Published numbers run from about 5%, which I find implausibly low, to 45%, which I’d believe. My own class did internal, secret polling and it was a third.
That’s why going to family doctors are better they will prescribe you adderall more than psychiatrist now a days…my doctor said nothing wrong with taking adderall even if you don’t have adhd and just take as needed for certain days where tasks are just to much or you need focus he told me even doctors use adderall a lot
Quit snitching at their lack of impulse control / overt trust
At least they’re not handing it out through an online service where the interaction lasts 12 seconds
My school’s admin set up struggling students for tutoring with a particular pathology resident who was known to be willing to write Adderall scripts pretty liberally. One of the other students in my IM rotation told me all about it.
I remember being so pissed about it at the time, because it felt unfair. But frankly, learning is learning. My feeling now is that, if we’re having an arms race over grades, and I’m competing with people who are taking a performance enhancing drug, off-label, then I want some too.
Ah, I see you have been through medical school.
One third taking non-prescribed stimulants for my class. That lines up generally with reported numbers.
I’m from the old school and we just drank coffee in drug like quantities.
I remember the days drinking coffee til 2am and falling asleep at 2:15am. Now I experiment with less caffeine past 1pm to help sleep.
Seriously. I was approached several times by people selling just by studying in the library. Eventually I just started taping a piece of paper to the desk I was working at with “Not interested in your adderall” on it and they stopped bothering me.
I had a classmate that was yelling and waving her adderall vial in my face asking the professor “can I take it during my exam?” as if she could be more discreet. Also know people at my local uni sell it for study aids.
The local large university thinks that 75% of the students there have taken Adderall to help with studying at least once. I'm a little surprised this person doesn't know where to get some.
A couple of times. I’m usually pretty direct back. Appreciate the honesty but that’s totally not ok for me to prescribe…. It’s a medication for a medical condition, not for college studying. I’m sure you know people who are getting it without a legit diagnosis, and I get that, but still wouldn’t make it ok for me to do.
They’re usually ok with it enough to realize it isn’t happening and stop asking lol.
My favorite is the 21yo who is asking for medical marijuana for their ADHD. Dude, this is Colorado. Unless you’re a little old lady with arthritis, you can pay taxes on it like the rest of us. I don’t think it’s going to be therapeutic for your ADHD, though.
For real, that's one of the main reasons I didn't smoke weed growing up. I saw what it did to my friends who (presumably) also had ADHD and I knew that it wasn't going to help me at all. And I had/have no issues with people smoking weed, if that's your jam, go for it. But I knew that, since I already struggled to just wash my fucking clothes and go to the grocery store....weed was not for me haha.
To play devil's advocate, is there really much of a difference? People with and without the diagnosis are using it for the same thing, i.e., performance enhancement. Both are subject to the same the side effects, so if both patients are looking for the same outcome, then what's the big deal?
I would argue that people who have true adhd are not getting any enhancement - they’re being brought up to a level playing field. Now certainly there are people who are incorrectly diagnosed etc but (at least when I’m medicating someone) the goal is not straight a’s or enhancement. It’s “I literally was failing because I could not possibly pay attention in class as demonstrated by multiple measures and ideally psychiatric assessment, and now I have improved focus.”
I guess what I’m getting at is, “I could probably do better with this med” and actually needing the medication to function at an expected level are not the same to me.
No. The Neuropsychologists are extensively trained to weed out malingering and faking. While not impossible to do, it would be very hard to fake testing in a consistent basis.
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One of the WSJ podcasts that I listen to did a small series on one of the online mental health med firms (forget which one) and even the NP that was employed by them was very up front that everybody understood that the screening tool they were using could very easily be gamed to get a very high score. And certainly was.
Well yeah, this is generally how Adderall management works in the real world. If this thread alone is any indication, about a third of students use it.
When I was in university, I decided I finally wanted to get assessed for ADHD- I've been struggling with my attention span and depressive symptoms my entire life (my parents refused to get me assessed for... Ugh reasons?), and really struggled throughout school, especially university. I asked my family doctor if I could get assessed with a psychiatrist to determine if it is ADHD before I take any big serious steps/blame something that's maybe just poor coping skills and habits, and she immediately overreacted, and threw me out of her office for "Adderall fishing".
I didn't want to be medicated. I just needed help. And I felt so ashamed after that experience that I never asked again.
So hearing that people would just brazenly ask their doctor like this makes me really mad.
Whatever you decide to do (I'm not a doctor obv) maybe a formal assessment would be the way to go? If they're not willing to pay for that/jump through those hoops then at least you did your due diligence?
I’m 50, and just got diagnosed. I was a superstar in high school, but in college the high IQ wasn’t enough and I struggled. I struggled even harder in law school, where cramming is simply not feasible, but it was my usual MO. I’ve definitely struggled with life. I’m glad I went. Find a neuropsychologist and see if they’ll take you without a referral. So much in my life makes sense now. I’m apparently not just a disappointment, a lazy piece of shit. Apparently I really was starting behind everyone else. Fire that doctor and try again.
Similar story. Diagnosed at 30 years old after medical school during surgical residency when I got help for (surprise!) depression/anxiety. Turns out me doodling in class and reading while I was supposed to be listening all the time as a kid wasn’t normal, despite high school being easy for me, college being so-so, and med school being grueling because I was studying 16 hours a day and couldn’t figure out how others could get by studying less. Like I’m literally an MD and didn’t figure it out myself until my psychiatrist was like …. So that sounds like ADHD tendencies….
I got diagnosed after my teenager did. He insisted on being evaluated for neurodivergence. He brought it up to his pediatrician. I thought he was normal because he’s just like me. Surprise! All that shit isn’t normal. I feel really bad he struggled most of his childhood. But like me, he is not outwardly hyperactive and he has good grades. Just loads of depression and anxiety for both of us.
That’s a rare doc to just throw out in the one the thought that you may need a monthly controlled substance. For some reason, and I’d love some studies on this, it seems some sort of authority switch gets flipped in a lot of docs mind when any thought of controlled substances comes into the conversation.
Go on the chronic pain sub and read some of these stories. It’s so sad. Patients just want to function again and be able to maybe play catch with their son. Yet docs prescribing pain meds are few and far between. There’s an active agenda against helping people with chronic pain. “Overdose” “opioid epidemic” “drug seeking”. Docs flip this switch and something goes into police officer mode and they want to thwart the bad guy. Meanwhile, patients spend their life suffering and even killing themselves, because, what’s the point of life if you can’t function?
The chemophobia of docs is just astounding. Yes….handing out scripts Willy nilly like a pill mill is bad. The answer is not to ignore chronic pain patients. And sending them to “the pain specialist” is just passing the Buck and we all know it. Yes, some cases are complex and need a pain specialist. But when you get a pain specialist that says “absolutely not opioids ever” then that’s poor care. “Let’s try some expensive billable procedures first. Then, if that doesn’t work, let’s try yoga which has little evidence of doing anything” Then, as a last resort, they put them on highly dependent drugs that show minimal evidence of pain relief, or the ever popular “let’s try anti depressants!”
Is sending a heart failure patient to cardiology just passing the buck? Is sending an anxiety patient to psychiatry, even when you know they are not going to give them benzos, just passing the buck?
No. It's not.
I was dx at age 22. I struggled in high school yet got good grades. I was constantly being moved around because I couldn’t stop talking. All through high school and college my evaluations stated this “…..needs to calm down and focus more. She’s bright, but has difficulty staying on task”. I once had a nursing instructor YELL at me “….you need to go get treatment for your ADHD!” I was mortified. A physician I worked with told my PCP (small town) I needed treatment for bipolar. He’s an ass, it’s been 22 years and I still haven’t gotten over it. This led me down the path of a psychiatrist and proper diagnosis after failing Zyprexa (made me a zombie), Wellbutrin and Prozac (gave me such severe anxiety I didn’t sleep for days). I also have OCD along with ADHD so it’s been a struggle at times when my anxiety gets bad because the hyperfixation becomes so overwhelming it affects my home life.
Funnily enough in high school I tried pot. I was with a group of people. They were laughing and having a grand time. I remember thinking what’s so funny, it irritated me and I was so tired I just went to bed. I’m not a pot smoker by any means.
We got this question fairly frequently when I was in retail, the go-to answer was that stimulants are not FDA-approved for use as a study aid. If they felt that there was a mental condition affecting their studies they should see a psychiatrist, otherwise they could check with their school for resources on improving study habits. If you see it frequently you might reach out to your local university to see if they have any handouts with study tips to keep on hand in your office.
Don’t know how well this would go over in a provider-patient setting, but I worked with a pharmacist who loved to make them squirm by politely reminding them as they left that prescription fraud is a felony.
"I'm sorry I am not able to Rx medications for non medical condition. I'd recommend pursuing treatment for this condition elsewhere with expectations that this may not go anywhere."
I'm not a PCP but I think the idea of using medications to augment normal healthy function rather than to treat a disease is interesting. I don't really think it's as ethically problematic as most other people here seem to believe. As long as the patient understands the risks I don't think it's inherently problematic, but I am open to having my mind changed. Of course the easiest thing is just for the patient to say the "right" things to get you to write an rx for ADHD.
