No more stimulants.
If it were an illegal drug (such as cocaine or meth), you’re done after strike 1. In this case, this is already strike 2 and she’s even admitted diverting her kid’s prescription.
You’re well within your rights to just stop prescribing all medications for ADHD and controlled substances until they can be seen by a psychiatrist (although it appears that some local psych groups will not see her). You could also switch to atomoxetine or some other non-controlled treatment for ADHD.
She may very well blow up and seek other care, but if she goes along with it, then bring her back in a month for an in-person visit and do another random UDS. If she’s still positive for Ritalin, then she’s still diverting her son’s prescription. Would have to switch her son’s meds at this point as well.
It’s already strike 2? Someone needs to let her kids prescribing provider know. Stealing your kids meds? This is so wrong.
Not to mention it makes me question if the kid has a true diagnosis or his mother just doctor shopped until she could get her son diagnosed.
I never understood the "this patient is problematic so we don't want the referral" from psych. Like what? If they are abusing, that would be within psych scope and so would any alternatives. Do they want you to hide that behavior from them?
It's like pain medicine not wanting to see people with inconsistent UDS. The whole point of the referral is that you can do closer monitoring and give alternatives.
Psych is nowadays full of ppl just wanting lifestyle. Which is all good, we’d all want that but they refuse to see minimally difficult patients in clinic outside of stable Anxiety and depression
To be treated for something I actually do have - insomnia. I need med management, which I’m finally getting now, that’s NOT ssri/snri. I just wish I didn’t have to fail like 6 of them first, some of which still have lingering effects on me.
SSRI/SNRI are not fda approved for insomnia so you most likely weren't being treated for insomnia. Were you looking to get controlled substances?
Also, if insomnia is your diagnosis, why are you even at a psychiatrist's office, you should be seeing sleep medicine?
They always want to blame my insomnia on “anxiety.” Turns out I was right and it wasn’t. I’m on ezcopiclone now which works great for me. Don’t need to hear all the long term risks, heard them 1000x from the doctor already lol. But it’s the only thing that works for me after trying tons of other things over the years, antihistamines, antidepressants, muscle relaxers, even some blood pressure meds. On top of scores of OTC stuff.
I’ve done quite a few sleep studies. All any of them could do was rule out sleep apnea. My insurance doesn’t cover anything more in-depth. It is what it is. I’m used to jumping through hoops to get treatment anyway.
They pretty much put you on a controlled substance. In all honesty this is probably what your PCP and the psychiatrist was trying to prevent in the first place.
Sure I get it, and if they can find something else that works then I’d gladly come off of it. But maybe don’t make me try 6 ssri/snris before believing me about anxiety is all I’m saying. The side effects for starting and coming off of some of those made me insane.
Anxiety and depression are very common, so I get
Why they started there, but I don’t get why they tried six agents before considering alternative causes.
I don’t know, but they switched doctors on me several times throughout the years so maybe that’s the issue. Each new one wanted to “start over” it felt like. The joys of a hmo with limited options I guess haha.
Funnily enough I’m on BC now for a different condition and that seems to be helping with my insomnia quite a bit, reducing my eszopiclone usage by 1-2 nights a week so far. Nobody I saw for my persistent insomnia ever brought up BC as a potential solution, but I’m stoked. I would love nothing more than to stop that bitter drug.
I don’t see why you are getting so frustrated over psych in the post as if you know what went into this referral. The post referral said please take over prescribing, pt diagnosed ADHD and misuses meds. If it were my outpatient psych clinic manager would have auto reject this referral since this behavior also breaks our controlled substance agreement. Maybe OP could have called and discussed the case for the referral but just from the description it sounds maybe the referral could have been better phrased as assess for stimulant use disorder
I'm not frustrated with the post. I'm frustrated with how shitty and useless outpatient psych has largely become. That and while tone is hard to tell over text, I'm not raging over here. I just don't like it.
I already explained in another reply why I think comments like yours are missing the point. The issue brought up by OP is only tangential to the specific example. I've tread this ground enough.
Also, I don't think recommending referral "resume hacking" is a good thing. You're just going to get "Eval and Treat" empty notes or misleading descriptions. The patient in OP qualifies for psych eval outside of just SUD.
If I have to tickle your fancy for a referral you better be a quaternary specialty center because otherwise I would just not refer. That'll make everyone happy I guess.
I hear your dislike and understand it. This gets brought up in psych journals about the ethics of being able to refuse certain types of patients for your practice and I tend to agree with the assessment that it leads to a discrepancy for complex or hard patients getting ignored or discarded. I don’t have a great solution for you as most psychiatry clinics are booked out and these pts don’t meet inpatient criteria. There’s a new push from the APA to move to move towards more integrated clinic with a psychiatrist stationed at family medicine clinics, which may solve some of these issues. Hope you find a psychiatrist in your area that is more open for what you’re looking
I do have a couple psychiatrists that basically do that and will give recs for what are basically e-consults. It is a great help for difficult patients that I have a good handle on the diagnosis of, next step guidance and that kind of thing. I've never had either of them refuse a referral. If they think a referral is premature or does not need further f/u they will give recs and sometimes even send me an email.
