ADD medication denial

[flipside]

Hi,

I was gigged on the medical by being on an ADD medication. Since I was on the medication for a single reason which was no longer relevant (marriage) I (with the prescribing doctor's agreement) went off of it.

That was almost two years ago.

I did a psych eval, in which the FAA was both most unhelpful and disorganized. They then sent those results to a reviewing third party psychiatrist who both cherry picked the results and made several serious errors of fact in the review. One of the biggest of these was that I was ever diagnosed with ADD: I was not, am not and have the documentation to prove it. Others are related to psychiatrists reviewing psychological tests in which they have never been trained.

I've taken the intervening period of time to collect and develop the materials to show that (1) I was never diagnosed, and (2) I do not currently have ADD. I don't have any other medical issues and my primary flight instructor has endorsed me in writing.

So my question is what's next? Sending them blindly to the FAA obviously is not the correct answer: they are in a default deny position and will happily maintain it. I have all but one piece of documentation: a letter explaining why I was referred for assessment at all, that should be available shortly.

 

[JeffDG]

Stand by for Doc. B. Whatever he tells you to do, do it...any other advice is "noise", Doc. B is an AME and knows the system better than anyone else you will run across.

 

[cg2112]

Was the medication Aderall?
According to a psychiatrist I saw while dealing with all this, adderall is being prescribed more and more as an anti-depressant or as an enhancement to anti-depressants. The FAA doesn't recognize that use, though, from what I understand from Dr Bruce, and treats a prescription as a diagnosis of ADD.

 

[flipside]

No. It was Ritalin class drug.

 

[bbchien]

First of all, YOU SURE WERE diagnosed. Any phsyciian who gives you an Rx for Ritalin class meds has ONLY one diagnosis that supports that Rx or he's in jail. That's dextroamphetamine, for heaven's sake. So lets dispense with that "righteousness". I do get the frustration, though.

You also don't recognize that once diagnosed, according to the American Psychological Assn, it is a lifelong information porcessing problem. As you are intelligent, hat you do as you mature to age 25 is build personality sorkarounds so that you present information to yourself in an effective manner. But we pick that up in the slowing of the "executive function". It's like runing Norton on your Windows computer- it consumes clock cycles.

Did you use a HIMS certified neuro-psych? The most common reason for it going to a third party is that the guy you used wasn't know to FAA. When I send someone for said workup, I wuse only the guys on the HIMS list, they ARE the consultants to FAA. So if the guy has a good eval, who are they going to send it to- the same guy?

I think the problem here is you used someone for the neuro psych eval who wasn't "in tune" with what the agency wanted. So that's why you percieve that the FAA consultant "cherry picked".

I try to explain this all the time to guys who then go to their local or cheaper guy, and this is the result.

 

[Unregistered]

Lots of pilots out there who were given ritalin in elementary school ( and then stopped taking it )

have a medical

Because it didn't occur to them to report it

 

[flyingron]

He wasn't a child. He was Dx'd and prescribed and taking it as an adult. Even children who report Ritalin use as children would have an easier time than he is.

 

[Jim Logajan]

First of all, YOU SURE WERE diagnosed. Any phsyciian who gives you an Rx for Ritalin class meds has ONLY one diagnosis that supports that Rx or he's in jail.

I'm sincerely confused - I thought off-label prescriptions by a doctor was legal? What law would the doctor be violating in this case without making an ADD diagnosis?

 

[bbchien]

I'm sincerely confused - I thought off-label prescriptions by a doctor was legal? What law would the doctor be violating in this case without making an ADD diagnosis?

For the amphetamines, that is the common ONE EXCEPTION. There have been state board actions in I think 30 states against physicians who were supplying amphetamines outside of legimate uses....

 

[bbchien]

Lots of pilots out there who were given ritalin in elementary school ( and then stopped taking it )

have a medical

Because it didn't occur to them to report it

That has stopped. the Healthcare act of 2012 specifically removed the diagnsis code, the pharmacy code and the procedure code from the medical record. That means that any credit bureau and yes, the FAA can see them anytime they want.

Lie if you wish, but the first time you call attention to yourself you PILOT certificate will be gone. For lying.

 

[Jeff Oslick]

Lie if you wish, but the first time you call attention to yourself you PILOT certificate will be gone. For lying.

What if you stop taking it when you're ten, and don't apply for a medical until your 20's or later? Intentional falsification is the crime, not "forgetfulness". Plausible deniability.

 

[bbchien]

Depends on when you were ten. The medical databases became robust about five years ago...

