OBSTACLES TO COMPLIANCE
Adherence to the prescribed drug regimen is notoriously poor among patients with ADHD. In a study that included more than 5600 patients taking several different drugs for ADHD, investigators found that half the patients stopped taking the drugs within 3 months of the start of treatment and that by 18 months, 80% of patients had discontinued their medication. Discontinuation rates were the same regardless of the medication that was prescribed. Race, sex, age, and prescription drug coverage status had no bearing on the findings.9 These data confirmed the findings of 2 previous studies. Perwein and associates10 found that 85% of children and 88% of adults were adherent for less than 2 months. Sanchez and colleagues11 demonstrated dropout rates of 50% to 63% in 9549 children with ADHD during a single school year.
Various studies have provided in sight into the factors that lead to poor treatment adherence among patients who receive prescriptions for ADHD medications. Perhaps the most common reason that patients stop taking prescribed medications is that they do not understand the goal of drug treatment. Medication levels the playing field so that patients can begin to learn the skills necessary to live with an interest-based nervous system.
Often, patients—and some physicians—expect a medication to eradicate ADHD symptoms in the same way in which an antibiotic appears to eradicate an infection.9 The treating physician must explain at the outset that ADHD is a chronic disorder that re quires lifelong treatment with medications and the constant honing of important skills. Patients need to know the consequences of discontinuing treatment. How would your patients answer if asked why they take medication for the symptoms of ADHD? How much do they understand?If patients sense that a physician is not supportive of medication or is un convinced of its benefits, they are less likely to comply with it. In this country, physicians tend to prescribe ADHD medication for use during the school week but not on weekends, in the evenings, or during vacations. Like the physician, the patient soon comes to think of ADHD as strictly a school- or work-related problem; but some of the most damaging consequences of ADHD, such as reckless sexual activity and substance abuse, occur during evenings, weekends, and vacations. An increasing body of clinical data suggests that these consequences of untreated ADHD are mitigated by diligent treatment and compliance.12
Sometimes, the patient simply is not organized enough to continue getting prescription refills and keeping appointments with the physician. We phone each patient the day before each office visit. Without these calls, our no-show rate is 50%. With reminder calls, we are able to cut unused clinical time to less than 10% by either avoidance of no-shows or rescheduling of appointments. We also send e-mail reminders when appropriate. Similar reminders are necessary to ensure that patients get the required blood tests. All instructions about medication should be provided to the patient in written form.
It takes considerable effort on the part of the clinician to find the best medication, the optimal dosage, the best dosing system, and the most favorable side-effect profile for an individual patient. Much of this effort is in vain without continually checking with the patient to assess compliance. We give every patient a pillbox timer. We always try to enlist a significant other to help monitor the medication regimen.
At each follow-up visit, we ask to see the pill bottle to assess compliance. A patient’s awareness that a physician or nurse will be checking his compliance regularly enhances his adherence to the medical regimen. Failure to assess compliance sends a message to these patients that the medication is not im portant. We obtain agreements from patients in advance to participate in occasional random drug screens to check for compliance with the regimen. Our attitude is "trust, but verify."
Patients sometimes point to side effects as the reason for discontinuing medication. As a rule, well-adjusted dos ages of stimulant medications cause few side effects after the first few weeks. When arousal side effects do occur in the course of treatment, they are almost always caused by the patient adding another stimulant medication. Caffeine(Drug information on caffeine), which patients may formerly have found beneficial, may now cause unpleasant jitteriness. Smoking produces both diastolic hypertension and rapid heart rates that may be attributed to the ADHD medication. Decongestants such as pseudoephedrine(Drug information on pseudoephedrine) are found in over-the-counter multisymptom cold/sinus/hay fever medication. Systemic corticosteroids cause significant hyperarousal when used concomitantly with any ADHD medication; inhaled and intranasal corticosteroids are usually tolerated well. Prescription and over-the-counter weight loss drugs may also contain stimulants.
MANAGED CARE AND FINANCIAL ISSUES
Can ADHD be treated successfully under managed care plans? That question arises frequently and causes con sid erable anxiety among practitioners. Thorough ADHD evaluations can be enormously time-consuming. The history-taking process is lengthy, and patients tend to loquacity. The review of prior treatment and school records, the neurologic evaluation, assessment for comorbidity, and the need for extensive patient and family education add to the time burden. Useful current procedural terminology-4 codes for these activities are shown in Table 4.
Helpful current procedural terminology-4 codes
|90885: Psychiatric evaluation of records for medical diagnosis
|90887: Consultation with family|
|96115: Neurobehavioral status examination (Mini-Mental State Examination, computerized continuous performance testing)|
|99080: Special reports (IEP input, accommodation letters)|
|99071: Patient education materials|
|99342: Home visits, moderate|
|IEP, individualized educational program. monitoring, or treadmill testing|
Certain administrative modifications ease the difficulties of treating adults with ADHD. We find it helpful to ob tain all paperwork in advance. We do not schedule appointments until paperwork is completed. Alternatively, some practitioners may ask patients to make an initial deposit of $100; this often enhances patient attendance at the first appointment.
Because a considerable amount of physician and/or staff time has been used or set aside, the fee is charged if the patient cancels or is absent, leaving the clinical time unused. We have found that our no-show rate is quite low after patients have made an investment in advance by completion of paperwork and/or payment of a non refundable deposit.
Financial neglect and impulsiveness are a common consequence of untreated ADHD and should be addressed early on. It is often necessary to require that payments be made at the time of service. We assess an extra charge for carrying a balance on the account. The patient must agree in writing to pay for all late or missed appointments.
Managing time and being punctual is an almost universal impairment in patients with ADHD. It is thus therapeutically, administratively, and financially important to clarify these time and payment issues from the very start of treatment. Remember that medical and drug costs can be a problem for many patients. The type of medication and treatment plan will be affected depending on coverage. None of the medications is cheap, and even working families that do not have insurance may find them financially out of reach. Many of the pharmaceutical companies have come together in the Partnership for Prescription Assistance program at a single Web site (www.pparx.org) to facilitate access to their assistance programs.
As you evaluate the adult patient with ADHD, be aware of the need to evaluate other members of his family. This condition is highly genetically linked. The evaluation may start with the identified patient, but the family will become involved as treatment proceeds. For example, if your patient has children, each has at least a 50% chance of hav ing ADHD. Very likely, this is a family in need of professional assistance. The demands of a child with ADHD may overwhelm any parent, especially one who himself has ADHD. You may also find that the patient has siblings or other relatives who require treatment for ADHD. In our clinic, we treat extended families. At one point, we were treating 40 related people in one family and 60 people in another.
I have described the difficulties and pitfalls of treating patients with ADHD, so it may surprise readers to know that I have quite a lot of fun with my pa tients. Where else in medicine would you have an opportunity to begin turning around a patient’s life in an afternoon? It is gratifying work. Begin building the emotional bond at the first visit, be sure patients understand the chronic nature of the condition, and give re peated reminders that medication and skill development work hand-in-glove.
Dr Dodson is medical director of the ADHD Treatment Center in Denver. He is a consultant to and on the speakers bureau of Shire Pharmaceuticals and is on the speakers bureau for Novartis Pharmaceuticals. This article is based on a talk given at the U.S. Psychiatric & Mental Health Congress in 2005.