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.

Question:  I have ADHD, and it is ruining my life.  I can’t function like everyone else.  I keep making appointments to see a therapist, but I never go.  I don’t want to do this anymore.  I want to go to college, but everyone I know says it’s not a good idea for ME.  Can ADHD people succeed in college?

- Stacy

Last Friday, February 10, 2006, headlines reported "Warnings advised on ADHD drugs." A 15 member advisory committee recommended (by a vote of 8-7) to the FDA that a black box be added to the labeling of stimulants used to treat ADHD. Concern about serious cardiovascular side effects is mainly due to the report of a small number of sudden deaths in kids and adults who were taking stimulants. The biggest problem with this proposal is … There is no good scientific evidence that incidence of these very serious events is any greater in patients taking stimulants than in the general population. Last February, Health Canada (Canadian equivalent of FDA) took Adderall off the market because of a similar concern. (see 2-14-05 Blog) But further study of the facts led them to put it back on the market a few months later. A reanalysis of all the facts last year by the FDA found no convincing evidence of serious risk. Adderall XR already carries a black box warning that abuse or misuse could cause serious side effects. The label also warns of possible risk of sudden death in patients with structural cardiac abnormalities. Advanced arteriosclerosis, moderate to severe hypertension (especially if not controlled), and hyperthyroidism are contraindications for use of amphetamines. When trying to decide whether to take a medication, ask two important questions: What are the benefits? What are the risks? In my opinion, based on over 30 years of experience, the benefits far outweigh the potential risks. Stimulants are clearly the most effective treatment for ADHD. Untreated ADHD markedly increases alcohol and drug abuse, reckless driving accidents, lost jobs, divorce, stress, and reduced self-esteem. We have 70 years of research and clinical experience with stimulants. Taken under medical supervision, any risk of serious side effects is extremely small. I feel confident that Shire, McNeil, and other pharmaceutical companies that market stimulant medications will keep us informed of any new information or cause for concern. In the meantime, I continue to believe these medications are safe. Links Shire press release, 2-10-06 CHADD.org statement

Question: Is there anything wrong with using stimulants just to help you study?
Answer: It use to be thought that if stimulants calmed you down and increased your focus and performance, it meant you were ADD. We know now that anyone can improve their focus and short term retention by using stimulants.

A recent study of diversion of stimulants in college found that the overwhelming majority of the time, it was to help study, not for recreational purposes. This is considered by main stream medicine to be misuse/abuse of medication and is illegal. When reported in the media, this has been referred to as “cosmetic pharmacology.”
My guess is that most of the time there are no adverse consequences, but there are situations where it can be harmful without medical supervision. “I only need the medication to …” study for exams or to write a paper or read a boring assignment becomes “I only need it to …” prepare a brief, write a report for my boss, do my taxes, etc.
Being ADHD means it’s hard to focus on anything you’re not interested in, it’s hard sticking with something over any length of time, and it’s hard to finish things because the final details get monotonous and time consuming. A lot of people with moderate severity ADHD do fine with day to day functioning, especially if they’re bright and have good social skills. They may not realize they are ADD, but they know that stimulants help them when higher levels of focus are required.
You don’t have to meet full diagnostic criteria for ADHD to warrant treatment. ADD NOS (not otherwise specified) is a category that roughly means some significant ADD symptoms.
It would not be acceptable medical practice for any physician to prescribe any stimulant just to help study in the absence of any ADD symptoms.

Question:  I am searching for help with an issue my adult son with a history of ADHD has run into.  As an adult, his physician put him on Paxil for his ADHD as other medications for ADHD were not as effective.  My son is functioning very well, has never been depressed, suicidal or any other issues associated with taking Paxil.  Seven months ago, my son had a flight physical by a certified FAA medical examiner, told the physician he was taking Paxil and the physician passed him, thus allowing my son to proceed with obtaining his private pilot’s license.  Now, seven months later, after he has completed all requirements, and has been flying the FAA sent him a letter stating they would not allow his medical exam due to him taking Paxil. 

My question is: Is Paxil used to treat adult ADHD?  What other drug could be used?  We have always been told that he does not produce enough dopamine therefore resulting in a chemical imbalance.  With the Paxil he is able to maintain focus and carry on a very normal, busy, independent life of a 32 year old single male.  Any information or help you may offer us would be greatly appreciated as we are going to try to fight this issue.  Personally I feel it is discrimination against ADHD. – S.B.

Answer:  Consensus of experts in the area of ADHD is that there are imbalances in the dopamine and norepinephrine brain systems, primarily due to genetics.  There are many sources of evidence to support this view.  There is disagreement as to whether the problem is primarily in the dopamine system or whether it’s primarily in the norepinephrine system or equally both.  It will probably turn out to be mainly dopamine in some people who are ADHD and norepinephrine in others and both in still others.   The problem is compounded by many factors, one of which is that dopamine and norepinephrine impact each other and may be high in some areas of the brain and low in others. 

