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Key points
- The Done ADHD prescribing scandal has been grabbing the headlines.
- Telehealth will still remain important for access to mental health treatment, which is so difficult to access.
- The larger issue is how do we get ADHD patients the treatments they need, both doctor visits and medications.
Sometimes it’s hard to imagine that different people have different goals. When we talk with patients in our offices, it’s our goal to help them as best as possible. Sometimes that means prescribing ADHD medications, sometimes it doesn’t, and that may or not align with the patient’s goals. When there is disagreement between what the patient wants and what we are willing to do for them, it becomes necessary to explain why we disagree, and hope that our relationship with the patient is enough to carry the day. Recent allegations regarding shady prescribing practices at Done—a telehealth provider of ADHD services—have made headlines and shaken the ADHD community. Two executives of that company have been arrested and indicted for distributing controlled substances, conspiracy to commit healthcare fraud, and other charges motivated by the allure of profits from prescribing stimulants. The Department of Justice alleges that Done pressured its providers to prescribe stimulants to patients who wanted them without ensuring appropriate diagnostic procedures, training, or clinical supervision, while simultaneously discouraging follow-up visits.
It’s horrible that a pandemic-inspired surge in telehealth practices may have spurred bad actors to overdiagnose ADHD and prescribe stimulant medications to people who don’t need them and might abuse them. However, the recent headlines about this incident also miss a wider point.
Somewhere around 4 percent of the population, including both kids and adults, are trying to regularly fill ADHD medications, and the number of these patients is growing. Some of the recent growth in ADHD diagnosis may be due to practices such as those alleged to have occurred at Done, and it’s easy to generalize from that to blame the telehealth system more generally. However, whatever its faults, the telehealth system has improved access for millions of people who otherwise would have problems getting diagnosis and treatment for mental health concerns—and it’s clear that mental health treatment access is inadequate.
Most medical practices are not built to handle the unique challenges of ADHD. Typically, ADHD runs in families, but most doctors are trained to deal with either kids or adults, not both, so different family members have to find different doctors. ADHD patients are often treated by psychiatrists, but insurance reimbursement is low for psychiatrists, leading many to have cash-only private practices. Access is difficult when patients must find a psychiatrist and pay out of pocket for services. In addition, some psychiatrists do not feel properly trained or equipped for ADHD patients or wish to take care of them—this makes the search for an appropriate doctor even more difficult. Meanwhile, other specialists are not exactly rushing in to fill the void: One of us (Sarah) is a neurologist who treats ADHD, but the neurology department at her institution does not want to “house” ADHD patients either.
Stimulants, the most effective class of medication for ADHD, are controlled substances with many restrictions on them placed by the DEA. We have written in previous posts that stimulant medications are abusable and abuse can lead to significant problems, but most people who take prescription stimulants for ADHD never develop abuse or addiction issues. Effective treatment of ADHD can diminish the tendency of some people with ADHD to abuse other substances, including alcohol, marijuana, and other drugs. Nonetheless, stimulant prescriptions are more restricted by the DEA than many other medications with an arguably higher abuse rate and a certainly higher addictive potential, such as benzodiazepine tranquilizers.
Due to their regulation as abusable substances, patients seeking stimulant medication are often required to be seen by their prescriber once per month to once every three months, even when they have been on a longstanding stable dose of the medication and don’t feel they need a doctor’s visit. Some pharmacists refuse to fill prescriptions for these medications if a patient has not been seen in person or frequently enough in the pharmacists’ opinion. This compounds ongoing shortages in the ADHD medication market that make the medications difficult to get at times and in certain geographic locations.
To help address these issues, some medical groups have created ADHD centers, with doctors focused on delivering appropriate care to these patients. That is appropriate: ADHD patients deserve to be able to go to a doctor or medical group that knows how best to care for them and does not view them as a burden. ADHD patients need appropriate care; this includes being diagnosed appropriately and seen as needed for medication changes and management of their symptoms, while not having to be seen more than is necessary. Telehealth visits, when done properly, can assist this process by providing patients with easier access to care.
The recent news stories have largely focused on the difficulties that Done’s former ADHD patients will now have in getting medications. This involves something like 50,000 patients, which is a lot, and it’s a pity. But it’s only a sliver of a much larger story: Millions of ADHD patients have difficulties trying to regularly and reliably obtain their appropriate medications. The headlines generated by the recent scandal should be about the limited access to specialized ADHD diagnosis, care, and medication that all ADHD patients face. Society has an interest in promoting treatment for inattention in those who need professional help. A world with more focused people would be more productive both at school and at work. It would also be safer: There would be fewer car accidents due to inattentive driving, as well as less domestic violence and fewer fights in general due to improved impulse control. Moreover, people with ADHD would feel better about themselves because they would be doing better: Earning promotions instead of losing their jobs; getting onto honor rolls instead of flunking out; and getting along with people instead of getting into fights with them.
What would our society look like if everybody had adequate access to mental health care and to the medications needed to treat their mental health problems? It would be nice to find out.