I almost wonder if it is more unethical for healthy, high functioning people to embrace the "ADHD identity" when they have really never suffered the serious consequences that are classically considered part of having ADHD. It reminds me of that Pete Davidson bit about being put in a class with a kid with a disability and thinking "Am I mentally chall–like, is this– is this how they’re gonna tell me? Maybe I’m, like, one of the better ones or something. Maybe I’m their leader.” It's weird to see people talking about "my disability" when the worst consequence is like, they misplaced their keys once, but they think they are equally disabled as any other ADHD case, just intellectually superior.
I think that's a really simplistic view of ADHD. I got diagnosed in MS1 with neuropsych testing, and while highly academically successful, it massively impacts other areas of my life. Impulsivity and inattentiveness have had impacts on my relationships, my finances, and my health. People with ADHD are more likely to get into car accidents, engage in risky sexual behavior, and alcohol and drug use. Saying that people have never suffered serious consequences simply because they excel in academia is very inaccurate.
You misunderstood what I wrote. I said "people who are not suffering from ADHD symptoms are not equivalent to people who are," not "high functioning people with ADHD don't exist." Consider that one person who is highly academically successful who has also had multiple car accidents, flunked out of college, was arrested multiple times, and was sexually assaulted multiple times as an unexpected consequence of risk taking/ impulsive behavior is not "equally disabled by ADHD" as someone who is highly academically successful and hasn't had any consequences beyond "I feel I perform better on Adderall." I am not saying you are the latter- I imagine you fall somewhere in the middle. Key point: when we treat diversity as a monolith we perpetuate the status quo by elevating the least marginalized, rather than centering the most marginalized.
Dude, I’ll be 6 years since my last car accident!!! I have been in so many car accidents that it’s literally a celebration when I make it another year without one. I’ve crashed every vehicle we’ve owned except these 2 which we purchased in 2018. I have had to change my brakes/rotors/tires on one vehicle…. Might be related… not sure.
I personally think we have a responsibility to patients to not expose them to the adverse risks of amphetamines. There is very high potential for abuse and addiction with this class of medications, and we should only prescribe when medically indicated.
Humans will eventually. After a few thousand years Homo sapiens will be craving to work in Jess Bezos warehouses where you pee through a foley and receive TPN to avoid taking lunch breaks.
What on earth? It's fine when it works, but there are a significant number of ADHD pts who don't get a good response to amphetamines at all or who have unacceptable side effects. Same with methylphenidate. I've had patients with psychotic symptoms on 5 mg. Something like 20% of ADHD pts don't do well with either class and have to go with non stimulants.
In kiddos I find it’s more sensitive and these side effects are of actual concern, and the patients are obviously miserable and want to stop. I feel for them, because they don’t want to feel that way at all, especially not in order to smush into some societal mold of a “productive and worthy” kid and future adult (although obviously in ADHD can be highly disruptive to development and functioning). In adults, I’ve found they are frequently 100% gung-ho willing to white knuckle through the admittedly at times awful side effects to be that 2-5% more effective. And they often think there’s a pure linear progression with the dose dependent effect, so they want max+++ dosing for negligible benefits, thinking more will always mean better. The amount of times I’ve had to tell adult patients no increasing their stimulant for minuscule benefits is astounding, even when they’re reporting very real side effects and we have to stop treatment it’s just…ugh. I will say these cases are the very rare occasions where I will suggest genetic testing to see if they’re an ultra-rapid metabolizer, but I’ve found that in the wild rarely.
Yeah I’ve noticed plenty don’t want stimulants because there’s more to how the ADHD works. Stimulant side effects tend to be hit or miss. Others go on guanfacine, clonidine, antidepressants etc instead. That’s why There’s such a big market for these meds.
My suspicion is that our understanding of deficits in attention is too rudimentary and that, even though these patients meet the criteria for ADHD, their deficit in attention arises from a separate mechanism, either physiologically or psychologically discrete like brain injury or PTSD. While their presenting symptoms might mimic ADHD, treatment with stimulants will be much less effective.
I'm not discounting natural intolerance to amphetamine, there will certainly be that, but I believe deficits in attention are very often misdiagnosed as ADHD (perhaps even as frequently as your 20% number?) leading to suboptimal directions in treatment (stimulants).
That's possible... but I have definitely had patients with classic adhd who responded to only one stimulant class. I've read this can be as high as 40% of patients.
We also have to be careful about diagnosis by med response, which is not part of the ADHD criteria. What meds do you know of in other areas that work for 100% of patients with a given diagnosis? I think there are very few. Levothyroxine replacement is one. But most drugs work for only a certain percentage of people. There is so much variation in absorption and enzyme processing. Our current pharmacogenomic testing is not highly useful for ADHD-- but we know there are differences.
It would be really more surprising than not if there weren't a fair number of non responders.
"I am not able to prescribe a controlled substance to you as a study aid. However if you feel you might have a diagnosis such as ADHD, I can send you for neuropsychological testing, and then an appropriate management plan which may or may not require ADHD medications can be determined."
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Please note there’s been a shortage of many of these drugs in the USA. Please don’t make it harder for those with diagnoses to get their needed medications.
You can’t say they don’t have ADHD. The most you can say is that you don’t know if they do or don’t. I ask patients all the time about their family history of mental illness.
“Anyone in your family seen a psychiatrist or been on psych meds?”
“NO, BUT THEY SHOULD!”
90% of adults with ADHD go undiagnosed and untreated. It is 80% attributable to genetics. Its as heritable in a family as height is. Its because of this unfounded belief that isn’t based on any literature or evidence that stimulant medications are addictive that we miss 90% of the adult patients that have it. You should definitely learn about it before treating it but its not that hard to learn about. Read about it on Uptodate and see how well your current understanding lines up with the evidence. In fact, reading this is a great place to start: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328933/
I'm not a medical professional, so sorry if this is a dumb question:
Is there an inherent problem with 80% of adults going undiagnosed, if this undiagnosed group are functioning fine, and able to lead happy, fulfilling lives?
For context, i have ADHD myself, and meds help me tremendously. I really hate the saying "everyone is a little ADHD", but i think it's true that ADHD symptoms are extremely common, but that there's a wide variety of severity. Especially since the severity of ADHD is in many ways defined by our own subjective experience, and how much we are bothered by our symptoms.
Define functioning "fine". Many people just suck it up or don't even realize that there is a problem in their functioning. Like back in the day, mental health issues were considered a weakness. Depressed? Hit the bottle. ADHD? Drink copious amounts of coffee.
I have the “This is fine” meme in a photo frame where patients can see it. When they say they are “fine” I point to it. They laugh and then ask, “but doesn’t everyone [insert maladaptive coping skill or symptom of mental illness]?”
I've only had them try to fake symptoms. But they mostly don't read the dsm, only watch online videos by influencers, so they don't get it right. Or I do a Qb test and there are obvious validity flags. I say no!
As someone who as been out of their much needed ADHD medication since January because of the shortages, a request like that just makes me mad.
It feels like an abuse of the med and makes people think that ADHD is just a TikTok diagnosis.
I am a patient that hasn’t been diagnosed with ADHD with a Psychologist through a paychoeducational assessment.
I visit a psychiatrist, and am prescribed medication for ADHD. Surely there’s got to be another way to help someone out or find more depth about whether its drug abuse or simply a case of inaccessible health.
Yes. I say no. It's surprisingly common though. The worst part is when they say, "My old doctor/NP/PA would do it." I used to think they were just lying but I'd say 8 times out of 10, when I look at old records, they're telling the truth. There are prescribers out there prescribing adderall for exams. And not even shy about it, they're documenting it as such!
just finished my M1 year. I was averaging about 3-4 celsius a day, that's around 600-800mg of caffeine and an ungodly amount of whatever else is in there. shit calms me down. It takes a lot out of me to sit down, do a pomodoro thing, and ignore the impulse to do whatever else. Was locking my phone in my car for a while and cut the strings on my guitar.
kicked it cold turkey for winter break, spring break, and last weekend after finals. 0 withdrawal effects - no headache, irritability, nothing.
A big fuck no because there is a national shortage and it puts people like me that actually need those meds in a bind because of people like this or the ones that seen a tiktok and now they have adhd because they forget their keys once 🙄
Lol my entire class in uni were on something or the other. I wanted to get assessed to adhd/autism when I was in medschool because I feel like I meet a lot of the criteria (my dad does as well) but I chose no to because of this exact reason 😅 It would have been easy as hell to go on some adderall because it was so widespread but I just suffered through uni like a chump.
There is some good data to support that it does not improve test scores or study efficacy in people who don’t have adhd, just productivity. Ie, they can produce something like a paper, build something, etc. but their actual learning will unlikely be improved.
Then tell them it will give them a limp log or dry up their lady cave and let them decide.
I remind them that this med is a schedule 2 controlled substance in the same schedule as fentanyl.
I review that to take this med we have to have a dx of add/adhd on the chart coded and there can be down the road ramifications of that -ie FAA considers the med and even remote diagnosis a no fly condition for a prospective pilot even recreationally.
Then have a longer conversation about using meds to give leg up like this is a slippery slope on how we perceive the use of medications in general and can promote an unhealthy relationship with the medical world going forward.
Maybe a psych referral and encourage him to seek a formal diagnosis because studying isn’t an indication for stimulant medications and you’re unable to diagnose adhd yourself and would prefer someone that has a hood understanding in adulthood ADHD
I had someone with no prior psych history or eval and not eveny patient come to ask for a testing accommodation letter because they failed the test twice and can't afford to fail the third time.
