How the hell are high-volume "adult ADHD" clinics still up and running?

[B52slinger]

In my area there is an "Adult ADHD" clinic where one single psychiatrist and a small army of equally unscrupulous NPs are cranking through an ungodly amount of daily stimulant prescriptions. Place has been up and running for years.

And this is all that this particular psychiatrist does, so his prescription records must show something like 90% stimulants. Would it even make a difference to file a report to the state board considering they have been operating like this for likely over a decade?

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[TexasPhysician]

Percent stimulants doesn’t matter.

Likelihood of an issue depends on whether a legit evaluation is performed, other conditions ruled out, and complying with regular appointments required.

 

[calvnandhobbs68]

Right, it’s not that hard to have someone fill out an ASRS, PHQ9 and GAD7, say their screening information suggests ADHD and you’ve ruled out other common psychiatric conditions, patient denies substance use issues and you think ADHD is the main issue causing “trouble focusing”, say they meet DSM5 criteria for ADHD, +/- make them do a UDS, check PDMP every now and then and come back every 1-3 months for their 15 minute appointment to refill stimulants.

Whether this is appropriate diagnostic technique or not can be discussed all day but you’re not going to get in trouble with the DEA for arguments in your field about the subtleties of diagnosing a condition, you’re going to get in trouble for doing things that are clearly outside of acceptable practice. Many of these ADHD clinics also do some kind of computerized/CPT testing they make the patient pay for which further adds a feeling of legitimacy to the diagnosis.

 

[WisNeuro]

Right, it’s not that hard to have someone fill out an ASRS, PHQ9 and GAD7, say their screening information suggests ADHD and you’ve ruled out other common psychiatric conditions, patient denies substance use issues and you think ADHD is the main issue causing “trouble focusing”, say they meet DSM5 criteria for ADHD, +/- make them do a UDS, check PDMP every now and then and come back every 1-3 months for their 15 minute appointment to refill stimulants.

Whether this is appropriate diagnostic technique or not can be discussed all day but you’re not going to get in trouble with the DEA for arguments in your field about the subtleties of diagnosing a condition, you’re going to get in trouble for doing things that are clearly outside of acceptable practice. Many of these ADHD clinics also do some kind of computerized/CPT testing they make the patient pay for which further adds a feeling of legitimacy to the diagnosis.

Yeah, I mean people are "diagnosed" with depression and anxiety, and medicated, based on screeners and like a 2 minute conversation all the time. I think one would have a hard time making an argument to the board that someone is outside of the standard of care by doing similarly in what is most likely a stimulant pill mill as long as they meet a minimum bar for documentation and follow-up procedures.

 

[randomdoc1]

The DEA probably knows and is keeping tabs. But to actually take action, there needs to be a strong enough leg to stand on. The patients are probably not going to complain about it. And it's harder to have an adverse medical outcome with stims as opposed to benzos.

 

[littlefred]

In my area there is an "Adult ADHD" clinic where one single psychiatrist and a small army of equally unscrupulous NPs is cranking through an ungodly amount of daily stimulant prescriptions. Place has been up and running for years.

And this is all that this particular psychiatrist does, so his prescription records must show something like 90% stimulants. Would it even make a difference to file a report to the state board considering they have been operating like this for likely over a decade?

They are playing most likely within the regulations, making that money and laughing all the way to the bank.

The major problem here is allowing these medications to be prescribed with little oversight (opioid, stimulant, benzo pill mills). Compare that little oversight to the oversight on methadone clinics (which is also a schedule II) ... it's a joke.

 

[Sushirolls]

Which sometimes, I almost just think we should open the flood gates, allow open access pharmacies like other countries. Role back the nuances of licensure/board cert etc to truly allow free for all. Let the quack NDs do what they want. OD do what they want. PharmD do what they want. RNs without NP or DNP... do what they want. Release the Kraken.

 

[littlefred]

Which sometimes, I almost just think we should open the flood gates, allow open access pharmacies like other countries. Role back the nuances of licensure/board cert etc to truly allow free for all. Let the quack NDs do what they want. OD do what they want. PharmD do what they want. RNs without NP or DNP... do what they want. Release the Kraken.

