Patients with multiple controlled substances.

[littlefred]

I'm seeing this constantly now, patients on 2-3 controlled substances at once by the same prescriber.

e.g. Xanax 2 mg TID, Adderall 20 mg BID, Suboxone 8-2 mg BID

I've been tempted to just tell patients I will only prescribe only 1 controlled substance at once.

How do you handle transfers or new patients with these regimens?

---

Members don't see this ad.

 

[dl2dp2]

Well, does the patient have ADHD?

I'm not a big fan of Xanax 2mg TID, and this should be converted to Klonopin and slow taper.

It's not unusual (in fact, very common) to have opioid patients who also have ADHD, so it wouldn't be unreasonable to continue the other 2. Is the diagnosis of ADHD solidified or is it just a 3 min questionnaire? Is immediate release Adderall the best choice? Are symptoms of ADHD longitudinally tracked so the stimulant doses are modified as appropriate? Is the patient taking the Suboxone? How well is the OUD managed? Should it be converted to a depot formulation? These are the issues that need to be sorted out if you are taking over someone like that.

There's no reason to arbitrarily discontinue controlled substances if they are indicated, but it probably makes sense to alter formulation to minimize dependence/withdrawal. You also need a long-term med plan for these patients: ultimately where do I want the med regimen to look like if the patient is in remission? Do I want to taper benzos as much as I can (yes). Do I need to taper stimulants and Suboxone in maintenance? (not necessarily). I think if you are not addiction-boarded it might be best to consult someone who's addiction-boarded to think through these big-picture issues. Opioid patients are non-trivial. Xanax 2 TID + Suboxone 8 BID can easily translate into overdose death at a time of relapse. If you don't prescribe arbitrarily withhold medications without a plan you increase the chance of relapse/lawsuits/deaths, etc.

 

[TexasPhysician]

While I can’t see why I would have anyone on the OP’s example regimen, I don’t see an issue with 2 controlled meds appropriately dosed.

 

[Sushirolls]

OUD patients don't get controlled substances, take off the adderall. Treat "ADHD" with anything else.

taper off benzos by klonopin.

Get sleep consult soon as possible, as will have central apneas, and be a contribution to the "ADHD". Needs that Apnea treated.

 

[hamstergang]

OUD patients don't get controlled substances, take off the adderall. Treat "ADHD" with anything else.

Do you not believe in a link between substance abuse and ADHD, or do you just not believe in ADHD in general?

 

[calvnandhobbs68]

Well, does the patient have ADHD?

have fun figuring that out in a 45 year old patient with a SUD history who's been on Adderall IR BID-TID from their candy man for the last 5 years and is having to transfer out for whatever reason.

I mean there are instances where multiple controlled meds make sense (ex. someone with a strong confirmed history of ADHD and OUD who's on Suboxone + Vyvanse for instance or really low dose Klonopin) but regimens like above scream "Dr. Feelgood".

I think if you are not addiction-boarded it might be best to consult someone who's addiction-boarded to think through these big-picture issues.

I think yes if you have someone who is a good addiction boarded doctor you can discuss possible plans with that's awesome. I've seen terrible regimens from addiction boarded docs though too. This was particularly bad in the era of cash only suboxone clinics before the waiver restrictions were loosened. I've said this before here I think but used to work with a (board certified) addiction doc in a suboxone clinic who would throw everyone on IR Adderall often quickly up to 30mg BID or higher with even a hint of "ADHD".

 

[littlefred]

Do you not believe in a link between substance abuse and ADHD, or do you just not believe in ADHD in general?

There is a link between untreated ADHD leading to substance use disorders, but once the cat is out of the bag then it gets complicated (aka once they have a full blown SUD).

If you read any source on treating ADHD for patients with concurrent SUD they either recommend staying away from stimulants or if you MUST then treat with XR formulations with close monitoring.

 

[littlefred]

have fun figuring that out in a 45 year old patient with a SUD history who's been on Adderall IR BID-TID from their candy man for the last 5 years and is having to transfer out for whatever reason.

Story of my life! Hah the age group is also on point. I don't mind prescribing ADHD meds to the younger population but once you are in adulthood it gets super sketch. Adult ADHD is kind of an oxymoron because it's supposed to be a neurodevelopmental delay in children/adolescents in comparison to their peers... How are you still delayed when you are 40 years and above?

Seems like everyone is getting stimulants up here and when they are held to any kind of scrutiny the diagnosis was made with some kind of self-administered questionnaire or prescribed by non-psychiatrists. Rough.

 

[Sushirolls]

Do you not believe in a link between substance abuse and ADHD, or do you just not believe in ADHD in general?

Prevention is valuable.
@littlefred nailed it.

I'm not disputing the overlap of the conditions. Placing a greater emphasis on the lethality of SUDs is more important. Untreated ADHD has a lower mortality than untreated SUDS.

 

[Sushirolls]

Story of my life! Hah the age group is also on point. I don't mind prescribing ADHD meds to the younger population but once you are in adulthood it gets super sketch. Adult ADHD is kind of an oxymoron because it's supposed to be a neurodevelopmental delay in children/adolescents in comparison to their peers... How are you still delayed when you are 40 years and above?

