the hot topic of stimulants continues....

Discussion in 'Psychiatry' started by randomdoc1, Dec 3, 2017.

  1. randomdoc1

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    I have to say in the past two years, I am seeing more and more people coming on stimulants to the point where unless you freely give patients whatever they ask, it can now have some challenges to build up a busy panel in private practice. (I was fortunate in that I inherited many patients from a retired provider.) Yet we all know that there is no way all these folks can have ADHD. It is so hard to talk people out of this, when their brains are flooded with DA secondary to the amphetamines they are on and combine that with the post amphetamine crash they get. These medications I find in the wrong patient to be so self reinforcing yet de-stabilizing. What I'm seeing more and more now is people who not only don't seem to have ADHD, but they're most likely pushing their limits. I see mothers with 3+ children and uninvolved fathers getting hooked on this after they get the honeymoon from the energy boost they get on it and needing escalating doses. I also see people with IQs of 100 who are in first tier colleges trying to double/triple major and pursue things like law and medical school. Well...no $h** it's gonna be challenging and no, 60mg of Adderall is not going to make you smarter. Not surprisingly, when I break this news to patients (delicately of course by explaining risks and benefits of longterm amphetamines, their indications, and the differential diagnosis, etc.) I am sometimes subject to displaced frustration. Most people do handle it maturely though. One person had the balls to give me a one star review and severely exaggerated things, fortunately the website was nice enough to take it off. Another person demanded to speak with the medical director of my clinic who sided with me after she reviewed the chart.

    I guess...what I am concerned about is the rate that more and more people are ending up on these amphetamines. There is no good literature about the longterm effects of their use, especially since most of these people don't sound like they have ADHD at all. I feel like it just delays diagnosis of the actual primary disorder and most importantly treatment. Rather than hoping a pill will solve your problems, treat the underlying issue and get better at coping and problem solving. Most of these prescriptions I see are started by PCPs and other providers with minimal training in psychiatry. Even more pregnant women are arriving on amphetamines and opting to stay on them during pregnancy. This month I saw two women started on Adderall in their 60's for "ADHD" and are on 60mg of Adderall! wtf?! I am seriously considering writing a letter recommending a good look be made at how the amphetamines are prescribed. It reminds me a little bit about how the heroin epidemic started. I really don't feel comfortable seeing amphetamines being prescribed so loosely by individuals with so little training (not to say there are not bad psychiatrists, there is plenty of that too but the bulk of what I see is from non-psychiatrists) when other agents can be used as initial line with less abuse potential (e.g. bupropion, atomoxetine, even Concerta or Vyvanse...just for goodness sake not Adderall IR!). I'm not sure what I'd recommend as a solution, but where I live, things don't seem to be headed in a good direction. My friends on C/L are also seeing more and more people coming in due to complications from stimulants being prescribed to them. Thoughts? (putting my flame shield up)
     
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  3. resident1985

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    I’m right there with you and I have also seen several women in their sixties started on stimulants by NPs. Wtf? Thankfully no pregnant women.

    I think overprescribing psychoactive medications in general is a huge problem and stimulants are no exception. So many, including psychiatrists, lack nuance and seem to just want to appease people.

    With antipsychotics it’s usually easy for me to remove them and for many cases benzo maintenance as well but stimulants are much more difficult to persuade people to stop.
     
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  4. erg923

    erg923 Regional Clinical Officer, Cenpatico National

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    I can understand the frustration. However, admittedly, as a non-Rxer, I also dont quite understand why more people aren't simply saying "no" when faced with a lack of diagnostic indication and/or work-ups? Personally, I say no to patients ALL the time when there is lack of evidence/indication for the requested intervention. I have denied ongoing psychotherapy when there are no real treatment goals or when they are clearly unable to participate at a frequency that is appropriate or when it will not substantially benefit their presenting issue (e.g., grief). I have denied triage/consult to the residential level of care for SUD when there is clear suboptimal motivation/commitment or when outpatient tx is clearly able to address the need. I have denied requests for psychological testing when all is needed is clinical interviewing or for the issue to be clarified via ongoing contact in treatment. I deny requests for "disability letters" and for emotional support animals. I view this as a job, with responsibilities and liability, and I am generally unaffected (emotionally or otherwise) when people get "mad" at me in a session. Freud and others told me this was par for the course in clinical psychology/psychiatry. :)

    Related, "panel management" is an integral part of the practice of clinical psychiatry/psychology, especially in settings where resources are limited and/or already overburdened (e.g., community mental health clinics). Psychiatry already has a reputation for over treatment or heavy handed treatment in general. Also, patients really need to be conditioned to the (inconvenient) reality that a medical or psychiatric condition needs to be reevaluated from time to time in order to receive ongoing treatment. When a patient transfers PCPs, they don't seem to object when their BP history is reviewed and reevaluated prior to Rx of a statin, right?

