Smoking is the prototype addiction, i.e. compulsive behavior, in spite of negative consequences.  Only the most extreme denial can rationalize smoking as something that is not harmful and allright to continue.  There is no question that smoking significantly increases two of the most common causes of premature death both cardiovascular disease and cancer, but in addition quality of life significantly decreases by illnesses such as Chronic Obstructive Pulmonary Disease.  Smoking is socially a nuisance and is increasingly expensive, and it accelerates aging especially of the skin.  Despite these facts, smokers argue "it relaxes me and I enjoy it."  For some individuals the increased risk and fear of gaining weight, especially among women, keeps them from quitting.    However, there are much better alternatives to these arguments.  

Addictions are not easily given up and smoking proves one of the most difficult.  In fact, inhaled addictive chemicals reach the brain faster than drugs given IV.  Since every puff reinforces smoking addiction, one pack per day provides 200 reinforcers per day.  The good news is that there are new treatment options that work through novel mechanisms to help smokers overcome the addiction.

"But I have to be ready to quit."  Not necessarily true.  With one new treatment, you can take the medication while you continue to smoke.  The medication interferes with the addictive power of the cigarettes.  Now with multiple medical options and cognitive behavioral techniques, you can give up your worst habit- or at least significantly reduce the number of cigarettes you smoke per day.  In addition, lifestyle modification and sometimes medication can prevent weight gain, and lifestyle coaching is useful and often necessary.

When researchers look at smokers who successfully quit, one thing stands out.  Most say they just decided one day to quit on their own.  Those that quit, however, were more likely to have been advised by their physicians.  That just reinforces my responsibility as a physician to educate and discuss the risks of smoking and the various treatment options available.   

One important consideration that should be taken into account when quitting is whether you have a history of depression or are currently depressed.  Quitting smoking can make your depression worse, and taking Bupropion (Wellbutrin, Zyban) or other antidepressants can be protective.

For more information or to schedule coaching to help you quit, contact Melissa King during regular office hours at 972-234-0489. 

ADDERALL XR (amphetamine-dextroamphetamine)

ADDERALL XR is a mixed salt amphetamine approved by the FDA for treatment of Attention Deficit Hyperactivity Disorder. Mixed salt amphetamines have been studied and used clinically to treat ADHD since the 1930’s.

Amphetamines, as a class of stimulants, increase activity of the brain’s natural stimulants, Dopamine and Norepinephrine. Dopamine regulates interest, motivation, energy, concentration, pleasure seeking and movement. Norepinephrine regulates alertness, focus, energy, and vigilance. Adderall’s effects on Norepinephrine are about equal to its Dopamine effect.

ADDERALL XR comes in 5, 10, 15, 30, 25, and 30 mg slow release capsules. The cost is the same for all 6 sizes. Total duration of effect for the XR form is 7-12 hours. Half of the dose is absorbed immediately, and takes effect in about 30 minutes. Half is absorbed in 4 hours.

ADDERALL tablets (scored) come in 5, 7.5, 10, 12.5, 15, 20, and 30 mg sizes. Duration of action for the tablets is 3 ½ - 6 hours. Tablets are more likely to have rebound side effects, and doses are more likely to be missed or delayed.

Unlike most prescriptions, ADDERALL cannot be called into the pharmacy. By state regulations all stimulants require written prescriptions, which MUST BE FILLED WITHIN SEVEN DAYS. This means a prescription written on Monday must be filled by Sunday.

HOW TO TAKE ADDERALL XR

GUIDELINES

DOSING

• STARTING DOSE is 10mg in am for adults, 5mg in am for children.
• Increase dose by 10mg every 1-4 days until symptoms are under control.
• Dosing needs to be individualized for optimal benefit but is in the 20-90 mg range for most people. Maximum total daily dose is usually 2/3’s body weight in pounds. (Do not go above prescribed dose without doctor’s approval.)
• Higher doses last longer and can be effective up to 10-12 hours.
• If nervousness or over-stimulation occurs, always REDUCE the dose.

