under the age of 30 using drugs.

I'd still stick to the rules I mentioned above in such a setting. 1) Psychological testing that is difficult to malinger 2) EKG 3) Clean UDSs 4) the medication has to provide some type of benefit 5) try a non-stimulant first. In such a setting I would try Strattera in addition to Wellbutrin. I hate saying it but from my own experience, if you're in a really bad area, hardly anyone will ever follow those rules.

 

[Manicsleep]

Adult ADHD is real. Its just not that common (in my clinical experience) and the percentage of people that show up asking for medication, compared to the percentage that actually have the disease is low.

I ask them to produce medical records from childhood with treatment of said disease and clarify that this will only get them testing. They must also have had a consistent PCP and we ask for their PCP. The vast majority will run for the hills at this point. The persistent ones left usually have the illness although we do catch shysters regularly.

Early on I was getting burned by these guys not paying me once I decided they didn't need the medication. So now we charge for the visits in advance and the call to the PCP(s). Anything phony and we ask them to find another psychiatrist. One thing I noticed was that the amount of guys trying to 'fish' for narcotics dropped dramatically after we instituted policies designed to weed them out. I think they all know each other and probably tell each other which doctor to go to for drugs, so if you are difficult to squeeze drugs from, they all get the news pretty quick.

 

[watto]

If CPAP is noisy, he probably has a mask leak
Bring him to me and I will daytime desensitize the hell out of him. He has to have his OSA treated given his cardiac comorbidities.
If you want me to send you the CPAP densitization protocol, PM me.