Patient's husband arrested, do you still provide substance of possible abuse?

[whopper]

Ethical question for all of you.

Let's say you got a patient with ADHD. After the patient tried several meds including Wellbutrin, Strattera, Clonidine, and Guanfacine, with hardly any benefit, you finally decide to try a stimulant. A TOVA test suggests she truly has ADHD and was it's symptom exaggeration index has no points (indicating it there is no reason to believe she was malingering).

She's taken Adderall for a few months and tells you she does well on it. Work is going better because she's more focused.

Okay, then you find out that her husband was recently arrested for illegal manufacture of methamphetamines. After calling her up about it, she mentions that the husband was arrested for this before, and he is innocent, and that this is actually part of the police and prosecutor's attempt to nail someone else that is actually manufacturing drugs, and the husband is only friends with him. The husband further corroborates the story. They believe the prosecutor is trying to strong-arm them into testifying against the friend. Both insist they do not provide the guy with ingredients for drug manufacture, and they've been trying to distance themselves from this other guy because they feel he is up to no good.

Also turns out that the husband (who has prior drug related charges) has a probation officer that even tells you that the guy's been doing well and he actually believes the husband.

Do you continue the Adderall? Remember it was her husband that was arrested, not her.

Another question: if it was the patient that was arrested, and her parole officer vouches that the patient was doing well, what would you do? Remember, the patient was not found guilty. She was only charged.

What would you do if the parole officer then tells you that in his opinion, the patient would likely not do well in the community without Adderall because he's seen an improvement and she was not able to maintain her job without it.

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[OldPsychDoc]

Continue the Adderall with strict numeric controls. Can also urine test for positive compliance in your patient. And document the Hades that all of the above are the appropriate reasons for your treatment decision. Also suggest to the husband's PO, since you seem to have all the releases to communicate, that the occasional random UDS might bolster his case as well.

 

[nitemagi]

Got another twist question -- how do you know she doesn't have a history of meth use and it's the withdrawal that's giving you a false positive on the TOVA? Remember meth is only detectable for about 2 days in urine.

 

[whopper]

OPD: gave me the answer I chose to do. I think I just wanted to hear it from someone else.

Nitemagi: the honest truth is we never know. Testing is never 100% accurate and has to be taken in concert with other data.

Many of you are probably figuring (right) that a case like this is going on with me now. In the real case the husband was arrested, but I started thinking what would I do if she were arrested? Do I stop meds for someone that was not found guilty?

I have had a few cases where the TOVA score suggested the person was likely malingering and as a result I refused to give a stimulant. It's the best test out there that I know of because all the other ones don't have a symptom exaggeration index.

As we've mentioned before, I really don't like ADHD because some people IMHO really have it, but many need a stimulant, and I hate giving those out. I know some psychiatrists that refuse to treat it.

 

[firedoor]

I would treat the ADHD.

 

[heyjack70]

Whopper, I think you've gone above the standard of care.

And I believe you have mentioned that patients would not go through all the time, testing, and non-stimulant drugs if all they wanted was a stimulant. They could buy it on the street. I think this is even more true in this case where you are concerned she would be selling the stimulant or manufacturing meth with it. It's too easy to make meth with sudafed for someone to go to all this trouble. So I doubt she deceiving you. (The exception to this would be someone actually wanting to take the pill themselves for a reason aside from true ADHD, eg improved cognition or weight loss, and going to the doctor is the path for legitimate access to the medication)

 

[dl2dp2]

Whopper, I think you've gone above the standard of care.

I second that. I know a couple of attendings who say that they don't really care if their patients deal with the drugs that they were prescribed, so long as it's clinically indicated. In the age where Seroquel has a street value you really can't be a doctor and the DEA at the same time.

I'm guessing though if someone ODs on drugs you prescribed and sold to a third party, you might be in a twisted way liable for a civil law suit, if you didn't do the due diligence of reasonably trusting that your patient isn't selling the drug. At least to me it sounds like such a case can be made. I guess it's more than reasonable to be extra careful.