If you live close to the border like I do, you will see patients get Adderall and Alprazolam and then tell you that they are prescribed meds. It's kind of funny really... I wonder if medicine in Mexico is different than in the US? (I'm being facetious)

 

[Merovinge]

If you live close to the border like I do, you will see patients get Adderall and Alprazolam and then tell you that they are prescribed meds. It's kind of funny really... I wonder if medicine in Mexico is different than in the US? (I'm being facetious)

I recently went to Mexico and checked out several pharmacies for personal curiosity. I saw plenty of benzos but did not see Adderall/any psychostimulants at any of them. Are these actually OTC in Mexico?

 

[littlefred]

I recently went to Mexico and checked out several pharmacies for personal curiosity. I saw plenty of benzos but did not see Adderall/any psychostimulants at any of them. Are these actually OTC in Mexico?

I know people that have gotten 30 mg IR through a pharmacy. They are technically not OTC a pharmacist has to dispense it to you.

I feel for them because border officials might stop them one day and get in trouble.

 

[whopper]

It's not fair to bash an place for diagnosing a lot of ADHD and treating it. The better question is are they too quick to diagnose it, are they too quick to offer a stimulant without offering alternatives, and are they doing the standard of care to make sure the medication is being used appropriately?

If a psychiatrist specializes in tough ADHD cases of course most of their cases are going to be ADHD. So are we supposed to have this guy nailed to a cross?

 

[allantois]

A lot of these places are rxing 60mg IR to patients on multiple controls and questionable diagnostic/substance use hx. While one may of course choose to see ADHD all day long, the pattern of prescribing is what DEA should look at. Ultimately, if all you have is a hammer, everything looks like a nail. And how many patients have comorbid bipolar, etc and getting that addressed/treated? Vitals monitored? Stimulants are much safer than benzos/opioids; but with high enough volume and substandard care, an adverse event is right around the corner

 

[tr]

Which sometimes, I almost just think we should open the flood gates, allow open access pharmacies like other countries. Role back the nuances of licensure/board cert etc to truly allow free for all. Let the quack NDs do what they want. OD do what they want. PharmD do what they want. RNs without NP or DNP... do what they want. Release the Kraken.

So we could have rampant antibiotic resistance and young healthy people dying from multidrug resistant bacterial infections like in India? No thanks.

 

[randomdoc1]

So we could have rampant antibiotic resistance and young healthy people dying from multidrug resistant bacterial infections like in India? No thanks.

Maybe that’s what it takes for patients to actually appreciate the rationale behind our decision making. It’s like raising a child. Let them experience the consequences of their actions lol jkjk. Although, that is how many benzo and stim abusing patients finally turned a corner. They escalated their use through the roof, realized they were going nowhere fast, and got tired of the cycle on their own.

 

[Sushirolls]

So we could have rampant antibiotic resistance and young healthy people dying from multidrug resistant bacterial infections like in India? No thanks.

Its already happening in the US, slower but still happening.

 

[B52slinger]

A lot of these places are rxing 60mg IR to patients on multiple controls and questionable diagnostic/substance use hx. While one may of course choose to see ADHD all day long, the pattern of prescribing is what DEA should look at. Ultimately, if all you have is a hammer, everything looks like a nail. And how many patients have comorbid bipolar, etc and getting that addressed/treated? Vitals monitored? Stimulants are much safer than benzos/opioids; but with high enough volume and substandard care, an adverse event is right around the corner

Do patients themselves have to report their own psychiatrist to the DEA for something to happen? Because I'd imagine 99% of them would be like "I needed the 60mg IR just to get out of bed! This psychiatrist was the only one who even tried to give me the right medication!!"

 

[comp1]

No, something adverse has to happen and then the police do an investigation and report it to the DEA. As others have said, this is a little less likely to happen with stimulants than depressants, so less reporting.

 

[TheRightMedication]

I would be happy to have a local Walter White to refer to. Especially if they do a half decent job.