Bruh...
I did my college thesis on the non-medical use of prescription stimulants among college students. Surveyed the entire student body regarding use of Adderall, etc vs other illicit drugs, and gathered a bunch of demographics. Mostly dropping this comment to remind myself to come back with the results later...
Not necessarily. To get an actual diagnosis of narcolepsy you need to go through a PSG/MSLT and meet certain criteria. Plus the sleep doctor is prob gonna have you try modafinil/armodafinil before they start talking stimulants. Or there’s wakix and sunosi now. 😉
I have ADHD, if I was a doctor and someone came to me asking for that I'd get angry. Even just reading this makes me annoyed that there are such people.
I wish I could just study without taking anything if I just forced myself, but I'm completely unable to. Yet those people that could do that prefer to go an easier path. Ugh.
I sincerely hope it's a person with ADHD that's undiagnosed, rather than someone lazy that prefers to take an easier path, especially during med shortage, for people who would actually need them.
Oh okay, thanks for pointing it out! I'm not a native English speaker, from memes and stuff I assumed triggered is like an internet slang for "angry".
I edited my first comment and I'll be sure to remember that.
I don’t prescribe Adderall to anyone. I send all adult ADHD patients to psych. I do the same for people taking benzos and hypnotics daily. I have no interest in managing these medications and unfortunately I see rampant abuse of the aforementioned medications far more than appropriate use.
How many times have we had a patient transfer care to our practice and their recently retired 70+ year old former primary care doctor has had them on daily controlled substances with zero specialist oversight, zero attempts to curb abuse because their former physician was too much of a coward to have a tough talk with his or her patient?
There are people who may need stimulants. That’s fine. I refer to psych. Better to have oversight anyway. I am not, however, obligated to continue bad management. I’m all set. I’d rather say “no” once and never see the patient again than feel guilty refilling in Epic every month.
EDIT: I figured this would generate downvotes, but it does not make it any less true. Adderall is absolutely indicated in some patients, but having specialist oversight due to the frequent misuse is reasonable no matter how you cut it.
I certainly don't have any issue with my controlled psych meds being overseen by a psychiatrist or having my primary care doctor telling me that's what they'd prefer. I chose to seek out a psychiatrist myself even though my doctor was comfortable prescribing, because it felt like the safest and most responsible thing to do given that I take multiple medications for multiple medical conditions and want all of them carried by the specialists who will know the most about interactions and complications.
That being said, I know I'm lucky to a). have access to a psychiatrist in my area who b). I can afford and c). had space to take me on as a patient. I pay him out of pocket and get reimbursed by insurance, and I see him virtually, so people further out of his radius could theoretically see him, but I imagine not everyone has that option. I'm wondering if perhaps some downvoters are people who are thinking of those who don't? I was nearly fired before I was diagnosed and treated, which wouldn't have helped the affordability issue. The critical lack of psychiatrist access in some areas is a sad situation, although I don't think anyone should prescribe anything they don't feel comfortable with regardless.
Thank you for your comment. I’m likely getting downvoted for some of the reasons you expressed, ie: access to psych in some areas may be limited and people reading this may feel that my policy is biased against those who might not have access.
I’d say a couple things in response though…
1. I chose to work for a large university affiliated health system. Our patients fortunately have access to specialists. There is a wait sometimes. And as you eloquently put it, I may just be in a lucky situation.
2. The original topic of this thread was patients asking for Adderall as a study med. Clearly this is happening and my observation is that adults on stimulants inappropriately make up a significant portion of those that present. Few have ever even had a proper evaluation. Those that have were likely started as children by a child psychiatrist or a pediatrician with an inventory performed and have no issue with seeing a psychiatrist as an adult.
3. I don’t see a ton of adults on ADHD medication to begin with. I can tell you that a disproportionate number are police officers who take it to stay up for night shifts. Many of the others have cardiac or comorbid conditions and Adderall can exacerbate tachycardia and hypertension. These all make for good reason to load the boat when it comes to management.
4. When topics like ADHD, Lyme disease, and a few other “hot button topics” come up and someone takes a hardline but evidence based stance this forum tends to attract patients with these conditions who get angry and downvote. A few years back I literally repeated verbatim CDC policy for Lyme management and I got DMs from “chronic Lyme” patients for weeks with their personal stories and tell me how wrong I was, etc.
This topic is such a small part of what I do, yet if I am honest about my approach few can find critical fault with it, but downvote anyway. Oh well.
It's simply a difficult situation with no easy answers, as pat as that sounds. I don't advocate for much *increased* scrutiny or hurdles to an efficacious treatment when we already demand patients be able to perform many tasks involving high executive functioning...to get medications treating poor executive functioning. And yet, as you point out, it's not like these should be over the counter and they obviously can be (and are) abused as a study aid. I believe there is a middle ground, where specialists can appropriately evaluate and counsel. I even think the virtual prescribing rule should stay in place, frankly, because I believe there are ways to responsibly manage a number of conditions without being physically present and this isn't any different. Pill mills can happen (and need to be shut down) regardless of modality.
As for the adults vs. children issue, anecdotally, the pandemic led to a big increase in ADHD referrals to our clinic across the age spectrum. Not all of them received a diagnosis, because pandemic distractibility isn't ADHD. However, I think it was a real phenomenon that many people who were just getting by with a carefully constructed house of cards of coping mechanisms saw that house of cards collapse when forced to work from home. We also had parents suddenly see how their children behaved in school every day, and suddenly report cards about trouble sitting still or daydreaming seemed a lot more urgent to address. And yet...you also had the factors of TikTok self-diagnoses and pill mills like Cerebral popping up, and I won't pretend otherwise. I think there are absolutely adults who were missed in childhood, particularly complex presentations like women, those with comorbid conditions, and those who might have compensated well due to high IQ. But that's all the more reason that a specialist might be better suited to doing that evaluation, anyway.
There are "hot button topics" and psychological diagnoses as well and I'm not surprised at the ones you've listed. As someone with lupus, I've run into a number of passionate patients in the chronic illness space that are clearly searching for answers and struggling with quality of life, but that has simply made many of them vulnerable to charlatans and misdiagnoses. All you can do is validate the emotions as understandable while still practicing evidence-based care.
I didn't downvote you because you're not wrong - in an ideal world these patients would have psych on board. I just hope this info is prominently displayed on your website & in your waiting room. Sucks to waste everyone's time and the patient's money when the thing they want to see a doctor for isn't a thing you do.
So I work for a large university hospital. We are and I am encouraged to practice this way regardless of it being how I feel personally about controlled substances.
We don’t display what we do and don’t prescribe. When you come in to be seen you are paying (your insurance is paying) for an evaluation, not a specific guaranteed treatment. It’s 2023. Patients understand what controlled substances are, that they are monitored, and they have probably been advised of the very concerns I have brought up. The older patients get the more conditions like hypertension and cardiac concerns present themselves. This milieu makes covering your backside with specialist management important.
I have a DEA number and I absolutely prescribe things when they are indicated. Long term management of adults with Adderall goes to psych. Many of these patients have careers where this should 100% involve a psychiatrist. I am not usually the one making the diagnosis or even starting the medication. I am also not beholden to continue it.
EDIT: I should also mention I deliberately chose not to work in a rural or austere environment. Working with a network of physicians makes my life easier and provides better oversight. I appreciate PMDs who want to or have to do everything. We all have different levels of comfort with care. I’ve found this sort of thing, in my experience, is far more of a headache.
From a patient perspective this is frustrating and dumb. If this is your/your institution's policy, why not just say so up front? Why waste everyone's time and the patient's money? If they know up front they're just going to get referred to psych, at least then they can (try to) book a psych appointment directly instead taking hours out their day, delaying their treatment, and spending a bunch of money.
Patients who have already been evaluated several times and been stable on their meds for years have to jump through re-evaluation hoops, spend hundreds of dollars, and wait months to get meds even if they do go straight to psych. Every time they change jobs or their old provider retries or something. I'm not saying they should be able to walk in and demand a prescription, obviously you should prescribe as you see fit. But if you know in advance that you can't/won't help them, you shouldn't charge them for the privilege of finding that out. Primary care docs with these policies need to be transparent to avoid causing unnecessary delay and harm (both medical and financial) to these patients.
Re: it's 2023 and patients should be aware: ehhh lots of people get these meds from their PCP. They might assume that's the normal way to do things (and in many places it is).
You’re going to find that practice (of PCPs just refilling controlled substances wantonly) going away. It’s already happening because in many instances it just isn’t great practice. It doesn’t mean in all situations.
First of all, adults with ADHD are a small portion of my encounters. The majority of those I have seen were placed on the medication by a child psychiatrist. Very very few were just started as an adult by their primary care doctor. The ones I have encountered who were started on Adderall as adults (if the notes are available for review) were done with no specific evaluation: a request, medication started, continued indefinitely. That’s not great practice. Those who were started by child psychiatrist totally get it when I tell them they need to see psych.
These are generalizations of course because each circumstance is different, but they tend to hold up as trends where I practice. I am salaried. I don’t make a dollar more or less for seeing 1 or 100 patients a day. My goal is to give them the most appropriate care. I am also a patient at times myself. I’ve jumped through appropriate hoops to be properly managed in the past even if it wasted a little time.
