John M. Talmadge, M.D.

A Blog Covering Many Topics

Adderall Time in Texas

We are six weeks into the academic year, and the requests for Adderall ("mixed amphetamine salts") are on the rise. As someone with considerable expertise and experience with ADD/ADHD, I know that stimulants can be very helpful for people who actually have attention deficit disorder. I worry, though, that a high percentage of people taking Adderall or other stimulants are simply looking for a "smart drug" or an energy boost. I also worry about diversion of these drugs, because medications in this class have considerable street value.
Here at the office, where I answer my own phone (and do my best to return all calls myself) I receive 4-5 calls weekly from individuals looking for a doctor who will prescribe Adderall or its long-acting cousin, Vyvanse (Lisdexamfetamine). Curious as it seems, many callers say that they are new to Dallas and need a new doctor to prescribe the medication. I say this is curious for two reasons. First, let's say that a doctor outside of Texas has a patient who is moving to Texas. One thing that prescribing doctor should do is help his or her patient to refer the individual to a reliable doctor in the new city; and apparently, many doctors from other states don't do this. Second, people taking stimulants don't usually have serious withdrawal problems, but coming off stimulants like Adderall can pose problems, because the person's brain has to adjust rapidly to the absence of the drug. The person who depends on Adderall will probably feel lethargic and "flat" when they don't have the medication on board. Students often panic, fearing they won't be able to study or put in the long hours required for academic performance.

As with other potentially risky medications (like Xanax, hydrocodone, oxycodone, etc.), the prescribing physician assumes certain risks and responsibilities in writing the prescription. I worry about this. Many patients tell me that they have only seen the doctor 3-4 times a year, and some say that they don't even see a doctor, because a mid-level practitioner (usually a nurse practitioner) writes the prescriptions under the "supervision" of a medical doctor. The typical "med check" or brief visit to renew a prescription lasts less than 20 minutes. This is not necessarily bad or wrong, but we certainly have to wonder whether the responsible doctor really knows very much about the patient. The Texas Medical Association has noted that authorities are cracking down on "pill mill" physicians in pain management clinics, and it's very likely that doctors prescribing other Schedule II ("dangerous") drugs will face similar scrutiny.
My expert opinion is that medications are very helpful in the treatment of attention deficit disorder. My further opinion is that many people, particularly students and younger adults, are using these medications inappropriately. This is one reason that I answer my own phone. I hate it when someone shows up expecting me to write controlled substances without any discussion. Yes, these are good medications that really help many people. And no, I won't write a Schedule II medication unless there's compelling clinical evidence that justifies the prescription.

Update 10/17/15: I have been reading commentaries by Larry Diller, M.D., a developmental pediatrician who has written extensively about stimulants. He has strong and generally well-informed opinions about the use and misuse of medications like Adderall, Vyvanse, Ritalin, and Concerta. His website and his opinions can be found here.

The Adderall Phone Call Trend

At least twice a week, and more often during certain times of the year, I get calls from college students looking for a doctor who prescribes medication for attention deficit disorder. I also get a lot of calls asking for sedatives like Xanax and Klonopin. Although these medications can be very helpful, my experience is that most of these students are not really suffering from ADD, and I tell most of them (not all) that I am not in the business of managing Schedule II drugs. Schedule II is the class of medications most closely monitored by the Drug Enforcement Administration. Special numbered prescription forms are mandatory and required, and the doctor found guilty of bad prescribing may likely lose his license to practice.

The underground trade in stimulants is massive. People will pay $20 for a single pill on the street.

ADD medications like Adderall and Ritalin are stimulants, amphetamines or amphetamine-related compounds. They can be miraculously helpful when the doctor has the right diagnosis and prescribes them appropriately. I am a big believer in the value of such medications, because they work. I also know from experience that they can be terribly abused.

Here are some tips from the American Academy of Child and Adolescent Psychiatry:

Many students with Attention Deficit Hyperactivity Disorder (ADHD) attend college. College students with ADHD face a number of challenges, including choosing a supportive school and community where they can find and access medical services, get help with organizing their schedule and life, and succeed academically

Most people with ADHD are diagnosed before college. However, some people may not recognize the signs and symptoms of ADHD until they are at college. Trying to balance school work and the freedom of living away from home for the first time may be challenging. It can be natural to feel unfocused, distracted, overwhelmed, or disorganized when attending college. However, if these issues have caused significant problems in the past and are getting in the way of current functioning, the student may have ADHD.

If a student is struggling, it may be helpful to seek consultation with a qualified mental health professional. The diagnosis of ADHD is made based on a comprehensive clinical assessment. This may include information from multiple sources, including rating scales, getting history from the student, family, or past teachers if possible. There is no single test (brain imaging, blood testing, or psychological testing) that can reliably diagnose ADHD. Research shows that medication is the most effective treatment for ADHD. Cognitive-behavioral therapy, social skills training, and academic support can also be helpful.

There are many ways to successfully manage ADHD before and during college.

Preparing for and Staying Organized While at College

Consider the best college environment to meet your needs, such as class size, workload, academic calendar, and availability of support services. Resources to help you find the best college include: high school counselors, parents, friends who are in or have attended college, and national ADHD organizations or websites.

Learn about the medical services available at colleges before choosing where to go. Some college and university health centers do not prescribe ADHD medications. You may need to find a doctor in the surrounding community. Think about the transportation options and ease of access to that provider.

Talk with your doctor about how to best manage your medications when at college. Do not make changes in your medication without consulting your doctor. Ask your current doctor and the doctor at college to coordinate care. It is also helpful to have a history of your medications and your response to those medications for your new doctor.

If you have used tutors or support before college, think about continuing at college, at least for a little while.

If you need specific support or accommodations, register at the college disability office. If you have a summary of treatment or any psychological tests that were done within the last 3 years, bring them to the visit.

Practice using planners, calendars, or scheduling apps while still in high school. The demands on time management and organization increase greatly in college. Even if your parents helped you in the past, it is important to learn to do it yourself.

Managing Medications at College

Many medications prescribed for ADHD have to be monitored regularly. While at college, you need to schedule and keep your own medical appointments. Changes to your medication should only be made after talking with your doctor.

Learn how to use pharmacy services. Pay attention to prescription start dates and expiration dates. Many medications prescribed for ADHD are “controlled substances” so states may have additional rules on how these medicines can be provided, including limits on how often prescriptions can be refilled.

Taking medication that is not prescribed for you, sometimes called “diversion” or “academic doping,” is illegal and unsafe. Your medications were prescribed by your doctor who knows you and your medical history. They should only be taken by you. There are serious cardiac, neurological, and psychological risks of misusing ADHD medications. There can also be serious risks to mixing medications with alcohol or other drugs.

Keep medications safely stored or hidden to protect against theft. If medications are stolen, report it to campus or local police.
Adjusting to the academic, social, and organizational demands of college is difficult for most students. It can be especially difficult for students with ADHD. Arranging for support from medical and school professionals can help students with ADHD have a successful college experience, as well as a long career after graduation.