Reality Check 2 Posted November 6, 2015 Share Posted November 6, 2015 Morning Folks! For those of us in FP and IM - how are you diagnosing ADD and ADHD in adults and starting meds? I inherited a retiring docs practice and have more adults than I expected to see on stimulant drugs for clinical ADD. The doc did not request any neurobehavioral testing and used clinical judgment based on history to start meds - 100% stimulant meds. With kids I ALWAYS get neurobehavioral testing so we can look for other issues such as dyslexia, learning issues, auditory processing etc and the kids can get an educational plan outlined by the PhD and counselors for the school to abide by. My preference would be that everyone get neurobehavioral testing to outline their needs AND get some counseling on behavior modification and activities to harness their abilities and have better success at work and in life. So far, 95% of the adults I have seen do not have tachycardia, appetite loss or sleeplessness but - again - I have no baseline for them and they never went through any testing or counseling. It feels weird signing a controlled substance script on someone who was seen 1-2 times, gave a clinical history and was just given drugs and set loose. Kind of my same problem with anxiety and benzos - counseling and behavior mod are the gold standard - not benzos. Your experiences and input would be greatly appreciated. Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted November 7, 2015 Share Posted November 7, 2015 I no longer work in FP, but my 'routine' was to have testing done prior to starting stimulants. I felt that this ensured I was not overlooking other conditions as you mentioned. I think that this also sort of weeded out the people who were just trying to add to their cocktail. They normally didn't want to go through the effort. People who actually had problems that interfered with their lives were willing to have testing done. .... Maybe a little cynical, but just my thoughts. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 7, 2015 Moderator Share Posted November 7, 2015 nope nope nope just say no to ritalin and other stimulants in the adult population.... Link to comment Share on other sites More sharing options...
Reality Check 2 Posted November 7, 2015 Author Share Posted November 7, 2015 Inheriting someone else's style and habits has been tricky. First, the doc I took over for had been in practice for over 30 years. Second, he is a DOCTOR --- and a man which is important to my old man patients. So, I am a girl (with grey hair) and I am NOT a doctor - despite 25 yrs of doing this. So, when I suggest changes - politely, clinically and with evidence to back it up - they think I am dissing the doc and am probably not smart and are freaked out by changes. So, the battle to remove stimulants or even modify them is similar to banging my head on a pointy rock. I won't be doing any new starts, that's for sure Now, the battle of 10 years of ambien, benzos and hydro continues…... Always something! Link to comment Share on other sites More sharing options...
kittryn Posted November 7, 2015 Share Posted November 7, 2015 Morning Folks! For those of us in FP and IM - how are you diagnosing ADD and ADHD in adults and starting meds? I inherited a retiring docs practice and have more adults than I expected to see on stimulant drugs for clinical ADD. The doc did not request any neurobehavioral testing and used clinical judgment based on history to start meds - 100% stimulant meds. With kids I ALWAYS get neurobehavioral testing so we can look for other issues such as dyslexia, learning issues, auditory processing etc and the kids can get an educational plan outlined by the PhD and counselors for the school to abide by. My preference would be that everyone get neurobehavioral testing to outline their needs AND get some counseling on behavior modification and activities to harness their abilities and have better success at work and in life. So far, 95% of the adults I have seen do not have tachycardia, appetite loss or sleeplessness but - again - I have no baseline for them and they never went through any testing or counseling. It feels weird signing a controlled substance script on someone who was seen 1-2 times, gave a clinical history and was just given drugs and set loose. Kind of my same problem with anxiety and benzos - counseling and behavior mod are the gold standard - not benzos. Your experiences and input would be greatly appreciated. in my experience, I NEVER give out adderall or other schedule II meds, esp to new pts. pts who come in claiming ADD/ADHD are told by me that I will not prescribe those for them; that they need to consult with BH for eval, and BH has to continue with them for f/u and to write for those meds. maaaaybe - if the patient seems on the level - I will prescribe a month's supply, with the caveat that they hook up with BH in that month. I am crystal clear with them that they will get no more of those meds from me. same with anxiety meds. I was new to a primary care clinic a bunch of months ago and had the "neighborhood test" - people coming in to see if "the new doc" would write without much oversight. I knew that if I wasn't strict, floods of addicts & street peddlers would be on my schedule. besides, it's just good medicine to be very strict with controlled substances. with narcs I get out a calendar and prescribe literally the exact # of pills they will need for a short course, based purely on what the issue is. I do have some pts who have chronic pain - and some of them are even former addicts - and we have a strict pain contract with random urine screens, pill counts, and agreement that they will fully participate in other pain-control modalities (injections, PT, etc), as the case may be. Link to comment Share on other sites More sharing options...
winterallsummer Posted November 8, 2015 Share Posted November 8, 2015 Don't do out pt care however my general recommendation is for any pt getting adhd meds would be a psych referal. If psych wants to confirm the dx then writing for these is acceptable. If a pt comes in for a refill but no formal specialist dx I would give them a psych referal and perhaps one week supply but politely refuse to give any other Rx for controlled substance unless psych gives them the formal dx. The risk is FAR outweighing of the benefit here. Giant caveat as I said earlier I don't practice out pt Med but that is my opinion. Link to comment Share on other sites More sharing options...
