As a psychiatrist in the MaineHealth system, I believe it is important to illustrate the careful efforts that we are making to provide excellent care for adult patients with attention-deficit/hyperactivity disorder (ADHD), while maintaining safety for our communities.

While I don’t know all the providers in our large network, I am proud of the efforts of my teammates and colleagues to provide care for patients with ADHD, despite substantial shortages in behavioral health resources, increasing demands on those resources and an evolving national landscape in which risks related to controlled substances are increasingly present.

Adult ADHD symptoms are common and range in severity from quite mild to so significant that they may impede a patient in all walks of life. Our patients very frequently seek our help regarding problems related to attention deficits, hyperactivity and/or impulsivity. These issues often arise in a primary care visit, and our primary care providers routinely assess for adult ADHD.

The diagnosis of adult ADHD can be challenging, as there are no blood tests or imaging studies that help with the diagnosis, so the diagnostic process requires a careful interview (often facilitated by the use of a structured questionnaire such as the Adult ADHD Self-Rating Scale), review of previous records when available, outreach to loved ones/teachers/supervisors for input and a medical evaluation to consider other reasons why the patient may be having trouble with their attention.

In some cases, the diagnosis still may not be clear. In these cases, our primary care teams typically have the opportunity to reach out to one of our behavioral health clinicians for additional support regarding the diagnostic process. These clinicians have additional training and experience in considering not only ADHD, but also the various other behavioral health challenges that can get in the way of a person’s function. Sometimes a thorough evaluation leads to the understanding that anxiety, depression or substance use in addition to or instead of ADHD may be causing problems. Our consulting behavioral health clinicians are often able to help with treatment, or they may refer the patient to another MaineHealth behavioral health resource.

There is excellent treatment that we can often offer our patients once diagnosed with ADHD. Stimulant medications (Adderall, Ritalin, Vyvanse, Concerta, etc.) can be very effective to relieve the symptoms of ADHD. However, this treatment is not without risk. Stimulants are classified by the DEA as Schedule II medication, with a “high potential for abuse.” This is noted against a backdrop of the increasing prevalence of stimulant use in the United States, with a doubling of stimulant treatment between 2006 and 2016.

Moreover, there is significant regional variation across the country regarding stimulant prescribing patterns, with use in the state of Maine being elevated in comparison to many other states. (In 2016, Maine and Vermont had the highest methylphenidate usage in the United States.)  Between 2005 and 2010, the frequency of emergency department visits in the United States related to use of prescription stimulants also more than doubled. During this time frame, ED visits related to “non-medical use” of stimulants was stable in children, but more than tripled in adults. In the 2015-2016 National Surveys of Drug Use and Health, 16 million U.S. adults used prescription stimulants, and 5 million (31%) of these reported misuse of stimulants at some point during the previous year.

Given the above statistics, it is important for us to cautiously consider stimulant treatment in adults with an eye toward the potential of diversion, misuse and toxicity. It is with the safety of our communities in mind that MaineHealth has established guidelines for safe treatment with stimulants, as it has with all controlled substances.

These guidelines recommend a thorough assessment that includes screening for substance use disorders or misuse of prescription medications, as well as evaluation for medical contraindications for the use of stimulants. For patients who cannot be safely treated with stimulants, there are alternative non-stimulant medications that can be quite effective. Our behavioral health clinicians are often able to offer meetings with the patient to consider cognitive behavioral strategies to help with ADHD symptoms.

One of our core values is to be patient-centered in our care. As such, we offer the most effective and safest treatment we can for each patient, based on their individual needs.