Taking over Adderall scrips

[PikminOC]

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So the NP who left our practice left me a bunch of adderral / xanax patients.
These patients are used to coming in for a cursory eval every 6 months and getting 3 months of amphets and then calling in for 3 months more.

One of these guys is on 40 mg bid, and other on 30 qd, and the other lady is on 20 mg bid and xanax.

So now I am taking over these patients. I cannot find one 90801 in the chart period. And the 90805's are very brief "patient is living with mother who is causing much stress. increase adderral to 20 tid"

I know what the right thing is to do. Full new patient exam, uds, therapy, collaboration, and go over childhood records. As this is not going to happen in private practice please help. The staff already thinks I care about money more than patients since I insist on being paid prior to appointments so I'm not wasting my time in the practice.

Now these patients are going to complain that I am a jerk and not giving them what they "Need". You know this.

Please advise.

 

[nitemagi]

So the NP who left our practice left me a bunch of adderral / xanax patients.
These patients are used to coming in for a cursory eval every 6 months and getting 3 months of amphets and then calling in for 3 months more.

One of these guys is on 40 mg bid, and other on 30 qd, and the other lady is on 20 mg bid and xanax.

So now I am taking over these patients. I cannot find one 90801 in the chart period. And the 90805's are very brief "patient is living with mother who is causing much stress. increase adderral to 20 tid"

I know what the right thing is to do. Full new patient exam, uds, therapy, collaboration, and go over childhood records. As this is not going to happen in private practice please help. The staff already thinks I care about money more than patients since I insist on being paid prior to appointments so I'm not wasting my time in the practice.

Now these patients are going to complain that I am a jerk and not giving them what they "Need". You know this.

Please advise.

I'd consider a 2-pronged approach, as an idea.
1. Find an alternative provider they can go to if they insist on staying on those meds. Then you've eased the process for them at least.
2. Develop a solid body of evidence how this med isn't actually helping them function better, and how the tx is best through xyz. "I want you to function the best possible, but that will require us to try things differently. Will you go down this road with me if it helps you have a better life [or less anxiety, etc]

As an alternative, refer them to whoever was supervising the NP and signing off on that nonsense. It should be their mess to clean up, IMHO.

 

[michaelrack]

For those on Adderall, if I were in your situation, this is what I would do-

See the patients once a month, and gradually get to know them. I wouldn't do a full new pt eval all at once, but gradually gather the info. Only one month of Adderall at a time; no post dated scrips, must come in for each prescription. Assess over several months if Adderall is increasing the patient's functionality, assess dose. UDS.

 

[cbrons]

So the NP who left our practice left me a bunch of adderral / xanax patients.
These patients are used to coming in for a cursory eval every 6 months and getting 3 months of amphets and then calling in for 3 months more.

One of these guys is on 40 mg bid, and other on 30 qd, and the other lady is on 20 mg bid and xanax.

So now I am taking over these patients. I cannot find one 90801 in the chart period. And the 90805's are very brief "patient is living with mother who is causing much stress. increase adderral to 20 tid"

I know what the right thing is to do. Full new patient exam, uds, therapy, collaboration, and go over childhood records. As this is not going to happen in private practice please help. The staff already thinks I care about money more than patients since I insist on being paid prior to appointments so I'm not wasting my time in the practice.

Now these patients are going to complain that I am a jerk and not giving them what they "Need". You know this.

Please advise.

Just curious why NP was allowed to prescribe those in the first place. At least in our state, NPs/PAs cannot write for C-IIs.

Was the NP haphazardly loading people up on alprazolam? Seriously, when are the state boards of pharmacy going to crack down the benzo polypharmacy? It's beyond the point of shameful in my area anyway.

 

[zenman]

So the NP who left our practice left me a bunch of adderral / xanax patients.
These patients are used to coming in for a cursory eval every 6 months and getting 3 months of amphets and then calling in for 3 months more.