SWITCHING FROM ADDERALL TABLETS TO CAPSULES (XR)

If switching from ADDERALL tablets to capsules (XR), total the daily dose of tablets in mg and take half as often. For example, if currently taking 30mg tablets twice daily, switch to 60mg XR in am (two 30mg XR capsules). If taking 15mg 4x per day, take 30mg XR twice per day.

MANAGING SIDE EFFECTS

Most side effects are mild and occur mainly in the first two weeks of starting medication. In studies, very few people stop medication due to side effects. If side effects are experienced to a bothersome degree, decrease the dose.

May aggravate tics.

Side effects that peak around 6 hours from dose are most likely due to the medication. Dose needs to be reduced.

Irritability and tiredness/fatigue that occurs more than 6 hours after last dose are more likely due to medication wearing off (rebound effect). Dosing may need to be adjusted by adding an extra dose or by increasing the dose.

Many side effects are well controlled by Tenex (Guanfacine).

APPETITE SUPPRESSION

Eat a good breakfast 15-30 minutes after the morning dose. A nighttime snack such as ice cream is also recommended. Appetite usually improves over time, but if not, other methods of management can be used. Weight loss is common especially in people who are overweight. This is usually not due to appetite decrease but to a decreased tendency to eat due to boredom or stress.

Tenex may help taken a.m., evening, or both.

Remeron (Mirtazapine) helps sleep and appetite. Start very low (7.5 mg or lower). Remeron can cause morning drowsiness, especially when first starting.

SLEEP DISTURBANCE

First, shift dose to earlier in the day. If earlier does not work, take dose LATER in day. This may be caused by a “rebound” of ADD symptoms. Sometimes, medications that provide normal sleep are needed.

NOTE: Blood pressure should be monitored especially if any of the following is used on a regular basis with Adderall. Tenex is the first treatment option since it directly counteracts the effects of Adderall and these medications on blood pressure.

• Caffeine-large amounts
• Appetite suppressants
• Thyroid
• Some asthma meds
• Wellbutrin XL
• Effexor XR
• Tricyclics
• Cymbalta

For full information, see package insert or prescribing information.

The power of addiction is almost constantly in the news - Ted Haggard, Mark Foley, To Catch a Predator, catholic priests …

What do you think is the main problem?

• Pre-Extraction Disorder - they have their heads up their **** - clueless as to what their problem is
• Milk of Magnesia Deficiency - they are full of @#$% - rationalize their behavior
• Total selfishness and hedonism - like the excitement too much
• No self-control - they are weak
• Need medical treatment - they have a serious deficiency of dopamine in their nucleus accumbens

As I’ve written before, addiction is not only incredibly powerful, but it’s also one of the most difficult illnesses to treat.  I’ll be writing more about this soon.  In the meantime, cast your vote in our poll and let me know what you think by posting a comment here.

Click here to see how Dr. Jones determines "Best Meds"

Stimulants are without a doubt my most successful medications.  All except Provigil require a triplicate prescription, which is ironic because stimulants are seldom abused when properly prescribed. Approximately 10% of adults will abuse prescription medication but what they abuse is primarily pain medications, especially Hydrocodone (4 to 1 over stimulants and tranquilizers 2 to 1 over stimulants). Ironically, pain medications and tranquilizers are much less regulated and can be called in with refills whereas stimulant prescriptions have to be written each time. In what way does this possibly make sense? To paraphrase an old Bullwinkle cartoon, “are you familiar with government intelligence?” “It sounds like a contradiction in terms to me sir.”

The single most important thing for all ADHD patients on stimulants is ALL DAY coverage.

AMPHETAMINE PRODUCTS

Adderall XR primarily and Adderall tablets to a somewhat lesser extent rank #1 in my practice. Adderall is a type of amphetamine. Amphetamines have been studied in patients since 1936. The fact that we have more years of scientific study and clinical experience with this type of medication than any other we use in psychiatry is reassuring to me and many of my patients. There is no evidence of long term problems with Adderall or other amphetamines.

