Prescription Misuse

[snfuse]

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What would you do if you found out that for an adolescent they're getting a prescriptions for stimulants from both they're pediatrician and their psychiatrist?

I inherited a patient where this was happening and haven't been able to get a hold of the parents to talk about the discrepancy which has been going on for almost 2 years. Is it something that would be reported?

 

[clozareal]

1. Call the pediatrician and previous psychiatrist first to ask about this. Both the pediatrician and psychiatrist should have been checking the state prescription drug monitoring program with regular frequency. The pharmacist typically does this too so it would be really strange for this to be going on for 2 years unnoticed.
2. Talk to the parents to find out why they are picking up both prescriptions.
3. Then talk to the adolescent to find out how much they are using and if they are diverting.
4. Make both of them sign a stimulant contract that clearly outlines when they will be discontinued from further prescriptions for misuse. Consider pill counts and urine drug screens at each appointment for adherence.
5. Come up with a plan that will help the adolescent the most: do they need a higher prescription of the stimulant that they're not getting from either physician alone? Sometimes undertreated ADHD will lead to adolescents using more than prescribed.
6. If they are diverting or their parents are diverting, tell them that this is a federal crime and that they can be prosecuted for a felony.
7. If they are abusing it, try to figure out the reason, frequency, and consequence of this and try to work with them.
8. If they meet criteria for a stimulant use disorder, recommend referral to an addiction specialist.
9. If there is a therapeutic impasse, get consultation and perhaps consider terminating their care depending on your risk tolerance for liability. For me, I tend to give patients and their parents benefit of the doubt and give them at least one chance to correct their behavior to stay in care.

Doesn't sound like it meets criteria for child abuse reporting unless you're suspecting factitious disorder imposed upon another (aka munchausen's by proxy).

 

[hamstergang]

1. Both the pediatrician and psychiatrist should have been checking CURES every 3 months. The pharmacist typically does this too so it would be really strange for this to be going on for 2 years unnoticed.

This is state dependent. I agree with the rest.

 

[Stagg737]

1. Call the pediatrician and previous psychiatrist first to ask about this. Both the pediatrician and psychiatrist should have been checking the state prescription drug monitoring program with regular frequency. The pharmacist typically does this too so it would be really strange for this to be going on for 2 years unnoticed.
2. Talk to the parents to find out why they are picking up both prescriptions.
3. Then talk to the adolescent to find out how much they are using and if they are diverting.
4. Make both of them sign a stimulant contract that clearly outlines when they will be discontinued from further prescriptions for misuse. Consider pill counts and urine drug screens at each appointment for adherence.
5. Come up with a plan that will help the adolescent the most: do they need a higher prescription of the stimulant that they're not getting from either physician alone? Sometimes undertreated ADHD will lead to adolescents using more than prescribed.
6. If they are diverting or their parents are diverting, tell them that this is a federal crime and that they can be prosecuted for a felony.
7. If they are abusing it, try to figure out the reason, frequency, and consequence of this and try to work with them.
8. If they meet criteria for a stimulant use disorder, recommend referral to an addiction specialist.
9. If there is a therapeutic impasse, get consultation and perhaps consider terminating their care depending on your risk tolerance for liability. For me, I tend to give patients and their parents benefit of the doubt and give them at least one chance to correct their behavior to stay in care.

Doesn't sound like it meets criteria for child abuse reporting unless you're suspecting factitious disorder imposed upon another (aka munchausen's by proxy).

You're more generous than I am. Unless they're filling it appropriately (only filling one Rx at a time regardless of who's prescribing), I would inform the parents that I would be discontinuing the medication and allowing the pediatrician to continue prescribing it. I'd obviously ask for an explanation, but other than the above exception I would not continue to prescribe controlled meds being filled inappropriately. I would not terminate the patient immediately, but I'd make it clear that I'd be watching them more closely regardless of if I'm prescribing controlled substances or not.

In the event that they are filling "appropriately", I'd counsel them that they need to be getting the med from one physician only and involve the pediatrician in the decision regarding who will continue prescribing it. Agree with most of what you're saying though, I'm just not willing to risk my license for people who have a record of lying to their physicians about major problems.

 

[Merovinge]

You're more generous than I am. Unless they're filling it appropriately (only filling one Rx at a time regardless of who's prescribing), I would inform the parents that I would be discontinuing the medication and allowing the pediatrician to continue prescribing it. I'd obviously ask for an explanation, but other than the above exception I would not continue to prescribe controlled meds being filled inappropriately. I would not terminate the patient immediately, but I'd make it clear that I'd be watching them more closely regardless of if I'm prescribing controlled substances or not.

In the event that they are filling "appropriately", I'd counsel them that they need to be getting the med from one physician only and involve the pediatrician in the decision regarding who will continue prescribing it. Agree with most of what you're saying though, I'm just not willing to risk my license for people who have a record of lying to their physicians about major problems.

Feels like there is more to this story. This person's insurance would also not cover it so they would have had to have two different doctors prescribe to two different pharmacies, one for cash pay, in a state that does not do well with schedule 2 monitoring. That's a lot of hoops to jump through, unless the patient is being Rxed something super dumb like Adderall 20 TID, for the street value of the medication. If they are really going through all that work it would be an immediate termination from me, I am not taking on the drug dealer (sociopath) parent, I value being alive and able to help my patients and family much more than that level of sociopathy.

 

[Stagg737]

Feels like there is more to this story. This person's insurance would also not cover it so they would have had to have two different doctors prescribe to two different pharmacies, one for cash pay, in a state that does not do well with schedule 2 monitoring. That's a lot of hoops to jump through, unless the patient is being Rxed something super dumb like Adderall 20 TID, for the street value of the medication. If they are really going through all that work it would be an immediate termination from me, I am not taking on the drug dealer (sociopath) parent, I value being alive and able to help my patients and family much more than that level of sociopathy.

There could be other things happening. Every so often I find a patient in our PDMP where it says no refills despite them refilling regularly. Have had to call a couple of pharmacies up to tell them they weren't logging stuff in the PDMP and ask how often the patient was refilling and if there were any extra prescriptions I didn't know about. In all but one of these situations, the patients weren't doing anything wrong and the pharmacy was* at fault. I do agree that there seems to be some deviant behavior going on, but firing the patient would be situational imo.

 

[Merovinge]

There could be other things happening. Every so often I find a patient in our PDMP where it says no refills despite them refilling regularly. Have had to call a couple of pharmacies up to tell them they weren't logging stuff in the PDMP and ask how often the patient was refilling and if there were any extra prescriptions I didn't know about. In all but one of these situations, the patients weren't doing anything wrong and the pharmacy wasn't at fault. I do agree that there seems to be some deviant behavior going on, but firing the patient would be situational imo.

Certainly I would need confirmation from the pharmacy or PCP that this was actually happening before firing the patient, mistakes can happen when entering into the monitoring systems. I'm stating if this story is to be taken at 100% face value how I would proceed.

 

[comp1]

The OP has got some investigating to do!