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CEimpact Podcast
The Effects of Medication Shortages on ADHD Treatment
Stay updated on ADHD care by reviewing new treatment options and navigating the dangers of medication shortages. With patients at risk from counterfeit drugs and overdose as a result of current shortages, now is the time to arm yourself with the knowledge to advocate for and protect your patients. Don't wait—this course is essential for ensuring the safe, effective management of your patients with ADHD.
HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact
GUEST
Jena Quinn, PharmD
CEO
Perfecting Peds
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Recognize the impact of ADHD medication shortages on patient safety, including the risks associated with counterfeit medications.
2. Discuss emerging ADHD treatment options and their potential applications in clinical practice.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-269-H01-P
Initial release date: 10/7/2024
Expiration date: 10/7/2025
Additional CPE details can be found here.
Hey CE Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and I'm really excited about our conversation today. In this episode, we'll focus on the critical impact of ADHD medication shortages on patient safety and care. With the rise in risks related to counterfeit drugs and potential overdose, understanding new treatment options and proactive solutions is more important than ever. Our discussion today will provide essential insights for navigating these challenges and ensuring the safe, effective management of our ADHD patients. It is so great to have Jenna Quinn with me today to dig into this topic and have her share more about effectively managing our patients with ADHD. So welcome, jenna. Thanks for joining me today.
Speaker 2:Thank you, and thank you, josh, for having me. I will put the big caveat in star in that I specialize in anything from pediatrics up to 24 years of age. So as we talk, I am well aware that adults also have ADHD, but I'm just going to pull from my clinical experience in the youth as well as in the young adult.
Speaker 1:Understood. Great disclaimer, very good. Well, on that note, before we jump in, jenna, I'll let you tell us a little bit more about yourself and then, as you kind of alluded, to your current role in practice and why you're so passionate about this topic, Like, why are you so excited to be with us today?
Speaker 2:Yeah, so my name is Jenna Quinn. I am the CEO and co-founder of Perfecting Peds. Before I will talk about my company, but before I started Perfecting Peds I was a pharmacist for over a decade locally at the Children's Hospital of Philadelphia as well as Cooper Hospital in Camden, new Jersey, and in both those hospitals I was a clinical pharmacist that rounded in the PICU, nicu and GenPeds. I started my company called Perfecting Peds really with the notice and the continued pattern that a lot of times, although the children were being imminent inpatient for these acute issues, that I was constantly intervening on their chronic medication so they would come in and even if they were again acutely ill in the ICU, I really was always identifying that there was areas of med optimization in their chronic med profile. And I didn't know this at the time.
Speaker 2:But there's only 1700 pediatric pharmacists in the United States, which puts us roughly at 0.5% of the pharmacist population.
Speaker 2:With that, as you know, josh, probably they didn't really equipped us very well in pharmacy school with pediatric pharmacology and so it really my hypothesis was, if we pull out the pediatric pharmacist that's been residency, trained, board certified and all things peds practice for some ties upward of decades in the hospital and put them in the longitudinal care setting in the AmCare space, that it would be much more effective, not only for the pharmacist, but also the quality of care and medication management for pediatric patients across the US.
Speaker 2:So that's what we're doing. So, just like you get your pediatrician, we're slowly making it become the standard of care. If you're a medically complex child, you get a pediatric pharmacist that you meet at minimum four times a year and upward of 12 times a year, and, just like any other member of the team, we're your go-to for all clinical services. So, that being said, a lot of our patients do have mental health as a diagnosis, and so, personally, this is something I've struggled with, which I'll share, and I think it's, you know, one of the many ways we're stopping the stigma, but then also making sure, through avenues like this, that we have our healthcare workers empowered to make these recommendations and give appropriate clinical input.
Speaker 1:Wow, that's fascinating. We're taking collaboration to a whole new level with other healthcare providers. That's great. I have a couple of nephews with special needs and I know that my sister will often message me about questions, which, again, I'm not a pediatric specialist pharmacist. Great that, like you know, to have that in your back pocket just to always be able to, to bring that pharmacist into the mix, because there's always medication questions or, you know, the metabolism is different because of the you know, disease state that they have or whatever. So it's just, it's that's great.
Speaker 2:So so good, I have pharmacy a Pete's pharmacy friend so you can always turf them to me. Perfect any amazing Peds pharmacists on our team.
Speaker 1:Perfect, I'm going to start forwarding those text messages when I'm watching my head looking it up, Okay. Well, thanks again for joining us. I want to jump right in because I want to focus on our topic for today, so let's just jump in. I really want us to talk a little bit about just a quick overview of ADHD. You know what's the prevalence right now and what are some of the treatment options that we're seeing in practice.
