The Rise in ADHD Diagnoses & Access to Care: A Conversation with Dr. Mina Boazak

In this episode of Thriving with ADHD, host Nada Pupovac sits down with Dr. Mina Boazak, founder and medical director of Animo Sano Psychiatry, to unpack some of the biggest conversations happening in the ADHD community today.

Together, they explore:

• The sharp rise in ADHD diagnoses among adults and what’s driving it
• Common misconceptions about ADHD in adults
• How telehealth is changing access to care
• The impact of new prescribing regulations on patients and providers

Dr. Boazak brings his experience as a psychiatrist and thought leader to shed light on these issues, offering insights that matter to anyone navigating ADHD or supporting those who are.

Whether you’re living with ADHD, supporting a loved one, or working in mental health care, this conversation will give you a clearer picture of the challenges—and opportunities—shaping ADHD treatment today.

Thank you for listening to Thriving with ADHD. This show is produced by Animo Sano Psychiatry. For more information about our clinic, please visit animosanopsychiatry.com.

Animo Sano Psychiatry has introduced new services for enhancement of our patients' mental health - ASP Concierge and Health & Wellness Program. Please visit our website to learn more.

Animo Sano Psychiatry is constantly looking for the talent in behavioral health. If you are a psychiatrist, nurse practitioner, physician assistant, or mental health therapist, we'd love to hear from you. Visit our Careers pages to learn more about the available positions. https://animosanopsychiatry.com/careers/

Transcript

 Access isn't bad. We're, we're improving access to care. Let's not go backwards

Welcome to Thriving With adhd, a podcast we'll share every day practical tips to thrive in life as an adult with adhd.  This podcast is brought to you by Animo Sano Psychiatry, a behavioral health practice with a specialist ADHD clinic based in North Carolina. And this is your host Nada Pupovac.


 Welcome to Thriving with a DHD dear A DHD community, and welcome to the new season. Before we jump into today's conversation. I want to sincerely thank each and every one of you for listening to our show.

We hope that the show has been helpful in managing your life with A DHD.  This month we are exploring some of the most pressing topics in the A DHD community at the moment,  the sharp prize in adult A DHD diagnosis, , the role of telehealth in improving access to care,

and the potential impact of new prescribing regulations on patients and providers.  Our guest speaker is Dr. Mina Boza, the founder and medical director of Animal Ano Psychiatry. Mina is a psychiatrist and a thought leader in A DHD space who is passionate about expanding access to quality mental health care.

His work focuses on balancing clinical excellence with practical solutions for patients navigating the challenges of A DHD.

 Welcome back to the show, Mina. I am delighted to have you with us again, as mentioned in the intro, uh, a rising A DHD diagnosis as well as telehealth and online prescribing regulations are the hot topics in the A-D-A-D-H-D community at the moment. And I feel like there is no better person to explore this subject with than you as Anos founder and also thought leader in the A DHD space and  psychiatry in general.

So welcome back and I really can't wait to dive into the questions with you.  Thanks, nada. That was, um,  a really kind introduction. Uh, I will  say to anyone listening, what I usually, uh, have in presentations that I give to, to different groups, uh, which is just like. John Snow for the Game of Thrones fans. I know nothing, , I, I hope, , that you'll for, forgive me when I do make errors, but I'll, I'll try to be helpful and informative as best as possible. 

, well, humble is always, but I think,  I think you're exactly the right person to talk about this. And of course, we don't have all the, the answers here, but we are doing our best and  to help our community to find the answers, , with the conditions. So, yeah, let's, uh, get started with the first question and that's, uh, why are we seeing such a sharp rise in, uh.

Adult, A DHD diagnosis in the United States. And, uh, how do the new clinical guidelines aim to bring more consistency and accuracy to these, , diagnosis? 

 Whenever I talk about A DH adhd, and I, I hope you'll forgive this, not a, um, I, I like to emphasize, uh, something to listeners  as  un unfortunately, in, in the world of psychiatry,  A DHD remains to be one of , these diagnosis that's still called into question.  Is it really a problem?

Is it really a condition? Uh, is it, uh, just someone being lazy? And the reason I like to bring this up is because I, um, I hope, uh, for, for the listener, I can establish a minimum, uh, agreeable standard as to how it is we make diagnoses in the world of psychiatry and, uh, why this applies to A DHD and the, the suffering from A DHD.

And then we could talk about the, the sharp rise. So first of all, uh, in the world of psychiatry, uh, we've, uh, based on the a PA, the World Health Organization, the NIMH, uh, classically defined mental illness as a combination of symptoms typically in emotion, thought or behavior and distress or dysfunction.

Uh,  so symptoms and. Distress or dysfunction? You could have symptoms. Uh, like, uh,  I don't know. My, my wife always, uh, makes fun of me when I give examples about nose picking. But let's say your symptom is picking your nose. Okay? Uh, but if you don't have distress or dysfunction, uh, you're not bothered, they'll surround you aren't bothered, it's not negatively impacting your life, then your nose picking is not a disorder or disease.