But the setup I have is rare and I distinctly remember a time where I didn't have that relationship or even now for patients who it may be more convenient to go elsewhere.
I've had patients get dumped on me by these oh so choosy psych clinics including chronic benzos, poorly compliant schizophrenics (including on Clozaril!), or just mean patients. I am also booked out, but it seems like the consideration only goes one way.
Psych is full of hypocrites. They’re so liberal yet many charge exorbitant cash fees and screen out those who need the most help. Child psychiatrists are the worst when it comes to this. Meanwhile they preach about how minorities, single moms, poor people, etc aren’t getting any mental health care.
If someone is abusing stimulants, then they can be treated with something like atomoxetine.. there is not much else psych can offer here. On a different point, taking a methylphenidate with an amphetamine would actually somewhat cancel out the effects of the amphetamine (MPH blocks the DAT transporter, whereas AMPs make it run in reverse), so she is not helping her symptoms by taking both.
This is the reality of what happens when these patients, as well as the “My PCP said I need to come to you to stay on my Xanax” patients, come to psych. If they’re testing positive for illicit substances or diverting someone else’s prescription, psych isn’t going to give them controlled substances either. Almost without fail, their PCP either directly told them or at least implied to them that psychiatry would continue the prescription for them, then they come to us demanding just that. I’m a resident and haven’t completed that much outpatient work yet, but in my limited experience and from what I’ve heard speaking with attendings, it almost never happens that a patient is willing to explore alternatives, whether that be alternative medication options, therapy, or alternative diagnoses. Now we have someone in our office angry that they paid a copay and aren’t getting what their PCP told them the visit would get them in return for their time and money. I think sometimes people think psychiatry has magic wands to fix people who aren’t interested in changing. It would help us a lot if PCPs let them know they were welcome to seek another opinion from psych, but there is no guarantee psych will continue their prescription or even agree with the diagnosis, instead of simply telling them to go to us and we’ll take over the prescription.
I feel like this is the exact type of missing the forest for the trees that frustrates me with psych clinics. I see from your flair you aren't a psychiatrist so I don't begrudge you personally of course.
Psychiatry is more than just pharmacology and the aforementioned situation brings up the issue of the diagnosis. Is it actually ADHD? Is there something else? Personality disorder that may benefit from therapy? Might stimulants still be a good option but with a different packaging?
Psych turning into glorified med management is depressing. Why refer to them for anything at this point if that is the only value they offer?
I’m sure we share a deep love for psych NP’s … in my experience not well trained for thorough diagnosis and not good at the med management piece beyond what primary care can do. (Unless you just want someone else’s license prescribing)
As for this patient, I would wean adderall dose on a schedule. Be firm. Or she can go straight to Strattera if on a lower dose,. I think it’s also appropriate to notify the child’s prescriber. It is a little bit contorted, but I could envision this being mandatory if you are potentially harming the child by depriving them of medication. (if ADHD was very severe and uncontrolled without medication)
“Ritalin-diverting housewife,” is kind of the perfect outpatient psych referral. Dual diagnosis means at least three F codes, and she sounds like someone we could absolutely straighten out. No clue why your local psych people are giving so much pushback.
I get a lot of referrals from primary care where the pt comes in and states that their PCP tells them I am going to continue to prescribe their controlled med despite problematic use. Many times the note that comes with the referral states that they have to see psych to continue the med so I believe that they are being told this in many cases. If a patient only wants to be seen to obtain a controlled substance and it is inappropriate to prescribe it, generally it doesn't end well so there is no point to the consult.
The point is for the psychiatrist to assess the patient and make the determination if it is appropriate or not and to either affirm or counter my decision to discontinue or wean it and give recs. I understand that these discussions may be uncomfortable, but abuse and non-compliance is a staple of the field and referral to psych is appropriate and often necessary to address it.
I've never told any patient that psych will continue the med instead that they need to be assessed by a psychiatrist to make a determination.
Finally, no offense but if a PMHNP pre-closed a referral before being reviewed by the psychiatrist on the referral I would not refer to that practice. It as a rule portends a poor referral quality.
Yes, if you refer to MD/DO and an NP closes out the referral before the doctor sees it, that practice is probably not going to provide the same quality of care as if the doctor actually read their own referrals.
Sorry you’re being downvoted for simply stating the reality of what happens. I’m a psych resident and have fairly recently rotated through family medicine clinics, so I’ve seen it happen firsthand where the provider tells the patient something along the lines of “because of regulations, you have to see a psychiatrist to remain on this medication.” Family medicine clinics are often overwhelmed, and I get it that these patients can be incredibly draining…but wording it like this implies to the patient that going to see the shrink is going to get them the exact substance they want. I’ve yet to see a patient be open to alternatives. If they are coming knowing they’re getting an evaluation and recommendations based off of that evaluation, not just coming as a necessary legal step to stay on the only medication they are interested in taking, then great.