Speaker 2:Yeah, so a little bit of background, of course. First and foremost is attention deficit hyperactive disorder. So it's a neural behavior disorder that usually presents in children and it can be as young of an age as five or six years old and there's a persistent pattern of inattentionness, hyperactivity, impulsivity or both in many circumstances, and the symptoms include difficulty staying focused, paying attention, difficulty controlling behavior and overall hyperactivity. I don't think for this part of it we'll explore, but there's a very just, like you're saying, organized, structured way to diagnose this, the DSM-5, which is beautiful. But a little bit of background is that, like many children with ADHD do go undiagnosed and I think over the years, just thinking of when I was a child versus now, the recognition and just the willingness to talk about it between teachers and caregivers. I also should add I'm a mom of three little girls who keep me going every day and with that you were identifying it earlier and intervening. We're becoming way more comfortable talking about it.
Speaker 2:But treatments available, as we'll talk about, do show really good evidence and the lack of treatment results in impaired outcomes. And so, as we talk about this, I think if you take anything away from our conversation today is, you know, there's this huge stigma associated with amphetamines. Literature actually shows that starting amphetamines on a patient with ADHD actually decreases their many risks as they age into adulthood. So they have decreased substance use, they acclimate better to society, they have more self-confidence, they're more willing to maintain a job, and so I think all those things, especially as a Peds pharmacist, are things that I think it's our job a thousand percent to destigmatize the treatment of ADHD. And so, if you, you know, take anything away from it, it should be that and the study.
Speaker 2:That really goes against what I think has been ingrained in all of our minds over the years, that it's it's you don't want to. You don't want to treat ADHD because the amphetamines are have such high addiction potential and they're probably doing awful things to the child and really what study shows is the exact opposite. You're setting them up for success by having that symptom control and we will go over things, but we're at a beautiful place now where we can actually intertwine pharmacogenomics into all of our treatments, as we'll talk about. You know, I think the epidemiology behind it all is it's one of the most common neurobehavioral disorders in childhood and, as I stated, it continues into adulthood a lot of times. The prevalence is increasing, with an estimate about 11%, and then the recent estimate shown that 7.2% of children worldwide and 9.4% of children so right around that 10% have this diagnosis. The average age of diagnosis although we do see it again usually around sometimes four or five is around seven years old, and we know that boys are twice as more likely as girls to have this diagnosis.
Speaker 1:Wow, that's fascinating. You know one thing I will interject there. This is it's, it's the whole, like it's not hearsay, because I was in practice and whatnot. But you know you, a lot of people say, oh, they just, they just slap a label on it nowadays, like everybody's diagnosed with ADHD or whatever. But you know you had mentioned that there there is a very complex system that that goes about, like getting the diagnosis. So I know, I know that that could be like a whole, a whole 30 minute episode on just the diagnosis. But but yeah, maybe just briefly talk about how you know if someone does come out with a diagnosis, it is, it's not, it's legit, right, like it's through the process, right.
Speaker 2:It is so. The DSM-5 criteria will work them up to see if they have persistent patterns of inattention or hyperactivity, slash impulsiveness and it will be obvious that it's actually interfering with their function and development. And then they make sure that it's in two or more settings.
Speaker 2:So if you think, of the teachers are pivotal for this diagnosis. So you want to know how they are at school versus how they are at home, versus how they are with work, with relatives. Like I can tell you, my oldest is the most hyperactive thing at home. At school, though, she's a perfect, quiet angel that listens and does very well, so she wouldn't receive this diagnosis because you have to have it in two separate settings. But as like a, as a personal thing, why I'm interested is you know, I was, I was diagnosed with anxiety and as I grow older I'm like I think some of that was, is and still is ADHD, and I think the comorbidity and the comorbid conditions that come with ADHD are it's almost like, as we'll talk about, you're trying to weed out which of the comorbid conditions is the is the most, is causing the most dysfunction or, you know, impact in their quality of life, and sometimes it's like they have so many overlapping conditions ADHD, anxiety, OCD. If you treat the one that's that's bothering the patient the most, a lot of times the other ones will dissipate or decrease.
Speaker 2:But the DSM-5 again there's for inattention or hyperactivity. They have this symptomatology list and so the symptoms have to be present for at least, at least six months. So this is we're taking a long-term snapshot of the child's life. It's not just saying okay, because for a couple of days is this happening, it's a full six months. And again the symptomatology can be has trouble holding attention in tasks or play activities, does not listen when spoken to, does not follow through on instructions, just to give a few examples. And they have to have six or more of these symptoms if they're under the age of 16, or five or more of the symptoms if they're above 17 years old or into adulthood. And so again, this is a pretty comprehensive checklist that they'll say okay, over the past six months, how many have interfered with their life substantially? And then from that, that's how we give the diagnosis.
Speaker 1:Great, yeah, that's great, that's great background. Again, you know you, I just when I was in community practice and when I had my pharmacy, you know filling a lot of those medications and whatnot, and you know, even some parents sometimes would say, like you know, I feel like it's people just the stigma, like they just think that I've slapped a label on my child just to like fix the problem or whatever. But you know, hearing that it's it's a very complex process to really get that diagnosis and to really make sure that this is what is affecting the child. So yeah, that's great, awesome. Okay, so briefly, let's talk a little bit about just what are the current treatment options. Obviously, you mentioned amphetamines. I know that there have been some new novel treatment options in the past as well that are not really in that category. So maybe just briefly touch on kind of where we are with what are the options that we have for our patients who've been diagnosed.
