Sunday, January 30, 2011

Living with ADHD State/Federal Drug Laws

I've written two posts so far about drug laws and their implications for treating adult ADHD.  The first post dealt with the drug laws in general and how they can make it a royal pain in the ass to fill your prescription.  The second dealt with doctors and how their fear of running afoul of drug laws leads them to under-treat ADD (or not treat it at all).

Today I thought I'd vent write about my own experience living under these laws.
  • I've had a hell of a time finding a doctor to treat me.  As I've written before, a lot of psychiatrists and general practitioners don't treat adult ADD.
  • I've faced judgment from doctors.  In the course of calling dozens of shrinks a single one who's willing to treat my condition, I've found that those who don't often tell me this in rather smug tones.  And no, they can't refer me to any colleagues who do treat it.  So sorry!
  • After I was diagnosed in college, the shrink I had wasted a year making me take Wellbutrin, Amitryptaline, and Nortryptaline before referring me to someone who actually would prescribe me stimulants.  None of these meds worked at all.  Wellbutrin actually turned me into an evil bitch from hell.  But I was in a small, rural college town, without a car, and had no option to seek a different doctor.  I was in my junior year by this time, and my coursework had gotten really challenging.  As a result of my pdoc playing medications roulette, my grades suffered more than they already had been.
  • My first ADD doctor was a pediatric psychiatrist because she was the only person at the mental health center who would prescribe stimulants.  For some reason pediatric psychiatrists are much more willing to prescribe stimulant meds.  It's not uncommon for adults with ADHD to be treated by child psychiatrists or pediatricians, usually because their child has been diagnosed and a parental diagnosis is suspected.
  • My first ADD doctor prescribed Ritalin, which worked sometimes but was problematic in others.  The problem with seeing a child psychiatrist is that they use the methods that work on their other patients.  Ritalin only sort of worked, because, as my current doctor put it, "you're not six".
    • The problem was that Ritalin screwed with my ability to play music expressively -- for some reason, it removed that state of consciousness that allowed me to listen to myself --  and since that was part of my double major, I could only take it sometimes.
  • Since college, I've had a hell of a time finding a doctor to treat me.  As I've written before, a lot of psychiatrists and general practitioners don't treat adult ADD.  In the past, I've had to call dozens of shrinks in order to find a single one who treats my condition.
  • I've faced judgment from doctors.  In the course of calling dozens of shrinks, those who don't threat ADHD have often told me this in rather smug tones.  And no, they can't refer me to any colleagues who do treat it ... So sorry!
  • I have one of the few doctors in town who treats adult ADD.  I found my current doctor through a packet of psychiatrists recommended by my clinic, which is attached to a major research university with a renowned psychiatry program.  Out of about 50 pdocs on the form, one of them treats adult ADHD.  I was lucky he was taking new patients.  And thank the gods he's good at what he does.
  • Like many psychiatrists, my pdoc is in private practice and doesn't take insurance.   I get to pay out of pocket for his services.  Since I'm really lucky, my insurer reimburses me about a third of the cost of this, so by the time they get around to reimbursing me it's only $160 a session. 
  • Pharmacists sometimes treat me like a junky.  Let me start by saying that most pharmacists are decent people who are good at their jobs.  However, back in the day, I met a couple of them who were seriously judgy.  They called me to their little window, demanded to know what condition this med was treating, how long I've been on it, gave me suspicious looks when I said I had ADD, and lectured me in an accusatory way about how I was absolutely, positively, under no circumstances to take more than my prescribed dose.  And then gave me more suspicious looks. 
    • I've since learned that pharmacists are only supposed to ask in a general way about conditions that might contraindicate the med -- for instance, whether you have a history of heart problems or high blood pressure.  They're not supposed to ask why you're taking that particular med.
  • Pharmacies get to enact their own weird procedures regarding Schedule II drugs.  Since ADHD meds can be sold on the street for a nice profit, and since the state and federal government take a dim view of this, pharmacists are terrified of being implicated in "drug diversion" -- controlled substances that never make it to the patient, either because the pharmacist is crooked, or the patient is selling drugs.  It's not uncommon for pharmacists to make patients show ID when they fill a scrip for stimulants.  
    • One of my local Walgreens goes so far as to photocopy my drivers' license whenever I fill my scrip.  This can't be Walgreens' policy, because my usual pharmacy doesn't require this.
  • Drug diversion causes other problems too.  I was almost unable to have my prescription filled at what is now my regular pharmacy.   The first time I filled there, shortly after that location opened, I called to check that they had my meds in stock.  The pharmacists said, "Well, we do ... but we can't fill it unless you're already in our system.  A bunch of prescription pads have gone missing throughout the city and we have to be really careful."  
    • Fortunately I was in Walgreens' system.  Better yet, the pharmacist had transferred from my previous usual pharmacy.  I told her my name, and she said, and she said, "Oh yeah, I know you! You used to go to the one up on X Street!  You'll be fine." And I haven't even had to give them my drivers' license or a blood sample.
  • Because I have ADD and choose to treat it, I'm in a state database that can be accessed by any healthcare provider who wants to look up my name.  So much for medical privacy.  California has a state database that automatically tracks all activity pertaining to Schedule II medication.  It's called CURES, even though it stands for "California’s Controlled Substance Utilization Review and Evaluation System", and its run by the California Department of Justice Bureau of Narcotics Enforcement.  
    • My name is in that database.  Ever time my pdoc writes a prescription, it's logged in that database.  Every time I fill a prescription, it's logged in that database.  I didn't find out about this until I'd been taking my current meds for a couple of years.  I mentioned my Walgreens experience to my pdoc, and he offered to see if there were any "flags next to my name".  I said "what?".  He said "I thought you knew ... ". 
    • The state assures us that our privacy will be protected, that only qualified and fully vetted medical personnel can access it.  Oh yeah, them and law enforcement.  But nobody else!  It's quintuple-encrypted and protected by fifteen firewalls.  Of course, I totally trust them.  Who wouldn't?
    • There were no flags next to my name, BTW.
    • Notice how this database is run by the Bureau of Narcotics Enforcement?  Not, you know, the health department or someone who might actually be interested in treating stimulant addiction?

