How do you respond to early refill requests for stimulants in stable patients who report lost or stolen medication?

I do not refill stimulants when they are reported lost or stolen.

When starting a treatment course of stimulants with a patient, I review a brief list of instructions and expectations. For stimulants, this includes that it is their responsibility to store and protect their medication from theft or loss. We review how to do this in a home, college, and work setting. I encourage patients to keep the fact that they are on stimulants to themselves to avoid being asked by peers and family to 'borrow or get some' of their supply. I highlight that cars (glove compartments) are not for medication storage - the 'someone broke into my car and stole my medication' story. I end with a very clear statement that I will not honor a refill request for a lo...

For me, the key is at the onset of forming an alliance. The doctor and patient agree that stimulants are powerful tools in our armamentarium to manage the core ADHD symptoms. Emphasis on special features of this treatment modality is made at the first visit, which includes special precautions for controlled & scheduled medicines. In case of temporary unavailability of this tool, an excellent opportunity to practice other skills of management of symptoms arises. This way, no situation should cause such an alarm to deviate from standards that are workable for the doctor and the patient, and it is a good test for the authenticity of the therapeutic relationship.

Agree with the comments, though I believe the approach should be both cautious and individualized. A thorough initial discussion and/or controlled substances contract, and more caution is often very helpful, especially with the younger adult demographic, where diversion is more common. I typically allow one early refill (i.e., benefit of the doubt) and use it as an opportunity to review how to handle controlled substances (in the way others described above). As mentioned by others, keeping track of early refills is important to catch the pattern, and the data is very useful in addressing the issue with the patient. Overall, I think the caution around refills of controlled substances needs to be balanced with compassion and the acknowledgmen...

Definitely a case-by-case thing for me. In our clinic, patients sign a controlled substance agreement, and I review these parameters with them. I will often refill enough medication to get a patient to their next appointment and schedule them to come into the clinic as soon as possible. We discuss the situation and determine if the remainder of a one-month prescription can be filled. I keep track of when and how often this happens and use that information in my discussions with patients. Rarely, this has led to termination of stimulant prescribing, but typically will be a short-lived issue, and patients learn to navigate appropriate stewardship of their medications. There are just too many individual factors in each patient's life to justif...

I tell the patient they are entitled to "one lost stimulant prescription per lifetime." This communicates a firm boundary and a bit of helpful humor. It has served well.

Vacation early-refills are infrequent in my practice, and I simply type the rationale in the e-prescription. If it requires interaction with the insurance company, I charge for my professional time according to our original agreement. Admittedly, this is a private practice situation that would not generalize to many clinical settings.

Side note: One pharmacy in town will fill a stimulant prescription for 90 days. I wish they would all do that.

I explain to patients when they start treatment with stimulants that they are responsible for their medications. I will not do a refill for “lost or stolen” medications under any circumstances. That results in a few requests for an exception. The occasional request is denied.

Depends upon the severity of ADHD and comorbidities. My usual answer is to wait until next due, but I can refill if in rare, genuine non-repeat cases without active family members with addiction.

I have a small private practice, and most of my patients have multiple diagnoses, including ADHD. We speak about the medicolegal aspects of stimulants throughout our work together. I’ve had no concerns about diversion, but I have had concerns about them missing doses due to having misplaced or lost their medication in the rare instances that this has happened.

While I can see why requiring contracts could be beneficial/prudent in addiction psychiatry settings and with patients who are in recovery, I find the statement that this is best practice for all to be punitive, especially, (as mentioned previously) given the nature of the core features of ADHD. Missing doses of stimulant medication can be devastating for those who suffer from severe ...