One of these guys is on 40 mg bid, and other on 30 qd, and the other lady is on 20 mg bid and xanax.

So now I am taking over these patients. I cannot find one 90801 in the chart period. And the 90805's are very brief "patient is living with mother who is causing much stress. increase adderral to 20 tid"

I know what the right thing is to do. Full new patient exam, uds, therapy, collaboration, and go over childhood records. As this is not going to happen in private practice please help. The staff already thinks I care about money more than patients since I insist on being paid prior to appointments so I'm not wasting my time in the practice.

Now these patients are going to complain that I am a jerk and not giving them what they "Need". You know this.

Please advise.

No one in the practice knew this was going on? I hardly ever dole out stimulants and only 1 month at a time...and no refills for "my dog ate them; my friends stole them, my house burned down, they were in my car and it was stolen, my wife stole them, etc...

 

[AleisterCrowley]

I would imagine that people seeking out both of those drugs in unison are more than likely using them recreationally.

 

[birchswing]

I recall you having a similar predicament before. I didn't offer advice at the time because I try to avoid giving advice. But you seem to want it.

I would say the time-old: dosage, timing, tact consideration is needed.

You have one reality. You presume your patients have a different reality. If that's true, you're not going to increase intersubjectivity by immediately denying their reality and imposing your own. In the previous predicament, I recall something about requiring the patients to go through a lot of steps and possible expense they were unwilling to. You have to begin with their reality, while introducing your own.

I think it's the same in any area of medicine. A primary care doctor is not going to get a patient to lose weight with harsh tactics. People can only take so much new information, and new information, especially when it comes to your mind, and change that will be happening to your brain can feel threatening.

It seems pretty simple in theory. Don't ask for more change than a person can or will give you. Unless your goal is for them to get the same drugs somewhere else.

 

[birchswing]

Just curious why NP was allowed to prescribe those in the first place. At least in our state, NPs/PAs cannot write for C-IIs.

Was the NP haphazardly loading people up on alprazolam? Seriously, when are the state boards of pharmacy going to crack down the benzo polypharmacy? It's beyond the point of shameful in my area anyway.

Are you near southeast Virginia? I've always wondered if this area is a twilight zone of misinformation regarding benzodiazepines. I've been asked not to share my experiences regarding psychiatrists and so I won't, but I have always wondered about the problem from a geographical perspective. Most of the psychiatrists here are FMGs but even the ones who aren't suffer from the same misinformation.

 

[SpecterGT260]

I recall you having a similar predicament before. I didn't offer advice at the time because I try to avoid giving advice. But you seem to want it.

I would say the time-old: dosage, timing, tact consideration is needed.

You have one reality. You presume your patients have a different reality. If that's true, you're not going to increase intersubjectivity by immediately denying their reality and imposing your own. In the previous predicament, I recall something about requiring the patients to go through a lot of steps and possible expense they were unwilling to. You have to begin with their reality, while introducing your own.

I think it's the same in any area of medicine. A primary care doctor is not going to get a patient to lose weight with harsh tactics. People can only take so much new information, and new information, especially when it comes to your mind, and change that will be happening to your brain can feel threatening.

It seems pretty simple in theory. Don't ask for more change than a person can or will give you. Unless your goal is for them to get the same drugs somewhere else.

True. All of this.

However, the doses she is talking about are appropriate for narcolepsy... being used for STRESS! With improper documentation to boot. I would be concerned that if my scripts were reviewed I could go down for trafficking. It isn't unheard of.

Obviously I'm not there yet in my career so I only fly by what I hear, but from where I sit, monthly visits with literature or guideline level treatments are a good starting point. I wouldn't be comfortable continuing another provider's scripts if they were at all suspect.