These medications help with staying calm and focused on what one chooses, not just what’s interesting. Adderall also tends to improve mood. It doesn’t usually decrease appetite but helps control weight because eating impulsively due to being bored or stressed is reduced. It is usually the best long term treatment for Bulimia-sometimes combined with an SSRI. The primary indication for Adderall XR and Adderall tablets is Attention Deficit Hyperactivity Disorder (ADHD).  Adderall was the first stimulant approved by the FDA to treat adult ADHD.

Adderall helps people to think about one thing at a time and to single out the important from the unimportant. The XR formula usually allows for once a day dosing although some people, especially those that want 16 hours of calm/focus and productivity, may take it twice a day. It has a low abuse potential because it takes 6 hours to reach maximum blood level, (3 hours for Adderall tabs). Abuse potential correlates highly with rate of onset of action.

Dexedrine is similar to Adderall and may be as effective for boredom or low motivation, but isn’t as calming.

Desoxyn (see below)

METHYLPHENIDATE PRODUCTS

Methylphenidate may be better than amphetamines for hyperfocusing. Moodiness may be a side effect, but it is less likely to affect blood pressure or erectile functioning. We have over 50 years of scientific study and clinical experience with methylphenidate and have no evidence of long term problems or loss of efficacy.

Daytrana patch is the most flexible and potentially longest lasting stimulant - up to 15 hours if removed at 12 hours or if left on for up to 24 hours.  It has a smooth onset of action and wears off 3 hours after it’s removed.

Concerta usually lasts 12 hours.   For patients who would do best on a methylphenidate product but who don’t like or can’t tolerate patches, Concerta is the best choice. 

Other forms of methylphenidate:

Ritalin and Methylin last 3-4 hours and rebound can be a problem. Methylin comes in chewable and liquid forms for children and adults that have trouble swallowing pills.

Focalin is the primary active ingredient in methylphenidate and may be better tolerated by a few patients.  It lasts 4-6 hours.

Focalin XR lasts approximately 8 hours and was the second stimulant approved by the FDA to treat adult ADHD.

Metadate CD is 30% release initially and 70% in 4 hours.  Ritalin LA is 50% immediately and 50% in 4 hours.  Both last around 8 hours.  Some people have a preference for one or the other.

WHY START WITH AMPHETAMINES?

Some people prefer methylphenidate and some prefer amphetamine products. In one study that compared methylphenidate to amphetamines, about 40% said either worked fine, 15% preferred methylphenidate, and 30% preferred amphetamine.  If the percentages are the same as the study and with no other factors to guide the decision, I feel patients are better off starting with Adderall XR. It will work well in at least 70% of people. If Adderall does not work, I would next try Daytrana.  This will get the success rate to 85%.

Pediatricians usually start with a methylphenidate product because they’re milder.  This is probably true.

There are a few patients that don’t tolerate Adderall, Dexedrine, Concerta, or other methylphenidate type stimulants. The most common side effects they complain of are nervousness and irritability. For these people Desoxyn (methamphetamine) usually works well. I have 15-20 patients who can’t tolerate other stimulants but who lead normal lives on this medication. Unfortunately, it is now only available in short acting tablets. It lasts 4-6 hours and is very expensive. Because it is the most likely of the stimulants to be abused it has to be monitored more closely. We have 60 years of clinical experience with this medication and there is no evidence of long term problems or loss of efficacy.

Provigil is a different type of stimulant. It does not require written triplicate prescriptions and basically has no abuse risk. Provigil was originally marketed for excessive daytime sleepiness associated with narcolepsy and has since added formal approval for daytime sleepiness associated with shift-work and sleep apnea.