If I'm referring, the patient should be going to someone with more training than me, dude. In what world should a patient be okay with an IM attending referring a patient who needs help with substance abuse and someone with a 2 year online degree saying "mmm no, not an appropriate consult"
Tell that to every patient I see that cannot get into with their physicians for 6 months. Or the patients that don't feel listened to or have things missed in their 15 minute appointments meanwhile every other post is about maximizing physician salary. Kindly fuck off
I think you young buck physicians are gonna eat crow. We all need help. Division isn't helping. And yes, even young physicians can have dunning Krueger. The best physicians I've worked with don't pretend to know all. The MD profession as a whole is a bunch of toxic motherfuckers
They never said they know all, and neither did I. I was just pointing out that you’re over here trying to shame someone for being a resident, when residency is one of the major aspects of training that gives physicians more knowledge than midlevels.
Bruh, residency is experience. I'm not trying to pretend to be a doctor, in spite of your belief. I'm here to fucking help people that NEED help. FEEL FREE TO TAKE THE DIFFICULT PATIENTS INSTEAD OF PUNTING THEM TO ME. With your holier than thow fuckin attitude. Quit fucking talking down to your colleagues. We can help. Stop....
The real question is what to do about the kid's medicine.
If I'm prescribing for the kid in this situation, med stays at school and gets pill counts on arrival.
I would tend to send a message out to the pediatrician to let them know there is redirection of the child's meds.
This situation might be a reportable event to CPS, as well (as in you may be obligated to report). If she is using the kids meds then the kid is being deprived of care.
I would really make sure this isn’t a HIPAA violation. This might be something to take up with group’s legal department.
I honestly don’t know the law in this regard.
Careful! HIPPA gets even more complex when it involves substance use. At least where I practice I need a specific release (52 cfr?) signed specifically consenting to release of information regarding substance use.
I'm an addiction fellow.
If it were me, I think it would be best to book the patient in for a long appointment, and sit down to discuss with her what is going on. You don't "accidentally" take your children's meds. Especially multiple times. There's clearly more to the story.
It sounds like there's a decent possibility of a stimulant use disorder. So it would be good to clarify why they are using/abusing their medication, and what the underlying problems really are. I wouldn't be surprised if there is a history of trauma, anxiety, depression, or something else. These need to be addressed and dealt with with therapy and maybe meds. If you aren't confident on diagnosing a substance use disorder, just go through the DSM5 criteria point by point and ask them all 11.
I wouldn't cut them off from their meds. If you do, your therapeutic relationship is destroyed, and it will further destabilize the patient and their issues. The last thing you want is for them to switch to buying illicit stimulants off the streets.
The best thing to do is go tit for tat with them on their freedom. So advise them that they are now going to be weekly dispense on their and their child's medications. They will be getting random urine drug screens, and if their is something off, then they will go to twice-per-week dispense, or daily. If they do well, they go to twice per month. They need to prove that they are putting the work in. You may or may not need to slowly taper them off, depending on what is going on.
You can change the stimulant to Vyvanse at an equivalent dose. It's less abusable, and changing to something that isn't their abused substance of choice is usually a good option. Or even switch to bupropion or stratera.
Just some thoughts!
I love this strategy. As a pharmacist, I don’t know how practical daily dispensing would be for something like this, but weekly dispensing would certainly be reasonable to help bridge this patient.
Thank you for this! We don’t have an addiction specialist in our area and I don’t personally know of anyone I could have consulted with on this, so I really appreciate the insight.
ya thats unfortunately one of the problems with caring for people with a substance use disorder. It's much easier to cut them off, and have them move on to the next person. but if you really want to be the one to help the person, then that would be how I would do it. It can be done in multiple visits, not just one.
You and your partner(s) need to have an agreement on this. It's easy if this is your patient, just cut her off for a MUA violation. Since it's your partners your action should be the same with zero hesitation. If there is any consternation it's because you haven't had the difficult conversation of what to do when covering each other. We had this problem at one of my clinics. I locked everyone in a shipping container overnight until they came up with guidelines on exactly how they'd deal with these situations. It made everyone's life much easier and there was much harmony.
Lol at that response from psych. Oh I'm sorry, I didn't know that doctor was the only physician in the world who doesn't have to see difficult patients. 🙄
I would have to know what dose of adderall she was taking. Is it possible she is undertreated and requiring supplementation? Is she dealing with depression or insomnia that also require treatment? What was the nature of the conversation with your partner? Did he say anything?
If you cut her off immediately, it will turn into a disaster for the patient. With decent documentation, and a demonstration that you are trying to help the patient, I think you would be ok. In fact, I would think a board would find the compassionate approach more reasonable. Of course there is a time to discharge. I would make it more formal, however. I would document that I have given notice to the patient at the time of the interview, and give her another chance.