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[SpecterGT260]

Grover, are you in a state that requires physician oversight for NPs or no? I am just curious because one of a few things could be happening
1) this is just how this practice runs... in which case I would be pretty uncomfortable (but... what do I know )
2) Someone there was careless in signing off on the charts and didnt realize how ridiculous some of these scripts were (again, what do I know?) But as someone whose doctors describe as having "terminal ADHD", doses like 80mg/day scare the crap out of me. I am a big guy and only on 30. 20sr and 10 generic in the afternoon and that is plenty. Sure, more amps feel damn good, but in my experience you tend to cover symptoms pretty quickly and then get into issues where people equate their wellness with things like energy level. Also.... 20mg qid is ridiculous and has abuse written all over it. Whats wrong with 40sr bid? I feel like a pocket full of fast acting amphetamines isn't necessary.
3) the NP had no oversight and treats meds like magic pills where more is obviously better - this being a likely function of them being RNs with a couple seminars on health business and team building/leadership (a concept which I find odd for a profession which is, by definition, not the leader of the healthcare team) might have showed a little bias there...... 😳

 

[billypilgrim37]

The published dose ranges for stimulants are pretty variable and interesting, and the most difficult thing for extrapolating for adults is that children have much higher clearance. It's not uncommon to dose 2 mg/kg of mph or amp salts for younger kids, with 0.6-0.8 being a more typical range for older kids (and probably adults). Some studies will use 1mg/kg safely. It looks like around 0.6 is where most of the effect is for the average patient. So 60-80mg in a 100kg person isn't so absurd if it's actually indicated, but that doesn't mean I would feel particularly comfortable prescribing that much either.

My question is what insurance company is willing to fill 80mg of Adderall XR for an adult? I hear stories like this, and our insurance companies around here are so strict I can't even get a reasonable dose approved for most adults any more, never mind an absurd dose. This is a bit frustrating, as stimulants are a reasonable antidepressant augmentation strategy in a very select population of patients, and I've had a few adults have to go off their low dose stimulant (10-15mg Adderall) only to relapse with depressive symptoms despite an optimized previously effective SSRI.

 

[vistaril]

I'd consider a 2-pronged approach, as an idea.
1. Find an alternative provider they can go to if they insist on staying on those meds. Then you've eased the process for them at least.
2. Develop a solid body of evidence how this med isn't actually helping them function better, and how the tx is best through xyz. "I want you to function the best possible, but that will require us to try things differently. Will you go down this road with me if it helps you have a better life [or less anxiety, etc]

As an alternative, refer them to whoever was supervising the NP and signing off on that nonsense. It should be their mess to clean up, IMHO.

Point 2 is just a waste of time and won't do any good. These patients don't come to be on Adderall for 'adult adhd'(dx'd at age 30 in a person who doesnt work probably) and scheduled xanax by iatrogenic accident. They've made their decision, and they've had the talks from responsible providers before. I'm not about to waste my time, enter into a bad therapeutic alliance, etc in those situations.

The choice for these kind of patients is the following: keep treating them and 'playing the game' vs telling them you aren't going to continue such nonsense and telling them that they are welcome to go somewhere else.

Maybe for *some* of this population you can choose a middle ground....for example, if you think their supposed adhd is maybe halfway legit and they are more attached to the stimulant than the xanax, keep prescribing the stimulant and monitoring it and occasionally do a UDS to make sure they arent getting benzos off the street. Such 'compromises' may be realistic in about 20% of these sorts of patients.

But this idea that anyone is going to take patients who have been seeking these sorts of physicians out for a long time and change their whole outlook on life and their mood/attention/anxiety d/o whatever are hopelessly naive....

 

[vistaril]

So the NP who left our practice left me a bunch of adderral / xanax patients.
These patients are used to coming in for a cursory eval every 6 months and getting 3 months of amphets and then calling in for 3 months more.

One of these guys is on 40 mg bid, and other on 30 qd, and the other lady is on 20 mg bid and xanax.

