On September 30, 2015, The New York Times ran an article in the Tuesday Science section on ADHD in older adults. I was interviewed for the article and discussed a former patient age 73 who was first diagnosis with ADHD by me and successfully treated. The article is an introduction into an important clinical area for ADHD heretofore ignored. As we discovered, 60% of children will continue to have ADHD symptoms to an impairing degree into adulthood. The presumption is that ADHD in adults will simply continue throughout one’s life. However, the research is only just accumulating to support this assumption. The largest collection of research in this age group is published by my colleagues in Amsterdam and additional research from other research groups around the world.
Early this year I wrote an article for CHADD’s Attention Magazine on issues related to diagnosis and treatment of ADHD in older adults. The diagnostic issues and treatment considerations in older adults are more complex. In brief, diagnosis needs to consider medical illnesses, medications, history of head trauma, and other medical illness that worsen thinking ability. Treatment consideration are complicated by the presence of medications and medical illnesses that might limit the use of ADHD medications. Older patients and families considering an evaluation for possible ADHD should see a psychiatrist or mental health professional who has expertise and experience treating adults with ADHD.
Remember, while attentional changes occur in those of us over age 50, the cornerstone for the diagnosis of ADHD is the presence of symptoms since childhood that are relatively chronic and unchanged over one’s life and that these symptoms cause impairment in daily functioning. A comprehensive evaluation of all possible psychiatric and medical is critical for the accuracy of the diagnosis.
In my periodic entries of insurance companies’ denial of ADHD medication dosing, I offer you this recent example.
A female in her late 20s treated for ADHD with a combination of Adderall XR and Strattera. Strattera adds a benefit for her executive function not optimized with Adderall XR. I carefully dosed the Strattera upward and suggested increase to 120 mg daily.
Well, the folks at BlueCross Northeastern Pennsylvania denied the dose “As per the FDA recommended dosing guidelines for Strattera in adults the maximum dose is 100 mg per day.” Correctly stated per the package insert for Strattera. “There are no data that support increased effectiveness at higher doses. Therefore medical necessity for 120 mg of Strattera per day has not been met.”
This last statement is a misrepresentation of the purpose of a drug package insert. In fact, the adult registration trial for Strattera submitted to the FDA lists the dose that was used as up to 120 mg daily. Registration trials are designed for the purpose of seeking drug approval for a specific disease state. This research DOES NOT answer the question “If the patient is suboptimally treated with x dose, will they improve further with a higher dose?” So the logic of their denial is a misrepresentation of research for the sole purpose of constricting treatment and conserving money, in my opinion.
Yet more damage is done with these letters. People reading these letters may think the doctor is over-dosing them and not considering safety issues. This is simply not true since safety data on medications are routinely undertaken at much higher doses. There was no unusual safety concern with Strattera at 120 mg daily in the adult registration trial.
It is unfortunate that I find myself blogging about the denial of medication authorizations for my patients who clearly need better outcomes from their medications. While these companies have set up appeal processes, this tends to administratively time consuming without any guarantee that the medical necessity and logic of the dose request will be reviewed with the patient’s interest in mind.
So, what can YOU do if this happens to you? Here are the steps:
1. Call the insurance company and respectfully explain why you need your medicine. If the person is unresponsive, ask to speak to supervisor. If you don’t get to speak to someone with authority, ask if the conversation is being recorded and tell them to “tag” the audio file so that the State Insurance Comissioner’s Office with be able to listen to the audio file. Now, write down the date and time.
2. File a complaint with your state insurance commissioner’s office. You can find the contact information online by searching “<your state> insurance commissioner office”. In your complaint, which should only be one page (no reads anymore), state your brief history of medication history and why it is necessary to have the new dosing authorized for coverage. Write that you spoke with the insurance on what date and time.
In my experience, more often than not, you’ll be getting your approval. However, no guarantees. Good luck.
You might think you’re exercising good judgment by enhancing your health and wellbeing by taking herbs and supplements. While the scientific research with replicated studies is limited, the nutraceutical companies have spent billions promoting their use. Yet now, the real problem is uncovered. The New York Times recently published a story on a investigation into herbs and supplements and found several companies whose products sit on shelves at national pharmacy chains don’t contain the ingredient on the label. UGH. Feeling trick and swindled. You bet. Read the full story here.
While I don’t discourage my patients from pursuing complementary and alternative treatments, understand that regulatory oversight and scientific research is critical in determining the real utility of treatments. Without this, marketing under the guise of education becomes the detrimental order of the day.
For those of you who follow my blog and others who have stumbled upon it, I wanted to bring this opportunity to your attention. Shire Pharmaceutical annually provides these scholarships to help students with ADHD get ahead. If you are interested and eligible, please look into this.