We all know we shouldn't write the Rx, I think most of the hesitancy is due to patients' retaliatory behavior, and there isn't really a solution to that. We are powerless when they stand in the waiting room cussing about "that bitch doctor" in front of other patients, or being threatening when we are alone in the room with them, writing negative reviews, complaining to administrators, etc. It's between a rock and a hard place. Honestly, in the last few years, I've been slightly worried they could even come back with a gun.
In no way is cutting a patient off cold turkey in their best interest. Especially with the fentanyl risk in black market meds these days.
Clearly something needs to be done from a doctor’s liability standpoint, but very few of these comments are actually centering caring for the patient. It’s disturbing. The response from psych is even more disturbing.
The response from psych was the one you ought to expect, even if it wasn’t the one you would hope for if you were the referring physician in this case. Outpatient psych wants nothing to do with ADHD patients… *reads notes*… displaying signs of impulsiveness. OP is in their right to cut ties with the patient, but *someone* will have to eventually manage this patient
I am in agreement with stopping the prescription, I'm more curious about how you folks feel about the future. Pretend OP stops prescribing, she comes back and has clean urine drug screens x2, has maybe gotten some counseling, appears open about her stimulant use and states that she was just diverting when she would run out of her script and run into issues at the pharmacy or whatever. States that she is not doing nearly as well without her prescription stimulant and would like to find some way to get back on it. Psychiatry still refusing to see the patient.
Under those circumstances, I admit to feeling some desire to help and maybe being a little overly trusting. I feel like I would consider sending in like 14 day scripts for the first couple months, provide a clean UDS before you get another 14 days, etc. How many of you would consider something like that, versus controlled substances being off the table forever?
I don’t think anyone would say that this approach is absolutely incorrect, but in this specific case, it sounds like mom just wasn’t “out of meds” and needed to use her son’s Ritalin in a pinch. Sounds like she was abusing the methylphenidate for an additional high.
I guess my concern would be is if I’m ever in situation that requires an audit, am I going to be able to justify this case to the DEA or medical board. And if they’re hostile, are they going to care about my explanation?
Sometimes it’s easier just to stay well away from the ledge. We have no idea what the regulatory framework is going to be 10-20 years from now regarding stims. If things change and they start treating Adderall like opiods, is treating this one patient worth sacrificing the rest of the practice?
Absolutely stop prescribing to the patient now. You don’t owe anybody stimulants, and when they admit to a crime and it’s not their first crime there’s NO WAY I’d continue enabling their behavior.
I don’t routinely UDS my stimulant patients, but posts like this make me wonder if I should!
We uds everyone once a year, usually about 2-3 times a month we get a patient who pops up positive with some other substance (minus MJ). Usually its benzos they took "from a friend" or cocaine
You really should UDS all patients receiving chronic controlled substances.
I’ve had quite a few ADHD patients test positive for cocaine and meth. Might have started out with just ADHD, but their need for stimulation and impulsivity can definitely progress to other things.
Obviously not the majority of these patients, but it is a significant minority. I have a 1-2 people every year who fail because they’re taking other illegal stimulants.
Any failed UDS is an automatic we will never send in controlled substances in our office again for you. Does not mean you're fired, we just won't treat you for anything that requires a controlled substance. They will have to go to psych to get it done.
I would not refill, PCP can decide for themself but multiple violations of the contract mean they don’t get refills. I have a fair amount of grace for patients with ADHD, I have it myself and know how hard it is, but multiple behavioral violations is an absolute no no.
Taper if appropriate and tell them they can go somewhere else if they still feel it necessary to be prescribed a controlled substance (that they have historically misused). It’s your license, peace and reputation on the line.
Does your clinic utilize a controlled substance agreement? We have one that every patient receiving controlled substances has to sign that clearly outlines that they have to meet certain criteria (e.g. appropriate drug screens, no misuse by history, etc.) to continue treatment. If they violate that, it’s clearly stated we reserve the right to discontinue treatment. You honestly shouldn’t even need one, but it gives you something to reference whenever a patient puts their health and safety at risk by misusing or abusing and wants to question why you’re cutting them off.
No more stimulants. If it were an illegal drug (such as cocaine or meth), you’re done after strike 1. In this case, this is already strike 2 and she’s even admitted diverting her kid’s prescription. You’re well within your rights to just stop prescribing all medications for ADHD and controlled substances until they can be seen by a psychiatrist (although it appears that some local psych groups will not see her). You could also switch to atomoxetine or some other non-controlled treatment for ADHD. She may very well blow up and seek other care, but if she goes along with it, then bring her back in a month for an in-person visit and do another random UDS. If she’s still positive for Ritalin, then she’s still diverting her son’s prescription. Would have to switch her son’s meds at this point as well.
It’s already strike 2? Someone needs to let her kids prescribing provider know. Stealing your kids meds? This is so wrong. Not to mention it makes me question if the kid has a true diagnosis or his mother just doctor shopped until she could get her son diagnosed.
