R.I. lawmakers align on ADHD prescription bill. Doctors are more divided.
A pair of bills moving through the Rhode Island General Assembly would permit patients to fill multiple months of their ADHD medications — like methylphenidate, or generic Ritalin, shown here — in a single visit to the pharmacy. (Photo by Alexander Castro/Rhode Island Current)
Legislation moving through the Rhode Island House and Senate could alleviate one pain point for parents: Filling a prescription for ADHD medications amid ongoing shortages.
On Tuesday, the Rhode Island House Committee on Health and Human Services OK'd an amended version of H5866, a bill led by Portsmouth Democratic Rep. Michelle McGaw that would improve patients' access to prescription stimulants by allowing pharmacies to fill and dispense a 60-day supply rather than in 30-day increments as is currently allowed. The drugs are mainly used to treat ADHD and ADD, hyperactivity and attention deficit disorders, and since 2022 have consistently faced shortages nationwide.
The bill's Senate duplicate — introduced by Sen. Alana DiMario, a Narragansett Democrat — was also heard in committee on Tuesday. It was held for further study, which is standard practice at a bill's initial hearing, but at least one of DiMario's colleagues on the Senate Committee on Health was supportive.
'As someone who has to do this, yes, it's very angst provoking for the provider and for the patient,' said Sen. Pam Lauria, a Barringon Democrat and primary care nurse practitioner.
DiMario's bill would permit a more plentiful prescription by allowing pharmacies to issue a 90-day supply in a single filling. The original version of McGaw's bill also endorsed a 90-day supply before being amended on March 28 ahead of its second committee hearing. The house's legal counsel said at Tuesday's hearing that there had been comments from physicians which spurred the change but did not provide details.
DiMario wrote via text message Thursday that for now, her Senate bill will retain the 90-day stipulation.
'We just had the hearing so the [Committee] Chair will review all the testimony and decide how to proceed,' DiMario wrote, 'but to my knowledge there isn't a compelling reason to shorten the timeline to 60 days given those prescriptions can be written 90 days at a time in three separate prescriptions already.'
DiMario and McGaw's bills are written to permit larger prescriptions for 'non-opioid, non-narcotic Schedule II substances.' Schedule II drugs can be very habit-forming, but have at least some specific clinical applications, including prescription stimulants like mixed amphetamine salts (Adderall), Ritalin and Vyvanse, which are used to treat ADHD and ADD.
Since 2007, the Drug Enforcement Administration has allowed doctors to write prescriptions for 90 days' worth of Schedule II medications. But these 90-day prescriptions cannot be picked up all at once, and they can't be sent to a pharmacy at the same time. A physician must write three separate prescriptions, three months in a row. The patient will then see their doctor for another round of prescriptions, and the cycle begins anew. Multiple prescriptions may also be written for different strengths, to divvy up a larger dose and get around shortages.
DiMario also sponsored a successful bill signed into law by Gov. Dan McKee last year that prepares state health officials to adopt a 2023 federal standard that allows for electronic transfers of ADHD prescriptions — another common obstacle for patients and doctors alike, as federal prescription regulations plus continued shortages frequently complicate accessibility for patients.
Dr. Gregory Fox, a pediatrician speaking on behalf of the Rhode Island chapter of the American Academy of Pediatrics, told senators Tuesday the bill was a 'no-brainer' from a physician's perspective as well.
'I sat down with my two nurses today and they told me, when they arrived this morning, there were 20 refills for ADD prescriptions waiting for them, and then many, many, many come on through the day,' Fox said, estimating that his office nurses spend 'at least three or four hours of administrative time per day on ADHD prescriptions,' which DiMario's bill would slash by a third.
Supportive testimonies for the legislation for DiMario's bill and McGaw's original draft came from the Rhode Island Pharmacists Association as well.
Dr. Howard Schulman, an internist and primary care doctor based in East Providence who said he often tried to bring a 'from the trenches' perspective on health care to lawmakers in his public testimonies, was the lone person to submit a letter Tuesday against the bill.
In a phone call Wednesday, Schulman noted he was more comfortable with the 60-day rule over the 90-day proposal. He emphasized that he understands the motivation for the legislation, and has empathy for the lawmakers who expressed frustration at having to refill their kids' medicine over and over.
'This bill, if we pass it, is going to make my life better,' said Rep. Jennifer Boylan, a Barrington Democrat, at the initial March 18 hearing of McGaw's bill. 'I'm one of the parents that is going to the pharmacy three times a month. They cannot synchronize the prescriptions. I'm calling the doctor for three different prescriptions every single month. It's ridiculous.'
But Schulman was not convinced it was wise to increase a patient's supply of drugs that can become more habit-forming with higher doses, especially when the drugs are often shared among young people.
'I'm always trying to minimize the amount,' said Schulman of the stimulant prescriptions he's been writing for 15 years in his practice. 'There's a fair number of people who are on it, [but] I'm not giving it out like candy.'
Schulman prescribes at most 60 milligrams once a day — half the amount some patients say they're taking when they arrive at his office from other prescribers. Schulman also asks his patients to read 'Generation Adderall,' a 2016 New York Times article that detailed one woman's account of dependence and eventual cessation from the popular amphetamine.
Asked if filling even larger prescriptions for the drugs could exacerbate existing shortages, Schulman chuckled but didn't speculate. He said his concern was with lawmakers who aren't doctors 'regulating something that could affect people getting addicted to it.'
Schulman said he hoped the Rhode Island Department of Health would have something to say about the bill. But the state health department 'has no position on this bill,' Joseph Wendelken, an agency spokesperson, wrote via email Wednesday.
The House bill will now go to a floor vote, likely the week of April 21, said House spokesperson Larry Berman in an email Thursday.
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