So there you have it.  I'm actually pretty damn lucky; most of what I've described is an inconvenience, a pain in the ass (with the exception of the database, which I consider to be a violation of privacy).  Now imagine that I'm in an HMO that gives you the doctor you get, and may or may not assign you to someone who treats adult ADHD with medications that actually work.  Imagine I can't afford my shrink, even with the PPO reimbursing me.  Or imagine that I'm uninsured.  Imagine that I live rurally and the nearest ADD doctor is three hours away.

On a different note entirely, imagine that I lose my meds.  Twenty amphetamine pills, unaccounted for.  This happened to a woman on the ADD Forums when she accidentally knocked three weeks of pills into the toilet.  She was worried that her doctor would think she was an addict.  In a case like this, some doctors won't even issue a new scrip; in others, they may stop prescribing stimulants all together.  And if they do, you can be sure that a flag would go up in that damn database.

Previous posts in this series are about ADHD and state and federal drug law, and the impact these laws have on prescribing doctors.

Sunday, January 23, 2011

Why Is It So Difficult to Find An ADD Doctor? More About Federal Drug Laws

This post is the second in a series about stimulant medications for adult ADHD.  In my first post, I talked about the challenges and inconveniences for ADHD patients who fill prescriptions for Schedule II stimulant medication.  But if you've ever sought treatment for ADD, you know that actually filling your scrip is only the last of many, many hoops you must jump through in order to treat your condition.  Thanks to Mo at Milligrams Blog for inspiring this series.

The first hoop? Finding a doctor who treats adult ADD with stimulant medication.

Yeah.  Many of us can't even find someone to treat our condition.  And if we can, a lot of doctors -- even psychiatrists -- refuse to prescribe stimulants, and instead rely on the very few (and often less effective) non-stimulant meds such as Strattera and Intuitiv.  Many others prescribe stimulants only grudingly.

What's up with that?

I hope to answer that question in this post.  I'll begin by talking about what the Federal Controlled Substances Act means for medical practitioners.  This includes not just doctors, but sometimes nurses, and always pharamcists.  I'll define and discuss terms like "prescription fraud", "doctor shopping", and "drug-seeking", and the impact these have on the prescripton of Schedule II meds.  I'll try to cover the basic laws concerning stimulant meds at the Federal level and at the State level (those in California; your state may be different).

Then I'll move on to the legal concerns of medical practitioners regarding Schedule II medications for ADHD.  Finally, I'll answer the question: are these legal concerns justified?

As always, the sections will be broken out in bold type for my ADD peeps, and I'll summarize with bullet points at the end.