Prescribing stimulants?

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Specializes in PMHNP.

I'm a relatively new. Psychiatric Nurse Practitioner. Recently I've noticed an uptick in people requesting stimulants. I want to know how other providers are making determinations to prescribe stimulants.  Currently at my practice, we used Tova screening. I have also requested people to get psychological evaluations. Sometimes the psychological evaluations are cost prohibitive, so people pushback on those. If it's a new patient to me, I usually start them with non-stimulants. Almost inevitably, it doesn't work for them. I tend to think they have tried an Adderall or two and they are really looking for stimulants. In my previous position, I worked at a solo practice and the doctor made the determination to start a stimulant. At my new position, I have to make the determination about the stimulants before I send them over to my supervising physician to sign. I want to make good judgment about my decision to start a patient on a stimulant. When assessing and asking about symptoms, everybody always presents with ALL the symptoms. It just seems like there's a lot of people requesting stimulants these days. 

I'm interested to know how you handle these situations in your practice. 

 

Thank you! 

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Specializes in Family Nurse Practitioner 2015 - present.

Hello! I agree - there has been a major increase in patients requesting assessment for ADHD/ADD - I work in Canada and there is a push for primary care providers to take this one and do the assessment and prescribe if appropriate. There is just not enough specialists doing this and the wait times in our public health system are many many months long. From my understanding there are a couple reasons for the increase in clients coming in for this - social media is talking about it more like TikTok, more news articles and discussions and it is talked about more in our conferences/CMEs etc. The reality that there is genetic component and more children are being diagnosed which could be the trigger for the parents to wonder if they have it too especially when they often help fill out the assessment forms. My colleagues and I have talked about how the changes to how school and work are structured during COVID have probably caused adults with ADHD to notice their symptoms more - whereas they were managing and coping in the structured environment - they are not now. Most patients don't abuse stimulants and you can assess for their risk beforehand - I had a 22yr client who was bipolar on lithium and known recent history of crystal meth use prior to being assessed for ADHD. She went to a different specialist for her ADHD assessment than her psychiatrist. They recommended that she was candidate for stimulants if her bipolar was managed and she was off crystal meth - her psychiatrist said that she had to have therapeutic level of lithium prior and clear urine prior to trial of stimulant. 

Anyways, I have found that my patients will notice a different right away if the stimulant will work for them - if not they stop it. I can be life changing for them.  Check if your scope of practice in the state you work allows you to diagnose and prescribe. I can prescribe all except the Adderall. I use the screening forms ASRS, WURS, PHQ-9, GAD - in our clinic we have an amalgamated form that includes questions about bipolar, ODD, OCD, sleep problems, substance use. 

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Specializes in Family Nurse Practitioner 2015 - present.

I should add that sometimes it takes a few visits with them to determine if yes their history and assessment points to ADHD/ADD. We generally only use the longer acting stimulants in adults like Vyvance and Concerta as first line. Wellbutrin or Strattera if they don't want stimulant or can't for other medical reasons. 

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As a 51 year old woman who has again run into the battle axe of NP trauma and not being allowed my medication after 14 months of trying again - even with a diagnosis -  after 10 years of being turned away or misdiagnosed and prescribed bipolar or depression poisons - I hope you to be merciful and listen to my post I make in pure despair- maybe you will help someone else - Please research  adult inattentive combined adhd -folks like us are in situations where we are the caregivers  of infirm parents and two grown children with adhd- I promise you that if you err on the side of listening and not judging you may actually help and not harm someone who has done the time in the hell of misdiagnosis because of the research on adhd that they didn't give you in your 30 credit certification - slinging abilify and lamictal and lithium and hurting neurodivergent people is criminal.  Please - I know you make 160000 or more - but your main understanding of stimulants is from the drug war - don't cause suffering and hell to those that crawled their way to your door one last time to be heard - give us a chance - and be honorable and investigate your craft. All the best -at least you're asking the question.

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Specializes in PMHNP.

Good day, Twoshea749,

Since posting, I have gained much more  experience and insight.  

My patients tell me how they are suffering and I hear them.  As a licensed mental health provider, my training has prepared me to assist those who have assessable diagnoses with available medication treatments.  What you present is not always the case with other patients and sometimes there are people who are drug-seeking.  I've seen it from both sides.  As you state "be honorable," I also would like the same assertion to be directed towards patients.  My approach in my practice is to believe my patients, until I can't/won't.  

