Thank you for having this perspective to help treat your adhd patients, wish there were more like you. I’ve encountered quite a few doctors who admitted they are scared of the DEA and losing their license and make us jump through flaming hoops to adjust dosages of stimulants or force us to navigate a byzantine maze of psychiatry to get to a psychiatrist that will take the liability away for prescribing/adjusting scheduled medications.
This is even with 10+ years of diagnosis.
Do you have any insight into why it is this way? Have physicians always feared the DEA and threat of losing their license in pursuit of helping their patients try different controlled medications? Did the pill mills ruin it for the entire medical industry?
Amphetamine has such an interesting history. Synthesized in 1887, first used in the 1930s, and in 1937 discovered to have a remarkably favorable effect on hyperactive boys. Methylphenidate (Ritalin) came along somewhat later.
85 years later these two drugs are still the mainstay of ADHD treatment. Sure delivery systems have proliferated and drug variants have been available. Stimulant-class medications remain first-line treatments. Amazingly even after nearly a century nothing better has ever been developed, and it certainly hasn't been for lack of trying.
Prior to 1970 there were relatively few restrictions, but widespread abuse lead to legislation establishing the DEA and tightened regulations. Drugs of abuse were sifted into a schedule of classes 1 to 5, where class 2 drugs were legal to prescribe but subject to limits intended to reduce diversion and misuse.
BTW one of the legal schedule 2 drugs is methamphetamine, approved for ADHD. We know it can be misused, leads to severe dependency problems, but used properly is an effective and quite tolerable treatment for ADHD. Indeed I have prescribed it for a number of patients in the past.
With the huge opioid crisis that's emerged in recent years scrutiny by state licensing boards has increased regarding prescribing patterns. This is making many prescribers nervous to the max. While the thrust of regulators has been in regard to opioid drugs other scheduled drugs such as stimulants, benzodiazepines are caught up in it as well.
Primary care docs are affected by the zealous "witchhunt" in regard to prescribing practices. Hospitals, clinic administrators, etc., are equally touchy about docs prescribing scheduled drugs. So prescribers anticipate getting static if they prescribe stimulants however reasonable it may be. Especially true for PCPs who lack specific training in managing ADHD--harder to defend their actions if challenged by admins.
Among psychiatrists (who should know about ADHD) other factors are operating. Some don't like dealing with ADHD patients, notorious for poor follow through, don't show up for appointments, lose prescriptions, don't pay their bills, etc. Also ADHD cases are frequently more complicated than average due to comorbidities, social issues (marriage/family problems, difficulty at job, etc.), potential for substance use disorder.
Patients without ADHD are more likely to be comparatively more straightforward to deal with, so ADHD sufferers aren't accepted as patients.
Yes indeed, "pill mills" have made everyone's life more difficult. But it doesn't mean every doc who prescribes scheduled drugs operates a pill mill. The tendency to throw out babies with their bathwater is fearsome to many doctors.
Here's my advice to colleagues: every patient deserves a thorough diagnostic evaluation. If ADHD is one diagnosis, it should be treated vigorously within appropriate clinical guidelines. If stimulant treatment is indicated start with a low dose, titrate gradually until reaching an effective and tolerable level. Do not neglect behavioral treatments, these are essential. (Book-length description in progress.)
The SECRET to successful treatment and keeping regulators at bay: excellent clinical documentation. I never was "in trouble" over prescribing, I had the records showing rationale for every prescription, so nothing to be afraid of.\
Your story isn't unusual, there's a shortage of qualified, and willing, providers in this domain. Combined with a cultural bias against and misunderstanding of people with ADHD the treatment situation is troublesome. Educating providers and the public is badly needed. If that's done, over time availability of high-quality care for people with ADHD will improve.
Thank you so much for your detailed and response. Your patients are so lucky to have you! You should really speak at conferences, your voice needs to be heard on this topic!
This is even with 10+ years of diagnosis.
Do you have any insight into why it is this way? Have physicians always feared the DEA and threat of losing their license in pursuit of helping their patients try different controlled medications? Did the pill mills ruin it for the entire medical industry?