....And stopping at ten hardly ever happens. That would imply a mommy and a daddy interested in more than just getting by....as in getting an expert opinion.

 

[JeffDG]

Lie if you wish, but the first time you call attention to yourself you PILOT certificate will be gone. For lying.

I don't think he was talking about folks lying, but more they were dx'd as young kids and were never told about the dx, then later answered truthfully to the best of their knowledge.

 

[Jeff Oslick]

Depends on when you were ten. The medical databases became robust about five years ago...

....And stopping at ten hardly ever happens. That would imply a mommy and a daddy interested in more than just getting by....as in getting an expert opinion.

No, it doesn't matter *when* you were ten, it matters what you *remember* from when you were ten.

My understanding is that the FAA wouldn't care if Mom and Dad got a new doc's eval that disproved an original diagnosis, unless the new diagnosis was done with full psych eval approved to the FAA's standards (whatever they will be x years from when the eval was done).

 

[Jim Logajan]

For the amphetamines, that is the common ONE EXCEPTION. There have been state board actions in I think 30 states against physicians who were supplying amphetamines outside of legimate uses....

I see, thanks. I was thinking only of the federal level. But if what I found is correct and I'm interpreting it correctly, state restrictions are variable enough that it seems possible the OP could have legally been prescribed amphetamines for something other than ADD. The following web page seems to contain summaries of the state laws concerning prescriptions of controlled substances:

http://www.medscape.com/resource/pain/opioid-policies

 

[bbchien]

I see, thanks. I was thinking only of the federal level. But if what I found is correct and I'm interpreting it correctly, state restrictions are variable enough that it seems possible the OP could have legally been prescribed amphetamines for something other than ADD. The following web page seems to contain summaries of the state laws concerning prescriptions of controlled substances:

http://www.medscape.com/resource/pain/opioid-policies

Amphetamines are NOT opoids, Jim. Not even close.

 

[pericynthion]

I thought Ritalin was not an amphetamine, but rather a methylphenidate?

Adderall is the ADD med that is essentially just amphetamine. Ritalin has considerably less abuse potential. And it MAY also be prescribed for off-label use in treatment-resistant cases of lethargy, Bipolar depression, Major Depressive Disorder, and obesity.

 

[bbchien]

I thought Ritalin was not an amphetamine, but rather a methylphenidate?

Adderall is the ADD med that is essentially just amphetamine. Ritalin has considerably less abuse potential. And it MAY also be prescribed for off-label use in treatment-resistant cases of lethargy, Bipolar depression, Major Depressive Disorder, and obesity.

Authoritative source! Wikipedia!

sigh.

If you try it for bipolar depression, expect every psychiatrist in the county to testify against you.

Lethargy- well I have seen it used in terminal cancer cases but nobody is suing there. When you're dopey from 600 mg of morphine a day for the cancer pain, okay, but I seriously doubt any of these young kids fit that category.

These were discredited in the 80s as diet pills.

I Just LOVE it when everyone here's a doctor, an organic chemist (I'm talking amphetamines (re-read post #9 , please); opoids ARE quite different and they get cited.....) and now wikipedia.

So why do you think it is so hard to get doctor to write, "no diagnosis of ADD. I prescribe him five years of amphetamines/stimulants with no diagnosis....."? Isn't that rather admitting something?

The two of you who are so badly equipped to carry on this conversation-why don't you just bag it?

Goodnight, Doctors all.

 

[Jim Logajan]

Amphetamines are NOT opoids, Jim.

I know, in fact I double-checked that before posting the link (I couldn't figure out why amphetamines appeared on that page.) But while they used the word opoids in the title and the URL, that page states that "The following is a summary of significant state laws involved with prescribing controlled substances for the physician." So state laws covering Schedule II drugs appear to be included.

I actually found it while searching for state laws regarding amphetamine prescriptions, which are included by name in a few places.

 

[bbchien]

I know, in fact I double-checked that before posting the link (I couldn't figure out why amphetamines appeared on that page.) But while they used the word opoids in the title and the URL, that page states that "The following is a summary of significant state laws involved with prescribing controlled substances for the physician." So state laws covering Schedule II drugs appear to be included.

I actually found it while searching for state laws regarding amphetamine prescriptions, which are included by name in a few places.

Um. You're kinda like that pilot who says, "there's no law preventing it so I can do it!"

This all doesn't work at the level of LAW. It's at the level of physician to physician review, doctor. Goodnight, Dr. Logajan. Get some sleep.

 

[Jim Logajan]

Um. You're kinda like that pilot who says, "there's no law preventing it so I can do it!"