Seems like everyone is getting stimulants up here and when they are held to any kind of scrutiny the diagnosis was made with some kind of self-administered questionnaire or prescribed by non-psychiatrists. Rough.

Sigh. And then all the non neuropsych psychologists "do testing" and say ADHD. Don't even bother to get Psych records, or see that patient is actively using cannabis, or needs an OSA workup. But hey, their testing is "truth" and time for adderal. I've gone from cannabis everywhere to now ADHD everywhere location.

 

[Crayola227]

Story of my life! Hah the age group is also on point. I don't mind prescribing ADHD meds to the younger population but once you are in adulthood it gets super sketch. Adult ADHD is kind of an oxymoron because it's supposed to be a neurodevelopmental delay in children/adolescents in comparison to their peers... How are you still delayed when you are 40 years and above?

Seems like everyone is getting stimulants up here and when they are held to any kind of scrutiny the diagnosis was made with some kind of self-administered questionnaire or prescribed by non-psychiatrists. Rough.

This indicates you completely misunderstand ADHD as a medical condition. I'll let someone else educate in thread.

 

[littlefred]

This indicates you completely misunderstand ADHD as a medical condition. I'll let someone else educate in thread.

Oh please enlighten me on the neuropathology of ADHD!

 

[calvnandhobbs68]

Oh please enlighten me on the neuropathology of ADHD!

Don't do it you're going to get a 5 page long essay

 

[littlefred]

This indicates you completely misunderstand ADHD as a medical condition. I'll let someone else educate in thread.

Here. A study to elaborate on what I said on layman's terms.

The neurobiological basis of ADHD

Attention-Deficit/Hyperactivity Disorder is not a single pathophysiological entity and appears to have a complex etiology. There are multiple genetic and environmental risk factors with small individual effect that act in concert to create a spectrum ...

www.ncbi.nlm.nih.gov

 

[littlefred]

Don't do it you're going to get a 5 page long essay

Created by ChatGPT

 

[Crayola227]

Kick rocks both of you.

 

[comp1]

The xanax has to go. It's a bad benzo (always) and it's going to counteract the benefits of the stimulant. There's no logical reason for it to be given with a stimulant and it does raise the risk of OD with opiates (although much less with suboxone). The suboxone and stimulant could potentially stay if there's some indication for each. Concur with above that you need to transition to a long acting benzo and do a gradual taper with the speed dictated by how long the person has been on it. The patient is of course always free to find another provider.

 

[littlefred]

Kick rocks both of you.

I would love to hear what you have to say, seriously. This stimulant thing has gone out of hand and we physicians need to start questioning it.

Remeber when opioids where prescribed nilly willy(and look at where we are now), I believe we are in a similar stage with stimulants.

 

[whopper]

You should give them a chance to wean off the meds one at a time in a safe manner, but if the patient doesn't do it terminate them.

 

[clausewitz2]

Here. A study to elaborate on what I said on layman's terms.

The neurobiological basis of ADHD

Attention-Deficit/Hyperactivity Disorder is not a single pathophysiological entity and appears to have a complex etiology. There are multiple genetic and environmental risk factors with small individual effect that act in concert to create a spectrum ...

www.ncbi.nlm.nih.gov

You seem to be coming to the conclusion that something that starts in childhood cannot affect someone in adulthood. This is a . . . novel medical hypothesis.

 

[Celexa]

There are absolutely pts stable on suboxone for OUD who carry legitimate diagnoses of ADHD with symptoms that started in childhood and continued to as adults. They deserve to have their ADHD symptoms addressed. For a small slice of them I'd consider long acting at stimulants.

I absolutely will not prescribe benzos and stimulants in the same person unless the benzo was a few times a year prn for a rare event. The dentist, MRI, flying in someone who flies once per year, whatever.

So regardless of diagnosis a patient like this I would tell if they continue under my care that benzo is coming down and eventually off. Exactly what I would do with the stimulant and when would depend on a lot of different patient specific variables.

 

[ObsequiousAplomb]

The xanax has to go. It's a bad benzo (always) and it's going to counteract the benefits of the stimulant. There's no logical reason for it to be given with a stimulant and it does raise the risk of OD with opiates (although much less with suboxone). The suboxone and stimulant could potentially stay if there's some indication for each. Concur with above that you need to transition to a long acting benzo and do a gradual taper with the speed dictated by how long the person has been on it. The patient is of course always free to find another provider.

idk about never a reason to give Xanax with a stimulant. Someone with severe Panic Disorder s/p CBT and years of other therapies and ADHD. The anxiety is there with or without a stimulant. Doesn't make as much sense when the Xanax is being given to treat anxiety caused by the stimulant, but relatively few patients actually have clinically significant anxiety from therapeutic doses of stimulants.

Xanax is far less sedating than the other benzodiazepines, so if ever there were a benzodiazepine to rationally add onto a stimulant, Xanax 0.25 or 0.5 mg has a pretty good case.