Guest Paula Posted November 8, 2015 Share Posted November 8, 2015 I'm dealing with a couple of patient's I inherited from a retired physician, on lots of benzo's along with zolpidem, and taken with alcohol. I'm pretty sick myself, I think, because I get this weird pleasure in educating the patient on why I won't refill the standard meds they got for years. I require counseling and BH health evaluation for anxiety. I recommend SSRI's and do not understand why the patient won't take them. The excuse is they don't want to take a drug they need to be on daily. But then ask for 30 day supply of zolpidem and alprazolam with 3 refills! Most are surprised I ask the pertinent questions: Drug and Alcohol history, family history or addictions, personal history or treatment, and then I look them up on the state prescription drug monitoring program for controlled substances. Some reports are very revealing, others are not. When I refuse to renew most have been polite, and I never see them again. They show up on someone else's schedule, but usually my dictation is pretty detailed as to why I won't prescribe. I just do not want my name on a prescription bottle next to a dead body found in an alley someday. I have a few adult patients with ADD/ADHD who I inherited and I request the records. Those are interesting to say the least. Quite a bit of discrepancy between what the patients says and what the Psychologist or Psychiatrist says. I am starting to convert those patients to contracts and am starting the random drug screens. I have a pretty strict policy.......no second chances if they blow it. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 8, 2015 Moderator Share Posted November 8, 2015 in cases like this I am always careful to never bash the prior provider (pa, np, md, do it does not matter) My favorite line is that "medical knowledge is always changing and todays thoughts is that these are the good meds to be be on...." doesn't say the prior management was wrong, but does state that you are trying to do the best by them Set out a clear plan - being wishy washy only makes things worse If it is litterally hundreds of patients you will need to invovled your clinic admin I would say a plan like this 1) will offer tapers to everyone - need monthly OV and signed controlled sub prescribing contracts (might well scare some away with that) 2) those that decline will be referred to psych for official testing to determine if they have the Dx and need this must be done with in X number or days - to provide a finite time to get it done - ie 90 days 3) once these actions are started there is no getting off it and no exceptions - hold firm and the clinic and patients will respect you in the long run Their is no defense in sitting in the court room saying "I didn't change it because that is was the way the prior DOCTOR had done it....." It is your license, protect it, practice medicine the way you know you should. But have compassion to the patients that this is a big change. Contracting also requires monthly visits, random pill counts, Utox screens..... and in general is a tough road that most will not want to do. Link to comment Share on other sites More sharing options...
Febrifuge Posted November 8, 2015 Share Posted November 8, 2015 From the perspective of a patient, I got tired of my PCP asking me "so for how long do you think you'll need meds for this?" so I went and got a Psych doc to take over my med management. She did a history, intake, a little bit of testing, and chased down the records from the guy who diagnosed me, 7 years ago in another state. After talking with him and with me, she was cool with maintaining my current regimen. She feels it's working well enough, and unless I have side-effect problems she doesn't want to mess with it. But at the same time, if we decide to make any changes at all, we've agreed that I'm going to formal, full testing, and I think that's absolutely appropriate. Patients who push back on this might (at least subconsciously) be fearful that they won't show an actual need for the meds, more an affinity for them. So, I dunno. If the "you and I need to be partners in managing your condition" thing doesn't work, and if the "let's be sure to apply the latest, greatest understanding of the best treatments for you" thing doesn't work, then you might have to have a Plan B, for people who don't like you taking away their candy. I will say, as an adult with actual, for-real ADHD, these people grind my gears. Don't feel too badly for them. Even if there's no intent on their part, they are making it tougher for others. Link to comment Share on other sites More sharing options...
Maynard Posted November 9, 2015 Share Posted November 9, 2015 nope nope nope just say no to ritalin and other stimulants in the adult population.... It strikes me as bizarre that someone would be fine with giving mind-altering stimulants to children but categorically dismiss their use in adults. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted November 9, 2015 Author Share Posted November 9, 2015 I don't dismiss their use in kids. Weight loss, missed psych issues and parental issues are of major concern. My original post dealt specifically WITH ADULTS, not kids. My original post states that kids HAVE to have neuropsych in order to establish educational guidelines and needs. So, there is no one here ignoring children - the post is about adults. Thank you Link to comment Share on other sites More sharing options...
BruceBanner Posted November 9, 2015 Share Posted November 9, 2015 I'm in family med and ADD/ADHD is a huge over-diagnosis. I hate it, to be honest. I think 90% of the time it is complete horsesh!t. When you have multiple 20-30 something adults coming in every week for their q 90 day Adderall refills (many of whom work mundane jobs or don't work at all), at doses upwards of 30,40, even 60 mg a day (!!), you just start to question the validity of this diagnosis. I think there is a spectrum of inattentiveness, but in most cases I dont think escalating doses of amphetamines are the answer. I'm just about to the point where I will stop doing new ADHD prescriptions, and I already refuse to refill any daily dose over 40mg. It's totally unnecessary. You have an addiction, not a disorder. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted November 9, 2015 Author Share Posted November 9, 2015 My forward policy is no new starts in kids or adults without neuropsych testing and behavior mod therapy. What to do with all the adults I am inheriting? - loaded question. I am trusting my gut - if it feels hinky - you get a drug holiday and testing. Everyone gets a drug screen as an adult on stimulant meds to see if you are actually taking them. AND, if you are taking ambien to sleep and need benzos for anxiety while on your stimulant med - hmmm, we missed the boat somewhere and you shouldn't be taking one med to counteract another one. Your meds will change............................ have to stay strong!! Link to comment Share on other sites More sharing options...
