Nothing Like Ativan In the Morning

I'm pretty depressed right now.  My life has been a bit like a bad country song lately: my cat died, my marriage is in trouble, I'm unemployed ... all I need is a midnight train out of town and the narrative would be complete.

Earlier in the week I was damn miserable.  I'm not suicidal or anything; I don't have "a plan", and I really don't want to die ... except that I felt like I wanted to die.  I didn't say this to my pdoc, but described my mood and motivation, and how they had suffered incredibly since the death of my dear kitty.

I figured that he'd up my abilify because it seems to be a very effective antidepressant for me.  Instead he recommended that I try taking .5 mgs of ativan during the day as needed.  At that dosage, he said, it shouldn't make me sleepy.

So yesterday I tried it.  Within half an hour I needed a nap -- pretty amazing, given that I'm also on 70 mgs of amphetamine for my ADHD.

So much for that idea.

More About Meds and Tooth Decay: Brush Several Times A Day

One of my most popular posts is the one about the dental problems that can result from taking meds for your brain.  As I said in that post, tooth problems aren't something that most pdocs even know about, let alone warn us about when we start taking crazy meds.  So you start a bunch of new meds for bipolar, depression, or ADHD, and suddenly your previously cavity-free mouth looks like that of a meth user.

I was at the dentist last week and learned something interesting, and a little counterintuitive, that I thought I should share with y'all: Drinking more water doesn't help your teeth.  I'd sort of assumed that it would.  I mean, if the problems are caused by your mouth being dry, wouldn't it make sense to make your mouth wet?

The problem with my hypothesis is that tooth decay, of course, is caused by bacteria.  Your mouth fights bacteria not with water, but with saliva.  Saliva has antibacterial properties.  Water does not.  Saliva also remineralizes your teeth, filling in any tiny pits that could develop into cavities later.  Water does not.  As my dentist said, "It just means you have to pee a lot".

My dentist recommends a lot of ways of dealing with this.  There's the high-flouride prescription toothpaste.  There are the mints and gum with xylitol in them, which stimulates saliva production.  Then there's plain old brushing.  By brushing your teeth several times a day, you get rid of that bacteria, and that prevents cavities.

What is it like to have ADD, Part II: The Radio Metaphor

A few months ago Mo at Milligrams requested a post about what it's like to have ADHD.  Since I was writing a blog post, I gave my long, detailed answer

This week I was asked the same question by a friend in my stained glass class.  When people in real life ask me about ADD, I don't give them the long answer.  They don't need to know what my typical day is like.  They don't need to know what it's like to have your mind wander all over creation.  They need to understand the experience of ADHD quickly and concisely.

Since I have trouble with "quick and concise" when I write, I've put the important bits in bold.  The bold face type is what I would say to someone in real life who asks about ADHD.  The rest is just elaboration and explanation, in case you're into that sort of thing.

When someone I know in real life asks what it's like to have ADD, I turn to my radio metaphor.  The radio metaphor looks something like this:

Having ADD is like driving through a rural area with your radio on.  Unfortunately, the radio in your car is stuck in the "on" position and the volume control died a long time ago.  Since you're out in the boonies, your radio is picking up two or three stations at once.   All you're getting is garble and horrible, earsplitting static.   You wish you could change stations, but you can't.  None of them come in clearly.   


I gave this explanation to my friend, who was very sympathetic.  "That sounds really hard," she said.  Another friend who had been listening, nodded and said, "I'm deaf in one ear, and it's a similar experience.   I can only process half of what people are saying, and I can't filter out what's important."

That was on Tuesday, and in the days since, I've been thinking about her hearing loss, and my grandmother's hearing loss, and how similar they are to the ADHD experience.  As with my mental "radio", they have trouble tuning into any one thing in their audible environments.  But I have ADD; I can treat my condition.  What does treatment do for the radio metaphor?

Taking medication for ADD allows your "radio" to tune to a single station.  Finally, you can enjoy some blessed quiet -- only one radio station at once!  But there's a catch (isn't there always?): you don't always have a choice about which station that is. 

For instance, you might open the fridge door, notice that it's pretty full, and decide that you'd have a lot more space if you put the leftovers in smaller containers.  So you do that.  You're on meds, so you can finish the task without getting distracted by something shiny.  Which is great, right?  Yay, a task has been accomplished!

