Practical Outpatient Prescribing The Speaker and Program Planners have no commercial interest as defined by Accreditation Council for Continuing Medical Education Catherine Chichester Monica Delehanty Anne Rogers Peggy Spencer William Schaffer Leah Vosmus James Wolak No commercial relationships or conflicts of interest to disclose among the presenter and the planners.
Community Health and Counseling Services
Stimulant Prescribing in Adults for the Bangor Municipal Substance Work Group W Allen Schaffer, MD, FACP, FAPA Chief of Psychiatry, CHCS February 2018
W Allen Schaffer, MD, FACP, FAPA • Chief of Psychiatry: Community Health and Counseling Service. Board Certified in Psychiatry and in Internal Medicine • Attending Psychiatrist: St Joseph Hospital, Wellspring Residential Programs, Aroostook County Mental Health Service (interim) • Formerly: Chief of Psychiatry, Eastern Maine Medical Center • Chief Medical Officer, Acadia Hospital • Director Substance Treatment Service, Acadia Hospital • Attending Physician, Maple Leaf Treatment Center, Underhill, VT
Schedule II Narcotics - Stimulants • We tend to view stimulants as “different” but the Rx rules are actually the same • Primary care is attempting to move free- standing stimulant prescribing to Behavioral Health prescribers. • Community providers are restricting use of stimulants with their narcotic prescribing • Patients seeking stimulants are self-referring to Behavioral Health prescribers
BOLIM on Schedule II Rx (Board of Licensure in Medicine) • “the Board will judge the validity of clinician’s treatment of the patient based upon available documentation, rather than solely on the quantity and duration of medication administration.” • “Board expects that clinicians will incorporate safeguards into their practice to minimize the potential for abuse and diversion of controlled substances.”
BOLIM Principles for Rx Schedule II • Evaluation of the patient • Treatment plan: objectives, adjustments • Informed consent /agreement for treatment • Periodic review of Treatment efficacy • Consultation or referral • Medical Records • Reportable Acts: PMP, UDS, pill counts
Stimulant Rx: New Environment • Changes in regional Rx practices • Comparability with other Agencies • State oversight of Schedule II prescribing • Federal standards for Schedule II • Risk recognized for adverse outcomes • Risk recognized for diversion • Prescriber Monitoring Program (PMP) use
Attention to Stimulant Rx • Influx of patients expecting free-standing stimulants • Wide variation in Community Rx practices • Recidivism in existing stimulants Rx • Splitting of prescribers • Influx of opioid replacement patients unable to obtain stimulants from prescriber • Accountability of Prescriber for diversion
Stimulant Rx practices 1. Stimulants free-standing for ADHD 2. Stimulants with Opioid Agonists 3. Stimulants with Anxiolytics 4. Stimulants with Antipsychotics
1.Free-standing Stimulants for ADHD • Documentation of diagnosis • Children are different • Medical contraindications under-recognized • Clear distinction from Anxiety disorders • Step Tx: Behavioral, alpha agonists, Rx alternatives bupropion, atomoxetine • Lifelong Rx: not recovery oriented
1. Free-standing Stimulants for ADHD • Indications must be specifically documented • A history of sustained childhood Rx needed • Step Tx must have been completed • Specific treatment goals/duration • Scheduled re-evaluation of benefits • Addiction hx cleared: sober 1 year & no hx of cocaine dependence.
