Schedule II Meds

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Specializes in psych/medical-surgical.

I have already had several patients come to me seeking specific types of medications (take a wild guess which ones) why STIMULANTS of course. I am a relative new grad and it makes me a bit uneasy RXing these for people that have demonstrated they have issues with substance use. I recently tapered someone off of 120 mg of Amphetamine D ... seriously WOW!? Some MD was giving them to this person and they ran out WEEKS EARLY. This guy was so numb he couldn't feel anything, and honestly, he seems better without them. 

I have another patient basically stating the only thing that will work is a stimulant. He also does OTC drugs like 1 PPD of cigarettes among other things ... seeing as this is going to be a common theme... What are the ethical/legal implications for this? Other than it being **** advanced nursing, as long as I do my due diligence, document in the record the patient agreed to use them properly, what is the risk for just handing them out bc the person asks? I imagine this is what started the opiate crisis.

TIA

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Specializes in Pediatrics, Women’s Health.

What kind of setting are you working in?

If you don't feel a medication is indicated and you don't feel comfortable prescribing it, don't! Think they're just going to get it elsewhere? Great, let someone else prescribe it! I would maybe talk this over with another provider in the practice and see how they handle it given your specific patient population. I say no all the time, but I'm also in a women's health office right now so I can always just say something along the lines of "I'm not comfortable prescribing that medication, make an appointment with your PCP to discuss". But obviously if you are the PCP that won't work ? 

 

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Specializes in psych/medical-surgical.

I'm a private outpt only practice as an independent entity. The problem is, these pts usually have had the medicine they are requesting from another provider. Seems that providers hand these out like candy for anyone that says they can't focus. I am pretty sure 1-2 of my "ADHD" are actually bipolar and not ADHD.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

This is probably easy for me to say since I'm still a new grad who hasn't started working in the real NP world yet. I think that if I didn't think a medication was appropriate I would just tell the patient that I don't agree with continuing that plan of care and we should discuss other options. One of those options would be that the patient find another provider if they don't agree with the plan of care. Now I'm not supporting myself based on my own advice, so maybe it's not worth much. I try to make sure that whatever I'm doing I could justify it if I ever get called into court. Good luck with your decision. 

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Not sure if your a PMHNP, but we see a lot of drug seeking for stimulants in practice for people that don't meet qualifications for ADHD. It's growing more common to refer all patients for psychological testing for adult ADHD, its just another hoop to go through and they get formal testing. You could always do that. You can always write for Strattera or Wellbutrin, nonstimulants that are FDA approved for ADHD instead. It's also DSM 5 criteria for ADHD to have symptoms prior to age 12. Hope this helps.

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Specializes in Informatics / Trauma / Hospice / Immunology.

If you are not specialized in psych, why are you prescribing psych meds? Especially sched 2? Are you actually a cocaine dealer? Be honest! 

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Specializes in Dialysis.
On 7/23/2021 at 12:33 PM, DrCOVID said:

The problem is, these pts usually have had the medicine they are requesting from another provider

Refer them back to that provider. You answer for yourself, the other prescriber will have to answer for their actions

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Specializes in Psych/Mental Health.

Prescribers can be investigated and have their licenses revoked or worse if they prescribe inappropriately outside usual standard of care. If a patient misuses, abuses, or diverts stimulants and for whatever reason the prescriptions are traced back to you, you better have a good defense.

Doing a thorough in-person assessment (or visual and audio until covid emergency ends) and rule out other causes is crucial, and some providers require neuropsych testing and collaterals. Requiring UDS (initial and ongoing random) is also key in order to ensure safety and possibly flag diversion. Ongoing UDS a must for those with substance use history, but generally I avoid controlled's with this population unless there're very solid evaluations backing up the diagnosis AND sustained remission from substance use. Anyone who tests positive for illicit drugs (current or recent) should not be prescribed any controlled substances even if they have a legit ADHD diagnosis.

Other measures for risk management include signed controlled substance agreement (not just you documenting that they agreed), thorough education/documentation on risks of dependence and addiction, no early refills or bridge scripts ever, prescription monitoring checks every appointment, utilize XR/ER formulation, avoid combinations of benzos and stimulants, weigh risks and benefits, and never prescribing outside of approved max doses.

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Specializes in psych/medical-surgical.
8 hours ago, umbdude said:

If a patient misuses, abuses, or diverts stimulants and for whatever reason the prescriptions are traced back to you, you better have a good defense.

Other measures for risk management include signed controlled substance agreement (not just you documenting that they agreed), thorough education/documentation on risks of dependence and addiction, no early refills or bridge scripts ever, prescription monitoring checks every appointment, utilize XR/ER formulation, avoid combinations of benzos and stimulants, weigh risks and benefits, and never prescribing outside of approved max doses.

Right, the main concern is misuse/abuse. I had my main problem child turn meds into the police 2 weeks ago since he was collecting them rapidly...

I always check the PMP before any stimulant RX. Always try to use the XR formulation for these yes. I would never early fill one of these for a person who has demonstrated poor use or issues with other OTC substances. 

I never thought of a UDS but thats a good idea. I haven't even been able to get regular people to have labs done though. I can't help but feel my hands are ultimately cuffed in some way.

On 7/28/2021 at 12:06 AM, _firefly said:

If you are not specialized in psych, why are you prescribing psych meds? Especially sched 2? Are you actually a cocaine dealer? Be honest! 

Busted, I am a crack dealer with 2 licenses and 6 background checks in the last year (school, different state licenses and DEA)!

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Specializes in psych/medical-surgical.
On 7/26/2021 at 10:27 AM, ThePMHNP said:

It's also DSM 5 criteria for ADHD to have symptoms prior to age 12.

I feel like a good % of people don't actually meet criteria for their DX history. 

All of the people that have come to me with "ADHD" have already had stimulants (mostly Adderall) many times.

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