About 500,000 women in the United States suffer from epilepsy and are of childbearing age.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma: Infants born to women with epilepsy have a 2- to 3-fold risk of congenital malformations compared with those whose mothers do not have epilepsy, mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neuro-cognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In 1 recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is not known.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancies and a neurologist or an epileptologist. In reality, those who live in areas with limited access to such specialized care or have limited health coverage may be cared for throughout their pregnancy by a family physician. This evidence-based review was developed with this family physician in mind.

Safeguarding mom and fetus starts before pregnancy

Mechanisms by which AEDs cause fetal and embryonic harm remain unclear. Possible causes include drug toxicity, drug-drug interactions, folic acid deficiency, the effect of suboptimally controlled convulsions, genetic predisposition, enhanced apoptotic neurodegeneration, and alterations in thyroid hormone status, among others.^6-9 Major congenital malformations may occur in a dose-dependent manner, and physicians should aim to use the most effective AED at the lowest effective dose for women of childbearing age.²

In reviewing antiseizure therapy for such patients, here are some considerations to keep in mind:

Avoid polytherapy, if possible. Taking multiple AEDs may increase the risk of major congenital malformations, especially when valproate is one of the drugs.1 Hence, an attempt should be made to switch women with epilepsy who are of childbearing age to monotherapy. Ideally, this should be done a year before planned conception so that good seizure control can be achieved and documented prior to pregnancy.

Avoid high-risk AEDs. Overall, an increased risk of major congenital malformations has been most convincingly found with valproate and phenobarbital.¹ Specific types of malformations have also been linked to certain drugs (TABLE). Cardiac malformations are associated with carbamazepine, phenobarbital, and valproate; spina bifida, hypospadias, porencephaly, and other brain anomalies, as well as limb reduction defects, are associated with valproate, particularly at doses >1100 mg/d.¹⁰

Choose newer agents, whenever possible. The risk of malformations with newer AEDs—including gabapentin, lamotrigine, levetiracetam, oxcarbazepine, and topiramate—remains unclear, but preliminary data for monotherapy with these agents suggest a lower teratogenic risk compared with traditional AEDs, such as phenobarbital and valproate.¹⁰

Initiate folic acid supplementation. Drug-induced folate deficiency has been proposed as a contributing factor in the teratogenicity of AEDs, so diligence is essential in ensuring that patients who have epilepsy and are of childbearing age take folic acid.¹¹ Studies have demonstrated a significant reduction in spontaneous abortion in women who are receiving AED therapy and taking folic acid supplements, and the benefits of folic acid have been found to be especially notable for women taking valproate.¹²

Folic acid supplementation, of course, is important for all women of childbearing age. At a dose of 0.8 mg/d, folate has been shown to reduce the risk of neural tube and ventricular septal defects in the general population. The American Academy of Neurology/American Epilepsy Society (AAN/AES) Practice Parameters recommend that all women of child-bearing age taking AEDs also take folate supplements (0.4-4 mg/d).¹³ An optimal dose has not been determined for this patient population, but we routinely recommend 1 mg/d for women with epilepsy of childbearing age and increase the dose to 4 mg/d after conception.

TABLE
Commonly used antiepileptic drugs: Major teratogenic risks^1,10,19

Switching (or stopping) AEDs before conception
Changes in AEDs are rarely made after conception. Any switches that patients may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year prior to planned pregnancy so good seizure control can be achieved before then.