So now I am taking over these patients. I cannot find one 90801 in the chart period. And the 90805's are very brief "patient is living with mother who is causing much stress. increase adderral to 20 tid"

I know what the right thing is to do. Full new patient exam, uds, therapy, collaboration, and go over childhood records.
Please advise.

I'm not sure that this is the "right thing to do".....after all, why waste your time and there time?

iirc this same issue was happening a few months ago, where you signed on to cover outpatients at a salaried hourly rate and weren't happy with the way things were being run.

I think the lesson here is that these sorts of jobs just aren't a good fit for you. And what I mean by that is outpt med mgt positions where it is an insured population of mostly mood and anxiety d/os and benzos/stimulants have become accepted as standard of care(and in a heck of a lot of private outpt settings this is the case). If you continue to take such positions(because after all they tend to pay ok), then you will continue to run into this same problem.

If you want to do outpt, maybe look into community mental health centers. The pay may be a little less, and it's going to be more of a seriously mentally ill patient population, but you usually don't feel compelled to give benzos or adderall because after the patients don't have a lot of choice. And in fact it's policy at some cmhcs to really limit benzo and stimulant usage.

Because this just isn't a good match for you. And honestly, I see a lot of blaming and criticizing other providers and that's really not optimal. You're mad at other providers because you feel they have put you in a bind with patients you now see, but that's really not the case.

 

[vistaril]

For those on Adderall, if I were in your situation, this is what I would do-

See the patients once a month, and gradually get to know them. I wouldn't do a full new pt eval all at once, but gradually gather the info. Only one month of Adderall at a time; no post dated scrips, must come in for each prescription. Assess over several months if Adderall is increasing the patient's functionality, assess dose. UDS.

thats a reasonable approach...sort of similar to the model some pain docs use. If I was going to do this though, I'd drop the benzo though as well. I think that, in combination with increased frequency of visits, is going to probably drive a lot of them away.

 

[vistaril]

No one in the practice knew this was going on? I hardly ever dole out stimulants and only 1 month at a time...and no refills for "my dog ate them; my friends stole them, my house burned down, they were in my car and it was stolen, my wife stole them, etc...

So for a guy with a dx of adhd, on adderall 10mg BID for 3 years, and is completely stable and on no other meds with no other symptoms you would see 12 times in the next 12 months?

Frankly, in private practice that is perhaps more unethical than being a candyman.....there is absolutely no need to see that pt every month. You can see them every 3 months or see and just post-date the 2nd and 3rd adderall script....that sort of thing(scheduling a stable pt with a known dx every month to bill) is no different in terms of the ethics than a pain med doc who doles out high dose chronic opiates as long as the patient will let them inject them or do various procedures on them every week or so and bill medicare/insurance.....you're using your power(ie an adderall script) to get them to do something that isnt needed often(visits every month) that benefits you financially

 

[SpecterGT260]

So for a guy with a dx of adhd, on adderall 10mg BID for 3 years, and is completely stable and on no other meds with no other symptoms you would see 12 times in the next 12 months?

Frankly, in private practice that is perhaps more unethical than being a candyman.....there is absolutely no need to see that pt every month. You can see them every 3 months or see and just post-date the 2nd and 3rd adderall script....that sort of thing(scheduling a stable pt with a known dx every month to bill) is no different in terms of the ethics than a pain med doc who doles out high dose chronic opiates as long as the patient will let them inject them or do various procedures on them every week or so and bill medicare/insurance.....you're using your power(ie an adderall script) to get them to do something that isnt needed often(visits every month) that benefits you financially

I know some states (or maybe its by institution) won't let you write more than one month out for these things. I get post dated scripts since refills aren't allowed.

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[vistaril]

I know some states (or maybe its by institution) won't let you write more than one month out for these things. I get post dated scripts since refills aren't allowed.

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that is true...and that's why people do post-dated scripts. If for some reason this isn't allowed, worst case is you can store the script at your office in the patient's file and just have the pt pick it up from the secretary or whoever between visits.