Provigil primarily increases alertness but may also improve cognitive functioning and learning. In a study in mice, Provigil enabled old mice (equivalent to 70 year old humans) to learn a maze as fast as young mice. Without Provigil the old mice took twice as long to learn the maze.

Provigil is very well tolerated but occasionally causes headaches or dizziness when first starting. Dose reduction usually solves this problem. It doesn’t work on boredom or low motivation. There are studies showing benefit for ADHD in some patients but it’s not on the order of magnitude of benefit we see with Adderall XR or methylphenidate. It is sometimes added to other stimulants or to antidepressants. It is also useful for chronic fatigue from physical causes such as fibromyalgia. It is pricey and insurance companies frequently try not to cover it. But it is very safe and effective, and many patients find it useful. Although it has only been on the market for a few years, we have no evidence of any long term problems.

Click the link below for latest info on new drugs:

www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

Tenex (Guanfacine) is usually taken once or twice daily.  It can be taken 3-4 times/day but it has a 16 hour half life so frequent dosing is not necessary.  If taken regularly total blood levels will gradually increase over the first three days and then will level off.

Tenex comes in 1 and 2 mg tablets that are easily broken in half.  If taken primarily for help with sleep or if an individual is very sensitive to side effects it can be taken in the evening.  For irritability, muscle spasms, anxiety, increased blood pressure or any symptoms associated with high levels of norepinephrine it is usually taken in the am or am and evening.

As with most medications, start with a low dose – ½ of 1mg and gradually increase as needed until the right dose is found.  Extra doses can be taken for acute symptoms like agitation associated with increased or unusual stress.

Side-effects are usually mild and transient – especially sluggishness or dizziness.  If any side effects are bothersome decrease the dose and take at bedtime only.

Tenex (generic Guanfacine) is a medication that has been used for years as a mild antihypertensive.  In the body and in the lower brain centers it reduces the release of norepinephrine (sometimes called noradrenalin).  In the prefrontal cortex in the front of the brain it decreases sensitivity to distracting stimuli and therefore helps with focus (on target stimulus).  A slow release form of Tenex will likely be FDA approved for ADHD within the next year or two. There are good controlled studies showing that Tenex benefits many ADHD symptoms although it doesn’t help with boredom or enhance ability to focus on things the ADHD individual has low interest in.  Only stimulants help the full range of ADHD symptoms and that’s why stimulants are considered the first line treatment.

 
Stimulants increase norepinephrine throughout the brain and sometimes in the body.  In the prefrontal cortex this helps decrease distractibility but in other areas of the brain it sometimes causes nervousness, insomnia, decreased appetite, or irritability and in the body can cause muscle twitches, stomach ache, or increased blood pressure.  In the lower brain centers in children it has sometimes been found to delay growth.

 
All of these negative effects can be reduced or eliminated by Tenex (Guanfacine) plus distractibility is further improved.  If taken in too high a dose it can cause sluggishness or dizziness and occasionally can cause swelling.  It is one of my top 10 most frequently prescribed medications – usually with stimulants or sometimes antidepressants.  It can be taken once or twice daily (See how to take) because it has a half life of 16 hours – it can be effective if taken just once a day.

 
Tenex is related to Clonidine.  But Tenex is 10 times stronger in the prefrontal cortex than in lower brain centers where Clonidine has the same potency in all brain areas and is therefore much more sedating – sometimes causing morning drowsiness when taken at night.  But some people need the higher sedation at night and it has a stronger enhancement of growth hormone – in fact Clonidine is sometimes abused by body builders to increase muscle building.

 
Many of my patients have found Tenex to be helpful for social anxiety.  It reduces symptoms like sweating, and dry mouth but it also decreases distractibility.  People with social anxiety are distracted by negative or “what if” thoughts.  They are also distracted by physical symptoms and they are distracted by any negative cues in their environment, e.g., if giving a presentation and one person yawns the immediate thought is, “I must be boring”.  It’s very hard to do a good presentation when your mind is jumping all over the place.  Stimulants also help social anxiety by increasing control of what you focus on.  The combination of stimulants (such as Adderall XR, Daytrana) and Tenex is especially helpful in lowering public speaking anxiety symptoms so that with adequate opportunities to practice, public anxiety response will gradually desensitize.