Guest Paula Posted November 10, 2015 Share Posted November 10, 2015 It's my understanding that a urine drug screen will not pick up ritalin? Is that true? I read somewhere that a serum test is needed for ritalin and also for tramadol. Maybe technology has changed recently with the UDA screens? Does anyone know? Link to comment Share on other sites More sharing options...
Reality Check 2 Posted November 10, 2015 Author Share Posted November 10, 2015 We run a panel that breaks down amphetamine and metamphetamine. We list the rx drug on the lab req and it comes back very detailed with quants and metabolites and even states if rx'ed drug is present. Works for all narcotics and some benzos in general. I think it is called a pain mgmt panel or something similar. Even checks alcohol and tramadol is standard now too. It is about $400 and pts have to sign a waiver that they will pay if not covered by insurance. The drug screen and expense are listed on the controlled substance agreement in our office. It has been very useful so far. Link to comment Share on other sites More sharing options...
sas5814 Posted November 10, 2015 Share Posted November 10, 2015 Morning Folks! For those of us in FP and IM - how are you diagnosing ADD and ADHD in adults and starting meds? I inherited a retiring docs practice and have more adults than I expected to see on stimulant drugs for clinical ADD. The doc did not request any neurobehavioral testing and used clinical judgment based on history to start meds - 100% stimulant meds. With kids I ALWAYS get neurobehavioral testing so we can look for other issues such as dyslexia, learning issues, auditory processing etc and the kids can get an educational plan outlined by the PhD and counselors for the school to abide by. My preference would be that everyone get neurobehavioral testing to outline their needs AND get some counseling on behavior modification and activities to harness their abilities and have better success at work and in life. So far, 95% of the adults I have seen do not have tachycardia, appetite loss or sleeplessness but - again - I have no baseline for them and they never went through any testing or counseling. It feels weird signing a controlled substance script on someone who was seen 1-2 times, gave a clinical history and was just given drugs and set loose. Kind of my same problem with anxiety and benzos - counseling and behavior mod are the gold standard - not benzos. Your experiences and input would be greatly appreciated. I live in a college town so there was a staggering number of people seeking treatment for their ADD/ADHD. It was clear most of them wanted some "study drugs" and didn't have need for treatment. So I sent all of them for testing and counseling. None...not one..ever met the criteria for treatment even if they did go for testing and 90% of them didn't. Benzos are a little harder but generally as a stand alone treatment for anxiety it is inappropriate. I just explain that and offer other modalities and I rarely see them again. As for pain management we just don't do long term pain management. No problem for acute stuff but if it is chronic I offer PT, counseling, exercises to improve their condition, non-narcotic treatments and, if they want it, a referral to pain management. It is a hard decision to make because it will cost you some business and it is very easy to begin justifying these kinds of treatments because you don't want to lose the business. No easy answer I am afraid. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted November 10, 2015 Moderator Share Posted November 10, 2015 I live in a college town so there was a staggering number of people seeking treatment for their ADD/ADHD. It was clear most of them wanted some "study drugs" and didn't have need for treatment. So I sent all of them for testing and counseling. None...not one..ever met the criteria for treatment even if they did go for testing and 90% of them didn't. To augment this point, I've even seen on this forum over the years a post here and there about a student using ADHD meds to help themselves study more Link to comment Share on other sites More sharing options...
Reality Check 2 Posted November 10, 2015 Author Share Posted November 10, 2015 ADD drugs are being touted as a mental power drug to help one focus and is perceived as performance enhancement. I can't see that working. I would never advocate it. There is no such drug as in Limitless. Folks have to face mortality and use the brain they were given. Those who really have ADD/ADHD will go through testing willingly and show to be true and their lives can be improved by the meds and behavior mod. I cannot stress behavior mod enough and patients do not get it. A pill can't fix everything - you have to learn how to use your own brain to its own ability. If a pill could just fix things - none of us would have jobs........................... Link to comment Share on other sites More sharing options...
BruceBanner Posted November 10, 2015 Share Posted November 10, 2015 I went through the neuropsych testing in college and had an Rx for Ritalin for a time. It did help with focus, but after my workload cooled down I never took it again. I didn't like the emotional highs and lows. I made it all the way though PA school without any of these drugs. I still believe to this day the vast majority of "ADHD" cases are people with some inattentiveness who just need to adjust their habits or find something that is interesting to them. It's amazing how you can stay focused when you are into something, or you have a real problem to solve. Link to comment Share on other sites More sharing options...
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