The 2015 Scholarship program will award $2,000 and one year of ADHD coaching services* to each of 50 recipients in the United States. Adults with ADHD who are pursuing higher education are encouraged to apply.
The scholarship program is for legal residents of the United States who:
✔
have been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD)
✔
are accepted to or will be enrolled in a 2- or 4-year undergraduate program** at an accredited college, university, trade school, technical school, or vocational school located in the United States
✔
are under the care of a licensed health care professional for ADHD
Void where prohibited by law. Contest is subject to all federal, state, and local laws, and full rules and regulations.
*Coaching services provided through the Edge Foundation.
Almost everyday insurance companies request pre-authorization for stimulant medication for my patients. While many of these requests are approved, many others are not. One obstacle to approval is stimulant dosing. Insurance companies routinely deny coverage for any stimulant dose that exceeds FDA drug label maximum dose. You might believe this is a safety issue and insurance companies are serving you well. I’d like to believe this too. Unfortunately, their decisions are often a guise for cost savings.
In order for you to understand the process, you need to know how the FDA approves the dosing of medication that it approved for a disease/disorder. Let’s take Concerta for example. The registration trial submitted to the FDA was conducted in the U.S. (Adler L, et al) with another trial conducted in German. The U.S. trial for adults had a dosing started at 36 mg in the morning and could be adjusted up to 108 mg in the morning if the subject had not achieved a predetermined improvement level. The FDA approved Concerta 72 mg as the maximum daily dose in adults. Why? Didn’t you say the trial went to 108 mg a day?
Yes, I did. The FDA decided that the higher doses (90 and 108 mg daily) didn’t produce any greater improvement than 72 mg daily. However, the trial was not designed to answer the question “If you don’t response to 72 mg, would your ADHD symptoms decline with 90 or 108 mg?”. Well then, of the subjects in the trial, what was the distribution of doses amongst all the adult subjects? (Remember, the researcher could increase Concerta dose if the subject hadn’t improved to a defined threshold on an ADHD rating scale)
Dose(mg) % of subjects
36 34%
54 15%
72 18%
90 15%
108 21%
So, you’ll notice that 36% (15+21) of adult subjects needed a dose over the FDA max daily dose. That’s 1 out of 3 subjects. Imagine that you are that patient whose ADHD needs a higher dose. Imagine that your doctor, unfamiliar with this research, tells you he can’t prescribe at doses higher than FDA approved max daily doses. Imagine that your insurance company denies what would otherwise be an effective dose. Imagine that you believe that the FDA max dose is related to safety (it’s not in this case). Imagine that the insurance company uses language to intimate safety concern.
The outcome of this imagination? UNDERTREATMENT. Persistent symptoms and daily impairments.
I provide this information so that my patients are educated about the state of the art for ADHD treatment and how to understand the avalanche of information available. Make the distinction between being informed by information and being educated by information.Being informed means having access to the information. Being educated means you understand how to interpret the information. The internet provides the former, I hope your physician provides the later.
With an increasing number of adults being nearly diagnosed with ADHD, the expense of ADHD medications for insurance companies has escalated. While the annual prescription increase for childhood ADHD is less than 3%, the ADHD prescription market is growing at approximately 10% per year. As a result of this change, companies are under increased pressure to reduce their pharmacy expense. While this issue is certainly not limited to ADHD medication, my patients are finding the course of the medication treatment disrupted by insurance companies obstructionistic prior approval requests for long-acting stimulant medications.
Patients and their treating physicians may struggle for some time to find the most effective individualized medication dose that produces an optimal reduction in symptoms with tolerable side effects. Patients have recently found insurance companies changing their coverage of authorized medications. That means, that despite prior approval for your current medication, the new coverage change may no longer authorize the medication and/or dose. This is becoming extremely disruptive to my patients finding themselves forced to change medication because of high deductibles, leaving them paying hundreds of dollars a month for their prior effective medication.
To give you a specific example, SavRx, a prescription management service in Fremont, Nebraska, informed my patient who has been treated with Adderall XR 80 mg in the morning for the past six months that the coverage for this was no longer available to her, despite the fact that it had been approved by the previous pharmacy management company. Having submitted the documentation of effective treatment for months, SavRx is still not approving her optimal dose.
My recent experience indicates that this approach to medication authorization is increasing in frequency across several companies. I will continue to post blogs giving examples from other companies.
My suggestion to patients who encounter this issue with their treatment is to call your insurance company and complain about your specific case. The insurance companies may not be aware of what is happening and they certainly don’t want unhappy subscribers, let alone bad public press. We will soldier on.