Question: What are the best medications for ADHD?

Answer: Surgeons are practical. “A difference that makes no difference is no difference”. Recognizing ADHD and finding the right treatment makes a dramatic difference in someone’s life.  ADHD is relatively easy to diagnose. There are more studies showing the effectiveness and safety of medication in treated ADHD than in any other mental health disorder and most general medical disorders.

Stimulants are almost twice as effective as other types of medication (like Strattera, Provigil, and Wellbutrin XL, Tenex). Long acting stimulants are usually safer (especially less rebound) and more effective. Sometimes short acting medications can be used to supplement the long acting stimulants. Some people do better on amphetamines and some do better on methylphenidate type of stimulants. Some do okay on either.

More people do better on amphetamines according to one study.  In another study amphetamines were more likely than methylphenidate to allow ADHD patients to function at the highest level.

In general, amphetamines are more effective for the majority of ADHD patients because they have a broader spectrum of action relative to both subtypes of ADHD symptoms.  Because amphetamines have been shown to be very effective for a higher percentage of patients than methylphenidate, I start most patients on Adderall. Because long acting medications are safer and generally more effective I start with the XR form. It generally has at least an 8 hour duration of good effect. Some people take it twice a day to get 16 hours of calm focus.

I use the new Daytrana patch if Adderall does not work well, or when the advantage of the patch lasting up to 15 hours is the most important clinical consideration.

Some patients prefer Adderall because of the help with weight control - not usually decreased appetite but they stop eating out of boredom or stress. They also are more physically active and more likely to be able to motivate themselves to exercise. In fact, stimulants in general enable an ADHD person to choose what they want to do or focus on instead of being at the mercy of only doing things they have a high interest in.

To me, the ultimate test of medication is how it does in the long term.  I tell patients I’m not interested in them coming back and saying, “I think it’s helping a little bit doctor”.  I’m looking for, “This medication is great. It has helped me change my life and I don’t have any significant side effects”, and they are still saying it 1 year, 5 years, etc. We have almost 70 years of research showing the effectiveness and safety of amphetamines and 55 years with methylphenidate. I have patients who have done well on stimulants for over 30 years. I don’t see any long term problems. I can’t say that for any other type of medication that I prescribe.

I frequently add Tenex (Guanfacine) to stimulants to enhance efficacy and to further minimize side-effects.

Click link below for new ADHD med info:

www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

Daytrana (methylphenidate)

Daytrana is an adhesive patch formulation of methylphenidate (such as Concerta, Ritalin, Focalin). It is the first patch to be approved by the FDA for treatment of ADHD. Although the formal indication is for use in children 6-12 years of age it can be used in all age groups.

The approved wear time is for up to 9 hours, providing 12 hours of effective control of symptoms. Wearing time for the patch can be individualized so that it is removed 3 hours before you want it to wear off. This allows for up to 15 hours of effectiveness, i.e., 12 hours wearing time. Many patients leave the patch on for 24 hours. The effect wears off in 15 hours and sometimes sleep is better when leaving it on.

HOW TO APPLY THE PATCH

The studies for approval were done by applying the patch to the side of the upper leg, just below the waistline of the underwear. It probably works just as well on the abdomen (in women) or on the side of the arm.

It is essential that it is applied properly.  Half the backing is removed and that side of patch applied to the body. The skin must be clean, dry, and have no hair. Then the other half is removed and pressure is applied by the palm of the hand for 30 seconds.

The combination of heat and pressure will keep the patch firmly attached. Most people begin to notice an effect in one hour, but for some it takes 1 ½ to 2 hours. To speed up the rate of onset it may help to keep firm pressure on the patch for a full minute.