Speaker 2:Yeah, so depending on age group, for across all age groups, specifically those again, it's broken into categories and how you should approach it based on the patient's age. So for four to six years old, the first line of treatment again should be parent training and behavioral management. So behavioral therapy, that's something that we really don't want to just gloss over it should be.
Speaker 2:You know, I think as pharmacists we're always thinking meds, meds, meds. But we have to ensure that the non-pharmacologic things have taken place before we do the pharmacologic. Not to say we shouldn't do them. There's absolutely a place for them. But I think sometimes, especially now with the deficit in psych services, I know for my four-year-old last year she was having massive anxiety going to school Trying to find her a child life specialist that again there's no way I was going to find it covered under insurance. That's a joke. So you think of social determinants, of health. You can't pay for it out of pocket, you're probably not going to get it, and then the closest psychiatrist is 25 minutes away. Of course I did it. But there's a very different type of psychology and whole child life it's play therapy. So again we're talking about health equity. That always, unfortunately, comes into play because that first step can be a huge barrier in getting the right or doing the right non-pharmacologic to pharmacologic approach.
Speaker 1:It's very similar to like you know in your diabetic or your hypertensive patients, where you know those non-pharmacologic things are also important, where you know those non-pharmacologic things are also important diet, exercise, you know nutrition and whatever and often you know you find out that they have a food insecurity and so they can't eat well or they don't have access to healthy foods and so kind of getting over that hurdle as well. So it's interesting that there's, you know, this kind of non-pharmacological thing that's very similar that pharmacists still need to be aware of. Yes, we can take care of the medication part, but we also need to be aware of the behavioral and other things. So, yeah, that's really good to hear.
Speaker 2:Yeah, and as part of our services at Perfecting Peds, like those are the questions we ask. And then we have a social worker and care coordinator that come into the back end and help organize those things. Worker and care coordinator that come into the back end and help organize those things, Because again, we're so inclined to be like all right, let's just add a drug, and it's like wait, hold on, did we do the other things? And a lot of times, just so you, just like you say you identify some blaring issue that they're like no, I couldn't afford it, or I didn't even know where to start, or you know like what's play therapy? So all these things that like you know like what's play therapy?
Speaker 2:So all these things that like you know that we kind of take for granted that we know about in the medical world, and then this does transpose into behavioral classroom management approach. So the teacher has to get involved and then medications can be used for the four to six year olds if the behavioral interventions did not significantly improve the quality of life or the symptoms in 12 weeks weeks and the child continues to have serious problems. For children that are in that 6 to 18 year age range it includes medications alongside with parent training, behavioral management and classroom intervention, so you can usually start both at the same time. But it's really important the younger we're trying not to just throw them right on amphetamines, which we'll talk about.
Speaker 2:So the first line of treatment for ADHD is the stimulants, and so stimulants, it's important to know how they work, because a lot of times that you can kind of like transpose into the other medications that we use that aren't stimulants that work for ADHD. But stimulants block the reuptake of norepi and dopamine in the presynaptic neurons and they stimulate the cerebral cortex and subcortical structures cortex and subcortical structures. So they are first line by far. They have superior efficacy in reducing symptoms and improving academic performance in children and just in all patients. So that is our first line, which one we use depends on their age, not to give a bunch of caveats, but because of a Pete's pharmacist, all these things are things that I need to know.
Speaker 2:But you have your two main classes of stimulants that are our preferred agents, methylphenidate, as well as amphetamine. Methylphenidate, specifically, is preferred in the preschool age, so anyone that's four to five years old. However, when they're greater than six years of age, either one can be used, whether it's the amphetamine or the methylphenidate, as first line, and it's pretty much a 50, 50 split in who will respond to what. So we're kind of just like blindly adding, blindly picking one or the other and starting if they're above the age of six.
Speaker 1:Okay, okay.
Speaker 2:So so that's really about the stimulants, and we want to give that stimulant at least six weeks of a trial run, for lack of a better word to deem if it has failed or not, based off of their symptom control. If that is not effective, we then alternate to the other class. So if you started with a methylphenidate, you rotate to an amphetamine and or vice versa, and you give about. You give six weeks for each one. If that doesn't work, the guidelines actually recommend to start going to other drug classes.
Speaker 2:I will add to, as talking about alternative therapies, like we have to be thinking of side effects in these patients. So is their appetite so decreased that they're not gaining weight? Are they not growing? Are they not sleeping? Are they? So we really, we really have to. I've seen horror stories in practice where you know the child's appetite is is so decreased they're falling off the growth curve and then the doctor adds growth hormone instead of changing them to another drug class. Or they're not sleeping because the parents didn't tell you hey, we're giving it later, at like 10 AM instead of 7 AM, and then we're giving Johnny trazodone and melatonin and every. So it's our job as pharmacists to to not only help select the drug but then to monitor for the side effects. If there is side effects, how are we going to negate them or help the patient work through them?