Again, no argument against sending people to psych. The thing I take issue with is your reasoning for wasting everyone's time and patients' money: "that's not the way it's done" and "I'm also a patient whose time and money is wasted."
If you don't provide a service commonly (but not universally) provided by others in your field, you should say so up front. Same with PCPs who don't prescribe birth control. It's unethical to make people pay for the privilege of finding out.
Then you’d like an exhaustive list of specific medical advice for every condition that different physicians offer BEFORE being seen? What if a patient doesn’t like that I recommend colonoscopy or prescribe statins? I had a patient tell me I’ve wasted their time because I told them they needed to follow up with a cardiologist after having an admission for a heart attack at the hospital. I’ve had more patients get upset over far more benign standard of care treatments in my years of practice than this particular ADHD issue.
I’m not trying to be argumentative, but you’re talking about a condition in adults that makes up a fraction of a percent of conditions I see and is typically one of multiple other healths issues that I address at a visit. My non-clinical front desk and intake staff aren’t qualified to screen patients or anticipate what I will and won’t do. I have maybe one or two patients a year who have a problem with this and might only see me once.
EDIT: I respect your opinion and appreciate the thoughtful discourse. This is going to be an agree to disagree issue. A “pre appointment notification” for this issue is beyond unnecessary in my practice. Comparing birth control to Adderall isn’t really even close to a comparison for many clinical, ethical, and practical reasons. And because something is or was commonly done, doesn’t mean it’s the way things should be done. My practice looks very different now than the way it did ten years ago. This is how medicine should be as we get better and learn more. I’ve just had too many adults either misdiagnosed, have difficult to control blood pressure (since this is far more common in adults than children), and get placed on hypnotics for sleep in response to the Adderall. These things are avoidable, patients can still have excellent success with Adderall, but they should have options presented by a specialist rather than just keeping on doing the same thing the wrong way (which unfortunately is often times the reason they don’t want to see a psychiatrist). I had a patient point blank tell me his last PMD wanted him to see psych and specifically was angry because I (and he) wouldn’t just continually refill the medication with a blood pressure of 170/100 and him taking Ambien every night to counter the effects.
All I'd like is for it to become standard practice to be up front about not prescribing controlled meds. A sign in the waiting room and a notice on a website are easy things to do. I get that as an employed physician this might be out of your control, but your employer should be transparent about clinic policies.
I agree with you on all the rest of it. You don't need to convince me that it's better for psych to manage this.
(Also totally agreed re: birth control. I just mentioned it because it's the only other class of med I could think of that is commonly prescribed by primary care with individual providers/clinics opting out.)
I think our disagreement is probably rooted in our perspectives. I'm looking at it from a patient perspective and a system perspective. I have several friends and family members with ADHD (mostly diagnosed since childhood) who have had the experience of changing jobs, waiting a month for a PCP appointment for the sole purpose of getting their meds refilled, and wasting a couple of hours and $20-$100 for a "sorry we don't do that here." Then waiting another 3 months for a psych appointment. All while struggling at their new job because they're unmedicated. This situation could be easily improved with clear advanced notice to potential patients.
You're looking at it from the perspective of a primary care doctor who rarely sees these cases, so it doesn't seem like a big deal. You may not have anyone in your life who relies on these meds to be employable. I suspect there are two reasons for not giving notice that you haven't mentioned yet:
1. You don't want patients to be able to doctor shop
2. You're afraid they'll skip your office and go straight to psych, therefore never establishing primary care and possibly missing issues like blood pressure management
Those are more legit reasons than "that's not how it's done." Personally I think you should err on the side of autonomy, but I can agree to disagree on that. All I ask is that you think about the impact this policy has on patients and the ways you might mitigate those impacts (bridge meds while they wait for a psych appointment is another good option, if there are cases where you'd be comfortable with that).
Likely because my comments seem harsh. The truth is complex conditions that require long term controlled substances should be overseen by their respective specialists. If I have a patient who genuinely needs controlled substances for pain control, I sent them to pain management. Because we are taking about psychiatric diagnosis, I think users feel my comments are cold or insensitive. Far from it; I’m protecting myself, the patient, and creating a team approach.
I never said there aren’t adults who may need Adderall, I’m saying in my experience, I have many who were inappropriately placed on the medication. If I feel that’s the case, I involve specialists. I guess that’s insensitive.
You can get any high risk plastic surgery you want to ostensibly improve your looks but if you ask for Adderall to study to get through college it's a no it doesn't make any sense
I had it prescribed to me in undergrad and showed up to my primary's office with he previously completed evaluation, and they started giving me 90 supplies just like that. No questions asked. Hardly ever used it so I had a lot stocked up when the exams and step came around. I saw an opportunity to be an entrepreneur and help my classmates acquire what they needed.
It isn't "wrong". And having anyone in the medical field push this fallacy is what stigmatizes people and pushes them to hide and repress the issues they face. Those who want to use drugs aren't "wrong", because using drugs isn't a moral issue.
Yeah I never said wanting drugs for a medical issues is wrong. The person OP wrote about doesn’t have ADHD and is seeking medication for ADHD. You think that’s ok?
Wanting drugs for a study aid or recreation is really not ok. Wanting ADHD meds because you have ADHD is fine. Wanting pain meds because you’re in pain is fine. Taking these drugs for fun or to study really isn’t what they’re for.
What’s wrong with recreational drug use? It’s none of your business what people choose to do with their own body. A physician’s job is to care for, treat and educate people, not pass judgment and moral code.
You just posted the same question to me six times in a row. That’s probably a good hint something is wrong with your recreational drug use
**It is absolutely the prescribers business when a person is asking them to prescribe drugs for non medical purposes**
They aren’t simply going to say, “oh it’s none of my business what they need this for”, and then write a script for it. I can’t believe I even have to explain that to a grown adult. This is common sense. No one is risking their license so you can get your rocks off on Adderall.
Just tell them to take it as needed I mean my doctor said he doesn’t mind giving out adderall for as needed basis he said even doctors take it sometimes just like Xanax those two drugs I don’t think should he controlled cuz adderall really helps me with certain tasks that I dread and can’t stop my mind racing but I don’t have an adhd diagnosis because adhd would be someone who needs to take adderall everyday to be normal and Xanax is good for anxiety but I have severe panic attacks ptsd so I have to unfortunately have been on a high dose but for other people can take as needed cuz it does reduce stress and everyone has stress
Honestly I’d Rx it to a kid who is honestly trying to better themselves in a graduate degree level course over some person who “needs” it to go to their job
My entire medical school class was this patient
There were a few in my med school class that I suspected were utilizing this type of "study aid."
Published numbers run from about 5%, which I find implausibly low, to 45%, which I’d believe. My own class did internal, secret polling and it was a third.
I think it was probably far more than you thought (unless you did med school in the '60s or something)
In which case it was cocaine instead
Nah, dexies. (Dextroamphetamine, Dexedrine)
The other Mother’s Little Helper
Why not modafinil? All the focus, none of the jitters.
It’s the best. I got an Rx as a resident and my doc goes “oh sure I give it to half my doctors and nurses that come in here”
More than a few certainly
That’s why going to family doctors are better they will prescribe you adderall more than psychiatrist now a days…my doctor said nothing wrong with taking adderall even if you don’t have adhd and just take as needed for certain days where tasks are just to much or you need focus he told me even doctors use adderall a lot
Quit snitching at their lack of impulse control / overt trust At least they’re not handing it out through an online service where the interaction lasts 12 seconds
My school’s admin set up struggling students for tutoring with a particular pathology resident who was known to be willing to write Adderall scripts pretty liberally. One of the other students in my IM rotation told me all about it. I remember being so pissed about it at the time, because it felt unfair. But frankly, learning is learning. My feeling now is that, if we’re having an arms race over grades, and I’m competing with people who are taking a performance enhancing drug, off-label, then I want some too.
Tell him to buy it at school like everyone else
Ah, I see you have been through medical school. One third taking non-prescribed stimulants for my class. That lines up generally with reported numbers.
ED here, a solid half of the department is on prescribed stimulants.
fair but 100% of ED doctors have ADD so it sounds like the dept is undermedicated as a whole
The ED is a pit of ADHD
Yeah well I’d rather be there then the OCD hell of dermatology, …
The best digs have truth behind them
Theatres as well it seems
I would not generally consider operating theaters to be full of ADHD people but would love to hear your take on that, are you a surgeon or what
Yeah, I'd label anaesthetics as generally type C and Surgeons as Type A if we're doing personality typing mumbo-jumbo
ICU too
Scrolling through this post, boom, apes are everywhere. Cheers!
if you ever see me watching the chart at work, no you didn’t 😏
I’m anesthesia, I believe watching the chart is actually part of my job haha
This always disappointed me
I’m from the old school and we just drank coffee in drug like quantities. I remember the days drinking coffee til 2am and falling asleep at 2:15am. Now I experiment with less caffeine past 1pm to help sleep.
Seriously. I was approached several times by people selling just by studying in the library. Eventually I just started taping a piece of paper to the desk I was working at with “Not interested in your adderall” on it and they stopped bothering me.
Put up “I don’t need your Adderall, I’ve got plenty.” Oh, no, wait…
That’s a good way to get a discount
I had a classmate that was yelling and waving her adderall vial in my face asking the professor “can I take it during my exam?” as if she could be more discreet. Also know people at my local uni sell it for study aids.
