Treating ADHD with ZERO urine tox/drug screening and pill counts?

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B52slinger

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I recently read a comment here stating:
"There are many other things the DEA is looking for like the drug screens and pill counts. I haven't see physicians get in trouble for not having the [neuropsych] testing. When I have seen physicians get in trouble with the DEA it's because the patients are having insufficient tox screens or failed ones. Or the physician is over prescribing like 90 days worth of meds in 30 days. The psychologist report isn't going to save them in those cases."

As a PGY-3 and PGY-4, among all of the outpatient attendings I worked with, maybe 5% of the time a drug screen was actually done at any point for an ADHD patient, and I have NEVER ONCE seen an attending do a pill count for stimulants (or any medication for that matter). And only one single attending I've worked with has ever ordered urine drug testing on an ADHD patient, the others simply never order it. How critical is it that drug screening and pill counts are done for ADHD patients? Should I be attempting to get routine urine drug tests and pill counts on all of my ADHD patients?

I have asked this question to one of my attendings recently and was told that urine drug tests and pill counts are totally unnecessary and I was being overly paranoid. I have had zero teaching whatsoever on how or when I should be doing urine drug tests or pill counts because attendings here are simply NEVER doing these things (this is an IMG-heavy program where attendings are routinely seeing 40+ patients a day). And what does "failed tox screen" mean exactly? That they are negative for amphetamines (and are therefore likely selling their prescribed stimulant on the street for cash)? Or do any non-amphetamine drugs testing positive mean that ADHD treatment must be immediately discontinued due to comorbid drug abuse?

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I’ll let others respond to the UDS side of things, but I never do pill counts on my patients and have only ever heard of this for addictions clinics. If I’m at the point where I felt it was necessary to do a pill count, I wouldn’t be prescribing a controlled substance to that patient.
 
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I will definitely be trying my best to screen out the "adult ADHD" patients from my practice. But for the patients with verified childhood collateral and thorough history supporting a legitimate ADHD diagnosis, what are the DEA screening regulations? I'm specifically interested in NY and FL rules. Do these patients have to get a certain number of urine drug tests per year?
 
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I recently read a comment here stating:
"There are many other things the DEA is looking for like the drug screens and pill counts. I haven't see physicians get in trouble for not having the [neuropsych] testing. When I have seen physicians get in trouble with the DEA it's because the patients are having insufficient tox screens or failed ones. Or the physician is over prescribing like 90 days worth of meds in 30 days. The psychologist report isn't going to save them in those cases."

As a PGY-3 and PGY-4, among all of the outpatient attendings I worked with, maybe 5% of the time a drug screen was actually done at any point for an ADHD patient, and I have NEVER ONCE seen an attending do a pill count for stimulants (or any medication for that matter). And only one single attending I've worked with has ever ordered urine drug testing on an ADHD patient, the others simply never order it. How critical is it that drug screening and pill counts are done for ADHD patients? Should I be attempting to get routine urine drug tests and pill counts on all of my ADHD patients?

I have asked this question to one of my attendings recently and was told that urine drug tests and pill counts are totally unnecessary and I was being overly paranoid. I have had zero teaching whatsoever on how or when I should be doing urine drug tests or pill counts because attendings here are simply NEVER doing these things (this is an IMG-heavy program where attendings are routinely seeing 40+ patients a day). And what does "failed tox screen" mean exactly? That they are negative for amphetamines (and are therefore likely selling their prescribed stimulant on the street for cash)? Or do any non-amphetamine drugs testing positive mean that ADHD treatment must be immediately discontinued due to comorbid drug abuse?
I don't use psych testing for a psychologist to save me. For me it's to ascertain the diagnosis. There's too much secondary gain with a patient walking into my office to recite all the bullet points to have the diagnosis.
 
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If I suspect substance abuse issues I'm more inclined to simply not prescribe a stimulant in the first instance, so the only time I really look at ordering a UDS is with inpatients, because it's otherwise impossible to ensure it is a legitimate sample.

I'm not exactly sure what "pill counting" entails, but we do have the ability to check exactly where and when a script has been dispensed which makes it easy to determine when someone has been getting their medication too early and calculate how much they are actually using versus what they claim to be the case. I'm not too bothered if there's a plausible benign explanation or they're early only by a few days, and more often than not my cohort of patients tends to use less than what I prescribe with extra repeat scripts often being expired. But every once in a while there is someone who somehow manages gets their meds dispensed in half the expected time or less. If they don't admit to it, it's now quite easy to decline these requests, and respond along the lines of "the system indicates you should have enough medication to last for a further x months."
 