 In the case of the conditions we have in the world of psychiatry, such as depression, anxiety,  A DHD, there are a constellation of predefined symptoms that represent what we typically see in a cohort of patients that kind of closely resemble each other. And due to those symptoms have either suffering direct to them or are, uh, witnessing negative impact in their own life that then leads to treatment.

Now, I said individuals, I kind of closely resemble each other because the reality is in the world of psychiatry, our, our diagnoses are heterogeneous. Meaning, uh, no one diagnoses represents just one clear, uh, underlying cause. There are multiple things to that that cause A DHD as we're talking about A DHD and what we, uh, call A DHD,  can represent so many different things.

And if, if it was just one thing, then we would, uh, get closer to a more definitive, consistent treatment. Um. That is not to undermine, uh, a later statement which I'll make about the mainstay treatment of A DHD, um, which is very effective. Uh, but that also isn't in contradiction with what may feel like cognitive dissonance.

The fact that A DHD is heterogeneous, and if it was a homogenous entity, our our treatments would likely be. Uh, much more targeted and effective. Mm-hmm. Uh, regardless. Uh, so symptoms, distress or dysfunction. In the case of A DHD, you have the inattentive and procrastination symptoms and, um, the, the consequence outcomes.

Uh, but inattention, procrastination, hyperactivity, impulsivity, that's all just a character flaw. And boy, oh boy, wouldn't it be great if it was, because then you could perhaps do something behaviorally to consistently help people. Um. But it, unfortunately, it isn't the case. Uh, I am, as you know, nada, I'm mm-hmm.

I'm AI person, and I occasionally, uh, peruse Reddit about the latest AI trends and the other day mm-hmm. I, I saw a Reddit post, um, uh, that went something along the lines of, uh, I recently asked chat, GPT what it would do if it were the devil, and it wanted to ensure a person did not succeed in life. Hmm. Uh, please look this up.

I'm, I'm not making this up. This is a, a true Reddit, uh, thing that someone posted and I reproduced it with chat, GPT. Mm-hmm. Incidentally, uh, four of the eight things that came up were procrastination, time blindness avoidance, um, A DHD symptoms.  Oh my God. So how is it that you prevent someone from succeeding in life, not just professionally, but personally?

Uh, give them a DHD symptoms. Uh, A DHD is a real condition. Um,  and, you know, we're not even talking yet about the fact that it is, uh, one of the most her,  uh, behavioral health conditions in the world of psychiatry. Yeah. Uh, it is a real condition and it causes real problems. Um, it cuts people's lives a little bit shorter. 

Uh, treatments for A DHD improve survival rates and all cause mortality in individuals who have the condition.  Uh, so that's, that's my preface. It's a real condition. Uh. If, uh, I, I hope at the, the very least, if, um, you're uncomfortable with acknowledging that it's a real condition that your discomfort, uh, apply to, unfortunately, to the world of psychiatry as a whole, because at least that doesn't mean we're biasing ourselves to just this A DHD space.

Uh, and, um, and do something about it. Ask for better ways for us to study our conditions, ask for more government funding, um, which is desperately needed right now to, to improve our understanding of what will hopefully be eventual homogenous conditions as opposed to heterogeneous conditions. Uh, mm-hmm.

So, A DHD, very real, um, why do I preface this around the spike. Um, an A DHD diagnosis and a DHD treatment? Well, because if you believe that A DHD is not a real condition, or its treatment is a mere source of abuse and nothing more, then the spike in diagnosis and treatment is a really bad thing. Rightly so.

Mm-hmm. Uh, if we're, if we're increasing, uh, the diagnoses of this thing that isn't a real condition, that's a problem,  uh,  that is not my belief. Uh, mm-hmm. I,  I do think there, uh, are misdiagnoses rates in, in the world, not just of psychiatry, of he, but of healthcare, uh, and that, uh, is innate to clinical evaluations on the whole, uh, we have no present 100% sensitive and 100% specific test for the evaluation of.

Any behavioral health condition, what does that mean? That means there is no test that allows me to say with definitive certainty that the patient I am seeing who I think has depression anxiety or A DHD truly has depression, anxiety or A DHD. That is the clinical problem. Um, that is a problem of clinical care, uh, and will remain to be a problem of clinical care well into the future.

It's not a problem that AI will solve, uh, for, for, uh, the ai uh, enthusiasts out there. Mm-hmm.  Uh, so, uh, going into, uh, with my circumstantial, uh, thought, the, the, the spike in a DHD diagnoses, the, the short answer is access to care.  Uh, the reason we saw an increase in A DHD diagnoses and the CDC did a report on this, um, uh, by late 2023 roughly, uh, 6% of adult Americans, uh, were diagnosed with a DHD, 50% of whom were diagnosed via telehealth.