 

[FlowRate]

Right, it’s not that hard to have someone fill out an ASRS, PHQ9 and GAD7, say their screening information suggests ADHD and you’ve ruled out other common psychiatric conditions, patient denies substance use issues and you think ADHD is the main issue causing “trouble focusing”, say they meet DSM5 criteria for ADHD, +/- make them do a UDS, check PDMP every now and then and come back every 1-3 months for their 15 minute appointment to refill stimulants.

Whether this is appropriate diagnostic technique or not can be discussed all day but you’re not going to get in trouble with the DEA for arguments in your field about the subtleties of diagnosing a condition, you’re going to get in trouble for doing things that are clearly outside of acceptable practice. Many of these ADHD clinics also do some kind of computerized/CPT testing they make the patient pay for which further adds a feeling of legitimacy to the diagnosis.

Last I looked, the ADHD clinic in Boston ("ADHD Boston") had a neuropsychologist (or maybe just a psychologist who did NPSY testing) and part of their required workup was NPSY testing for all patients. At particularly pricey cash fees. That both increases clinic revenue and adds an additional layer of "legitimacy" to the ADHD diagnoses.

There was an ADHD-specialized clinic here and patients we get from that doc are on super wacky regimen. Dissolving doses in water, 3-4 different stim formulations concurrently, etc. That doc is one of the featured contributors to (pharma sponsored) ADDitudes mag...

 

[hamstergang]

Its already happening in the US, slower but still happening.

I'd much rather have this process happen slower. That gives us time to find solutions. Your post seems to imply that since it's happening at all, who cares how quickly.

 

[randomdoc1]

I'd much rather have this process happen slower. That gives us time to find solutions. Your post seems to imply that since it's happening at all, who cares how quickly.

Maybe we need polio and small pox to come back too. So people can also appreciate vaccines again. jk jk.

 

[mistafab]

Last I looked, the ADHD clinic in Boston ("ADHD Boston") had a neuropsychologist (or maybe just a psychologist who did NPSY testing) and part of their required workup was NPSY testing for all patients. At particularly pricey cash fees. That both increases clinic revenue and adds an additional layer of "legitimacy" to the ADHD diagnoses.

There was an ADHD-specialized clinic here and patients we get from that doc are on super wacky regimen. Dissolving doses in water, 3-4 different stim formulations concurrently, etc. That doc is one of the featured contributors to (pharma sponsored) ADDitudes mag...

This is the type of doctoring that disgusts me.

The patient's become clients. The quacks become experts.

 

[Sushirolls]

I'd much rather have this process happen slower. That gives us time to find solutions. Your post seems to imply that since it's happening at all, who cares how quickly.

This has been going on for 20+ years. The warning flags have been flying high for decades. That is more than enough time to find solutions of different types. The powers that be have not had the desire/motivation/incentive to make positive headway on this. Furthermore it is a world wide issue, so even when some countries have more adept management these microbes still circumnavigate the globe.

What you read is apathy on my part, is best viewed from the angle radical acceptance of how things are. Real solutions won't happen until things are at a crisis level.

The bugs/fungus are coming.

 

[FlowRate]

This is the type of doctoring that disgusts me.

The patient's become clients. The quacks become experts.

A patient of mine came in for follow-up earlier this week saying that his therapist told him he probably had ADHD and should return to me to discuss treatment, which already happens enough with therapists in general to be annoying, but what particularly bothers me is the therapist's psychologytoday profile says he specializes in "late diagnosed adult ADHD and autism" and the therapist himself disclosed to my patient that he was recently diagnosed with ADHD.

That's not being an expert, that's diagnostic closure before you've ever even met any patients. Overidentification. Poor boundaries. A crusade.

 

[whopper]

PsychologyToday profiles usually over-advertise. I liken it to a dating website. The big fat guy is going to put the best looking pic of himself when he wasn't as big and fat.

When doing a profile you're supposed to check off your specialties. I've seen several of these people put down neuropsych testing as a specialty but hardly any of them could do it. E.g. when asked they'll say a PHQ-9 is a neuropsych test. No.

 

[FlowRate]

PsychologyToday profiles usually over-advertise. I liken it to a dating website. The big fat guy is going to put the best looking pic of himself when he wasn't as big and fat.