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I’ve certainly never heard of anyone getting in trouble with the DEA for not doing tox screens in a general outpatient clinic for patients taking stimulants. People do tox screens but that’s just their own policy around controlled meds. I don’t even know anyone who regularly does pill counts and I can count on one hand the number of times I’ve done a pill count on patients in my life.
 
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Generally, I try to at least do a baseline UDS if I can, because I dont think it hurts. The reality is, the people who are drug seeking are not very good at it. Hate to say it. We see the patterns time and time again, and the same tricks are used consistently. The labs down here such as quest, as i have mentioned sucked. They require pt apt, are understaffed/overworked. Often times they screw up the lab order. Realistically, if a patient was clever enough to outsmart me with drug seeking, im sure theyre smart enough to time the UDS. Though again, these people are generally obvious.

If someone is stable on adderall 10mg qam xr, doing well, and not asking for increases, has no criminal/drug history, then suspicion of misuse is fairly low.

Obviously if they have a pertinent substance use history i would be very strict on my requirements.

Hard to build a therapeutic alliance when you're doing pill counts on patients. I mean you can see when they're filling the medication/how often, so im not sure what that would even really solve. Sounds like a prison thing, lol.

At the end of the day you cant control human behavior. If someone abuses drugs while you're prescribing them a stimulant, but you believe they have ADHD- how is it your fault? Realistically. They could have been clean at iniation/during initial UDS but use later on. Who knows. The adverse result they're getting is because they're not following the agreement (i make everyone sign a controlled substances agreement) that was outlined. Not because you're genuinely trying to help the person. Obviously if you know the patient has a significant history of selling controlled substances/recent significant drug abuse and your still giving out ridiculous amounts of controlleds to them, then yea i think the case against you becomes a lot stronger.

We cant always fix people. We cant always stop someone from using substances. We cant always make someone not depressed. We only advice, do our best, and hope the patient puts in the work and makes the right choice. Inevitably in psychiatry, they will make the wrong choice at times.
 
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ADHD is a clinical diagnosis. It's a waste of time and resources to do neuropsychological testing and inconvenient, if even available. Get collateral information, take the necessary time evaluating the patient. ADHD is not an emergency, despite what patients may sometimes say.

Like others said, if I feel pill counts would be needed, I just don't prescribe stimulants. I do use the prescription database every time I prescribe stimulants to confirm the patient is getting stimulants prescribed by only me. Like another said, I know people travel, holidays exist, and have life situations happen and so I take into account good explanations for slightly early renewals.

My organization requires a urine drug screen at least every 90 days by policy for patients prescribed stimulants. If the patient doesn't want to give a sample every 3 months, then I don't prescribe stimulants. I don't prescribe stimulants to anyone with an active substance abuse problem.
 
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I've done it at the VA but all that I find it does is delay care.

If diversion is a concern a UDS won't prove it unless you suspect they're taking something they shouldn't be, and if they are, don't prescribe them stimulants.
 
Something to think on:

Let’s say I’m prescribing Adderall XR 30mg qam - 30/month. Especially with the national shortage, this is unusual, but it’s probably the most abused so let’s start there.

If the drug screen shows negative, does it change management? People with adhd often choose to not take meds daily and sometimes inattention leads to forgetting the meds. So if amphetamine negative, I’ll still Rx.

So now it comes down to what to do if something is positive. Studies have shown that treating adhd reduces the odds of substance abuse except for stimulant abuse. So + THC may lead me to discuss the benefits of stopping THC, but it is unlikely to lead me to stop Adderall XR.

As research shows stimulants only increase the risk of stimulant abuse, stimulants are the primary focus on UDS. If not asking for early refills or wanting to constantly switch stimulants each month, what are the odds someone is abusing 30 Adderall XR per month? So then how many UDS’s and at what cost are we spending to catch 1 person abusing stimulants without red flags?

I’m not claiming to know the answer to that last question, but I’d bet a ton of $ is spent with little return.

I typically do UDS with those in treatment for substances for accountability or reward systems. I also UDS with red flags or to rule out other issues.
 
