PRN Adderall for Adult ADHD?

[reca]

I've now seen 4 patients who were transferred to me from outside providers who've come in with a prescription for PRN adderall for ADHD. They've all had their provider (2 psychiatrists, 2 NP's) prescribe it on a PRN basis and told them to use it when they have extra meetings at work or a big test coming up. This isn't just them saying it, I've verified that this is indeed what their previous provider told them.

Is this normal? It seems like a backdoor way of using stimulants as performance enhancers rather than to actually treat ADHD. I couldn't find much literature on the use of stimulants PRN in ADHD and was wondering if anyone here had insight into this?

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[Ceke2002]

I've now seen 4 patients who were transferred to me from outside providers who've come in with a prescription for PRN adderall for ADHD. They've all had their provider (2 psychiatrists, 2 NP's) prescribe it on a PRN basis and told them to use it when they have extra meetings at work or a big test coming up. This isn't just them saying it, I've verified that this is indeed what their previous provider told them.

Is this normal? It seems like a backdoor way of using stimulants as performance enhancers rather than to actually treat ADHD. I couldn't find much literature on the use of stimulants PRN in ADHD and was wondering if anyone here had insight into this?

(Personal anecdote) I don't know how common it is, but it was presented to me as an option when I was taking medication to treat ADHD. After about 2 weeks on dexamphetamine (this was the 90s) I found the side effects outweighed any benefit I was getting, so my treating Psychiatrist at the time decided I could go on an 'as needed' basis if I wanted to (so if I was just relaxing at home, don't take the medication; if I had a work/study day or whatever, then take the medication). I think I tried it that way for about a week or so before I decided I just wanted to not be on the medication at all, and instead to concentrate on finding non medication ways of dealing with symptoms. I got the thinking behind 'prn' but I'm not sure if I ever thought it was going to be effective just using the meds as a sort of performance enhancer like that.

 

[lyla]

i know patients who wouldn’t take it on weekends (since they were off work). This is new to me though to take it prn.

 

[Liquid8]

Those looking for a brief performance boost tend not to come to my attention, as it’s generally cheaper to obtain drugs through alternative channels than to wait months to see a psychiatrist. Most of my ADHD patients require medication regularly and notice benefits outside of academic or occupational settings - PRN use can be indicated depending on the individual patient.

For example - have a patient who manages well on Vyvanse 50mg which covers their standard work day, but every so often has extended days where the medication runs out with hours to spare. They had originally been started on dexamphetamine, but found the effects ran out after a couple of hours, it was too much of a hassle to dose multiple times per day, leading to the switch to the long acting Vyvanse. As such, in this case I can justify prescribing dexamphetamine PRN to use for those longer work days.

Another patient has a similar regime with Concerta during the working week, but has had a long standing social commitment on most Friday nights. As such they tend to sleep in on Saturdays and taking Concerta too late in the day doesn’t work well for them. Hence they are prescribed immediate release Ritalin which they can take around midday with no adverse effects.

 

[NickNaylor]

I haven't had patients prescribed stimulants on a truly PRN basis, but I have had many patients who do not take their stimulants regularly (e.g., they may take it a few days a week). Is this a "backdoor" for cognitive enhancement? I don't know, maybe. But from my perspective this is less concerning for abuse/misuse - although I suppose you could technically consider this misuse - and I typically won't address the stimulant use unless there is a reason to.

 

[Mass Effect]

Yes, it's a thing. I had a patient with a legit ADHD history, dating back to grammar school. I had collateral from patient, mom, and sis. She was someone who couldn't tolerate Adderall side effects and wanted to just use coffee, as she had all her life, but she was in law school and doing very poorly. So I told her she could take low-dose Adderall only on exam weeks and see how she does (no hx of misuse or abuse). She did this and began doing very well. She went from being on academic probation to getting Bs.

 

[TexasPhysician]

Common in certain populations. For instance, some firefighters find that regular use endangers their lives. They want to be distracted by every small thing in a burning building to ensure they make the best decisions possible. When the action has ended, they utilize prn medication to write up the reports in chronological order of what happened.

 

[FlowRate]

For instance, some firefighters find that regular use endangers their lives.

Which brings us back to the somewhat compelling "some people are wired to attend differently" theory. As you point out, sometimes being a little aware of everything is better than being fully aware of just one thing. But that's not usually true in school or in boring desk jobs.

