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Ugh. I could really have used my damn meds, I'm resorting to going through my luggage in the hope that there's something leftover. A perk of having ADHD is that something probably is.
I feel for you, but it really boggles the mind. Why would he prescribe capsules if they aren't a thing in the UK? How is it even possible for him to do that? Does he make the mistake frequently, I wonder?
I wouldn't be so harsh on him, and I'm actually quite sympathetic. Let the doctor who hasn't made a spelling mistake or mistaken a dose cast the first stone, and I'm not chucking any. Nothing glaring, or lethal, thank god, but all the steps we take to avoid this only seek to minimize the risk, and can't eliminate it.
He didn't get the name or dose of the medication wrong, and usually capsules versus tablets is an irrelevant detail. If he was doing it electronically, it would be constrained by the list of meds recognized in the system. With pen and paper? Much more scope to go wrong.
Dextroamphetamine isn't the first choice for ADHD here, probably somewhere around 2nd or 3rd line. I can understand why he might just look up dose, refer to something that wasn't the BNF, and then put that down.
In fact, when I called back today to get this sorted out, I learned he'd called in sick today, so it's possible that he wasn't feeling so well when I saw him.
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Brutal, sorry man. I'd be tempted to use the dark net at that point, or have a friend with good insurance in a country with shorter waits ship it...
Thanks my dude. Luckily I did find a good couple months worth of my previous prescription languishing in a dark corner of my room, so I won't be entirely screwed over if there's a large delay in getting the prescription amended, but it's a pain either way.
I'm too scared to actually try the Dark Web, largely because I have more to lose than the average citizen (I could be deported!). I did once have a friend with an Adderall prescription he didn't use, but he turned out to be an asshole and I wouldn't reach out to him.
My absolute fallback would have been scheduling a flight home and bring as much Ritalin back with me as I could, or just have my family send it over with extended friends and family coming back.
For now I'm hoping a few phone calls will sort this out, and if not, I'll just suffer a little longer from taking a suboptimal medication that beats nothing.
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Wait what’s the problem with capsules?
Absolutely nothing, except that they don't exist in the UK. It's tablets or nothing, as far as the NHS is concerned, and private prescriptions have the same issue AFAIK.
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Capsules are not tablets.
He does not have a prescription for tablets, therefore he can not receive tablets. He has a prescription for capsules, and nobody can give him capsules.
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Y'all don't have eprescribing in the GB?
Also why no Addy (or better yet - Vyvanse).
We do have e-prescription! It's the default, but while the psychiatrist didn't mention a rationale behind a written one, it was likely because he did it in a hurry, or because he's the old-fashioned type.
https://www.astralcodexten.com/p/know-your-amphetamines
Purely d-amphetamine works better than l-amphetamine or a racemic mixture. And I read elsewhere that dexedrine beats methylphenidate in terms of pure efficacy in adults.
I was the one who suggested it, mainly because I'm sick of the side effect profile of methylphenidate. If I experience anything too unbearable, and I hope some of that is idiosyncratic and dexedrine would be more tolerable. I'll probably ask for an extended release formulation during the next follow-up appointment.
Low-key I prefer it most of the time because if the pharmacy is out of whatever the patient can just roll to the next one. Clearly I am positively geriatric.
Okay soooooo
Puts on attending hat.
This is eventually going to become part of your bread and butter - you should feel very certain that amphetamines of all kinds are better than methylphenidate (or not!) and eventually be familiar with the considerations for use of one or the other (especially since it impacts your own personal life).
You should also stop reading Scott for these things, he writes for lay people and in a very entertaining way, but you have the toolset to actually do a lit review and deal with the less engaging/more scientific writing.
This is going to be important for a few reasons, one is that Scott often elides some of the practical concerns that we need to know about (like actual availability, as you ran into) and he cues into very specific old evidence bases at times which is fine for what/who he writes about but misses new innovation (lets see.....psych example....how about the conversation about Trazodone as a sleep aid?) and importantly isn't necessarily the standard of care - your attendings, billing processes, and potentially malpractice attorneys (yes yes UK) are going to look at you funny if you take him seriously.
He also has a tendency to miss or underemphasize some of the research errors (some spotted in this article! What they are is left to the learner lol).
IIRC Vyvanse is now generic in the U.S. but in short supply (as is basically everything else for ADHD), I don't know what it is like in the UK but for my money it is almost always the better choice if the patient can get it and afford it. Being a prodrug presents a ton of advantages and I'm mildly irked at the way Scott is minimizing it.
Very much my choice for "if my family member asked me what to get for ADHD I'd say try this first..."
Caveat: like all doctors I have my things I am very insistent and convinced about, others may not agree.
It turns out that at least in outpatient settings, the rule is that controlled substances need a hand-written prescription. Which strikes me as odd given that in all my inpatient work, I just had to tick a few boxes and sign a physical copy when it came to those classes of drugs.