    A crappy psych report or some PCP note from 5 years ago is not enough to be Rx stimulants for a purported dx of AD/HD, obviously. The diagnosis, especially in adults, requires a profound diagnostic workup. Not a bunch of tests mind you (not necessarily anyway), but substantial clinical interviewing and history taking from somebody who knows that the **** they are doing. Make sure you get acquainted with the local experts in your area. If its a psychologist, they need to have a reputation as a solid general psychiatric diagnostician. My impression over the years is that many psychiatrists/residents simply do not have time for such labor intensive diagnostics. If you are in a rural area without referral resources, this sucks...but not sure it can/should be used as an excuse for sloppy practice/prescribing.
     
    #3 erg923, Dec 3, 2017
    Last edited: Dec 3, 2017
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  5. birchswing

    birchswing Patient/Interested in Psychiatry

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    When stimmies came out, this was the indication.
     
  6. randomdoc1

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    Agree with erg923. I have been doing some networking with PCPs to keep my referral sources fresh and they have ALL asked me about patients inquiring them about ADHD. None of them knew that ADHD is by definition a neurodevelopmental disorder. Most thought that if the patient is able to come up with numerous examples of being inattentive currently, that it means they have ADHD which is why they asked me if it really is a legitimate disorder. They told me they've reluctantly started Adderall on some patients and sometimes asked they see a MH provider to provide the diagnosis before starting the Adderall. Most of the patients seem to have done some provider shopping and found a therapist of some sort who was comfortable with slapping them with that diagnosis despite a very inadequate developmental history. As one PCP told me, they felt it seems that if you look hard enough, you can find someone who is willing to diagnose you with it and they didn't feel they knew better than the people working in MH so they reluctantly start the amphetamine. Quite scary if you ask me... :(
     
  7. Ceke2002

    Ceke2002 Purveyor of Strange

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    I think I've told this story before, but when I was placed on Dexamphetamine as an adult in the 90s (note, I didn't stay on it as I found the side effects outweighed the benefits and have a preference for treating conditions without medications where possible) these are the stages I had to go through:

    1) Got to a GP and get a referral to a Psychiatrist

    2) Go to a Psychiatrist for a full assessment (assessment included providing as much corroborating evidence for a child diagnosis of ADHD as I could, undertaking a couple of different psychological scale type tests, and undergoing a brain scan/neurological testing to rule out other conditions)

    3) Once said Psychiatrist was satisified the diagnosis was the correct one, then they had to make an application to the health department to get permission to prescribe stimulants.

    4) Once permission was given, I then had to enter into a contract with the health department as well, that was reviewed every 12 months.

    Since then the rules have changed again, and you are now required to have two separate Psychiatrists make an independent diagnosis of Adult ADHD before you have any chance of being prescribed stimulants. The fact that stimulants can be prescribed by family medicine practitioners in the US quite frankly astounds me.
     
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  8. Liquid8

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    Most Australian states operate on similar lines, although the requirement for a second opinion seems to be unique to SA. Victoria has what can best be described as a single permit holder rule, meaning that only one doctor is allowed to hold the prescribing permit for a patient at any one time. This gives prescribers an out in situations where it's quite clear that there isn't a reasonable indication for a stimulant.

    A lot of our GPs are cautious about initiating psychotropic medications in general and many won't prescribe drugs like mood stabilisers, let alone stimulants without supporting specialist input. The process of having to get a referral from a GP to see (and more importantly, pay) a psychiatrist also helps to rule out most drug seekers/time wasters.
     
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  9. Ceke2002

    Ceke2002 Purveyor of Strange

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    I'm pretty sure single permit is what we have here for other Schedule 8's, such as Morphine. Apparently that's transferable between states, according to my GP who assures me all I have to do is find a Doctor in Victoria who's happy enough to take over the Drugs of Dependence Units authorisation and continue prescribing my limited monthly dosage of MS Contin. I'm not so sure it's gonna be that easy, so I have a feeling I might be making some trips back to SA until everything is moved and sorted. Yep, I'm gonna be a Victorian in about 2 weeks time. :D

    (thought about transferring to a Psych over there as well, but decided 5-6 years of therapy maybe was the right time to see how I went by myself).

