Balancing Patient Need and Safe Prescribing

Let me set the scene for you: You have a new patient scheduled in your 2 p.m. slot. Unfortunately, you are already running a little behind because a previous patient was late. You politely greet your new patient, a 25-year-old man. He reports that the reason for his visit today is to establish care for treatment of attention deficit disorder. He tells you that he's been on Adderall for several years and that it's working well. He signed a medical release of information at the front desk when he checked in, but you know that it will likely be weeks before you see those records. What do you do?

This scenario has happened to most primary-care clinicians and likely some specialists as well. While logically we understand that the most likely situation is that the patient is telling the truth, it is hard to avoid the cynical thoughts. Maybe he's selling or abusing the stimulant. He may have been fired from his last doctor for misusing his medication.

As self-diagnosis of attention deficit disorder becomes more common among adults and the "right" answer to diagnostic questioning is relatively simple for patients to deduce, it can be challenging to feel confident that you are making the right diagnosis and pursuing the correct treatment plan. While you don't want to punish all patients for the very few that are misusing their prescriptions, it does become hard to discern on a first visit who is telling the truth. Is it better/safer/wiser to assume the best or to assume the worst?

Most of us probably try for a middle ground of sorts. We seek to provide compassionate care while taking precautions against misuse. This may include checking with the patient's pharmacy about the history of refills or re-examining the patient to support the diagnosis independently. Some physicians, likely burned in the past and fearful of potential misuse, may refuse to prescribe altogether. That can leave the patient in a difficult position as well.

I personally have become increasing frustrated with patients who assume that I will happily take over prescribing their stimulant, narcotic, or benzodiazepine after they have left or been fired from a previous physician. Often, any talk of alternative approaches is met with refusal, perhaps because it was tried and failed before. I have learned the hard way not to continue a prescription that I would not have written in the first place.

I think this fine balance we need to employ between meeting the needs of our patients and being safe prescribers of potentially dangerous medications is one of the hardest to achieve for new and experienced clinicians alike. Never before were so many patients prescribed so many controlled substances. With patients moving or changing insurances, it is inevitable that patients will need to transfer care. The question facing physicians is how to accept the new patient in a way that is professional and caring while also reasonable and diligent. I would love to hear how readers have tackled this in their own practices.