If you’re reading this blog, you are one of the millions of people who now use the Internet to gain information on medical issues. In a recent survey of consumers, this is where people are looking for medical information.
Most accessed online resources:
53% web M.D.
22% Wikipedia
19% health magazines and websites
16% advocacy group websites
12% YouTube
10% Facebook
10% blocks
9% Pharma company websites
(results from third annual national consumer survey by Makovsky Health and Kelton, 2014)
I would like to take this opportunity to direct your attention to the attitude magazine website that has a large number of webinars from noted academic and professional experts in ADHD. For many with ADHD it’s often easier to watch a video on a specific ADHD topic then to read a book. While many with ADHD can sit and read for extended periods of time, it always struck me as odd that clinicians referred patients to books knowing their ability to sustain attention would be limited, especially in the evening when it medication affect us dwindled.
Explore the webinars on this site as a can be extremely helpful. On this blog site, I will continue to direct my patients in readers to reliable sources of information and clinical insights from my practice not available elsewhere.
Anticipating over 300 attendees, the 13th Annual ADHD Conference for parents, teachers, professionals and adults with ADHD on Saturday, February 22, 2014 from 8:00am to 1:00pm will feature several expert speakers. West Chester University is just outside Philadelphia. Below is the program of speakers and topics.
Marie Paxon, program coordinator, invited me to present on the science of diagnosis and treatment of ADHD in adolescents and adults. If you reside in the area, please consider attending because it is a great way to learn a great deal about ADHD quickly and network with people with ADHD and those who offer guidance and treatment. See you there.
ADHD and the Brain: Knowledge Matters Speakers
Marilyn B. Benoit, M.D. is a child and adolescent psychiatrist. She is senior vice president of Clinical and Professional Affairs and chief clinical officer at Devereux. She is a past president of the American Academy of Child and Adolescent Psychiatry. Dr. Benoit has served on the faculties of Howard and George Washington Universities and is a clinical associate professor of psychiatry at Georgetown University Medical Center, from which she received the Vicennial Silver Medal of Honor for 20 years of distinguished service.
David W. Goodman, M.D. is assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. He is also director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville and medical director of Suburban Psychiatric Associates, LLC. Dr. Goodman is the author of The Black Book of ADHD.
Marjorie Johnson, LCSW, PCC is a licensed clinical social worker and certified coach who provides leadership and career coaching, training, and counseling. She specializes in helping students and professionals with ADHD. Ms. Johnson serves on Chester County/Main Line CHADD’s Professional Advisory Board and is a professional member of ADDA (Attention Deficit Disorder Association.). She is past president of the International Coaching Federation-Philadelphia chapter and was named the 2011 Small Business Person of the Year by the Exton Chamber of Commerce (PA).
Jesse D. Matthews, Psy.D. is a licensed psychologist and has worked with individuals with ADHD for a number of years. He is in private practice at The Center for Psychological Services in Paoli and Ardmore and also works at Holcomb Behavioral Health Systems, a community mental health organization. He evaluates adolescents for substance abuse at the Chester County Youth Center in West Chester and does substance abuse evaluations and treatment in an outpatient program in Kennett Square. Dr. Matthews is an adjunct professor at Immaculata University. Previously, Dr. Matthews worked for six years as a counselor at Hill Top Preparatory School, and he facilitated the Chester County/Main Line CHADD teen ADHD support group for two years.
Joan M. Polka, Ph.D. is a psychologist in the Counseling Center at West Chester University assigned full time to the Act 101 portion of the Academic Development Program (a developmental education opportunity for underprepared first-time college students). She is also co-chair of Chester County/Main Line CHADD’s Adult Program and was the 2011 CHADD Educator of the Year.
Martin Patwell, Ed.D. is director of the Office of Special Services for Students with Disabilities at West Chester University. He has also been the director of evaluation clinic at Landmark School. He has presented “Trends and Issues in Disabilities in Higher Education” at Jiangxi University, Nanchung, China. He is also a consultant to The College Board, Inc.
Preeti Singh, M.S. is the associate director of the Twardowski Career Development Center at West Chester University.
Sharon Watson, M.S. is assistant director of West Chester University’s Office of Services for Students with Disabilities. She has over 20 years of experience working with students with learning differences, mental health, and physical disabilities.
8:30 a.m. Welcome
Chester County/Main Line CHADD and West Chester University
West Chester University
Earl F. Sykes Student Union
110 West Rosedale Avenue
West Chester, PA 19383
8:45 –9:15 a.m.
ADHD Across the Lifespan
Marilyn Benoit, M.D.
