Brain meds are screwed up, prescriber sucks, advice on fixing?
May 7, 2022 1:57 PM   Subscribe

I am on adderall for adhd, and in February was put on bupropion for depression. I started seeing a psychiatric nurse practitioner at my university when I was floundering in jan and feb and sunk into said depression. She took over my adderall prescription from my gp who was handling it just as a maintenance dose. I think she's doing the wrong things and its causing some problems with insurance and me feeling like i'm on the wrong medications and she's not addressing in a way I'm satisfied with or a timely manner.

Right now, there are issues with adderall for adhd, largely because of insurance problems and slow responsiveness to prior authorizations from her office. She wants me on two different types xr and ir, and a slightly higher dose. I was concerned because my insurance is through the state (medicaid hmo) and in the past they would not let me have two types. I was really nervous about any change because almost every semester since I've been back at school, there has been some sort of insurance issue. But she said it would be fine, and that she's never heard of that being a problem. Of course, it's all gone wrong.

I am now supposed to be taking 25mg xr a day alongside 10mg ir 3x a day.

There seems to be three issues with the adderall prescription:
- She is slow getting the prior authorizations back to the pharmacy
- Prior to this change, the pharmacy only dispensed 58 of 75 of my previous dose, so when they tried to put the prescription through for the two new ones, it exceeded the total number of pills the insurance allows to be dispensed in a month.
- In trying to get around that, she prescribed a different dose for the ir, 20mg to be broken in half and taken 3x day. though she wrote it to be take 1 tab in morning, .5 tab in afternoon out of concern that they may not like a 3x a day dosing schedule (though I was prior to this) The max limit is 136 a month.
- The pharmacy is confused and seems to think I'm supposed to be on a lower dose, not two different adderall pills at different doses and delivery methods. When I explained that I actually dropped both prescriptions off at the same time, and that only one was rejected because of the aforementioned pill limit, they even said they didn't have a record of the xr prescription I already picked up. I told them I was holding the bottle in my hand and could come in and show it to them if they had any questions.

On top of that, I am concerned because we switched my bupropion dose from 150 sr to 150 XL, I feel like my depression has been back sliding since then, and my adhd symptom control has not been as good. We switched because on the sr, I was having a serious issue with depressive symptoms at night and when I first woke up. Adderall and buproprion have are synergistic; which is why she thought adderall was a better, I would get more affect quickly and we're nearing the end of the semester. She also felt that I had likely become tolerant to the adderall, that it could have been what lead to my depression, so thought this would help the quickest.

I saw her yesterday, which was my two week checkup from when we were supposed to have started the new adderall dose started. Even though we discussed the prior authorization issue a few days ago, she said she just got it from the front office right before my appointment. I again reiterated that I thought depression right now was a bigger deal. But also I wasn't sure what I should do given I'm on a smaller dose of adderall because of the insurance stuff. She said she would finish up the prior authorization right after I left. The pharmacy said they did not get it yet.

I am frustrated, all I want to do RIGHT RIGHT now is go back to my old dose of adderall and through my GP because she is more responsive. But because its a controlled substance and because insurance is involved, I don't think I even CAN.

On top of that, I do think the depression needs to be addressed, because it seems to be the difference between feeling like a failure and basically being ready to give up, and recognizing the hurdles I've faced are not a reflection of me as a person. The difference was profound when it was working. I've also not regressed to where I was prior to being medicated, but I'm not in a great headspace.

I know that there are some issues with the XL formulations between brand and generics. I also don't know if its because the peak concentration taking the XL would not get as high as the SR taken once a day, even if the same total amount. I brought this up to here again, saying that I didn't know what it was, but I felt like we needed to address that. She still wanted to try the adderall change first, and as mentioned above, said she'd finish and fax the prior auth as soon as my appointment was over. She obviously did not.

I am so frustrated and I don't know where to take this. I don't have another psych lined up, when I saw her, I was at a low point and the welbutrin did seem to help, so I wasn't really thinking of switching providers, just getting through the semester. Now though, she or her office at the university is dropping the ball and feeling incredibly frustrated, and not sure what options I have.