 

[comp1]

There is abundant literature specifically studying the combination of stimulants and benzos. It is very, very bad and should be avoided. Neuropsych testing shows major deficits. The stimulants mask the sedation so you don't necessarily fall asleep, but the attention issues are severe. If someone's ADHD is so mild as to be able to tolerate adding on a benzo without functional problems, I'd recommend tapering the stimulant too. Further, 8% of patients have anxiety caused from SUBtherapeutic doses of stimulants. It's not rare. In terms of why Xanax is a never drug, it's just because there are better medications. There is a reason Xanax has the highest street value, it's fun. It works extremely quickly and is gone almost as fast. This leads to a huge level of addiction. The up and down of intoxication/withdrawal over just the course of one day is just going to make things so much worse.

 

[littlefred]

You seem to be coming to the conclusion that something that starts in childhood cannot affect someone in adulthood. This is a . . . novel medical hypothesis.

Granted, we don't know the brain as much as we know other organs like for example the kidneys... but it was a philosophical stretch. If there are neurodevelopmental delays then with brain maturation those delays would eventually catch up. Unless the brain remains in stasis developmentally, but again we wouldn't know definitively given our limited knowledge of the brain.

 

[romanticscience]

GAD is essentially neuroticism for my practical purposes. I could diagnose it in almost every one of my patients. @splik once did a good job of describing it as the most non-anxious anxiety disorder. I believe he cited that it doesn't have strong associations with other "anxiety" disorders (Panic, SAD, Phobia).

How in the world did Xanax get approved for GAD? I never understood this. Mania or catatonia, for sure. Panic or phobia, maybe. But general anxiety? That. is. like. everyone! It seems to contradict the behavioral science that avoidance learning perpetuates anxiety. We know that benzos are associated with poor recovery from PTSD.

Maybe I'm just frustrated by people who talk about this "anxiety" thing and justify taking "Xanax" for it. I have a lady who has a really bad somatic symptom disorder and wonders why I won't consider Xanax. I told her that treatment of anxiety demands a more specific diagnosis of the worry (e.g., people with persecutory delusions are "anxious").

 

[PsyDr]

How in the world did Xanax get approved for GAD?

Hydroxyzine is FDA indicated for psychoneurosis. The world is a funny place.

 

[comp1]

I'd much rather have someone on Vistaril than Xanax. (Anything the rat won't press the lever for.) Of course, I'd still recommend against both with a stimulant.

 

[Celexa]

GAD is essentially neuroticism for my practical purposes. I could diagnose it in almost every one of my patients. @splik once did a good job of describing it as the most non-anxious anxiety disorder. I believe he cited that it doesn't have strong associations with other "anxiety" disorders (Panic, SAD, Phobia).

How in the world did Xanax get approved for GAD? I never understood this. Mania or catatonia, for sure. Panic or phobia, maybe. But general anxiety? That. is. like. everyone! It seems to contradict the behavioral science that avoidance learning perpetuates anxiety. We know that benzos are associated with poor recovery from PTSD.

Maybe I'm just frustrated by people who talk about this "anxiety" thing and justify taking "Xanax" for it. I have a lady who has a really bad somatic symptom disorder and wonders why I won't consider Xanax. I told her that treatment of anxiety demands a more specific diagnosis of the worry (e.g., people with persecutory delusions are "anxious").

GAD is hilariously over diagnosed. Every patient who I've had with a legitimate GAD diagnosis could be addressed with a low dose SSRI (I find GAD ruminative thinking specifically is often wonderfully sensitive and fast to respond to SSRI) + therapy to learn all that anxiety isn't normal and they don't have to live that way.

Treating GAD with a benzo is like treating MRSA bacteremia with oral vancomycin. Sounds sort of like you're doing the right thing, until you realize oral vanco doesn't reach the bloodstream and oops now you've created new problems by taking a flamethrower to the normal gut flora. And they're still bacteremic.

 

[calvnandhobbs68]

Granted, we don't know the brain as much as we know other organs like for example the kidneys... but it was a philosophical stretch. If there are neurodevelopmental delays then with brain maturation those delays would eventually catch up. Unless the brain remains in stasis developmentally, but again we wouldn't know definitively given our limited knowledge of the brain.

There is good evidence a significant number of people will continue to show impairment into adulthood. Last paragraph of "epidemiology and clinical course" in the practice parameter below:

https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext

It's a tricky thing to define though and it's almost exclusively looked at as following patients who had a confirmed ADHD diagnosis in childhood into adulthood and measuring symptoms and impairments as adults. It's also tough because symptom criteria are based on kids so you're naturally going to see more of those fall off over time.

What is not well studied is "how can we make a good diagnosis of a neurodevelopmental disorder in an adult with multiple confounding comorbidities" which is often what you're looking at in your original post (I've absolutely run into the patients you're describing and it's a rare one who had a thorough diagnosis of ADHD starting in childhood/adolescence).

It is also absolutely not clear that these people need to be on Adderall IR multiple times a day no matter what.

 

[Crayola227]

idk about never a reason to give Xanax with a stimulant. Someone with severe GAD and ADHD. The anxiety is there with or without a stimulant. Doesn't make as much sense when the Xanax is being given to treat anxiety caused by the stimulant, but relatively few patients actually have clinically significant anxiety from therapeutic doses of stimulants.