Except that you opened the fridge door for an entirely different reason -- you need to make lunch and eat it before you have to meet someone in half an hour.  In other words, you needed your radio to be tuned to the "making lunch" station, but it jumped over to the "deal with leftovers" station instead.  And you don't know to change it back.  Fortunately, since you're on meds, after you finish the task you remember that you have somewhere to be, only now you have ten minutes instead of half an hour.  So how do you tune your radio?

Pills don't teach skills.  Getting control of your radio is a skill.   

In order to tune your radio to the station you want, you need to learn skills.  You need to learn a lot of them, but I'll use just one as an example: scaffolding.

"Scaffolding" refers to creating habits and routines that support your day to day existence.  For instance, my keys and my sunglasses are in the hat that I wear every day.  I know they will be there, so I don't have to spend half an hour looking for my keys every time I leave the house.  My wallet?  Always in the outer pocket of my bag.  My cell phone?  Either on the charger or in my left jacket pocket.

Neurotypicals can take paying attention for granted.  For ADDers, it takes a ton of energy.  By building the scaffolding I described above (and believe me, that's only a small part of it) I can free up a great deal of mental energy.  I can put that energy toward learning other ADD coping skills.  I can learn how to keep track of what tasks I need to accomplish, and I can learn how to tell which ones are the most important or time-sensitive.  Eventually, when something unexpected happens to disrupt my routine, I can figure out how to deal with it instead of allowing it to disrupt my whole day -- or my whole week.

In other words, I'm finally in charge of choosing the station on my radio.

Lamictal 300 mgs: Plus 2 mgs Abilify, minus 5 mgs Adderall

The short version: my mood has been all over the place for the last week and a half.  My pdoc had two options.  Number 1: Go back on 12.5 mgs of Zoloft, which would numb me out a bit, and shouldn't give me SSRI problems because they'd be tempered by the lamictal.  Or, number 2: go back on Abilify for the short term at a very low dose; I'd still feel my feelings, but I won't be reduced to tears over stupid shit.

In other words, the lamictal is helping a lot with the depression, but it's not stabilizing my mood as much as it needs to, and it needs help.

We decided to try Abilify first. We know from past experience that it will work immediately.  I also think it's important to feel my feelings; I just need not to be completely overwhelmed by them.  I feel pretty good about this.  I can start it tomorrow and stop crying like an emo kid.

We're also removing the Adderall from my cocktail.  After two weeks it's clear that while it does help my mood, it doesn't help enough.  It also wreaks havoc with my sleep.   Unless I can be sure to squeeze in some seriously vigorous exercise, and I can't always do that, and messed up sleep equals messed up mood.

A few words about my mood lately.  At some times I'm feeling really good, almost too good, and for no particular reason.  Then if I'm triggered (or sometimes when I'm not), I crash and crash hard.  I start sobbing and simply can't talk myself down, let alone stop, for several hours.  When I finally do, I last about ten minutes before I start sobbing again.

What do I mean when I say "stupid shit"?  Well, let me tell you about the day after Thanksgiving.  We like to cook our own small turkey, because we like to do things with the leftovers.  But, unbeknownst to us, the turkey was partially frozen.  It probably was up against the side of the refrigerator case or something.  Anyway, it took all afternoon to cook (way too long for a 12 lb turkey, so I was already crying about that).  Then we cut into it, half of it was raw.

The rational side of my brain, and my husband, told me that this wasn't my fault, and that we could just use the turkey for stock, so it wouldn't be a total loss.

The crazy part of my brain was in tears because I'd wasted all day and my husband was sick so he couldn't help me cook so we hadn't spent time together and he was leaving the country the next day AND I RUINED THE HOLIDAY!

Don't even ask what happened when he returned from his trip and didn't immediately give me a hug.

I can't be crying so much that it interferes with my life.  And with my husband probably also being depressed, I can't be triggering that feedback loop where does something without knowing it will upset me, and then I start crying, and then he feels bad for upsetting me ... and gets stressed ... and I feel bad for stressing him out, so I cry more ... and he withdraws from me emotionally ... so I get more upset ... and the cycle begins anew.

To wrap up: Abilify.

ADHD Medication and Federal Law: Why Is It Such A Hassle To Get My Medications?

A few weeks ago, Mo over at Milligrams asked me to write a post on ADHD.  I realized that responding to his comment on my post actually required a series of several more posts.

Today's post addresses is actually one in a sub-series, concerning the legal issues that pertain to ADD medication.   This post United States covers federal drug laws, which operate under the United States Federal Controlled Substances Act.  When you're having trouble finding treatment for your adult ADHD, it pretty much comes down to the Controlled Substances Act.  That's why I'm beginning my series with this topic, even though it's rather dry.


