The Telehealth Company Closed and the Adderall Ran Out: A Nurse Practitioner's Decision on Continuing a Schedule II Stimulant for a New Adult Patient
[Student Name]
University of Phoenix
NRP/507: Advanced Pharmacology
Week 1 Assignment
[Instructor Name]
[Date]
The patient and clinic are composites written for a model paper. State rules differ; students should apply their own state's law.
Ms. R., a 31-year-old graphic designer, arrives as a new patient at a rural family practice where I work as a family nurse practitioner. For two years she received mixed amphetamine salts, 20 mg of the extended-release form each morning, through a telehealth company that has now closed. She has four days of medication left and asks me to take over the prescription. She brings a screenshot of her last prescription and says she was diagnosed with attention-deficit hyperactivity disorder after a 30-minute video visit. This paper explains how I decide whether, and how, to continue a Schedule II stimulant for a patient I have just met.
Step 1: Do I Have the Authority?
Mixed amphetamine salts are Schedule II controlled substances under federal law. Prescribing them requires DEA registration that includes Schedule II and authority under state law. In our state, nurse practitioners have full practice authority and may prescribe Schedule II drugs, but the board of nursing requires a check of the prescription drug monitoring program before the first prescription of any Schedule II drug and at least every three months after that. Some states limit nurse practitioners to a short supply of Schedule II drugs or require a physician agreement; a nurse practitioner in those states would face different constraints. Schedule II prescriptions cannot be refilled, and each must be issued as a new prescription, usually electronically.
Authority to prescribe is not a reason to prescribe. The legal question tells me whether I may write the prescription; the clinical questions tell me whether I should.
Step 2: The Monitoring Program Report
The first action is the monitoring program check. Ms. R.'s report shows monthly fills of the same dose from one telehealth prescriber and one pharmacy for 22 months, with no early fills, no other stimulant prescribers and no opioids or benzodiazepines. The pattern is reassuring. Prescription drug monitoring programs were created to help prescribers see what a patient receives across prescribers, and their implementation has been associated with sustained reductions in Schedule II opioid prescribing (Bao et al., 2016). The report cannot confirm a diagnosis, but it does show consistent use.
Step 3: Is the Diagnosis Established?
A diagnosis made in one short video visit may or may not be sound. Adult attention-deficit hyperactivity disorder requires symptoms beginning in childhood, present in more than one setting and causing impairment, with other explanations considered. I will request the telehealth company's records, which the company is required to keep even after closing, and ask Ms. R. for school records or report cards and permission to speak with a parent about childhood behavior. Today, I will complete a structured history and a standardized adult self-report screen, and screen for depression, anxiety, sleep problems and substance use, since each can mimic or accompany the disorder.
Ms. R.'s history is consistent with the disorder: teachers' comments about distractibility from elementary school, a pattern of missed deadlines that improved on treatment and a stable job she has held throughout treatment. She reports no substance use beyond two glasses of wine a week.
Step 4: Is the Drug Appropriate for Her?
If the diagnosis holds, the choice of drug is reasonable. A network meta-analysis of 133 trials concluded that, weighing efficacy and tolerability, amphetamines are a preferred first choice for short-term treatment of adults with the disorder, and methylphenidate for children and adolescents (Cortese et al., 2018). Before continuing, I check for conditions that make a stimulant unsafe: her blood pressure today is 118/76 mm Hg and her pulse 78; she has no history of heart disease, syncope, chest pain with exercise or family history of sudden cardiac death. She has a hormonal IUD and a negative pregnancy test today. Her weight is stable. She reports mild appetite suppression and no insomnia.
Step 5: What Is the Misuse Risk?
Prescription stimulants are commonly used and sometimes misused. In a national survey of about 102,000 adults, 6.6% had used prescription stimulants in the past year; 1.9% misused them without a use disorder and 0.2% had a use disorder, and the most common source of misused stimulants was friends or relatives (Compton et al., 2018). Ms. R. has no history of substance use disorder, and her fill history is consistent. Her risk appears low, but diversion is a risk for any patient, and the plan must address safe storage.