 

[whopper]

I think I am going above the standard of care, but then again, I think the standard of care blows. What we are told is the standard in training is not the standard I see in real life. I often see doctors spot diagnosing ADHD. As many of us know, stimulants cause improvement in concentrating and mental focus even if you don't have it. People often fake symptoms to obtain a substance of abuse for the wrong reasons, and the DSM guidelines for diagnosis are easily faked, and if taken to an extreme, someone could argue that almost everyone has it.

I know of a doctor that actually argued that we should give our patients as much benzos and stimulants as they want because these are people who aren't doing well and they need as much money as they can get. Yes the guy fully meant they could sell their drugs on the street. Geez, if you're going to be a drug supplier, at least do it the right way so you could be a multimillionaire and not a guy making 6 figures (you bastard..not only are you unethical, you don't have any business sense either!)

I know a couple of attendings who say that they don't really care if their patients deal with the drugs that they were prescribed, so long as it's clinically indicated.

IMHO such an attending should have their license removed though I'd bet the farm nothing happens to them.

In the age where Seroquel has a street value you really can't be a doctor and the DEA at the same time.

No but you can do what I do. Do not give out Seroquel unless there's a specific reason to give it more so than other antipsychotics. Seroquel per CATIE performed the worst of the antipsychotics, it does not have a favorable side effect profile, and it's expensive. IMHO, I see no reason to give it unless the person is sensitive to EPS, or it's the only antipsychotic that works. I've never seen a situation where Seroquel worked and Zyprexa didn't for psychosis or mania. They're both benzo-derived, and Zyprexa is much more efficacious.

I've never officially counted, but I probably give out Seroquel less than 20 times per year, and the only times I've done so were to EPS sensitive patients, or patients with a clean history that were already started on it from someone else.

In private practice, hardly anyone I know wants it when I tell them it causes weight gain and there's other meds available that don't cause that problem or not as bad that could be tried instead. Most people already on it want off of it after they've gained tremendous amounts of weight, and when I tell them there's other options that don't have that problem they often flip out, "why didn't my other doctor tell me that!?!?!" The only times I've seen people obsessively demand it were people with a drug abuse problem or people where I suspect they are not using it for therapeutic purposes.

I have seen a subgroup of people withe a dual diagnosis such as anxiety and a drug abuse problem that insist upon it that I suspect actually are trying to stay clean. I do try to steer the patient away from Seroquel in cases like that and treat their anxiety with an SSRI. Choices: one med is not FDA indicated for anxiety, causes hundreds of $/month, it's abusable, has a street value, requires labs (via APA and ADA guildelines), has several antipsychotic related side effects, causes metabolic problems vs $4 med that hardly causes weight gain if at all, no antipsychotic related side effects, not abusable, no street value, that's FDA indicated, and has much more data to support it's use for anxiety.

Given the above why are so many doctors giving out Seroquel first line for anxiety? I am fairly open to giving it out for bipolar depression because it's one of the only meds with an FDA approval for it, but like I said, when I mention the weight gain issues, several patients are hesitant.

 

[daru1]

innocent until proven guilty.

 

[whopper]

Reasonable medical certainty, one of the legal standards for acceptable medical practice is over 50% certainty.

Beyond reasonable doubt is supposed to be above 95% certainty.

I certaintly would be within my practicing power to stop or continue the stimulant. The idea of giving out a stimulant to someone who may be chronically abusing it is the problem here not the legal repercussions. I believe I am practicing above the standard of care, I am practicing with reasonable medical certainty, and I have evidence to support a decision either way.

Just the idea of not being comfortable either way grinds at me. I want to treat people and continue it if it helps. I don't want to enable abusers. I don't like this situation and I can't think of anything else to get more of an idea to figure it out other than to call up the prosecutor but I'll refrain from that because it's inappropriate.

 

[Technotronic]

 

[ghost dog]

Ethical question for all of you.

Let's say you got a patient with ADHD. After the patient tried several meds including Wellbutrin, Strattera, Clonidine, and Guanfacine, with hardly any benefit, you finally decide to try a stimulant. A TOVA test suggests she truly has ADHD and was it's symptom exaggeration index has no points (indicating it there is no reason to believe she was malingering).

She's taken Adderall for a few months and tells you she does well on it. Work is going better because she's more focused.