Research has proven that ADHD does not end with childhood. Over the course of a lifetime, the scenarios change, but the struggles might not. What does ADHD look like at each stage of life and what is the impact? This fast-paced-but-thorough presentation will help attendees learn more about this complex disorder and will provide a summary of current treatment and management options. Don’t miss this valuable session to gain a better understanding of childhood, teen, and adult ADHD.
9:15 –10:30 a.m.
ADHD and the Brain – What You Need to Know About Treatment and Management
David W. Goodman, M.D.
Those with ADHD express frustration with the disorder’s symptoms: trouble focusing, procrastination, forgetfulness, and difficulty filtering out distractions. Some people have a slower processing speed and others struggle with impulsivity. To make things even more complex, many people with ADHD will have a co-occurring condition like learning disabilities, anxiety, depression, or autism. The good news is that treatment is available, and there are strategies to counteract these challenges. Dr. Goodman will provide an overview of medications and pro-social treatments for ADHD and discuss common co-occurring conditions in this valuable presentation. Children and adults report that they receive unhelpful advice like “try harder,” “start applying yourself,” and “pull yourself up by your bootstraps.” Attend this session to learn about evidence-based treatments for ADHD and how they make a difference.
10:45 –11:30 a.m.
ADHD and Social Interactions
Jesse Matthews, Psy.D.
Social interactions can consist of anything from a casual conversation with an acquaintance to daily communication with loved ones. This can present challenges for both children and adults with ADHD. Those with ADHD may feel isolated and disconnected from others. They may find that executive function challenges can cause them to misinterpret social cues, which are usually unspoken or vague. The invisible challenges of impulsivity, forgetfulness, and an inability to regulate emotions can have a negative effect on forming and maintaining friendships. Fortunately, new information and strategies are available through the field of social learning and social cognition. Attend this session to learn more about this exciting topic and how to apply it to everyday life.
• Facilitated activity: Mindfulness Meditation and ADHD
Marjorie Johnson, LCSW
Mindfulness meditation is a way to calm the mind and relax the body while increasing the ability to sustain attention and manage distractibility. Hear about compelling research and daily applications of mindfulness meditation. Practice it to experience the deep relaxation it generates.
11:45 a.m. –1:00 p.m.
Becoming Successful in College and Early Career
ADHD and Career Success
Preeti Singh
Career development is a life-long process, involving decision making, self-awareness, exploration, preparation, and experience. What tools are available to help students successfully navigate this territory? This brief presentation will provide an overview of resources and strategies.
WCU Student Panel
Sharon Watson, facilitator
Current students at West Chester University who have “been there, done that” tell it like it is. Their transitions, challenges, and routes to where they are today provide a look at what real students face in college.
• Facilitated activity: ADD and Loving It?!
This video blends humor, hope, and science to dispel the myths about adult ADHD. Comedian Patrick McKenna seeks a diagnosis for adult ADHD and learns the facts from an impressive array of experts. Funny, moving, and transformative, this fascinating documentary will hold you spellbound!
My discussion with Dale Archer, M.D. (psychiatrist, best-selling author) on WYPR September 27, 2014 about ADHD, over- diagnosis, and over-prescribed medications was lively. While Dr. Archer advocates “medication as a last resort” and “the goal of treatment is to get off medication” after learning new skills, I offered the research on medication benefit and a quality of life measure to evaluate medication utility. Certainly, treatment of ADHD at all ages incorporates behavioral therapy, organization skills, couple/family/individual therapies, and academic/occupational accommodations, in addition to medication, when indicated.
For those of you interested, the radio broadcast is available and runs 35 minutes. I invite you to listen and decide for yourself the merits of each position. Ultimately, this information best serves those who have ADHD and their families.
I have been invited as an expert on ADHD to participate in an interview on the Mid-day with Dan Rodricks show on WYPR on January 27 1-2pm. This is a live panel discussion that will include Dale Archer M.D., a psychiatrist and writer, to discuss the use of medication and treatment options for ADHD. The discussion is moderated by Dan Rodricks who is a distinguished journalist in Baltimore with a regular feature in the Baltimore Sun newspaper.
Dr. Archer wrote an article online for Forbes on January 6, 2014 on his perspective of ADHD and the overuse of medication and the over-marketing of ADHD. His article highlights and echoes the sentiments of Alan Schwatz in his New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013.
This one-hour program will give me the opportunity to highlight the national and international scientific literature and research on ADHD. I hope to highlight the well documented negative consequences over the course of one’s life with untreated ADHD as reflected in several international prospective studies following ADHD children into young adulthood.
This program promises to be a lively discussion and offers listeners the opportunity to call in with questions. I encourage you to mark your calendar. I believe the program can be accessed online. If you listen, please leave me your comments for feedback.