In attempting a change in medication, start by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That allows you to determine the baseline therapeutic drug level and dose at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dose, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

What about stopping AED therapy entirely if your patient wants to get pregnant? Stopping AEDs is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis, and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests she may have recurrent seizures, explain that the risk of discontinuing the medication is greater than the risk of fetal exposure to AEDs. It is also important to point out that more than 90% of women with epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider in the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry, available at http://aedpregnancyregistry.org. We recommend that physicians caring for pregnant women with epilepsy encourage them to enroll early on, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women taking AEDs—particularly those on higher-risk drugs such as valproate—undergo a detailed first trimester ultrasound study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible; if needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk for major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ while a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in the pregnancy. In some cases, dramatic increases—several multiples of the preconception dose—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels
Our approach to monitoring AED levels in a pregnant woman with epilepsy includes the following:

• Check levels at baseline—prior to conception, whenever possible—and monthly throughout the pregnancy, with more frequent checks for women with recurrent seizures and those taking lamotrigine.
• Use the dose at which the patient was seizure-free prior to conception as a target level during pregnancy.
• Adjust the dose as needed to maintain the preconception serum drug level.

Drug-specific considerations. As phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the free level of the drug with the following formula:

Free phenytoin = measured level/ [(0.2 × albumin level) + 0.1].

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/d folic acid for pregnant women with epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women with epilepsy (phytonadione 10 mg/d) starting at 36 weeks’ gestation and continuing until delivery despite the lack of a proven benefit because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes AEDs—to prevent hemorrhagic disease.¹³

Should women taking AEDs breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with AEDs are generally concerned about the possibility of contaminated breast milk. While antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with AEDs.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients with epilepsy who are being treated with AEDs, and is not contra-indicated by the AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women with epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the factors to consider in managing epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

CORRESPONDENCE Nitin K. Sethi, MD, Comprehensive Epilepsy Center, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, Room K-615, New York, NY 10021; [email protected]

About 500,000 women in the United States suffer from epilepsy and are of childbearing age.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma: Infants born to women with epilepsy have a 2- to 3-fold risk of congenital malformations compared with those whose mothers do not have epilepsy, mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neuro-cognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In 1 recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is not known.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancies and a neurologist or an epileptologist. In reality, those who live in areas with limited access to such specialized care or have limited health coverage may be cared for throughout their pregnancy by a family physician. This evidence-based review was developed with this family physician in mind.

Safeguarding mom and fetus starts before pregnancy

Mechanisms by which AEDs cause fetal and embryonic harm remain unclear. Possible causes include drug toxicity, drug-drug interactions, folic acid deficiency, the effect of suboptimally controlled convulsions, genetic predisposition, enhanced apoptotic neurodegeneration, and alterations in thyroid hormone status, among others.^6-9 Major congenital malformations may occur in a dose-dependent manner, and physicians should aim to use the most effective AED at the lowest effective dose for women of childbearing age.²

In reviewing antiseizure therapy for such patients, here are some considerations to keep in mind:

Avoid polytherapy, if possible. Taking multiple AEDs may increase the risk of major congenital malformations, especially when valproate is one of the drugs.1 Hence, an attempt should be made to switch women with epilepsy who are of childbearing age to monotherapy. Ideally, this should be done a year before planned conception so that good seizure control can be achieved and documented prior to pregnancy.

Avoid high-risk AEDs. Overall, an increased risk of major congenital malformations has been most convincingly found with valproate and phenobarbital.¹ Specific types of malformations have also been linked to certain drugs (TABLE). Cardiac malformations are associated with carbamazepine, phenobarbital, and valproate; spina bifida, hypospadias, porencephaly, and other brain anomalies, as well as limb reduction defects, are associated with valproate, particularly at doses >1100 mg/d.¹⁰

Choose newer agents, whenever possible. The risk of malformations with newer AEDs—including gabapentin, lamotrigine, levetiracetam, oxcarbazepine, and topiramate—remains unclear, but preliminary data for monotherapy with these agents suggest a lower teratogenic risk compared with traditional AEDs, such as phenobarbital and valproate.¹⁰

Initiate folic acid supplementation. Drug-induced folate deficiency has been proposed as a contributing factor in the teratogenicity of AEDs, so diligence is essential in ensuring that patients who have epilepsy and are of childbearing age take folic acid.¹¹ Studies have demonstrated a significant reduction in spontaneous abortion in women who are receiving AED therapy and taking folic acid supplements, and the benefits of folic acid have been found to be especially notable for women taking valproate.¹²

Folic acid supplementation, of course, is important for all women of childbearing age. At a dose of 0.8 mg/d, folate has been shown to reduce the risk of neural tube and ventricular septal defects in the general population. The American Academy of Neurology/American Epilepsy Society (AAN/AES) Practice Parameters recommend that all women of child-bearing age taking AEDs also take folate supplements (0.4-4 mg/d).¹³ An optimal dose has not been determined for this patient population, but we routinely recommend 1 mg/d for women with epilepsy of childbearing age and increase the dose to 4 mg/d after conception.