Xanax is far less sedating than the other benzodiazepines, so if ever there were a benzodiazepine to rationally add onto a stimulant, Xanax has a pretty good case.

What's really remarkable about the diversity of patients, medical conditions, and the medication tools at our disposal, is the sheer combinations that then might be indicated, even if under a very specific set of variables.

Why even have psychiatrists if one is just gonna have blanket rules like "only one controlled substance at time, ever." "There is no such thing as ADHD as a lifelong condition." May as well just hand the kingdom over to the NPs then.

 

[littlefred]

May as well just hand the kingdom over to the NPs then.

We kind of already did, hence many of our predicaments.

 

[Crayola227]

Granted, we don't know the brain as much as we know other organs like for example the kidneys... but it was a philosophical stretch. If there are neurodevelopmental delays then with brain maturation those delays would eventually catch up. Unless the brain remains in stasis developmentally, but again we wouldn't know definitively given our limited knowledge of the brain.

That's just it, it's not just a "delay." Everything I have seen suggests that the brain literally functions in a measurably different way, and many of these differences are essentially permanent*. You're not going to wake up tomorrow left brained if you're right brained. (Not as a normal part of development, certainly there are traumas that can affect laterality).

The brain anatomy of attention-deficit/hyperactivity disorder in young adults – a magnetic resonance imaging study

This is one of the first studies to examine the structural brain anatomy and connectivity associated with an ADHD diagnosis and child as well as adult ADHD symptoms in young adults. It was hypothesized that an adult ADHD diagnosis and in particular childhood ...

www.ncbi.nlm.nih.gov

Just something I pulled off a search. If you go looking for evidence of structural or functional changes in the brain associated with ADHD, with persistence in some individuals into adulthood, you will not be disappointed. Same with symptom persistence, measurable affects on neuropsych testing or other validated measures. It's something that can be easily observed in some people.

It's totally valid to debate what this means practically for treatment. But sort of waving your hand that all ADHD brain functions and affects on life in adulthood sort of vanish with age... it's not just an interesting medical hypothesis. It's just plain wrong and really flies in the face of a whole body of research and understanding. That's all.

Keep in mind, I'm not claiming ALL cases of childhood ADHD persist indefinitely. But at any age there will be some individuals persisting and some not.

*Yes, you can see adaptations and coping skills that render some of the persisting changes a
effectively symptom-less. And yes, not ALL the changes seen are permanent. But many are.

 

[littlefred]

That's just it, it's not just a "delay." Everything I have seen suggests that the brain literally functions in a measurably different way, and many of these differences are essentially permanent*. You're not going to wake up tomorrow left brained if you're right brained. (Not as a normal part of development, certainly there are traumas that can affect laterality).

The brain anatomy of attention-deficit/hyperactivity disorder in young adults – a magnetic resonance imaging study

This is one of the first studies to examine the structural brain anatomy and connectivity associated with an ADHD diagnosis and child as well as adult ADHD symptoms in young adults. It was hypothesized that an adult ADHD diagnosis and in particular childhood ...

www.ncbi.nlm.nih.gov

Just something I pulled off a search. If you go looking for evidence of structural or functional changes in the brain associated with ADHD, with persistence in some individuals into adulthood, you will not be disappointed. Same with symptom persistence, measurable affects on neuropsych testing or other validated measures. It's something that can be easily observed in some people.

It's totally valid to debate what this means practically for treatment. But sort of waving your hand that all ADHD brain functions and affects on life in adulthood sort of vanish with age... it's not just an interesting medical hypothesis. It's just plain wrong and really flies in the face of a whole body of research and understanding. That's all.

Keep in mind, I'm not claiming ALL cases of childhood ADHD persist indefinitely. But at any age there will be some individuals persisting and some not.

*Yes, you can see adaptations and coping skills that render some of the persisting changes a
effectively symptom-less. And yes, not ALL the changes seen are permanent. But many are.

Lots of good points! I'll just refer the above patients to docs like you, multiple controlled substances at the same time and belief that chronic meds will fix issues that have no biological underpinnings!

Docs like you think this way... Pain> chronic opioids
Anxiety>Chronic benzos
ADHD>chronic stims

Notice that none of these are actually attempting to fix the underlying problem, just masking them.

 

[comp1]

Sure, infinite diversity in infinite combinations. Anything is possible. There might be some person for whom Xanax and stimulants are actually appropriate. That person should be written up as a case report. Honestly, there would be better care in general if we all, NPs too, did just a bit more algorithmic medicine around controlled substances, not completely, but a bit more. The problem with saying well sure there are some people who would benefit from the combination, you can't be black and white about it, is that you have 15 minutes with a patient. If that's on the table, you're going to reach for it a heck of lot more often than you should and certainly a heck of a lot more often than the risk/benefit ratio (which is darn near all risk/no benefit) says you should. This is a different discussion than adult ADHD in general which is much more complicated and nuanced than the clear harm of benzo/stimulant combos.

 

[Crayola227]

Lots of good points! I'll just refer the above patients to docs like you, multiple controlled substances at the same time and belief that chronic meds will fix issues that have no biological underpinnings!

Docs like you think this way... Pain> chronic opioids
Anxiety>Chronic benzos
ADHD>chronic stims

Notice that none of these are actually attempting to fix the underlying problem, just masking them.

