Honestly, why do some many Psychiatrists not like CAP

[clozareal]

Now that I'm no longer in CAP and am working with very sick adults, I've got to say- it is 100% the family dynamics. Most kids don't end up with mental illness for no reason, and when the dysfunction is coming from inside the house, as it were... Well let's just say it can become quite stressful to provide meaningful care when you can't change the environment. Yet parents expect you to "fix" their child while often making no changes themselves, and then blaming you if progress doesn't occur.

Disagree with the bolded. I know some kids with pretty great families who have kids with autism, ADHD, anxiety, depression, PTSD for reasons outside their family. Family dynamics of course play into it but to ignore other non-familial environmental factors as well as genetic contributors isn't a helpful formulation.

Most parents I work with don't expect a quick fix with meds. Many DON'T want meds for their kids and want environmental/parental modifiers first. I do a LOT of parent management training, parent-child interaction therapy, supportive parenting for anxious childhood emotions, and mentalization based treatment for families so many parents are indeed willing to put in the work.

---

Members don't see this ad.

 

[PikminOC]

Disagree with the bolded. I know some kids with pretty great families who have kids with autism, ADHD, anxiety, depression, PTSD for reasons outside their family. Family dynamics of course play into it but to ignore other non-familial environmental factors as well as genetic contributors isn't a helpful formulation.

Most parents I work with don't expect a quick fix with meds. Many DON'T want meds for their kids and want environmental/parental modifiers first. I do a LOT of parent management training, parent-child interaction therapy, supportive parenting for anxious childhood emotions, and mentalization based treatment for families so many parents are indeed willing to put in the work.

Are you a psychiatrist? Because by the time they reach me, all they want are meds.

And all the cap kids you put on stimulants become adults on ever increasing doses a their lives get more complicated.

I rarely see people do anything other than take meds. The rest requires work. Much like in other fields of meds.

 

[Mad Jack]

Disagree with the bolded. I know some kids with pretty great families who have kids with autism, ADHD, anxiety, depression, PTSD for reasons outside their family. Family dynamics of course play into it but to ignore other non-familial environmental factors as well as genetic contributors isn't a helpful formulation.

Most parents I work with don't expect a quick fix with meds. Many DON'T want meds for their kids and want environmental/parental modifiers first. I do a LOT of parent management training, parent-child interaction therapy, supportive parenting for anxious childhood emotions, and mentalization based treatment for families so many parents are indeed willing to put in the work.

I'm saying what pushes people away from the field is largely the family dynamics, not that the dynamics are always what causes the illness. In those cases where the parents are often the core of the problem and have significant personality issues, mental illness, or issues with the manner in which they approach parenting that they are not amenable to changing, treatment becomes very hard. 90% of families are great. The 10% that aren't... They make life very challenging. My time was spent in a high-acuity community clinic that only patients whom had previously failed treatment or medically complex cases got referrals to, so perhaps it is an atypical experience. But the challenging parents were enough to put me off of the field forever.

 

[Mad Jack]

Are you a psychiatrist? Because by the time they reach me, all they want are meds.

And all the cap kids you put on stimulants become adults on ever increasing doses a their lives get more complicated.

I rarely see people do anything other than take meds. The rest requires work. Much like in other fields of meds.

Yeah, as another difficult example that came up with some frequency: parents who would get angry because they would insist their child had ADHD due to behavioral issues in the home. Meanwhile the kids were thriving and well-behaved outside of the home and doing well in school. I would recommend parenting strategies, therapy, etc as appropriate but often would get an earful about being "wrong" and "not knowing their child." This sort of thing would happen about once every other month. I get it though. The number of intact families I had in my clinic was very low, and people want quick fixes because they're single parents struggling to get by, often with multiple children and jobs that don't pay living wages. Perhaps they think some medication will magically turn their child into an angel, and they have neither the time nor energy for therapeutic approaches. Waitlists for therapy stretch 6 months long, so they waited months to see me and now they've got to wait months for something that will take further months to help.

So yeah, people would get angry and yell at me. Some would insult my skills as a physician after I don't give them their desired diagnosis. This sort of thing doesn't bother me in inpatient adult psychiatry, because my patients are typically very ill. But in the outpatient setting? It grates on me.

