Another would you ever...

[eaglepsych]

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A new County-type job of mine has me working with quite a number of persons with severe substance abuse histories and various degrees of poverty, as well as some histories consistent with Antisocial PD.
I have found myself considering things that I never would have considered before (coming from a background in CMHC and private practice) in an effort to try and help patients at times. For instance, i think for most people its always easier to say no to prescribing an abusable substance to one with signif risk factors if that scenario is not all that common in one's practice. Whereas, if/when most of your patients have substance abuse histories and are requesting certain treatments AND many members of treatment community are a bit more loosey-goosey when it comes to prescribing and supporting certain treatments, it can make one consider things that otherwise we wouldnt consider.

Wanted to share an example with you: adult with hx of ADHD who has many year hx of incarceration and hx of opiate dependence, may or may not be on suboxone maintenance, and readily admits to buying stimulants off the street (mostly a controleld dosage of Vyvanse last # of months) to treat his ADHD to make him feel "normal," not crave other substances, be more productive at work, etc. Pt is not an mj smoker or alcohol user per pt. let's say it really looks like this pt is trying to do the right thing in life at this time.

would anyone ever consider writing a script for vyvanse for a pt in such a situation? obviously a confluence of very serious risk factors. lets say wellbutrin/strattera/tenex dont work.

any thoughts would be greatly appreciated.

 

[Doctor Bagel]

Honestly, no, I wouldn't be willing to take on that type of risk. The fact that he has a long history of lying about things also suggests he's likely to lie to you about things even if you're prescribing him what he wants. Now, if you ever did prescribe it, I think you'd want a few years of sobriety (not with buying crap off the streets), confirmed engagement in treatment, regular UAs and a treatment agreement that you will discontinue it if there are any concerning signs (asking for early refills, failing a UA, missing appointments, etc).

 

[smalltownpsych]

I have quite a few years working with substance abusers in a variety of contexts and the two most important things to know are that they lie and that they like to take drugs to change the way they feel. I also strongly believe that both psychiatry and psychology are of extremely limited use with this population and the irony is that the more we recognize that, the more we actually can be of help. Also, the right medication or therapy will not make them stop wanting to get high. The concept of self-medicating can have some serious flaws and is more often than not used as a rationalization for continued substance abuse.

 

[vistaril]

A new County-type job of mine has me working with quite a number of persons with severe substance abuse histories and various degrees of poverty, as well as some histories consistent with Antisocial PD.
I have found myself considering things that I never would have considered before (coming from a background in CMHC and private practice) in an effort to try and help patients at times. For instance, i think for most people its always easier to say no to prescribing an abusable substance to one with signif risk factors if that scenario is not all that common in one's practice. Whereas, if/when most of your patients have substance abuse histories and are requesting certain treatments AND many members of treatment community are a bit more loosey-goosey when it comes to prescribing and supporting certain treatments, it can make one consider things that otherwise we wouldnt consider.

Wanted to share an example with you: adult with hx of ADHD who has many year hx of incarceration and hx of opiate dependence, may or may not be on suboxone maintenance, and readily admits to buying stimulants off the street (mostly a controleld dosage of Vyvanse last # of months) to treat his ADHD to make him feel "normal," not crave other substances, be more productive at work, etc. Pt is not an mj smoker or alcohol user per pt. let's say it really looks like this pt is trying to do the right thing in life at this time.

would anyone ever consider writing a script for vyvanse for a pt in such a situation? obviously a confluence of very serious risk factors. lets say wellbutrin/strattera/tenex dont work.

any thoughts would be greatly appreciated.

Depending on the individual situation I might...sure....I'll definitely say it wouldn't be a definite no.

 

[Doctor Bagel]

Other thoughts -- what does "normal" mean. You've got someone who relies on chemical substances to feel "normal," which is part of the whole baseline problem. Most people feel better and function better on stimulants -- that doesn't mean they need them. So, again, if I ever (which I wouldn't), I'd want to lock down that ADHD diagnosis as thoroughly as possible ideally looking for documented impairment before adulthood, which is hard to get. Actually working and needing a medication to sustain stable employment would be another reasonable requirement -- kids take drug holidays when not in school.

Again, with me, too many red flags at the start with this guy, so I wouldn't feel comfortable. IMO, based on all the contingencies, you'd need to offer this is a system where you have a lot of support for ongoing monitoring, which is a rare thing.

