ADD/ADHD resources

[Acebecker]

All -

 

Been receiving a bunch of requests from patients for help "concentrating" or "focusing" or "remembering" stuff.  They all think they have ADD/ADHD.  They all think they need Adderall, Vyvanse, or Strattera.  I'm not an expert in this area, so these requests are really driving me nuts.  Most of these issues come from a lack of self-discipline and structure, not a chemical issue.  There is no quick fix. 

 

What resources are you all using to get good at managing these people with as few meds as possible? 

 

Andrew

[BruceBanner]

Bump them to psych or behavioral health for a quantitative eval. If you start these people on stimulants you will never get rid of them. If they can come back to you with a Dx of ADD/ADHD made by a mental health professional (most wont go through the trouble), then at that point you pretty much "have" to treat them. Interestingly, Up-To-Date recommends stimulant pharmacological therapy over CBT, Grade 2B evidence.

 

Personally I think ADD/ADHD is one of the most over-diagnosed, superfluous diagnoses there is. This used to drive me crazy in private practice. I felt like a drug dealer, giving amphetamines to perfectly functional ADULTS who work and hold normal jobs. I eventually stopped giving new Rx's to anyone claiming they had ADD/ADHD. I just said I no longer prescribe these drugs, there is a dependence/abuse problem in the community.

 

Seriously though, dont get involved in this if at all possible. You arent doing anyone medical harm by refusing to prescribe stimulants and, mark my words, you will never get rid of them. You know, because "they just cant concentrate" without their crutch dope I mean meds..

[sk732]

I'm functionally ADD...a reason I seem to have gravitated to EM I think.  Only stimulant I need is some caffeine in the am and MAYBE a bit more midday if I'm on a long shift.  Most of the issues people think they need speed for is concentration - most of which can be resolved with a bit of self-discipline.  I can concentrate for hours on stuff I'm interested in or like - if I'm not interested, well, I have issues concentrating...because I'm not interested.  Does/did cause issues with school work - I'm working on a degree right now and really hate psychology (ironic I know), so it takes every ounce of effort to stay on task with it.  Doesn't mean I need Adderall, means I need to kick myself in the junk and pull my head out.  Where I do need help is the fact I'm one of those easily irritable types...and Adderall isn't going to fix that.  Mindfulness training helps with my irritability/anger issues somewhat...and violence therapy in the gym gets rid of the rest.  Exercise also helps the concentration as well...since the brain starts getting more O2 and blood flow.

 

Bruce - I agree totally about not getting rid of the folks once they show up looking for something they're either abusing or selling (that's more of a problem than the use/abuse issue where I'm from).  Easier to make them wait/pay for the assessment and if someone says they need it, well, then MAYBE they really do.

 

SK

[LKPAC]

I agree that getting a psych diagnosis and treatment recommendation is a necessary first step.  I agree that we have to watch out for abusers.  I agree that the diagnosis is made too often.  I agree that meds are not the only answer.

 

I don't agree that we have to worry about "not being able to get rid of these people."  ADD is a legitimate diagnosis for some people.  When the diagnosis is made correctly, we should be treating patients to the best of our ability.  Sometimes that is medication, sometimes therapy, sometimes learning skills needed to deal with the condition.

[BruceBanner]

You know I dont even think most of the patients I saw for ADD meds were abusing at all, I just think they were hooked. Adderall, Vyvanse, Ritalin are physiologically addictive drugs and should never prescribed haphazardly. I just saw so many refill appointments (several per day) that I started to question if there was really a functional deficit in these people. I dont know how they were evaluated.

 

The other piece too is that I was diagnosed with ADD in college, and was on meds for a time. They helped, and they didnt. I made it all the way through PA school with ADD and coffee, so maybe my empathy level is low for some desk jockey who needs 30mg of Adderall BID.

 

So to curtail this annoying problem and do my part in responsible controlled prescribing, I just started mandating a psych eval first or telling suspicious characters I did not Rx those drugs. Luckily, at that job, I had an understanding SP.

