Friday, May 3, 2013

College Health Centers and ADHD

by Ruth Hughes, PhD

This week we have seen yet another story from New York Times journalist Alan Schwarz about ADHD and stimulant abuse linked with a story of suicide. Like many of the recent media articles on this serious issue, there is a more complex and I think more compelling story. Unfortunately, too many readers, clinicians, and institutions are ending up fearful of treatment for legitimately diagnosed ADHD while the issue of reducing stimulant abuse and diagnosing ADHD accurately often goes by the wayside.
While stimulant abuse is a very serious and out-of-control problem, the consistent link to suicide in many of these stories is highly misleading. When there is suicidal behavior there are always serious mental health problems and often substance abuse as well. Appropriate use of stimulants is not causally related to suicide. But reading the spate of media on this topic, you would easily be convinced that they are related. Creating an atmosphere of fear does not help us to rationally and effectively address the problem of stimulant abuse.

I was very dismayed at the description of college health centers that have stopped diagnosing and treating ADHD because it takes too much time to do it right. Do we stop diagnosing cancer, depression, appendicitis, or any other medical problem because it takes too much time? Proper and thorough evaluation combined with multimodal treatment within a university setting is one of the important things that a university can do to control stimulant abuse on campus. It seems to me that some of the knee-jerk reaction is more out of concern about liability and reputation, than about good medical treatment.

When working on this story, Alan Schwarz contacted CHADD and asked for our take on this issue. I would like to share with all of you the written comments I gave to the New York Times in their entirety.
[Text of comments to NYT]

At CHADD we are very concerned about stimulant abuse for a series of reasons. First, no one should be using any prescription drug that has not been prescribed for them. There are the consequences of side effects, drug interactions and other problems that may place a person at risk. If an individual feels it’s okay to use a stimulant, it is too easy to then take an opiate that has not been prescribed and is then entering even more dangerous practices. Prescription abuse is never acceptable.

Second, stimulant abuse and the emotional reaction that it have engendered has many adverse consequences for people who need stimulant treatment for ADHD. It makes it more unacceptable to seek diagnosis and treatment and creates a culture of fear and stigma. Many of our members reported during the drug shortage last year that they were treated like drug addicts when they had to go to more than one pharmacy to find who had stimulant medications.

CHADD strongly advocates for a good diagnostic and evaluation process which entails spending extensive time with a patient, getting an in depth history of the patient and the family, asking for reports from family members, teachers, or employers, as well as observation of the patient directly and utilization of symptom checklist. This cannot be done in ten minutes. If a physician is unable or unwilling to do an in depth evaluation, then a patient should be referred to a specialist who will do this level of evaluation.

Looking at the information you provided about college response to this issue, it seems to me a very mixed group of interventions. Here are the questions I would urge a college to consider when making policy about stimulant abuse:
  1. Any policies related to stimulant abuse should be consistent for all controlled medications. So if a college health center asks a student to attend sign an agreement about abuse, it should also be used for a student prescribed a pain killer given for a sports injury. 
  2. Are the actions proposed going to both help the patient as well as reduce the possibility of stimulant misuse?
  3. Are there other disorders that have the same or higher level of risks, and are those disorders being treated in a similar fashion?
  4. And are the policies in the best interest of the student presenting with the symptoms?
  5. What other actions need to be taken to reduce stimulant misuse on campus?
Requiring students to sign a release to allow the physician to contact parents for a history is good medical practice and should always be happening. A proper evaluation for ADHD should ALWAYS include the reports of other key informants, a lifetime history of either treatment for ADHD or the symptoms of ADHD and an in-depth evaluation that cannot be done in ten minutes. For the same reason CHADD understands the requirement of monthly counseling sessions. This is always a component of good, multimodal treatment for ADHD. I hope these treatment sessions are designed to help the student with the challenges of college life and ADHD, and are not just centered on stimulant misuse.

I am very concerned about any university health center that refuses to diagnose students with ADHD or does not allow a clinician to prescribe stimulants. It appears to me that these schools are more concerned about liability issues than good medical treatment or controlling abuse of stimulants. And I would also suggest that this deviates significantly from the established standards of care and practice guidelines for physicians dealing with ADHD. It is also discriminatory if the health center does not do the same for all controlled medications. The abuse of pain medications is a much larger problem with much more serious consequences. Are they also refusing to treat pain related to injury, treatment, or illness? If a university is very concerned about stimulant abuse, I would think the worst thing they could do is to relinquish this responsibility to unknown community practitioners. Nonprescribed use of stimulant medications on campus is a serious problem that can’t just be punted to someone else outside the school grounds.

CHADD is deeply concerned about the misuse of stimulants. We work with our members and young adults to learn how to more safely manage the medications, and how to deal with peer pressure to share. We are also concerned that legitimate diagnosis and treatment of ADHD in young people in particular is endangered, because of concerns about stimulant misuse.

[End of comments to NYT]

I share my written comments to the New York Times here primarily to inform our members about CHADD’s take on the issue of health care on college campuses as well as to provide insight into CHADD’s outreach efforts with the media.

CHADD will continue to provide evidence-based information about ADHD. We will strive to increase understanding of the complex issues of ADHD diagnosis and treatment. The press doesn’t always get it right, and in the case of a medical condition like ADHD, may do unintentional harm by adding to the stigma and fear associated with the disorder or the treatment. For all of you who have ADHD or have a loved one with ADHD, it is imperative that we set the record straight, and help our communities understand that ADHD is a real neurological disorder that can be accurately diagnosed and effectively treated.

Ruth Hughes, PhD, is CEO of CHADD.

1 comment:

CHADD of Grand Rapids said...

I was stunned, two weeks ago, when I learned that the 22 year old son of a longstanding member of our CHADD Chapter committed suicide. His future looked brighter than most... He came from a good home and loving family. His parents firmly believe their son’s suicide was not due to depression but the impulsivity of having AD/HD. His dad said he doubted his son would have made the same decision if he’d taken another half hour to think things over.

Especially because we know what works, we must not let the diagnosis and treatment of AD/HD be trivialized. With some, we only get one chance.

Health centers should not “get out of the AD/HD business” because they “don’t have time to do it right.” Ruth Hughes nailed it when she said we would not quit diagnosing depression, cancer, or appendicitis because it takes too much time! Treating AD/HD prevents far more costly outcomes, so it isn’t the expense.

Though we talk about trying to reduce mental health stigma for other psychiatric disorders, when it comes to AD/HD, we create it! People with AD/HD should not have to beg or be deemed "deserving," or be automatically assumed to be drug addicts.

Oren Mason, M.D., writes: “It’s ironic that parents worry that their kids are partying with these drugs to get high, when the main illicit use of Adderall is to study. In the library!”

He states that though he in no way condones the use of Adderall as a “study drug,” and even dislikes seeing coffee used this way, if these medications were highly addictive, children would be begging their parents for their next dose! He says that when taken as prescribed, medications used to treat AD/HD reduce rates of substance abuse and addiction, not cause them.

Not treating AD/HD is not “playing it safe.”

Perhaps medication that allows people to control their behavior, conflicts with our core beliefs about morality and needing to earn what we get. Perhaps treatment for AD/HD seems too good to be true!

On the other hand, if being responsible means allowing people to have the tools they need to reach their inherent potential, then let's let them have them and get out of their way! In my experience, people with AD/HD are well worth the investment!