Okay, then you find out that her husband was recently arrested for illegal manufacture of methamphetamines. After calling her up about it, she mentions that the husband was arrested for this before, and he is innocent, and that this is actually part of the police and prosecutor's attempt to nail someone else that is actually manufacturing drugs, and the husband is only friends with him. The husband further corroborates the story. They believe the prosecutor is trying to strong-arm them into testifying against the friend. Both insist they do not provide the guy with ingredients for drug manufacture, and they've been trying to distance themselves from this other guy because they feel he is up to no good.

Also turns out that the husband (who has prior drug related charges) has a probation officer that even tells you that the guy's been doing well and he actually believes the husband.

Do you continue the Adderall? Remember it was her husband that was arrested, not her.

Another question: if it was the patient that was arrested, and her parole officer vouches that the patient was doing well, what would you do? Remember, the patient was not found guilty. She was only charged.

What would you do if the parole officer then tells you that in his opinion, the patient would likely not do well in the community without Adderall because he's seen an improvement and she was not able to maintain her job without it.

Interesting case.

It seems like she is obtaining benefit from this medication. However, The above new information would change stimulant prescribing for me.

You could potentially:

1. Perform FREQUENT urine drug screens with gas chromatographic analysis. In this way, you will detect anything she is taking (i.e. benzos, opioids, meth, THC, etc.).

2. Prescribe small amounts (i.e. weekly or biweekly intervals), and perform pill counts to ensure she is not diverting / selling.

3. Have her sign a substance of abuse contract. By doing so, you are protecting both yourself and the patient with this agreement: she will know the consequences of running out early, my dog ate it, meds got stolen, and the usual laundry list of bogus excuses, etc.

In my experience with patients taking scheduled substances: the higher the opioid risk tool score, the more likely they are to demonstrate problem behavior at some point.

opioid risk tool:

http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b02.html

 

[whopper]

Already doing what you mentioned but...

1. Perform FREQUENT urine drug screens with gas chromatographic analysis. In this way, you will detect anything she is taking (i.e. benzos, opioids, meth, THC, etc.).

IMHO, in terms of the husband's charge, it's useless. If she's providing him with stimulants to make meth, doesn't matter if she's using amphetamines or not. UDS of (+) or (-) doesn't matter either way.

I don't really think you can apply numbers to it but I love how forensics people try.

There's a lot of truth to this. I love how Resnick, during a mock trial, where he plays the opposing lawyer will shred apart one of his fellows. "How did you come up with your numbers?" "I'll ask you again since you're not answering, HOW!?!?!" "I'll ask you again, HOW!?!?!"

 

[ghost dog]

Already doing what you mentioned but...



IMHO, in terms of the husband's charge, it's useless. If she's providing him with stimulants to make meth, doesn't matter if she's using amphetamines or not. UDS of (+) or (-) doesn't matter either way.

QUOTE]

I'm confused.

From the perspective of prescribing stimulants to this patient, if you are concerned that she is diverting your prescription to her husband the above suggestions should easily catch her sooner or later (very likely sooner). Specifically:

1. Small dosing intervals.

2. Pill counts.

The majority of high risk patients ain't that bright.

I have learned the above from hard experience, unfortunately.

Once caught, D/C script. Your responsibility is terminated.

 

[whopper]

If a UDS is (+) for amphetamines, okay fine, she's taking it. If it's negative, she could easily just tell me she forgot to take it for a few days. I didn't clarify that and I apologize because that's really what explains my comment.

What I really want is being able to tell if she's using the meds appropriately without doubt. I can't do that. In fact one can never truly have that when it comes to stimulants and ADHD IMHO. At least with nonabusable meds, you know the person isn't getting high.

If it's positive for things like cocaine and marijuana, then it does help. A UDS here is a good idea, but it won't calm my mind as to whether or not she's using stimulants appropriately. It's like having 3 layers of wax paper blocking your vision and now, using the test, one of those layers is removed.

I was being egocentric when I made my remark, and I should've explained my thought process.

 

[Mattchiavelli]

In the age where Seroquel has a street value you really can't be a doctor and the DEA at the same time.