Speaker 1:Yeah, that's really.
Speaker 1:That's a really great point.
Speaker 1:If I may just jump in there really quick, you know, in thinking about you, know who our listeners are and some of you that are in practice where you're like, okay, well then you know, I know that the question is always how does this affect me here, how can I help or what can I do, and so I think that that's a really good place for you know our learners out there who are in a community practice site or even an AmCare site, and they see patients, younger patients, who are on, like you said, a trazodone or you know something else in addition to it could be just as simple as asking those questions of when, when were you dosing the ADHD med?
Speaker 1:Or maybe we can scoot that up and maybe we can get rid of this medication, because then you know, you, I feel like sometimes it just snowballs and then you just you start, you you treat this part with this, and then, okay, now they have severe dry mouth with the trazodone, and so that you treat this part with this, and then okay, now they have severe dry mouth with the trazodone, so that you know, or whatever, and so where does it stop? So I think that's something.
Speaker 1:Yeah, I think that's something where you know just pharmacists and even technicians you know in that space can maybe ask the right questions to say, hey, you know, have you had a discussion about, like, the timing of the dose, or, you know, do you want to talk about that and what are the drug?
Speaker 2:holidays, like drug holidays if you like, slipping off the growth curve, say like hey, just this is kind of really needed during the summer or the weekend. Can we give them some time off to stimulate their apicate, to help them grow? Because we know that studies show that the drug holidays, of course if it's a complete disservice to the patient and they can't function off of it, but if it's like little tips and tricks like that that we know to cancel on, can like make the biggest difference in the patient's life.
Speaker 1:That's great, that's great, okay, awesome.
Speaker 2:So then we come to this like you know, you have your amphetamines and then a lot of times, you roll them over into one of the literally hundreds of different dosage formulations that we have, which we'll talk about.
Speaker 2:I think the amount of dosage forms can be wonderful, but also an overwhelming disservice for the healthcare providers because they're like okay, well, this one's backward, like where the heck do I go next? And so we will talk through that. It's very experiential. It is not literature-based, because they of course there's not a lot out there, but that's where we thrive in the pediatric space. But you have different ones nowadays. You can give them at night and they start acting in the morning. There's so many different doses, formulations, and I the most. The best advice, which was the most common sense advice I've ever gotten in my career from a mentor, was when is the patient having symptoms? I'm like, uh, like eight o'clock, and like one o'clock. She's like well, what drugs peak at that time? And I'm like oh my god. It was like she was saying like, like, and this was like. 10 years into practice, this isn't't like. Oh, I don't like. Oh, my God, like. Why have I never thought of that?
Speaker 2:Like yes the patient when they're having symptoms literally the times of the day, and then use a drug because there's a million of them that coordinate with the times of the day their attention, or hyperactivity, is peaking.
Speaker 1:Yeah.
Speaker 2:So that was golden advice.
Speaker 1:That's great, that's great, that's great. Okay, so you've alluded to a little bit of the fact that they're back order and whatever, and that's, you know, kind of the meat of really what we wanted to talk about today. And shortages, because you hear about them so much right now, especially in this category of medications, and I do know I have peers that you know are constantly struggling and they're like, oh my gosh, we just got all of our patients switched to this and now it's on back order or you know whatever. So what are? I guess? Obviously we don't want to like call out the ones that are on shortage, necessarily, but where are we seeing the problems and what are some of the solutions? Like what, what can our pharmacists do to try to alleviate the problems? Because it because with this now it's a trickle down effect, it's not only affecting the patient, but it's usually affecting the patient's parents or caregivers, it's probably affecting the teachers, the teachers, the other students in the classroom are probably being affected because of, you know, the lack of of treatment and care.
Speaker 1:So you know there's a there's a large trickle down effect. So how can we as pharmacists, like really get in?
Speaker 2:there and I can tell you like on a personal note, like my daughters both have a bad kid and when they're talking about I'm like, oh my god, they have untreated ADHD and they talk about how disruptive they are and how, like, what bad of a kid they are.
Speaker 2:I'm like they're not a bad kid, like you know. They they're probably just struggling to, you know, control their energy, but it does. It affects the entire classroom and we all had that kid in our class that was like, oh all, right, here we go and it's almost like a show, but it's awful because, you know, it derails everybody in the classroom and the poor kid does not have control of it. So, like, like I alluded to before, probably one of the the best things you can do is ask the patient when they're having symptoms, because or alternatively, say, hey, I noticed, I don't know, I'm just going to throw out here I noticed you're on Vyvanse. When I look at Vyvanse let's see if I can pull this one up Okay, we, when we think of like when it peaks, we think of multiple times, so usually around one hour, and then it peaks again, the metabolite, around three and a half hours. And so really asking them, you know, does that work for you? Does it have good symptom control, without getting, like, even asking too many? If they say, yes, that's when that works. Beautiful for me. I'm well controlled, my symptoms are controlled. When that works beautiful for me. I'm well controlled, my symptoms are controlled.