When doing a profile you're supposed to check off your specialties. I've seen several of these people put down neuropsych testing as a specialty but hardly any of them could do it. E.g. when asked they'll say a PHQ-9 is a neuropsych test. No.

This wasn't a "check everything under the sun" profile. It was literally only three things, two of which were: ADHD and Late-diagnosed ADHD and/or Autism.

 

[mistafab]

Overidentification. Poor boundaries. A crusade.

Unfortunately I've also seen MDs do this. Giving people the same meds that worked for them. Crusaders - and overdiagnosing. I am particulalry thinking of an MD doing this with ADHD/depression.

It's just poor practice. Should have been fixed through supervision.

 

[whopper]

I've told this to residents and students. Patients are allowed to develop personal relationships with meds. Doctors-no.

How a med works on one patient can highly differ vs another patient.

This wasn't a "check everything under the sun" profile. It was literally only three things, two of which were: ADHD and Late-diagnosed ADHD and/or Autism.

Which then shows your original point has more emotional verve. If this guy only mentions ADHD among his specialties you figure then he should know his ADHD.

 

[FlowRate]

Which then shows your original point has more emotional verve. If this guy only mentions ADHD among his specialties you figure then he should know his ADHD.

TBH depending on which way I read your post I'm not sure if you're agreeing or disagreeing with me here or being sarcastic.

 

[ChudsMgee]

Why does it bother you? Amphetamines and other stimulants should be recreationally legal anyway

If you are concerned about people's health I am more worried about antipsychotics being thrown out like candy and zero lab work being done

 

[aim-agm]

Amphetamines and other stimulants should be recreationally legal anyway

Can you elaborate on why you believe that?

 

[Merovinge]

Can you elaborate on why you believe that?

Don't feed the troll. Almost no one anywhere on Earth believes these medications should be recreationally legal.

 

[clausewitz2]

Don't feed the troll. Almost no one anywhere on Earth believes these medications should be recreationally legal.

I would like to introduce you to Reddit.

 

[calvnandhobbs68]

I would like to introduce you to Reddit.

lol yeah I think "no one anywhere on Earth" is a bit of a stretch....go meet up with some of your local libertarians, bring up drug legalization with them and crack open a cold one cause you'll be there a while

 

[FlowRate]

lol yeah I think "no one anywhere on Earth" is a bit of a stretch....go meet up with some of your local libertarians, bring up drug legalization with them and crack open a cold one cause you'll be there a while

I have to say, though--with regard to stim deregulation as wish fulfillment--that making them a "behind the counter" drug, like pseudoephedrine, with strict quantity limits and the modern advent of the PDMP, would save us a lot of frustrating "ADHD" consults... Let everyone get up to 1800mg Adderall per 30 days and leave me out of it.

Not that I think this would actually be a good thing for society.

 

[randomdoc1]

I have to say, though--with regard to stim deregulation as wish fulfillment--that making them a "behind the counter" drug, like pseudoephedrine, with strict quantity limits and the modern advent of the PDMP, would save us a lot of frustrating "ADHD" consults... Let everyone get up to 1800mg Adderall per 30 days and leave me out of it.

Not that I think this would actually be a good thing for society.

Yes. Do it, do it, deeeeeew iiiiit. It’s the passive aggressive side of me coming out. They think it’s the solution and want to blame us for “gatekeeping”? Have at it and see for yourself. I won’t have to screen through the bogus prospective patients at least.

The new patient inquiries drain my soul. About 80% of it is:
-I want to see a female provider and refuse to consider a male
-evening and weekends please
-oh, and I want Adderall, maybe a benzo to compliment it

So…they’re basically looking for a boutique with a hot young female doling out speed in the evenings? That sounds more like a drug party and not psychiatry to me. No thanks. Although, I do appreciate the compliments myself and other providers get on how cute we all look at least.

 

[Liquid8]

The new patient inquiries drain my soul. About 80% of it is:
-I want to see a female provider and refuse to consider a male
-evening and weekends please
-oh, and I want Adderall, maybe a benzo to compliment it

Refer them to a nightclub?