*** Today's post concerns federal law and how it affects the simple act of filling your prescription.  I will begin with a brief overview of the classification of ADD medications under the federal Controlled Substances Act.  I will define the term"Schedule II medication".  I will go on to describe what that classification means when it comes to filling prescriptions ADHD meds.

As always, this long and complicated post is broken up into sections which are named in bold.  I will recap the main points of my post at the end.


And because it makes me feel better to write it, even though I'm sure you know better, I want to make it clear that I am not a lawyer, and this post should in now way be construed as legal advice. ***

The United States Controlled Substances Act: Schedule II

By and large, medications for ADHD are psychostimulants, and they generally fall into one of two categories: amphetamines and methylphenidate.  Under the US Controlled Substances Act of 1970, these drugs were designated as Schedule II controlled substances.  Schedule II includes any medication that has a high potential for abuse and addiction.  To put this in some context, other meds in this category include cocaine and opium.  

(To put it in even more context, the only class of medications that is more restrictive is Schedule I.  Schedule I drugs have no recognized medicinal purpose in the US and can only be used for research.  An example of a Schedule I drug is heroin.)

Notice the bold font I used up there, in the section on Schedule II? I wanted to make the point that this is some serious sh*t. 

As you might imagine, Schedule II drugs are tightly regulated by the feds.  But that's not the only set of laws that regulates these meds.  The Controlled Substances Act permits states to enact whatever regulations they want to regarding a controlled substance -- as long as those state regulations are even more stringent than federal law. I'll get into that in a later post.

What Does the Schedule II Classification Mean for Filling Prescriptions of ADD Medications?

Obviously, any prescription medication needs a prescription from a practitioner order to be dispensed -- otherwise, it wouldn't be a prescription med.  Where Schedule II medications differ from other meds is how the scrip can be transmitted to the pharmacy, and how many refills are allowed.  Unlike other, less regulated medications, Schedule II drugs are subject to the following rules.  And these are just the rules that pertain to pharmacists:

• Schedule II drugs cannot be dispensed without a written prescription from a medical practitioner.  There are two exceptions to this:

• The prescribing doctor is the one giving you the meds, and is you're the end user.  In other words, your pdoc can give you free samples of Medication X  -- if you are the person who will be taking the medication -- to make sure the medication is effective, you can tolerate it, etc, before you pay for a whole month's prescription.  Basically this means that you have to be an adult patient.  Your child's pdoc can't give you free samples on behalf of your kid, because you're not the end user.  And you can't just go giving drug samples to kids.

• It is a medical emergency, in which case oral permission from a practitioner is sufficient.

• There can be no refills of a Schedule II medication.

In short: None of the conveniences available for other prescriptions are available in the case of a Schedule II.  You have to have a written scrip -- your doctor cannot phone it or fax it in.  And when it comes time to refill?  You have to bring in a whole, brand-new, written prescription.

(The section of the Controlled Substances Act that governs the dispensation of Schedule II drugs is

Title 21 > Chapter 13 > Subchapter I > Part C > Section 829.  It can be found at on the website at the Cornell University Law School.  Go on, click on it.  It's exciting!  Besides, all the cool kids are doing it.)

What Do Schedule II Dispensation Rules Mean For Patients With ADHD?
 
Reading the last paragraph, it might sound like federal law requires people with ADD to see their psychiatrists once a month just to keep taking their prescribed medication.  Sounds like a major inconvenience, doesn't it? Is this really the case? Well, that depends.

Prescribing Schedule II Drugs Under California State Law:

In California, the answer  -- from a legal perpective at least -- is NO.  Granted, some pdocs might prefer to check in with their patients on a monthly basis, sometimes for good reasons, and sometimes for bad ones (more on that later).  But as far as the law in concerned, psychiatrists can write multiple prescriptions for a Schedule II medication and post-date them.

This is what my pdoc does.  By this point he knows me and trusts me, so I see him once every three months for a med check/depression check, and he then he writes three scrips with an "OK to fill after [this date]" notation.  That being said, he saw me once a month at the beginning; partly this was to check in with the meds, and (though he didn't say this outright) to make sure I wasn't tweaking. 

Other doctors like to see their patients once a month regardless.  It's not their legal obligation; they just feel more comfortable checking in more often.  Or, in some cases, they might prefer to bill the insurance company a monthly fee, and make more money than they would by seeing the patient every three months.