Speaker 2:Then, just alternatively, we have like a cheat sheet but I know they're available out there I love pearls, I don't know if you are familiar. Okay, so like stuff like that that has like the literally the cheat sheet, or like we made one for our team. But then like go down and say, okay, what are the kinetics, what are some of the things? Even like, without getting too dorky, are they taking it with food? Are they not taking the food? Because it's all going to affect the absorption and when it peaks? But look down and see, okay, they're controlled on by vans. Here's the kinetics. Which drug has the closest kinetics? Or alternatively, ask when do when are you having the symptoms?
Speaker 2:And if they can tell you the time of the day, then just go by the kinetics.
Speaker 1:Okay, so that's what I was going to say. So so, for those of us again that have been out of practice for quite some time, just refreshing my memory what your meaning is like. So, for example, if you say it peaks at one hour and then again at three hours, so like, if they're taking this at 8am, are they having their symptoms at nine o'clock and then at lunch, basically. So that would be kind of what we're trying to do is like okay, so I'm good, but I start getting really, you know, unfocused around the early morning and then again right around lunch, and so if that were the case, then we're going to be looking for a medication that has, you know, around that peak time or, like we talked about before, adjusting the time in which we take it. So maybe if they have a peak time that starts at 11, then and that's the first time they see it then maybe we don't take it till 10 o'clock or, you know, have a snack at 10, or you know, whatever.
Speaker 2:So, okay, all right, exactly, and then no, that's a great, that's a great question.
Speaker 2:Cause sometimes I talk like so dorky, it's like what are you trying to say here, jen? But but seem like, alternatively, like a huge thing is like no, my kids symptoms start when they wake up, like I cannot get them out the door. And so there's a new formulation called journey PM, where you can give it at night and then in the morning it's going to kick in. And or you know, like I, my kids symptoms are the worst in the morning, lunch and when they come back from school.
Speaker 2:And so again, looking at what, what the kinetics are, you can, and then I feel like that's a foolproof way to you know, know, navigate and switch from drug to drug, to drug to drug, because we don't have any other guidance. So we're just like blindly shooting to say, oh, I don't know, we're on Vyvanse, I don't know, let's just start getting my Concerta there, and so it's really a disservice for the patient. So if we think of it in that objective way, we can kind of get our best shot, because there aren't guidelines on like, okay, they were on this, it's on shortage. Here's what you're going to do.
Speaker 1:Right, right, you have to get a little creative. Yeah, that's great, and you know that also makes sense. Now I'm thinking back when I used to fill a lot of prescriptions for for my patients with ADHD and you know they would often have that like 3pm dose or whatever dose or whatever. In addition to you know, like they had a long acting and then they would have an immediate acting at that 3 pm and that was probably because that patient was having was still having some major issues when they came home or when they were at the afterschool program or something like that. So it's really it's kind of I know this is like you said 10 years into practice and you had a light bulb, like it's kind of like a light bulb.
Speaker 1:I knew what that meant when I filled them, but it's really kind of fascinating to see now that like, okay, that was because they were having an issue. It wasn't just to like get them through the rest of the day, it was because they were having some sort of a breakthrough continuation of their symptoms at that time and this is how we were going to treat it. So yeah, that's really fascinating. Thanks for connecting those dots.
Speaker 2:Oh no, no problem. Like I said, mine came like so many years later. Like, have you ever asked the patient when they're having?
Speaker 1:symptoms, I'm like, oh my God, it's as easy as pie.
Speaker 2:Oh my God. No, I have not, and that is like the most you know, common sensing and sometimes not the things that we learn in school. But to that point, I also just want to focus on or talk about, like the drugs that we also use. Because if somebody is having adverse reactions, like I said, like if you're going to put a growth hormone on a kid or you're going to just throw all these sedatives so they can't they can go to bed, please don't like, there's other options. So like, yes, they're not as effective.
Speaker 2:But if you have a, if decreasing the dose or taking drug holidays or doing things are not working, like that snowball effect is real. And that's like what we at perfecting peds. We're like constantly unraveling the mess and it takes months to unravel and you're like, oh my god, how did we get here? Like we're on constipation meds because, yeah, we started an anticholinergic med for them to go to sleep. Now they're constipated. Now they're retaining it's, it's a nasty. Then we're on gi meds. They're constipated, now they're retaining it's, it's a nasty. Then we're on GI meds from the constipation and we have delayed it's, it's a mess. So, again, like taking a pause and saying, okay, this isn't working. We've decreased the dose, we've done drug holidays or, alternatively, we've done two or more stimulants. It's failed. So once you, once you hit two at six weeks, that most likely the stimulants aren't going to work for that patient.