Hmm.  Now, does that mean that all of those individuals received treatment? Absolutely not. Only 30% of those individuals, uh, were on the first line choice. And this is not based on Mina Bozas opinion. This is based on almost every single international guideline  that exists on the topic of a DH ADHD treatment.

None of them were on the first line treatment, uh, of choice, which are stimulant medications. Uh, or no, not none of them. Only 30% of them. We're, we're on a first line treatment of choice. Um, why is it that that's the case? Well, 70% of them reported having difficulties with access to treatment. Um, a challenge that, uh, has related to supply chain management.

Um, and we've seen a lot of back and forth between pharma and the DEA about who's responsible for what without clear solutions, uh, being developed to address the, the problem. Hmm. Uh. So the, the spike is due to improvement in access in care. I would posit that there is no clear evidence that the, uh, increase in access to care has resulted in a change in the proportion of misuse or divergence of the medication.

So I'm, I'm very, I I wanna be clear about that word proportion, not absolute counts. Mm-hmm. If I have a hundred people, and I, so I said earlier, sensitivity and specificity. Um, so say I, um, I'm able to diagnose with certainty, um, 90% of those individuals that leaves 10 people, um, being misdiagnosed with let's say a DHD, who then I, I go on to treat with, um, the first line treatment.

If, if I'm following guidelines.  Well, um, it, what if another five people, um, so 5%, uh, are malingering, they're faking symptoms and I only catch one of them. So, uh, 1% it will, let's make it, let's not complicate the numbers. So 5% are malingering, um, and I don't catch any of them. And I also treat them with the first line, um, treatment of choice, which is stimulant medication.

Um, unfortunately that means there are 15 people, five of whom are abusing the medication and 10 of whom. Uh, uh, I think they have the condition when they don't mm-hmm. Who are on a treatment that doesn't represent the, the best treatment option for them. And I would posit that Malingerers are suffering with something.

It's not a DHD. Um, and perhaps, uh, there, there should be some form of therapy that happens with them, but the, the treatment for them is not stimulants. Um,  what if I increase those hundred people to a thousand people, um, because a thousand people now have access to care? Well, , if my, uh, error rate is still that 15%, then 150 people, um, fall into, into that category of receiving the wrong medication.

So the, the problem here is not an issue of we have.  Uh, more proportions or a higher proportion of abusers, but we have an absolute increase of misdiagnoses and, um, abuse rates. The  where we struggle then is societally, we haven't decided  what it means to increase access to care and whether or not we're willing to take on, um, the consequences of treating in additional 850 people, um,  when we know that the proportion change in malingering will not change.

, so if, if we wanna say, hey, we're not comfortable with, uh, an additional a hundred and, uh, an additional, um,  135 individuals, um, being treated with the wrong medication, uh. Then we're also necessarily uncomfortable with the additional, uh, I, I'm, I'm not gonna do the math well enough. Mm-hmm. But call it 700 and, uh, I think it's 65 individuals, uh, receiving care.

Uh, the, it's not a telehealth issue that we're struggling with. What we're struggling with is a healthcare system that has imperfect beings and imperfect diagnostic processes, which will remain to be the case well into the future as we continue to slowly iterate upon that imperfection. Um,  so it has these imperfections and we're struggling with.

What are tolerances as a society, uh, for what it means to broadly increase access to care, uh, despite, um, that meaning that that will also mean, uh, a proportionate increase in misdiagnosis rates and, uh, a proportionate increase in access to the malingers.  Uh, um, I hope what I said just made sense, but, uh, ultimately the, the, the sh the short of the long of it is the reason we're seeing increases is because of access, because, yes.

And the, that would be, I, I would just quickly reflect and try to summarize, so.  First, and for foremost, A DHD is a real condition. So there is, it's not a character flaw, uh, although it would be very convenient that it is, but it's not. And, um, it's good that people have access to care, to access to diagnosis, access to, uh, medication.

But with that, because,  um, diagnostic is not perfect, humans are not perfect.  There is a room for error and there will always be a proportion of people who will be receiving treatment that it's not supposed to be for them. Um, so I suppose it'll always be a possibility and it'll always be happening. Um, but

this shouldn't affect the majority of people who actually do need the care.  So that, that's my, that's my understanding from, from everything that you said, and probably the, um,  professionals and people working in mental health space probably should be advocating for the, um,  for profession and for their patients to get proper access to care.

Maybe that's one of the, the answers here.  Oh, 100%. Yeah. And I, I would, um, so  it is my opinion that, and not just my opinion, but um, certainly most of the medical societies in the United States that have come out to, to comment on what we'll soon talk about, which is mm-hmm.  Um, uh, regulations around telehealth.