Are you sure I'm the one with the reductive and simplistic style of thinking about these things?

 

[Celexa]

Sure, infinite diversity in infinite combinations. Anything is possible. There might be some person for whom Xanax and stimulants are actually appropriate. That person should be written up as a case report. Honestly, there would be better care in general if we all, NPs too, did just a bit more algorithmic medicine around controlled substances, not completely, but a bit more. The problem with saying well sure there are some people who would benefit from the combination, you can't be black and white about it, is that you have 15 minutes with a patient. If that's on the table, you're going to reach for it a heck of lot more often than you should and certainly a heck of a lot more often than the risk/benefit ratio (which is darn near all risk/no benefit) says you should. This is a different discussion than adult ADHD in general which is much more complicated and nuanced than the clear harm of benzo/stimulant combos.

Yeah I don't know why the conversations are getting conflated. "should anyone be on both a benzo and stimulant daily?" and "do some people with adhd continue to have functionally impairing symptoms into adulthood?" are WILDLY different conversations.

 

[Crayola227]

Lots of good points! I'll just refer the above patients to docs like you, multiple controlled substances at the same time and belief that chronic meds will fix issues that have no biological underpinnings!

Docs like you think this way... Pain> chronic opioids
Anxiety>Chronic benzos
ADHD>chronic stims

Notice that none of these are actually attempting to fix the underlying problem, just masking them.

Some people took issue with certain statements you made specifically about ADHD in general, not just the notion of people wanting to change the specific regimen in the specific patient you're discussing.

I have commented where I disagreed. I have liked posts often where I agreed. Lots of people have made suggestions about how they would change or d/c meds in this scenario and nowhere have I contradicted that.

I have commented providing support and the opinion that cookie cutter responses, whether like the one you provide above, or others you have alluded to, I don't see as appropriate across the board given the diversity in cases. People may be making a comment about less common scenarios or a scenario that doesn't fit your patient, but that doesn't make their points wrong or not useful.

Ultimately it will be up to you to decide what best fits your patient. But if you don't consider less common things, then you will commonly miss the uncommon. Rigidity, especially based on wrong premises ("all adults outgrow ADHD") will be a disservice to someone at some point given enough cases.

 

[littlefred]

Some people took issue with certain statements you made specifically about ADHD in general, not just the notion of people wanting to change the specific regimen in the specific patient you're discussing.

I have commented where I disagreed. I have liked posts often where I agreed. Lots of people have made suggestions about how they would change or d/c meds in this scenario and nowhere have I contradicted that.

I have commented providing support and the opinion that cookie cutter responses, whether like the one you provide above, or others you have alluded to, I don't see as appropriate across the board given the diversity in cases. People may be making a comment about less common scenarios or a scenario that doesn't fit your patient, but that doesn't make their points wrong or not useful.

Ultimately it will be up to you to decide what best fits your patient. But if you don't consider less common things, then you will commonly miss the uncommon. Rigidity, especially based on wrong premises ("all adults outgrow ADHD") will be a disservice to someone at some point given enough cases.

Look I understand that we shouldn't deal with absolutes and more times than I care to admit I have continued medication regimens that I would never even consider starting.

I just stated a scenario that I see in my practice which is addiction which repeats itself consistently and wanted some input from the board. Deprescribing controlled substances is very hard and tiresome to be honest, I just wish ADHD diagnoses weren't thrown around like the GAD diagnosis someone mentioned above.

Appreciate all the input from others here, yours included. Just wish we had more definitive evidence about what we treat and how he we should do treat them like other medical specialities.

 

[Crayola227]

Yeah I don't know why the conversations are getting conflated. "should anyone be on both a benzo and stimulant daily?" and "do some people with adhd continue to have functionally impairing symptoms into adulthood?" are WILDLY different conversations.

The relationship here, is that if you determine that all people with ADHD will NOT need stimulants as adults, then you would likely conclude that all adult ADHD patients on a benzo and stimulant should have the stimulant stopped. This may or may not be the right answer. But wrong reason right answer is not going to be appropriate across the board.

 

[Stagg737]

I think yes if you have someone who is a good addiction boarded doctor you can discuss possible plans with that's awesome. I've seen terrible regimens from addiction boarded docs though too.

100% agree. The worst medication list I ever saw was from a "very respected" addictions doc near where I did residency. I remember getting the consult from inpatient family med unit at 2 am for "med recs" and being angry until I saw the med list (SSRI + SNRI + several other serotonergic meds, 3 antipsychotics, 2 benzos, stimulants in IR and XR formulation, suboxone, and some muscle relaxers). Consult was specifically asking which meds they could safely hold while admitted to the hospital for sedation and a fall.

Doesn't make as much sense when the Xanax is being given to treat anxiety caused by the stimulant, but relatively few patients actually have clinically significant anxiety from therapeutic doses of stimulants.

Xanax is far less sedating than the other benzodiazepines, so if ever there were a benzodiazepine to rationally add onto a stimulant, Xanax 0.25 or 0.5 mg has a pretty good case.