Again, this is the case in California, and if you live in another state the situation might be completely different.  Even so, when it comes to prescribing Schedule II's, doctors can impose all kinds of restrictions on their patients.  But that's a topic for another post.

To recap for my ADHD readers who just skimmed this post (and if I hadn't written it, believe me that's what I would have done):

• ADD meds are placed in Schedule II under the Controlled Substances Act, along with drugs like opium and cocaine.
• Schedule II substances require a written prescription, with a few exceptions (such as emergencies)
• Schedule II substances cannot be refilled
• Some doctors require monthly visits from their ADHD patients in order to give them the written scrip
• In some states, this is the law; in others, it's the doctor's personal preference

The next post in this series discusses drug laws and the impact they have on prescribing doctors.  The third post is about what it's like to live under these laws.

Lamictal 300 mgs: Depression and Some Thanksgiving Gratitude

I complain a lot in this blog.  Its intended purpose was to be a mood diary, and while it is that, it's also become a place for me to vent about my life.  I write here to clarify my thoughts and feelings -- but also to bitch about -- my meds, my mental illness, my learning disabilities, and the impact they have on every single area of my life.

Today I've decided to do something else.  In honor of Thanksgiving weekend, I've decided to list the things I'm grateful for.  I've also decided to make this a weekly feature of my blog.  I whine a lot.  In fairness, the last year of my life has really sucked.  But there are also plenty of good things about my life that I should acknowledge more often. 

Besides, gratitude has been shown to protect against stress and depression, so it will even do me some good.  Ironically, given a post I wrote a few days ago, I'd like to express gratitude for my medications.  For all my issues with Big Pharma, for all my concerns about the long-term side effects they might have, the simple fact is that my meds dramatically improve the quality of my life. 

My Pharmacoepia

Just for fun the other day, I decided to compile a list of all the medications I take.  Here they are in all their scary, scary glory.

Morning cocktail:

• Lamictal, 300 mgs (mood stabilizer)
• Vyvanse, 70 mgs (long-release amphetamine to treat ADD)
• Claritin, 10 mgs (anti-histamine)
• Nasacort, 2 puffs each nostril (corticosteroid to keep my sinuses and ears from inflaming)
• Singulair (leukotriene inhibitor to prevent asthma symptoms

Midday:

• Adderall, 5 mgs  (used as an amphetamine "booster" to treat late-afternoon mood slump)

Bedtime: 

• Ativan, 1.25 mgs.  

Monthly:

• My good and dear friend, the Nuvaring (birth control)

As Needed:

• Q-var (corticosteroid for wheezy asthma -- I pretty much have this for emergencies)
  
• Abuterol (corticosteroid for acute asthma attack -- I need this even less often than the Q-var)
• Phenlyephrine (decongestant that is MY BEST FRIEND, because I can't tolerate Sudafed; for the longest time there were no other decongestant options out there, but phenylephrine was released because you can't cook meth from it.  Thanks, crystal meth epidemic!)
• Advil (If you don't know what this is, you live under a rock and probably don't have internet anyway)
• Booze (for fun.)

My poor liver.  My poor, poor liver.

 

Lamictal! Adderall! Ativan! The Musical!

In yesterdays post I wrote about feeling tied to my sunlamp for most of the day.  This is particularly bad during the late afternoon during my usual 4pm to 8 pm slump.  It's seriously cramping my style.

I saw my pdoc recently, and he was concerned about the slump.  He wants to try other things before raising the dose of lamictal.  It which seems fair enough. 300 mgs of lamictal is as high as they usually go to treat mood disorders; 400 mgs and upwards puts you into anti-convulsant territory.

So his suggestion is to take 5 mgs of Adderall XR in the afternoon.  Great.  Another drug.  I wasn't already feeling like my pee could be sold as a street drug that "will really make you trip, man!  This stuff is primo!"

Hmmm.  Maybe there's a profit to be had there ...

Yesterday was the first time I tried the Adderall booster.  It definitely helped my mood, but I slept like crap last night.  I was exhausted, and hope to sleep like a baby.  As I sometimes (OK, all too frequently) do these days, I had two drinks to make damn sure I would sleep well.

Testing for ADHD: Simple Psych Evaluation? Or Complete Pysch Battery?

This post is long, so out of kindness to readers with ADD, I've summarized it at the end with nice bold bullet points.  Also, I'm not a doctor and I'm not a psychologist, so you know this isn't medical advice, right?  

Good.