Yes, yes. Uh. That access to care in and of this itself is not a bad thing. Um, and what I'm saying isn't, Hey, uh, our diagnoses processes in, in the world of healthcare are imperfect. Let's just accept it willy nilly and that's it. Yeah, no, uh, we, what we need to do is identify,  the  real causes of the challenges before us and work to address them in a fashion that truly moves towards improvement as opposed to a fashion that, uh, artificially, um, minimizes absolute counts and, , limits access to those who truly suffer.

, the reality is.   Uh, outside of the world of A DHD, outside of the world of patients who are managed, uh, with scheduled medications, there are still imperfect diagnostic processes.  Yeah. And there will still be an absolute count of individuals who, um, receive, uh, medications that they should not be receiving because our diagnostic symptoms are, imper systems are imperfect.

Yeah. Uh, the, the, the discomfort with scheduled medications is due to safety. Certainly. Um, and we could minimize the risk by implementing systems that minimize the absolute counts that any one person, uh, receives. Certainly at the start of a clinical relationship.   Thanks. And, uh, yeah, I, I would definitely, uh, move on to the next topic.

And that's the role of telehealth in, um, making the A DHD evaluations and treatment more accessible, which we said it's not a bad thing, it's a good thing. And, um, this is especially important for adults who may not have sought help otherwise.  , telehealth most certainly is the, the reason, uh, is the large reason for the, the spike in, uh, uh, A DHD diagnostics and treatment, uh, since the COVID era.

Uh, the one thing that I don't see discussed as often that I've witnessed in, in my own patients is, um. What's also leading more A DHD patients, uh, uh, adult, A DHD patients to approach and require care? Um, since, uh, the, the pandemic  is the transition in the way we do work and the way we do life. Um, a lot of people are now working from home.

Uh, and the, the consequence of that for most individuals with A DHD, even though I know some of you out there are gonna, uh, disagree with this, um, is for most individuals, uh, it leads. To increased distractibility, uh, a reduced sense of accountability due to the manager or colleagues being nearby, and a shift in what would be called the yys dossin curve, um, which evaluates sort of the, the, the stress to productivity bell curve. 

That, uh, leads to, uh, reduced overall, uh, work being done. Uh, so there, there's been a shift due to, uh, this move of work from the workplace to working from home. Certainly with the right accommodations, those types of things could be addressed, but I, I do think there's also an element there. Um, telehealth has been tremendous in improving behavioral healthcare access.

On, the whole. In the United States, we have, um, the, the world of behavioral health , has one of the largest disparities in care access. Uh, and that's only expected to increase over, uh, the next decade. , consequently what that means is for many individuals, they may find themselves in regions where, , they have no access to a provider. 

Or if they do have access to a provider, um, the timing of a visit that they can have with the provider or the travel distance, uh, to and back from the provider to their work is just so long that it, um, it makes it really hard for them to, to engage in behavioral healthcare. Uh. You compound A DHD symptoms on that time.

Blindness, uh, uh, procrastination with, uh, scheduling one's visit, uh, a tendency to to be late for, for everything. And then you have patients who, even if they get to the point of scheduling a visit, odds are they're gonna be so late for the visit, um, that they're gonna be. Canceled or their visit's gonna be canceled, or they, they just might forget their visits altogether.

Um, so telehealth and for those patients has certainly, um, improved things in that at least, uh, even if the patient forgets their visit, when they get the, the reminder texts, they don't have to worry about driving x amount of time to get to the office. And certainly anyone in the world of behavioral health who's, uh, either partially or fully transitioned to telehealth will tell you that the, um, show rates, um, of, of patients is, is much better for, um, uh, telehealth versus in-person care.

Um. And, and, and that's a really good thing. Uh, it promotes treatment utilization and getting to the right treatment. It promotes safety. Uh, amongst the things that I've personally witnessed in the world of telehealth is, um, in, in the world of telehealth, we think about, uh, the subjective, uh, actually in the world of healthcare in general.

Mm-hmm. The subjective exam. Um, what the patient tells me is going on and then the physical exam. What's the physical exam for a psychiatrist or a behavioral healthcare provider? Well, it's what we call the mental status exam. Um, and it it's things like the, the appearance of the pa, the patient, their behavior, their speech patterns, um, their affect and mood.

Um, o one thing that I've, um, begun incorporating in my thinking of the mental status exam that we hadn't had in the past is the environment. The patient's environment has become diagnostically relevant to me because if I see their home, I know what things are looking like, uh mm-hmm. If they're telling me they struggle with chore management and are unable to, to keep up with, uh.

Cleaning their, their environment. And they're, they're in a pristine place. And yes, I do ask them to move up the camera around if they're comfortable with doing so. Um, then they, that, uh, allows me to get a better picture of the, the possibility and the, it doesn't necessarily always mean that the patient is making up symptoms.

Um, but the possibility that there's a, some discordance there and I could talk to the patient about, about it. What about pill counts? Well, , it's, uh,  amongst the things we could do to minimize, um, misuse rates of, um, high risk medications is to do pill counts. Does the patient have as many. Um, tablets or capsules of whatever the medication is, as they should based on when I last prescribed the medication.