Speaker 2:And so a lot of times, as we talked about, we have the comorbid conditions that can occur. So specifically we take care of high patients with autism, with autism, with autism and ADHD. We have the clonidine alpha agonist, which work beautifully, and we have the brother of clonidine for lack of a better word which is guanfacine, the old school hypertension meds back in the day. But they're great because they do a lot of things. So they help with sleep, which is great Sometimes if you can get the kid to sleep. They're going to have a little bit more symptom control of their ADHD. We already talked about they use. They're used for blood pressure medications, old schools. They're used for even pain. There's some case reports of pain. They're used for ADHD. And then a fun fact we use it for I'm not sure in adults, but in neonates that are withdrawing from opioids, benzos, any sort of substance. These actually regulate their autonomic instability and cause it's a beautiful drug so I love them.
Speaker 2:Obviously one of the side effects we're thinking about. Well, two is are the blood? Is the blood pressure okay, which usually children tolerate it very well, assuming that you're going up in incremental doses, you're not just slapping a huge dose on. And then the other thing is sedation. So two things to monitor for which is why this is just a practice style. I start them on immediate release, get them to a good dose and where they're, and then transfer over to er, because sometimes I'm like I don't, I don't want to shoot high and the sedation is real. That can occur.
Speaker 2:The other one which we can talk about there's two different ones now on the market and I just learned all about Quelbrey and I, you know, definitely want to use it more in my adolescents who again are failing these other drugs, so I should say two. So the norepinephrine intake inhibitor, sostratera. Huge caveat and side effect is it can cause aggression and behavior changes. So you want to make sure that that's communicated to the family and they tell you if that happens. It does not happen in every patient, but I've seen enough for it to really solidify that it is a real, known side effect and can massively infect. Ok, you have maybe have their ADHD under control, but now they're super aggressive in the classroom, so we have to be aware of that. There are pharmacogenomic repercussions, so optimal if you have a PGX. They also have its brother, which is big in Europe for depression, but now it's here in the States called Quelbrey, and that is another drug that we use for ADHD. It does not have the PGX repercussions and although they can't market it, it does have the benefit of if your child has depression.
Speaker 2:Cool two birds with one stone, so really good to know. Cool Two birds with one stone, so really good to know. In that same vein, we have buperion, which I feel like you could use for everything well Buterin, smoking sensation, bipolar ADHD. Yes, the guidelines say, okay, adhd, you have to go with the amphetamines. But if I, if I have a kiddo which just literally just happened a couple weeks ago adhd, bipolar depression, all on different meds, I'm like can we just put the kid on well butrin, like you know? So I I'm all for guidelines, I'm all for evidence-based, but I think when there's, it gets a little foggy because a lot of these patients have comorbidities, and so those are all the non-stimulant options, things that you can think about if, for some reason, they fail.
Speaker 1:That's great and I think you know another take home here for our listeners is, you know again, like what can I do? I think we can approach it. I feel like sometimes we're so hands off on the PEDS patients because they're PEDS and you know they're little people and you know I can't, you know whatever. But I think approaching it in the sense of just like we do with our adult patients and saying, okay, we've got them, they're on a lot of different things. Is there something we can get rid of? Is one thing causing the other?
Speaker 1:That's causing the other, that's why they're on this and you know, doing almost like a med rec and just really kind of looking at the whole situation and seeing like, is there something like in the sense of the bupropion? Is there something that could kill three birds with one stone? Like can we just can we get rid of some of this stuff and really just kind of make life easier for the patient and the parent and the teacher and you know whatever. So yeah, that's really great information, just to kind of realize that. You know, yes, it's a whole different breed of a patient. They do have different. You know metabolism and kinetics and whatever. But in the same sense. We can still approach it the same way we do with our adult patients so.
Speaker 1:I want to dig in with a few minutes of our leftover time here and just really talk a little bit about those drug shortages and you know we've talked about now looking at the list of you know what else has the similar peak times and this is how you can do kind of that transfer, because there's no, like if they were on two milligrams of this and they should be on four milligrams of this, like there are no bridge documents, you know.
Speaker 1:So that's really good advice to help, because I know a lot of people struggle with a lot of our pharmacists struggle with, like, okay, well, now we're out of this one, what are we going to do now? And we're seeing doctors are now writing for this and now it's on back order or whatever. So that's really good advice as well. Is there any pointers that you can share for our pharmacists and you know team members that are dealing with that as far as like any sort of collaborative tips when calling back to the providers who are prescribing it? Like what, what can we say? Because we don't just want to constantly be like we're out of that one too, you know, or or we, we think this one's a good idea, like we want to be sure that we you know based and we we have our ducks in a row before we give an advice. So any tips you could have on that would be great to share.
Speaker 2:Yeah, and I this is something interestingly that working with providers for now 13 years, directly, like every day, I thought you know everyone has this great communication skills with providers and this massive amount of autonomy and respect. And as we grow our team, I'm like, oh man, this is a skill, like, this is this is a skill. And some pharmacists are wildly intimidated to call a doctor and be like, hey, like this is not what I would recommend for this patient. And so what I have been, like really hounding on with my team, is concise, is better. You know I I hate when my pharmacists say well, I think, or maybe you should consider, or like, be confident one.
