Handling the ubiqitous "Adult Onset" ADD/ADHD --- what is your practice?

[JustPlainBill]

I've recently had a spate of adults (22 y/o+) that have either a) never had childhood ADD/ADHD or b) stopped meds prior to starting college who have presented requesting ADD/ADHD treatment -- usually self diagnosed, new stress at work, feel like they can't focus, have trouble multi-tasking -- some of these are college grads, etc. or are now faced with office paperwork after a promotion and are struggling ---

2 recent cases have prompted this thread --

Had a young male that had moved from another state and wanted to establish care -- knew medications, doses, etc. -- went ahead and filled the script, and requested records; don't see the patient for about 2 months (given 30 day supply) -- shows up 2 months after first visit requesting 90 day supply citing copay costs, etc. -- Do a drug screen and refill one month (new to my practice, etc.), refer to psych -- drug screen returns a few days later positive for cannabis (illegal in my state) -- patient returns in one month, didn't follow up with psych, tell them I'm not writing until I get a negative UDS (we drew one that day) -- patient gets a little ugly telling me I'm interfering with his life, he's just trying to do right, etc. --- UDS drawn that day comes back positive -- discharge the patient from my practice -- likely seeking behavior.

Another case -- young male who stated he was on meds as a kid, no knowledge of med/dose -- start low dose Adderall after appropriate screening and draw UDS at first visit --- UDS is positive, patient comes back 6 weeks after initial visit -- states he was out of town x 2 weeks -- again, getting another UDS -- will refill based on outcome of UDS ---

Also had a female who self dx'd with ADD, tried a friends medication which "helped a lot", wanted meds that day -- told her that since she had 1) finished college with no problems 2) was not sleeping well 3) had just been promoted with more responsibilities and taskings, this was likely not ADHD and I would refer her to psych for further eval just to be sure, hence I was not going to prescribe -- she became a bit hostile and told me that she wanted a prescription-- told her I understood, but she was being referred to psych -- not a happy camper.

There's a part of me that doesn't even want to handle this and just send adult ADHD to psych for eval and initiation of treatment -- I'll handle them after that --- but then it's really not too hard.

I've had some conversations get ugly, had a few belligerent patients, etc. Being an employed physician, I'm always cognizant of how the partners are going to react if I wind up dismissing too many patients or get patient complaints.

How does everyone else handle this type of stuff?

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[smq123]

I've recently had a spate of adults (22 y/o+) that have either a) never had childhood ADD/ADHD or b) stopped meds prior to starting college who have presented requesting ADD/ADHD treatment -- usually self diagnosed, new stress at work, feel like they can't focus, have trouble multi-tasking -- some of these are college grads, etc. or are now faced with office paperwork after a promotion and are struggling ---

2 recent cases have prompted this thread --

Had a young male that had moved from another state and wanted to establish care -- knew medications, doses, etc. -- went ahead and filled the script, and requested records; don't see the patient for about 2 months (given 30 day supply) -- shows up 2 months after first visit requesting 90 day supply citing copay costs, etc. -- Do a drug screen and refill one month (new to my practice, etc.), refer to psych -- drug screen returns a few days later positive for cannabis (illegal in my state) -- patient returns in one month, didn't follow up with psych, tell them I'm not writing until I get a negative UDS (we drew one that day) -- patient gets a little ugly telling me I'm interfering with his life, he's just trying to do right, etc. --- UDS drawn that day comes back positive -- discharge the patient from my practice -- likely seeking behavior.

Another case -- young male who stated he was on meds as a kid, no knowledge of med/dose -- start low dose Adderall after appropriate screening and draw UDS at first visit --- UDS is positive, patient comes back 6 weeks after initial visit -- states he was out of town x 2 weeks -- again, getting another UDS -- will refill based on outcome of UDS ---

Also had a female who self dx'd with ADD, tried a friends medication which "helped a lot", wanted meds that day -- told her that since she had 1) finished college with no problems 2) was not sleeping well 3) had just been promoted with more responsibilities and taskings, this was likely not ADHD and I would refer her to psych for further eval just to be sure, hence I was not going to prescribe -- she became a bit hostile and told me that she wanted a prescription-- told her I understood, but she was being referred to psych -- not a happy camper.

There's a part of me that doesn't even want to handle this and just send adult ADHD to psych for eval and initiation of treatment -- I'll handle them after that --- but then it's really not too hard.

I've had some conversations get ugly, had a few belligerent patients, etc. Being an employed physician, I'm always cognizant of how the partners are going to react if I wind up dismissing too many patients or get patient complaints.

How does everyone else handle this type of stuff?

I work at a community health center - several physicians (peds, FM/IM, OB, dental).

Most of our adult physicians will not manage ADHD meds unless they were started by one of our peds physicians and the patient has "aged out" of peds. If we do manage these meds, we do require documentation from the previous prescribing physician.

For your first patient, I would not necessarily assume that they are drug seeking. Many patients use marijuana, whether or not it is legal - especially young patients, and it is common for ADHD patients to use pot to help them deal with underlying anxiety/depression. Unless you specifically warned the patient that he could not use marijuana, and then he did it anyway, I would not dismiss him as a drug seeker. It is fair to refuse to refill the meds because you couldn't get records, though.

2nd patient - I would not refill or manage unless you can get records from the original prescriber.

The female patient - I agree, and would refer her to psych.

Even if it's "not hard," if you don't feel comfortable managing it, don't do it. And yes, ADHD med management isn't "hard," but you also have to weigh how much stress disruptive patients will place on your staff, your nurses, your front desk and phone room staff. Imagine if your patient loses a prescription - are they going to lose their s*** at some poor receptionist just because you refuse to refill it?

