While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.