That is certainly not an excuse to need to see a stable ADHD pt on the same dose month after month after month after month for years......

 

[SpecterGT260]

that is true...and that's why people do post-dated scripts. If for some reason this isn't allowed, worst case is you can store the script at your office in the patient's file and just have the pt pick it up from the secretary or whoever between visits.

That is certainly not an excuse to need to see a stable ADHD pt on the same dose month after month after month after month for years......

I agree. Our pharmacy will take post dated scripts. So we do 3 months.

I think monthly is good for her to do for a bit until she gets this sorted out.

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[PikminOC]

I have seen pharmacies who need prior auths for such a high dose...and if they dont cover it..the patient miraculously comes up with cash to pay for it.

Dropping the benzo is more problematic. I have seen docs get in trouble at the med board level for dropping them too fast, even when the patient is doing whatever tehy want with teh meds tehy are given.

I have no problem dropping stimulants all at once...I have done it many times.

Vistaril, you are correct that these places dont fit me. I have also worked at CMHC taht have not worked out also: there were too many social problems (homelessness, etc) that my meds were not going to fix at all.

I actually ended up starting a practice completely on my own with NO ONE's input. I screen and choose my patients so I don't take these patients at all bc I know what they want and expect. And the money isnt worth it to deal with ppl who are so used to getting what they want with no accountability (Uds, therapy, etc).

My state requires collaboration with a physician by NP's. But I was not the physician on the case...and this is small potatoes for a med board.

These patients DO NOT want the one month at a time when they are used to getting it with 6 months between visits.

There is a risk of diversion and abuse.

My med board actually has rules on prescribing stims..and ADD/HD is not one of the approved reasons at all...narcolepsy is one though..

And the dose IS like a narcoleptic dose...The NP may have been giving these patients more than they should...she was also increasing doses by 20 mg at a time with minimal documentation...I do feel she put me in a bind and the other doc at this clinic did not want this patient either..

The other time I talked about adderall, on hindsight, were written by a physician who did have appropriate documentation, other than the UDS. Doesn't mean I agree with the people he gave the med to, but at least the documentation was not completely absent.

Sorry for the rambling..

 

[vistaril]

My med board actually has rules on prescribing stims..and ADD/HD is not one of the approved reasons at all...narcolepsy is one though..
..

what does this mean? med board? You mean state medical board? I find it hard to believe any state medical board would not find prescribing stimulants as appropriate for adhd, seeing as how in adhd stimulants are the STANDARD OF CARE.

Also, what do you see as your ideal practice setting? If you want to do outpatient, and you don't like cmhcs(too many social issues) and you don't like writing benzos and stimulants for insured chemical copers, that really only leaves therapy and whatever other outpatient psych med mgt patients exist outside of cmhc outpatients and benzo and stimulant patients. Now I don't want to suggest that there aren't high functioning insured patients with mood and anxiety d/os who aren't on benzos or stimulants and see psychiatrists for med mgt, but they certainly aren't falling out of the sky in a lot of places.....

 

[michaelrack]

what does this mean? med board? You mean state medical board? I find it hard to believe any state medical board would not find prescribing stimulants as appropriate for adhd, seeing as how in adhd stimulants are the STANDARD OF CARE.
.....

I agree. Some state med boards get hung up on only using controlled substances for FDA-approved indications (usually not a hard-and-fast rule, but using controlled subtances for non-indicated purposes can be used against the doc)... but there are stimulants with an ADHD indication, just as there are a few older stimulants with a narcolepsy indication.

 

[PikminOC]

I'm just letting you know what my state board has written..thats all..

I havent seen them bust anyone for this unless there is a complaint to the board (when the patient is cut off from their med supply)...

then the board goes after the doc to make sure about the documentation, EKG, uds, etc..

 

[michaelrack]

I googled "medical board stimulant rules"

Arkansas seems to be quite enlightened and allows tx of adhd, the board's guideline states that the standard of care is seeing stable pts every 3-6 months.