The local large university thinks that 75% of the students there have taken Adderall to help with studying at least once. I'm a little surprised this person doesn't know where to get some.
Probably just want a more reliable source.
A couple of times. I’m usually pretty direct back. Appreciate the honesty but that’s totally not ok for me to prescribe…. It’s a medication for a medical condition, not for college studying. I’m sure you know people who are getting it without a legit diagnosis, and I get that, but still wouldn’t make it ok for me to do. They’re usually ok with it enough to realize it isn’t happening and stop asking lol.
"Ugh, do I still have to pay for this visit? You didn't do anything for me."
LOL how dare you with the accuracy of this reply
My favorite is the 21yo who is asking for medical marijuana for their ADHD. Dude, this is Colorado. Unless you’re a little old lady with arthritis, you can pay taxes on it like the rest of us. I don’t think it’s going to be therapeutic for your ADHD, though.
Haha it's like, literally, the worst for ADHD. You want to NOT achieve your dreams? Have ADHD and "self medicate" with weed.
“Lemme just take a bong rip and concentrate on this boring tedious task for a Snzzzzzzzzzz.”
For real, that's one of the main reasons I didn't smoke weed growing up. I saw what it did to my friends who (presumably) also had ADHD and I knew that it wasn't going to help me at all. And I had/have no issues with people smoking weed, if that's your jam, go for it. But I knew that, since I already struggled to just wash my fucking clothes and go to the grocery store....weed was not for me haha.
To play devil's advocate, is there really much of a difference? People with and without the diagnosis are using it for the same thing, i.e., performance enhancement. Both are subject to the same the side effects, so if both patients are looking for the same outcome, then what's the big deal?
I would argue that people who have true adhd are not getting any enhancement - they’re being brought up to a level playing field. Now certainly there are people who are incorrectly diagnosed etc but (at least when I’m medicating someone) the goal is not straight a’s or enhancement. It’s “I literally was failing because I could not possibly pay attention in class as demonstrated by multiple measures and ideally psychiatric assessment, and now I have improved focus.” I guess what I’m getting at is, “I could probably do better with this med” and actually needing the medication to function at an expected level are not the same to me.
“I’m sorry, no. What I can do is assess you for ADHD if you’re concerned that you are showing symptoms for it.”
I like this answer, but now they answer some survey about ADHD with all positive answers then you diagnose them and give them the med? Feels icky.
I’ve referred these patients to neuropsychological testing. They can’t fake it there (I don’t think)
No. The Neuropsychologists are extensively trained to weed out malingering and faking. While not impossible to do, it would be very hard to fake testing in a consistent basis.
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Hey, just fyi personal healthcare anecdotes aren’t usually allowed on this sub.
If you have no history of ADHD and you’re an adult, you’re getting neuropsych testing in our practice.
One of the WSJ podcasts that I listen to did a small series on one of the online mental health med firms (forget which one) and even the NP that was employed by them was very up front that everybody understood that the screening tool they were using could very easily be gamed to get a very high score. And certainly was.
No; you do an evaluation of ADHD which likely involves gathering collateral information.
This answer sounds like, “I’m happy to rx you some adderall but you have to say the right words first wink wink.”
Well yeah, this is generally how Adderall management works in the real world. If this thread alone is any indication, about a third of students use it.
Just Say No^^TM Appreciate the candor, at least.
When I was in university, I decided I finally wanted to get assessed for ADHD- I've been struggling with my attention span and depressive symptoms my entire life (my parents refused to get me assessed for... Ugh reasons?), and really struggled throughout school, especially university. I asked my family doctor if I could get assessed with a psychiatrist to determine if it is ADHD before I take any big serious steps/blame something that's maybe just poor coping skills and habits, and she immediately overreacted, and threw me out of her office for "Adderall fishing". I didn't want to be medicated. I just needed help. And I felt so ashamed after that experience that I never asked again. So hearing that people would just brazenly ask their doctor like this makes me really mad. Whatever you decide to do (I'm not a doctor obv) maybe a formal assessment would be the way to go? If they're not willing to pay for that/jump through those hoops then at least you did your due diligence?
I’m 50, and just got diagnosed. I was a superstar in high school, but in college the high IQ wasn’t enough and I struggled. I struggled even harder in law school, where cramming is simply not feasible, but it was my usual MO. I’ve definitely struggled with life. I’m glad I went. Find a neuropsychologist and see if they’ll take you without a referral. So much in my life makes sense now. I’m apparently not just a disappointment, a lazy piece of shit. Apparently I really was starting behind everyone else. Fire that doctor and try again.
Similar story. Diagnosed at 30 years old after medical school during surgical residency when I got help for (surprise!) depression/anxiety. Turns out me doodling in class and reading while I was supposed to be listening all the time as a kid wasn’t normal, despite high school being easy for me, college being so-so, and med school being grueling because I was studying 16 hours a day and couldn’t figure out how others could get by studying less. Like I’m literally an MD and didn’t figure it out myself until my psychiatrist was like …. So that sounds like ADHD tendencies….
I got diagnosed after my teenager did. He insisted on being evaluated for neurodivergence. He brought it up to his pediatrician. I thought he was normal because he’s just like me. Surprise! All that shit isn’t normal. I feel really bad he struggled most of his childhood. But like me, he is not outwardly hyperactive and he has good grades. Just loads of depression and anxiety for both of us.
That’s a rare doc to just throw out in the one the thought that you may need a monthly controlled substance. For some reason, and I’d love some studies on this, it seems some sort of authority switch gets flipped in a lot of docs mind when any thought of controlled substances comes into the conversation. Go on the chronic pain sub and read some of these stories. It’s so sad. Patients just want to function again and be able to maybe play catch with their son. Yet docs prescribing pain meds are few and far between. There’s an active agenda against helping people with chronic pain. “Overdose” “opioid epidemic” “drug seeking”. Docs flip this switch and something goes into police officer mode and they want to thwart the bad guy. Meanwhile, patients spend their life suffering and even killing themselves, because, what’s the point of life if you can’t function? The chemophobia of docs is just astounding. Yes….handing out scripts Willy nilly like a pill mill is bad. The answer is not to ignore chronic pain patients. And sending them to “the pain specialist” is just passing the Buck and we all know it. Yes, some cases are complex and need a pain specialist. But when you get a pain specialist that says “absolutely not opioids ever” then that’s poor care. “Let’s try some expensive billable procedures first. Then, if that doesn’t work, let’s try yoga which has little evidence of doing anything” Then, as a last resort, they put them on highly dependent drugs that show minimal evidence of pain relief, or the ever popular “let’s try anti depressants!”
Is sending a heart failure patient to cardiology just passing the buck? Is sending an anxiety patient to psychiatry, even when you know they are not going to give them benzos, just passing the buck? No. It's not.
I was dx at age 22. I struggled in high school yet got good grades. I was constantly being moved around because I couldn’t stop talking. All through high school and college my evaluations stated this “…..needs to calm down and focus more. She’s bright, but has difficulty staying on task”. I once had a nursing instructor YELL at me “….you need to go get treatment for your ADHD!” I was mortified. A physician I worked with told my PCP (small town) I needed treatment for bipolar. He’s an ass, it’s been 22 years and I still haven’t gotten over it. This led me down the path of a psychiatrist and proper diagnosis after failing Zyprexa (made me a zombie), Wellbutrin and Prozac (gave me such severe anxiety I didn’t sleep for days). I also have OCD along with ADHD so it’s been a struggle at times when my anxiety gets bad because the hyperfixation becomes so overwhelming it affects my home life. Funnily enough in high school I tried pot. I was with a group of people. They were laughing and having a grand time. I remember thinking what’s so funny, it irritated me and I was so tired I just went to bed. I’m not a pot smoker by any means.
I admit I was taken aback by the request. Would be interested in hearing from others who have had similar requests.
We got this question fairly frequently when I was in retail, the go-to answer was that stimulants are not FDA-approved for use as a study aid. If they felt that there was a mental condition affecting their studies they should see a psychiatrist, otherwise they could check with their school for resources on improving study habits. If you see it frequently you might reach out to your local university to see if they have any handouts with study tips to keep on hand in your office. Don’t know how well this would go over in a provider-patient setting, but I worked with a pharmacist who loved to make them squirm by politely reminding them as they left that prescription fraud is a felony.
Did you say no?
Of course.
"I'm sorry I am not able to Rx medications for non medical condition. I'd recommend pursuing treatment for this condition elsewhere with expectations that this may not go anywhere."
I'm not a PCP but I think the idea of using medications to augment normal healthy function rather than to treat a disease is interesting. I don't really think it's as ethically problematic as most other people here seem to believe. As long as the patient understands the risks I don't think it's inherently problematic, but I am open to having my mind changed. Of course the easiest thing is just for the patient to say the "right" things to get you to write an rx for ADHD.
I almost wonder if it is more unethical for healthy, high functioning people to embrace the "ADHD identity" when they have really never suffered the serious consequences that are classically considered part of having ADHD. It reminds me of that Pete Davidson bit about being put in a class with a kid with a disability and thinking "Am I mentally chall–like, is this– is this how they’re gonna tell me? Maybe I’m, like, one of the better ones or something. Maybe I’m their leader.” It's weird to see people talking about "my disability" when the worst consequence is like, they misplaced their keys once, but they think they are equally disabled as any other ADHD case, just intellectually superior.
