1. Home>
2. Specialties>
3. Psychiatry>
4. Summary and Comment

The Right ADHD Dose

A second-opinion Medicaid program reduces overuse of ADHD medications.

Psychotropic medications are increasingly prescribed to children (see JW Psychiatry Apr 1 2000), leading to concerns about overuse. These authors developed an ADHD prescription safety program for children enrolled in fee-for-service Medicaid in Washington State.

The program required second-opinion consultations for prescriptions of stimulants and atomoxetine for ADHD that were above safety thresholds. These thresholds were high doses (e.g., dextroamphetamine >60 mg/day; methylphenidate or atomoxetine >120 mg/day), young age (children <5 years), or combination prescriptions for longer than 30 days. Preselected committees of community practitioners provided the second opinions.

The database included approximately 21,000 children taking medication for ADHD; around half were aged 6 to 11. Drugs were prescribed by primary care physicians, psychiatrists, nurse practitioners, and physician assistants. Five percent of prescriptions were above the thresholds. Dosage adjustments occurred in 51% of these prescriptions after second-opinion committees requested records for further review (25% of prescriptions were altered before reviews occurred). Adjustments were made to prescriptions from all types of prescribers. After implementation of this program, high-dose prescriptions decreased by 53%, combination prescriptions decreased by 44%, and children under 5 years receiving medications decreased by 23%. Costs did not decrease because many clinicians prescribed newer, more expensive brands.

Comment: At doses lower than these guidelines (i.e., 40–60 mg), methylphenidate saturates the dopamine transporter (presumably, the mechanism of action of stimulant drugs). Therefore, the study thresholds might have been overbroad, possibly leading to an underestimate of inappropriate prescriptions. Nevertheless, these findings support the effectiveness of monitoring. Clinicians should keep in mind the high rate of noncompliance with stimulants (JW Psychiatry Jun 22 2009) and consider this possibility before increasing or adding medications.

— Barbara Geller, MD

Published in Journal Watch Psychiatry July 13, 2009

Citation(s):

Thompson JN et al. Second opinions improve ADHD prescribing in a Medicaid-insured community population. J Am Acad Child Adolesc Psychiatry 2009 Jul; 48:740.

• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• ADHD and EXECUTIVE DYSFUNCTION
  NITI MANOJ SAPRU, 28 Dec 2010 11:46 AM EST
  Specialty: Child & Adolescent Psychiatry
  Executive Dysfunction( ED) and The Pre Frontal Cortex(PFC) are intimately linked . The PFC is the primary seat of neurological... [more]

2011 Year in Review