By Bradley C. Diner, MD, Board Certified Psychiatrist, Arkansas Psychiatric Society Member
Originally printed in the AR State Medical Board’s Winter 2012 Newsletter Issue #52
The Arkansas State Medical Board recently published an update of Regulation 7 governing the use of stimulant medication. This update was a much needed revision of a previous regulation which included outdated diagnostic terminology, inadequate inclusion of all stimulants on the market and ambiguity in the clarification of physician requirements for prescribing. The update was given much thought and included editing by the Arkansas Psychiatric Society in order to provide acceptable guidelines that reflect the current standard of practice.
A public hearing was conducted and testimony was heard regarding the proposed amendment. Though it was initially adopted, there have been a number of letters expressing confusion regarding the changes in Regulation 7. This article is designed to address those concerns and provide better clarification.
There were questions regarding which diagnoses are considered legitimate medical indications for stimulants. Several diagnostic terms in the original document were replaced (i.e. hyperkinetic disorder) as they are outdated or no longer utilized in the literature. Physicians are encouraged to review the DSM 4 for current psychiatric medical terminology. At this time, attention deficit hyperactivity disorder with or without hyperactivity and narcolepsy are the only approved FDA indications for stimulants. However, physicians use stimulants in a variety of off-label conditions. The update of Regulation 7 is partly designed to make more diagnoses appropriate for stimulant usage.
It is asked, however, that when treating off-label conditions such as other sleep disorders, augmentation of antidepressants or post-stroke depression that appropriate medical rationale and documentation of evidence based research and experience be included in the medical record.
There was more confusion about the wording that “no second or subsequent prescription for these controlled drugs may be written for the patient until the physician reassesses the patient and documents in the medical record.” Concerns expressed by interested physicians reflected uncertainty of what was meant by “a reassessment” and whether or not the patient needed to be seen on a monthly basis. It is not the intent of the authors of Regulation 7 to have stable patients seen on a monthly or more frequent basis. The spirit of the reassessment requirement is to ensure that a physician adequately reassess the need for medication, as well as the appropriateness of dose and the consideration of side effects. The current standard of practice includes an office visit to reevaluate a new patient being prescribed stimulants with in the first month. This office visit should utilize an interim history which might include reports from school counselors and/or parents or teachers, as well as a careful consideration of side effects and/or risks and benefits. An adjustment in the dose at that time may be appropriate. Following that second visit, the standard of practice is to see patients on stimulants every three to six months. At this juncture, three prescriptions may be written for any patient on stimulants. They are dated on the day that they are given to the patient, but instructions are given as to the earliest possible refills (i.e. in 60 days and in 90 days). There is no reason to see an established patient on a stable dose of a stimulant every month. However, subsequent prescriptions should be documented in the chart and notes from telephone conversations or collateral data could be added to further document ongoing safety and stability.
The update of Regulation 7 is designed to better reflect the current evidence based practice of physicians in the State of Arkansas as well as to ensure continued safe and effective prescribing. It is hoped that this will make it easier and more efficient for physicians to treat their patients with stimulants while following safe and well established guidelines.
This regulation is available on pages 4-5 or on the Board’s website under the Arkansas Medical Practices Act. 4