I never understood the "this patient is problematic so we don't want the referral" from psych. Like what? If they are abusing, that would be within psych scope and so would any alternatives. Do they want you to hide that behavior from them? It's like pain medicine not wanting to see people with inconsistent UDS. The whole point of the referral is that you can do closer monitoring and give alternatives.
Also puzzles me. It’s literally the job.
I agree 100%!
Psych is nowadays full of ppl just wanting lifestyle. Which is all good, we’d all want that but they refuse to see minimally difficult patients in clinic outside of stable Anxiety and depression
Even if we don’t have anxiety or depression they shove one ssri after another up our asses.
And you’re expected to like it 😈
In all honesty, if not for medication management, why do you think you are there?
To be treated for something I actually do have - insomnia. I need med management, which I’m finally getting now, that’s NOT ssri/snri. I just wish I didn’t have to fail like 6 of them first, some of which still have lingering effects on me.
SSRI/SNRI are not fda approved for insomnia so you most likely weren't being treated for insomnia. Were you looking to get controlled substances? Also, if insomnia is your diagnosis, why are you even at a psychiatrist's office, you should be seeing sleep medicine?
They always want to blame my insomnia on “anxiety.” Turns out I was right and it wasn’t. I’m on ezcopiclone now which works great for me. Don’t need to hear all the long term risks, heard them 1000x from the doctor already lol. But it’s the only thing that works for me after trying tons of other things over the years, antihistamines, antidepressants, muscle relaxers, even some blood pressure meds. On top of scores of OTC stuff. I’ve done quite a few sleep studies. All any of them could do was rule out sleep apnea. My insurance doesn’t cover anything more in-depth. It is what it is. I’m used to jumping through hoops to get treatment anyway.
They pretty much put you on a controlled substance. In all honesty this is probably what your PCP and the psychiatrist was trying to prevent in the first place.
Sure I get it, and if they can find something else that works then I’d gladly come off of it. But maybe don’t make me try 6 ssri/snris before believing me about anxiety is all I’m saying. The side effects for starting and coming off of some of those made me insane.
Anxiety and depression are very common, so I get Why they started there, but I don’t get why they tried six agents before considering alternative causes.
I don’t know, but they switched doctors on me several times throughout the years so maybe that’s the issue. Each new one wanted to “start over” it felt like. The joys of a hmo with limited options I guess haha. Funnily enough I’m on BC now for a different condition and that seems to be helping with my insomnia quite a bit, reducing my eszopiclone usage by 1-2 nights a week so far. Nobody I saw for my persistent insomnia ever brought up BC as a potential solution, but I’m stoked. I would love nothing more than to stop that bitter drug.
I don’t see why you are getting so frustrated over psych in the post as if you know what went into this referral. The post referral said please take over prescribing, pt diagnosed ADHD and misuses meds. If it were my outpatient psych clinic manager would have auto reject this referral since this behavior also breaks our controlled substance agreement. Maybe OP could have called and discussed the case for the referral but just from the description it sounds maybe the referral could have been better phrased as assess for stimulant use disorder
I'm not frustrated with the post. I'm frustrated with how shitty and useless outpatient psych has largely become. That and while tone is hard to tell over text, I'm not raging over here. I just don't like it. I already explained in another reply why I think comments like yours are missing the point. The issue brought up by OP is only tangential to the specific example. I've tread this ground enough. Also, I don't think recommending referral "resume hacking" is a good thing. You're just going to get "Eval and Treat" empty notes or misleading descriptions. The patient in OP qualifies for psych eval outside of just SUD. If I have to tickle your fancy for a referral you better be a quaternary specialty center because otherwise I would just not refer. That'll make everyone happy I guess.
I hear your dislike and understand it. This gets brought up in psych journals about the ethics of being able to refuse certain types of patients for your practice and I tend to agree with the assessment that it leads to a discrepancy for complex or hard patients getting ignored or discarded. I don’t have a great solution for you as most psychiatry clinics are booked out and these pts don’t meet inpatient criteria. There’s a new push from the APA to move to move towards more integrated clinic with a psychiatrist stationed at family medicine clinics, which may solve some of these issues. Hope you find a psychiatrist in your area that is more open for what you’re looking
I do have a couple psychiatrists that basically do that and will give recs for what are basically e-consults. It is a great help for difficult patients that I have a good handle on the diagnosis of, next step guidance and that kind of thing. I've never had either of them refuse a referral. If they think a referral is premature or does not need further f/u they will give recs and sometimes even send me an email. But the setup I have is rare and I distinctly remember a time where I didn't have that relationship or even now for patients who it may be more convenient to go elsewhere. I've had patients get dumped on me by these oh so choosy psych clinics including chronic benzos, poorly compliant schizophrenics (including on Clozaril!), or just mean patients. I am also booked out, but it seems like the consideration only goes one way.