I will say, the vast majority of the kids I saw did need meds though, by the nature of where I worked. Many of the parents were very grateful for the care I provided, but that 10% that were challenging really just spoiled the whole experience

 

[PikminOC]

Yeah, as another difficult example that came up with some frequency: parents who would get angry because they would insist their child had ADHD due to behavioral issues in the home. Meanwhile the kids were thriving and well-behaved outside of the home and doing well in school. I would recommend parenting strategies, therapy, etc as appropriate but often would get an earful about being "wrong" and "not knowing their child." This sort of thing would happen about once every other month. I get it though. The number of intact families I had in my clinic was very low, and people want quick fixes because they're single parents struggling to get by, often with multiple children and jobs that don't pay living wages. Perhaps they think some medication will magically turn their child into an angel, and they have neither the time nor energy for therapeutic approaches. Waitlists for therapy stretch 6 months long, so they waited months to see me and now they've got to wait months for something that will take further months to help.

So yeah, people would get angry and yell at me. Some would insult my skills as a physician after I don't give them their desired diagnosis. This sort of thing doesn't bother me in inpatient adult psychiatry, because my patients are typically very ill. But in the outpatient setting? It grates on me.

I will say, the vast majority of the kids I saw did need meds though, by the nature of where I worked. Many of the parents were very grateful for the care I provided, but that 10% that were challenging really just spoiled the whole experience

The affluent parents are no different. They "know" what they need .....

 

[Mad Jack]

The affluent parents are no different. They "know" what they need .....

Despite being perhaps 1% of my clinic, affluent parents were 50% of my problems

 

[calvinhobbes]

I would say the “family dynamics” problems people are afraid of in CAP, is no different than geriatric psych, where the little old lady or man comes in with 5 family members, all trying to explain their version of the story for their 90 year old demented relative that “suddenly” needs help. Psychiatry usually always has demanding family members, so I don’t think the issues brought up here with CAP are any different than the elderly. Even patients in their 30s-60s will still call the office and bother you, it’s a job that requires people skills and quite frankly I find CAP easier because once you get the parents on your side, the kid usually is easy to treat. Geri psych is harder in my opinion because no matter how many times you make granny happy, angry daughter will always blame you for some side effect, etc. Parents are usually so grateful when little Timmy finally is doing better in school, however. I guess it’s all relative but if people don’t go into CAP because their afraid of family dynamics and family therapy, well, then they shouldn’t go into psychiatry in the first place.

 

[Candidate2017]

There's huge demand for CAP and CAP pays more than adult psych. And yet, many CAPs prefer to spend 50% of their clinical time seeing adult patients. OP, think about that.

 

[PikminOC]

I would say the “family dynamics” problems people are afraid of in CAP, is no different than geriatric psych, where the little old lady or man comes in with 5 family members, all trying to explain their version of the story for their 90 year old demented relative that “suddenly” needs help. Psychiatry usually always has demanding family members, so I don’t think the issues brought up here with CAP are any different than the elderly. Even patients in their 30s-60s will still call the office and bother you, it’s a job that requires people skills and quite frankly I find CAP easier because once you get the parents on your side, the kid usually is easy to treat. Geri psych is harder in my opinion because no matter how many times you make granny happy, angry daughter will always blame you for some side effect, etc. Parents are usually so grateful when little Timmy finally is doing better in school, however. I guess it’s all relative but if people don’t go into CAP because their afraid of family dynamics and family therapy, well, then they shouldn’t go into psychiatry in the first place.

The parents I see don't want to change or face dynamics . Just fix Timmy.

 

[clozareal]

I'm saying what pushes people away from the field is largely the family dynamics, not that the dynamics are always what causes the illness. In those cases where the parents are often the core of the problem and have significant personality issues, mental illness, or issues with the manner in which they approach parenting that they are not amenable to changing, treatment becomes very hard. 90% of families are great. The 10% that aren't... They make life very challenging. My time was spent in a high-acuity community clinic that only patients whom had previously failed treatment or medically complex cases got referrals to, so perhaps it is an atypical experience. But the challenging parents were enough to put me off of the field forever.

I misread your initial post. I am in a low acuity private practice so our experiences are likely very different. I do have extremely challenging parents but they usually don't stick around to pay my fees. Another benefit of not taking insurance.

 

[clozareal]

Are you a psychiatrist? Because by the time they reach me, all they want are meds.

And all the cap kids you put on stimulants become adults on ever increasing doses a their lives get more complicated.

I rarely see people do anything other than take meds. The rest requires work. Much like in other fields of meds.

Yes, I'm a child and adolescent psychiatrist. I enjoy doing therapy which is probably why I see a lot of it.