Ohio's rules imply that stimulants are ok for childhood ADHD, my reading of the regs don't clearly indicate that treating adult adhd is ok http://home.fuse.net/adherence/Ohio Law Restrictions on Prescribing Controlled Substances.pdf

Utah uses similar language as ohio, but takes out the word "childhood"- so ADHD is ok

too lazy to review them all

 

[vistaril]

I'm just letting you know what my state board has written..thats all..

I havent seen them bust anyone for this unless there is a complaint to the board (when the patient is cut off from their med supply)...

then the board goes after the doc to make sure about the documentation, EKG, uds, etc..

I think you have to be misunderstanding what your state board is saying. What state is this?

Because if there was a state that has a policy where you can't/shouldn't prescribe stimulants to ADHD patients, there would be uproar and we would know about it. Because that is nonsensical at face value. It would be something that hundreds of clinicians would have already pointed out how absurd it is, and the policy would have been changed. One could even argue that for many adhd patients it is malpractice and disregarding the standard of care to *not* have them on a stimulant.

More likely, the medical board just wants proper documentation of these adhd cases. For example, wants you to document how they met criteria for adhd(for example was it based on a carryover from a childhood dx, do you have symptom rating scales in chart if not, etc)......

Because what you are describing otherwise makes no sense.

As for the other documentation(ekg, uds), these sort of things are grey areas. I don't get a regular UDS on every adhd pt on a stimulant, and I'd argue it is not the definite standard of care. There are a few problems with UDS regularly for adhd patients....for one, the standard of care is going to be confirmation, and this is *expensive*.....you can't just base final decision making on a dipstick.

 

[michaelrack]

I'm just letting you know what my state board has written..thats all..
..

Are you saying that your board only allows stimulants for childhood adhd, or not at all for adhd????

 

[SpecterGT260]

I think you have to be misunderstanding what your state board is saying. What state is this?

Because if there was a state that has a policy where you can't/shouldn't prescribe stimulants to ADHD patients, there would be uproar and we would know about it. Because that is nonsensical at face value. It would be something that hundreds of clinicians would have already pointed out how absurd it is, and the policy would have been changed. One could even argue that for many adhd patients it is malpractice and disregarding the standard of care to *not* have them on a stimulant.

More likely, the medical board just wants proper documentation of these adhd cases. For example, wants you to document how they met criteria for adhd(for example was it based on a carryover from a childhood dx, do you have symptom rating scales in chart if not, etc)......

Because what you are describing otherwise makes no sense.

As for the other documentation(ekg, uds), these sort of things are grey areas. I don't get a regular UDS on every adhd pt on a stimulant, and I'd argue it is not the definite standard of care. There are a few problems with UDS regularly for adhd patients....for one, the standard of care is going to be confirmation, and this is *expensive*.....you can't just base final decision making on a dipstick.

In my state, adult ADHD requires 3rd party testing. I believe from a clinical psychologist or a psychiatrist versed in the test. once completed and reported with a positive finding, scripts can be issued (by psychiatrist). Could this be what she is getting at?

 

[PikminOC]

I think you have to be misunderstanding what your state board is saying. What state is this?

Because if there was a state that has a policy where you can't/shouldn't prescribe stimulants to ADHD patients, there would be uproar and we would know about it. Because that is nonsensical at face value. It would be something that hundreds of clinicians would have already pointed out how absurd it is, and the policy would have been changed. One could even argue that for many adhd patients it is malpractice and disregarding the standard of care to *not* have them on a stimulant.

More likely, the medical board just wants proper documentation of these adhd cases. For example, wants you to document how they met criteria for adhd(for example was it based on a carryover from a childhood dx, do you have symptom rating scales in chart if not, etc)......

Because what you are describing otherwise makes no sense.