 

[birchswing]

I have quite a few years working with substance abusers in a variety of contexts and the two most important things to know are that they lie and that they like to take drugs to change the way they feel. I also strongly believe that both psychiatry and psychology are of extremely limited use with this population and the irony is that the more we recognize that, the more we actually can be of help. Also, the right medication or therapy will not make them stop wanting to get high. The concept of self-medicating can have some serious flaws and is more often than not used as a rationalization for continued substance abuse.

I'm not saying you're wrong, just that it's surprising that you think psychiatry and psychology are of limited use in treating drug addiction. There are addiction psychiatrists and substance abuse counselors, but I don't know of any other area of medicine that deals with addiction at all. It's fairly well accepted, at least as a lay person, that taking drugs in some people creates a disease process. Who treats such a person if not a psychiatrist?

 

[michaelrack]

Wanted to share an example with you: adult with hx of ADHD and readily admits to buying stimulants off the street (mostly a controleld dosage of Vyvanse last # of months) to treat his ADHD to make him feel "normal," . let's say it really looks like this pt is trying to do the right thing in life at this time.

would anyone ever consider writing a script for vyvanse for a pt in such a situation? .

any thoughts would be greatly appreciated.

I would tell him that I would really like to help, and tell him that he may benefit from a stimulant prescription, but that I was unwilling to risk my medical license/DEA license and that therefore I would be unable to write him a prescription for controlled substances.

 

[erg923]

just that it's surprising that you think psychiatry and psychology are of limited use in treating drug addiction.

I disagree strongly as well. MI and ME can be helpful , but probably not that robust. However, once the patient is in the door and ready to make a change, Marlats RP model, combined with some mindfulness stuff has moderate effects size outcomes in the literature.

I'm curious what the perceived benefit is to the patient in the above posted scenario? Using a substance to "feel normal" is substance dependence, basically. Why not have him worked up for ad/hd and then Rx whatever med is indicated if that diagnosis is confirmed. Claiming "a hx of ADHD" means squat really. Confirm it yourself. And be wary of the 2 billion differentials for an adult claiming this diagnosis as well. This might be one of the small segment of cases where some testing would be helpful.

 

[Ceke2002]

I have quite a few years working with substance abusers in a variety of contexts and the two most important things to know are that they lie and that they like to take drugs to change the way they feel. I also strongly believe that both psychiatry and psychology are of extremely limited use with this population and the irony is that the more we recognize that, the more we actually can be of help. Also, the right medication or therapy will not make them stop wanting to get high. The concept of self-medicating can have some serious flaws and is more often than not used as a rationalization for continued substance abuse.

As a recovered addict I can say that in my experience at least this is partly true. I tried the whole abstinence combined with therapy approach - sitting there week after week trying to analyse and understand all the inner mechanisms that had lead to my addiction, and how I could use these new found insights to conquer my addiction - and it just didn't work. As a matter of fact I was far more likely to be triggered into using after a therapy session, considering I'd just spent 45 minutes talking about my drug use, and hey why not sit a heroin addict down and talk about their heroin use in minutely examined detail for close to an hour, and then turn them back out onto the streets...I mean it's not like the first thing they'll think to do is head straight to their dealer's (she said sarcastically). What did eventually work for me was a far more straightforward approach - Methadone with a slow taper schedule combined with a short course of being taught simple CBT style exercises that gave me options for dealing with things like cravings and triggers. Yes I'd also reached a point where I was damn near ready to crawl through broken glass just to get clean, and I did also make the decision to completely change my environment (avoiding certain areas, cutting ties with people who were still using, and so on), but when it came down to the actual treatment side of things it was less a case of me needing therapy and far more a case of me responding best to just being taught some pretty straightforward, practical solutions for managing daily life as a non addict.

In terms of having both a hx and dx of adult ADD, yes absolutely I self medicated (I self medicated a lot of stuff). I've always maintained my drug of addiction was heroin, but my drug of choice was pretty much anything in the amphetamine class (especially crystal meth). When I was using amphetamines I could think clearly, keep my house clean and organised, hold down a job, drive a car safely, - all great stuff, so you'd think that my being prescribed amphetamine based ADHD meds would have been the ideal solution, get me off the illicit stuff, get me properly medicated and I'd be sorted. Except it didn't exactly turn out that way, because I wasn't just using amphetamines to feel and function as a normal person would, I was taking them to get ripped off my face. So I jumped through all the required hoops to get my shiny new, legitimate script for Dexamphetamine - and then promptly started popping them like they were going out of style, or just using meth on top of them anyway. The sum total of any positive effect I received from being properly medicated for my ADD, after years of self medication, was exactly zero. While I was still an addict, I behaved as an addict regardless of whether my need for a certain medication was legitimate (it actually was) or not.