Completely disagree with the bolded points. I get consulted for both of these points (new panic attacks on patients recently started on stims, xanax contributing to significant sedation). Very low doses of any benzo are less sedating, but I can tell specific stories about even 0.25mg of Xanax completely snowing people.


To OP, my general opinion is that when patients are on the unholy trinity/triad (benzos, opioids, stims) that they probably "need" one of them (especially if the opioid is suboxone) but the others were either started or continued inappropriately. Typically, the benzo is the one I'll refuse to continue unless tapering as it adds the greatest risk without indication/benefit and I make that clear to my patients. Stims are hit or miss for ADHD with SUD, as others said very hit or miss. I almost never do IR stims in that population unless they've been on them since childhood and that's just what works. If it's a new ADHD diagnosis or patient has been off stims for years, I'll try non-stimulant options first and only go to stims if actually necessary.

For context for those "special cases". I've only ever seen 2 patients where I thought keeping all 3 was reasonably defended, and both patients were relatively young and on hospice where patient and family wanted stims continued so they could interact with them meaningfully. Beyond that I can't imagine a scenario where all 3 med classes would be acceptable as scheduled/regularly used meds...

 

[ObsequiousAplomb]

100% agree. The worst medication list I ever saw was from a "very respected" addictions doc near where I did residency. I remember getting the consult from inpatient family med unit at 2 am for "med recs" and being angry until I saw the med list (SSRI + SNRI + several other serotonergic meds, 3 antipsychotics, 2 benzos, stimulants in IR and XR formulation, suboxone, and some muscle relaxers). Consult was specifically asking which meds they could safely hold while admitted to the hospital for sedation and a fall.



Completely disagree with the bolded points. I get consulted for both of these points (new panic attacks on patients recently started on stims, xanax contributing to significant sedation). Very low doses of any benzo are less sedating, but I can tell specific stories about even 0.25mg of Xanax completely snowing people.


To OP, my general opinion is that when patients are on the unholy trinity/triad (benzos, opioids, stims) that they probably "need" one of them (especially if the opioid is suboxone) but the others were either started or continued inappropriately. Typically, the benzo is the one I'll refuse to continue unless tapering as it adds the greatest risk without indication/benefit and I make that clear to my patients. Stims are hit or miss for ADHD with SUD, as others said very hit or miss. I almost never do IR stims in that population unless they've been on them since childhood and that's just what works. If it's a new ADHD diagnosis or patient has been off stims for years, I'll try non-stimulant options first and only go to stims if actually necessary.

For context for those "special cases". I've only ever seen 2 patients where I thought keeping all 3 was reasonably defended, and both patients were relatively young and on hospice where patient and family wanted stims continued so they could interact with them meaningfully. Beyond that I can't imagine a scenario where all 3 med classes would be acceptable as scheduled/regularly used meds...

So because you, the consultant who would see people who have a panic attack after starting Adderall, have seen it in your specific narrow niche of a role, every single person who has ever even smelled Adderall must have severe panic attacks? Your experiences means it's "nearly all" instead of "relatively few"?

Also, you're entirely proving my point. You get consulted on people who had a panic attack after starting a stimulant. Naturally, you stop the stimulant instead of starting Xanax. Rational psychiatrists aren't out there starting Xanax after someone had a panic attack from the first dose of Adderall. You are describing irrational Adderall and Xanax, which I agree is far more common than rationally prescribing that combination.

To be clear, I am in no way advocating for prescribing Adderall and Xanax for anyone. I was only saying that there exist some unique situations in which the use of Xanax in particular was preferred over other benzodiazepines to add to Adderall for a rational reason. I have never, ever started this combination for anyone. I have never added any stimulant to any benzodiazepine, or vice versa. I, like seemingly everyone else in this thread, really only inherit people with this combination.

Generally, if I am planning on seeing this person again, I will write my first prescription of the combination to be the same dose they had been taking, and we gradually talk about gradually decreasing the dose. If it's someone who I don't want to do this for ... I don't offer to be their doctor at the initial consultation.

 

[annoyedpsychiatrist]

This is a question that will result in 15 different opinions, as evidenced by the replies in this thread.

This is my personal thought process, and I try to act in a very logical manner using guidelines, personal experience, and weighing risks/benefits.

1. I have people on stimulants + sleep medications sometimes. its not uncommon to have ADHD and chronic insomnia. If you look at american academy of sleep guidelines, if patient has failed CBTi, pharmacotherapy is warranted. I have a patient on adderall xr + belsomra for example for sleep maitenance.

2. I have some patients on very low dose benzo (.25-.5mg of ativan for example) and a stimulant. I am a bit of a more "hard ass" when it comes to benzos. I tell my patients, that I dont like drugs that make people stupid or gain weight. Personally I think benzos only worsen things in the long run, but I recognize that if someone walks in 30 years of klonopin through idiot prescribing that I cant just pull the rug out from under them. Build therapeutic alliance + taper to lowest possible dose while maintaining quality of life. I can think of over 10 ppl this year where ive tapered town to .5mg or less when they were on 4-6mg dose equiv of klonopin and are doing great.