I would say the “family dynamics” problems people are afraid of in CAP, is no different than geriatric psych, where the little old lady or man comes in with 5 family members, all trying to explain their version of the story for their 90 year old demented relative that “suddenly” needs help. Psychiatry usually always has demanding family members, so I don’t think the issues brought up here with CAP are any different than the elderly. Even patients in their 30s-60s will still call the office and bother you, it’s a job that requires people skills and quite frankly I find CAP easier because once you get the parents on your side, the kid usually is easy to treat. Geri psych is harder in my opinion because no matter how many times you make granny happy, angry daughter will always blame you for some side effect, etc. Parents are usually so grateful when little Timmy finally is doing better in school, however. I guess it’s all relative but if people don’t go into CAP because their afraid of family dynamics and family therapy, well, then they shouldn’t go into psychiatry in the first place.

I do have lots of young adults in their 20s and now even in their 30s and 40s with parents being highly involved. It's much more common nowadays that 20 and 30 year olds are living with their parents/family. I don't see many geriatric patients nowadays but my 70 year old geriatric patient has her father pay for appointments and has always had a tenuous enmeshed relationship with him.

For my caseloads, a vast majority of my CAP patients with ADHD or anxiety get better with meds + therapy. I am surprised to have so many teens in my PP who refuse to get off their SSRI because they are scared to get anxious or depressed again and are doing so well in high school and with friends on it. This wasn't my experience during residency/fellowship though.

 

[Merovinge]

Yes, I'm a child and adolescent psychiatrist. I enjoy doing therapy which is probably why I see a lot of it.


I do have lots of young adults in their 20s and now even in their 30s and 40s with parents being highly involved. It's much more common nowadays that 20 and 30 year olds are living with their parents/family. I don't see many geriatric patients nowadays but my 70 year old geriatric patient has her father pay for appointments and has always had a tenuous enmeshed relationship with him.

For my caseloads, a vast majority of my CAP patients with ADHD or anxiety get better with meds + therapy. I am surprised to have so many teens in my PP who refuse to get off their SSRI because they are scared to get anxious or depressed again and are doing so well in high school and with friends on it. This wasn't my experience during residency/fellowship though.

I mean that's exactly what the research suggests. A big issue is disseminating meds+therapy to the general population. Of course that's a great part of doing the work, you don't need to do anything heroic, just help kids get the best practice treatment and have a good network of therapists to refer to and results are typically pretty good (or be a boss and do the therapy yourself).

 

[Stagg737]

Is it though? I’m CAP in PP and yes, the shortage is annoying but (and maybe this is just the area I’m in + luck) ADHD is absolutely one of the most satisfying things to treat. I’ve had several where it has been life-changing to find the right treatment. I also enjoy all of the associated therapy to help patients with better habits and organization/productivity. Nowhere near being a nightmare from my perspective!

Completely depends on the area. The outpatient portion of my job is a telehealth clinic to a rural area of our state. Some patients have to travel over an hour to get their stimulants and won't even know if they're available at that pharmacy from month to month. Even in the "cities" where there are multiple pharmacies for my patients they sometimes will have to call 4 or 5 and then travel out of town to get them. It is 1000x more painful than when I was a resident and the shortage wasn't an issue.

 

[PikminOC]

Completely depends on the area. The outpatient portion of my job is a telehealth clinic to a rural area of our state. Some patients have to travel over an hour to get their stimulants and won't even know if they're available at that pharmacy from month to month. Even in the "cities" where there are multiple pharmacies for my patients they sometimes will have to call 4 or 5 and then travel out of town to get them. It is 1000x more painful than when I was a resident and the shortage wasn't an issue.

The shortage is due to overprescribing. Stimulants are overprescribed.

 

[Mad Jack]

There's huge demand for CAP and CAP pays more than adult psych. And yet, many CAPs prefer to spend 50% of their clinical time seeing adult patients. OP, think about that.

Around here it pays less, unless you do inpatient or private practice. The reimbursement is trash, literally would have taken a 27k pay cut versus adult inpatient to do outpatient child at the same place

 

[TexasPhysician]

The shortage is due to overprescribing. Stimulants are overprescribed.

Both true and false. There are caps on stimulant production, so you can’t ramp up production. Over-prescribing by certain clinicians or groups like Cerebral certainly exists. It is a problem which is why Ryan Haight laws should return. As a country, research shows the USA does not over-diagnose ADHD compared to other countries on average. Eliminate the Covid loopholes and I’d argue we do pretty well at managing ADHD compared to other countries.