DOSING

The patch is 10, 15, 20, & 30mg in strength. This refers to the amount of medication released during a 9 hour wearing time. If left on longer than 9 hours additional medication is released.  After 4-5 weeks of regular wear, absorption improves and up to twice as much medication is released.

This may result in better efficacy or may cause side-effects. In the event of side-effects the dose just needs to be reduced. Total dose should not exceed the maximum published dosing limits of 2mg per kg of body weight.

This translates to:

100kg = 220 pounds

50kg = 110 pounds

1 kg = 2.2 pounds

The medication is equally distributed throughout the patch. Although it’s not part of the formal FDA approval some patients report that cutting the patch in half and wearing on separate days works well.

Patients may wear 2 patches at one time when requiring a higher dose. It is recommended they both be put on the same side. The patch should be alternated between the left side and the right side. If any redness remains don’t put the patch on the red area but move it down or further back on the hip.

Each patch has 2 ¾ the total medication on the label.  This means that:

10mg has 27.5mg

15mg has 41.3mg

20mg has 55mg

30mg has 82.5mg

A unique feature of Daytrana is that after 4-5 weeks of regular use the absorption of medication improves and close to twice as much medication is released into the system.

If switching from Concerta 36mg, Daytrana 30mg was found to be equivalent.  After 4-5 weeks the dose of Daytrana may need to be reduced. 72mg of Concerta (2 x 36mg) may require 2 patches of 20-30mg initially but after 4-5 weeks one patch will be sufficient.

The patch sizes are:

1 ½ x 3 ½ inches(30mg)

1 ½ x 2 ½ inches(20mg)

1 3/8 x 1 7/8 inches(15mg)

1 3/8 x 1 3/8 inches(10mg)

SIDE-EFFECTS

Side-effects are the same as for all methylphenidate products except for possible skin irritation. In a large clinical trial only 7% discontinued due to side-effects and about ½ of those were due to skin irritation.

Other side-effects include:

• Decreased appetite
• Sleeplessness
• Sadness/crying
• Muscle twitches
• Weight loss
• Nausea

Most of the significant side-effects like muscle twitches, insomnia, irritability, and possibly even decreased appetite and stomach ache can be improved by reducing the dose. But if side-effects persist at the effective dose then Tenex (Guanfacine) ½ to 2mg once or twice daily can be very effective plus it also improves distractibility.

Most patients do not have any skin reaction or have mild redness that goes away quickly once the patch is removed. A small percent of people will have more marked redness that may persist for a few hours and a very few may develop a more significant localized skin allergic rash.

GENERAL INFORMATION

Remember that after 5 weeks the amount of medication released is almost double the dose on the label if worn for 9 hours and even higher if worn longer.

Because the patch provides up to 15 hours of effective symptom control and can be flexibly dosed to wear off within 3 hours when removed, it should be considered the first line form of methylphenidate in clinical practice. No other stimulant on the market provides more than 12 hours with single dosing and in ADHD it is hard to remember to take second and third doses of medication.

Note: If there are concerns about the possibility of growth delay – especially in children in the bottom quartile, Tenex can be given at bedtime. Clonidine is even stronger but is frequently too sedating. Tenex is also effective for the occasional person that has increased blood pressure from stimulants.

LAMICTAL (lamotrigine)

LAMICTAL (lamotrigine) is formally classified as an anticonvulsant drug.  However, it has been used for many years for migraines and pain.  It is also effective for treating bipolar depression.

WARNING: STOP THE MEDICATION IMMEDIATELY IF A RASH APPEARS.

Lamictal comes in scored tablets of 25, 100, 150, and 200mg. It is most cost effective to buy the larger sizes and cut them in half.

The dose may need to be increased to a total of 250-400mg.

SIDE EFFECTS

If significant side effects occur (e.g. dizziness on 25mg), the dose may be reduced even further. 

To decrease side effects (especially risk of rash) take each dose for 2 weeks.