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The optimal amount of diversion and misuse of prescription stimulants, from a clinical systems perspective, is not zero.

I'll let that sink in.

We could trivially stop all diversion and misuse of prescribed stimulants. All we have to do is never prescribe stimulants, done, hooray we can all go home.

If we believe prescribing stimulants is beneficial and a good idea in some cases, and should be allowed to happen, we enter the realm of tradeoffs between actually prescribing and implementing measures meant to reduce diversion. We then have to weigh how burdensome the later ends up being and whether that represents a worthwhile tradeoff compared to its impact on the former. If I required everyone I prescribe stimulants to to submit 24/7 bodycam footage covering the intervals between our appointments, I would have a) less diversion and b)vastly fewer patients receiving stimulants. We can probably agree this is an excessive burden. Similarly, if we just put out baskets of stimulant pills in our waiting rooms and a sign inviting patients who are sure they have ADHD to help themselves to as much as they think they need, we can agree this is an inadequate burden.

@TexasPhysician makes an excellent point. This is a cost-benefit issue. Just like there is an optimal amount of identity theft in a functioning financial system (since you probably don't want your bank to require you to appear in person with a notarized statement from 8 people who have known you since childhood asserting that you are who you say you are every time you want to withdraw some cash), there is an optimal amount of diversion and misuse of prescription medications.

The only question is how much is tolerable.
 
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I do not do any UDS or pill counts for any medication. (I do not prescribe suboxone)
 
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If I suspect substance abuse issues I'm more inclined to simply not prescribe a stimulant in the first instance, so the only time I really look at ordering a UDS is with inpatients, because it's otherwise impossible to ensure it is a legitimate sample.

I'm not exactly sure what "pill counting" entails, but we do have the ability to check exactly where and when a script has been dispensed which makes it easy to determine when someone has been getting their medication too early and calculate how much they are actually using versus what they claim to be the case. I'm not too bothered if there's a plausible benign explanation or they're early only by a few days, and more often than not my cohort of patients tends to use less than what I prescribe with extra repeat scripts often being expired. But every once in a while there is someone who somehow manages gets their meds dispensed in half the expected time or less. If they don't admit to it, it's now quite easy to decline these requests, and respond along the lines of "the system indicates you should have enough medication to last for a further x months."
Pill counting entails patient bringing in their pills and you counting how many they have left. You can catch people who are overusing because they'll run out too soon, but it's pointless if you suspect diversion as they'll just keep the appropriate number of pills and just divert them later.
 
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I would say the following are required for stimulant prescribing in adult ADHD:

-Check your state's prescription drug monitoring program as required by law, or every three months (presuming your state has implemented one)
-Watch for red flags: early refill requests, lost prescriptions, sharing their prescription with others, receiving controlled substances from other prescribers, evidence suggesting substance abuse such as developing paranoia or using the medication by non-standard routes. When red flags are present, address them. Starting random Utoxes in this setting might make sense.
-Take a thorough substance use history. Make sure any substance abuse issues are adequately addressed. As Texas mentioned, if ADHD is actually present then adequately managing it may actually help with managing the substance use disorder. But do not just look the other way, be sure it remains part of the conversation. If you find the patient is lying to you about substance abuse, that is a time to become more uncomfortable than when they are reporting honestly (even if there is a history of problem use).
-Take a good history to confirm ADHD. Ideally this involves contacting collateral (parents) and asking the patient to produce old records (such as past testing or notes from past providers who have treated them). Specifics of what is needed will vary case to case. I find that patients are typically open with producing these records when you explain the importance of getting the diagnosis right / making sure we are not overlooking other explanations for their attention problems.

Things that can be used on a case to case basis:
-Getting random Utox (as above). I would only recommend this if there are red flags, and then you need to weigh going this route versus just stopping the stimulant and moving to a non-controlled option if you believe the ADHD is genuine.
-Conditioning Stimulant use on appropriate engagement with treatment for any substance use disorders that might be present.

Things that don't make sense:
-Pill counts. As others have pointed out, you can see exactly when your patient fills the prescriptions and whether they are getting other prescriptions. Given that you have access to this information, I think pill counts would serve more to disrupt the alliance you have with your patient than to add useful information to management.
 
