Applying the New Multiple Prescription Rule to Practice
by Richard L. Rubin, MD

Beginning December 19, 2007, the US Department of Justice Drug Enforcement Administration allows doctors to prescribe 90 days of Schedule II controlled medicines at one time. This covers both forms of stimulants used for ADHD: the methylphenidate medicines such as Concerta, Daytrana, Focalin, Metadate, and Ritalin, and the amphetamine medicines such as Adderall, Dexedrine, and Vyvanse. During the past year's public comment period, much of the controversy over this rule change involved abusable pain medicines, while the consensus viewed better availability of stimulants to ADHD patients as a significant benefit. In addition to relief from the logistics of obtaining a new written prescription each month, this 90 day time period between office visits is more consistent with current medical care guidelines for stable patients. It also allows doctors flexibility to prescribe medicine amounts matching coverage by payment programs.

However, the new procedure is quite specific, as detailed in 17 pages of description on the DEA website.

• Multiple prescriptions are allowed to total 90 days, but they all must be dated the day written and include a statement "Do not fill before (date)". Post dating the script or writing refills on one script is not allowed.
• The duration of medicine provided must still conform to good medical care. The practitioner should consider needs such as more frequent visits for initial medicine titration or monitoring of less stable patients. "Nothing in this section of rules shall be construed as mandating or encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing Schedule II substances. Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so."
• The practitioner should "properly determine there is a legitimate medical purpose for the controlled substance prescription." With ADHD, this means after an appropriate diagnostic evaluation. The practice of trying a stimulant as a diagnostic test is wrong, both clinically and legally.
• Screening for drug misuse is required. "The individual practitioner should conclude that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse."
• These Federal rules do not preempt State laws. The prescriber needs to follow more restrictive state regulations, such as an individual prescription expiring 10 days after written. If this rule change is not accepted by a doctor's state, the multiple prescriptions will not be allowed by local pharmacists. While considered in the public commentary, the DEA rejected possibility of less restrictive rescheduling or refill allowances for these Schedule II ADHD medicines.

Next month's teleconference features psychologist, Thomas Phelan, Ph.D. who will be speaking about 1-2-3 Magic! to help manage children's behavior at home and in school.

Join this free teleconference on Wednesday, February 13, 2008 from 8:30 - 9:30 pm Call: (646) 519-5883 Pin: 2648 at 8:30 pm EST to join the teleconference.

The following ADHD research abstracts were provided by Dr. Sam Goldstein, editor of the Journal of Attention Disorders

Pliszka, S.R., Glahn, D.C., Semrud-Clikeman, M., Franklin, C., Perez, R., & Xiong, J. (2006). Neuroimaging of inhibitory control areas in children with ADHD who were treatment naive or in long-term treatment. American Journal of Psychiatry, 163, 1052-1060.

Fifteen healthy comparison subjects and 17 children with ADHD Combined Type completed fMRI studies while performing a stop signal task. Eight subjects with ADHD were treatment naive. The remainder had a history of long-term treatment with stimulants but they were medication free at the time of the fMRI. No individual had a learning disability or comorbid psychiatric condition other than oppositional defiance. Both the ADHD and comparison subjects activated the right dorsal lateral pre-frontal cortex on stop trials relative to go trials. This increase was greater in subjects with ADHD. When inhibition was unsuccessful relative to successful inhibition, healthy comparison subjects strongly activated the anterior cingulate cortex and the left ventral lateral prefrontal cortex. In contrast, subjects with ADHD did not show these differences. Activations in treatment-naive and ADHD subjects treated in the long-term did not differ significantly in any brain regions. The authors concluded that in relation to comparison subjects, those with ADHD failed to activate the anterior cingulate cortex and left ventral lateral pre-frontal cortex after unsuccessful inhibition. Of importance is the finding that these differences appear in treatment naive individuals and are unlikely to be an artifact of long-term treatment with stimulants or the abrupt termination of stimulants before imaging.

Pliszka, S.R., Matthews, T.L., Brasow, K.J., & Watson, M.A. (2006). Comparative effects of methylphenidate and mixed salts amphetamine on height and weight in children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 520-526.

These authors sought to determine whether methylphenidate and mixed salts of amphetamine had different effects on growth in children with ADHD in patients treated for a year with either substance. A linear aggression was performed to determine the effect of stimulant type, patient gender, cumulative stimulant dose and length of time in treatment on change in Z score for height. A subset of patients was identified who had three years of consistent treatment with either preparation as well. The linear regression showed no effect of stimulant type, drug holidays or length of time of treatment on changes in height Z score. For patients treated for three years, there were no effects of stimulant or time on height Z scores. Mixed salts of amphetamine produced more decrease in weight and body mass index Z scores than methylphenidate. All subjects were heavier than average at baseline. The authors concluded that these substances did not differ in their effects on height. Mixed salts of amphetamine had more of an effect on weight with than methylphenidate although the effect was modest in magnitude and suggested to be of limited clinical significance.

Pressman, L.J., Loo, S.K., Carpenter, E.M., et al. (2006). Relationship of family environment in parental psychiatric diagnosis to impairment in ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 346-354.

These authors sought to identify and understand how family environment factors as well as parental ADHD status were associated with variability in ADHD. They set out to examine the links among family environment, parental psychiatric diagnosis and childhood impairment within a sample of ADHD effected sibling pairs, ages five to eighteen years. Parents of children with ADHD rated their families as higher in conflict and lower in achievement and organization than the normative sample. High family conflict was significantly associated with impairment in ADHD. Parental psychiatric diagnosis revealed no significant direct link to sibling impairment but rather a significant indirect link to impairment mediated by family conflict. Direct associations with parental diagnosis appear dependent upon birth order. The authors suggest that there were strong links between impairment in children with ADHD and family environment. They note that different processes and mechanisms may contribute to impairment in different children, even within the same family.

Below are some Treatment Tools developed by Wilma Fellman, M.Ed., LPC in her book, Finding a Career That Works for You. These myADHD.com tools can help those making career decisions and applying for new jobs in 2008.

• #9002 Matching Your Interests and Your Career Choice: Part I
• #9003 Matching Your Interests and Your Career Choice: Job Activities
• #9004Matching Your Career Interests and Your Career Choice: Occupations
• #9006 Preparing Your Resume