doinmdirndest

Guys-Can A Dr. Of Osteopathic Medicine Rx Adderall?

39 posts in this topic

recently the internist that continued my 300mg/d Adderall regimen (wisely i pill shy @ 270mg/d) after the md that began the rx dropped me (it's a long story) told me he'd be leaving the clinic where i see him.  his new job will not include this kind of md work.

 

he said a new md was coming to the clinic.  said he's "pretty sure" his rx's will simply be continued by the new md @ clinic, mine included.   just learned the new doc is a dr. of osteopathic medicine, or d.o.  

 

 

can a d.o. write schedule II prescriptions?  i sure hope so.

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They *can* but they might not be willing to.  My GP can provide stimulants, but refused to give me anything even with the results from my PSG in her hands, and found me asleep in the office when she came in.....

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Objective- In the US, licensed physicians (MD or DO) can prescribe controlled substances with a valid DEA number.

 

Subjective- The physicians willingness to prescribe depends on their comfort level with the medical condition and the drugs.

 

Just because they can prescribe, does not mean they will.

 

A primary care physician unfamiliar with N may only prescribe what has been initiated by a specialist. They do not like to treat conditions they know nothing about. This is not only an ethical decision, it is also a liability decision.

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yeah the outgoing MD-my provider- explained that he'd be continuing dr. Picker's 300 mg/d Adderall regimen IF dr sassin, the local sleep specialist, also the one to whom the local clinic refers regarding 'specialty meds'.

 

dr sassin was also the dr from whom my evaluation was ordered by dr. picker, a psychiatrist/neurologist.  dr. sassin ordered procedures at Stanford sleep.  unknown to us, he then began a 3 month vacation, never having reason to suspect i'd need access to him, not even by email.  (dr sassin is normally accessible to his patients in this way)

 

dr sassin gave us his blessing and my rx was/is continued wisely 1 pill shy @ 270 mg/d.

 

Stanford was a disaster for us.  the reason dr picker ordered the evaluation was that I had requested we titrate up to 450mg/d.  he granted the upwards titration to 300mg/d from 150 when + results from the MSLT he ordered were in. 

 

he had awareness all along, 8 years, that my stimulant intake was not exclusively his rx.  I may not elaborate the details of this here.  prior to the MSLT, sleep apnea (mild) and ADHD were the diagnoses that had us working w/Adderall.

 

he began the visit by explaining that he was entering us into a verbal contract under which I would cease to be rx'ed Adderall by him if I should obtain stimulants ever again, even once, that he did not prescribe.  advised he may drug test me at any time.  I agreed.  he then asked how much Adderall I needed.  after the briefest look of apparent shock on his face, he picked up his pen and granted my 300 mg/d.

 

my wife and I were obsessed w/confining my treatment to dr. picker's rx.  it was very difficult, but for 6 months I was a mainstream American.  looking back, it's so fleeting.  like in the matrix trilogy where neo and trinity become the only 2 living humans to see the sun, that's what it reminds me of.

 

so when we decided to 'fire' Stanford and we got no reply from dr sassin to our emails saying as much, we believed we were being ignored by dr sassin.   by the time I took it to dr picker in an email, I was highly agitated.  and who wouldn't be?  my wife has had 9 documented suicide attempts.  nothing makes her more despondent than 'the coma' our term for my untreated EDS.

 

thinking, "this time i'm going to fix things up for good" I sought the 450mg/d.  in the end, dr picker replied to our email.  but only to tell me I was 'manic' and that my Adderall was stopped.  little wonder.  I was so duly p.'ed off.  he was clueless as to why. after all, he did not know dr sassin was on a 3 month vacation either.  all he knew was that I was coming to him about a matter for dr sassin, and that I was doing so in an agitated state.  I wish I could be4 in dr picker's practice again but  I can't re-open communication.  all my asking/explaining to him is met w/silence.

 

next, the alternate source of my treatment became the exclusive one.  this was a very difficult 6 months, until my regimen was continued @270mg/d, the final fill date for the final rx from my provider is tomorrow, thurs. 11/7.   the 270mg/d might become unavailable to me, ever again, beginning next month.

