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.

Schedule II Drugs and Medical Practitioners: Federal Law

In order to prescribe Schedule II medications, practitioners are required to register with the US Drug Enforcement Agency.  To be qualified to register with the DEA, the practitioner needs to fulfill all of the requirements necessary to practice medicine in the state in which they do business -- in other words, they need a medical license or nursing license.  They must also be authorized by their state to handle controlled substances.

If a practitioner meet both these requirements, they may now register with the DEA and receive a DEA number.  They must renew their registration every three years.  Their DEA number and registration are revoked if they run afoul of their states medical licensing laws.  This brings us to the various state laws regarding Schedule II drugs -- and here's where doctors get twitchy.

Schedule II Drugs and Medical Practitioners: State Laws

Schedule II drugs are regulated under the US Controlled Substances Act. As you learned in my previous post, which I'm sure you read very carefully because it was such a nail-biter, the Act was enacted at a federal level, but allows states to make their own laws regarding controlled substances such as Schedule II drugs -- as long as those laws are more restrictive than the federal laws.

In this section, I'll be sticking to California state laws.  California is the most populous state in the nation, so these laws affect a disproportionate number of people.  Its laws are also some of the most restrictive, so if you live in another state your life might be a little easier.

What Do These Laws Mean For Prescribing Physicians?


Basically, these laws put the fear of the gods into most doctors when it comes to Schedule II medications.  Unfortunately, in many cases these fears aren't justified.  California, for instance, takes "prescription fraud" pretty seriously; this is when a physician prescribes medication either outside their regular practice, or prescribes addictive medication to an addict.  Physicians can lose their license for this, and sometimes even face jail time.

However, as long as the physician is acting in good faith, they're not committing prescription fraud.  In other words, if a doctor doesn't know that the person they've written a prescription for is an addict, they're "acting in good faith" and have a valid defense for their actions.

In spire of that, doctors fear the legal consequences of prescribing Schedule II drugs to the wrong person. These doctors are vigilant about drug seeking and doctor shopping.  Drug seeking is basically when a person fakes symptoms to get a prescription.  Doctor shopping is when a person goes from doctor to doctor until they find one who will give them the medication they want.

To summarize, doctors are afraid of running afoul of various state and federal drug laws.  They're afraid of unwittingly committing prescription fraud, they're afraid that they'll get in trouble for prescribing to an addict, or worse yet, to a drug dealer who will sell their prescription on the street.  Whether their fears are reasonable or not, they're terrified of the potential legal consequences of prescribing Schedule II medications.

Are doctors fears justified?  Well, in 2006, the Bureau of Narcotics Enforcement took action against nine doctors for overprescribing.  That's nine out of 96,000 doctors practicing in the state of California.  That's 0.0009%.  As for fraud, in the five years leading up to 2006, the Bureau of Narcotics Enforcement investigated two whole doctors in the previous five years for prescription fraud.  Scary stuff, right?

What do these laws mean for treating adult ADHD?

It means that we don't get treated.  Or, if we do, it's only with great difficulty.

Basically, doctors are so afraid of getting into legal trouble with Schedule II's that many won't deal with them at all.  In California, nearly 40% of doctors don't have a DEA number.  27% of doctors won't work with schedule II's because of fear of addiction, and 27% of them won't write scprescriptions for Schedule II's because they fear leal or regulatory consequences.  Less than 30% will even write a prescription for a Schedule II medication.  At all.  Under any circumstances.*

But that's not all. Remember what I said about doctor shopping in the previous paragraph?  Those of us with ADD often have no choice but to "doctor shop" simply to find someone to treat our condition.  If word gets around that we've seen a lot of doctors, it's even harder for us to receive the treatment we need.

*My data for this section is from 2003, because I couldn't find anything more recent.  Given my personal experiences, though, I suspect that not much has changed since that time.

In Summary: The Fear of Legal Repercussions Dramatically Restricts Access to ADD Care 

Let's summarize, shall we?

  • In order to prescribe a Schedule II medication, such as any of the stimulants used to treat ADHD, doctors must register with the Drug Enforcement Agency
  • Physicians are subject to federal drug laws as well as the drug laws of the state in which they practice
  • State laws may by more restrictive than federal laws.  
  • Only 60 % of doctors in California have a DEA number.
  • Only 30 % of doctors in California will prescribe a Schedule II medication.

There you have it folks.  The reason why it's so damned hard to find a doctor to threat adult ADD is because only 30% of them will do so.  When you add in the fact that these docs will scrutinize you for potential "addictive behavior", and that they will deny a prescription to a patient who they think is "doctor shopping", it's obvious that getting medication for ADHD becomes even more complicated.  Then consider the fact that so many of us have no choice but to doctor shop, because we're looking for that elusive 30%.

Yeah.  It's pretty ridiculous.

To see my first post, regarding the complications of filling ADD prescriptions, click here.  In my next post, I will be writing about how the fear of legal repercussions has impacted my own experience with ADHD.

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