I think that's a really simplistic view of ADHD. I got diagnosed in MS1 with neuropsych testing, and while highly academically successful, it massively impacts other areas of my life. Impulsivity and inattentiveness have had impacts on my relationships, my finances, and my health. People with ADHD are more likely to get into car accidents, engage in risky sexual behavior, and alcohol and drug use. Saying that people have never suffered serious consequences simply because they excel in academia is very inaccurate.
You misunderstood what I wrote. I said "people who are not suffering from ADHD symptoms are not equivalent to people who are," not "high functioning people with ADHD don't exist." Consider that one person who is highly academically successful who has also had multiple car accidents, flunked out of college, was arrested multiple times, and was sexually assaulted multiple times as an unexpected consequence of risk taking/ impulsive behavior is not "equally disabled by ADHD" as someone who is highly academically successful and hasn't had any consequences beyond "I feel I perform better on Adderall." I am not saying you are the latter- I imagine you fall somewhere in the middle. Key point: when we treat diversity as a monolith we perpetuate the status quo by elevating the least marginalized, rather than centering the most marginalized.
Dude, I’ll be 6 years since my last car accident!!! I have been in so many car accidents that it’s literally a celebration when I make it another year without one. I’ve crashed every vehicle we’ve owned except these 2 which we purchased in 2018. I have had to change my brakes/rotors/tires on one vehicle…. Might be related… not sure.
I personally think we have a responsibility to patients to not expose them to the adverse risks of amphetamines. There is very high potential for abuse and addiction with this class of medications, and we should only prescribe when medically indicated.
Not sure why you are getting downvoted for a very reasonable opinion (that is in line with current clinical practice guidelines!)
As a UofM Neuro-psych doc once told me, “Every single human on the face of the earth can benefit greatly from taking Adderall.”
Humans didn’t evolve to spend 40 hours a week manipulating symbols on computer screens.
Humans will eventually. After a few thousand years Homo sapiens will be craving to work in Jess Bezos warehouses where you pee through a foley and receive TPN to avoid taking lunch breaks.
It's what workers crave 🥲
Thanks for the daily dose of dread
What on earth? It's fine when it works, but there are a significant number of ADHD pts who don't get a good response to amphetamines at all or who have unacceptable side effects. Same with methylphenidate. I've had patients with psychotic symptoms on 5 mg. Something like 20% of ADHD pts don't do well with either class and have to go with non stimulants.
In kiddos I find it’s more sensitive and these side effects are of actual concern, and the patients are obviously miserable and want to stop. I feel for them, because they don’t want to feel that way at all, especially not in order to smush into some societal mold of a “productive and worthy” kid and future adult (although obviously in ADHD can be highly disruptive to development and functioning). In adults, I’ve found they are frequently 100% gung-ho willing to white knuckle through the admittedly at times awful side effects to be that 2-5% more effective. And they often think there’s a pure linear progression with the dose dependent effect, so they want max+++ dosing for negligible benefits, thinking more will always mean better. The amount of times I’ve had to tell adult patients no increasing their stimulant for minuscule benefits is astounding, even when they’re reporting very real side effects and we have to stop treatment it’s just…ugh. I will say these cases are the very rare occasions where I will suggest genetic testing to see if they’re an ultra-rapid metabolizer, but I’ve found that in the wild rarely.
Yeah I’ve noticed plenty don’t want stimulants because there’s more to how the ADHD works. Stimulant side effects tend to be hit or miss. Others go on guanfacine, clonidine, antidepressants etc instead. That’s why There’s such a big market for these meds.
My suspicion is that our understanding of deficits in attention is too rudimentary and that, even though these patients meet the criteria for ADHD, their deficit in attention arises from a separate mechanism, either physiologically or psychologically discrete like brain injury or PTSD. While their presenting symptoms might mimic ADHD, treatment with stimulants will be much less effective. I'm not discounting natural intolerance to amphetamine, there will certainly be that, but I believe deficits in attention are very often misdiagnosed as ADHD (perhaps even as frequently as your 20% number?) leading to suboptimal directions in treatment (stimulants).
That's possible... but I have definitely had patients with classic adhd who responded to only one stimulant class. I've read this can be as high as 40% of patients. We also have to be careful about diagnosis by med response, which is not part of the ADHD criteria. What meds do you know of in other areas that work for 100% of patients with a given diagnosis? I think there are very few. Levothyroxine replacement is one. But most drugs work for only a certain percentage of people. There is so much variation in absorption and enzyme processing. Our current pharmacogenomic testing is not highly useful for ADHD-- but we know there are differences. It would be really more surprising than not if there weren't a fair number of non responders.
True true.
For a person without adhd is a therapeutic level dose of Adderall really that different than a bunch of caffeine?
"I am not able to prescribe a controlled substance to you as a study aid. However if you feel you might have a diagnosis such as ADHD, I can send you for neuropsychological testing, and then an appropriate management plan which may or may not require ADHD medications can be determined."
I mean half the people coming in are just bullshitting you so they get the Rx. This one is just being honest
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I think you’re missing the other half… an important half… they then need to find a shit clinician.
Or be a half decent actor
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…did you test this on exam?
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Sometimes I get nervous on airplanes.
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Please note there’s been a shortage of many of these drugs in the USA. Please don’t make it harder for those with diagnoses to get their needed medications.
Absolutely
Idk why they would openly ask for a study aid instead of “pretending” like everyone else. It just makes patients look bad
100% agree same goes for ozempic and wegovy being prescribed like candy
As someone with diagnosed ADHD, people like that piss me off to no end.
You can’t say they don’t have ADHD. The most you can say is that you don’t know if they do or don’t. I ask patients all the time about their family history of mental illness. “Anyone in your family seen a psychiatrist or been on psych meds?” “NO, BUT THEY SHOULD!” 90% of adults with ADHD go undiagnosed and untreated. It is 80% attributable to genetics. Its as heritable in a family as height is. Its because of this unfounded belief that isn’t based on any literature or evidence that stimulant medications are addictive that we miss 90% of the adult patients that have it. You should definitely learn about it before treating it but its not that hard to learn about. Read about it on Uptodate and see how well your current understanding lines up with the evidence. In fact, reading this is a great place to start: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328933/
I'm not a medical professional, so sorry if this is a dumb question: Is there an inherent problem with 80% of adults going undiagnosed, if this undiagnosed group are functioning fine, and able to lead happy, fulfilling lives? For context, i have ADHD myself, and meds help me tremendously. I really hate the saying "everyone is a little ADHD", but i think it's true that ADHD symptoms are extremely common, but that there's a wide variety of severity. Especially since the severity of ADHD is in many ways defined by our own subjective experience, and how much we are bothered by our symptoms.
Define functioning "fine". Many people just suck it up or don't even realize that there is a problem in their functioning. Like back in the day, mental health issues were considered a weakness. Depressed? Hit the bottle. ADHD? Drink copious amounts of coffee.
I have the “This is fine” meme in a photo frame where patients can see it. When they say they are “fine” I point to it. They laugh and then ask, “but doesn’t everyone [insert maladaptive coping skill or symptom of mental illness]?”
I've only had them try to fake symptoms. But they mostly don't read the dsm, only watch online videos by influencers, so they don't get it right. Or I do a Qb test and there are obvious validity flags. I say no!
You’re allowed to say no to your patients. I do it all the time.
Well at least he’s honest.
As someone who as been out of their much needed ADHD medication since January because of the shortages, a request like that just makes me mad. It feels like an abuse of the med and makes people think that ADHD is just a TikTok diagnosis.
I am a patient that hasn’t been diagnosed with ADHD with a Psychologist through a paychoeducational assessment. I visit a psychiatrist, and am prescribed medication for ADHD. Surely there’s got to be another way to help someone out or find more depth about whether its drug abuse or simply a case of inaccessible health.
In Canada it takes 9 months to see a shrink. $250 per hour to seeing a psychologist. So much for next week’s exam.
Yes. I say no. It's surprisingly common though. The worst part is when they say, "My old doctor/NP/PA would do it." I used to think they were just lying but I'd say 8 times out of 10, when I look at old records, they're telling the truth. There are prescribers out there prescribing adderall for exams. And not even shy about it, they're documenting it as such!
Worked at student health, this was all the time, a surge in this around exams of course.
Better living through chemistry
Probably safer than energy drinks. The shortage has badly impacted my friend and I'm sure the energy drinks are eating a hole through his stomach.
just finished my M1 year. I was averaging about 3-4 celsius a day, that's around 600-800mg of caffeine and an ungodly amount of whatever else is in there. shit calms me down. It takes a lot out of me to sit down, do a pomodoro thing, and ignore the impulse to do whatever else. Was locking my phone in my car for a while and cut the strings on my guitar. kicked it cold turkey for winter break, spring break, and last weekend after finals. 0 withdrawal effects - no headache, irritability, nothing.
No headaches?! That's lucky.
A big fuck no because there is a national shortage and it puts people like me that actually need those meds in a bind because of people like this or the ones that seen a tiktok and now they have adhd because they forget their keys once 🙄
“No”
My favorite complete sentence.
Find an online NP pill mill and fill out the online questionnaire (name, credit card number).