 

[Ceke2002]

I disagree strongly as well. MI and ME can be helpful , but probably not that robust. However, once the patient is in the door and ready to make a change, Marlats RP model, combined with some mindfulness stuff has moderate effects size outcomes in the literature.

I believe Marlats RP model, or at least a variation of it was what was used in my case. Very practical, CBT style relapse prevention measures. It worked.

 

[smalltownpsych]

I have used Motivational Interviewing and RP and encouraged patients to participate in recovery-oriented groups. All of these approaches have about the same success rate according to the literature. What I am referring to is the concept that there is something causing the addiction and that if we treat that, then the addiction will go away. In my experience, this mistaken belief is pervasive throughout the field. Many clinicians misunderstand the concept of dual-diagnosis or co-morbidity, as well, and mistake this for causality. Substances of abuse can medicate just about any symptom you can have. Alcohol is probably the oldest and most effective psychotropic medication around. Alleviating severe psychiatric symptoms can be a key component of recovery, but what I see every day is an overdiagnosing and overmedicating of psychiatric symptoms that are a result of long-term substance use. Another problem is that the research on addiction tends to be relatively short-term when you are looking at a chronic life-long issue. It is difficult to explain or reference the points I am making since I do have work to do, but as this is part of my dissertation research, there is lot of info that i have on this topic. A final point to make is that there was published research about chronic alcoholics being able to resume drinking in moderation. This issue gets rehashed every few years. In my research, I cam across an unpublished thesis that did a ten year follow-up of one of these studies and found that out of an initial sample of 100, 10 had died directly from alcohol related illness, 80 had been arrested, a big percentage (I forget that number) had been to inpatient treatment again. Out of the group of a 100 only one was found to have continued with moderate drinking.

 

[Ceke2002]

What I am referring to is the concept that there is something causing the addiction and that if we treat that, then the addiction will go away. Many clinicians misunderstand the concept of dual-diagnosis or co-morbidity, as well, and mistake this for causality.

Yes, this is what I was trying to say, in particular the point I've bolded. You, of course, have managed to condense it into a couple of simple sentences whereas I waffled on for a whole paragraph, but regardless - Quoted For Truth 😀

 

[splik]

i think it is unfortunate that we can be very moralistic about substance use and concerns about people getting high off drugs. i am not really convinced prescribed psychotropic drugs are any better than street drugs (and in many cases they are the same thing). but i have prescribed stimulants commonly in patients with ADHD and substance abuse where there was a clear developmental history suggestive of it, and where there were clear outcomes for measuring treatment success and regular UA monitoring. as far as abusable drugs go stimulants are a lot safer than benzos and opioids which are heavily overprescribed by our internal medicine colleagues. as long as there is a clear rationale for prescribing, monitoring, and outline of grounds for stopping/continuing treatment i think it could be considered. even if the patient was on suboxone. but you would have to know what they were on. i absolutely won't prescribe benzos and stimulants together which seems much more common practice than makes sense. also in terms of treating ADHD, stimulants are first line pharmacotherapy. abuse potential does not seem a good reason to use inferior drugs such as wellbutrin or straterra which don't really work all that well if at all.

 

[dl2dp2]

I would tell him that I would really like to help, and tell him that he may benefit from a stimulant prescription, but that I was unwilling to risk my medical license/DEA license and that therefore I would be unable to write him a prescription for controlled substances.

There's not enough information to make this statement.

You could consider getting an addiction psychiatry consultation, but perhaps there's insufficient resources to do that.

If someone has ADHD, it's documented, obvious, supported by collateral/psychological testing, the standard of care is a combination of medication and therapy, and there's good evidence that treating the ADHD has a positive effect on the substance use disorder that's co-morbid, though the evidence is very confusing. The last big NIDA study on this is from the clinical trials network (CTN-0028, Concerta in adolescents with SUDs), which had an overall negative result, but subgroup analysis showed that more specifically in patients with more severe problems, such as conduct disorder and ASPD, Concerta was helpful.