I'm glad to be in correspondence with Mo over at Milligrams Blog.  We've been through a lot of the same shit.  And lately he's been raising some very good questions about ADHD -- what it's like, how it's treated, and the latest question, how it's diagnosed.

He thinks that a lot of his symptoms could be explained by ADHD, and recently asked his doctor about getting an evaluation and medication for the condition.  In a comment to my earlier post, he said that his doctor, who's an addiction specialist among other things, wants him to get a full neuropsychological evaluation before putting him on potentially addictive meds for ADD.  The psych eval will take several hours.  His insurance company won't cover it.  And he's never heard of this one before.

I'd always read that ADD is diagnosed by a psychiatrist carefully interviewing the patient, their family members, and looking at records like old report cards in order to establish that the symptoms have been present since childhood.  Symptoms must also be present in all areas of a patient's life -- education, work, home, leisure, interpersonal relationships ... you name it.

I'd also read that neuropsych evals were considered problematic for diagnosing adult ADHD, and were not often done.  Certainly there are plenty of folks on ADD Forums who were diagnosed through psychiatrist interviews alone.

I was surprised to learn that (according to Wikipedia and WebMD anyway) neuropsych batteries are supposed to be part of the adult ADD diagnosis. 

Fun Facts About ADHD Medication

To start with, I'd like to explain why I keep alternating between the acronyms "ADD" and "ADHD".  This is because the DSM keeps changing them on us.  When I was diagnosed, it was ADD -- attention deficit disorder.  Shortly thereafter it was changed to ADHD -- attention deficit hyperactivity disorder.  There's some talk of changing it back to ADD in the next iteration of the DSM.  Since both acronyms are used, I'd like to make it easier for people to find my post, regardless of which acronym they're using.

A few weeks ago, Mo over at Millgrams Blog asked me to do a post on ADHD.  In his comment to the post, he raised several interesting issues.  So many issues, in fact, that responding to them requires a series of posts.  In this post I'm going to cover the general facts about ADD meds and how they work.  In following posts I'll talk about the legal issues surrounding ADHD meds.  The final post will deal with the social issues that come with medicating ADD.

Since this post is pretty long, I've put the topic sentences in bold.

By Request: What Adult ADHD Feels Like

Today's post is is by request, by Mo over at Milligrams blog.  I had left a comment on a post he had written called "Depression Without Sadness".  He described having a week off work, feeling like he should get off the couch and go do something, but lacking the motivation to do it -- even though his mood was pretty good.  I commented that this sounded a lot like me, before I was medicated for my ADHD.  Mo emailed me to ask me to write about ADD.  Could I write a post about my experiences with it?  What does it feel like to have it?  What meds do I take?  What's my experience on those meds?

Some of these questions are hard to answer.  It would be easier for me to describe how it "feels" to have ADHD if I had any idea how it felt not to have ADHD.  As for my experiences with ADD ... well, that would be my life story.  I decided to tackle this by considering my subjective experience of the world -- how I perceive it, internalize it, interact with it.

What I wrote is still pretty long, so I apologize if you have ADHD and find it overwhelming.  To help with that, I've broken it into sections, which are titled in bold face.  The sections describe my unmedicated brain on those rare "good" days, and then my unmedicated brain on "bad" days (which was most of them).  This is followed by an attempt to put the ADD experience into an analogy that a non-ADDer might understand.  Finally, there is a section about my experience with my ADD medication.

ADHD and Exercise: Should You Dial It Back If You Take Stimulants?

A question came up in an ADD Forum thread last week about exercising while on stimulants.  One of the forum members had been told by her pdoc that since she was on Adderall, it was important to keep her heart rate below 160.  If she didn't she might go into cardiac arrest!  On the one hand, she loves to exercise; on the other, she'd prefer to avoid cardiac arrest.  She wondered if any of the other forum members could speak from experience.

I can speak from experience.  Her doctor is talking up his ass.  His advice is based on research that was done in the early seventies on patients with heart disease.  It was never meant to be applied to the general population.

About a year ago, I too was concerned about my max heart rate.  When I ran on the treadmill, I would inevitably hover at 185, and could easily get up to 194 for several seconds at a time.  According to the helpful heart rate chart on the machine, my "maximum" heart rate is 184.  You're familiar with those Helpful Chart, right?  They're the ones that determine your maximum heart rate by subtracting your age from 220.  By subtracting still more numbers, you learn your "target" heart rates for anaerobic and aerobic exercise.

Image credit: Morgoth666, retrieved from wikipedia.org on 9/19/11

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.

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.