, the patient isn't always gonna remember to bring their medication to the office during visits, but if you're meeting them from their home environment, that's something you could definitely do. Uh, and if the medication isn't there, that certainly presents itself an opportunity for discussion and, uh, an evaluation by the clinician.

Uh, so yes, telehealth has played a tremendous role in improving access to care. Um, it is my strong opinion that, um, for the most part, there are certain exceptions. Um, telehealth is equal to, and in some instances, superior to the in-person evaluation, um, for clinical care. And in my opinion, that is definitively true for most of my A DHD patients.

Um, you know, some, some individuals will ask about urinary drug screens. Well, there's nothing stopping me from inputting a urinary drug screen lab for a patient that I see via telehealth. I just ask them to go to their LabCorp, their Quest Diagnostics or their PCP office. Um. I, I, uh, in terms of vitals, um, we, we certainly, uh, are lucky to have, uh, information Rev to us, routed to us through the health information exchange.

And we have primary care vitals, uh, in addition to primary care notes. But, uh, we can also ask, uh, patients to collect their vitals with, uh, cuffs that they could get from Walgreens or collect them from their PCP. Uh, when I first started, um, it was my goal to send, um, uh, blood pressure cuffs to all our patients, um, though that, uh, eventually proved to be a, a costly endeavor given that our, our margins are generally, um, tight.

Um, mm-hmm. But the,  again, I can't emphasize, um, the, the extent to which telehealth has been important. Yeah. And the. We as practice figure out a way to collaborate with, , other providers to, uh, allow us to get the measurements of physical health that we needed. So there is always a way and to find, and I think what you share here was very valuable.

I personally  didn't think that you could figure out based on, uh, talking to someone, um, online. So I think this was very, , valuable discussion. And,  uh, I would like to continue, uh, with the next question, which  continues the, this discussion. And that's  DEA proposed , A requirement for in-person visits before prescribing controlled A DHD medications.

And, I think that that can affect the access to care, particularly for people who, uh, live in rural areas or under, uh, undeserved areas. So what's your opinion on that situation?  I think based on what I've said so far, I, I bet most individuals could guess that I'm a fan of telehealth. Yeah. And, uh, in most instances, think that telehealth is, uh, equal to in-person care. Uh,  let's, uh, first talk about where the DEA is coming from. Mm-hmm. Uh, and what the de a's goals are, because I think the,  the  goal is  well founded, the means, 

 regulations they're trying to develop to meet those goals are  misinformed. , the in-person requirements actually predated, um, COVID era flexibilities, and they were based on this act called the Ryan Hay Act. Um, eh, and that act, uh, was developed in the early two thousands based on a young man, Ryan, uh, who was 18 years old at the time, and, uh, managed to get a provider he never saw, uh, to prescribe him Vicodin and to have that Vicodin shipped to him via an online pharmacy.

And, uh, Ryan, uh, who is a, uh, based on, I.  Read a little bit more about him, although he, he comes up on the regular, , when discussing , the Ryan Haight Act, um, uh, who was a straight A student, , and, um, well regarded in, in his school, uh, ended up overdosing and, and dying  due to the Vicodin overdose.

Mm-hmm. Uh,  the consequently, uh, the Rhine Hate Act was developed to protect individuals from malicious prescribing  and, uh, dispensing patterns.  Uh, this was in  Lake.  Early-ish era of the internet. Um mm-hmm. Before we had, and most certainly early era of electronic health records, uh, and reporting requirements, uh, before we had, um, a strong prescription drug monitoring program.

Uh, things look significantly different now. Uh, there is,  I cannot put in a, uh, single and a a, at least in the state of North Carolina. Um, and I, in fact, most, if not all, states in the United States, uh, the, uh, prescriptions, the scheduled substance prescriptions you put in are reported, um,  and easily tracked, besides, which, .

 There are strict regulatory requirements, uh, regarding, uh, your responsibilities as a provider to check.  Prescription history for patients you see for whom you prescribe scheduled substances. , there are strict requirements, um, and ethical standards around the need to do a comprehensive clinical evaluation of patients, uh, before prescribing any medication, including scheduled substances.

Um, so why, uh, why the in-person requirement now? Uh, well, to and and what is the requirement now? Well, so you guys are aware, um, I'm sure some of the listeners are receiving A DHD care and stimulant management despite, uh, maybe never having seen a provider in person. And that's because since COVID, the DEA, , under the, .

 National emergency has, , put in pandemic error flexibilities that basically say you don't need to see a provider in person, uh, for them to prescribe a scheduled medication to you. That's set to expire at the end of this year.  And starting next year, um, we're gonna go to one of two areas. Uh, right now, the DEA has, uh, a set of proposed rules that still haven't been finalized.