Speaker 2:I think that in life, right, like, if we know the guidelines say this or we had a discussion and we we know from the kinetics it's very factual. So I'll say, hey, doc, it's jenna introduce myself. I'm a pediatric clinical pharmacist. I was reviewing johnny's meds and I noticed that, based off of his symptoms, the vivans wouldn't be appropriate. But the kinetics of the concerto would, because and just give very factual like, because Johnny's symptoms are X, y and Z and this is when the meds peak. Would this be something you would consider? And I always leave an open-ended question, and that's my sales girl mentality, because I've had to learn that skill starting my own business but would you be open to that?
Speaker 2:Or what are your thoughts? Thoughts, but giving a very concise. Here's my recommendation, with confidence. Here's why I'm thinking it, whether it's again as concise as possible. The literature shows, or this guideline is, or the kinetics are. So they're not, they know, you're not like coming out of left field and just like being a pain in their butt because, like sometimes when I call, they're like oh god, a pharmacist, and I'm like and then tell them I don't own a pharmacy, they're like well then, what the hell are you doing? And so, yeah, it's just why are you promoting this?
Speaker 1:yeah, why are?
Speaker 2:you. I'm calling you to give you clinical advice. They're like oh god, so I think again. Confidence, short, concise, here's what I recommend very objectively. Here's why. Here's why I think it would be best for the patient. What are your thoughts is? This something you consider our team. When we approach it like that, we have a 98 acceptance rate. But it is. It is an art yeah, it is again you, I, I swear.
Speaker 2:We have now nursing uh care managers who make sure all of our recommendations are implemented. The one who leads it is has been a pediatric nurse for 20 plus years and I swear her confidence. And because we give her all the literature and how she articulates to the providers, whether it's via phone or concisely via fax or concisely via portal, they're like oh, that makes sense, but even coachings we have. Take Rutgers students. I was coaching the students. I'm like, when you cannot say I think or I feel or I, it sounds so silly, or I'm sorry, I'm sorry, I'm sorry, I'm so sorry, or I'm sorry, I'm sorry, I'm sorry, I'm so sorry, I'm so sorry.
Speaker 2:Sorry to brother you yeah, exactly all these little things they pick up on and they're like what are you? Are you doing something wrong? Do you not know what you're? You're not what you're talking about. Do you know what you're saying next?
Speaker 1:and like I think those naturally occur as you mature in your career, but they're so important yeah, they're so important and I think the conciseness is important and that's a lesson for everyone, especially myself. I'll step on my own toes. If there's one thing I'm not, it's brief. Usually Brevity is not one of my fortes, but that's okay. I'm learning and trying to be better. But yeah, you're exactly right trying to be better. But yeah, you're exactly right. Giving them the facts and and being confident with the facts and then not just word vomiting, more and more and more because they're busy and very busy yeah.
Speaker 1:And you know, honestly, the, if the confidence comes across to them, then they're going to trust you and it, you know, especially if there's good results for that patient and then the next time you call they're going to trust you and it, you know, especially if there's good results for that patient and then the next time you call they're going to trust you more, because you fixed Johnny right the first time, so now we're going to fix Susie, and you know, I think that that is it's really easy to to kind of gain that trust and that confidence, especially if you know, like you said, you're you're not even in that community setting where you're calling the same doctor multiple times, if you're calling the same practice over and over, because you have 20 of their patients at your pharmacy, it's going to be way better and way easier for you to gain their trust and then you're actually going to think of you as a thought partner in the future.
Speaker 1:They're going to actually probably reach out to you when they have a problem and ask your opinion. So, yeah, so that's great, Great advice. So be confident, be concise, evidence-based and give the facts, Like you said. Don't just say we should switch to this one, Like why? Why should we switch to that one? Because there's symptoms and here's the peak times.
Speaker 2:I know what I'm talking about't want to just say there's a shortage. They're going to be like okay of course they're.
Speaker 1:Yeah, what do you want me to do?
Speaker 2:we know that. But, like I think how we gain trust as a profession is hey, doc, there's a shortage of vivance. I would recommend this other drug based on the kinetics that we have in stock. Does that work for you? Could you send over another script, like the confidence and then giving them the solution is is a game changer. Cause that's as a profession, that's what we need to do. We need like we can't just say, oh, there's a problem and let me put it back on you to to figure it out, we're the med experts.
Speaker 1:Exactly, exactly, okay. So in our last, last couple minutes I do want to touch on, because I think this was the impetus for this episode coming out. You know, was some of us, when we were sitting around looking at topics, we saw an article that was talking about the medication shortages, especially for ADHD meds, were leading to patients taking counterfeit meds. And you know, have you seen that in practice? Is that something that you feel like has been a big problem? And maybe just from your professional advice, you know to offer to our learners out there? You know, like be aware of this, maybe it's hopefully not an urgent, urgent matter, hopefully we're not seeing it a lot, but you know and what we're getting right and then it could lead to overdoses, it could be laced with fentanyl, you know, whatever. So you know, have we seen, have you seen a lot of that in your practice area or just in general, and maybe are there any tips for our learners out there?
