Controlled Substances During COVID-19

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Prior to the whole country engaging in social distancing, an adult patient saw me and received a 30-day prescription for stimulants. After a week, the patient was extremely anxious about not getting enough medications in the midst of a pandemic and wanted more stimulants. I had another session with the patient prescribed more and in the instruction to the pharmacy specified to fill it in the middle of April (around 30 days after the fill-date of the previous subscription). Patient was aware of the instruction to the pharmacy as I went over it with the patient in the session and patient was fine with it. Over the past few days, patient kept calling the office wanting to me to lift the instruction to the pharmacy as patient wants to fill it ASAP.

For essential medications, I have no problem giving an early refill. But with a potential substance of abuse with minimal life-threatening withdrawal effects, I feel very reluctant to refill it early. If the country is in such a bad shape that major pharmacies are closed, I doubt the patient would be working.

1. Any guidelines for prescribing non-essential medications during COVID-19?

2. What would you have done in this case?

 

[wolfvgang22]

Patients get anxious all the time. You are doing right.
Controlled stimulants are due for renewal when they are due, not earlier. Patients won't die from Adderall withdrawal. You spelled out the policy on this for this patient already. Be sure you documented this education you provided the patient. Consider having the patient sign a controlled substance contract. Reassure the anxious patient and treat anxiety if needed. Maintain proper limits and boundaries as you already are. Use your good clinical judgment and carry on as you are doing. Be sure and document it. Check out the DEA website. Also SAMSHA. They have advice about controlled substances during this pandemic.

I am letting established patients I know well skip routine vitals and labs, drug screens for now during social distancing, if previous values were good and I have no concerns. I make sure the patient knows risks increase with not getting routine labs, and the risk is greater the longer it is not done. I have a vulnerable COPD patient on clozapine that I am taking this approach with, and he is monitored weekly by nursing and social workers. I am following the clozapine REMS advice and the VAs National Clozapine Coordinating Center. You can find their phone numbers on their website if advice is needed. I am seeing patients by video and telephone as much as possible and obtaining only necessary labs (i.e., the patient's lithium was 1.5 and CBC was abnormal, we reduced lithium and must follow up on it.)

 

[Merovinge]

Prior to the whole country engaging in social distancing, an adult patient saw me and received a 30-day prescription for stimulants. After a week, the patient was extremely anxious about not getting enough medications in the midst of a pandemic and wanted more stimulants. I had another session with the patient prescribed more and in the instruction to the pharmacy specified to fill it in the middle of April (around 30 days after the fill-date of the previous subscription). Patient was aware of the instruction to the pharmacy as I went over it with the patient in the session and patient was fine with it. Over the past few days, patient kept calling the office wanting to me to lift the instruction to the pharmacy as patient wants to fill it ASAP.

For essential medications, I have no problem giving an early refill. But with a potential substance of abuse with minimal life-threatening withdrawal effects, I feel very reluctant to refill it early. If the country is in such a bad shape that major pharmacies are closed, I doubt the patient would be working.

1. Any guidelines for prescribing non-essential medications during COVID-19?

2. What would you have done in this case?

Pharmacies are going to be the last of the last essential services to close, there is zero chance one would need Adderall if pharmacies are closed. I think it's fairly likely this patient is either abusing the drug to cope with COVID stress or selling the drug to deal with COVID loss of income. Absolutely no chance I'm filling it early and would be on high alert for abuse/diversion.

 

[TexasPhysician]

No reason to early fill this.

 

[birchswing]

Pharmacies are going to be the last of the last essential services to close, there is zero chance one would need Adderall if pharmacies are closed. I think it's fairly likely this patient is either abusing the drug to cope with COVID stress or selling the drug to deal with COVID loss of income. Absolutely no chance I'm filling it early and would be on high alert for abuse/diversion.

The CDC was telling people weeks ago to have extra supplies of medication. Anecdotally my doctor without my prompting switched all my meds to 90 day supplies and suggested using a drive through pharmacy. Maybe they're being unusually cautious because they're entirely shut down and all appointments are now telehealth. I don't think it's a fear that pharmacies would close, but more a problem of getting out to the pharmacy if you're under quarantine and also more generally the less exposure the better. I've read on this forum that people can get very depressed when stopping amphetamines, even if it isn't directly life threatening. It doesn't seem irrational to me to *attempt* to stockpile medicine if people are stockpiling literally everything else. I say attempt because it sounds like all this patient did was ask. Not saying it should be granted but just that the asking at this particular moment seems to have another more likely explanation than abuse/diversion.

 

[birchswing]

I just talked to a pharmacist friend who works at one of the big chains who said they (the pharmacists) have been petitioning for curbside pick-up/drive-through only, and that that this particular big chain which up until now had not done store delivery of controlled substances is moving very soon toward delivery of controlled and temperature sensitive drugs so that all orders can be delivered because of the epidemic. They've been given an allotment of two masks per week. I've read in the past (regarding flu) that the masks lose efficacy fairly quickly. I'm in a fairly high hit area right now, so that's not ideal for them obviously. Delivery would hopefully mitigate a lot of the risk. Right now they're doing an unofficial curbside pick-up for vulnerable populations even though the store is not really set up for it.

 

[liquidshadow22]

Is it true that for many states you can perform telemedicine visits in states that you do not have an active license during COVID. Does this apply to indirectly related covid care ie. psychiatrists?

 

[Taddy Mason]

Is it true that for many states you can perform telemedicine visits in states that you do not have an active license during COVID. Does this apply to indirectly related covid care ie. psychiatrists?

It depends on interstate agreements, so is variable depending on the states in question.

 

[hamstergang]

Is it true that for many states you can perform telemedicine visits in states that you do not have an active license during COVID. Does this apply to indirectly related covid care ie. psychiatrists?

https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

 

[SourceOfDenial]

Reading this thread you’d think adderral only helps people with ADHD perform work.

If attention is only an issue at work, it’s probably not ADHD.

 

[milesed]

My only issue is with a new patient rx is complying with my state medical board's requirement to have a signed "controlled substance agreement" form when my agency sees no one in person during this. I'm noting why it isn't done and having it signed once they start back in person.