3. As a rule, I tend not to continue benzos if on opiates. Risk of OD is up to 10x more when using benzo+ opioid. Dont like it. Dont want to risk it. Sedative hypnotics im slightly more flexible on, due to less respiratory depression (if any, depending on what you read)

4. Usually you can tell whose using the controlled substances for the wrong reason, because they walk in with adderall 20mg tid and xanax 1mg QID or something absurd. They tend to be easy to spot.

5. In my county I also do a quick arrest report to look for prior instances/recent arrest for drug related charges. This is fast and easy collateral and weeds out a lot of people.

6. Hx of OUD is not a reason for me to not treat ADHD. However, I am for sure more cautious. I have multiple people with OUD in remission on a stimulant who I believe have ADHD. They are also on suboxone, and they are regularly getting UDS for suboxone and have never had supciious activity and are very, very compliant reliable people. One past mistake shouldnt be the reason to exclude them for future treatment. If theyre not in a remission for an extended period of tme, dont think they have significant ADHD sx, or give me suspect vibes then obv i wouldnt hand them a stimulant. Arrest reports, UDS, collateral, etc.

7. This is more and more common that people are on stupid medication regimens and overprescribed controlled medicaitons. It will only get worse. If i excluded all the people who came to me on multiple controlled substances then my clinic would be like 1/3 the size it is now. People will surprise you if you give them a chance. Many people have been willing to work with me and trust me and ive used that trust to deprescribe stupid stuff.

8. There are some people who believe stimulants are under utilized. Realistically they tend to be pretty safe in the long run, can objectively increase someones quality of life, and have a very favorable risk/benefit profile in most patients. There are many adults with ADHD who were never treated for ADHD as kids. Its a lot harder to diagnose those at times, due to lack of collateral, but thats when you have to use clinical judgement and weigh risk/benefit ratio. I mean hell, my dad thought ADHD was a made up diagnosis to put kids on pills basically, lol. Are they also prescribed? For sure. Thats why we have to do our due diligence and weigh risk/benefit. If I have a 30 year old patient with no red flags, coming to be with significant inattention sx at work, no medical comorbidities, and shes failing her courses in college why would you not consider ADHD just because of her age? I mean if you give her vyvanse and her job performance goes up, she aces school, and now is financially doing well, and things are going better at home, with no downside, i dont understand why you wouldnt treat.

 

[clausewitz2]

This is a question that will result in 15 different opinions, as evidenced by the replies in this thread.

This is my personal thought process, and I try to act in a very logical manner using guidelines, personal experience, and weighing risks/benefits.

1. I have people on stimulants + sleep medications sometimes. its not uncommon to have ADHD and chronic insomnia. If you look at american academy of sleep guidelines, if patient has failed CBTi, pharmacotherapy is warranted. I have a patient on adderall xr + belsomra for example for sleep maitenance.

I have a number of type 2 narcolepsy patients on similar combinations, sometimes it does end up being a BZD. not my first choice, but if it's been what was historically useful and does not appear to be causing other problems it is not something I am going to discontinue quickly.

Also if you have ever worked with any kiddos with epilepsy, I am sure our CAP colleagues can confirm that Onfi + a stimulant is not a super rare combination.

6. Hx of OUD is not a reason for me to not treat ADHD. However, I am for sure more cautious. I have multiple people with OUD in remission on a stimulant who I believe have ADHD. They are also on suboxone, and they are regularly getting UDS for suboxone and have never had supciious activity and are very, very compliant reliable people. One past mistake shouldnt be the reason to exclude them for future treatment. If theyre not in a remission for an extended period of tme, dont think they have significant ADHD sx, or give me suspect vibes then obv i wouldnt hand them a stimulant. Arrest reports, UDS, collateral, etc.

Agreed. If I can look in the PDMP and see they've been on a stable dose of suboxone from the same provider for multiple years and not getting opioids elsewhere, I am not really going to hesitate to treat ADHD appropriately that has been properly assessed.

7. This is more and more common that people are on stupid medication regimens and overprescribed controlled medicaitons. It will only get worse. If i excluded all the people who came to me on multiple controlled substances then my clinic would be like 1/3 the size it is now. People will surprise you if you give them a chance. Many people have been willing to work with me and trust me and ive used that trust to deprescribe stupid stuff.

I started a thread a while back about one of my success stories that was like this, a complete and utter train wreck who came to me on TID stimulants, BID clonazepam, ambien qHS, AND temazepam qHS. It took many months but they've been benzo and BDRA free for almost six months now and their ADHD as such is mostly managed via clonidine. Won't know until you give people a chance.

8. There are some people who believe stimulants are under utilized. Realistically they tend to be pretty safe in the long run, can objectively increase someones quality of life, and have a very favorable risk/benefit profile in most patients. There are many adults with ADHD who were never treated for ADHD as kids. Its a lot harder to diagnose those at times, due to lack of collateral, but thats when you have to use clinical judgement and weigh risk/benefit ratio. I mean hell, my dad thought ADHD was a made up diagnosis to put kids on pills basically, lol. Are they also prescribed? For sure. Thats why we have to do our due diligence and weigh risk/benefit. If I have a 30 year old patient with no red flags, coming to be with significant inattention sx at work, no medical comorbidities, and shes failing her courses in college why would you not consider ADHD just because of her age? I mean if you give her vyvanse and her job performance goes up, she aces school, and now is financially doing well, and things are going better at home, with no downside, i dont understand why you wouldnt treat.