TABLE
Commonly used antiepileptic drugs: Major teratogenic risks^1,10,19

Switching (or stopping) AEDs before conception
Changes in AEDs are rarely made after conception. Any switches that patients may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year prior to planned pregnancy so good seizure control can be achieved before then.

In attempting a change in medication, start by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That allows you to determine the baseline therapeutic drug level and dose at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dose, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

What about stopping AED therapy entirely if your patient wants to get pregnant? Stopping AEDs is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis, and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests she may have recurrent seizures, explain that the risk of discontinuing the medication is greater than the risk of fetal exposure to AEDs. It is also important to point out that more than 90% of women with epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider in the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry, available at http://aedpregnancyregistry.org. We recommend that physicians caring for pregnant women with epilepsy encourage them to enroll early on, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women taking AEDs—particularly those on higher-risk drugs such as valproate—undergo a detailed first trimester ultrasound study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible; if needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk for major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ while a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in the pregnancy. In some cases, dramatic increases—several multiples of the preconception dose—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels
Our approach to monitoring AED levels in a pregnant woman with epilepsy includes the following:

• Check levels at baseline—prior to conception, whenever possible—and monthly throughout the pregnancy, with more frequent checks for women with recurrent seizures and those taking lamotrigine.
• Use the dose at which the patient was seizure-free prior to conception as a target level during pregnancy.
• Adjust the dose as needed to maintain the preconception serum drug level.

Drug-specific considerations. As phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the free level of the drug with the following formula:

Free phenytoin = measured level/ [(0.2 × albumin level) + 0.1].

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/d folic acid for pregnant women with epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women with epilepsy (phytonadione 10 mg/d) starting at 36 weeks’ gestation and continuing until delivery despite the lack of a proven benefit because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes AEDs—to prevent hemorrhagic disease.¹³

Should women taking AEDs breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with AEDs are generally concerned about the possibility of contaminated breast milk. While antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with AEDs.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients with epilepsy who are being treated with AEDs, and is not contra-indicated by the AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women with epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the factors to consider in managing epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

CORRESPONDENCE Nitin K. Sethi, MD, Comprehensive Epilepsy Center, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, Room K-615, New York, NY 10021; [email protected]

About 500,000 women in the United States suffer from epilepsy and are of childbearing age.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma: Infants born to women with epilepsy have a 2- to 3-fold risk of congenital malformations compared with those whose mothers do not have epilepsy, mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neuro-cognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In 1 recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is not known.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancies and a neurologist or an epileptologist. In reality, those who live in areas with limited access to such specialized care or have limited health coverage may be cared for throughout their pregnancy by a family physician. This evidence-based review was developed with this family physician in mind.

Safeguarding mom and fetus starts before pregnancy

Mechanisms by which AEDs cause fetal and embryonic harm remain unclear. Possible causes include drug toxicity, drug-drug interactions, folic acid deficiency, the effect of suboptimally controlled convulsions, genetic predisposition, enhanced apoptotic neurodegeneration, and alterations in thyroid hormone status, among others.^6-9 Major congenital malformations may occur in a dose-dependent manner, and physicians should aim to use the most effective AED at the lowest effective dose for women of childbearing age.²

In reviewing antiseizure therapy for such patients, here are some considerations to keep in mind:

Avoid polytherapy, if possible. Taking multiple AEDs may increase the risk of major congenital malformations, especially when valproate is one of the drugs.1 Hence, an attempt should be made to switch women with epilepsy who are of childbearing age to monotherapy. Ideally, this should be done a year before planned conception so that good seizure control can be achieved and documented prior to pregnancy.