 

[ChudsMgee]

Don't feed the troll. Almost no one anywhere on Earth believes these medications should be recreationally legal.

Why am I a troll for having a different opinion than you? Like someone else said sit down with any random libertarian and bring up drug legalization while preparing yourself for a long rant.

You can walk into any local fast food joint and order a 2000 calorie lunch that is harder on the body than a low dose amphetamine. You can walk into a supplement shop and purchase workout powder concoctions with powerful stimulants like DMAA(now illegal but was widely available for awhile in things like Jack3d). Synthetic cathinones (street "bath salts) were on the counter at every gas station for a good period as well. Caffeine is legal and can be just as dangerous as any prescription stimulant so I guess you want that illegal as well? Where do we stop? Have you seen Demolition Man with Stallone?

 

[claypigeon]

I second the above and am also a big believer in legalizing ALL recreational drugs. There are a fair amount of us out there. So much Ron Paul was able to make the argument at a Presidential debate to much applause. Give this a listen to hear a quick summary of the argument for legalization. I'd add on to this the right to bodily autonomy. Though that apparently doesn't exist given recent rulings on abortion.

 

[ChudsMgee]

I second the above and am also a big believer in legalizing ALL recreational drugs. There are a fair amount of us out there. So much Ron Paul was able to make the argument at a Presidential debate to much applause. Give this a listen to hear a quick summary of the argument for legalization. I'd add on to this the right to bodily autonomy. Though that apparently doesn't exist given recent rulings on abortion.

Abortion is a little different situation for me. That is another human life being affected and America's history of Planned Parenthood is rooted in eugenics and racism against my people. However making abortion less accessible increases crime rates in the long run and also increases the amount of left leaning citizens which also increases crime rates/civil unrest/alt left terrorism/extremism. I cannot quite figure out where I stand in this matter.

Regarding recreational drugs the government doesn't really have any right what to tell people to put into their own bodies. I do think so called "gender affirming care" through pharmaceuticals should be illegal for minors but that is another topic. If you are adult age and want to take anabolic steroids, hormone blockers, whatever it doesn't bother me.

 

[littlefred]

I didn't know I was on a QAnon forum. Got lost here for a second.

 

[ChudsMgee]

I didn't know I was on a QAnon forum. Got lost here for a second.

Is Qanon libertarian?

 

[FlowRate]

I didn't know I was on a QAnon forum. Got lost here for a second.

That's a really strange conflation to make.

 

[calvnandhobbs68]

this thread is getting great, don't stop now

 

[Merovinge]

That's a really strange conflation to make.

Seriously? Someone opining about being torn on abortion rights because they are worried about increasing the number of left leaning citizens and altleft terrorism with zero discussion about, oh you know, the woman, is not making you think about being on qanon or 4chan?

 

[littlefred]

Seriously? Someone opining about being torn on abortion rights because they are worried about increasing the number of left leaning citizens and altleft terrorism with zero discussion about, oh you know, the woman, is not making you think about being on qanon or 4chan?

We went from ADHD pill-mills to abortion somehow, but hey I'm conflating here.

 

[ChudsMgee]

Seriously? Someone opining about being torn on abortion rights because they are worried about increasing the number of left leaning citizens and altleft terrorism with zero discussion about, oh you know, the woman, is not making you think about being on qanon or 4chan?

What the hell is a woman? Can you define it?

 

[Jules A]

What the hell is a woman? Can you define it?

hahaha had to open that box huh?

 

[FlowRate]

Seriously? Someone opining about being torn on abortion rights because they are worried about increasing the number of left leaning citizens and altleft terrorism with zero discussion about, oh you know, the woman, is not making you think about being on qanon or 4chan?

TBH I somehow skipped over that specific post and thought littlefred was implying Ron Paul == QAnon. I retract my prior statement.

 

[randomdoc1]

If you guys want more new patient leads with a less preponderance of emphasis on controlled substances, I recommend:
-investing in getting some high quality studio photos where you look smokin' hot.
There's good data backing up higher conversion rates and longer time staring at the pics which boosts your SEO
I hear the topless ortho practice down the street be hoppin' as well

😂​