 

I hope we survive.

 

 

 

.

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"the coma"  what a truly apt term. I'm sorry for your struggles to access both the dr and your rx dose that works for you. 

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Adderall 300mg a day is far beyond the maximum daily dose -- most people with narcolepsy take less than 100mg daily.  And 450mg a day would be lethal for most people.  Any doctor writing you prescriptions for either amount would be putting his or her license on the line.  The DEA comes after doctors who write prescriptions like that on the presumption that some of the medications are being sold on the street.  But more than that, it's bordering on malpractice, because it's way too high to be safe.  Regardless of the legal issues, our bodies are not designed to tolerate stimulation at that high a level on a daily basis.

 

I won't presume to know your story or how you ended up on such a high dose.  But even though you have narcolepsy and ADHD, it won't protect you from developing physical or psychological problems from overuse of stimulants, and you've already mentioned that your intake is "not exclusively [this doctor's] rx," which is a red flag indicating you're at high risk of already having or developing an addiction to Adderall.  You could easily have a heart attack or stroke, or you could wind up with permanent brain damage from chronic use like you see in methamphetamine addicts, and then you won't be able to look out for the woman you love.

 

I can only give you one piece of advice:  Start tapering your Adderall intake now.  You don't know if the new doctor will continue your prescription at that dose, or even at all, and if you have to stop cold turkey, you could easily develop very severe mood swings or even psychosis.  So start reducing the amount you take every few days.  You don't need to be off it entirely by the end of the month -- it's actually not even a good idea to taper it that fast.  But you need to do this to ensure you'll have enough pills left at the end of the month to continue a safe taper of the medication even if you don't get a new prescription.

 

Good luck to you.  It's a hard road, but there are better ways to successfully treat narcolepsy and ADHD.  I hope you find a doctor who will work with you to find those ways.

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i'm no more addicted than is a diabetic to insulin. nor could I be. same for all of us. we (all pwn, as a group if we can somehow act unilaterally in our own best interests on an organized basis.*) should adopt a -0- tolerance policy w/all who use the word "addiction" (as well as synonyms/all conjugations) when discussing or writing about in any way the treatment of excessive daytime sleepiness of any hypersomnia w/indicated wakefulness promoting medication.

it simply does not apply to us. our regimens are NOT elective, if wakefulness/normalcy are non-negotiable must-haves for a given such patient.

if a diabetic were doubtful as to whether the next dr. will prescribe enough insulin, they do what I must do: get ready to find a new dr. if needed.

purpley, thank you for your heartfelt concern. what is difficult to explain clearly enough is the fact that my doses are well tolerated. my avg bp =110/70, my rested heart rate is 60. if brain damage is an eventual certianty then it has already happened, and my treatment has deprived the world of another einstien or another hawking and the damage leaves me a man of normal capability.

to taper off my doses would automatically mean performance at work would deprove substantially, as likely will compel my employers to cease employing me. much more importantly the effects of my medication wearing off on site compromise my alertness and thus increase greatly the probability of my being injured or killed on site, depending on my task. this happens anyway. the last time the somnolenscence began at work I inadvertently stepped beckward into a floor penetration on a pier/beam foundation home remodel (some flooring removed to expose crawlspace/active utilites therein. 30" down to the dirt.) jammed my leg. this could easily have been a fracture.

tapering down my doseaging on a workday = asking for one, if not my getting 'fired'. period of not working a non-option; we but make the condo payments w/-0- to spare.

nothing but the truth. as howard Cosell would say "that's telling it like it is." again, thank you for your concern and your time and effort to compose a detailed posting reply for my benefit. this was a kind, sweet thing to do, purpley.

* I am NOT a good choice to organize and/or 'rep' for pwn, or any interest because any time I've treid my hand at this it went over like a lead balloon. i'm a proven innefective leader. it's like a jockey attempting NFL linemanship.