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And as for neuropsych testing, I agree with others that it is not needed. Honestly I find you typically cannot get it even if you want it. The waitlists are incredibly long, and at least when I have attempted to do so the psychologists have no interest in testing for suspected ADHD (they basically say that it is a clinical diagnosis and that testing is not indicated). Your only option there might be cash-only psychologists, and a full testing battery is likely to be very expensive out of pocket.
 
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So yeah, don't give 90 days worth of meds in 30 days... But in regards to UDS and pill counts, these are rumors, not necessarily standard of care. If you have a clinical reason to do those things, do them.
 
Ok, so we pretty much answered this.

Another thing that happens a lot: How do you worthy colleagues deal with adult ADHD patients that develop hypertension while being prescribed stimulants? I'm wondering if my approach is the same as everyone elses.
 
Ok, so we pretty much answered this.

Another thing that happens a lot: How do you worthy colleagues deal with adult ADHD patients that develop hypertension while being prescribed stimulants? I'm wondering if my approach is the same as everyone elses.
Risks and benefits, if they want to continue you can try to decreasing or get them to see PCP for HTN meds
 
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im sure theyre smart enough to time the UDS.
Simple fix: "You must get this done in the next 7 days."

If a patient clears MJ within 7 days, they're probably not using all that heavily.

The other purpose is to catch anyone dumb enough to do other substances and show up to the UDS.

As for pill counts, there's no reason to do that in an age of PDMP. I could see doing it back when it was harder to verify that they weren't getting multiple fills.
 
Ok, so we pretty much answered this.

Another thing that happens a lot: How do you worthy colleagues deal with adult ADHD patients that develop hypertension while being prescribed stimulants? I'm wondering if my approach is the same as everyone elses.
I just had one of these patients today and was thinking of consulting this fine lot on SDN. Patient has been on adderall XR 20mg for several years, functioning well, also has PTSD diagnosis. She has had multiple documented times of mildly elevated BP (130's-140's/ 80's-90's) and tachycardia (100-108 bpm) going back at least last 1.5 years with intermittent times of normal BP/HR. She also has had extreme up tick of her anxiety over the past year due to some stuff with her child culminating in a PCS to our location so her anxiety is not controlled at all on prozac 40mg. PCM last month stopped her adderall and referred to psychiatry and cardiology. She's had 2 EKG's since the PCM appointment that other than sinus tach were unremarkable. She's 35 with no other major comorbid health issues, no family cardiac hx that I'm aware of.

BP is about the same in my office, HR mildly tachycardic, no symptoms of CP/SOB/Palps that she endorses today but anxiety is higher now off med. Patient in my office today is literally falling apart, crying, regarding how this has impacted her functional ability at work, high anxiety, worried this will lead to administrative action due to poor work performance (I'm active duty and that is certainly something that can happen and has happened before she was diagnoses with ADHD, improved with treatment). She wasn't even begging me to get back on a stimulant because she does want to take the concerns of the PCM seriously. She's trialed wellbutrin, strattera, guanfacine. All ineffective or intolerable side effects. Discussed the concerns for cardiac risks which she acknowledged. Offered her we could return to strattera (PCM trialed this and only went 40mg but patient tolerated well it was just not effective, offered increased dose of this) and wait cardiology results, return to adderall with close f/u for BP checks (like every 1-2 weeks to check in) and strongly emphasized the recommendation to f/u with the cards referral, or trial another stimulant (because she disclosed that the adderall was effective but she noted increased irritability with it) and close f/u either way, still see cards. She opted for vyvanse as she has trialed concerta and follow up next week for check in.

Would ya'll do anything different?
 
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And to the OP, I don't do UDS often if ever for stimulant treatment, never count pills with patients
 
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I just had one of these patients today and was thinking of consulting this fine lot on SDN. Patient has been on adderall XR 20mg for several years, functioning well, also has PTSD diagnosis. She has had multiple documented times of mildly elevated BP (130's-140's/ 80's-90's) and tachycardia (100-108 bpm) going back at least last 1.5 years with intermittent times of normal BP/HR. She also has had extreme up tick of her anxiety over the past year due to some stuff with her child culminating in a PCS to our location so her anxiety is not controlled at all on prozac 40mg. PCM last month stopped her adderall and referred to psychiatry and cardiology. She's had 2 EKG's since the PCM appointment that other than sinus tach were unremarkable. She's 35 with no other major comorbid health issues, no family cardiac hx that I'm aware of.