    Sorry went off topic there for a sec. I guess bottom line, controls in place for these sorts of medications = less abuse potential. I mean you'd have to be pretty dedicated to jump through that many hoops just to get a few tabs.
     
  10. SeniorWrangler

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    Only you can decide what you want to put up with in your practice.
     
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  11. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    A little Devil's Advocate here. Many, if not most, insurance companies do not pay for ADHD evals. I can do them, but I will get it kicked back by insurance because they consider it a psychoed eval. Therefore, it's on our list of referral that get instantly referred out to some pp cash pay options for the most part. If they can't get a school to do these evals in the states, it can be costly. So, I can see why a lot of these diagnoses are made without a proper eval in place.
     
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  12. HooahDOc

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    What the OP describes is not unique to psychiatry or psychology. It is the current state of medicine in general, which has enabled the culture of entitled and demanding patients through its shift from actual clinical care to making RVUs and the highest patient satisfaction scores it can possibly get. Treating patients like customers has fostered the idea that their lay opinion of diagnosis and treatment carries equal weight to the opinions of experts.
     
  13. Ceke2002

    Ceke2002 Purveyor of Strange

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    Patient satisfaction surveys should consist of three questions, and three questions only: Are you still alive? Are all your limbs still attached? Did you suffer irreversible brain damage?
    Next.
     
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  14. birchswing

    birchswing Patient/Interested in Psychiatry

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    It's an economy of entitled and demanding patients, which is also a culture—I agree— but it's a consciously constructed culture. There are a lot of moving parts, but capitalism intersecting with balkanized markets is at the center of it. There are other factors, too, like the medical school system and the reliance on pharmaceutical companies for research and treatment options.

    I agree that patients shouldn't be treated like customers, but they are customers of one of the world's largest industries. That wasn't a decision people today made, but one that was put into motion a long time ago.

    I don't know about this forum, but the people in the anesthesiology forum for sure would not be happy with the alternative, in which doctors are paid a reasonable amount based on their work and not the investment they made in this industry and in which patients are simply patients. I think it would be nearly universal for people who want to be doctors in the US, just as you see the near universality of demanding consumers. It's sort of like if you were Apple and were scratching your head wondering why there are lines of people waiting to give you cash for this year's iPhone. Except with Apple there's just one market so everything makes a bit more sense.

    Edit:

    To expand on the healthcare/Apple analogy, some of the markets are such that you're allowing groups of people into an Apple Store and saying you can take whatever you want as long as you get a manager to approve it (which there is implicit pressure to do because Apple advertises that these are good products), some can go in but the prices for them are really high, and some people aren't allowed in at all unless their old computer is crashing and get to go to the genius bar but nowhere else.
     
    #13 birchswing, Dec 4, 2017
    Last edited: Dec 4, 2017
  15. Jules A

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    I don't get it either, in fact I say no all the time to a plethora of requests that I don't feel have a sound clinical rationale.
     
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  17. Trismegistus4

    Trismegistus4 Worried Wellologist
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    Because they just keep scheduling follow-ups every month and coming back begging you for the requested intervention over and over, implying they're about to decompensate without it, weeping and wailing that they're about to get fired from their job or fail out of school without it. Some people do this even if you tell them at the first visit, flat-out, "I don't prescribe stimulants to adults." They just keep coming, and begging, and in some cases, eventually, you give in.
     
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  18. AcronymAllergy

    AcronymAllergy Neuropsychologist
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    I've heard this (and every version of yelling/screaming/throwing furniture) through my "next door neighbor" psychiatrists' offices, and don't envy you. Happens more with benzos than stimulants, but the latter can certainly aggravate folks as well. I try to lessen the blow during my feedback sessions (e.g., after ADHD assessment) by letting people know that research would suggest medication X may not be indicated or helpful, or may make some of their problems worse given how they're using it, but I'm not sure how much of an effect that actually has.
     
  19. HooahDOc

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    There's a huge difference between not prescribing a treatment because you don't think they have a diagnosis that warrants it and not prescribing a treatment simply because of your own personal beliefs. Your blanket statement of, "I don't prescribe stimulants to adults", makes me think yours is the latter. If true, you have no business seeing patients for such concerns and have an obligation to get them to someone who would be willing to provide the treatment that is SOC.
     
