One of your patients who suffers from ADHD repeatedly loses his prescription for methylphenidate (Ritalin), and often calls reception to obtain a new one. However, you are aware there is a black market for ‘smart drugs’ such as methylphenidate and are concerned the patient may be selling their medication on. How would you respond to the next request for a replacement prescription?
Consider switching to postdated prescriptions
There are a couple of issues to consider here: the diagnosis of ADHD and its on-going review, and potential misuse and diversion of prescription drugs.
There is a market for so-called ‘smart drugs’ including methylphenidate, modafinal and donepezil, which have been shown to improve cognitive performance – for example, there are reports of them being used by those taking exams. Many of them are also used as stimulants as well.
Unfortunately you can’t use toxicology tests to confirm that the patient is taking his prescribed medication so your approach will need to depend on a face-to face review in the first instance. While it may seem difficult, you need to discuss the request for repeat scripts up front and let the patient realise that diversion of drugs is a known problem.
Ritalin is a schedule 2 controlled drug and therefore could be issued on an instalment basis using a blue script, FP10MDA. If this was felt to be too draconian, I would instigate a policy of issuing the drug one week at a time – future scripts could be postdated to cover until the next review.
While this wouldn’t remove the risk of diversion it would minimise it without excessive inconvenience to the patient, and regular reviews will be beneficial in dealing with the patient’s chaotic nature.
Dr Stephen Brinksman is clinical lead for the Substance Misuse Management in General Practice network and a GP in Birmingham
Invite the patient to come in with a partner or relative
While it is possible that the patient is diverting or misusing medication, chaotic behaviour and losing important items is characteristic of ADHD and it may be that his current treatment is inadequate or there is another good explanation.
I would arrange to review the patient, issuing the next prescription only up to the day of the review. I would invite him to bring a family member or partner, while being mindful of the need to maintain trust to manage the situation appropriately.
I would try to establish if he had developed a co-morbid mood or anxiety disorder or substance misuse disorder. I would ask him about his mood, how well he feels his symptoms are controlled, whether he is using alcohol or recreational drugs, and whether he is under additional stresses.
I would discuss how he takes his medication. Patients who self-manage their ADHD may take their medication purposefully – that is, in an increased dose when they need to concentrate, and decreased on days that pose fewer demands.
Following the consultation, I would discuss the situation with a member of the specialist team. Methylphenidate is prescribed under a shared-care agreement, so if I felt the patient was misusing it, I would arrange for him to be seen urgently and cease prescribing in primary care. Other changes to treatment (such as changes in dose or preparation, and psychosocial interventions) could be undertaken in primary care with specialist support.
Lastly, I would consider issuing weekly prescriptions until the patient is stabilised again.
Dr Penny Schofield is RCGP regional drug training lead for north-east England and a GP in Newcastle
Enlist the help of your local pharmacy
Discuss your concerns about the frequent prescriptions with the patient. With their consent, you might include a family member in the next consultation, and discuss whether the relative could help the patient collect or administer the medication (although this would not absolve the GP from the responsibility of monitoring drug use).
You may consider that sending the prescriptions directly to the pharmacy would remove the risk of the patient losing the prescription. If you need to monitor the case more closely, then the pharmacy and doctor could institute limited (for instance weekly) dispensing, but the impact of such tight controls on the patient would need to be considered carefully.
The case highlights the importance of individualised assessment when addressing concerns that may relate to or impact on a diagnosis.
Doctors should have a system to ensure they review prescriptions regularly, especially for repeat prescriptions and drugs with serious side-effects.
Dr Richard Brittain is a medical adviser for the Medical and Dental Defence Union of Scotland