Nu 670 Unit 8 Journal
You have a patient who is a new referral to you from the court system for substance abuse issues. This patient is a 32-year-old man who has a history of heroin abuse and bipolar II disorder. He began using heroin at age 19 and has been clean for the past 6 months.
He tells you that he was diagnosed with attention deficit hyperactivity disorder (ADHD) at age 11 and was prescribed Adderall. His drug use began at age 13 with smoking marijuana with friends and escalated from there. He was diagnosed with bipolar II disorder in his 20s but has never been hospitalized. His current medications include Suboxone 8 mg, risperidone 1 mg BID, Lamictal 200 mg daily, and Klonopin 1 mg TID PRN anxiety.
He meets with you and tells you he is committed to his sobriety and reports he is having a hard time at work. His attention and focus are poor, and he is at risk of losing, “the only job I could get after getting out of jail. I need this job because my fiancée has cancer and I have to support her three kids.” He tells you he was a patient at your clinic 10 years ago and was treated with Adderall by the psychiatrist at the time (during a period of sobriety). Once he relapsed, he stopped coming to the clinic and spiraled from there.
He tells you he was on Adderall IR 30 mg TID. He works 12-hour shifts and “needs to get through his shift” so he can provide for his family. He tells you he is not currently taking his Suboxone but does have it in case he has a craving for heroin.
Use the information above to address the following:
- Given his substance abuse history, would you prescribe this patient Adderall IR?
- Give an alternative treatment option. Why would this be a better option?
- What dose would you use?
- What steps can be taken to show adherence and prevent diversion?
Given his substance abuse history, would you prescribe this patient Adderall IR?
No, I would not prescribe Adderall IR 30 mg TID for this patient. There are several compelling clinical reasons for this decision. First, Adderall carries a boxed warning and is contraindicated in patients with a history of drug abuse. Second, the patient is not currently taking his Suboxone, indicating that his recovery is not yet stable. Guidelines from NICE and the Royal College of Psychiatrists advise that ADHD should only be treated with stimulant medication once substance use has stabilized. Third, the patient is requesting a high-dose, immediate-release formulation (Adderall IR 30 mg TID), which has a higher potential for abuse and diversion compared to long-acting or prodrug formulations. Fourth, he is already prescribed Klonopin 1 mg TID PRN, and adding a high-dose stimulant could increase the risk of adverse cardiovascular effects and anxiety.
Give an alternative treatment option. Why would this be a better option?
A safer alternative would be atomoxetine (Strattera) , a non-stimulant, selective norepinephrine reuptake inhibitor approved for ADHD. This would be a better option for several reasons. Atomoxetine has no abuse potential, eliminating the risk of diversion or misuse. Clinical practice guidelines recommend atomoxetine for patients with ADHD and comorbid substance use disorder, and both atomoxetine and psychostimulants appear to be safe in patients with any SUD. NICE and RCPsych specifically recommend non-stimulant options such as atomoxetine in early recovery. Additionally, atomoxetine has shown benefit in reducing ADHD symptoms in patients with alcohol and cannabis use disorders. A non-stimulant approach also avoids the potential for stimulant-induced anxiety or exacerbation of his bipolar II disorder.
What dose would you use?
For atomoxetine, the recommended starting dose for adults is 40 mg daily. After a minimum of 3 days, the dose may be increased to 80 mg daily, administered either as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon. After 2 to 4 weeks, the dose may be increased to a maximum of 100 mg daily if clinically indicated and tolerated. Given this patient’s complex psychiatric history (bipolar II disorder, anxiety), I would start at 40 mg daily and titrate slowly, monitoring closely for mood instability, agitation, or worsening anxiety. I would also consider the potential for drug interactions with his current medications (risperidone, Lamictal, Klonopin). It would be prudent to start at the lower end of the dosing range and increase gradually based on response and tolerability.
What steps can be taken to show adherence and prevent diversion?
To ensure adherence and prevent diversion, I would implement a comprehensive monitoring plan. First, I would establish a controlled substance agreement that clearly outlines the expectations for medication use, including the prohibition of sharing or selling medication, and the requirement for random urine drug screens to confirm adherence and detect illicit substances. Second, I would prescribe the medication in weekly or biweekly supplies rather than 30-day supplies to reduce the quantity available for diversion and allow for more frequent monitoring. Third, I would coordinate care with his addiction treatment provider and require attendance at counseling or support groups as a condition of continued prescribing. Fourth, I would educate the patient about the risks of diversion and provide strategies for refusing requests to share medication. Fifth, I would require that he resume taking his Suboxone as prescribed, as this is essential for maintaining sobriety and reducing the risk of relapse. Finally, I would schedule frequent follow-up visits (every 2-4 weeks initially) to assess response, monitor for adverse effects, and reinforce adherence.
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