  20. Igor4sugry

    Igor4sugry Junior Member

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    I agree with everything said by the OP. Don't give in. If diagnosis is not correct don't prescribe stimulants, if dosage is too high by previous prescriber don't continue the high dosage. If psychiatrist are not putting their foot down and pointing out when stimulants are improperly prescribed, who will?

    I do feel our attempts to control prescribing will not have much benefit. Look at the sales of Vyvanse, $1.5billion+. They then wanted more money and got it approved for binge eating disorder. They also developed Mydayis to keep patent extended.
    Look how advertising for stimulants has now shifted to millennial customers. The ones that grew up on stimulants as children and college students. The market is very big, lots of money to be made.

    The forces that increase overprescribing is ADHD criteria itself (can easily convinve a doc you have it, and easily over-diagnosed), societal pressure to prescribe (doc needs patients, and avoid negative reviews), performance improvement in anyone that takes stimulants (ie if it worked you must have ADHD attitude), Methamphetamine addicted population, Advertising, Advertising, Advertising to patients and docs.
     
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  21. SeniorWrangler

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    If you look at the opioid crisis, the pharmacy companies involved got off with paying fines, but prescribing doctors got hammered.
    IF the pendulum swings on stimulants, Shire will get criticized but the prescribers will get sued and investigated.
    So you might as well do the right thing now, prescribe only when you think it's appropriate and otherwise refuse.
     
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  22. Bartelby

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    I think it comes down to a few things:

    1 - The diagnosis of ADHD, and especially adult ADHD, is fuzzy. A kid who is hyperactive and inattentive across multiple settings will often end up with the diagnosis, and it's easy for many people claiming adult ADHD to tell a story consistent with childhood ADHD, whether diagnosed or not.

    2 - Many psychiatrists are uncomfortable with gathering collateral, such as interviewing the parents about childhood symptoms or demanding school report cards and behavioral reports. We often, even typically, rely on patient self-report in clinical interviews unless there is good reason not to. That makes the ADHD history difficult to disconfirm. And even if they had good grades etc, what if they had compensatory strategies that are no longer working?

    And most importantly:

    3 - All of us have seen the individual coming into our office sloppy intoxicated on 6 mg of klonopin a day, slurring their speech and acting belligerent. We have seen people OD on their Xanax and alcohol, drive intoxicated, become violent, and end up relatively nonfunctioning on misprescribed benzos. We see people become nonfunctional slaves to their opiates. What do we see with stimulants? A well put-together person who is polite, friendly, and tells us how the stimulant has been a true miracle for them. How it saved their job, how being more attentive decreases their anxiety, how they are more present with their kids. Personally, I have not yet seen nightmare outcomes from prescribed stimulants (psychosis, ruined lives, violence, etc). In a typical worst case, they are selling the stimulants to others who want to use them as "academic steroids," or they are snorting the stimulant to get a brief high. Rarely someone injects, but by that point they are probably moving on to harder stuff anyhow.

    So I think that's the jist of it. Psychiatrists weigh risks and benefits, see that the risks are not too extreme (especially compared to benzos and opiates), and see a patient who lists off many benefits. I try to confirm as much objective information as possible when I prescribe stimulants for ADHD, and I think I am more stingy with stimulants than average (typically prescribing only after working with the person for some time, talking to old prescribers, trying non-pharmacological strategies first, or seeing a very robust history) but it's hard to even feel sure that an individual does or does not have ADHD, and it can feel a little cruel to watch someone fail at work or school while begging for the one thing that has worked for them (which would be no sweat at all for me to prescribe).
     
  23. SeniorWrangler

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    Clemow, David B., and Daniel J. Walker. "The potential for misuse and abuse of medications in ADHD: a review." Postgraduate medicine 126.5 (2014): 64-81.
     
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  24. Jules A

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    I'm at a facility in an area with several local colleges where we frequently see the adverse effects of stimulant misuse.
     
  25. randomdoc1

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    My intake yesterday wanted to be resumed on Vyvanse. She was on 140mg a day. WTH does that even treat anymore? Anyways, turns out she has Cushings, sleep apnea, and a raging etoh use disorder...I said fix those first and then we'll have another look at your sx. Fortunately she's willing to still follow up. Treating her depression in the meantime, lol.
     
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