Avoid high-risk AEDs. Overall, an increased risk of major congenital malformations has been most convincingly found with valproate and phenobarbital.¹ Specific types of malformations have also been linked to certain drugs (TABLE). Cardiac malformations are associated with carbamazepine, phenobarbital, and valproate; spina bifida, hypospadias, porencephaly, and other brain anomalies, as well as limb reduction defects, are associated with valproate, particularly at doses >1100 mg/d.¹⁰

Choose newer agents, whenever possible. The risk of malformations with newer AEDs—including gabapentin, lamotrigine, levetiracetam, oxcarbazepine, and topiramate—remains unclear, but preliminary data for monotherapy with these agents suggest a lower teratogenic risk compared with traditional AEDs, such as phenobarbital and valproate.¹⁰

Initiate folic acid supplementation. Drug-induced folate deficiency has been proposed as a contributing factor in the teratogenicity of AEDs, so diligence is essential in ensuring that patients who have epilepsy and are of childbearing age take folic acid.¹¹ Studies have demonstrated a significant reduction in spontaneous abortion in women who are receiving AED therapy and taking folic acid supplements, and the benefits of folic acid have been found to be especially notable for women taking valproate.¹²

Folic acid supplementation, of course, is important for all women of childbearing age. At a dose of 0.8 mg/d, folate has been shown to reduce the risk of neural tube and ventricular septal defects in the general population. The American Academy of Neurology/American Epilepsy Society (AAN/AES) Practice Parameters recommend that all women of child-bearing age taking AEDs also take folate supplements (0.4-4 mg/d).¹³ An optimal dose has not been determined for this patient population, but we routinely recommend 1 mg/d for women with epilepsy of childbearing age and increase the dose to 4 mg/d after conception.

TABLE
Commonly used antiepileptic drugs: Major teratogenic risks^1,10,19

Switching (or stopping) AEDs before conception
Changes in AEDs are rarely made after conception. Any switches that patients may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year prior to planned pregnancy so good seizure control can be achieved before then.

In attempting a change in medication, start by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That allows you to determine the baseline therapeutic drug level and dose at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dose, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

What about stopping AED therapy entirely if your patient wants to get pregnant? Stopping AEDs is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis, and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests she may have recurrent seizures, explain that the risk of discontinuing the medication is greater than the risk of fetal exposure to AEDs. It is also important to point out that more than 90% of women with epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider in the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry, available at http://aedpregnancyregistry.org. We recommend that physicians caring for pregnant women with epilepsy encourage them to enroll early on, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women taking AEDs—particularly those on higher-risk drugs such as valproate—undergo a detailed first trimester ultrasound study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible; if needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk for major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ while a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in the pregnancy. In some cases, dramatic increases—several multiples of the preconception dose—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels
Our approach to monitoring AED levels in a pregnant woman with epilepsy includes the following:

• Check levels at baseline—prior to conception, whenever possible—and monthly throughout the pregnancy, with more frequent checks for women with recurrent seizures and those taking lamotrigine.
• Use the dose at which the patient was seizure-free prior to conception as a target level during pregnancy.
• Adjust the dose as needed to maintain the preconception serum drug level.

Drug-specific considerations. As phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the free level of the drug with the following formula:

Free phenytoin = measured level/ [(0.2 × albumin level) + 0.1].