The Decision
I will write a bridging prescription for 14 days of her current dose so that she does not stop abruptly while the diagnosis is confirmed. This is not a commitment to long-term treatment. I will document why: consistent monitoring program history, a history consistent with the disorder, a normal cardiovascular screen and no substance use disorder. I will schedule a follow-up in 12 days to review the records and screens.
The Written Plan
If the diagnosis is confirmed, continued prescribing will follow a written controlled substance agreement covering one prescriber, one pharmacy, no early refills, secure storage in a locked box, no sharing and random pill counts or urine testing if concerns arise. Visits will be monthly at first and quarterly once stable, each with blood pressure, pulse, weight, sleep and function reviewed each time and the monitoring program checked before each prescription.
What Would Change the Plan
If records show no real diagnostic evaluation and the history is less clear, I will refer for a formal evaluation and discuss a nonstimulant option in the meantime. If the monitoring report later shows another stimulant prescriber, the plan will stop. If blood pressure rises above 140/90 mm Hg on repeated readings, I will adjust the dose or switch agents.
Why Not Stop the Drug Today?
Refusing any prescription until records arrive might seem the safest course, but it carries its own risks. Stopping an amphetamine abruptly does not cause dangerous physical withdrawal, yet it commonly brings fatigue, low mood and a return of the symptoms that were treated, and Ms. R. relies on concentration for her work. A patient left without a prescriber may also seek medication from other sources, which is exactly the diversion the safeguards are meant to prevent. A short, documented bridge with a firm follow-up date keeps her in care while the evidence is gathered.
Documentation
The note will record the monitoring program query with date and time, the history and screens, vital signs, the reasons for the bridging prescription, the plan and the patient's agreement. Clear documentation protects the patient, who deserves continuity, and the prescriber, whose decisions may later be reviewed.
Conclusion
Continuing a Schedule II stimulant for a new patient requires answering four questions in order: may I prescribe it, is the diagnosis established, is it safe for this patient and what safeguards will surround it. For Ms. R., a short bridging prescription while records are gathered balances the risk of abrupt discontinuation against the need to confirm the diagnosis, and a written agreement will govern any longer course.
References
Bao, Y., Pan, Y., Taylor, A., Radakrishnan, S., Luo, F., Pincus, H. A., & Schackman, B. R. (2016). Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Affairs, 35(6), 1045-1051. https://doi.org/10.1377/hlthaff.2015.1673
Compton, W. M., Han, B., Blanco, C., Johnson, K., & Jones, C. M. (2018). Prevalence and correlates of prescription stimulant use, misuse, use disorders, and motivations for misuse among adults in the United States. American Journal of Psychiatry, 175(8), 741-755. https://doi.org/10.1176/appi.ajp.2018.17091048
Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S2215-0366(18)30269-4
How this NRP 507 Week 1 example is structured
The NRP/507 Week 1 work usually centers on prescriptive authority and the safeguards around controlled substances. This paper moves in the order a prescriber should: whether the nurse practitioner may prescribe the drug, whether the diagnosis is established, whether the drug is safe for this patient and what controls will surround the prescription if it is written. Students search this week as NRP 507 Week 1, NRP507 Wk 1 or NRP/507 Wk 1; all three are the same assignment.
NRP/507 Week 1 questions, answered
What does NRP/507 Week 1 usually cover?
Many sections open with nurse practitioner prescriptive authority, federal DEA registration, state limits on controlled substances and safeguards such as prescription drug monitoring programs.
Can nurse practitioners prescribe Schedule II stimulants?
In most states, yes, with DEA registration for Schedule II and within state rules, which may add limits such as supply duration or a collaborative agreement. Students should check their own state's law.
Should a nurse practitioner continue a stimulant started elsewhere?
Only after confirming the diagnosis, reviewing the monitoring program report and prior records, screening for cardiovascular and misuse risk and setting a written plan. Continuing without these steps is the most common error.
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