Prescribing stimulants?

[MoonChile, MSN, APRN]

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! 

[nursee78, BSN, RN, NP]

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. 

[nursee78, BSN, RN, NP]

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.