However, the risk of abuse/diversion may be too high. If that's the case, you can provide a way to circumvent that. For example, you can tell him to fill the script and have his parole officer to give it to him once a week. If he's at a halfway house you can have a behavioral contract and collateral system set up so that only the staff at the halfway house can dispense the medication to him.

If he really has ADHD, he'll agree to these maneuvers. If he's lying to you he won't agree. If you try it for a few weeks you'll know if he's lying or not.

Addiction psychiatry isn't rocket science, but it might be worthwhile talking the case through with someone who has more subspecialized experience.

 

[vistaril]

i think it is unfortunate that we can be very moralistic about substance use and concerns about people getting high off drugs. i am not really convinced prescribed psychotropic drugs are any better than street drugs (and in many cases they are the same thing). but i have prescribed stimulants commonly in patients with ADHD and substance abuse where there was a clear developmental history suggestive of it, and where there were clear outcomes for measuring treatment success and regular UA monitoring. as far as abusable drugs go stimulants are a lot safer than benzos and opioids which are heavily overprescribed by our internal medicine colleagues. as long as there is a clear rationale for prescribing, monitoring, and outline of grounds for stopping/continuing treatment i think it could be considered. even if the patient was on suboxone. but you would have to know what they were on. i absolutely won't prescribe benzos and stimulants together which seems much more common practice than makes sense. also in terms of treating ADHD, stimulants are first line pharmacotherapy. abuse potential does not seem a good reason to use inferior drugs such as wellbutrin or straterra which don't really work all that well if at all.

We'll I think in many cases it is not a moral case or a do they Deserve to get high case, but rather a case of worrying about things like diversion or the pt being arrested for other drugs or whatever.

And yes there are some possible safeguards, but in every setting they don't exist. Many agencies for example aren't going to have a structure in place that allows for regular ua monitoring....which is easy to get around for most drugs anyway.

As for benzos and stimulants, yes I agree it is extremely common amongst private practice psychs. It makes plenty of sense from a pt and practice management standpoint. I'm also seeing this increase a bunch amongst child psychs.

 

[michaelrack]

There's not enough information to make this statement.

.

Sure there is:

I would tell him that I would really like to help TRUE

tell him that he may benefit from a stimulant prescription TRUE

I was unwilling to risk my medical license/DEA license and that therefore I would be unable to write him a prescription for controlled substances TRUE


Now someone with more addiction experience may be willing to take the risk (and it is still a risk even with the safeguards you describe), but I wouldn't. However, I guess I should make the effort to try to refer him to an addiction expert (although without $$$ resources, this patient is going to be out of luck in most areas)

 

[vistaril]

Sure there is:

I would tell him that I would really like to help TRUE

tell him that he may benefit from a stimulant prescription TRUE

I was unwilling to risk my medical license/DEA license and that therefore I would be unable to write him a prescription for controlled substances TRUE


Now someone with more addiction experience may be willing to take the risk (and it is still a risk even with the safeguards you describe), but I wouldn't. However, I guess I should make the effort to try to refer him to an addiction expert (although without $$$ resources, this patient is going to be out of luck in most areas)

I think the key thing to point out is that the safeguards mentioned are usually not going to be realistic or feasible. And thats the difference between the real world and the fantasy world. Most of us are out here practicing in the real world, and we're limited to that reality.....

 

[dl2dp2]

I think the key thing to point out is that the safeguards mentioned are usually not going to be realistic or feasible. And thats the difference between the real world and the fantasy world. Most of us are out here practicing in the real world, and we're limited to that reality.....

There's no argument from me there. It *might* be something OP can work out, and it's not absolutely out of the question to prescribe someone a stimulant like that in such a case, but without the proper system I would never hand out a prescription willy-nilly to someone like that. I'm just saying that in principle (or fantasy, as you say), there's no scientific reason why this wouldn't be part of good practice. But yes, lots of evidence based treatment aren't implemented because of "real world" problems. Whether or not this is applicable in this case is a judgement OP needs to make.

