by Danielle Ofri
New York Times
Amy, a single mother living in a middle-class suburb (she asked that only her middle name be used), is an educated professional who is reasonably savvy in most medical matters. But every month she goes through an arduous, prolonged and humiliating process: filling a Ritalin prescription for herself and her 11-year-old son.
Most physicians think little about prescriptions after they hand them off to their patients. Usually, the only time I hear about it is when a patient calls from the pharmacy because the insurance plan has changed which statin it covers or a medication is not covered by insurance and the price is simply astronomical — what could I substitute?
But Amy’s experience is quite different. Pharmacies just seem to be out of Ritalin, and no one seems to know when more will arrive. And without medications to treat their attention deficit hyperactivity disorder, life can fall apart. Amy’s ability to do her job and run a household can become overwhelming. More painfully, her son’s schooling suffers.
“For each new prescription,” Amy says, “I must muster up energy to begin the hunt. Maybe I’ll get lucky and my order can be filled on the first try. But most often, it’s the start of a very difficult search that can take weeks, and burns precious resources.”
As recently reported in The New York Times, there is a debate over whether there is a true shortage of A.D.H.D. medications like Ritalin. The active ingredient, methylphenidate, is a controlled substance and has potential for abuse. Pharmaceutical companies claim that the Drug Enforcement Administration is limiting the supply of methylphenidate. The D.E.A. claims that the pharmaceutical companies are choosing to produce costlier brand-name versions at the expense of cheaper generics, creating an artificial shortage while raking in profits.
Whichever the case, the reality is that for patients like Amy and her son, every month feels like a new round of playing Russian roulette with their health. “We need our medication,” Amy says, “and having it denied is humiliating. After having my request rejected, I’m often disheartened or left suppressing resentment. But most often I’m left feeling shamed, like I’m a criminal in the attempted act of illicit behavior.”
Amy’s words reveal an emotional gantlet about which doctors are largely unaware.
I tried to imagine the situation if the prescription in question were another drug, like thyroid medication. The fallout would be radically different. One of my patients, for example, prefers an older version of thyroid medication that is manufactured by one company only. Periodically, that company falls behind in production, and we have to rejigger the prescription, redo blood tests, await the results, then recalibrate the medication dosage. Then we have to repeat the whole process when the original medication again becomes available. It’s a huge pain in the neck, for both of us, but there’s no shame and humiliation involved.
Everything changes when it comes to controlled substances — whether it is painkillers like Oxycontin and morphine, anti-anxiety drugs like Valium and Xanax, or A.D.H.D. medications like Ritalin and Adderall. The facts, myths and cultures around these medications are so complex, and so fraught, that there is never a sense of “routine” when these medications are prescribed.
Whenever a patient requests one of these medications from me, the emotional temperature of the clinical encounter is immediately elevated. Almost all doctors — myself included — have been burned by patients who have lied to us about symptoms and then abused or sold the medications we prescribed. And though these cases represent only a tiny percentage of patients, they leave lasting impressions (not to mention legal ramifications) that cause us to scrutinize every future patient, often excessively so.
The scrutiny and judgment add a layer of suspicion between doctor and patient. Whether verbalized or not, such suspicion is always evident to the patient and is not exactly the basis for a trusting, compassionate doctor-patient relationship.
Many patients say that this scrutiny and judgment extend to the pharmacy as well, where a prescription for a controlled substance is received quite differently from that for a blood pressure medication. Whether it’s a drug for pain, anxiety or A.D.H.D., there seems to be an unspoken perception that the patient is somehow part of the problem, and that there is a chance the patient might be abusing the medication or selling it.
That there is an ongoing shortage of any basic medication in the 21st century is absurd and unacceptable, though it is largely out of the hands of doctors and pharmacists. What is in the hands of doctors and pharmacists is the attitude we convey around controlled substances and other medications that may come with some stigma — medications for schizophrenia, for example, or for depression and alcoholism. Of course we must be alert for medication abuse, but that in no way should diminish a respectful and compassionate manner. Shame and humiliation shouldn’t be part of any aspect of medicine.