!?!?!I never realized this... I swear I learn something new every time I sneak in here...

 

[Sneezing]

almost everything is a drug of abuse. go to erowid.org and have some interesting light reading.

 

[OldPsychDoc]

If a UDS is (+) for amphetamines, okay fine, she's taking it. If it's negative, she could easily just tell me she forgot to take it for a few days. I didn't clarify that and I apologize because that's really what explains my comment.

What I really want is being able to tell if she's using the meds appropriately without doubt. I can't do that. In fact one can never truly have that when it comes to stimulants and ADHD IMHO. At least with nonabusable meds, you know the person isn't getting high.

If it's positive for things like cocaine and marijuana, then it does help. A UDS here is a good idea, but it won't calm my mind as to whether or not she's using stimulants appropriately. It's like having 3 layers of wax paper blocking your vision and now, using the test, one of those layers is removed.

I was being egocentric when I made my remark, and I should've explained my thought process.

I have had pts that I suspected were trying to get an Adderall script in order to "excuse" future amphetamine-positive urines (since most "standard screens" are just +/- for all species). It is rather simple to order gas chromatographic confirmation, however. If there's methamphetamine detected in the urine, it's NOT Adderall!

 

[whopper]

True.

An interesting thing is the parole officer actually wants the patient on a stimulant because she allegedly was doing better on one. She was able to get a job, do well at work, and the parole officer of all people is corroborating the story of the patient and her husband.

From my experience the good parole officers give a damn, and the bad ones bully their parolees.

 

[kugel]

as was already mentioned... document, document, document.
And not just what you did and what the pt said...

Document your decision-making! "Although there is a risk of _______, pt agreed that _________ is more approp at this time because ___________."
Over and over, risk mgt attorneys have told me that this is what saves a case.

The contract idea is worthwhile, and it can include random drug screens:
"I'll give you a lab slip, but don't do it until I call you. Then you have 24 hrs to go to the lab and provide a sample. So make sure I have working contact #'s for you, and make sure you listen to your messages."

I would suggest that when you talk to the PO (with consent, of course) that you make your notes while still on the phone and then read it back to him/her for confirmation of what you're being told - and document that you did that. If the state pursues a case against this patient, the PO may feel (s)he has to side with the state and minimize (or ignore entirely) all the positive things you were originally told. If you have in your chart that you confirmed your understanding of what you were told, it would be very hard for anyone to conclude that you misunderstood the PO. And, of course, by the time any case gets to trial, there may be a new PO on the case who has a very different point of view.

All this is probably overkill, but I tend to be a bit paranoid about such cases.

And, as I've said many times, Consult Your Risk Management Attorney.
When trying to determine how to "bullet-proof" your case in progress, why wouldn't you ask the person who has the expertise, experience and the motivation to help you with that?

 

[Bernardo_11]

Interesting discussion. I was just wondering your thoughts about using Vyvanase since, supposedly, there is less potential for abuse. I was also thinking of Daytrana (methylphenidate patch) as an option as well.

 

[whopper]

Those are great options, and anytime we can give a med that's harder to abuse, the better.

A problem here is she pays for the meds out of pocket. Adderall comes in a cheaper generic form.

I haven't, however, offered this as an option to her and I should, and it would calm my mind a bit concerning possible abuse. I'll have to do that during our next meeting.

 

[billypilgrim37]

OPD should comment on this because I might way be off base, but if someone's drug of choice is cocaine or meth, is there really that much concern of what they're going to do with their prescription stimulant?* I remember reading some papers in medical school about how cocaine abuse didn't predict stimulant abuse, but I can't seem to find that now. If your drug of choice is the overwhelming whoosh of cocaine, is the little blip of snorting adderall really worth it to you? And while I'm sure the answer is probably a "yes, you still have to worry about it," I'm wondering if the real answer is more like "you have to think about it, but for the most part, the risk benefit analysis seems like it might favor prescribing. Now, to clarify my own clinical practice, I'm about as stingy as whopper, but I often wonder if I'm being stingy for all the right reasons, or just because I have an overdeveloped superego.



*besides, of course, using the stimulant to cook up meth in their trailer.