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there needs to be a distinction between addiction, and dependency here for clarification

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First of all, doin, it was dead wrong of me to imply that you might be an addict.  That was just plain rude, and I apologize.  I do know the difference between physiological dependence -- which is a given in anyone who takes high doses of stimulants -- and addiction, and no one can distinguish one from the other simply based on the dose of a medication someone takes.  I think I just reacted out of shock.  My immediate thought was that you're in deep trouble (in more colorful language), because the vast majority of doctors would never prescribe the dose you take, and you were saying you have a single prescription left.  And that you were already in deep water with the legal risk by getting medications from more than one source.  So I really do apologize for not thinking enough before speaking.

 

But, if I haven't lost credibility altogether, let me disagree about the diabetes analogy.  Diabetics take the exact chemical which is lacking in their bodies.  But when we take stimulants for narcolepsy, we're not replacing something that's missing (if only we could!) or curing the illness -- we're just ameliorating the symptoms.  Even if we have narcolepsy or ADHD, we become physiologically dependent on them and we become tolerant to them.  Even worse, we can end up exacerbating the very symptoms we're trying to treat.  Just like people who take very high-dose opiates for long periods of time can develop hyperalgesia, where they actually have *more* pain in response to noxious stimulation and need to take higher and higher doses, people who take high-dose stimulants for long periods of time can develop the equivalent syndrome, where they develop *worse* somnolence, and need to take more and more stimulants to stay awake.  The only way to fix the problem is to come down on the dose to a more typical one, which means treating the narcolepsy symptoms with something else.  Otherwise, you'll be stuck.  You may be lucky this time and find a doctor who will prescribe this megadose for you, but you'll still need to keep increasing the dose just to get the same effect.

 

So I do completely agree with you that treatment for narcolepsy is not elective.  I just think this particular treatment plan is a raw deal.

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test.  previous attempt keyed in w/ light gray font, and windows pop up w/'there is no post' when post icon clicked.  disregard.

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so here's where we're at:  my Adderall fixes nothing, but with it I am able to continue physically demanding work full time.  the scale of doseaging my treatment requires was established well in advance of my first rx.  the exsisting dose covers work, and even a bit of 'family time'. 

 

we have anonperson suffering the debilitating symptoms of severe EDS.  higher doses of Adderall may get an improved response, yet the effects of nuvigil are preferential in this case.  patient has let us be aware up to 70 mg/d has been taken, this is a thing I as well have done-exceed doseaging of the day's needs w/no meds at all another day, yet to come, prior to next fill date.

 

here is another, other that the puny doseaging criteria negating much, if not most, of Adderall prescription benefit, unfair aspect deleterious to the treatment of excessive daytime sleepiness w/stimulants: unlike Adderall, for which any amount prescribed is covered by medicare and most insurance, 400mg/d is the most that will be covered in nuvigil.  anything more is private pay at about 30$ a pill.

 

I, too once had a nuvigil rx in this amount.  if I took 1000-1500 mg/d I could hack the workday, but it was not so well tolerated.  mental lapses included 2 instances of inadvertent shoplifting, and shimmering hallucinations.  nuvigil has not been continued since I left dr. picker. 

 

for anonperson, a ceiling of 400mg/d exsists that is, unlike the puny 60 mg/d guideline I must face, absolutely impenetrable.   my lot, albeit w/ extremely daunting challenges in obtaining optimal treatment, is a far better one.  the 1000mg/d nuvigil-or perhaps less-would very likely be effective for this case.  but unless anonperson has vast personal wealth, an optimal daily nuvigil intake is impossible to ever have prescribed.

 

it is not right.  insurers really ought to be persuaded to cover nuvigil in any amount.  just as manufacturer's recommended maximums for amphetamines must be seen for the puny, ineffectual doses they truly are.  the former issue is clearly of the greater urgent need.

 

if we PWN could simply decide collectively that sub-optimal treatment for one of us must be addressed as though it impacted all of us(ultimately it does) we could act as a group and fix this.

 

I may be the worst at attempting leadership that ever stood on a soap box, but if not far too many, here at least, are a bit 'sheep like' and do not object, doubt, and certainly do not buck authority. and PWN as I have come to know the ways of simply accept what they are given.  how about this time?  insurers must be compelled by any means we can find to cover nuvigil in any amount an md sees fit to prescribe.

 

anybody concur?