 

[Mad Jack]

The shortage is due to overprescribing. Stimulants are overprescribed.

That isn't necessarily true. The DEA comes up with arbitrary quotas that they provide no justification for that each pharmacy is allotted. No one knows how the formula is determined or whether it is accurate because it is not public. Some pharmacies and areas seem to get more generous allocations than others and no one knows why because, well, they don't tell us (or anyone).

The solution to overprescribing should be targeting the people prescribing meds inappropriately, not by providing arbitrary barriers that are most likely to be overcome by the exact population that you're trying to keep said drugs away from. If someone is looking to sell or get a fix, they'll go to every pharmacy in the state. My kids with severe, aggressive ADHD that had families without cars that had one pharmacy in walking distance? They were SOL and ended up staring down expulsions, suspensions, and DCF involvement because of the good 'ol DEA

 

[PikminOC]

I have seen stimulants given out like candy from physicians.

Both true and false. There are caps on stimulant production, so you can’t ramp up production. Over-prescribing by certain clinicians or groups like Cerebral certainly exists. It is a problem which is why Ryan Haight laws should return. As a country, research shows the USA does not over-diagnose ADHD compared to other countries on average. Eliminate the Covid loopholes and I’d argue we do pretty well at managing ADHD compared to other countries.

Pls post the citation. And the treatment they use in other countries is stimulants?

 

[PikminOC]

That isn't necessarily true. The DEA comes up with arbitrary quotas that they provide no justification for that each pharmacy is allotted. No one knows how the formula is determined or whether it is accurate because it is not public. Some pharmacies and areas seem to get more generous allocations than others and no one knows why because, well, they don't tell us (or anyone).

The solution to overprescribing should be targeting the people prescribing meds inappropriately, not by providing arbitrary barriers that are most likely to be overcome by the exact population that you're trying to keep said drugs away from. If someone is looking to sell or get a fix, they'll go to every pharmacy in the state. My kids with severe, aggressive ADHD that had families without cars that had one pharmacy in walking distance? They were SOL and ended up staring down expulsions, suspensions, and DCF involvement because of the good 'ol DEA

I see the affluent and drug abusers seek stims out esp when inappropriate

 

[clozareal]

I have seen stimulants given out like candy from physicians.

Pls post the citation. And the treatment they use in other countries is stimulants?

The cross-country differences in rates of diagnosis of ADHD was required reading in my CAP fellowship.

The worldwide prevalence of ADHD: is it an American condition? - PMC

Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that affects up to 1 in 20 children in the USA. The predominance of American research into this disorder over the past 40 years has led to the impression that ADHD is largely ...

www.ncbi.nlm.nih.gov

Some countries have banned Adderall, like Japan, Singapore, Bali, Thailand, UAE, and much of Europe, but not lis/dexamphetamine for Europe due to it's abuse potential from being more rewarding (although diversion rates are similar). There is a neurotoxic effect from amphetamines is much more than methylphenidates, where it can be neuroprotective in certain cases (parkinson, stroke, meth abuse). Methylphenidate is first line in most places.

 

[PikminOC]

The cross-country differences in rates of diagnosis of ADHD was required reading in my CAP fellowship.

The worldwide prevalence of ADHD: is it an American condition? - PMC

Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that affects up to 1 in 20 children in the USA. The predominance of American research into this disorder over the past 40 years has led to the impression that ADHD is largely ...

www.ncbi.nlm.nih.gov

Some countries have banned Adderall, like Japan, Singapore, Bali, Thailand, UAE, and much of Europe, but not lis/dexamphetamine for Europe due to it's abuse potential from being more rewarding (although diversion rates are similar). There is a neurotoxic effect from amphetamines is much more than methylphenidates, where it can be neuroprotective in certain cases (parkinson, stroke, meth abuse). Methylphenidate is first line in most places.

Thank you. So stimulants are used much more sparingly in other countries rather than the US where it's a free for all.

 

[PikminOC]

The cross-country differences in rates of diagnosis of ADHD was required reading in my CAP fellowship.

The worldwide prevalence of ADHD: is it an American condition? - PMC

Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that affects up to 1 in 20 children in the USA. The predominance of American research into this disorder over the past 40 years has led to the impression that ADHD is largely ...

www.ncbi.nlm.nih.gov

Some countries have banned Adderall, like Japan, Singapore, Bali, Thailand, UAE, and much of Europe, but not lis/dexamphetamine for Europe due to it's abuse potential from being more rewarding (although diversion rates are similar). There is a neurotoxic effect from amphetamines is much more than methylphenidates, where it can be neuroprotective in certain cases (parkinson, stroke, meth abuse). Methylphenidate is first line in most places.