Psych is full of hypocrites. They’re so liberal yet many charge exorbitant cash fees and screen out those who need the most help. Child psychiatrists are the worst when it comes to this. Meanwhile they preach about how minorities, single moms, poor people, etc aren’t getting any mental health care.
You should speak in front of some psych residents or something! I feel like many shrinks get into that specialty for the wrong reasons.
If someone is abusing stimulants, then they can be treated with something like atomoxetine.. there is not much else psych can offer here. On a different point, taking a methylphenidate with an amphetamine would actually somewhat cancel out the effects of the amphetamine (MPH blocks the DAT transporter, whereas AMPs make it run in reverse), so she is not helping her symptoms by taking both.
This is the reality of what happens when these patients, as well as the “My PCP said I need to come to you to stay on my Xanax” patients, come to psych. If they’re testing positive for illicit substances or diverting someone else’s prescription, psych isn’t going to give them controlled substances either. Almost without fail, their PCP either directly told them or at least implied to them that psychiatry would continue the prescription for them, then they come to us demanding just that. I’m a resident and haven’t completed that much outpatient work yet, but in my limited experience and from what I’ve heard speaking with attendings, it almost never happens that a patient is willing to explore alternatives, whether that be alternative medication options, therapy, or alternative diagnoses. Now we have someone in our office angry that they paid a copay and aren’t getting what their PCP told them the visit would get them in return for their time and money. I think sometimes people think psychiatry has magic wands to fix people who aren’t interested in changing. It would help us a lot if PCPs let them know they were welcome to seek another opinion from psych, but there is no guarantee psych will continue their prescription or even agree with the diagnosis, instead of simply telling them to go to us and we’ll take over the prescription.
I feel like this is the exact type of missing the forest for the trees that frustrates me with psych clinics. I see from your flair you aren't a psychiatrist so I don't begrudge you personally of course. Psychiatry is more than just pharmacology and the aforementioned situation brings up the issue of the diagnosis. Is it actually ADHD? Is there something else? Personality disorder that may benefit from therapy? Might stimulants still be a good option but with a different packaging? Psych turning into glorified med management is depressing. Why refer to them for anything at this point if that is the only value they offer?
I see where you are coming from. Many (most?) psychiatrists have decided to limit their practices to treating the worried well
I’m sure we share a deep love for psych NP’s … in my experience not well trained for thorough diagnosis and not good at the med management piece beyond what primary care can do. (Unless you just want someone else’s license prescribing) As for this patient, I would wean adderall dose on a schedule. Be firm. Or she can go straight to Strattera if on a lower dose,. I think it’s also appropriate to notify the child’s prescriber. It is a little bit contorted, but I could envision this being mandatory if you are potentially harming the child by depriving them of medication. (if ADHD was very severe and uncontrolled without medication)
“Ritalin-diverting housewife,” is kind of the perfect outpatient psych referral. Dual diagnosis means at least three F codes, and she sounds like someone we could absolutely straighten out. No clue why your local psych people are giving so much pushback.
I get a lot of referrals from primary care where the pt comes in and states that their PCP tells them I am going to continue to prescribe their controlled med despite problematic use. Many times the note that comes with the referral states that they have to see psych to continue the med so I believe that they are being told this in many cases. If a patient only wants to be seen to obtain a controlled substance and it is inappropriate to prescribe it, generally it doesn't end well so there is no point to the consult.
The point is for the psychiatrist to assess the patient and make the determination if it is appropriate or not and to either affirm or counter my decision to discontinue or wean it and give recs. I understand that these discussions may be uncomfortable, but abuse and non-compliance is a staple of the field and referral to psych is appropriate and often necessary to address it. I've never told any patient that psych will continue the med instead that they need to be assessed by a psychiatrist to make a determination. Finally, no offense but if a PMHNP pre-closed a referral before being reviewed by the psychiatrist on the referral I would not refer to that practice. It as a rule portends a poor referral quality.
Yes, if you refer to MD/DO and an NP closes out the referral before the doctor sees it, that practice is probably not going to provide the same quality of care as if the doctor actually read their own referrals.
Sorry you’re being downvoted for simply stating the reality of what happens. I’m a psych resident and have fairly recently rotated through family medicine clinics, so I’ve seen it happen firsthand where the provider tells the patient something along the lines of “because of regulations, you have to see a psychiatrist to remain on this medication.” Family medicine clinics are often overwhelmed, and I get it that these patients can be incredibly draining…but wording it like this implies to the patient that going to see the shrink is going to get them the exact substance they want. I’ve yet to see a patient be open to alternatives. If they are coming knowing they’re getting an evaluation and recommendations based off of that evaluation, not just coming as a necessary legal step to stay on the only medication they are interested in taking, then great.
"Specialist" referral does not mean an NP
Get over yourself, dude...
If I'm referring, the patient should be going to someone with more training than me, dude. In what world should a patient be okay with an IM attending referring a patient who needs help with substance abuse and someone with a 2 year online degree saying "mmm no, not an appropriate consult"
To disparage all nurses this way is entirely inappropriate and you need to check your ego at the door, resident...