This all doesn't work at the level of LAW. It's at the level of physician to physician review, doctor. Goodnight, Dr. Logajan. Get some sleep.

You used the word jail, sir. I wanted to know why. Now I know what you really meant. (You appear to be the one up late; I'm west coast. My wife's mother lives in Wasburn, not too far from Peoria; sounds wet there, so stay dry!)

I have tried to avoid any pretense of expertise. To be clear, there has been no attempt on my part to engage in debate, just clarification, but I realize now it can appear like I'm debating when I'm merely explaining my understanding. I like facts and appreciate them when you share them (even when they are delivered in a needlessly surly manner.) If there is no possible way that the OP can have gotten a prescription without a diagnosis of ADD or physician misconduct, I wanted to understand how that could be given what I thought I knew about the law. I now know more; thanks.

P.S. What about the OP's claim he has documentation proving no ADD diagnosis; is it also proof of physician misconduct or simply not what he thinks it is?

 

[pericynthion]

Amphetamines are NOT opoids, Jim. Not even close.

And Ritalin is NOT an amphetamine, Bruce. Since you don't like wikipedia (which over the past couple of years has become much more reliable as a source of factual information), do you have a source to support either of your claims that
1. Ritalin is an amphetamine
or
2. It is illegal to prescribe ritalin (methylphenidate) for off-label use?

It seems to be commonly used for narcolepsy and depression, to name two examples.

Ritalin is certainly a powerful stimulant with many side effects and I'm not suggesting that pilots should be popping it. But it is not the same as adderall, and it is not exclusively used in treating ADHD.

I have no dog in this fight...

 

[bbchien]

It isn't proof, but if it ever got before a board of his peers, it wouldn't go well.

The bottom oline on "diagnosis": The FAA view is that a physician somewhere thinks he has ADD. That's all that counts for this disucssion.

If he had terminal cancer treated with an alertness agent, or any of the other conditions, he would be unfit to fly as well. So yes, he has been diagnosed. Or "lethargy" Or any other of the ones you have listed, with the exception of obesity (for which the stimulants have been discredited more than 20 years ago...e.g BAD medicine).

This is one of the most common "but I'm totally allright!" protests I hear in the office- maybe twice a day.

1. Ritalin is an amphetamine
or
2. It is illegal to prescribe ritalin (methylphenidate) for off-label use?

Reread the whole string. I never made that claim. Others have tired to put that into my mouth. Now you.

I am so out of here.

 

[flipside]

Thanks for all of the comments.

A prescription does not constitute a diagnosis. A diagnosis requires a finding, in this case defined in the DSM IV following an evaluation, tests since they are available and an analysis. I have the benefit of having the records. I understand that in the absence of additional information a prescription would make a diagnosis presumptive. But there is additional information and in this case that additional information documents that no evaluation was made, no tests were performed, that only a prescription was written. Litterally the only record of the visit is (1) routine administrative forms and (2) the prescription.

There are protocols, procedures and standards. They were not adhered to in this case. There was no diagnosis. I have additional supporting information but that is not relevant to this discussion. I am neither a lawyer nor a physician so I won't discuss legal or ethical issues.

Thanks for the information regarding HIMS certified neuro-psychs. I asked the FAA in writing for a means of identifying professionals that could administer the tests they stipulated. The FAA stated that they did not make referrals, that I should go to the yellow pages(!) and find someone. After the evaluations were submitted they then suggested two names for reviewing the evaluation already submitted, reversing their previous position. I have no idea if those individuals are HIMS certified. I think that covers the factual basis for 'unhelpful and disorganized'. Had they said 'find a HIMS certified neuro-psych' I may have a different situation today.

Re: Cherry picking
Those are the evaluating psychologist's words, not mine. He disagreed with the FAA psych's evaluation seriously enough to write a rebuttal on all of the major points. So this is a professional difference of opinion, not just mine.

The false positive and false negative rates of the objective test for ADD (e.g. the CPT) are substantial enough to render them almost useless in anything but very clear cases. I fall into the normative mean, meaning probably half of the people reading this would perform worse than I did.

Everything else, in the words of another psych I know, "is rather subjective".

 

[AggieMike88]

Had they said 'find a HIMS certified neuro-psych' I may have a different situation today.

If it helps you in your quest, there is a list of HIMS AME's who, from what I understand from Bruce, will be the right folk to monitor and guide your submissions through the FAA certification airspace. They are also the ones who have the right contacts for the right additional testing and will write the report in the format the FAA desires.