No more recent article than 2003? That's 20 years ago. Have the numbers changed since then?

 

[clozareal]

No more recent article than 2003? That's 20 years ago. Have the numbers changed since then?

You can't Google this yourself? The question is nuanced because it does depend on the methodology (which DSM version they are using), what methodology is used for the studies (parents, teachers, clinicians), and what demographics are looked at.

General Prevalence of ADHD - CHADD

GLOBAL A meta-analysis of 175 research studies worldwide on ADHD prevalence in children aged 18 and under found an overall pooled estimate of 7.2% (Thomas et al. 2015). The US Census Bureau estimates 1,795,734,009 people were aged 5-19 worldwide in 2013. Thus, 7.2% of this total population is...

chadd.org

 

[PikminOC]

You can't Google this yourself? The question is nuanced because it does depend on the methodology (which DSM version they are using), what methodology is used for the studies (parents, teachers, clinicians), and what demographics are looked at.

General Prevalence of ADHD - CHADD

GLOBAL A meta-analysis of 175 research studies worldwide on ADHD prevalence in children aged 18 and under found an overall pooled estimate of 7.2% (Thomas et al. 2015). The US Census Bureau estimates 1,795,734,009 people were aged 5-19 worldwide in 2013. Thus, 7.2% of this total population is...

chadd.org

So the numbers are steadily increasing. I rarely prescribe stimulants

 

[allantois]

DSM is not used in Europe.
I would not expect ADHD prevalence to differ across the world, what is different is that it is over treated in the US much in the same way opioids are overprescribed in the US. As a European, I will say that there is just a much different attitude towards medicating away ailments in the US vs in Europe

Controlled Substance Market | Global Industry Report, 2027

Controlled Substance Market by Drug (Opioids, Stimulants, Depressants, Cannabinoids), Application (ADHD, Pain Management, Depression, Sleep Disorder, Cough Suppression, Anxiety, Seizure, Others), Distribution Channel (Hospital Pharmacies, Retail Pharmacies, Online Pharmacies), Geography and Forecast

www.transparencymarketresearch.com

 

[PikminOC]

DSM is not used in Europe.
I would not expect ADHD prevalence to differ across the world, what is different is that it is over treated in the US much in the same way opioids are overprescribed in the US. As a European, I will say that there is just a much different attitude towards medicating away ailments in the US vs in Europe

Controlled Substance Market | Global Industry Report, 2027

Controlled Substance Market by Drug (Opioids, Stimulants, Depressants, Cannabinoids), Application (ADHD, Pain Management, Depression, Sleep Disorder, Cough Suppression, Anxiety, Seizure, Others), Distribution Channel (Hospital Pharmacies, Retail Pharmacies, Online Pharmacies), Geography and Forecast

www.transparencymarketresearch.com

Yes.

 

[smalltownpsych]

I am pretty sure that we diagnose at a much higher rate than the actual prevalence. Last I looked into this the stats were like 10% of school age boys being diagnosed and prevalence estimates being 3%. That was years ago and I could be misremembering or misstating.

 

[Stagg737]

The shortage is due to overprescribing. Stimulants are overprescribed.

Sure, but access to stims wasn't an issue 3-5 years ago the way it is now. Most of the patients I'm seeing/referring to have been stable on their stims for 10+ years and have not had issues getting them until the last year or two. Unfortunately, most recent prescribing data I can see is for 2021, so doesn't really cover the years when access has become a major issue for those legitimately needing them.

 

[PikminOC]

Sure, but access to stims wasn't an issue 3-5 years ago the way it is now. Most of the patients I'm seeing/referring to have been stable on their stims for 10+ years and have not had issues getting them until the last year or two. Unfortunately, most recent prescribing data I can see is for 2021, so doesn't really cover the years when access has become a major issue for those legitimately needing them.

Yes because during covid they were even more overprescribed than usual.

Just because your patients could get it before 21 doesnt mean they weren't overprescribed then too.