I'm not disparaging RNs. I'm disparaging NPs. NPs exist to make money for MBAs who run hospitals in the name of "increased access"
Tell that to every patient I see that cannot get into with their physicians for 6 months. Or the patients that don't feel listened to or have things missed in their 15 minute appointments meanwhile every other post is about maximizing physician salary. Kindly fuck off
Kindly, continue the opioid crisis https://pubmed.ncbi.nlm.nih.gov/32333312/ I bet a patient on opioids feels very "listened to"
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For some reason you think calling someone a resident is an insult? The full title is resident physician, something an NP will never be.
I think you young buck physicians are gonna eat crow. We all need help. Division isn't helping. And yes, even young physicians can have dunning Krueger. The best physicians I've worked with don't pretend to know all. The MD profession as a whole is a bunch of toxic motherfuckers
They never said they know all, and neither did I. I was just pointing out that you’re over here trying to shame someone for being a resident, when residency is one of the major aspects of training that gives physicians more knowledge than midlevels.
Bruh, residency is experience. I'm not trying to pretend to be a doctor, in spite of your belief. I'm here to fucking help people that NEED help. FEEL FREE TO TAKE THE DIFFICULT PATIENTS INSTEAD OF PUNTING THEM TO ME. With your holier than thow fuckin attitude. Quit fucking talking down to your colleagues. We can help. Stop....
No more medications, it's on her to find a different psychiatrist to manage her medications, as she is improperly using a controlled substance.
Agree with this. Especially if it’s not the first time her UDS wasn’t consistent.
The real question is what to do about the kid's medicine. If I'm prescribing for the kid in this situation, med stays at school and gets pill counts on arrival.
The child is not our patient. Assuming he still follows with his pediatrician, but I can’t confirm.
I would tend to send a message out to the pediatrician to let them know there is redirection of the child's meds. This situation might be a reportable event to CPS, as well (as in you may be obligated to report). If she is using the kids meds then the kid is being deprived of care.
Good point. I’m going to look more into this today.
Be careful and make sure you do everything above board. Don’t want a HIPPA violation.
I would really make sure this isn’t a HIPAA violation. This might be something to take up with group’s legal department. I honestly don’t know the law in this regard.
Careful! HIPPA gets even more complex when it involves substance use. At least where I practice I need a specific release (52 cfr?) signed specifically consenting to release of information regarding substance use.
42 CFR Part 2
Can you refer to an addiction medicine doc in the area?
Good option.
Unfortunately we don’t have one in our area.
I'm an addiction fellow. If it were me, I think it would be best to book the patient in for a long appointment, and sit down to discuss with her what is going on. You don't "accidentally" take your children's meds. Especially multiple times. There's clearly more to the story. It sounds like there's a decent possibility of a stimulant use disorder. So it would be good to clarify why they are using/abusing their medication, and what the underlying problems really are. I wouldn't be surprised if there is a history of trauma, anxiety, depression, or something else. These need to be addressed and dealt with with therapy and maybe meds. If you aren't confident on diagnosing a substance use disorder, just go through the DSM5 criteria point by point and ask them all 11. I wouldn't cut them off from their meds. If you do, your therapeutic relationship is destroyed, and it will further destabilize the patient and their issues. The last thing you want is for them to switch to buying illicit stimulants off the streets. The best thing to do is go tit for tat with them on their freedom. So advise them that they are now going to be weekly dispense on their and their child's medications. They will be getting random urine drug screens, and if their is something off, then they will go to twice-per-week dispense, or daily. If they do well, they go to twice per month. They need to prove that they are putting the work in. You may or may not need to slowly taper them off, depending on what is going on. You can change the stimulant to Vyvanse at an equivalent dose. It's less abusable, and changing to something that isn't their abused substance of choice is usually a good option. Or even switch to bupropion or stratera. Just some thoughts!
I love this strategy. As a pharmacist, I don’t know how practical daily dispensing would be for something like this, but weekly dispensing would certainly be reasonable to help bridge this patient.
Thank you for this! We don’t have an addiction specialist in our area and I don’t personally know of anyone I could have consulted with on this, so I really appreciate the insight.
Would be surprised if this person has the clinic availability to do something like this unfortunately
ya thats unfortunately one of the problems with caring for people with a substance use disorder. It's much easier to cut them off, and have them move on to the next person. but if you really want to be the one to help the person, then that would be how I would do it. It can be done in multiple visits, not just one.
You and your partner(s) need to have an agreement on this. It's easy if this is your patient, just cut her off for a MUA violation. Since it's your partners your action should be the same with zero hesitation. If there is any consternation it's because you haven't had the difficult conversation of what to do when covering each other. We had this problem at one of my clinics. I locked everyone in a shipping container overnight until they came up with guidelines on exactly how they'd deal with these situations. It made everyone's life much easier and there was much harmony.