The list can be found on this page, http://www.faa.gov/pilots/amelocator/ just look toward the bottom for "Listing of HIMS Independent Medical Sponsors"

 

[JeffDG]

A prescription does not constitute a diagnosis.

You're technically correct, a prescription does not constitute a diagnosis...however for these drugs the prescription has a diagnosis as a prerequisite, and as such, the presence of a prescription creates a very strong presumption that the diagnosis was made.

 

[Palmpilot]

...wikipedia (which over the past couple of years has become much more reliable as a source of factual information)...

It's true that Wikipedia has improved a lot, but in my experience the quality of the information presented there still varies widely. However, one of the most important improvements is that the articles list their sources much more often than they used to. It's generally more useful to look up those sources, and if they're credible, cite those instead of the Wikipedia article itself. That avoids side-tracking the discussion away from the main issue.

 

[bbchien]

Thanks for all of the comments.

A prescription does not constitute a diagnosis. A diagnosis requires a finding, in this case defined in the DSM IV following an evaluation, tests since they are available and an analysis. I have the benefit of having the records. I understand that in the absence of additional information a prescription would make a diagnosis presumptive. But there is additional information and in this case that additional information documents that no evaluation was made, no tests were performed, that only a prescription was written. Litterally the only record of the visit is (1) routine administrative forms and (2) the prescription.

There are protocols, procedures and standards. They were not adhered to in this case. There was no diagnosis. I have additional supporting information but that is not relevant to this discussion. I am neither a lawyer nor a physician so I won't discuss legal or ethical issues.

Thanks for the information regarding HIMS certified neuro-psychs. I asked the FAA in writing for a means of identifying professionals that could administer the tests they stipulated. The FAA stated that they did not make referrals, that I should go to the yellow pages(!) and find someone. After the evaluations were submitted they then suggested two names for reviewing the evaluation already submitted, reversing their previous position. I have no idea if those individuals are HIMS certified. I think that covers the factual basis for 'unhelpful and disorganized'. Had they said 'find a HIMS certified neuro-psych' I may have a different situation today.

Re: Cherry picking
Those are the evaluating psychologist's words, not mine. He disagreed with the FAA psych's evaluation seriously enough to write a rebuttal on all of the major points. So this is a professional difference of opinion, not just mine.

The false positive and false negative rates of the objective test for ADD (e.g. the CPT) are substantial enough to render them almost useless in anything but very clear cases. I fall into the normative mean, meaning probably half of the people reading this would perform worse than I did.

Everything else, in the words of another psych I know, "is rather subjective".

Flipside, all that matters is that if a licensed practitioner gives you a stimulant, in the eyes of the Federal Psychiatrist you have somone out there who thinks you have ADD. The criteria that the FAS uses are NOT DSM, and the guys in the community don't understand that. You clearly don't either, but it probably has never been explained to you. FAA uses an aviaton set of standards.

The burden then falls upon us to convince the Federal Air Surgeon otherwise. The counseling you suggested as a diagnosis privately is not an acceptable diagnosis in and of itself.

As I suggested, you need to use a higher quality, higher ranking practitioner who has been to FAA training and understands the FAS criteria, before you take another swing at this. Your guy clearly did not.

 

[AggieMike88]

As I suggested, you need to use a higher quality, higher ranking practitioner who has been to FAA training and understands the FAS criteria, before you take another swing at this.

Can his local HIMS AME provide a name and contact of this higher ranking practitioner?

 

[RJM62]

Flipside, all that matter is that if a licensed practitioner gives you a stimulant, in the eyes of the Federal Psychiatrist you have somone out there who thinks you have ADD. The criteria that the FAS uses are NOT DSM, and the guys in the community don't understand that. They use an aviaton set of standards.

The burden then falls upon us to convince the Federal Air Surgeon otherwise. The couneling you suggested as a diagnosis privately is not an acceptable diagnosis in and of itself.

As I suggested, you need to use a higher quality, higher ranking practitioner who has been to FAA training and understands the FAS criteria, before you take another swing at this.

I think this is the reason why some people have a hard time understanding Doc Bruce's advice. This is an Aviation Medicine forum, and Doc Bruce answers question from the perspective of how FAA looks at things.

You can think FAA's viewpoint is right, wrong, or whatever -- hell, I've tossed a few rants in these threads myself. But in the end, what matters is what FAA thinks. That is the framework in which your case will be considered, and therefore that's the framework in which the Doc frames his replies.

I have to say, Doc Bruce has the patience of a saint to put up with some of the mess he gets here.