2.Stimulants & Opioid Agonists • SAMHSA protocols do not support use • Two addictive agents in same addict • Need for stimulants usually indicates dosage of opioid agonist is too high • Regional Mental Health prescribers not Rx • Patients seeking stimulants are self-referring • High potential for diversion
2. Stimulants with Opioid Agonists • Practice should be discontinuing stimulant prescription for patients in opioid replacement. • Stimulant discontinuation should allow dosage reductions for methadone/Suboxone • Stimulant taper is not necessary, but can help with therapeutic alliance • Protocol: 30-90 day notice to patient possible
3. Stimulants with Anxiolytics • Limited indications, must be carefully documented • Generally contraindicated • Stimulants :Glutamate/dopamine/norepinephrine stimulation and GABA down regulation • vs • Anxiolytics : GABA agonists/glutamate antagonists • Two addictive controlled substances working in opposition
3. Stimulants with Anxiolytics • Current regimens should be identified and taper of one agent discussed with patient • ongoing medication regimen containing both benzos and stimulants should be subject to peer review • new patients should be informed that they cannot continue an existing regimen containing both agents
4. Stimulants with Antipsychotics • Limited indications, must be carefully documented • Generally contraindicated • Dopamine agonist vs Dopamine antagonist • Can create or increase psychosis • Can increase anxiety/agitation • Should prompt full review of regimen
4. Stimulant with Antipsychotics • Patient stability is THE MOST IMPORTANT CONSIDERATION • If not carefully and symmetrically implemented we may destabilize patients – Decreasing stimulant unilaterally can sedate – Decreasing antipsychotic unilaterally can create psychotic regression
4. Stimulant with Antipsychotics • This is the most complicated transition • This has a high benefit/risk outcome • This is an opportunity to reduce dosages of antipsychotics as countervailing stimulant doses are reduced • This is a sensitive negotiation with patient- safety implications • We can improve the care of SPMI clients by bringing these changes
Stimulants use by Specialists • Off label uses (usually low dose) • Treatment-resistant Depression • Brain injury • Cognitive impairment • Pervasive Development Disorders
Recognizing that…… • There will be individual exceptions • Patient well-being and stability is the primary concern • Documentation of exceptions must be completed and supported by clear explanations of risk/benefit and of treatment goals directed toward Recovery
Rx Concept • “One Controlled Substance per Brain” – Optimizes medication effect – Reduces drug interaction – Enhances patient safety – Minimizes diversion – Reduces documentation and UDS burden – Elevates the Standard of Practice
Stimulant Prescribing Changes: How do we do this? • Organizational leadership support • Stop starting these Rx • Preparation for the change in policy • Talking points for patients • Education and Negotiation • Timing and time, this is not usually an emergency • Reasonable expectations
Delivering the Message • “We have a new Policy and we have to do this” • “There are new Agency guidelines and this is the way we are going” • “We are using some newer methods…” • “I think we may be able to help you feel better by reducing some medications…” • “If we make some changes in your medication we can help you move toward your goal of….”
Upgrading UDS • Molecular testing vs dipstick or lab routines • Specific and quantifiable results • Alcohol metabolites identify problematic use • Quantified results allow tracking of use – Of special interest in THC • One UDS identifies all substances of interest • Methods not subject to question/contention
Next Steps • Create peer review process for complicated cases • Create systematic monitoring practices • Implement the Prescription Monitoring Program ( PMP) tool in each clinic • Implement state of the art Urine Drug Testing – Molecular and quantified testing – Include alcohol in your testing
ADDENDUM • Free-standing Rx for Adult ADHD • Minds are made up, so no arguments on merit • 1. Prescriber behaviors • 2. Best Practices if you choose to Rx
Prescriber Behaviors: Adult ADHD Rx • Skeptic – Uncertain of dx and Rx merit • Accommodator – Ambivalent re issue – Responds to patient requests for Stimulants – Conceptualizes “good candidates” • Enthusiast – Stimulants benefit many dx and sx – Often a revenue/volume building tool
Skeptical prescribing • Not convinced that dx is significant • Subscribes to alternative tx • Concerned about academic and workplace abuse of drug • Not wanting to Rx without clear end point • Agency can offer support by excluding free- standing stimulants in adults except in specific protocols
Skeptic: what medications merit lifelong Rx? • Life-long EVIDENCE-BASED: • Insulin, ACE/ARB for renal sparing, Beta-blockers post MI, ASA preventive, COPD, hypothyroidism • Life-long PERHAPS: – biologics for RA, MS, IBD, CLL, antidepressants, mood stabilizers • Life-long NOT ESTABLISHED: – oncologic, reproductive/growth hormones, Stimulants
Skeptical Prescribing • Once started: when and how to d/c the drug? • Schedule II monitoring requirements • Dosage creep • Diversion • Aging and contraindications • Pressure for colleagues and competitors
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