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Private practice APRN's and stimulant medications

By James Benn posted 07-11-2015 09:33 AM

  
I am interested in knowing how private practice APRN's handle clients with stimulant medications.  Are these clients shared with supervising physicians, simply not taken on as clients, or referred when it is known or determined that stimulant medications are or will be indicated.

Please be as specific as possible in your response.

Thank you,

J Benn, PMHNP
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08-29-2015 04:41 PM

I practice with full prescriptive authority. I screen rigorously for ADHD, Anxiety, and other underlying issues upon admission and periodically as expected by our standards of practice. Many ADHD patients appear to have symptoms similar to anxiety and unless it is straight ADD/ADHD I will treat on hierarchy of symptoms. We have had a prescriber abuse their prescriptive authority with DEA scrutinizing prescribing (which I am happy about), so I am VERY firm about stimulant medications. If they are lost, stolen, misplaced ect... the patient or child/adolescent is out of luck. Patients may suffer from symptoms of their ADHD but it is not life threatening. I rarely will give Amphetamine salts related to the high street value. Most patients who come to me know my reputation and respect me for it. I hope this helps.

07-20-2015 12:20 PM

I have a private practice and see adults only. My attitude about prescribing stimulants is the same as that for other medications. l am comfortable making the diagnosis, as I've been trained to do, and treat symptoms just as I would in other circumstances. The adults I see often present with fairly clear histories that are further confirmed with screening tools. If the diagnosis seems unclear, I will wait to see what develops. I'm in no hurry to treat, since we're not usually talking about a life-threatening emergency.
There is no supervising physician involved in my state. I don't refer these patients to other clinicians unless the patient and I disagree, in which case, the patient may want a different opinion. My education, training, and credentials qualify me to diagnose and treat ADHD and I see no reason for viewing others as better qualified to determine that diagnosis.
Having said all of that, I should add that I specialize in treating patients with anxiety disorders. Some come with concurrent problems that need treatment as well. Since I don't do med-management-only appointments, all of my patients are in thererapy with me. This affords me a knowledge of my patients that some practices may not. We work very closely together and, for the most part, I trust that we are on the same page. My patients are not generally the kind of people who are looking for a quick fix or a drug scam. Having worked as a staff nurse in corrections for 14 years, I feel fairly confident of my ability to read this. Could I be scammed or manipulated? Of course. But I do everything in my power to minimize that possibility and do not expect absolute perfection in my practice. Treating patients is a dynamic thing and I am not always right.
But I'm okay with my batting average and think most of my patients would agree.
There appears to be a backlash trend in our field to fear the use of stimulants and benzodiazepines, as well. My feeling is that both of these classes are extremely useful in treating very specific circumstances when used in a judicious manner and monitored closely. I am not a fan of marginalizing patients whose treatment is enhanced by these drugs and believe they should not have to scour the earth looking for someone to treat their very real comditions. Be careful, but do the work you are trained to do and, with the patient's well-being in mind, the chances of a good outcome will be improved.

07-16-2015 06:44 PM

I have a fee for service private practice where ~3/4 of my patients are adults, the rest adolescents. I have conferred with my collaborative physician when a patient isn't responding as robustly as they should to "typical" dosing and I want to push the dose, eg. I have a patient who is on 150 mg of Vyvanse (yep, that's really high. And yep, his symptoms were that bad...and yes there were several doctors, the patient, the patient's wife and the patient's couples therapist in on the decision making) but the vast majority of my patients do well at usual and customary doses, thus I rarely involve my collaborative doc.
Regardless of a previous dx. of ADHD, I do a comprehensive psychiatric evaluation in which I'm looking for evidence of a h/o and current evidence consistent with ADHD, evidence of h/o and current mood, anxiety or thought disorder. I include screening for all of the DSM ADHD criteria, but I don't just stick to this, because it's too easy for a bright person who wants a stimulant to simply spit out the signs and symptoms of ADHD. This is especially true of college students who don't really have the disorder, but think a stimulant will give them an academic edge. I always get a ROI and get previous treatment records. Most of my patients are referred by area therapists, so I get a ROI and talk to the therapist for corroborative information. When possible, I get corroborative information from a family member or spouse.
I rarely get someone who has had psych testing because it's simply too expensive and/or not available in a timely manner. There have been times when I think other learning disabilities are at play however, and if this is for an adolescent going off to college, I recommend the parent do whatever they can to obtain testing.
Even if I think the person meets criteria for ADHD, if they also meet criteria for an anxiety or mood disorder (as opposed to the ADHD driving anxiety/frustration/depression), I will treat those disorders first. Although I usually end up treating the ADHD eventually, I have seen cases where once the mood and anxiety disorders are treated, their concentration, procrastination, etc. are reduced enough that they no longer need/are interested in trying a stimulant. Moreover, if I'm too quick to put an anxious person on a stimulant...there's a good chance their anxiety will get worse.
I spend as much time working with them on coping skills as on medications. I work closely with the person's therapist. I emphasize that there is no magic pill. These things are obviously important for the patient's treatment, but it also takes away the notion that I am "that person who will prescribe stimulants." To that end, I don't like other providers to think of me that way, and I stopped subscribing to CHADD when I realized people were seeking me out to prescribe a stimulant.
Especially if a teenager or young adult--I discuss the fact that their stimulant is a highly controlled substance. That it is dangerous and illegal to share their medication with anyone else. etc. Although I will replace a lost prescription for a patient who is well known to me who does not have a pattern of "losing" their prescription (and even with those folks--I will do it once...if more than once...sorry....) I make it clear to all of my new patients, I will not fill early.
Finally--I rarely prescribe immediate release stimulants as a stand alone treatment. The vast majority of my patients with ADHD are on either Concerta or Vyvanse. I have a few who do not have insurance who are on IR mixed amphetamine salts (Adderall), but it's not ideal --coverage isn't as good, people feel them "kick in" and sometimes feel as though they are "going over a cliff" mood and energy wise when they wear off abruptly and they are cumbersome (we're asking someone with ADHD to remember to take a medication b.i.d to t.i.d...really?!...).
You asked us to be specific...

07-15-2015 05:44 AM

I prescribe stimulants,often after neuropsych testing confirms the diagnosis but not always, as cost may be prohibitive for some clients. I look at the family history. I treat this disorder with care but also in a similar manner to other disorders. I do tox screening randomly to make sure they are taking it and not taking other substances of concern. They are not allowed to ask for early refills and I see them every 8 weeks. I go on our state website to make sure other prescribers are not involved. I see this as similar to treating pain, which I do not do, but people have pain and need opiates at times. Sometimes bupropion and Strattera don't work and stimulants do.

07-13-2015 04:25 PM

If I myself cannot determine an ADD/ADHD diagnosis, for example, I send the patient for psychological testing for the diagnosis. If a patient comes in already on stimulant, I ask who diagnosed them, when, and ask for the provider's contact information. I then speak with the provider telling that them I want documentation of the diagnosis for the patient's record in my office. The provider is usually happy to fill my request.
I hope this helps
Maria Naples RN,CS; APRN-BC