 

[WisNeuro]

I good portion of my evals when someone is prescribed stims for ADHD, it's PRN. This is pretty common in my experience. Don't know about the peds population as I haven't worked in that arena in over a decade.

 

[clausewitz2]

Which brings us back to the somewhat compelling "some people are wired to attend differently" theory. As you point out, sometimes being a little aware of everything is better than being fully aware of just one thing. But that's not usually true in school or in boring desk jobs.

Sitting still and focusing on something boring for a long time is a learned skill that has a significant cultural component to it. In some other societies patterns typical of ADHD are seen as more normal behavior, at least for men. I did some fieldwork in the Republic of Georgia many years ago, and part of it involved trying to get Georgian-speakers to listen to some speech sounds and press one of two buttons. Whole thing took maybe 5 minutes.

Out of 22 attempts exactly one adult male participant who had agreed to complete it sat through this. Most of the others just wandered off after a minute or two or refused to continue because it was not very interesting and "we are southern people who are passionate". Georgian culture is very chauvinistic and the conservative, mythical ideal man always carries knives, excells at close-harmony singing, and drinks wine by the gallon. My female adult Georgian participants, however, had zero trouble completing this. Guess who ends up doing approximately 100% of tedious domestic tasks?

 

[Merovinge]

I good portion of my evals when someone is prescribed stims for ADHD, it's PRN. This is pretty common in my experience. Don't know about the peds population as I haven't worked in that arena in over a decade.

It is not a common experience in Peds and puts up a lot of red flags if it is only being used PRN. What is appropriate is a daily long acting medication (Focalin XR, Concerta, Vyvanse, Adderall XR being the top 4) with a prn in the afternoon for times when additional concentration is required as the medication is trailing off. I have a patient who takes Focalin XR daily and then on driver's ed days takes prn Focalin IR for example but not on his other days.

 

[Mass Effect]

It is not a common experience in Peds and puts up a lot of red flags if it is only being used PRN. What is appropriate is a daily long acting medication (Focalin XR, Concerta, Vyvanse, Adderall XR being the top 4) with a prn in the afternoon for times when additional concentration is required as the medication is trailing off. I have a patient who takes Focalin XR daily and then on driver's ed days takes prn Focalin IR for example but not on his other days.

Why would it raise red flags? I would think that during the school year, a long acting is great, but over the summer, don't a lot of kids take med holidays? During those months, I can see needing a prn if they were, say, needing to complete their reading list, had summer school, or were involved in some activity that required attention. One of my classmates in middle school took a theater class over the summer and only used her ADHD med (don't know what she took) on class days, but if we were out swimming, at the mall, etc, she skipped it.

 

[futuredo32]

I have patients who take weekends or holidays off. As someone with ADHD I tried everything under the sun for it and couldn't tolerate the side effects. I tried it again for the board exam and it just made my anxiety worse.

 

[reca]

Why would it raise red flags? I would think that during the school year, a long acting is great, but over the summer, don't a lot of kids take med holidays? During those months, I can see needing a prn if they were, say, needing to complete their reading list, had summer school, or were involved in some activity that required attention. One of my classmates in middle school took a theater class over the summer and only used her ADHD med (don't know what she took) on class days, but if we were out swimming, at the mall, etc, she skipped it.

I'm not talking about having a scheduled + PRN for evening classes or meetings that go on long. I'm talking about getting a prescription for 5-10 pills of adderall IR to last for a month. Used solely when there's an exam coming up or close to a project deadline. I'm wondering how someone can truly have ADHD but do perfectly fine in their work/school, relationships, life in general to the point that without medication, they're not experiencing difficulties. BUt when there's an exam, suddenly their ADHD is relevant and adderall is indicated? How is this any different than a college student without ADHD who abuses stimulants? Does fine until there's an exam, stimulant helps cram for the exam, then no need for stimulants after the exam is done.

 

[Mass Effect]

I'm not talking about having a scheduled + PRN for evening classes or meetings that go on long. I'm talking about getting a prescription for 5-10 pills of adderall IR to last for a month. Used solely when there's an exam coming up or close to a project deadline. I'm wondering how someone can truly have ADHD but do perfectly fine in their work/school, relationships, life in general to the point that without medication, they're not experiencing difficulties. BUt when there's an exam, suddenly their ADHD is relevant and adderall is indicated? How is this any different than a college student without ADHD who abuses stimulants? Does fine until there's an exam, stimulant helps cram for the exam, then no need for stimulants after the exam is done.