 

[mabinante]

Why send to psych though? We are family docs...pretty easy to screen in the office using a basic screening exam or a standardized questionnaire.
I guess it is good to just go once and get evaluated but sending a drug seeker to psych only pawns things off. I'm guessing that will tick off the accepting physician.
Just my $.02

 

[VA Hopeful Dr]

For adult onset, they need more testing than your average family doctor has time to do. There are a huge number of other conditions that can cause difficulty with concentration - depression, anxiety, fatigue, thyroid (both directions), and several personality disorders. If they've post-puberty and never bee diagnosed before, they need some form of psych to see then - can by psychiatry or psychology.

In your cases, unless you made it clear at the onset that they had to stop all illicit substances then you may have been a bit harsh. Its not a bad idea to have a controlled substances contract for stimulants (like what most use for chronic narcotics) that mentions that. Would definitely need records from previous doctors before I'd treat.

Both DSM-4 and -5 require symptoms before 7 and 12 years of age, respectively, so I also would not have treated that third case either.

 

[JustPlainBill]

Why send to psych though? We are family docs...pretty easy to screen in the office using a basic screening exam or a standardized questionnaire.
I guess it is good to just go once and get evaluated but sending a drug seeker to psych only pawns things off. I'm guessing that will tick off the accepting physician.
Just my $.02

I hear you ...but then again, I've had a few patients that wanted to "transfer care" to me from a psych (too far to drive) -- and they were self-titrating Adderall ostensibly at the directions of psych -- it got a little fishy and the patient was unsure of the meds they were on -- ER vs IR, etc. -- so I called their psych -- got into an interesting discussion about people on long term Adderall and having to keep an eye on them to be sure they were going into psychosis or developing mania/bipolar disorder ---

 

[deleted87716]

My practice is to get a good history, have them fill out a Jasper-Goldberg screen, and if it all seems to fit, prescribe a trial of meds with a short-term follow-up appointment after the first month to assess for side effects and efficacy. If something seems fishy, or if they have a substance abuse problem or psychiatric co-morbidities, I will send them to psych. That doesn't happen too often in my practice, however, as I'm typically treating people I've known for a while.

I don't tend to do a lot of UDS for ADD meds unless there's some sort of red flag, but I will routinely check our state's Prescription Monitoring Program (PMP) to make sure they aren't doctor-shopping.

Here are some articles on AFP:

http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=68
http://www.aafp.org/afp/2000/1101/p2077.html
http://www.aafp.org/afp/2012/0501/p890.html

 

[cabinbuilder]

Why send to psych though? We are family docs...pretty easy to screen in the office using a basic screening exam or a standardized questionnaire.
I guess it is good to just go once and get evaluated but sending a drug seeker to psych only pawns things off. I'm guessing that will tick off the accepting physician.
Just my $.02

In all fairness, some of us (talking about myself) have never had ANY psych training nor do I have any training ever starting psych medication. Where I did training, meds were initiated by psych and we just refilled based on their recommendations. I have never done office screening nor ever used any questionaire. Completely foreign to me.

 

[anthroguy]

I'll refill them for one month if a new patient. . Make them a f/u with a psychiatrist, or give them number to call if Medicaid (ask them to call that day as it is difficult to get a psych appointment).

This, like chronic pain I avoid like the plague.

I'm new in practice, but I actually have a few people in their 20s being taken off the stimulants due to development of HTN and in one case actual LVH!
I make a note of that to all people asking for stimulants so that they understand these meds are not risk free!

 

[BigSib]

I'll fill them for patients who have a confirmed diagnosis with supportive prior testing and a long history of taking these, but I typically still give them the option to either taper off or establish with a new psychiatrist after having a generalized discussion about adult ADHD management. I'm a lot more reluctant to fill these if there is no functional goal for the medication as I believe it should be benefiting them in some way and, commonly, people are unable to relate a perceivable benefit other than feeling better on the medication. If records are unavailable I'll fill for 2 weeks and require they fill out a request that day and call the prior office to speed up the process. More often than not I find a prior physician started them on something as a trial without sufficient documentation of the diagnosis or supportive testing.

For adults presenting for a new diagnosis of ADHD I ensure there is no other contributing problem (e.g., consider TSH, depression/anxiety screen, insomnia) and discuss coping mechanisms first. Usually there is some kind of adjustment disorder or major life stressor contributing, and most of the time these patients do not meet criteria for the diagnosis outright. If they are persistent/demanding then I refer them for testing. I never newly prescribe stimulants for adults.

 

[clausewitz2]

There are probably legitimate cases of ADHD that go undiagnosed until one of the more burdensome tasks of adulthood are imposed on the person in question (college, graduate school, a real job) and then old coping strategies fail. This is probably particularly likely in inattentive type ADHD, since it generally doesn't cause the kind of behavioral problems in school that leads to teachers advocating for medication.

To figure that out, though, and separate it from the people who really just believe they need stimulants but would benefit more from other approaches - that takes really careful history and a thorough evaluation. Psychologists will tell you there is no single instrument that allows you to diagnose ADHD reliably. This sort of thing seems like it would take far more time and effort than you lot generally have in clinic.

Frankly I think the family docs who advertise "ADHD clinics" are mostly hucksters. If you have not encountered the species, well, tour market is lucky. They are right up there with the PCPs who hand out Xanax QID to anyone who is anxious for any reason.