Pharmacological Calvinism has been a recognized issue in our field for many decades.

 

[Stagg737]

So because you, the consultant who would see people who have a panic attack after starting Adderall, have seen it in your specific narrow niche of a role, every single person who has ever even smelled Adderall must have severe panic attacks? Your experiences means it's "nearly all" instead of "relatively few"?

Also, you're entirely proving my point. You get consulted on people who had a panic attack after starting a stimulant. Naturally, you stop the stimulant instead of starting Xanax. Therefore, as I said, rational psychiatrists aren't out there starting Xanax after someone had a panic attack from the first dose of Adderall.

My point was that relatively low doses of stimulants, even sub-therapeutic doses, can easily cause anxiety. I see it frequently. I’m also outpatient and get plenty of referrals for managing “ADHD”. I never said “nearly all”, just that it’s not uncommon, especially for people who don't actually have ADHD.

I agree that starting Xanax on someone having anxiety as a side effect from a stimulant is inappropriate though.

 

[FlowRate]

If I have a 30 year old patient with no red flags, coming to be with significant inattention sx at work, no medical comorbidities, and shes failing her courses in college why would you not consider ADHD just because of her age?

I think these threads bring different opinions from different people in part because there are very different patient presentations that I think some of us are seeing (or reacting to) more than others. I think few of us would deny ADHD treatment to someone with obvious ADHD just because they weren't diagnosed as a kid.

What some people are likely reacting to are all of the "straight-A's since kindergarten, top of my law school class, reasonably effective in my law job, but just not as efficient/focused as I think everyone else must be." Who then come up with (typically relatively mild) examples for each and every one of the inattentive ADHD symptoms without any signs of hyperactivity or in-the-room inattention. They almost always say "I always thought I had it as a kid but my parents didn't believe" or something along those lines. These patients probably don't have ADHD.

I think the the range of acceptable "impairment" to be considered to have the diagnosis was dramatically broadened by the DSMIV-TR to DSMV transition including a very generous severity spectrum (e.g. Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning) and moving from "There must be clear evidence of clinically significant impairment in social, academic or occupational functioning" to "There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning."

This discussion usually brings out the multiple people (especially on reddit, but also here), who identify with their ADHD diagnosis, find stimulants helpful, and also did well through med school etc. prior to diagnosis who reiterate that we all must be heartless and uninterested in helping patients. But you can see how it presents a very challenging clinical situation.

 

[vanfanal]

do we agree though that just because someone takes a friends adderall and “feels better”, it doesn’t certify a diagnosis of ADHD. I encounter flawed logic too much. They come in and say that they were more focused and productive, inevitably energy was better too, so they think this confirms the diagnosis and they want a prescription. Most people who take a stimulant will feel good, of course, it’s a stimulant, the neurochemical basis for happiness itself.

Half my class got it prescribed during studying for steps.

 

[comp1]

So you can definitely do diagnosis by medication trial for some conditions, but not for ADHD. The vast majority of people feel better and are more functional on stimulants, ADHD or not.

 

[Merovinge]

So you can definitely do diagnosis by medication trial for some conditions, but not for ADHD. The vast majority of people feel better and are more functional on stimulants, ADHD or not.

Really, like which ones? Other than catatonia with benzo challenges, I was instructed that there are a lot of perils to diagnosis based on response to trials and virtually no benefits.

 

[ObsequiousAplomb]

So you can definitely do diagnosis by medication trial for some conditions, but not for ADHD. The vast majority of people feel better and are more functional on stimulants, ADHD or not.

I, too, am curious what conditions other than catatonia you can diagnose by medication trial (and even then you're just identifying the catatonia modifier for the underlying condition). I was taught that it's really not appropriate to diagnose based on a medication trial (even people unconscious for non-opioid reasons sometimes wake up after Narcan, etc)

 

[Stagg737]

Really, like which ones? Other than catatonia with benzo challenges, I was instructed that there are a lot of perils to diagnosis based on response to trials and virtually no benefits.

I, too, am curious what conditions other than catatonia you can diagnose by medication trial (and even then you're just identifying the catatonia modifier for the underlying condition). I was taught that it's really not appropriate to diagnose based on a medication trial (even people unconscious for non-opioid reasons sometimes wake up after Narcan, etc)

"Definitely can" vs should are different things. If I've got a hyperactive patient in the hospital with negative UDS, pressured speech, and grandiosity who hasn't slept in 5 days, they get worse after 2 days of monitoring, and then get better in 3-4 days after starting a loading dose of depakote I'm putting my money on bipolar disorder. is that how I'd diagnose them for certain? No, but Occam's razor says they're bipolar unless there's something else major being missed.

I'll disagree with Comp a bit in that I've seen a patient with severe ADHD that our residents thought was bipolar until he got 10mg of ritalin on the unit and became "normal". However, that's someone whose ADHD was so bad it was incredible to me that no one had figured it out before he got "manic". But for "mild ADHD" I agree that "improvement" with stimulants certainly is not diagnostic.