BP is about the same in my office, HR mildly tachycardic, no symptoms of CP/SOB/Palps that she endorses today but anxiety is higher now off med. Patient in my office today is literally falling apart, crying, regarding how this has impacted her functional ability at work, high anxiety, worried this will lead to administrative action due to poor work performance (I'm active duty and that is certainly something that can happen and has happened before she was diagnoses with ADHD, improved with treatment). She wasn't even begging me to get back on a stimulant because she does want to take the concerns of the PCM seriously. She's trialed wellbutrin, strattera, guanfacine. All ineffective or intolerable side effects. Discussed the concerns for cardiac risks which she acknowledged. Offered her we could return to strattera (PCM trialed this and only went 40mg but patient tolerated well it was just not effective, offered increased dose of this) and wait cardiology results, return to adderall with close f/u for BP checks (like every 1-2 weeks to check in) and strongly emphasized the recommendation to f/u with the cards referral, or trial another stimulant (because she disclosed that the adderall was effective but she noted increased irritability with it) and close f/u either way, still see cards. She opted for vyvanse as she has trialed concerta and follow up next week for check in.

Would ya'll do anything different?
She doesn’t need to come to the office to get BP checks it is more accurate if she checks it at home with BP cuff. I just do whatever the patient wants given they understand the risks. Tell them BP can kill them but also not having a job can kill them so choose what you’d like. Once you take off all the responsibility of making the best choice and give it to the patient, medicine becomes much much easier.
 
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As for pill counts: If a patient brought 20 capsules, could you identify that they are the drug listed?

With the many generics, I’m not sure I could accurately identify beyond tablets and capsules.
 
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Simple fix: "You must get this done in the next 7 days."

If a patient clears MJ within 7 days, they're probably not using all that heavily.

The other purpose is to catch anyone dumb enough to do other substances and show up to the UDS.

As for pill counts, there's no reason to do that in an age of PDMP. I could see doing it back when it was harder to verify that they weren't getting multiple fills.
for quest labs here, it takes >7 days to get an apt with them. not even lying.
 
Ok, so we pretty much answered this.

Another thing that happens a lot: How do you worthy colleagues deal with adult ADHD patients that develop hypertension while being prescribed stimulants? I'm wondering if my approach is the same as everyone elses.

in my experience its usually people are already borderline (and most likely will go into that range with time anyways) the stimulant may push them a bit more. Or they're already hypertensive and the stimulant just exacerbates it a bit. I generally dont see big increases in BP with them, more smaller increases.

I use it as a incentive for weight loss, which is biggest factor for hypertension, besides maybe genetics. Improved diet/healthy eating. Possibly BP meds, which again, patient likely was already hypertensive or on his way. If its a young patient who was completely normal then developed it, maybe id try a methylphenidate and see if the BP effect improves.
 
I just had one of these patients today and was thinking of consulting this fine lot on SDN. Patient has been on adderall XR 20mg for several years, functioning well, also has PTSD diagnosis. She has had multiple documented times of mildly elevated BP (130's-140's/ 80's-90's) and tachycardia (100-108 bpm) going back at least last 1.5 years with intermittent times of normal BP/HR. She also has had extreme up tick of her anxiety over the past year due to some stuff with her child culminating in a PCS to our location so her anxiety is not controlled at all on prozac 40mg. PCM last month stopped her adderall and referred to psychiatry and cardiology. She's had 2 EKG's since the PCM appointment that other than sinus tach were unremarkable. She's 35 with no other major comorbid health issues, no family cardiac hx that I'm aware of.

BP is about the same in my office, HR mildly tachycardic, no symptoms of CP/SOB/Palps that she endorses today but anxiety is higher now off med. Patient in my office today is literally falling apart, crying, regarding how this has impacted her functional ability at work, high anxiety, worried this will lead to administrative action due to poor work performance (I'm active duty and that is certainly something that can happen and has happened before she was diagnoses with ADHD, improved with treatment). She wasn't even begging me to get back on a stimulant because she does want to take the concerns of the PCM seriously. She's trialed wellbutrin, strattera, guanfacine. All ineffective or intolerable side effects. Discussed the concerns for cardiac risks which she acknowledged. Offered her we could return to strattera (PCM trialed this and only went 40mg but patient tolerated well it was just not effective, offered increased dose of this) and wait cardiology results, return to adderall with close f/u for BP checks (like every 1-2 weeks to check in) and strongly emphasized the recommendation to f/u with the cards referral, or trial another stimulant (because she disclosed that the adderall was effective but she noted increased irritability with it) and close f/u either way, still see cards. She opted for vyvanse as she has trialed concerta and follow up next week for check in.