As for the other documentation(ekg, uds), these sort of things are grey areas. I don't get a regular UDS on every adhd pt on a stimulant, and I'd argue it is not the definite standard of care. There are a few problems with UDS regularly for adhd patients....for one, the standard of care is going to be confirmation, and this is *expensive*.....you can't just base final decision making on a dipstick.

I am in Wi. Please read the medical rules. It is well defined for stims..and childhood ADD/HD is not on the list.

Maybe I'm reading it wrong. It's a list of 8 or so conditions for stims and nothing else..

and the board doesnt go after regular uds testing, but they want to see at least one test done at some point..

 

[vistaril]

In my state, adult ADHD requires 3rd party testing. I believe from a clinical psychologist or a psychiatrist versed in the test. once completed and reported with a positive finding, scripts can be issued (by psychiatrist). Could this be what she is getting at?

well it wasn't mentioned, but if so this would be silly. Neuropsych testing really isn't the standard for an adhd diagnosis. It's not always a bad idea depending on the situation sometimes. I think the expense and time committment probably deters some patients, so in that way I guess it is a good thing. But NP testing doesn't do a very good job of teasing out the bs'ers, and more importantly for very intelligent people who are used to answering those sorts of questions they can have ADHD and still 'pass' the test.

 

[vistaril]

I am in Wi. Please read the medical rules. It is well defined for stims..and childhood ADD/HD is not on the list.

Maybe I'm reading it wrong. It's a list of 8 or so conditions for stims and nothing else..
QUOTE]

I tried to find these and couldn't. Alternatively, I googled a ton of things related to this and couldn't find any evidence that somehow the Wisconsin medical board viewed stimulants wildly different than other state medical boards. Seeing how Wisconsin isn't some tiny state by any means, if the practice/rules for stimulants were wildly different in wisconsin from other states then it stands to reason that I could find some evidence for this somewhere online.

 

[billypilgrim37]

well it wasn't mentioned, but if so this would be silly. Neuropsych testing really isn't the standard for an adhd diagnosis. It's not always a bad idea depending on the situation sometimes. I think the expense and time committment probably deters some patients, so in that way I guess it is a good thing. But NP testing doesn't do a very good job of teasing out the bs'ers, and more importantly for very intelligent people who are used to answering those sorts of questions they can have ADHD and still 'pass' the test.

👍👍👍

 

[michaelrack]

I am in Wi. Please read the medical rules. It is well defined for stims..and childhood ADD/HD is not on the list.

Maybe I'm reading it wrong. It's a list of 8 or so conditions for stims and nothing else..
QUOTE]

I tried to find these and couldn't. Alternatively, I googled a ton of things related to this and couldn't find any evidence that somehow the Wisconsin medical board viewed stimulants wildly different than other state medical boards. Seeing how Wisconsin isn't some tiny state by any means, if the practice/rules for stimulants were wildly different in wisconsin from other states then it stands to reason that I could find some evidence for this somewhere online.

I also coudn't find this

 

[SpecterGT260]

well it wasn't mentioned, but if so this would be silly. Neuropsych testing really isn't the standard for an adhd diagnosis. It's not always a bad idea depending on the situation sometimes. I think the expense and time committment probably deters some patients, so in that way I guess it is a good thing. But NP testing doesn't do a very good job of teasing out the bs'ers, and more importantly for very intelligent people who are used to answering those sorts of questions they can have ADHD and still 'pass' the test.

I just know that is what they require before starting treatment. It may be an institutional thing rather than a state thing. This is through student health. Maybe a 3rd party test will scare away students just looking to score stims around finals. I didn't have to go through any of that due to a long standing diagnosis w/ documentation.

 

[billypilgrim37]

I just know that is what they require before starting treatment. It may be an institutional thing rather than a state thing. This is through student health. Maybe a 3rd party test will scare away students just looking to score stims around finals. I didn't have to go through any of that due to a long standing diagnosis w/ documentation.