Thanks for sharing your lived experience.  I hope you get the support you need. 

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Thanks so much for your thoughtful response - I did not expect a reply but was rather screaming into the wind.  I'm very glad to hear that you have opened your heart to exploring the newer research and reality of adhd in adults, especially older women.  Unfortunately, the field of psychiatric education is woefully inadequate and hopelessly out of touch and is too often destructive to vulnerable people who seek help.  We know ourselves and likely our disorder from the inside - especially if we have faced a lifetime of misdiagnoses and invalidation.  Please just never err away from adhd and/or autism in favor of deadly and stigmatizing conditions like bi-polar and schizophrenia if there is any doubt or your patient is self advocating against jumping to such a serious and invalidating conclusion.  The identity destruction and the medication harm caused by misdiagnoses is truly injurious and can cost people their lives- 

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Specializes in APRN.

The stimulant drive and everyone suddenly having ADHD now is one of the reasons, about 30% really, of why I no longer enjoy my career.  Also, therapists, who don't know anything about anything, are sending people to me "to get tested for ADHD."  I don't do "testing."  What the actual...?

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Specializes in Psychiatry.
twoshea749 said:

As a 51 year old woman who has again run into the battle axe of NP trauma and not being allowed my medication after 14 months of trying again - even with a diagnosis -  after 10 years of being turned away or misdiagnosed and prescribed bipolar or depression poisons - I hope you to be merciful and listen to my post I make in pure despair- maybe you will help someone else - Please research  adult inattentive combined adhd -folks like us are in situations where we are the caregivers  of infirm parents and two grown children with adhd- I promise you that if you err on the side of listening and not judging you may actually help and not harm someone who has done the time in the hell of misdiagnosis because of the research on adhd that they didn't give you in your 30 credit certification - slinging abilify and lamictal and lithium and hurting neurodivergent people is criminal.  Please - I know you make 160000 or more - but your main understanding of stimulants is from the drug war - don't cause suffering and hell to those that crawled their way to your door one last time to be heard - give us a chance - and be honorable and investigate your craft. All the best -at least you're asking the question.

Most of us NPs, maybe more than physicians, do listen to our clients and really try. Hence the OP even having the humility to post this asking for help because they do not want to misdiagnose someone or err on the side of caution when it is not warranted. Your post here came across somewhat incendiary, you attacked the education process, made a snide remark about income, and threw out baseless accusations. We are all very sorry for your previous experiences with some medical providers, but please do not use that as a weapon to come demonize an entire profession of people who truly want to help you. Wishing you the best and better care in the future. I truly hope you find someone who does listen to you moving forward.

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I'm a hard send someone to psychology for mental health evaluation regarding ADHD. A referral should never be " cost prohibiting" if they can see me in clinic to ask the question. If they have the diagnosis in the past, I have no problem verifying them on it and restarting meds. I have no doubt there are many adults who likely have ADD/HD who either never got tested or had parents who refused to chase that diagnosis. But in family health, that diagnosis is not my specialty. 

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Specializes in Psychiatric and Mental Health NP (PMHNP).

More people are seeking help for ADHD because awareness of this issue has increased.  It doesn't mean these people are drug-seekers.  ADHD has been underdiagnosed in adults until recently:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9884156/

 

1.  Your organization and state have prescribing guideliness for prescribing controlled substances.  Learn them and adhere to them.

2.  There is a lot of information out there on how to assess and diagnoses ADHD.  Follow those.  In addition, there is now an "objective" test:  QB Check.  The test itself costs around $70 and many providers add additional charges for their time.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301281/

https://www.CDC.gov/adhd/diagnosis/index.html

 

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Specializes in NICU, PICU, Transport, L&D, Hospice.
FullGlass said:

More people are seeking help for ADHD because awareness of this issue has increased.  It doesn't mean these people are drug-seekers.  ADHD has been underdiagnosed in adults until recently:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9884156/

 

1.  Your organization and state have prescribing guideliness for prescribing controlled substances.  Learn them and adhere to them.

2.  There is a lot of information out there on how to assess and diagnoses ADHD.  Follow those.  In addition, there is now an "objective" test:  QB Check.  The test itself costs around $70 and many providers add additional charges for their time.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301281/

https://www.CDC.gov/adhd/diagnosis/index.html

 

Thank you so much for this post.  So very many people in the USA struggle with this and other mental health issues with scant little affordable or convenient access to supportive care.  Then they are too often treated with suspicion. 

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