Would ya'll do anything different?
Those BPs and HRs don't worry me at all. There's an essentially meaningless added absolute risk with SBPs in the 130s compared to 120s. Looks like the numbers didn't go down when the stimulant was stopped. As others have said, in-office BPs tend to be higher and less accurate than home BPs. In an anxious patient I would expect this to be the case.

Do they even start BP meds these days (prior to recommending weight loss) for SBPs in the 130s?

IME, Strattera has similar if not worse effects on BPs and HR compared to stimulants.

I would recommend home BP checks and maybe check the BP when they come to my office. I wouldn't go overboard with extra demands, since no PCP would be checking someone's BP this often with those values. Add another 20-30 and maybe they might do it for a month to confirm a diagnosis.
 
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Those BPs and HRs don't worry me at all. There's an essentially meaningless added absolute risk with SBPs in the 130s compared to 120s. Looks like the numbers didn't go down when the stimulant was stopped. As others have said, in-office BPs tend to be higher and less accurate than home BPs. In an anxious patient I would expect this to be the case.

Do they even start BP meds these days (prior to recommending weight loss) for SBPs in the 130s?

IME, Strattera has similar if not worse effects on BPs and HR compared to stimulants.

I would recommend home BP checks and maybe check the BP when they come to my office. I wouldn't go overboard with extra demands, since no PCP would be checking someone's BP this often with those values. Add another 20-30 and maybe they might do it for a month to confirm a diagnosis.

Yeah, I was going to say, when did BPs in the 130s start being a reason to discontinue anything?
 
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Yeah, I was going to say, when did BPs in the 130s start being a reason to discontinue anything?
PCP here. I start HTN treatment in the 140/90 or greater range. 130s is fine and needs no treatment.

Technically the guidelines say we shouldn't start until 150/95 or more.

I've started using Strattera for old folks with low BP and it works well, but other than that I've never been impressed with ADHD meds increasing BP in most people.
 
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For those doing UDS are you dismissing patients based on positive cannabis screens? My state like many others has medical cannabis and it seems like the everyone coming in the door has their card.

I don't do UDS at intake. Check blood pressure, weight, pdmp each visit. Just caught someone getting prescribed Phentermine at another practice and had to dismiss them as I had previously told them they cannot take both.
 
"I haven't see physicians get in trouble for not having the [neuropsych] testing.
Why would someone "get in trouble" for diagnosing a disorder and treating it? If you can't diagnose ADHD without getting "neuropsych testing," how exactly do you call yourself a psychiatrist? God forbid someone works in an area without widely available neuropsych testing or here's a wild idea, with a population who cannot afford neuropsych testing or a population with bad insurance that doesn't cover neuropsych testing. What do you do then? Make patients suffer because you're incompetent, or scared that they may one day possibly maybe just might abuse it even though they've given you no evidence they will? I'm sorry but we need to do better.
 
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PCP here. I start HTN treatment in the 140/90 or greater range. 130s is fine and needs no treatment.

Technically the guidelines say we shouldn't start until 150/95 or more.

I've started using Strattera for old folks with low BP and it works well, but other than that I've never been impressed with ADHD meds increasing BP in most people.
Interesting, 3-4 years ago docs were quoting the SPRINT trial saying goal should be systolic pressure <120 and I remember a Curbsiders episode with specialists saying we should be considering initiating treatment above 130. Looking at AAFP, their current recs are indeed to treat to below a systolic of 140 and ACC/AHA only recommends starting treatment at 130 for those at high risk. Wonder what changed as previous ACC guidelines were indeed to initiate treatment at systolic >130...
 
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Interesting, 3-4 years ago docs were quoting the SPRINT trial saying goal should be systolic pressure <120 and I remember a Curbsiders episode with specialists saying we should be considering initiating treatment above 130. Looking at AAFP, their current recs are indeed to treat to below a systolic of 140 and ACC/AHA only recommends starting treatment at 130 for those at high risk. Wonder what changed as previous ACC guidelines were indeed to initiate treatment at systolic >130...
Yeah, that trial is utter garbage in the real world. If I was trying to get everybody to a systolic of less than 120 I would have a plethora of orthostatic patients, some of whom would actually pass out and break something.
 
