Salty About Stimulants…signed: a prescriber

My practice has strict prescribing practices around stimulants and benzodiazepines. People seem to get the most irritated by these practices with stimulants though. Over the years multiple therapists have voiced their displeasure at us for not prescribing a stimulant to some one suffering with ADHD because: they smoke cannabis, their urine screen popped positive for a substance, they don’t have anxiety it’s all driven by ADHD, etc.

Mental health prescribing is by far one of the most Monday morning quarterbacked fields of practice. Every one knows better including but not limited to Google, WebMD, ‘My Aunt/Mom/Sister/boyfriend’s sister who is a nurse’, ‘my therapist who is not licensed to prescribe medications and has no training in prescribing’, their primary care doctor, their neurologist, and any one else who wants to hop on board the “we know better than people with actual psychiatry training” train. Not that I’m bitter. Imagine me saying all of this in a very singsong smiley voice.

I did not have such strict policies when I started practicing. I’d be more open to prescribing stimulants to some one who used cannabis or would not grab a urine toxicology screen on everyone. But then shit hit the fan.

To assume you know better than some one who has been working in this field and trained in this field when you are not working or trained in this field is…annoying at the very least and dangerous at the most.

In the past 12 months alone the practice has had four urine toxicology screens pop positive for substances that were not disclosed to the prescriber in the appointment. Two of the positives revealed a significant substance use disorder that could have otherwise been missed and that the primary psychotherapist knew nothing about.

Addiction does not discriminate- and these positive urine screens were gateways to a dialogue for potentially life saving treatment for people. God forbid the other 98 people have to pee in a cup because it’s so judgmental and punitive….I’ll send 1,000 people for a urine screen because even if just one pops positive that’s one person who has been potentially struggling with addiction in the dark, alone, and is at risk of overdose and death. I can’t as a prescriber in good conscious just say, “Well I see that hurts your feelings when I ask you to pee in a cup and test it for substances before I prescribe a controlled substance you, so you’re good.” It’s not punitive. It’s just that people have lied about substance abuse and addiction. And I’m not saying that in a derogatory way- part of addiction is living with it in isolation which contributes to shame and guilt- people don’t disclose because they are ashamed. It’s part of the cycle of addiction.

Every time I prescribe a stimulant I receive a letter from the insurer- especially Anthem and Aetna- they send letters that they noticed I prescribed a stimulant to one of their members- and they name the member- then they have about two pages of why prescribing a controlled substance is dangerous and they hope I’m prescribing it responsibly and I should really consider getting the patient off the stimulant as quickly as possible. Not making this up.

Then I get an email from the state of CT who tells me they noticed I prescribed another controlled substance- and it’s in a report of all the controlled substances I’ve prescribed in the last month. It’s one of those “We see you and we are watching” e-mails. I attest to my liability company that I prescribe controlled substances. I have to sign off on federal guidelines to have a DEA. AKA it’s a big freaking deal every time I write a prescription for a controlled substance.

In case you missed it, people are dying at record numbers from drug overdoses. Guess what? Most overdoses are not just one substance- they are often multiple substances- including stimulants because people snort them after drinking alcohol to perk themselves back up, or after heroin or opiate use. Then they may want another buzz or high so they drink more or take more opiates or heroin…you can see where I’m going right? You need more and more upper to overcome the downer, and more and more downer to overcome the upper. Then you die.

So no. I do not prescribe stimulants to patients concurrently using cannabis. Cannabis=downer stimulant=upper. Also- long term cannabis use (daily for over a year) causes cognitive clouding and blunting in the form of short term memory impairment, slowed cognition and slowed reaction times, in ability to focus and difficulty concentrating….guess what all those are also symptoms of? You’re right! ADHD.

So how do I know some one truly has ADHD when they’ve been smoking weed daily for five years and did not have ADHD prior to weed use? I don’t. The answer is I don’t. And I won’t until they get off the weed for at least three months.

Next let’s talk about the world in the last few years. It’s gone to hell. The effects of chronic stress are well documented in children who grow up in abusive households, in adolescents who live in homophobic households, and in war veterans who are exposed to chronic combat stress. Guess what the symptoms are? Cognitive clouding, poor focus, poor concentration, short term memory impairment, poor organizational skills, and anxiety that can present as impulsivity….sound familiar? Yes. All symptoms of ADHD. Executive dysfunction is a symptom of chronic stress. You can’t have existed in the world since March 2020 without being under some form of chronic stress which results in executive dysfunction. So no, you did not suddenly develop ADHD at age 40. It started two years ago because that’s when the world went to hell.

People generally do not like to hear that though. They want a pill and a quick fix and a treatable diagnosis.

In the past two years I’ve had countless patients tell me they have ADHD. I disagree with the diagnosis sometimes. I decline to prescribe stimulants other times even if I agree with the diagnosis due to substance use. And then there are a couple people in the past year who came to me for “anxiety”. And within about two minutes of our intake I was thinking ‘how the hell do they exist in the world with this severe of an ADHD?’

Careful history taking, chronic struggles academically, chronic struggles socially, chronic struggles occupationally, has had people in their life tell them they have ADHD, and not nicely. They also talk non-linearly. It’s hard to describe but there’s definitely a feel to them. They often wander off from the answer they are trying to give to a question then ask “What was the question?” somewhat embarrassed. There is more to it than that, but suffice to say it’s quite overt after you’ve seen it a few times. Which I have. Because this is what I do every day all day for ten years.

These are my favorite people though. They legitimately have ADHD. They have been misdiagnosed or not diagnosed at all because they are usually female- and females are super under diagnosed for a variety of reasons- including but not limited to: it’s inattentive type, not hyperactive, and they are able to compensate in other ways that allow them to still be mild to moderately successful.

These people when I mention ADHD and do some psychoeducation around it, and say maybe the anxiety is driven by an ADHD and they have a learning disorder…they break down and cry. Because they usually have always suspected it, and they check all the boxes, and there is effective treatment. These people, when they come back after the urine screen and trial of a stimulant cry again because they are grieving that they have lived so long without a proper diagnosis and in relief at being able to function just generally better.

Do I prescribe stimulants? YES. Do I do so carefully in order to protect the patient and myself from liability? YES. Do I see how incredibly life changing these medications can be? Absolutely.

I do actually know how to assess and diagnose ADHD. I also know how to safely prescribe psycho-stimulants. And I’m not going to waver because it may cause some one to feel upset that I prescribe this way. Safely. It’s unfortunate that offends some people. But it is what it is.

So to any one out there diagnosing yourself off TikTok. Please stop.

Couple things- you can’t have sudden onset ADHD, chronic stress causes the same symptoms of ADHD, PTSD can present as ADHD, chronic anxiety also can present as ADHD. I’m not saying don’t get a second opinion if you disagree with the person you do an intake with. Get as many opinions as possible for you to feel confident in the diagnosis and treatment. But also don’t assume you know more than a provider with education and clinical training and experience.

And for any one truly suffering with ADHD if you suspect you have it, seek treatment! There is treatment. And it can work. Just don’t get salty if you’re asked to do a toxicology screen in order to receive a prescription for a controlled substance. These medications are serious and heavily regulated. Have some respect for that. I sure as hell do.