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doctors (should) know better than an insurance carrier, most would agree, but here's the tricky part

doctors (should) be primarily focused on treating the sick.  as a result, some doctors may (in the eyes of the insurers) manipulate the system to provide care they may not be entitled to.  Since the insurer doesn't administer the dosages themselves, who is to say, from the insurance point of view, that the doctor isn't billing one patients insurer, for 2 patients drugs in order to maximize his patients well being?

 

It's pretty common in dentistry, for the doctor to fudge the 50% co-pay to the maximum, and "lose" the cash receipt.

 

that's not even getting into the possibilities of a doctor prescribing a dosage that the insurance company doctors have deemed too high, potentially exposing them to liability.

 

It's all about the money

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That much residual Adderall will screw up your sleep, and that's why you keep needing more.  Are you nuts?  That is not safe.  Anyone prescribing that much can lose his license if you die on it.  If you can't function, go on disability.  What are you trying to prove?

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I will always work.  it appears very likely I will live a normal life term. 

 

the loss of the work ethic, if anything, will be the downfall of America. 

 

I am glad to be wakeful and will not settle for less.  why should any of us?  if no pwn did, more effective treatment would be forthcoming for many. 

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by the way, you get used to residual Adderall and sleep as well as you would before it was began.  I did, at least.  that was over 30 years ago.

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doctors (should) know better than an insurance carrier, most would agree, but here's the tricky part

doctors (should) be primarily focused on treating the sick.  as a result, some doctors may (in the eyes of the insurers) manipulate the system to provide care they may not be entitled to.  Since the insurer doesn't administer the dosages themselves, who is to say, from the insurance point of view, that the doctor isn't billing one patients insurer, for 2 patients drugs in order to maximize his patients well being?

 

It's pretty common in dentistry, for the doctor to fudge the 50% co-pay to the maximum, and "lose" the cash receipt.

 

that's not even getting into the possibilities of a doctor prescribing a dosage that the insurance company doctors have deemed too high, potentially exposing them to liability.

 

It's all about the money

so why no limit on Adderall, allegedly a more dangerous med than nuvigil?  because  it's far less costly?  the same liability issue exists, no?

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probably because it's older, and had more observations done.  No history of major claims or liability issues, etc.  Since it's considered more "dangerous", I guess you could always push for "the patient abused them, not our fault!".  Could also be because they're not as commonly rx'd now.

 

Hard to say though, for sure.  The Canadian drug trade and insurance practises are different up here.  We cap drug costs, and since we're (mostly) all on government health care, many of us don't have a secondary insurer for drugs/dental and pay out of pocket.  For those who aren't insured and can't afford drugs, there are programs.  IIRC, Xyrem is 1/3rd the cost here, regardless of insurance status.

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We are all different, with different symptoms and different needs for meds but we all have Narcolepsy. I've said it before, that a WRITTEN letter signed by the patient and witnessed should be enough to let the Doctor off the hook and the insurance company can either cover it or cover it up to their maximum.

So, let's put the shoe on the other foot...and I do believe that IdiopathicHypersomnia will understand this analogy the best. EVERYONE WITH NARCOLEPSY MUST TAKE XXXX MEDICINE AT XXXX DOSAGE...PERIOD. There will be no variance for anybody.

Well, that scenario doesn't work either does it? And it doesn't have anything to do with severities of symptoms either.

WE ARE EACH UNIQUE AND MEDS SHOULD BE TAILORED TO EACH INDIVIDUAL'S NEEDS. Nobody is asking for what they "want"...they are asking for what they "need" to function. IMHO, it's not an unreasonable request. It is "with blinkers on" that a medical professional cannot or will not understand this. Rant over (maybe).

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The problem with written consent by a patient to sign off on a drug, is that in some cases they aren't able to consent, that's why hospitals have an ethics board and a legal team.  If there is the possibility that addiction can, or has taken already taken root, it is the doctors responsibility to intervene, right?  Some may simply not be willing to risk their career or potentially the life of a patient if they feel they are not in the right state of mind to consent.  Even if addiction isn't the issue, some lack true "informed consent" or just want a quick resolution to the issue with what seems right, even when there's a possibility that there could be other methods of treatment that they either don't know about, or are unwilling to try.