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Wait you don't get all your diabetic blood sugars below 120?
 
I just had one of these patients today and was thinking of consulting this fine lot on SDN. Patient has been on adderall XR 20mg for several years, functioning well, also has PTSD diagnosis. She has had multiple documented times of mildly elevated BP (130's-140's/ 80's-90's) and tachycardia (100-108 bpm) going back at least last 1.5 years with intermittent times of normal BP/HR. She also has had extreme up tick of her anxiety over the past year due to some stuff with her child culminating in a PCS to our location so her anxiety is not controlled at all on prozac 40mg. PCM last month stopped her adderall and referred to psychiatry and cardiology. She's had 2 EKG's since the PCM appointment that other than sinus tach were unremarkable. She's 35 with no other major comorbid health issues, no family cardiac hx that I'm aware of.

BP is about the same in my office, HR mildly tachycardic, no symptoms of CP/SOB/Palps that she endorses today but anxiety is higher now off med. Patient in my office today is literally falling apart, crying, regarding how this has impacted her functional ability at work, high anxiety, worried this will lead to administrative action due to poor work performance (I'm active duty and that is certainly something that can happen and has happened before she was diagnoses with ADHD, improved with treatment). She wasn't even begging me to get back on a stimulant because she does want to take the concerns of the PCM seriously. She's trialed wellbutrin, strattera, guanfacine. All ineffective or intolerable side effects. Discussed the concerns for cardiac risks which she acknowledged. Offered her we could return to strattera (PCM trialed this and only went 40mg but patient tolerated well it was just not effective, offered increased dose of this) and wait cardiology results, return to adderall with close f/u for BP checks (like every 1-2 weeks to check in) and strongly emphasized the recommendation to f/u with the cards referral, or trial another stimulant (because she disclosed that the adderall was effective but she noted increased irritability with it) and close f/u either way, still see cards. She opted for vyvanse as she has trialed concerta and follow up next week for check in.

Would ya'll do anything different?
I worry about patients with PTSD and stimulants because what I have seen at times is that instead of treating the underlying issue of increased CNS activation, it makes the person able to function better at a constant state of CNS activation. I know of very high functioning patients with PTSD who have adopted this type of strategy, either with stimulants or without. It seems like when they hit 50 is when the crash tends to happen. They usually have a little or a lot of etoh in the mix too. Not saying that is where this patient is at, just makes me think of a recent pattern I have been seeing and it’s pretty fresh on my mind because one of them committed suicide a few months back.
 
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I do pill counts by looking at when patients fill their meds (actually I do this with all meds). Even then most patients don’t take their meds daily
 
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Check your PMP. This is critical step number one.

Don't prescribe early. If a patient comes to me and claims their dog ate your amphetamines or they left them in their car, that's a them problem.

Don't have a panel that is largely comprised of ADHD as a specific diagnosis, as this puts more eyes on you as a possible pill mill. You can do it, if you so choose, but that's where you will have to be more careful about limiting diversion and making sure your diagnoses are good and those PMPs are checked with great regularity. Even then, you may find someone from the DEA wanting to skim your records to make sure at some point if you're an outlier in local prescribing patterns.
 
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Interesting, 3-4 years ago docs were quoting the SPRINT trial saying goal should be systolic pressure <120 and I remember a Curbsiders episode with specialists saying we should be considering initiating treatment above 130. Looking at AAFP, their current recs are indeed to treat to below a systolic of 140 and ACC/AHA only recommends starting treatment at 130 for those at high risk. Wonder what changed as previous ACC guidelines were indeed to initiate treatment at systolic >130...
There was found to be no significant benefit and increased complications with initiation of treatment at 130 vs 140.

 
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For those doing UDS are you dismissing patients based on positive cannabis screens? My state like many others has medical cannabis and it seems like the everyone coming in the door has their card.

I don't do UDS at intake. Check blood pressure, weight, pdmp each visit. Just caught someone getting prescribed Phentermine at another practice and had to dismiss them as I had previously told them they cannot take both.
In my state it's legal for recreational use. Dismissing a patient for cannabis would be akin to dismissing them for alcohol use. Though I would be inclined to imply that perhaps their attention deficit was substance-induced and request a period of sobriety before initiation of stimulant, which would probably send them out my door in a hurry.
 
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