 

[michaelrack]

I'm just saying that in principle (or fantasy, as you say), there's no scientific reason why this wouldn't be part of good practice. But yes, lots of evidence based treatment aren't implemented because of "real world" problems. .

agree, and one of the "real world" word problems is an occasionally over-zealous DEA/state licensing board

 

[Doctor Bagel]

i think it is unfortunate that we can be very moralistic about substance use and concerns about people getting high off drugs. i am not really convinced prescribed psychotropic drugs are any better than street drugs (and in many cases they are the same thing). but i have prescribed stimulants commonly in patients with ADHD and substance abuse where there was a clear developmental history suggestive of it, and where there were clear outcomes for measuring treatment success and regular UA monitoring. as far as abusable drugs go stimulants are a lot safer than benzos and opioids which are heavily overprescribed by our internal medicine colleagues. as long as there is a clear rationale for prescribing, monitoring, and outline of grounds for stopping/continuing treatment i think it could be considered. even if the patient was on suboxone. but you would have to know what they were on. i absolutely won't prescribe benzos and stimulants together which seems much more common practice than makes sense. also in terms of treating ADHD, stimulants are first line pharmacotherapy. abuse potential does not seem a good reason to use inferior drugs such as wellbutrin or straterra which don't really work all that well if at all.

Why do you think stimulants are lower risk than benzos? I guess I feel like they're both risky with addictive potential, dangerous side effects and lots of diversion possibilities.

As far as the moralistic component, I don't know that I would never prescribe stimulants to someone with an addiction history, but I would be hesitant to do so for someone with pretty clear antisocial personality disorder and a long history of misusing/not taking/potentially diverting medications without a pretty big infrastructure to behind me. I think that's a little more realistic than moralistic.

 

[billypilgrim37]

Crack is so much easier to get than Vyvanse.

I had a mom on methadone and hx of dealing pull her kid out AMA last week because I wouldn't prescribe her kid Adderall, only Vyvanse. Shame, too, as kid was doing great for the few days on the Vyvanse.

I'm not sure (ie, I'm wondering, not questioning so much) what trouble you could possibly get into for prescribing a normal dose of Vyvanse to someone with ADHD, regardless of other noncardiac factors.

With due diligence as suggested by others, you could make a big difference in this guy's life if you wound up correctly treating his ADHD. A lot of diligence required. Impulsive decisions are the hallmark of the disability associated with adult adhd, and decreasing a few of those here and there can go a long way.

 

[whopper]

would anyone ever consider writing a script for vyvanse for a pt in such a situation? obviously a confluence of very serious risk factors. lets say wellbutrin/strattera/tenex dont work

Yes, but it'd have to be under several circumstances that most would not be able to be in.
1) Is there a level of supervision or oversight at least several hours a day with frequent drug testing?
2) Has the person been clean for at least a month?

If both are yes, and the person is found to function significantly better on a stimulant, I'd be open to giving it. Remember that it's virtually impossible to get situations 1 & 2 done.

But I'd be open, that's it. The next things that would have to happen is 3) the person could only take the stimulant with supervision (so they could not pocket/cheek it and then sell it) 4) The person supervising the administration would have to be very trust-worthy.

Again, we're setting situations that are next to impossible to achieve in the community.

 

[Ceke2002]

However, the risk of abuse/diversion may be too high. If that's the case, you can provide a way to circumvent that. For example, you can tell him to fill the script and have his parole officer to give it to him once a week. If he's at a halfway house you can have a behavioral contract and collateral system set up so that only the staff at the halfway house can dispense the medication to him.

If he really has ADHD, he'll agree to these maneuvers. If he's lying to you he won't agree. If you try it for a few weeks you'll know if he's lying or not.

Having similar safeguards put in place would have really helped me, I would have agreed to it as well. I think nine times out of ten if someone does have a legitimate diagnosis they want help with they will agree to any measures requested of them. Back then I might have been legit, and had the best of intentions, but once that bottle of tablets was in my hand everything went out the window.

 

[Indodo]

I might want to give a solid try of the wellbutrin/strattera/tenex in combination with therapy and drug tests.

 

[billypilgrim37]

Again, we're setting situations that are next to impossible to achieve in the community.

In child, I often have the benefit of dependable parents. Not always, of course, but fairly often. The biggest diversion risk for stimulants in that age group (and the college crowd) is selling their stimulants to the smart kids and then using the money to buy pot, or just trading it outright for pot. That's where I can get burned on Focalin XR, Concerta, or Vyvanse, all of which are not very useful to get high, but are plenty useful for studying.