Any advice on how to approach this? I'm lost, I feel like my hands are tied but also that this is unacceptable. I just don't know how to get out of this limbo, be it going back to my old prescription or getting the issue with the new dose sorted. And I don't know what to do on the welbutrin front, but I do feel as though that is pretty important as well.
posted by [insert clever name here] to Health & Fitness (8 answers total)
Response by poster: Oh, I forgot to add, I cannot pay out of pocket for the adderall prescription that the insurance won't cover because its through the state. If I do, I risk losing medicaid. That seemed like the "easy" option, especially as goodrx brings the price down to "not insane" and while I couldn't do all the time, could swing it one time. But when I asked about that, they said that was the issue. If it wasn't a covered medication, I could self pay. But as a covered medication, I can't because let's make this that much harder?
posted by [insert clever name here] at 2:06 PM on May 7, 2022

I'm sorry you're dealing with this. As a physician who prescribes brain meds (though not Adderall) I will say that the prior auth process has gotten MUCH worse in the few years. I have a staff of 3 whose entire job is PA, along with a pharmacist and 2.5 social workers to assist, and we repeatedly have issues where we send things in, get a fax confirmation that it went through (we keep these confirmations, because CYA) and the insurance says they never received anything from us. Or they supposedly send requests for more info, but we never receive them, or get them weeks later (because I can see the timestamp at the top of the fax when it was sent). I have personally faxed or electronically signed things, have called for appeals, and am getting the same runaround.

Just to point out that it's not necessarily your new NP being flakey; this is a system-wide issue in the US. Unfortunately the only workaround I know of is out-of-pocket bridge prescriptions (which aren't an option in certain circumstances, as you describe).
posted by basalganglia at 3:06 PM on May 7, 2022 [7 favorites]

Was the information that you risk losing medicaid if you pay for something out of pocket from the pharmacy? I would try to verify that with someone from medicaid itself.
posted by needs more cowbell at 3:16 PM on May 7, 2022

I am not a mental health care provider of any kind and it's possible you know this, but: any port in a storm, and in a bad enough storm, caffeine is similar enough to the Rx ADHD meds to get by.

I am confused about whether the ongoing prior authorization (PA) mess has caused you to actually drop your adderall dose or start withdrawing, or if you're just afraid it's going to do that. In either case, going from adderall or ritalin to nothing is a nightmare, cognitively and emotionally, and I don't recommend it.

If there are formats of caffeine you tolerate (soda/coffee/pills/whatever), I would look into sourcing those immediately.

Caffeine and buproprion also synergize, and insufficient stimulant usage can be hard to distinguish from depression in a bunch of adhd people.
posted by All Might Be Well at 3:51 PM on May 7, 2022

Response by poster: To clarify, the Adderall mess has meant the last week I have only been taking 25mg xr daily. Prior to Monday I was taking 50mg daily as 20,20,10. The first week I had a weeks worth left. But as it’s stretched into week 2, I don’t.

I did try doubling on my own because I am dragging so bad. But it was over stimulating even though the same dose and I could not sleep that night at all. I told her that I tried it once and she advised I not do that again because the xr is stronger.

The issue I noticed with depression resurfacing happened before my adderall dose change/reduction. In fact, I didn’t actually realized it had until talking to a friend about how helpful it’s been, except once I started explaining, I realized for the week prior, it had not felt that way.

I have been adding a small amount of caffeine, but any more sends my anxiety through the roof.

Right now, I do strongly feel that the depression is more of an issue. I do understand that withdrawing from Adderall use in part or full can have similar effects, but it it was two weeks on the bupropion xl before the Adderall change/problems and I was noticing the problems- 1 week when explaining to friend and then another week of feeling “yeah it’s getting worse”. It’s even worse this week, but I don’t know if it is Adderall withdrawal from a smaller dose, or a continuation of worsening depression. Or both.
posted by [insert clever name here] at 4:18 PM on May 7, 2022

If your GP was ok with prescribing your Adderall and was better at handling the pre-authorization stuff, it would be worth it to check in with them, explain your current situation and see if they would be willing to Rx both the Adderall and bupropion. If the psych NP is providing any kind of counseling along with prescribing you could continue with her for that but I sympathize, she sounds awful at managing the admin stuff that is really important for patients to get the meds they need. My experience with GPs is that they are much more willing to prescribe antidepressants than stimulants so this may be no big deal for yours. Good luck!
posted by Jemstar at 4:31 PM on May 7, 2022 [1 favorite]

I am a psychiatrist, though not yours. I don't quite understand the thought process behind what's happening with your meds, and a lot of what your provider is telling you does not make pharmacological sense. My recommendation would be to see a psychiatrist or go back to your GP (assume they are an MD or DO), until your psychiatrist referral comes through.
posted by namemeansgazelle at 5:33 PM on May 7, 2022 [4 favorites]

Response by poster: Can I ask what doesn’t make sense? Some of it didn’t make sense to me either, but I was trying to not be my know-it-all, engineers disease self and assume because I did some googling that I knew better.
posted by [insert clever name here] at 7:20 PM on May 7, 2022 [1 favorite]

« Older My rent was paid in full, but a new charge popped...   |   Deck screws replacement Newer »
This thread is closed to new comments.