This is a common policy among student health centers, but that's mainly because student health centers would really like to not be in the business of evaluating and treating new diagnoses of ADHD, for obvious reasons.

 

[PikminOC]

I'm sorry I will have to look for it at another time.
I have read many cases of board action (as I have had time to read this), usually against opiods but sometimes opiods and amphets.
I'm sure I make a much bigger deal out of this than I should.

 

[vistaril]

I'm sorry I will have to look for it at another time.
I have read many cases of board action (as I have had time to read this), usually against opiods but sometimes opiods and amphets.
.

Ummmm....well yeah. I think everyone is aware that physicians do lose their licenses(and sometimes go to jail) for doing things with opiates that is wrong and outside the standard of care. But what you initially stated(with respect to stimulants and adhd) would be like the state medical board saying 'opiates aren't approved to treat pain'.

Nobody disputes that state medical boards can and have taken action against physicians in the past for their stimulant rx practices. That is obvious. But that is a million times different than the rather outrageous claim that stimulants are not allowed/approved for adhd, which is what you originally said.

 

[AcronymAllergy]

well it wasn't mentioned, but if so this would be silly. Neuropsych testing really isn't the standard for an adhd diagnosis. It's not always a bad idea depending on the situation sometimes. I think the expense and time committment probably deters some patients, so in that way I guess it is a good thing. But NP testing doesn't do a very good job of teasing out the bs'ers, and more importantly for very intelligent people who are used to answering those sorts of questions they can have ADHD and still 'pass' the test.

Just my input--any neuropsychologist worth his or her salt is going to include objective assessment of motivation and engagement in an attempt, in part, to tease out the "bs'ers" you mention. Beyond that, no, neuropsych testing of course isn't necessary for a diagnosis of ADHD (although it's often required for various forms of accommodations, such as in classes or on standardized tests), as the diagnosis is based solely on behavioral characteristics and self-report by the patient and others.

What a neuropsych assessment can do is make an informed contribution to teasing out whether the individual's symptoms/distress are perhaps related to other conditions "masquerading" as ADHD. The testing will also help to provide objective evidence of the impact of symptoms on cognitive testing performance and ability, although in the case of ADHD, absence of "abnormal" findings certainly doesn't automatically = absence of the disorder, and vice-versa.

 

[vistaril]

Just my input--any neuropsychologist worth his or her salt is going to include objective assessment of motivation and engagement in an attempt, in part, to tease out the "bs'ers" you mention.

yes, but with saavy patients they often can't provide a definitive answer. You usually get the 'can't r/o.....' bit. We have some good psychologists and I've asked them to do this on many occasions...

Overall, I've just found NP testing in these cases to be not cost effective at all. Unless there is a lot of other stuff potentially there as you mention.

 

[AcronymAllergy]

yes, but with saavy patients they often can't provide a definitive answer. You usually get the 'can't r/o.....' bit. We have some good psychologists and I've asked them to do this on many occasions...

Overall, I've just found NP testing in these cases to be not cost effective at all. Unless there is a lot of other stuff potentially there as you mention.

Agreed in that for just a "vanilla" ADHD evaluation, a full-on neuropsych eval would neither be warranted nor cost-effective (unless, as previously mentioned, the individual is looking to seek some type of formal accommodation). We actually discourage those type of evaluations here, at least to some extent.

However, I've found that very rarely is it ever just a question of ADHD. Even in these cases, though, a thorough psychological evaluation (complete with clinical interview and various ratings scales) coupled with selected measures of cognitive functioning can attempt to uniquely address some of the "can't r/o..." situations you've mentioned (albeit not all of them by any stretch of the imagination, of course). Beyond that, we can be at an advantage in these situations in no small part because of the sheer amount of time we're able to devote to a case, both directly and with regard to records review.

It's an interesting area of work to be sure, and one in which (unfortunately) thorough evaluations are not conducted as often as might be helpful.

Sorry to somewhat derail the thread, though. I'll stop my sidebar here.