 

That's really the problem with N - there's nothing to handle the problem, just mask the symptoms and try our best to pretend it's not there.

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God help us all from some Doctor's concept of Intervention and their concept of what is "good" for the patient. They even ignore DNR wishes if it serves their purposes. Wishes that were written by patients and signed and witnessed when they were of sound mind and body. However, I am now off topic.

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For insurance companies, everything related to stimulant prescribing is about money. For doctors, money isn't the issue -- it's medical ethics in caring for patients, and liability.

If you [this is the generic "you," not anyone in particular] go to a doctor and tell them that only 300mg a day of Prozac works for you when the maximum recommended dose is 80mg, they won't mind writing a prescription because the minimum lethal dose is well over 1000mg in most cases and there's no street value to it. Plus there aren't any studies showing that people who take 300mg a day of Prozac can end up with even more depression and need escalating doses of the med to get the same effect. So they might have you sign a form to show you've been told of the remote chance of an arrhythmia, but that's it.

There's no absolute toxic dose for Adderall because people develop tolerance over time. But there's no way for a doctor to tell the difference between someone who's tolerant and someone who's not, or even between someone who takes the full prescription or not. A drug test only proves you've taken some, but not how much. Just 300mg can cause a heart attack or stroke in someone who's drug naive -- 450mg without question. And even a history of filled prescriptions doesn't prove tolerance because there are people who fill prescriptions and then sell them. So you're in the really lousy position of going to a doctor and asking for a potentially lethal dose, of a drug with high street value, and of a drug that's known to potentially cause increasing problems with sleep and wakefulness the more you use of it. Many doctors wouldn't write that prescription. Not because they're ignorant, but because they just can't know the truth of the matter and they're going to err on the side of not killing you or making your narcolepsy worse, not losing their license, and not potentially contributing to the US drug trade. And many of them are the really good docs, the ones who would rather lose your business than write that prescription.

So that's the problem. And we can rail against it, but there isn't any easy answer.

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If you have built up a tremendously high tolerance to Adderall overtime, so that you require 300+mg/day, that is the reason for the high dose.

 

It is not as though you have such extreme Narcolepsy/Hypersomnia that only that dose will control your EDS. You have developed and extremely high tolerance.

 

As time goes on, your dependence will continue to increase.

 

So, Adderall is not your only stimulant option. I am no expert on stimulants and I do not tolerate them well. Switching over to a Ritalin, concerta or Focalin could allow you to move onto a reasonable dose of a different stimulant while re-setting your tolerance to Adderall.

 

My opinion is that you are strongly committed to a losing cause because you will eventually run out of doctors willing to prescribe. You are painting yourself into a corner.

 

You have built up an enormous tolerance. You are looking for a doctor to accommodate your tolerance and accept all the risks that go along with that.

 

My opinion is that you need a doctor to find a way to address your tolerance and prescribe a different stimulant to treat your EDS.

 

So, your EDS is not as severe as your tolerance. In my opinion your posts actually speak to the severity of your tolerance, not the severity of your EDS. It is also apparent that you are not fully aware of that.

 

It reminds me of a news show about a 900 pound man and how much he "needed to eat". Yes- he needed all that food to maintain his 900 pound weight. He and his wife considered all that food to be what he "needed". What that man needed was a doctor to propose a diet plan to decrease his weight. He did not need a doctor to prescribe more food to maintain his obesity.

 

So, to me, your extreme tolerance seems like the huge food intake of a 900 lb man.

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Interesting point of view Hank and I hope that Doin' will consider all other options if at all possible.

 

And then there's the person who consumes so many calories during the course of the day that they should weigh far more than they do...but they're skinny as a rail. And then there's the majority of Narcoleptics who hardly eat anything but can't get rid of the weight even with dieting and exercise. I fell into the last category until I started taking 100 mg. of Provigil a day...30 pounds gone in 4 months with no other changes.

There are many things that are unexplainable.

 

I wish you the best Doin'....even if you're an unexplainable anomaly.

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i'll take some of what you're having please.

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