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Thanx 4 your thoughtful response re Pstim Paranoia

Posted by trialerror on September 2, 2002, at 6:24:50

In reply to Re: And to follow up on something Fachad wrote . . . . » trialerror, posted by sudhira on September 1, 2002, at 17:39:19

Sudhira wrote:

>>> Levels of stimulant paranoia vary from one doctor to the next. In WA I had a doctor who let me try ritalin as an AD augment after one session of discussing my symptoms. He supposed I may have inattentive ADD--but I was not evaluated by a specialist. Like you I have many but not all the symptoms that would indicate ADD--

>>> I moved to OR and my new doc was very anti-stimulant; suspicious of my diagnosis because it was not "official". Before she would consider a prescription for a stimulant she first wanted to see if other less risky medications would address my symptoms of SSRI induced apathy and lethargy. Medications that "act" like stimulants. I tried Provigil, no luck. Used Wellbutrin for 2 months, same story. It became obvious that since the supposedly activating meds did nothing for me that adding a stimulant ought to be the next step.

[snip]

>>> So finally I was prescribed ritalin again. I don't know whether or not I have ADD. I do know that adding a stimulant has benefited me signifigantly. There are studies and posts that indicate that stimulants can further potentiate the positive effects of ad's. Doctors also use them in cases of refractory depression. I have noticed some mood improvement and better ability to organize my thoughts and be productive. <<<

DSM-IV seems to contain large regions of "terra incognito" inhabited by the likes of you & me (and likely many, if not most, "certified" ADHD adults) who may not satisfy the strict "B" prong diagnostic requirement of symptoms by age 7.

And yet we may well benefit from CNS stimulant meds as the FIRST line of treatment.

I've finished up my internet research for the time being. It looks like prescribing Schedule II p-stims to kids is pretty much a no-brainer. But writing p-stim prescriptions for adults requires a much more conscientious and dedicated physcian, one who is prepared to use his or her own best professional judgment and not follow robotically the most simple minded interpretation of the DSM and Merck guidelines.

It seems that under DSM, Merck, and the "literature", p-stims are permitted as a FIRST line medication ONLY in cases of:

1. certifiably dx'ed ADHD;
2. narcolepsy;
3. depression in the terminally ill.

P-stims are permitted as a THIRD or FOURTH line medication to "augment" or use as an "adjunct" in cases of "TRD" - treatment resistant (or "refractory") depression. So in other words, the paranoid physician will put you through months of trials on Schedule IV SSRI's and other meds before daring to stick his or her neck out and prescribing one of those fiendishly addicting Schedule II drugs.

I've also done a little research to try & find out exactly what this physician p-stim paranoia is all about.

Virtually no doctors, it appears, are being officially reprimanded or have their medical licenses and/or DEA controlled substance privileges suspended or revoked simply on account of over-prescribing p-stims.

Some MD's are disciplined on account of their own substance abuse.

The real fear, however, seems to be of malpractice suits and/or criminal negligence in case something goes deeply awry, such as a serious drug reaction or OD (if the patient is also getting supplied from other sources), or the patient just decides to sue for the heck of it, as many do. The doctor's records would then be subpoenaed & audited; the physician's notes would be examined to determine how complete the diagnosis was and how closely "established" (i.e. robotic) guidelines were followed; and his or judgment in prescribing the drug would of course be questioned & second guessed & harped upon before a judge & jury -- if it ever got that far, because the insurance carrier would probably pay out a costly settlement in aniticipation of a runaway jury verdict.

That's the only explanation I can come up with for this hyper-CYA, patient-welfare-be-damned paranoia. In the case of Ritalin and Dexedrine, however, if prescribed in low, controlled dosages, I don't see how such paranoia is at all justified. But then no one calls me "Doctor" either.

>>> Have you tried any of the activating meds that "act" like stimulants? Docs are much more willing to prescribe these and sometimes they prove so helpful that real stimulants aren't needed. <<<

Not yet.

I'd really rather not have to go through a long trial period wishing & hoping but not actually knowing whether we'll eventually get down to business with something that has a higher likelihood of working. (If it ends up that I have to do my own unsupervised "trials", I'll order Provigil by mail; supposedly it's OTC in UK & France.)

>>> I read in a post that someone wrote a letter to a doctor before she met with him. She described her situation and detailed why she felt a trial of a stimulant might be helpful. She wanted to find out if he was open minded enough to have this discussion or not. <<<

Thank you for pointing that out. I found a couple of threads describing "mass mailings" to pdocs to find one with an open mind and whose committment to healing outweighs his or her acute risk-averseness.

>>> Basically in some cases the use of a stimulant is justified even if a person has not been diagnosed with ADD. I brought research to show my doctor. It might be helpful for you to share the article you provided in your first post with your doctor. If you have no history of drug abuse and have used prescription medications responsibly there's no reason why a closely monitered trial of a stimulant should not be considered. Especially if you feel that your ad does not address all of your symptoms. <<<

I'll give it a try.

>>> Am I making any sense? <<<

Splendid sense!

>>> I wish I wrote as clearly and effectively as you. <<<

Coming from one whose writing flows so well and whose points are expressed so lucidly, I take that as high praise. But were it only so. ;)

>>> I related to your situation. Docs can make you feel so defensive about wanting to improve the quality of your life. I recall thinking: Aargh! I'm not trying to get high, I just want to function better! <<<

I'll second that emoticon. :)

-trial&error

p.s. -- To anyone who's read this far - my knowledge of this subject is obviously very recent, no doubt superficial, and certainly full of e's & o's (errors & omissions) if not outright bs. Corrections, comments, criticism, etc., is much appreciated.


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