We're gonna find out in the next month or two, um, what they look like. Uh, it, and if those don't get finalized, then we might see the older Rhine Hate Act rules, which is, uh, that rule is, requires providers to see the patient at least once in person period prior to, to prescribing a scheduled medication.

Sounds simple enough. But for those patients that, uh, live, uh, rurally, uh, it's just, uh, not tenable. And just from a clinical perspective, for many patients, it's, it's unnecessary. Mm-hmm. Like it, it's just a checkbox exercise that, in my opinion, doesn't protect patients against much, because malicious providers can still document that they saw the patient in person. 

If someone is malicious enough to prescribe to a patient a scheduled medication, despite not having seen the patient or done a thorough evaluation of the patient, then what's to prevent them from saying on a piece of paper, which they document that they saw the patient in person. Um, the, so th this is just, this is restrictions on the honest providers.

Mm-hmm. , so regardless.   So we're either gonna go to the Rhine hate or to the new rules. And the new rules, uh, sort of introduce a little bit of flexibilities, but not really. There's an advanced registration pathway that allows providers, uh, allows some providers, um, psychiatrists, uh, included, and, , board certified, uh, nps and PAs, , to, , prescribe schedule two medications, stimulants included, um, for 50% of their patient load.

Uh, so if you're, or, or sorry, 50% of the schedule two medications, um, must be under the, or can be under the advanced registration, which means the other 50% still require, uh, an in-person visit. So  it's arbitrary. Like why Yeah. What, what, you know, their, their thinking is somehow it protects people, but it does it really, uh, like they, I just, it it doesn't make sense.

Sense. Yeah. They, they're, uh, the, the other concerning thing is they're basing their judgment on what they're calling, uh, the next opioid, um, uh, epidemic. Mm-hmm. Uh, re relating to stimulant, uh, use increases or stimulant abuse increases, which by the way are due to, um, uh, an increase in methamphetamine use and, uh, stimulant spiked, uh, fentanyl.

Uh, not relating to prescription stimulants. Um, yes, methamphetamine can be prescribed, but I don't know of a single provider who prescribes methamphetamine. , so, , they're, they're basing their judgments based on that and saying, broadly stimulant medications, which we use for the treatment of a well-known, uh, well-documented condition that causes significant life altering distress and dysfunction.

Um, uh,  we, we need to apply restrictions on that. Um, so. Uh, they're, they're proposing, um, those rules. What, what will those rules result in? Uh, invariably it will result in a decrease in access, um, without question. And that decrease is gonna significantly impact our rural populations, um, uh, individuals who are underprivileged.

Why? Because even if I live in a city with psychiatrists, um, I'm not gonna be able to, uh, leave my, uh, second or third job that I'm working today for two hours to drive to them, get seen by them and drive back. Um, and for a DHD patients in particular, you still have the issues of procrastination, forgetfulness, yeah.

Um, the.  So, yeah, we're, we're gonna see reductions besides, which I can't emphasize this enough. Mm-hmm. It is my strong clinical opinion based on my personal clinical experience that if anything, uh, clinical evaluations when done properly via telehealth for  a DHD result in better diagnostic assessments allow me to do more consistent pill counts, uh, and allow me to do  a more thorough evaluation of not just the patient but their environment.

You can ask them to bring in family members if they're comfortable and their family members are often in their own house. Um,  so all that's to say is it's. Unnecessarily going to reduce access to care, um, at a time where tragically we could provide the care to the patients that needed. But yeah.

, are unwilling to  we heard you loud and loud and clear. So, um, and hopefully there, there are more clinicians out there advocating for, um,  just better accessibility to the care. I think that's the goal. Um, I think next question is kind of reflection on it, uh, on what we were talking about right now. 

Um, I think those regulations their intent is to,  safeguard and recommended bonds in accurate diagnosis and, um, prevent the risk of over-diagnosis, especially in online and telehealth based settings. But based on everything you said right now, I, I don't think that's necessarily what you think is going to happen, but maybe we can reflect on these safeguards and the rules, um, and what are they going to bring? 

Yeah. So , the safeguard essentially is a restriction in access for those that  are gonna be evaluated via telehealth. Yes, yes. Uh,  the presumption, therefore, being  that  I am  only able to, uh, predict. Misuse or abuse patterns in individuals I see in person as opposed to those IC via telehealth.  Based on my experience, the logic doesn't  hold well. 

Uh,  the rather, um, my sense is if we truly wanna see improvements  or reductions in,  prescriptions to potential malingering, um,  or, uh, misusing individuals.  Then we have to implement those things or those systems that we know to be working or to have worked. Um, the, in the DA's new proposal, uh, incidentally, one of the things that they did not definitively say would go into effect next year is  a national prescription drug monitoring program.

Mm-hmm. As opposed to what's being done now, which is state level prescription drug monitoring program that would help, uh, requiring providers to monitor, uh, their prescription drug monitoring program. Uh,  not just prescribing providers, but dispensing providers like pharmacists is  an important step to ensuring,   individuals are safe.

