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Prescribing ADHD Medication & The Doctors Role...



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hi this is dr. Jenny Byrne I'm an adult

psychiatrist I have a practice called

cognitive psychiatry of Chapel Hill here

in North Carolina and today I wanted to

talk to you a little bit about a very

disturbing article that was in The New

York Times this past Sunday and without

going into too many of the details the

article told a very tragic story of a

young man who faked symptoms of ADHD

attention deficit hyperactivity disorder

to obtain stimulant medications I think

in particular was adderall so that he

could study and do well in his pre-med

classes and the story goes on to tell

how he became addicted to the stimulants

and he abused them and the stimulants

actually caused psychiatric symptoms

like mood changes and some unusual

symptoms called psychotic symptoms like

paranoia and these symptoms went on to

cause a psychiatric hospitalization and

even after that he was continued to be

prescribed these medications and had a

very sad ending to the story where he

took his own life some of the points in

the story that I want to talk about

today are what the stimulant medications

are what it means that they could be

abused ADHD and how is it possible

someone could fake that and also the

role of the doctor in all of this

because I actually think that's one of

the most important thing is the role of

the doctor so just briefly stimulant

medications are used to treat attention

deficit hyperactivity disorder they've

been around for a long time

one class of medication or amphetamines

like adderall they used to be people

used to worry a lot about cardiovascular

problems with these medicines but recent

studies have shown that they're very

safe as long as you don't have an

underlying heart or cardiovascular

problem so people with ADHD take these

medications and instead of making them

more revved up more hyper they actually

tend to calm them down and that's called

a paradoxical reaction so these

medications are often used to treat ADHD

in children and then also in adults now

the complicated part is that the

stimulants can also be used as a

cognitive enhancer and the idea there is

that someone who needs to have a very

high degree of focus like someone

studying for an exam someone in college

who has a performance he really needs he

or she needs to do really well they may

want to take these medicines to help

them study and the medicines kind of

help keep you up keep your energy up and

some people think it enhances their

cognition in general now the literature

doesn't really support that if you are a

normal quote unquote person does not

have ADHD the literature does not

support the idea that the amphetamines

actually do improve your cognition but

people feel like it does and probably

the main reason they feel like it helps

them is because their heart goes faster

they're more awake they're more alert so

it feels like it's really helping so

these medications are used to treat ADHD

another question that came up in this

article is well how is this student able

to get these medications and abuse them

and why would they lead to abuse so this

student would fake symptoms of ADHD and

what that means is is he studied

probably the definition of ADHD he

studied the symptoms and then he would

go to doctors and tell them that he had

these symptoms and since many doctors

just rely on what the patient is telling

them

and they don't really do a test of

attention it's pretty easy to fake the

symptoms if you study up on them and you

try hard enough

now some doctors and some psychiatrist

will have you do some additional testing

which makes it harder to fake the

symptoms I talked a little bit about

this later in any case this student

faked the symptoms he obtained the

stimulants and then he became addicted

to them so how do you become addicted to

stimulants

well stimulants are medications which

work in your brain and they can activate

something called the reward pathway and

the reward pathway is a pathway in your

brain that responds to pleasurable

things so normal happy things in your

life can activate the reward pathway but

drugs of abuse can also activate it and

when the drugs of abuse activate it

sometimes it's very strongly activated

and you can become dependent on the

medications so in his case that's

probably what happened after taking them

for a while his brain got used to the

medicines and he became addicted the

next step in this sad story is that he

developed some mood changes because of

the stimulants now this is something

that can happen although I would say

it's pretty unlikely it would happen if

you were taking the medications as

prescribed for ADHD but it's not unheard

of certainly I suspect in his case he

was taking too much of this medication

and since he didn't really have ADHD it

was really setting his brain into an

altered state so he had some mood

changes and some paranoia and again if

you're taking the medication

appropriately this is very unlikely but

in someone who's abusing the medication

taking it over and over again when you

shouldn't it's possible

so after this person was hospitalized he

came out of the hospital and he was

continued to be prescribed these

medicines and here's the point where I

think this is actually one of the most

important takeaways of the story so even

after was hospitalized even though

people didn't think he had ADHD and

even though he had already been treated

for the mood problems in the paranoia

he'd continued to get the medicines and

here's where the role of the doctor is

so important as a doctor if you're going

to prescribe these medications it is

very important that you don't just

refill them without thinking or

observing or testing or you know being

very cautious so there's different

things doctors can do they can have the

