What is the best course of action for a 61-year-old female patient requesting a bridge prescription of Adderall (amphetamine and dextroamphetamine) until she can establish care with her new psychiatrist?

Management of Adderall Bridge Prescription for a 61-Year-Old Female

A bridge prescription of Adderall ER 20mg is appropriate for this stable 61-year-old female patient until she can establish care with her new psychiatrist. 1

Assessment of Current Situation

The patient presents with:

• Previously established care with a psychiatrist (Dr. Cobb)
• Upcoming appointment with a new psychiatrist
• Stable on current medication regimen
• Slightly elevated PHQ-9 and GAD-7 scores, but patient reports feeling stable
• No new or worsening symptoms of depression or anxiety
• No suicidal or homicidal ideation
• Appropriate affect during visit
• Adderall has been effective for her symptoms
• PMP check shows no signs of medication abuse

Bridge Prescription Recommendations

1. Medication Continuation:

   • Continue Adderall ER 20mg at current dose
   • Provide only enough medication to last until the upcoming appointment with the new psychiatrist
   • Document clearly in the chart that this is a bridge prescription

2. Monitoring Considerations:

   • Verify the date of the upcoming psychiatry appointment
   • If the appointment is more than 30 days away, consider providing a partial refill with a follow-up appointment in your office

3. Documentation Requirements:

   • Document the PMP check showing no signs of abuse
   • Note that the patient is stable on current regimen
   • Record that this is a time-limited bridge prescription
   • Document the upcoming psychiatry appointment date

Important Considerations for Stimulant Medications

Safety Considerations

Amphetamine medications like Adderall require careful monitoring, especially in older adults:

• Cardiovascular Effects: Monitor for hypertension, tachycardia, or other cardiovascular symptoms 1
• Psychiatric Effects: Watch for signs of worsening anxiety or mood changes
• Potential for Abuse: While the PMP shows no signs of abuse, continued monitoring is important as Adderall is a Schedule II controlled substance 1

Rationale for Providing Bridge Prescription

1. Continuity of Care: Abrupt discontinuation of stimulant medication can lead to withdrawal symptoms and return of ADHD symptoms 2
2. Patient Stability: The patient reports effectiveness of current regimen with no concerning side effects
3. Established Treatment: The medication was previously prescribed by a psychiatrist, indicating appropriate diagnosis and treatment plan

Common Pitfalls to Avoid

1. Prolonged Prescribing Without Specialist Input: Ensure the bridge is truly temporary and that the patient follows through with the psychiatry appointment

2. Inadequate Documentation: Clearly document the rationale for continuing the medication, the PMP check, and the limited nature of the prescription

3. Failure to Consider Age-Related Factors: In older adults, be particularly vigilant about:

   • Cardiovascular effects of stimulants
   • Potential drug interactions with other medications
   • Possible changes in medication metabolism due to age

4. Missing Signs of Misuse: While the PMP shows no concerns, continue to monitor for any signs of medication misuse

By following these guidelines, you can provide appropriate continuity of care while ensuring the patient transitions smoothly to her new psychiatrist for ongoing management of her condition.