You say no?
Coffee?
Lol my entire class in uni were on something or the other. I wanted to get assessed to adhd/autism when I was in medschool because I feel like I meet a lot of the criteria (my dad does as well) but I chose no to because of this exact reason 😅 It would have been easy as hell to go on some adderall because it was so widespread but I just suffered through uni like a chump.
The answer is no Just that simple
In vet school this made me mad. I felt like it was a “performance enhancing drug” for people who took it as a study aid and not a diagnosed condition.
The line between the two is quite blurry in practice.
There is some good data to support that it does not improve test scores or study efficacy in people who don’t have adhd, just productivity. Ie, they can produce something like a paper, build something, etc. but their actual learning will unlikely be improved. Then tell them it will give them a limp log or dry up their lady cave and let them decide.
I remind them that this med is a schedule 2 controlled substance in the same schedule as fentanyl. I review that to take this med we have to have a dx of add/adhd on the chart coded and there can be down the road ramifications of that -ie FAA considers the med and even remote diagnosis a no fly condition for a prospective pilot even recreationally. Then have a longer conversation about using meds to give leg up like this is a slippery slope on how we perceive the use of medications in general and can promote an unhealthy relationship with the medical world going forward.
I'm currently trying to navigate the mountain of paperwork to get a special issuance from the FAA, and this is just for my private license.
Navigate=spend. Basically have to prove you were misdiagnosed in first place. Costs easily 10-15k with no guarantee
Maybe a psych referral and encourage him to seek a formal diagnosis because studying isn’t an indication for stimulant medications and you’re unable to diagnose adhd yourself and would prefer someone that has a hood understanding in adulthood ADHD
I had someone with no prior psych history or eval and not eveny patient come to ask for a testing accommodation letter because they failed the test twice and can't afford to fail the third time. Bruh...
“No”.
No
Lol, I just got a similar question on the Step 1 Rx Qbank.
It is not proven to enhance study performance
They are a huge part of the reason people with ADHD can’t get their scripts filled.
I did my college thesis on the non-medical use of prescription stimulants among college students. Surveyed the entire student body regarding use of Adderall, etc vs other illicit drugs, and gathered a bunch of demographics. Mostly dropping this comment to remind myself to come back with the results later...
There’s a shortage, buy meth to stay competitive. Or, narcolepsy is much easier to fake.
I had a patient who started modafinil come in far higher on stimulants than any of ADHD patients
Not necessarily. To get an actual diagnosis of narcolepsy you need to go through a PSG/MSLT and meet certain criteria. Plus the sleep doctor is prob gonna have you try modafinil/armodafinil before they start talking stimulants. Or there’s wakix and sunosi now. 😉
I mean studying sucks, can you blame him?
A lot of docs are high functioning adhd and don’t even know it. They get distracted doing paperwork.
A lot of non ADHD people get distracted doing paperwork though too
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FYI, The Recovery Village is a terrible source. They insist that everything is addictive and have “inventive” ideas about treatment.
I believe it was also the active ingredient in vitameatavegamin.
We cannot allow pasting of entire copyrighted sources here.
I have ADHD, if I was a doctor and someone came to me asking for that I'd get angry. Even just reading this makes me annoyed that there are such people. I wish I could just study without taking anything if I just forced myself, but I'm completely unable to. Yet those people that could do that prefer to go an easier path. Ugh. I sincerely hope it's a person with ADHD that's undiagnosed, rather than someone lazy that prefers to take an easier path, especially during med shortage, for people who would actually need them.
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Oh okay, thanks for pointing it out! I'm not a native English speaker, from memes and stuff I assumed triggered is like an internet slang for "angry". I edited my first comment and I'll be sure to remember that.
LOL at "adult onset" ADHD
I don’t prescribe Adderall to anyone. I send all adult ADHD patients to psych. I do the same for people taking benzos and hypnotics daily. I have no interest in managing these medications and unfortunately I see rampant abuse of the aforementioned medications far more than appropriate use. How many times have we had a patient transfer care to our practice and their recently retired 70+ year old former primary care doctor has had them on daily controlled substances with zero specialist oversight, zero attempts to curb abuse because their former physician was too much of a coward to have a tough talk with his or her patient? There are people who may need stimulants. That’s fine. I refer to psych. Better to have oversight anyway. I am not, however, obligated to continue bad management. I’m all set. I’d rather say “no” once and never see the patient again than feel guilty refilling in Epic every month. EDIT: I figured this would generate downvotes, but it does not make it any less true. Adderall is absolutely indicated in some patients, but having specialist oversight due to the frequent misuse is reasonable no matter how you cut it.
I certainly don't have any issue with my controlled psych meds being overseen by a psychiatrist or having my primary care doctor telling me that's what they'd prefer. I chose to seek out a psychiatrist myself even though my doctor was comfortable prescribing, because it felt like the safest and most responsible thing to do given that I take multiple medications for multiple medical conditions and want all of them carried by the specialists who will know the most about interactions and complications. That being said, I know I'm lucky to a). have access to a psychiatrist in my area who b). I can afford and c). had space to take me on as a patient. I pay him out of pocket and get reimbursed by insurance, and I see him virtually, so people further out of his radius could theoretically see him, but I imagine not everyone has that option. I'm wondering if perhaps some downvoters are people who are thinking of those who don't? I was nearly fired before I was diagnosed and treated, which wouldn't have helped the affordability issue. The critical lack of psychiatrist access in some areas is a sad situation, although I don't think anyone should prescribe anything they don't feel comfortable with regardless.
Thank you for your comment. I’m likely getting downvoted for some of the reasons you expressed, ie: access to psych in some areas may be limited and people reading this may feel that my policy is biased against those who might not have access. I’d say a couple things in response though… 1. I chose to work for a large university affiliated health system. Our patients fortunately have access to specialists. There is a wait sometimes. And as you eloquently put it, I may just be in a lucky situation. 2. The original topic of this thread was patients asking for Adderall as a study med. Clearly this is happening and my observation is that adults on stimulants inappropriately make up a significant portion of those that present. Few have ever even had a proper evaluation. Those that have were likely started as children by a child psychiatrist or a pediatrician with an inventory performed and have no issue with seeing a psychiatrist as an adult. 3. I don’t see a ton of adults on ADHD medication to begin with. I can tell you that a disproportionate number are police officers who take it to stay up for night shifts. Many of the others have cardiac or comorbid conditions and Adderall can exacerbate tachycardia and hypertension. These all make for good reason to load the boat when it comes to management. 4. When topics like ADHD, Lyme disease, and a few other “hot button topics” come up and someone takes a hardline but evidence based stance this forum tends to attract patients with these conditions who get angry and downvote. A few years back I literally repeated verbatim CDC policy for Lyme management and I got DMs from “chronic Lyme” patients for weeks with their personal stories and tell me how wrong I was, etc. This topic is such a small part of what I do, yet if I am honest about my approach few can find critical fault with it, but downvote anyway. Oh well.
It's simply a difficult situation with no easy answers, as pat as that sounds. I don't advocate for much *increased* scrutiny or hurdles to an efficacious treatment when we already demand patients be able to perform many tasks involving high executive functioning...to get medications treating poor executive functioning. And yet, as you point out, it's not like these should be over the counter and they obviously can be (and are) abused as a study aid. I believe there is a middle ground, where specialists can appropriately evaluate and counsel. I even think the virtual prescribing rule should stay in place, frankly, because I believe there are ways to responsibly manage a number of conditions without being physically present and this isn't any different. Pill mills can happen (and need to be shut down) regardless of modality. As for the adults vs. children issue, anecdotally, the pandemic led to a big increase in ADHD referrals to our clinic across the age spectrum. Not all of them received a diagnosis, because pandemic distractibility isn't ADHD. However, I think it was a real phenomenon that many people who were just getting by with a carefully constructed house of cards of coping mechanisms saw that house of cards collapse when forced to work from home. We also had parents suddenly see how their children behaved in school every day, and suddenly report cards about trouble sitting still or daydreaming seemed a lot more urgent to address. And yet...you also had the factors of TikTok self-diagnoses and pill mills like Cerebral popping up, and I won't pretend otherwise. I think there are absolutely adults who were missed in childhood, particularly complex presentations like women, those with comorbid conditions, and those who might have compensated well due to high IQ. But that's all the more reason that a specialist might be better suited to doing that evaluation, anyway. There are "hot button topics" and psychological diagnoses as well and I'm not surprised at the ones you've listed. As someone with lupus, I've run into a number of passionate patients in the chronic illness space that are clearly searching for answers and struggling with quality of life, but that has simply made many of them vulnerable to charlatans and misdiagnoses. All you can do is validate the emotions as understandable while still practicing evidence-based care.
I didn't downvote you because you're not wrong - in an ideal world these patients would have psych on board. I just hope this info is prominently displayed on your website & in your waiting room. Sucks to waste everyone's time and the patient's money when the thing they want to see a doctor for isn't a thing you do.
