Are Stimulants the Next Opioid Crisis?

The opioid epidemic has been a constant topic of discussion throughout the medical community and political sphere. However, as we focus on this dire situation, could we be overlooking another looming crisis? While opioids now account for most drug overdose deaths in the U.S., the number of stimulant abuse-related deaths is also on the rise as a growing number of adults and adolescents misuse stimulants either for recreational purposes or to enhance performance at school and work. According to recent data from the CDC, the number of overdose deaths due to psychostimulant abuse, both obtained via prescription and illegal methods, jumped nearly 30 percent in 2016, claiming the lives of 7,542 people.

The number of overdose deaths due to stimulants jumped nearly 30 percent in 2016, killing 7,542 people.

Attention deficit hyperactivity disorder (ADHD) is among the most common behavioral disorders exhibited in children and adolescents. While one of the most effective ways to treat this disorder is regular use of stimulants, the growing availability of these types of drugs has led to an increase in abuse. In fact, in 2016, approximately 1.4 million people aged 12 or older misused prescription stimulants for the first time.

Given the increase in prescription stimulant misuse, it’s important for prescribers to take steps to protect themselves against liability risks. In my practice, we have recently seen a number of areas of concern when defending prescribers under government investigation for improper stimulant prescribing. Below, I have compiled three key ways that physicians can mitigate potential liability.

1. Make an Accurate Diagnosis

Some of our cases have involved prescribers who allegedly failed to correctly diagnose the need for stimulants. The two biggest issues: “inheriting” a diagnosis from another prescriber without performing due diligence to confirm the diagnosis and believing a patient’s “self-report” of a diagnosis from another provider (for example, in another state). In this situation, prescribers must always remember to obtain a copy of the patient’s chart from the previous stimulant prescriber. Depending on the timing of the previous diagnosis, the physician may then need to create a new treatment plan based on updated testing. As I have often heard from officers in regulatory hearings, “You are not entitled to continue the mistakes of a previous prescriber.”

2. Use a Treatment Agreement

A Treatment Agreement memorializes informed consent, the terms of the physician-patient relationship, and the education of the patient or the patient’s parents/guardians. Given the potential for stimulant abuse and diversion, particularly in the high school and college populations, it’s important that the patient agrees to random urine drug screens, pill counts, and the prescriber’s review of the patient’s history within his or her state’s prescription drug monitoring database. These tools protect physicians and prevent potential diversion and abuse. Medical Mutual has a database of more than 200 consent forms for members, including one for treatment of ADHD with stimulants that can be accessed here.

3. Be Aware of the Signs

A few things to watch for that may signify diversion, abuse, or addiction:

• Traveling long distances to see the prescriber
• Early refills or purported frequent trips “out of town” to justify the need for an early refill
• Lost prescriptions
• Phone calls from the pharmacist about early refills and the patient paying in cash
• Inaccurate pill count
• Urine drug screens that are not positive for the prescribed stimulant
• Patients who continue to cancel appointments yet request that a prescription be left at the front desk for pick up
• Inconsistent PDMP reports

I have represented numerous prescribers who have ignored these warning signs, or worse, believed the patient’s excuses, and continued to prescribe. Given the current regulatory environment, patients are no longer entitled to the benefit of the doubt. Believing a patient’s word contrary to concrete evidence of misuse often leads to a prescriber receiving discipline from a state licensing board. Finally, while diverters and abusers typically say they are avoiding office visits “because of the cost,” the real reason is that they would fail pill counts or a urine screening. Prescribers should make sure that their EMR or other internal system does not allow the issue of a prescription refill unless the patient is seen in person in reasonable intervals.

The misuse of prescription stimulants appears to be increasing to the point that the precautions for prescribing stimulants now mirror those for opioids. By following the guidelines listed above and using common sense and critical thinking, prescribers will have a strong defense if they are ever investigated for incorrectly prescribing stimulants.

Disclaimer: This post is written in general terms and is not a substitute for legal advice or intended to create an attorney-client relationship.