QA: The “Treatment Overlap” speech and giving an ultimatum in clinical care

by | Jan 9, 2023 | Curbside Consults

Question: If you see a new patient and you’re recommending discontinuation of amphetamines due to side effects (like high anxiety) and it leads to patients considering discontinuing care with you, how much will you work with them and prescribe for the time being? A 12 year old had this scenario; on his first visit, his mother was demanding a refill of methylphenidate 50 mg/d which he had been receiving from his prior psychiatrist. Lots of issues in the family so I hate for them to leave my care as the boy could use serious help.

Answer: This is a difficult question. In general, I would argue strongly against ever refilling a prescription for a controlled stubstance, especially amphetamines, on the first visit. The only time I did this in my career, the patient overdosed and died by suicide. It turns out that he had been seeing various doctors and collecting prescriptions for amphetamines on the first visit. Never do it on the first visit. Have them come back even a few days later, or a week later. It’ll prove that at least they aren’t doing something illegal or suicidal.

On the larger question of the case, there is always the dilemma of where the clinician should put his or her bright line in the sand; in other words, when are you going to give an ultimatum. You can’t practice well clinically if you have no bright lines, if you are unwilling ever to give an ultimatum to patients. On the other hand, if your threshold for ultimatums is too low, you will not be practicing well either. I always told patients that the office door was open for them to enter, and open for them to leave. Nothing forced them to stay in treatment with me. I also gave my “Treatment Overlap” speech, which went something like this:

“Treatment happens when you and I agree on what your treatment should be. It is not just up to me; and it is not just up to you. You do not have the sole right to decide what is prescribed, and neither do I. My role is to give you my scientific knowledge and clinical judgment. I will give you a list of options that are scientifically valid and clinically appropriate for you, based on my experience. Your role is to provide your personal preferences and your level of willingess to take risk. All drugs have risks, so the decision partly depends on how much risk you are willing to take. You don’t have to take anything, but I’m also not forced to give you anything. I’ll give you my list of options, and you give me your list of preferences. If our lists overlap, then we can begin those treatments. If our lists don’t overlap at all, then we can’t do any treatment, and then you should leave and seek another clinician who would be willing to provide the treatments you seek.”

Taking this approach, most people would agree to something within the options I would provide them. Essentially, your role as a clinician is to limit the universe of options so that patients choose from scientifically sound choices. They can’t just take anything, or whatever they want. You have the obligation and the right to limit the range of choices for them, although not necessarily to say they have to do one thing and nothing else.

All that said, in this case you want to keep working with the child, so you could exercise your discretion to make temporary compromises. You might give the amphetamine to the mother with the proviso that it would only continue for another 2-3 months while you explored with her and the child other factors in the child’s life that might be affecting him. Then three months later, you would revisit the amphetamine prescription; you might continue it again for another three months on the same conditions. After 6 months or so, if you were getting nowhere with the family, you might then be justified in giving an ultimatum and saying you would not provide further amphetamine treatment and they could seek treatment elsewhere.