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/d folic acid for pregnant women with epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women with epilepsy (phytonadione 10 mg/d) starting at 36 weeks’ gestation and continuing until delivery despite the lack of a proven benefit because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes AEDs—to prevent hemorrhagic disease.¹³

Should women taking AEDs breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with AEDs are generally concerned about the possibility of contaminated breast milk. While antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with AEDs.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients with epilepsy who are being treated with AEDs, and is not contra-indicated by the AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women with epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the factors to consider in managing epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

CORRESPONDENCE Nitin K. Sethi, MD, Comprehensive Epilepsy Center, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, Room K-615, New York, NY 10021; [email protected]

Dr. Casey reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychiatrists need to be aware of aspects of psychiatric and pain management that are unique to end-of-life care for patients with advanced dementia. The palliative care philosophy presents an opportunity to honestly acknowledge the terminal nature of advanced dementia, limit intrusive and unnecessary care, and thoughtfully address pain and suffering.

Studies suggest that nursing home patients with severe dementia have an average life expectancy of 2 years.¹ These patients often have substantial medical comorbidity, frequently with multiple illnesses, each of which has an accepted management that may involve several medications and interventions. Treatment guidelines for individual conditions don’t necessarily take into account multiple interacting illnesses in advanced dementia. Applying recommended treatments for multiple conditions simultaneously may entail prescribing many medications and interventions. Often these techniques are designed to prevent or modify disease over long term, which a patient with advanced dementia is not likely to achieve.²

Such polypharmacy and intensive intervention are not likely to extend life or improve its quality. In fact, the opposite may occur. Dementia patients react poorly to polypharmacy and may require restraint or sedation to accommodate invasive interventions. Feeding tubes are particularly challenging. Studies have revealed that feeding tubes do not extend life in advanced dementia patients.³

Goals for palliative care. The palliative care approach emphasizes relieving suffering in the near term. Applying this philosophy to advanced dementia depends on acknowledging that the patient will not recover from this condition, has a limited life expectancy, and is not likely to benefit from—and in fact may be harmed by—an aggressive approach to comorbid conditions. Instead, these conditions are best managed by controlling pain and suffering in the near term. Hospitalization and invasive interventions are minimized.

Psychiatric management fits well within this approach. Near the end of life, dementia patients often suffer agitation, psychosis, depression, and delirium that may require the expert, judicious use of psychopharmacology. Patients often experience pain, but might not be able to communicate this, except through behavioral changes. Physicians may be overly concerned with possible adverse effects of pain medications, but when appropriately prescribed, these drugs may help relieve suffering. Psychiatrists also have a role in assisting staff and families during an emotionally difficult time.⁴

Dr. Casey reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychiatrists need to be aware of aspects of psychiatric and pain management that are unique to end-of-life care for patients with advanced dementia. The palliative care philosophy presents an opportunity to honestly acknowledge the terminal nature of advanced dementia, limit intrusive and unnecessary care, and thoughtfully address pain and suffering.

Studies suggest that nursing home patients with severe dementia have an average life expectancy of 2 years.¹ These patients often have substantial medical comorbidity, frequently with multiple illnesses, each of which has an accepted management that may involve several medications and interventions. Treatment guidelines for individual conditions don’t necessarily take into account multiple interacting illnesses in advanced dementia. Applying recommended treatments for multiple conditions simultaneously may entail prescribing many medications and interventions. Often these techniques are designed to prevent or modify disease over long term, which a patient with advanced dementia is not likely to achieve.²

Such polypharmacy and intensive intervention are not likely to extend life or improve its quality. In fact, the opposite may occur. Dementia patients react poorly to polypharmacy and may require restraint or sedation to accommodate invasive interventions. Feeding tubes are particularly challenging. Studies have revealed that feeding tubes do not extend life in advanced dementia patients.³

Goals for palliative care. The palliative care approach emphasizes relieving suffering in the near term. Applying this philosophy to advanced dementia depends on acknowledging that the patient will not recover from this condition, has a limited life expectancy, and is not likely to benefit from—and in fact may be harmed by—an aggressive approach to comorbid conditions. Instead, these conditions are best managed by controlling pain and suffering in the near term. Hospitalization and invasive interventions are minimized.