-Rich

 

[bbchien]

Can his local HIMS AME provide a name and contact of this higher ranking practitioner?

I have already done so.

 

[SCCutler]

I have already done so.

Bless you, oh Marvelous Doc Who Can Also Cook Grilled Meats!

 

[jcwCT]

... the Healthcare act of 2012 specifically removed the diagnsis code, the pharmacy code and the procedure code from the medical record. That means that any credit bureau and yes, the FAA can see them anytime they want...

I'm confused. They were "removed" but any credit bureau and the FAA can see them any time they want?

 

[Unregistered]

As someone who was recently issued a medical with a previous ADD diagnosis and a somewhat extended use of medication, I would like to encourage everyone in this situation to follow the good doc's recommendations. Get off the meds, do the proper testing with a qualified neuropsych doc and go to an AME who is knowledgable about the system. With the proper documentation and possibly even more important, the proper wording on your paperwork, everything will be ok.

 

[pericynthion]

do you have a source to support either of your claims that
1. Ritalin is an amphetamine
or
2. It is illegal to prescribe ritalin (methylphenidate) for off-label use?

Reread the whole string. I never made that claim. Others have tired to put that into my mouth. Now you.

I am so out of here.

First of all, YOU SURE WERE diagnosed. Any phsyciian who gives you an Rx for Ritalin class meds has ONLY one diagnosis that supports that Rx or he's in jail. That's dextroamphetamine, for heaven's sake.

 

[gprellwitz]

... the Healthcare act of 2012 specifically removed the diagnsis code, the pharmacy code and the procedure code from the medical record. That means that any credit bureau and yes, the FAA can see them anytime they want...

I'm confused. They were "removed" but any credit bureau and the FAA can see them any time they want?

They were removed from the medical record and placed in the unprotected section of the information, removing any privacy expectations. At least according to the government.

 

[bbchien]

The class of stimulants includes not only ritalin, but also dextroamphetamine.

They are treated as a "class" of agents, doc. Whereas Ritalin is not, Adderal is. In the eyes of most practice boards, they are still serious drugs to Rx and the presumptive diagnosis is indeed ADD.

Terminal Cancer patients (ritalin) are rx'd for the stimulant properties and even that is inspected very carefully. Too many of those and the state investigates you....even yes, "just" ritalin.

 

[DJTorrente]

The bottom oline on "diagnosis": The FAA view is that a physician somewhere thinks he has ADD. That's all that counts for this disucssion.

This strikes me as close to "arbitrary and capricious". Any bloke with a script pad can brand and ground prospective airman for life practically from the cradle. OTOH, he needs Moses and the tablets to disprove the dx. Seems like a classic "Type II" problem.

 

[Jeff Oslick]

This strikes me as close to "arbitrary and capricious". Any bloke with a script pad can brand and ground prospective airman for life practically from the cradle. OTOH, he needs Moses and the tablets to disprove the dx. Seems like a classic "Type II" problem.

We've also been given information here that the FAS is using an evaluation criteria "different from the DSM". I'm not sure what to make of that, but it raises concerns for me whenever a federal agency appears they might be making up rules on its own without full public disclosure and comment.

It would seem the Pilot's Bill of Rights should force the agency to provide more clarity and disclosure on the grounds for medical denials:

From PBOR:
(3) to give medical standards greater meaning by ensuring
the information requested aligns with present-day medical judgment and practices; and
(4) to ensure that—
(A) the application of such medical standards provides
an appropriate and fair evaluation of an individual’s qualifications; and
(B )the individual understands the basis for determining medical qualifications.

Under this last section, if I were to be denied a medical, I would think I would have the right to demand all relevant information used by FAS to support the denial. Perhaps some more sunshine is in our future.

 

[bbchien]

We've also been given information here that the FAS is using an evaluation criteria "different from the DSM". I'm not sure what to make of that, but it raises concerns for me whenever a federal agency appears they might be making up rules on its own without full public disclosure and comment.

It would seem the Pilot's Bill of Rights should force the agency to provide more clarity and disclosure on the grounds for medical denials:

From PBOR:
(3) to give medical standards greater meaning by ensuring
the information requested aligns with present-day medical judgment and practices; and
(4) to ensure that—
(A) the application of such medical standards provides
an appropriate and fair evaluation of an individual’s qualifications; and
(B )the individual understands the basis for determining medical qualifications.

Under this last section, if I were to be denied a medical, I would think I would have the right to demand all relevant information used by FAS to support the denial. Perhaps some more sunshine is in our future.

Bull hockey. It's published. Here it is....