Unfortunately, that's going to take a while. My current placement is psychiatry of old age, and the next one ought to be General Adult. It's probably not till I do one for children and adolescents (or learning disabilities) that I would be personally prescribing any. I can only go off my own experience, having exhausted the options back in India, and what I read online for now.
I did do a literature review! (though given that I have ADHD and unmedicated when I did it, it's not going to be published anytime soon haha)
The effect sizes for dexedrine vs methylphenidate were 0.9 vs 0.8 in adults, within spitting distance. My impression is that methylphenidate is better tolerated in some, but it's already been so unpleasant for me that I am eager to try anything else. (Don't even ask what fucking atomoxetine did, it was highly NSFW to say the least).
It's exceptionally cruel for you to burden a neurodivergent trainee with additional research burdens :(
That being said, I do hold Scott in very high esteem. I don't consider him infallible, of course, but I would have the presumption of deferring to him unless I had overwhelming evidence of error. I certainly wouldn't formally cite him in my medical decisions at least at the resident level, but thankfully consultants have significantly more leeway in that regard, and I hope I get to that point eventually.
(I'm aware of trazodone as a sleep aid being an occasional prescription decision, do I take this as you asking me to evaluate whether it's ineffective at that job? I've only heard weak evidence, and mirtazapine would be the first port of call anyway for insomnia)
The UK is also grappling with a supply shortage. I think dexedrine is comparatively uncommon enough that I have better odds of getting it than the alternatives!
I've previously been on an extended release formulation of methylphenidate, and it did nothing good for due to the increased duration of action. I've never tried an immediate release variant of either, but I'm willing to try the devil I don't know at this point.
Hmm probably helps prevent fraud and such.
....Priapism from the Atomoxetine? Meds you would not expect can cause that.
It does sound like you did do some research but you should be looking things up, reading /r/psychiatry and /r/medicine - always be learning! (especially if you feel like you aren't getting enough at work). Be curious! Just the other day I was looking up the pharmacology of a med I use all the time (ODT Zofran) because I realized I had forgotten some details. Chasing stuff like that will make you a better doctor.
Scott is smart and is a good writer but he has a very idiosyncratic bent to his medical views that often doesn't match other clinicians. Beware. The Last Psychiatrist on the other hand is fucking incredible (and importantly - equally entertaining). I make everyone in every specialty I see who has deep questions about pharmacology of any kind read his receptor article.
In the U.S. Family Medicine, Sleep Medicine, Neurology, and Psychiatry all have different views on Trazodone (and everything else). For a long time lots of these were like "the evidence says it does jack shit" but some recent literature has some weird noodly explanation about why that's all wrong. It's hard to evaluate. Many docs go off anecdotes.
In the U.S. we do use Remeron but are often cautious because we have enough weight to go around... for the right patient it is great though.
Officially the answer is sleep hygiene and other lifestyle mods/therapy (and especially CBT-I first and foremost and all the time before using meds).
I mean if it works who cares, but if you end up needing something else going forward keep that in mind.
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I feel this on a cellular level when my sertraline refill gets screwed up and I start getting spazzy vertigo like a spinning open wire waiting for it. My fist goes to you, hope you find some leftovers.
Tbf you absolutely do not want to go CT on antidepressants, at least stimulant meds don’t really have withdrawals
One time I had to wait two weeks for my refill and by the time I got it I was glitching out of the damn Matrix.
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Lo and behold, after your kind blessings, I dug through a pile of belongings in the back of my closet, and found two pristine boxes of Ritalin, just ripe for the taking. I knew there had to be some of the fuckers lying around around haha
I have only mild ADHD but never found Ritalin all that effective. Better than nothing though. Adderal and dex are definitely way better
I'd say my ADHD is quite mild. You wouldn't be able to tell at a glance, and I'm used to working hectic and cognitively taxing jobs without my meds, though they do help.
I'd say Ritalin was 6/10 effective for me, on a platonic ideal where 10/10 would have me locking in and working till I drop. It does help me focus, and I simply can't study without meds. I'd have flunked med school since my old habit of cramming at the last minute no longer cut it as the textbooks approached the dimensions and weight of a healthy newborn, if it hadn't been for Ritalin.
It's mostly the side effects and come downs that put me off it. I get anxious and jittery, and even taken early in the day, it makes me insomniac enough to be debilitating. This is mostly just bad luck and idiosyncratic, it gives my brother, who has ADHD worse than mine, terrible headaches at the lowest dose. He breaks his tablets in half just to try and get by with less.
If you read Scott's review of stimulants, the one that's consistently the cause of rave reviews is desoxyn, which is a polite way of saying meth. At actually therapeutic doses, it works wonders, but it's not available legally in the UK, and most psychiatrists are scared to prescribe it even in the States.
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That’s what I’m talking about (=´∀｀)人(´∀｀=)
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Well, it seems that despite showing up as proper greentext in the comment preview, the local parser doesn't like zero width spaces. Pretend there's a > as appropriate please.
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