[DizzyJ]

I'm working psych now and yes this is a big issue.  I agree that many are over diagnosed.  First off is to follow the DSM-V criteria for ADD/ADHD.  Be aware that other conditions can mimic ADD/ADHD (i.e. depression, mania, anxiety).  Even for psych people it is difficult to differentiate between them.  UpToDate has an excellent review of diagnosis and meds.  They have an awesome chart that breaks down each type of med, onset, duration, dosages.  It is a good reference reference

.  

With prescribing, you can have the patient come in monthly for a face-to-face and check your state reporting database to be sure they are not getting meds from others.  Also, I only prescribe long acting versions.  Long acting may have less abuse potential then the immediate (in my opinion as I have no specific studies to reference). 

[Guest ERCat]

When I was dealing with my eating disorder (past issue, purging type anorexic) and seeing a psychiatrist, I got it in my head that part of my purging was an impulse control issue and maybe I had ADHD. I also knew stimulants would help me with weight loss. I was given a 10 or so question questionnaire which I answered honestly and bam - next thing I know he was prescribing Adderall - yes, for an anorexic. On top of Wellbutrin (yes, for an eating disorder patient who purged!). He had me on 40 my Adderall daily. On the days I didn't take it I felt horrible, and it was hard to discontinue the medication as I would just sleep all day and feel achy. Looking back this psychiatrist was absolutely nuts and there's no way he could have my best interest at heart. On the plus side the one take away is now I know that 1) anyone can get an ADHD diagnosis and stimulant RX and 2) I don't want no part of those mess.

[Reality Check 2]

The practice panel that I inherited from the retiring doc is full of adults who "can't concentrate" and he put on stimulants. NO PSYCHOLOGICAL or behavioral testing. Years and years of meds with maybe once a year monitoring and no real substance of documented change.

 

I will not RX meds to adults and certainly not children without testing AND behavioral modification. Meds won't work in adult with ingrained behavior issues who were never taught to LIVE with ADD.

 

My recent 56 yr male was getting in trouble at work and his friends told him to get tested for ADD. He saw a local psychologist who diagnosed him with ADD, inattententive predominant. Sent me a 7 page report stressing use of long acting stimulants with rapid ramping up to max dose. The guy is obese, hypertensive, metabolic syndrome.

 

I agreed to try Adderall. Max dose for 4 weeks and he says he isn't seeing any good changes. HE NEVER GOT ANY BEHAVIOR MOD TRAINING. No one taught him how to work with his brain not maximize results.

 

AND, my biggest hunch was that this guy just isn't smart - lower rung IQ AND ADD to boot. I think he believes the ADD drugs are like the movie Limitless where meds make you smart. 

 

ADD meds can make someone with a true disorder capable but they won't make someone smart or make the right decisions. 

 

So, at age 56 on stimulant meds with somewhat controlled hypertension, persistent obesity and inactivity with habits that he has muddled through with for 56 years - he didn't see the results he wanted with a med. Hmmmm, let's ponder that one.

 

I discontinued meds and said he had to see a psychiatrist for further evaluation. I need backup of my suspicion of lower rung IQ and to actually cement the diagnosis.

 

While waiting for the psychiatrist - he has a TIA and ends up in the ER. Well, one problem solved. He and stimulant meds are now incompatible. 

 

He still hasn't seen the psychiatrist..........

 

Somehow folks think a diagnosis of ADD can protect them, gain sympathy, make them special and use as an excuse for poor production, decisions and outcomes. 

 

ADD/ADHD is very very real. But I strongly suspect the number of folks with true disease are much fewer than those claiming the disorder.

 

Some of the markers of bipolar disorder are oddly close to those of ADD/ADHD and need close attention to differentiate.

 

So, I won't Rx meds without a battery of testing and then repeat testing or eval on meds and close monitoring.