Yeah. One, one thing that. Amongst the many that would be great to ensuring patients are safe is including an attestation. Because at the, at the end of the day, this is  in everything we do, we're essentially attesting to having done X, y, z. Uh, so that the underlying presumption is if the individual is attesting, then hopefully they've done this requiring an attestation to misuse diversions or substance abuse, uh, screening.

Uh, so has the provider who is prescribing a scheduled substance that can potentially be abused, screened the patient for substance abuse, and if the patient does have a substance abuse history, um, and the provider then moves forward with prescribing the medication, what is the justification? Yeah. Uh,  the, and uh, to, to be clear, uh. 

In the case of A DHD stimulant treatment, uh, for individuals with A DHD tends to actually reduce substance abuse rates as opposed to increase it. Um,  it though that doesn't negate the necessity to do a substance abuse screening and to ensure that the individual isn't abusing medications that could be deadly in, in combination with, with stimulants.

 The next item is, I mentioned pill counts a couple of times. Yes. Um, pill, pill counts if, if you're concerned about someone misusing or diverting their medication, uh, then that is a basic thing. , it doesn't take a lot of work to have an individual count their medication with you. Um, so why not have providers document that?

Mm-hmm. Uh, in instead of, um. Having requirements that don't appear to have, uh, clinical justification behind them. , my sense is mm-hmm. What the DA is trying to do is minimize the absolute count, which we talked about earlier. Yes. Of individuals, uh, receiving the wrong medication. Um, but the, the cost of that is. 

Most certainly an absolute reduction of people receiving appropriate care. Um, and that's like saying, you know, we, we have a thousand people who have a gangrenous leg and need an amputation, but because we know five of them,  um, are unfortunately going to have the wrong leg amputated, or 5% of them are gonna have the, the wrong leg amputated, then we're only gonna treat a hundred of them and let the remaining 900, um, have happen to them.

Whatever happens to them. Um, I, I just, that doesn't sit well with me. Uh, so there, there are certain things you can be done that, that can be done. Um, urinary drug screens, I think are, um, a, a good way to evaluate for misuse, diversions, uh, or certain substance abuse. Uh, some of the time, uh, I don't, uh, so. Many, um, guidelines do not blanket recommend urinary drug screens.

, if the DEA feels it, uh, necessary, uh, to minimize risk, then uh, blanket UD ss certainly may help. Mm-hmm. It's better than the current, um,  the current, uh, in-person proposal. Yeah. Uh, and then, you know, just from a, like a standard care perspective, you also need to document, um, a full and comprehensive clinical evaluation.

Yeah. Hey, does, does the DA wanna know if, if you've done a comprehensive clinical evaluation, um, ask the provider how much time they spent with the patient? , let's be realistic. Mm-hmm. There are some intakes out there.

Uh, some clinics that do 10 minutes long, uh, diagnostic assessments, prescribe a medication and that's it. Um.  You know, nata? I am, yes. Super proud of what we've made, uh, yes or what we've built here at a SP. Our intakes are 75 minutes in length. I know we, we advertise them as 50 minutes. Um, but in fact we, we schedule 75 minutes of time for the provider, uh, just in case the intake needs to go long.

And we emphasize to our providers that, um, first visits don't need to result in a diagnosis or a diagnosis. If you're not certain of what's going on, have the patient come back. We need to make sure we are doing comprehensive assessment. Yes, our follow-ups are 30 to 45 minutes long. We take our time with the patient.

Does that mean, uh, reasonably shorter visits? Uh, don't result in adequate care? Absolutely not. But I could tell you that a 10 minute intake, a 15 minute intake, is not gonna lead to, . Equally accurate, , differential diagnoses as a 45, 60 minute intake or longer. Uh, so  can we just look at how much time the providers are spending with their patients?

Uh, that's, that's a good, a good way to, evaluate the quality of care, uh, not to limit access.   I think following good practices and implementing them, um, to these rules might be a better solution than restrictions, if I understand this correctly.

So there are solutions out there and if the lawmakers would just sit down with clinicians,  especially those who are, uh, providing exceptional care. There could be solutions and, um,  for everyone involved, and most importantly patients, uh, for, for their benefit.  Um, I would like actually to, um, reflect on the impact of these rules to, um, women, minorities,  uh, maybe people and adults who are late diagnosed.

And then we can talk about, uh, some solutions and best practices in telehealth. So, uh, with everything being said, what are your thoughts about, , those, , groups that I just mentioned and how the potential new rules would affect them?  So we know that, uh, since the COVID, uh, pandemic, the, uh, largest  increase in a DHD diagnoses  was in adult women. 

Between the age of 20 to 29. Mm-hmm. I, I think that was the age group.   And a large proportion of that diagnostic increase,  is due to, uh, increase in access through telehealth. So likely what's gonna happen is, um, in restricting access, we're gonna see, , women in particular within that age group, , disproportionately.