Psychiatric management fits well within this approach. Near the end of life, dementia patients often suffer agitation, psychosis, depression, and delirium that may require the expert, judicious use of psychopharmacology. Patients often experience pain, but might not be able to communicate this, except through behavioral changes. Physicians may be overly concerned with possible adverse effects of pain medications, but when appropriately prescribed, these drugs may help relieve suffering. Psychiatrists also have a role in assisting staff and families during an emotionally difficult time.⁴

Dr. Casey reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychiatrists need to be aware of aspects of psychiatric and pain management that are unique to end-of-life care for patients with advanced dementia. The palliative care philosophy presents an opportunity to honestly acknowledge the terminal nature of advanced dementia, limit intrusive and unnecessary care, and thoughtfully address pain and suffering.

Studies suggest that nursing home patients with severe dementia have an average life expectancy of 2 years.¹ These patients often have substantial medical comorbidity, frequently with multiple illnesses, each of which has an accepted management that may involve several medications and interventions. Treatment guidelines for individual conditions don’t necessarily take into account multiple interacting illnesses in advanced dementia. Applying recommended treatments for multiple conditions simultaneously may entail prescribing many medications and interventions. Often these techniques are designed to prevent or modify disease over long term, which a patient with advanced dementia is not likely to achieve.²

Such polypharmacy and intensive intervention are not likely to extend life or improve its quality. In fact, the opposite may occur. Dementia patients react poorly to polypharmacy and may require restraint or sedation to accommodate invasive interventions. Feeding tubes are particularly challenging. Studies have revealed that feeding tubes do not extend life in advanced dementia patients.³

Goals for palliative care. The palliative care approach emphasizes relieving suffering in the near term. Applying this philosophy to advanced dementia depends on acknowledging that the patient will not recover from this condition, has a limited life expectancy, and is not likely to benefit from—and in fact may be harmed by—an aggressive approach to comorbid conditions. Instead, these conditions are best managed by controlling pain and suffering in the near term. Hospitalization and invasive interventions are minimized.

Psychiatric management fits well within this approach. Near the end of life, dementia patients often suffer agitation, psychosis, depression, and delirium that may require the expert, judicious use of psychopharmacology. Patients often experience pain, but might not be able to communicate this, except through behavioral changes. Physicians may be overly concerned with possible adverse effects of pain medications, but when appropriately prescribed, these drugs may help relieve suffering. Psychiatrists also have a role in assisting staff and families during an emotionally difficult time.⁴

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”

All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.¹

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

• understand the legal and ethical status of a doctor-patient relationship
• know the proper way to end treatment relationships
• decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.^2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).³

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.² If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.² If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”² Physician abandonment can lead to malpractice liability,⁴ complaints to state licensing authorities,⁵ and ethical condemnation.⁶

Table 1

A patient’s responsibilities

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.^7,8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,⁹ nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.³ Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.¹⁰

Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:

• notification that the physician-patient relationship is terminated
• a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
• an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.¹¹

More discussion of the possible contents of termination letters appears in Table 3.^7,12-14

Table 2

Common reasons to consider terminating a patient’s care

Table 3

Potential elements of termination letters

Deciding to ‘fire‘ a patient

Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.¹⁵ But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”¹

Having an anonymous consultation with a colleague offers several potential benefits, such as:

• If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
• You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.^15,16
• A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
• A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
• If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.¹²

Revisiting the case patients

With these thoughts in mind, we return to Dr. C’s clinical dilemmas.

Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:

• Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
• Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.

Mr. B. Concerning Mr. B, we wonder, “Why not just leave the chart open?” As is the case with care provided by other specialists—including internists, obstetricians, or dermatologists—psychiatric treatment may occur in discrete episodes over many years. Patients regard a previous care provider as “their doctor” for decades after a treatment episode, and it’s comforting and valuable for former patients to know they can see their “shrink” again if they need to.

Related Resource

• Henderson SM. Advice on abandonment. Oklahoma Board of Medical Licensure and Supervision. www.okmedicalboard.org/download/19980401MD.htm.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina

Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.

The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.

Lew Borman,

media relations,

Blue Cross Blue Shield of North Carolina