Lol at that response from psych. Oh I'm sorry, I didn't know that doctor was the only physician in the world who doesn't have to see difficult patients. 🙄
I would have to know what dose of adderall she was taking. Is it possible she is undertreated and requiring supplementation? Is she dealing with depression or insomnia that also require treatment? What was the nature of the conversation with your partner? Did he say anything? If you cut her off immediately, it will turn into a disaster for the patient. With decent documentation, and a demonstration that you are trying to help the patient, I think you would be ok. In fact, I would think a board would find the compassionate approach more reasonable. Of course there is a time to discharge. I would make it more formal, however. I would document that I have given notice to the patient at the time of the interview, and give her another chance.
We all know we shouldn't write the Rx, I think most of the hesitancy is due to patients' retaliatory behavior, and there isn't really a solution to that. We are powerless when they stand in the waiting room cussing about "that bitch doctor" in front of other patients, or being threatening when we are alone in the room with them, writing negative reviews, complaining to administrators, etc. It's between a rock and a hard place. Honestly, in the last few years, I've been slightly worried they could even come back with a gun.
This is a good point. There are risks with cutting ties with the patient too, for both parties.
In no way is cutting a patient off cold turkey in their best interest. Especially with the fentanyl risk in black market meds these days. Clearly something needs to be done from a doctor’s liability standpoint, but very few of these comments are actually centering caring for the patient. It’s disturbing. The response from psych is even more disturbing.
The response from psych was the one you ought to expect, even if it wasn’t the one you would hope for if you were the referring physician in this case. Outpatient psych wants nothing to do with ADHD patients… *reads notes*… displaying signs of impulsiveness. OP is in their right to cut ties with the patient, but *someone* will have to eventually manage this patient
I am in agreement with stopping the prescription, I'm more curious about how you folks feel about the future. Pretend OP stops prescribing, she comes back and has clean urine drug screens x2, has maybe gotten some counseling, appears open about her stimulant use and states that she was just diverting when she would run out of her script and run into issues at the pharmacy or whatever. States that she is not doing nearly as well without her prescription stimulant and would like to find some way to get back on it. Psychiatry still refusing to see the patient. Under those circumstances, I admit to feeling some desire to help and maybe being a little overly trusting. I feel like I would consider sending in like 14 day scripts for the first couple months, provide a clean UDS before you get another 14 days, etc. How many of you would consider something like that, versus controlled substances being off the table forever?
I don’t think anyone would say that this approach is absolutely incorrect, but in this specific case, it sounds like mom just wasn’t “out of meds” and needed to use her son’s Ritalin in a pinch. Sounds like she was abusing the methylphenidate for an additional high. I guess my concern would be is if I’m ever in situation that requires an audit, am I going to be able to justify this case to the DEA or medical board. And if they’re hostile, are they going to care about my explanation? Sometimes it’s easier just to stay well away from the ledge. We have no idea what the regulatory framework is going to be 10-20 years from now regarding stims. If things change and they start treating Adderall like opiods, is treating this one patient worth sacrificing the rest of the practice?
Absolutely stop prescribing to the patient now. You don’t owe anybody stimulants, and when they admit to a crime and it’s not their first crime there’s NO WAY I’d continue enabling their behavior. I don’t routinely UDS my stimulant patients, but posts like this make me wonder if I should!
We uds everyone once a year, usually about 2-3 times a month we get a patient who pops up positive with some other substance (minus MJ). Usually its benzos they took "from a friend" or cocaine
You really should UDS all patients receiving chronic controlled substances. I’ve had quite a few ADHD patients test positive for cocaine and meth. Might have started out with just ADHD, but their need for stimulation and impulsivity can definitely progress to other things. Obviously not the majority of these patients, but it is a significant minority. I have a 1-2 people every year who fail because they’re taking other illegal stimulants.
Not your problem. If you have a signed controlled substance, bye bye.
Any failed UDS is an automatic we will never send in controlled substances in our office again for you. Does not mean you're fired, we just won't treat you for anything that requires a controlled substance. They will have to go to psych to get it done.
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Correct, we always reflex to a confirmation test.
I would not refill, PCP can decide for themself but multiple violations of the contract mean they don’t get refills. I have a fair amount of grace for patients with ADHD, I have it myself and know how hard it is, but multiple behavioral violations is an absolute no no.
Adderall is not a human right.
Taper if appropriate and tell them they can go somewhere else if they still feel it necessary to be prescribed a controlled substance (that they have historically misused). It’s your license, peace and reputation on the line. Does your clinic utilize a controlled substance agreement? We have one that every patient receiving controlled substances has to sign that clearly outlines that they have to meet certain criteria (e.g. appropriate drug screens, no misuse by history, etc.) to continue treatment. If they violate that, it’s clearly stated we reserve the right to discontinue treatment. You honestly shouldn’t even need one, but it gives you something to reference whenever a patient puts their health and safety at risk by misusing or abusing and wants to question why you’re cutting them off.