Politics and Prescribing: The Case of Atomoxetine

Prior authorizations for medications have been a huge waste of physician time and they are a now classic strategy used by PBMs and managed care companies to force physicians to prescribe the cheapest possible medication. The politics for the past 20 years is that all of the medications in a particular class (like all selective serotonin reuptake inhibitors) are equivalent and therefore the cheapest member of that class could be substituted for any other drug. The managed care rhetoric ignores the fact that the members of that class do not necessarily have the same FDA approved indications. It also ignores basic science that clearly shows some members of the class may have unique receptor characteristics that are not shared by all the members in that class. Most of all it ignores the relationship between the physician and the patient especially when both have special knowledge about the patient's drug response and are basing their decision-making on that and not the way to optimize profits for the managed care industry.

The latest best example is atomoxetine ( brand name Strattera.).  Atomoxetine is indicated by the FDA for the treatment of attention deficit hyperactivity disorder. It is unique in that it is not a stimulant and that it is not potentially addicting. Many people with attention deficit hyperactivity disorder prefer not to take stimulants because they feel like they are medicated and it dulls their personality. In that case, they may benefit from taking atomoxetine. The problem at this time is there are no generic forms of atomoxetine in spite of the fact that there are many good reasons for taking it rather than a stimulant. As a result physicians are getting faxes from pharmacies requesting a "substitute" medication for the atomoxetine. Stimulants are clearly not a substitute. Some people respond to bupropion or venlafaxine but they are not FDA indicated medications for attention deficit hyperactivity disorder. Guanfacine in the extended release form is indicated for ADHD in children, but it is also not a generic and is probably at least as expensive.  There is no equivalent medication that can be substituted especially after the patient has been out of the office for a week or two and a discussion of a different strategy is not possible.

I am sure that in many cases the substitutions are made and what was previously a unique decision becomes a decision that is financially favoring the managed care industry. I would like to encourage anyone in that situation to complain about this to the insurance commissioner of your state.  It is one of the best current examples I can think of to demonstrate the inappropriate intrusion of managed care into the practice of medicine and psychiatry.

George Dawson, MD, DFAPA

Adult ADHD treated by Internists

I caught this eye-opening quote in the AMNews the other day: "ADHD is common enough that the average internist has 20-80 patients with this disorder".  The physician interviewed for the article suggest getting collateral data, making the diagnosis over several visits, getting an adequate family history, using a screening instrument and not prescribing stimulants on the first visit.  The final pearl in this column is:"Any patient who gets mad that you are not prescribing a stimulant after one visit should be a red flag."  With about 150,000 internists and another 130,000 family physicians that represents a lot of adults being treated for ADHD.

The physician suggested approach in this case is fairly comprehensive and includes corroborating symptoms in childhood and adolescence, obtaining collateral information, and using a standardized checklist. There is no mention of screening for addiction, discussing prior exposure to stimulants, or the use of performance based testing as opposed to diagnostic checklists. There is also the frequent scenario of a clinic that is set up to do expensive test batteries referring patients to physicians for the purpose of prescribing stimulants and advising the referred patient that they have in fact made the diagnosis of attention deficit hyperactivity disorder.

These are not insignificant problems given the flood of stimulants available on college campuses these days and at least one cultural viewpoint using stimulants as "cognitive enhancers" rather than medications to treat a specific diagnosis. There is also no accounting for clinician to clinician variability in terms of who is prescribed stimulant medication. The largest dividing point is persons with a history of addiction and the associated politics of believing that a stimulant should not be denied anyone with the appropriate diagnosis as opposed to a person with an addiction being placed at risk by stimulant prescription.

The best approach is a network of interested clinicians who have access to uniform diagnostic and treatment methods and who are dedicated to consistent treatment practices that include not treating at least some people with stimulants and using non-stimulant approaches to the treatment of attention deficit hyperactivity disorder.

George Dawson, MD, DFAPA

Christine S. Moyer.  Orchestrating Drug Management.  American Medical News.  May 21, 2012. 55(10): 12-13.

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