 

[Mad Jack]

So the numbers are steadily increasing. I rarely prescribe stimulants

Stimulants were literally life changing for kids and their families in my clinic. I am not a fan of them, but they have their place. A lot of adults likely have undiagnosed ADHD, but I rarely prescribe them to my adult patients unless they've got a well-established or verifiable histories of childhood behavioral and attention problems

 

[PikminOC]

Stimulants were literally life changing for kids and their families in my clinic. I am not a fan of them, but they have their place. A lot of adults likely have undiagnosed ADHD, but I rarely prescribe them to my adult patients unless they've got a well-established or verifiable histories of childhood behavioral and attention problems

Opioids were life changing too. Doesn't mean they are not overprescribed

 

[Merovinge]

Opioids were life changing too. Doesn't mean they are not overprescribed

That's such a profoundly disingenuous statement for any physician to make. Opioids have nearly no data suggesting any benefits to their long-term use and had active subterfuge of their addictive, dependence, and pain hypersensitivity issues. Psychostimulants have a mountain of cross-population and cross-generation data showing long-term benefits in a way that very few chronic medication interventions do. That's not to say online ADHD pill mills aren't a problem (they absolutely are), but to conflate psychostimulants for ADHD with opioids used for "the fifth vital sign" or chronic pain is just rubbish.

 

[PikminOC]

That's such a profoundly disingenuous statement for any physician to make. Opioids have nearly no data suggesting any benefits to their long-term use and had active subterfuge of their addictive, dependence, and pain hypersensitivity issues. Psychostimulants have a mountain of cross-population and cross-generation data showing long-term benefits in a way that very few chronic medication interventions do. That's not to say online ADHD pill mills aren't a problem (they absolutely are), but to conflate psychostimulants for ADHD with opioids used for "the fifth vital sign" or chronic pain is just rubbish.

Stimulants are in the same dea category as opioids when it comes to abusability, tolerance, etc.

And how do other countries manage without prescribing them?

And I'd say concentration has become the fifth vital sign 🤣

 

[ObsequiousAplomb]

Stimulants are in the same dea category as opioids when it comes to abusability, tolerance, etc.

And how do other countries manage without prescribing them?

And I'd say concentration has become the fifth vital sign

You know, nobody in this thread has presented any data saying that stimulants in general are given in lesser quantities in other countries. Just that different stimulants are given in different countries. It may be methylphenidate, dexamphetamine, lisdexamfetamine, bupropion, atomoxetine, or Provigil instead of Adderall. Saying that one drug is banned in some countries means the entire class isn't used is downright illiterate.

 

[PikminOC]

You know, nobody in this thread has presented any data saying that stimulants in general are given in lesser quantities in other countries. Just that different stimulants are given in different countries. It may be methylphenidate, dexamphetamine, lisdexamfetamine, bupropion, atomoxetine, or Provigil instead of Adderall. Saying that one drug is banned in some countries means the entire class isn't used is downright illiterate.

So how many other stimulants used in other countries where Adderall is banned? Enlighten me

Know Before You Go: International Travel with ADHD Medications - CHADD

Do you plan to travel out of the United States, either for business or on vacation? Before you go, you need to reach out to both the US Department of State and the embassy of the country you plan to visit if you intend to take your ADHD medication with you. “Travelers should not assume…

chadd.org

 

[clozareal]

Yes because during covid they were even more overprescribed than usual.

Just because your patients could get it before 21 doesnt mean they weren't overprescribed then too.

Can you back up your claims with data if you're going to be making the claims?

The stimulant shortage was largely in part due to a manufacturing delay in one manufacturer. Teva pharmaceuticals having huge issues hiring people during COVID. They are the largest producer of Adderall so this had a cascading effect on the other stimulants as patients switched to other meds to replace it. This delay has been resolved though as of March this year. This is due to the tight regulations on the number of medications that can be made by each manufacturer, which the FDA and DEA just released a letter last week to address this.

Stimulants do seem to have increased by about 10% from 2020 to 2021 according to the CDC (although in the FDA letter above they said 45% increase?). However, overprescribing is subjective term. How do we know that telehealth didn't increase the access to psychiatrists and more people are adequately being treated as opposed to being undertreated before?

Regardless, it seems like it's multifactorial. Manufacturing delays combined with more prescribing due to laxer rules led to this perfect storm and headache we are dealing with.