Speaker 2:Yeah, I think that's a real thing to consider. Like a lot of times the pediatricians, depending on their age, and patients a lot of times, do a urine drug screen because you want to make sure, one, that they're taking the med but two, not taking other meds, and there is a high risk of I haven't, transparently, and transparently I probably haven't haven't run into this because I don't know if my patients would tell me I hope not. Like I mean, I am very upfront with our adolescents and and say, like I was a teenager once, like you know, I I was not the best teenager either, so I dabbled in things and so you will be up front, I haven't seen that they have had counterfeit. What I've seen is, just like you're saying, we have johnny who thinks taking the med, but they're really selling it to Sally and that's one. Or Johnny ran out of his meds, his ADHD so bad he's self medicating with alcohol, with THC, with you know any of the drugs he can get ahold of, and I and I obviously that's all correlated Like, if you can't have a patient having good symptom control, they're going to self-seek and they're going to self-medicate, and so I think that's where we can play like as pharmacists, make sure that if there's a shortage, we're on top of it, we're quickly correcting it, getting the patient the medication that works, advocating for them to do the 90 day where they write the three scripts so that they have it, so they don't have to go back to their office every month to get that script filled, like little things, you know, proactively screening.
Speaker 2:Okay, we have a back order. Who are the patients on it? Even if they're not going to fill it for 10 days, why don't we work on just letting their provider let, letting them know what our recommendation is for change? So, to your point, I haven't seen the counterfeit thing, but I have seen in college, like even my personal, like, oh you know, let's all take Tim's, whatever, and methylphenidate or Ritalin, and that's how, like the college students study. Obviously that's something that we want to advocate. They do not do. And then, of course, just I think the best thing we can do is make sure we're proactively planning for these, giving the providers solid recommendations on what to do and making sure that johnny isn't self-medicating with all the other things that we have in the universe that are probably not effective, for I love those.
Speaker 1:I love those tips of being proactive. So you know, if you see that you're out of something, look ahead, see what normally gets filled around that time of the month and go ahead and try to get those changed, because what you don't want to do is wait until it's time to fill. Then you can't, and then it's seven days back from the doctor or before you get the next med in or whatever, because that is when you have the patient start spiraling. So that's great advice. And you know, one of the things I always tell my pharmacy peers is you have to be a detective and I, you know I kind of heard that's what you were saying was you know, if you're seeing someone who is self-medicating with other things alcohol or whatever or if you suspect that, then maybe it's because they're not well controlled, like, you need to do a little bit bigger, a bigger dive into again the kinetics and when should we be dosing and what medication might actually work best for you. So yeah, Okay, very nonjudgmental?
Speaker 2:I think yes, oh bringing it up and being like hey, I noticed x, y and z about you. Is it fair to say that you're like? Have a blunt conversation with a lot of respect and not be judgmental like I'm not? I? I start with all my adolescence with mental health. I'm not here to judge. I've struggled with anxiety and OCD since the age of 12, been on meds since 16. I want you to be as honest as you can with me, because I can't help you if you're not.
Speaker 2:And this is like a sacred place where it's just me and you. I legally can't share anything you tell me, even with your caregivers, so I need you to be as honest as you can so I can take the best care of you, and so that disclaimer helps a lot.
Speaker 1:Yeah, that's great advice, a question we always ask at the end of the podcast, because the name of the podcast is Game Changer. So what is the game changer here? What's the most important point that you want to leave our listeners with as they navigate the challenges around like ADHD, meds and dosing and shortages and things like that? Like, what would you? What would you say?
Speaker 2:this is, this is the game changer here and this is what you should walk away from this episode with the game changer is we have a ton of autonomy, and so if we can all practice at the top of our license like this and and own it, like the drug shortage, isn't the doctor's problem, the medic, that anything related to medications are our problem, not only our problem, but, like we have to, we have the clinical knowledge and the skills to to this, to take care of this, to give great recommendations, and I think every problem or you know, shouldn't say problem, but every hurdle should be viewed as another way to elevate our profession, like COVID, for example. We got to shine in COVID. This shortage, I think, is just a great way for us to show like, hey, providers, we have all this amazing knowledge, we want to help you and then, hopefully, just continue to elevate our profession.
Speaker 1:I love that. The game changer here is to own it and shine. Practice the top of your license and shine. That's great. Yeah, that's great. Well, that's all we have time for this week. Jenna, thanks again for joining us. So much great information. I feel like our time flew by and I could have gone on for hours still learning about other things. So this is great.
Speaker 2:Thank you, Josh.
Speaker 1:Yeah, thank you so much. All right, so if you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I cannot wait to dig into another game-changing topic with you all next week. Thank you,