ADHD doesn't have to be debilitating to be real. Many people have a legitimate diagnosis, don't use stimulants, and are able to cope in relationships and life in general, especially by the time they reach adulthood. That doesn't mean they don't have it. It just means they choose not to use stimulants to control it or they are high functioning enough that they can compensate without 24/7 meds. It's a spectrum. I had a classmate in med school who nearly failed MS 3 year due to untreated ADHD. It was so bad, the rest of us could see it a mile away. Truly scattered. Even his presentations and notes were all over the place. Somehow he got through MS1 and MS2 without meds (or so he said), but by MS3 there was no hiding it. Then you have people who complete med school and compensate without meds all the way through, but can't pull it off in residency. They may be fine when they're in clinic 9 - 5 with an attending keeping them on track, but when they're on a 24 hour shift by themselves, they may realize they can't get anything done because they're all over the place. And then you have those who are fine in med school during regular weeks because they compensate, but during exam week, when they're already stressed and have multiple things to study, their ADHD is out of control and they can't focus on one subject/lecture at a time. When they take the test, their concentration just isn't there and they're sunk the second someone gets up to use the bathroom or the second someone finishes the exam and turns it in.

I think prns are totally okay in the above scenario. In fact, I think we should be pushing for prns in general rather than daily dosing even when the patient doesn't need it. Why should someone who can compensate 90% of the time be forced to take the med and suffer the side effects every single day? There's really no justification for that, in my opinion, if they genuinely can get by without it.

As for prn doses being the same as abusing stimulants, I couldn't possibly disagree more. I'll offer this: would you feel that someone s/p car accident who takes opiates prn for pain (and finds that sometimes all he needs is Tylenol) is the same as the guy who buys opiates off the street without pain?

 

[keifernny2]

ADHD doesn't have to be debilitating to be real. Many people have a legitimate diagnosis, don't use stimulants, and are able to cope in relationships and life in general, especially by the time they reach adulthood. That doesn't mean they don't have it. It just means they choose not to use stimulants to control it or they are high functioning enough that they can compensate without 24/7 meds. It's a spectrum. I had a classmate in med school who nearly failed MS 3 year due to untreated ADHD. It was so bad, the rest of us could see it a mile away. Truly scattered. Even his presentations and notes were all over the place. Somehow he got through MS1 and MS2 without meds (or so he said), but by MS3 there was no hiding it. Then you have people who complete med school and compensate without meds all the way through, but can't pull it off in residency. They may be fine when they're in clinic 9 - 5 with an attending keeping them on track, but when they're on a 24 hour shift by themselves, they may realize they can't get anything done because they're all over the place. And then you have those who are fine in med school during regular weeks because they compensate, but during exam week, when they're already stressed and have multiple things to study, their ADHD is out of control and they can't focus on one subject/lecture at a time. When they take the test, their concentration just isn't there and they're sunk the second someone gets up to use the bathroom or the second someone finishes the exam and turns it in.

I think prns are totally okay in the above scenario. In fact, I think we should be pushing for prns in general rather than daily dosing even when the patient doesn't need it. Why should someone who can compensate 90% of the time be forced to take the med and suffer the side effects every single day? There's really no justification for that, in my opinion, if they genuinely can get by without it.

As for prn doses being the same as abusing stimulants, I couldn't possibly disagree more. I'll offer this: would you feel that someone s/p car accident who takes opiates prn for pain (and finds that sometimes all he needs is Tylenol) is the same as the guy who buys opiates off the street without pain?

I think that the problem with your analogy is that most prescriptions for opiates are intended to be time-limited, during the healing process. Your description of the use of stimulants PRN would theoretically go on forever.

 

[Mass Effect]

I think that the problem with your analogy is that most prescriptions for opiates are intended to be time-limited, during the healing process. Your description of the use of stimulants PRN would theoretically go on forever.

Not necessarily. Take a med student who only used meds during exam week or when taking the STEPs, that person does not necessarily need/want to take Adderall forever. There are doctors out there with ADHD who choose not to take medications for it and especially as attendings, they may not need to.