 

[Mad Jack]

Opioids were life changing too. Doesn't mean they are not overprescribed

We've got plenty of long-term data on these kids that show stimulants both have good and durable outcomes when compared to nontreatment. You should also keep in mind I work with cases that were typically DCF involved due to school behavioral issues/refusal, violence toward peers and siblings, etc. Their outcomes without intervention were headed toward expulsion and possibly being removed from their own homes, and typically every non-medication intervention had already been tried, as had non-stimulants. To equate those kids doing well on meds with people getting opioids for pain, it's beyond ridiculous as a comparison

As to overprescribed, I have yet to see any data supportive of it. Some practices overprescribed, certainly, but given the overall resolution rate of ADHD in adults being 50/50 in the better studies out there, on a pure numbers basis it could easily be argued stimulants are vastly underprescribed in adults based upon the available evidence

 

[PikminOC]

I've seen many places that don't ask much to give out stims, don't drug test, or pill count. There's a reason stims are being sold on college campuses and elsewhere. There are many extra floating around by people who don't need them.

 

[TexasPhysician]

I've seen many places that don't ask much to give out stims, don't drug test, or pill count. There's a reason stims are being sold on college campuses and elsewhere. There are many extra floating around by people who don't need them.

In prisons, seroquel, trazodone, Wellbutrin, Benadryl, and many other meds have value and are floating around.

In high schools, cough medicine and cleaning solvents are abused.

Should we ban all of those?

Pill counts? That is a waste of time. Do you do this with lisinopril to ensure compliance? If the patient abused lisinopril and replaced the pills with a different pill altogether, are you familiar enough with all generic sizes and colors of lisinopril to ensure they weren’t all switched?

There is no indication to drug screen the average patient much like there is no reason to do full body MRI’s. You won’t find out how many the patient took via drug screen and if anything, you’ll discover a lack of abuse when patients forget to take it.

We have tons of data that we are under-treating ADHD and that stims reduce the risk of substance abuse overall.

Are there some clinics that make it too easy to get them? Sure. Just like there are too many urgent cares giving out abx for viral issues. We will never achieve med perfection, but the overall benefit with stims far outweighs negatives.

 

[PikminOC]

In prisons, seroquel, trazodone, Wellbutrin, Benadryl, and many other meds have value and are floating around.

In high schools, cough medicine and cleaning solvents are abused.

Should we ban all of those?

Pill counts? That is a waste of time. Do you do this with lisinopril to ensure compliance? If the patient abused lisinopril and replaced the pills with a different pill altogether, are you familiar enough with all generic sizes and colors of lisinopril to ensure they weren’t all switched?

There is no indication to drug screen the average patient much like there is no reason to do full body MRI’s. You won’t find out how many the patient took via drug screen and if anything, you’ll discover a lack of abuse when patients forget to take it.

We have tons of data that we are under-treating ADHD and that stims reduce the risk of substance abuse overall.

Are there some clinics that make it too easy to get them? Sure. Just like there are too many urgent cares giving out abx for viral issues. We will never achieve med perfection, but the overall benefit with stims far outweighs negatives.

It's a c2. That's a great reason to drug test and do pill counts. It's nor Lisinopril. I see you don't do drugs screens. So you don't know if it's being diverted or combined with illicit drugs.

 

[TexasPhysician]

It's a c2. That's a great reason to drug test and do pill counts. It's nor Lisinopril. I see you don't do drugs screens. So you don't know if it's being diverted or combined with illicit drugs.

You have been asking for research on this thread to back up claims and other posters have provided it.

Please provide data demonstrating that pill counts and drug screens should be utilized on every C2 patient including how they reduce risk of illicit drug use and diversion.

I drug screen patients when concerns arise.

 

[VA Hopeful Dr]

It's a c2. That's a great reason to drug test and do pill counts. It's nor Lisinopril. I see you don't do drugs screens. So you don't know if it's being diverted or combined with illicit drugs.

Interestingly, the DEA does make a distinction between opioids which are schedule 2 and things like stimulants which are technically schedule 2N the N being for non-narcotic).

 

[calvnandhobbs68]

It's a c2. That's a great reason to drug test and do pill counts. It's nor Lisinopril. I see you don't do drugs screens. So you don't know if it's being diverted or combined with illicit drugs.

Yeah I mean pill counts are just kind of not useful in general. I think I've done it once and honestly it wasn't really that useful it was just to kind of make it clear to a college kid that I'd be keeping an eye on them.

Anyone with half a brain will just build up a little extra supply of like half a month's worth over time and then just use that to account for any missing pills unless they're literally selling their whole prescription (and even then, they'll just keep a month's worth of meds as backup to use for pill counts). People who are misusing prescription stimulants are not generally misusing it in the way people misuse oxycodone or benzos or even a stimulant like methamphetamine....it's more of a performance enhancement so they'll build up a supply and use it to stay up all night coding or studying or something or they'll sell off part of their supply to other people to use to study/work.