, suffer, , due to, , losing access, right? Mm-hmm. , in terms of minority populations in general, uh, we know that, uh, the Hispanic and black population, uh, tends to, uh, be underdiagnosed as compared to, uh, Caucasian patients with A DHD. So, uh, I'm, I'm not sure that we've, we have much data, uh, there, there may be out there demonstrating that, uh, telehealth leads to increased diagnostic rates for that population in particular.

Um, what I can say is, um,  that,  , financially underprivileged minorities will. Probably see a, a significant impact again, due to that challenge of, well, they, they just don't have the time to , go to the appointment, do the appointment, and then come back from the appointment.

It's one thing to have a one hour appointment. It's quite another to also have to do the 45 minute drive, the wait and the 45 minute drive back, or the 20 minute drive, the wait. Um,  so, uh. There, there's definitely going to be a disproportionate negative impact on minority communities. Uh, and that's not even, um, to say that, uh, the access deserts, so there are, there are, uh, plenty of rural communities out there who just have zero psychiatrists nearby.

Um, oh, and by the way, the, the DA flexibilities, so that who, who tends to provide care for those patients? It tends to be primary care provider, but the,  da, uh, uh, re, , special designation or the advanced special designation, um, doesn't allow for primary care providers, uh, to register. So that then, um, is sort of a double whammy for, for the rural, uh, community patient.

Yeah. I, it doesn't sound good. But, uh, yeah, hopefully there will be some, uh, solutions because, uh, lots of people will be affected. So, um, I would like to now look ahead  and maybe discuss how can policy and technology and clinical standards work together.

I think we touched on this and, uh, you were kind enough to, uh, provide already some solutions, but let's maybe, uh, summarize how all of these factors can work together to ensure that, um, adults with A DHD,  have the care that will remain both accessible and high quality in, and preferably largely in the digital healthcare landscape.

Because as we could see. , it's not just the future. I believe it's the present and it shouldn't be the standard of the care.  Yeah. So we're already seeing part of that. Yes. Um, why telehealth care is  safer now than it was 20 plus years ago when,  Ryan died, is because we have  state level and hopefully soon national level systems Yeah.

That allows us to monitor prescribing practices and other data elements if we want to, uh, collect those other data elements. , the benefit of technology, , is broad. Um, I'm sure eventually we can have. AI evaluation systems that, , will, , conduct better, , evaluations in a human can of potential malingering due to inconsistency patterns, , or misuse patterns. 

I'm, uh, also sure that, uh, if a strong enough investment were to be put in, we can add additional data elements to our prescription drug monitoring program to evaluate for some of the things that I mentioned earlier, um, that, that would improve, , or reduce, , prescriptions going to, , high risk patients. 

  Ultimately what it comes down to is our technology allows us to document, in a fashion, , that is, , now more than ever easier, uh, allows for easier data ingestion. , our ability to evaluate the data and report on the data, , due to a combination of, uh, fantastic, , business intelligence solutions.

Um, and, , the support of AI and architecting solutions, uh, is easier than it ever has been. Yeah. And our knowledge, uh, clinically of, um, what works and what doesn't is also, , 20 years ahead of where we were. , and we know that in general, telehealth works and the, the malicious actors aren't malicious. 

Because of telehealth, but despite it, and they'll continue to be. So even if we, , if we, uh, remove, , telehealth flexibilities, the ultimately I, I think, , to, to truly protect patients from the malicious actors,  , what, uh, and by that I mean prescribers and dispensers, , what we need is some form of automated system that captures, , a true encounter.

Uh, and that's most certainly more possible to do, , via the virtual world then it is via the in-person world. , I'm meandering because,

because I think there still is some work to be done, but what can be done is gonna be much easier in the telehealth world.  Absolutely 100%. , we can,  wrap up now and  if there is maybe one thing, , that we can take away from this episode and, I would say I would address both our patients.

People may be living with A DHD, but also the lawmakers. I think it's important that,  everyone have some takeaways from this episode. What would be your message to both of these groups? Roofs.  Yeah. Access  does not equal   maliciousness. Yes.  Remember that proportions are different from absolute counts.

 Access isn't bad. We're, we're improving access to care. Let's not go backwards.  Thank you. Thank you so much. It'll be interesting to see the next couple of months how the situation will, , change and how the practices including ours will adopt, and then patients as well. And I'm sure, , we will continue advocating for the access of care.

That's 100, 100%. So  thank you so much, Mina, for joining us. Thank you for sharing your opinion on, , those important topics and let's hope, um, everything will turn out for the best for, for our patients.  Thanks, nada. 

Thank you for listening to Thriving with adhd. This show is produced by Animo Sano Psychiatry. Please follow, rate or share our podcast on Spotify, Apple Podcast, or any other streaming app of your choice. Music is by Daddy's Music music from Pixabay. For more information about Animo Sano Psychiatry, please visit animosanopsychiatry.com