Perils
There are reasons doctors are sometimes reluctant to see patients with ADD.
● primary care physicians and the majority of psychiatrists and neurologists have relatively little experience evaluating and treating ADD. Although the majority of cases are straightforward, some are more complicated, and this understandably concerns the less experienced doctor.
● the most common treatment of ADD are the stimulants such as Adderall, Vyanse, Ritalin, and others. Stimulants can be abused or given or sold to others. Some patients sell or give them to friends, some use them recreationally, some take higher doses than are prescribed. The magnitude of these problems are greatly exaggerated by the media but they do exist. Because they can be abused, the Federal Narcotics Bureau keeps an eye on stimulant prescriptions. Some doctors worry that they may get into trouble with the bureau even if they carefully obey the law. This concern is greatly overblown. I have had one narcotics bureau inquiry in 30 years of practice, the last fifteen of which were spent specializing in ADD. (A pharmacist had called the bureau because he thought the patient’s dose was too high. The narcotics agent asked me about the dose, I explained that the dose was an adult dose (for an adult patient). The agent was satisfied and I never heard about the incident again. Some clinicians try to get around this potential problem by prescribing a non-stimulant, such as Strattera or guanfacing (Intuniv or Tenex) for ADD. Unfortunately, these medications are rarely as effective as the stimulants.
● people with ADD not infrequently forget their appointments. Even with reminders, they are more likely than other patients to cancel or not appear for their appointments because of traffic, jury duty, baby sitter problems, car problems, or other last minute emergencies. If the physician is not reimbursed for the time set aside, it makes treating ADD patients less remunerative. If the patient agrees to pay for missed appointments out of his own pocket and does so, this may mitigate this problem. But most doctors are unwilling to put a procedure code on a bill when the patient did not get the service being billed.
● patients with ADD need to take their medication every working day or they will fall back into the distractible and inefficient condition that they were in before starting treatment. (They are not addicted in that they do not have serious withdrawal symptoms, but they do depend on their medication to help them, and the medication wears off quickly.) Refills for stimulants cannot be called in to a pharmacy. They must be written on a prescription and brought to the pharmacy. Not infrequently patients do not make appointments for refills in advance but plan to call for a refill appointment when they run low on medication. Because procrastination is often a problem with ADD, they often wait until the last moment before calling then urgently request a refill or an appointment. This can be disruptive to the doctor’s practice. The doctor has to be very vigilant to make sure that patients who say their schedule temporarily prevents them from making a follow up appointment do make one before it becomes an emergency.
● a small percent of people with ADD procrastinate about paying their medical bills.
● doctors who want to do psychotherapy with all their patients will be disappointed that there is no psychological basis for most patients’ ADD. A large portion of the psychological problems are caused by the effects of their ADD symptoms on their lives and self esteem. Most who benefit from medication treatment experience a significant decrease in secondary psychological symptoms.