 

[Stagg737]

Yes because during covid they were even more overprescribed than usual.

Just because your patients could get it before 21 doesnt mean they weren't overprescribed then too.

True, but if a patient has been on the same dose for 10+ years, showed significant improvements when taking it and significant deficits when not taking it (I've had more than one patient who only got into car accidents when they didn't have their prescriptions), and there's no evidence of abuse, you think that's a problem? Because that's the population I've been prescribing to.

I've seen many places that don't ask much to give out stims, don't drug test, or pill count. There's a reason stims are being sold on college campuses and elsewhere. There are many extra floating around by people who don't need them.

The general uselessness of pill counts has been discussed on this forum several times. Drug screening can be valuable when warranted, but is unnecessary and wasteful bloat/expense when not done with appropriate discretion. Yes, many places do not ask much to diagnose and give out stims. The same applies for benzos or really any psych med as plenty of places practice garbage medicine. Frankly, I see far more patients abusing and diverting benzos than stimulants and the idea that stims are schedule 2 and benzos schedule 5 says more about the bias in the scheduling than the actual evidence for those categories.

 

[PikminOC]

True, but if a patient has been on the same dose for 10+ years, showed significant improvements when taking it and significant deficits when not taking it (I've had more than one patient who only got into car accidents when they didn't have their prescriptions), and there's no evidence of abuse, you think that's a problem? Because that's the population I've been prescribing to.


The general uselessness of pill counts has been discussed on this forum several times. Drug screening can be valuable when warranted, but is unnecessary and wasteful bloat/expense when not done with appropriate discretion. Yes, many places do not ask much to diagnose and give out stims. The same applies for benzos or really any psych med as plenty of places practice garbage medicine. Frankly, I see far more patients abusing and diverting benzos than stimulants and the idea that stims are schedule 2 and benzos schedule 5 says more about the bias in the scheduling than the actual evidence for those categories.

Do patients lie? I thought benzos were schedule 4.
They are both dea classified and the same steps should be taken with each, starting with the drug screen prior to starting and during treatment
Why do you need a drug test for ADHD meds?


Such screenings are designed to check if ADHD patients are safely taking their pills, such as Adderall, and not selling them, taking too many, or using other drugs.Mar 25, 2023

 

[PikminOC]

Interestingly, the DEA does make a distinction between opioids which are schedule 2 and things like stimulants which are technically schedule 2N the N being for non-narcotic).

Yes but it's still Dea classified.

 

[PikminOC]

Too many people are getting these meds for performance enhancement which is not adhd.

My states I have licenses in require this drug testing, and it makes sense to me.

Obviously neither of us is going to change each other's minds.

I would make a lot more money if I was looser with the prescriptions, looked the other way in terms of drug testing etc, but I choose not to practice that way.

I think all controlled subs should be treated the same way. Imho

 

[Mad Jack]

I've seen many places that don't ask much to give out stims, don't drug test, or pill count. There's a reason stims are being sold on college campuses and elsewhere. There are many extra floating around by people who don't need them.

My general policy is to not treat my patients like criminals unless I have a reason to suspect otherwise

 

[PikminOC]

Yeah I mean pill counts are just kind of not useful in general. I think I've done it once and honestly it wasn't really that useful it was just to kind of make it clear to a college kid that I'd be keeping an eye on them.

Anyone with half a brain will just build up a little extra supply of like half a month's worth over time and then just use that to account for any missing pills unless they're literally selling their whole prescription (and even then, they'll just keep a month's worth of meds as backup to use for pill counts). People who are misusing prescription stimulants are not generally misusing it in the way people misuse oxycodone or benzos or even a stimulant like methamphetamine....it's more of a performance enhancement so they'll build up a supply and use it to stay up all night coding or studying or something or they'll sell off part of their supply to other people to use to study/work.

If they're building up a supply they don't need it for true ADHD. And people find any ways to abuse stimulants too

 

[PikminOC]

My general policy is to not treat my patients like criminals unless I have a reason to suspect otherwise

It's not treatment like criminals. It's trusting but verifying. I know it's hard to believe, but some patients lie.

My states require classes in controlled substance prescription classes in each state and these are their recommendations. My states have been coming down hard on these issues too.