person come to appointments more

frequently so sometimes the doctor will

have you come once a month they can do a

test again most doctors don't do this

but there are computer tests of

attention that you can do the doctor can

look at a controlled substances database

and in North Carolina we have one that

any doctor can access for free and you

can see prescriptions for all controlled

substances that that person has filled

so if the person is going to three

different doctors and getting

prescriptions you'll be able to see that

and under the law you're actually

allowed to notify the other doctors that

are prescribing that this person is what

we call doctor shopping or going to

multiple doctors so that's another

important thing the doctor can do in a

story in the New York Times I think one

of the biggest tragedies was that the

parents of this young man tried to

contact the doctor tell him what they

observed tell him that they thought he

was abusing the medicines that he was at

risk and the doctor told them I can't

talk to you unless your son gives me

permission I can't listen to you if your

son doesn't give me permission and while

it is true that the doctor-patient

relationship is confidential the doctor

cannot tell the parents things that the

son has told him in confidence it is not

true that he couldn't listen to the

parents so the parents could have gone

to him and told him what they observed

and he could have just sat quietly and

not said anything now in my practice

I've had this situation come up

frequently where friends or family

members think it's important to tell me

something about the patient that they

have observed

and the way I handle it is I tell them

that I can't give them any information

about that person I can't even tell them

if that person is in the practice

however they can tell me whatever they

want or if they want to mail me a letter

and tell me their observations they can

mail it to me they can call me whatever

so the doctor can listen he just he or

she just can't reveal information now

the only exception to that is if the

doctor feels that the patient is an

acute danger to himself or herself or

others and what that means is is that

person at risk of killing themselves is

that person at risk of harming someone

else is that person at some sort of

acute risk and in that situation the

doctor can break doctor-patient

confidentiality to make sure that nobody

is harmed but in most cases he can help

he or she can always listen to what the

other person says so kind of pulling it

all together for this article it was a

very sad and a very scary story of what

happened to this young man because of

stimulant medications and also because

the medical system was not serving him

well and allowing him to take

medications that he didn't need and

probably giving him too many of them

what most people come in to talk to me

about is the idea that well maybe I

shouldn't take these medicines maybe

this is too scary

you know this risk is too high and what

I feel is from this article the most

important takeaway message is actually

that the doctor really needs to be more

careful this is something that doctors

need to think about carefully in their

practices they need to be cautious when

prescribing these medications and

thoughtful and it really is our role to

try to prevent some of this from

happening now of course we can't prevent

everything from happening if somebody is

gonna go and do risky behaviors you know

we can't follow them around and know

what they're doing all the time but we

can take some safeguards we can have

more frequent appointments

we can check the database to make sure

they're not doctor shopping we can do

more extensive testing instead of just a

verbal report we can listen to

information from friends and family so

there are things that we can do to try

to minimize tragic things like this from

happening so I think if you've read this

article and you're reacting strongly to

it again I think the big takeaway is

that the system doesn't work very well

right now and if they're things that

doctors should be doing to make it

better

I think the second main takeaway should

be that if you're a family member or a

friend of someone and you think that

they have a similar problem like you

think they're abusing these medications

or they're pretending to have ADHD to

obtain these medicines you can share

this information with the doctor

prescribing the doctor may not be able

to tell you anything the doctor may not

be able to tell you that person even

sees them but you can provide that

information to them and hopefully the

doctor will listen and I think most

doctors probably will if you feel like

your friend or family member is in

danger like you see them abusing these

medicines you really think they're going

to harm themselves or they can kill

themselves or the you know they're

driving around impaired and they're

gonna hurt someone else you do always

have the option to take them to the

emergency room for evaluation and you

can say that you think they need an

emergency psychiatric evaluation because

you think they're a danger to themselves

so you do always have that option so I

think that's important to know for

friends and family but the takeaway that

many people get from this article is

that these are bad medicines and that

they don't help people and we should get

of them and I would disagree with that i

think when used cautiously and

thoughtfully these medicines help many

many people in their lives but again

it's the doctor that maybe needs to be a

little bit more cautious so it's kind of

a long answer to some of the questions

I've been getting about this article but

I hope maybe it clarifies some things

for you and tells you a little bit about

my take on it if you have more questions

or you want to talk to me further about

it please feel free to contact me at the

information below and I'd be happy to

help

Thanks the white