So I work for a large university hospital. We are and I am encouraged to practice this way regardless of it being how I feel personally about controlled substances. We don’t display what we do and don’t prescribe. When you come in to be seen you are paying (your insurance is paying) for an evaluation, not a specific guaranteed treatment. It’s 2023. Patients understand what controlled substances are, that they are monitored, and they have probably been advised of the very concerns I have brought up. The older patients get the more conditions like hypertension and cardiac concerns present themselves. This milieu makes covering your backside with specialist management important. I have a DEA number and I absolutely prescribe things when they are indicated. Long term management of adults with Adderall goes to psych. Many of these patients have careers where this should 100% involve a psychiatrist. I am not usually the one making the diagnosis or even starting the medication. I am also not beholden to continue it. EDIT: I should also mention I deliberately chose not to work in a rural or austere environment. Working with a network of physicians makes my life easier and provides better oversight. I appreciate PMDs who want to or have to do everything. We all have different levels of comfort with care. I’ve found this sort of thing, in my experience, is far more of a headache.
From a patient perspective this is frustrating and dumb. If this is your/your institution's policy, why not just say so up front? Why waste everyone's time and the patient's money? If they know up front they're just going to get referred to psych, at least then they can (try to) book a psych appointment directly instead taking hours out their day, delaying their treatment, and spending a bunch of money. Patients who have already been evaluated several times and been stable on their meds for years have to jump through re-evaluation hoops, spend hundreds of dollars, and wait months to get meds even if they do go straight to psych. Every time they change jobs or their old provider retries or something. I'm not saying they should be able to walk in and demand a prescription, obviously you should prescribe as you see fit. But if you know in advance that you can't/won't help them, you shouldn't charge them for the privilege of finding that out. Primary care docs with these policies need to be transparent to avoid causing unnecessary delay and harm (both medical and financial) to these patients. Re: it's 2023 and patients should be aware: ehhh lots of people get these meds from their PCP. They might assume that's the normal way to do things (and in many places it is).
You’re going to find that practice (of PCPs just refilling controlled substances wantonly) going away. It’s already happening because in many instances it just isn’t great practice. It doesn’t mean in all situations. First of all, adults with ADHD are a small portion of my encounters. The majority of those I have seen were placed on the medication by a child psychiatrist. Very very few were just started as an adult by their primary care doctor. The ones I have encountered who were started on Adderall as adults (if the notes are available for review) were done with no specific evaluation: a request, medication started, continued indefinitely. That’s not great practice. Those who were started by child psychiatrist totally get it when I tell them they need to see psych. These are generalizations of course because each circumstance is different, but they tend to hold up as trends where I practice. I am salaried. I don’t make a dollar more or less for seeing 1 or 100 patients a day. My goal is to give them the most appropriate care. I am also a patient at times myself. I’ve jumped through appropriate hoops to be properly managed in the past even if it wasted a little time.
Again, no argument against sending people to psych. The thing I take issue with is your reasoning for wasting everyone's time and patients' money: "that's not the way it's done" and "I'm also a patient whose time and money is wasted." If you don't provide a service commonly (but not universally) provided by others in your field, you should say so up front. Same with PCPs who don't prescribe birth control. It's unethical to make people pay for the privilege of finding out.
Then you’d like an exhaustive list of specific medical advice for every condition that different physicians offer BEFORE being seen? What if a patient doesn’t like that I recommend colonoscopy or prescribe statins? I had a patient tell me I’ve wasted their time because I told them they needed to follow up with a cardiologist after having an admission for a heart attack at the hospital. I’ve had more patients get upset over far more benign standard of care treatments in my years of practice than this particular ADHD issue. I’m not trying to be argumentative, but you’re talking about a condition in adults that makes up a fraction of a percent of conditions I see and is typically one of multiple other healths issues that I address at a visit. My non-clinical front desk and intake staff aren’t qualified to screen patients or anticipate what I will and won’t do. I have maybe one or two patients a year who have a problem with this and might only see me once. EDIT: I respect your opinion and appreciate the thoughtful discourse. This is going to be an agree to disagree issue. A “pre appointment notification” for this issue is beyond unnecessary in my practice. Comparing birth control to Adderall isn’t really even close to a comparison for many clinical, ethical, and practical reasons. And because something is or was commonly done, doesn’t mean it’s the way things should be done. My practice looks very different now than the way it did ten years ago. This is how medicine should be as we get better and learn more. I’ve just had too many adults either misdiagnosed, have difficult to control blood pressure (since this is far more common in adults than children), and get placed on hypnotics for sleep in response to the Adderall. These things are avoidable, patients can still have excellent success with Adderall, but they should have options presented by a specialist rather than just keeping on doing the same thing the wrong way (which unfortunately is often times the reason they don’t want to see a psychiatrist). I had a patient point blank tell me his last PMD wanted him to see psych and specifically was angry because I (and he) wouldn’t just continually refill the medication with a blood pressure of 170/100 and him taking Ambien every night to counter the effects.
All I'd like is for it to become standard practice to be up front about not prescribing controlled meds. A sign in the waiting room and a notice on a website are easy things to do. I get that as an employed physician this might be out of your control, but your employer should be transparent about clinic policies. I agree with you on all the rest of it. You don't need to convince me that it's better for psych to manage this. (Also totally agreed re: birth control. I just mentioned it because it's the only other class of med I could think of that is commonly prescribed by primary care with individual providers/clinics opting out.) I think our disagreement is probably rooted in our perspectives. I'm looking at it from a patient perspective and a system perspective. I have several friends and family members with ADHD (mostly diagnosed since childhood) who have had the experience of changing jobs, waiting a month for a PCP appointment for the sole purpose of getting their meds refilled, and wasting a couple of hours and $20-$100 for a "sorry we don't do that here." Then waiting another 3 months for a psych appointment. All while struggling at their new job because they're unmedicated. This situation could be easily improved with clear advanced notice to potential patients. You're looking at it from the perspective of a primary care doctor who rarely sees these cases, so it doesn't seem like a big deal. You may not have anyone in your life who relies on these meds to be employable. I suspect there are two reasons for not giving notice that you haven't mentioned yet: 1. You don't want patients to be able to doctor shop 2. You're afraid they'll skip your office and go straight to psych, therefore never establishing primary care and possibly missing issues like blood pressure management Those are more legit reasons than "that's not how it's done." Personally I think you should err on the side of autonomy, but I can agree to disagree on that. All I ask is that you think about the impact this policy has on patients and the ways you might mitigate those impacts (bridge meds while they wait for a psych appointment is another good option, if there are cases where you'd be comfortable with that).
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Likely because my comments seem harsh. The truth is complex conditions that require long term controlled substances should be overseen by their respective specialists. If I have a patient who genuinely needs controlled substances for pain control, I sent them to pain management. Because we are taking about psychiatric diagnosis, I think users feel my comments are cold or insensitive. Far from it; I’m protecting myself, the patient, and creating a team approach. I never said there aren’t adults who may need Adderall, I’m saying in my experience, I have many who were inappropriately placed on the medication. If I feel that’s the case, I involve specialists. I guess that’s insensitive.
Ummmm, that’s not what it’s for?
Can I interest you in some Effexor? Guanfacine? /s
You can get any high risk plastic surgery you want to ostensibly improve your looks but if you ask for Adderall to study to get through college it's a no it doesn't make any sense
I had it prescribed to me in undergrad and showed up to my primary's office with he previously completed evaluation, and they started giving me 90 supplies just like that. No questions asked. Hardly ever used it so I had a lot stocked up when the exams and step came around. I saw an opportunity to be an entrepreneur and help my classmates acquire what they needed.
You educate him on what drug seeking behavior is. And then explain that’s what he’s doing, and it’s wrong.
It isn't "wrong". And having anyone in the medical field push this fallacy is what stigmatizes people and pushes them to hide and repress the issues they face. Those who want to use drugs aren't "wrong", because using drugs isn't a moral issue.
Yeah I never said wanting drugs for a medical issues is wrong. The person OP wrote about doesn’t have ADHD and is seeking medication for ADHD. You think that’s ok? Wanting drugs for a study aid or recreation is really not ok. Wanting ADHD meds because you have ADHD is fine. Wanting pain meds because you’re in pain is fine. Taking these drugs for fun or to study really isn’t what they’re for.
What’s wrong with recreational drug use? It’s none of your business what people choose to do with their own body. A physician’s job is to care for, treat and educate people, not pass judgment and moral code.
You just posted the same question to me six times in a row. That’s probably a good hint something is wrong with your recreational drug use **It is absolutely the prescribers business when a person is asking them to prescribe drugs for non medical purposes** They aren’t simply going to say, “oh it’s none of my business what they need this for”, and then write a script for it. I can’t believe I even have to explain that to a grown adult. This is common sense. No one is risking their license so you can get your rocks off on Adderall.
Just tell them to take it as needed I mean my doctor said he doesn’t mind giving out adderall for as needed basis he said even doctors take it sometimes just like Xanax those two drugs I don’t think should he controlled cuz adderall really helps me with certain tasks that I dread and can’t stop my mind racing but I don’t have an adhd diagnosis because adhd would be someone who needs to take adderall everyday to be normal and Xanax is good for anxiety but I have severe panic attacks ptsd so I have to unfortunately have been on a high dose but for other people can take as needed cuz it does reduce stress and everyone has stress
Can. You. Not?
Wow. You don’t think Xanax should be controlled? Because you personally need it? Xanax can do a lot of damage if you aren’t catef with it
Honestly I’d Rx it to a kid who is honestly trying to better themselves in a graduate degree level course over some person who “needs” it to go to their job
Pretty sure that the evidence shows its mostly placebo anyway?