There is currently no scientific evidence that serotonin modulators such as Paxil help ADHD.  Paxil has a very weak modulating effect on norepinephrine, but this is not believed to be clinically relevant (unless one takes very high doses).  Most SSRI’s, including Paxil, will actually lower dopamine levels.  Norepinephrine modulating antidepressants, tricyclics (desipramine, imipramine), Strattera (actually approved for ADHD but not depression, higher doses of Effexor (150 mg and above), Wellbutrin, and theoretically Cymbalta can help ADHD – though on average 1/2 as effective as stimulants. 

Your son benefits from Paxil.  What does this mean?  My guess is that your son is not ADHD, or at least that’s not what Paxil is helping.  Many other things can cause some of the symptoms of ADHD.  Sustained concentration requires ignoring distractions, either in the environment or from the mind (“What if …?”).  Anxiety means “danger” and danger means monitoring the environment more closely and thinking about all the relevant “What ifs.” 

Clinical depression involves deficiencies in one or more brain transmitter systems that frequently interferes with focus.  Also, calm, sustained focus activates more left brain functions, but stress, anxiety and depression activate the right brain more.  I recommend a complete reevaluation before any other steps are taken.  Dealing with the FAA reminds me of my days as an Air Force psychiatrist.  You can’t let logic or fairness cloud your thinking.  It’s all about the regulations.  How to deal with them would need to come after the evaluation.

Question: What is the association between Tics/Tourette’s and ADHD/stimulants?
Answer: Tics are sudden muscle movements, jerks, or spasms. They are most common in the head (eye blinking, facial twitches), neck (head turns), or arms/shoulders. They usually start in early childhood and tend to get better with age. They sometimes persist into adulthood, and ironically, the most severe cases are in adults. Tics occur in 1-2% of kids.
Tourette’s is a more severe form of tic disorder and includes some form of vocalization, not limited to speech. This may take the form of a cough or throat clearing. I have made the diagnosis in several people over the years who weren’t aware they had tics of Tourette’s Syndrome (TS). In TS tics usually precede vocalization by 1-2 years.
Both of these disorders are more common in kids/adults with ADHD or OCD. In fact, Tourette’s is 10x more common in people with OCD than in the general population. Tics/TS are genetically based and involve a hypersensitivity to dopamine.
Because stimulants (e.g., Adderall, Concerta) increase dopamine activity, and the most effective treatments for tics/TS are dopamine blockers (Haldol, Orap), it was previously thought stimulants were contraindicated. Also, since sometimes tics first show up in a child taking a stimulant, it has been thought that the stimulant was the cause. Current evidence does not support this. Some kids with tics/TS do better on Concerta, some better on Adderall, and some can’t take either without aggravating their tics.
Before using Haldol/Orap, I usually first try milder meds like clonidine (blood pressure med), Tenex, or milder dopamine blocking agents like Abilify or Risperdal.
It is important to be aware of the frequent association of tics/TS with ADHD and OCD and to recognize the symptoms are sometimes subtle because there can be adverse effects, especially social. Most of the time, symptoms can be well controlled.

FAQs: ADHD

Does treatment of ADHD with stimulants increase the risk of substance abuse?
This question has been extensively researched by Dr. Wilens and Dr. Biederman at Harvard Medical School Department of Psychiatry. There were two significant findings.
First – Untreated ADHD doubles the risk of alcohol and/or recreational drug abuse.
Second – Treatment of ADHD with stimulants cuts the risk in half, equal to the general population.
As with other measures of functioning medical treatment of ADHD doesn’t eliminate problems but levels the playing field. FAQ’s ADHD

Question: How do we cope with our ADHD/angry/grown-child who is living at home?

Answer:  Unfortunately, I frequently hear “ADHD/angry/grown-child living at home with no job for several months and parents feeling helpless.”  Blames you for ______ is also common.  Not taking responsibility for one’s problems and life situations may be immaturity.  ADHD kids are usually found to be at least 2-3 years behind.  In more serious cases, frequent blaming behavior can be part of a personality disorder, which is difficult to deal with and may persist, sometimes for life. 

One issue is leverage, or power.  When kids are little you have the “power of the pop.”  With teenagers you have “the power of the purse.”  When I did hospital psychiatry years ago, sometimes the only leverage I had was cigarettes – I know, pretty desperate, but when that was the only thing someone cared about that I could have control of, that was my only option. 

Question: Once we have a diagnosis of ADHD what is next?
Answer: The role of medication in treating ADHD is as strong as the role of antihypertensive medications for high blood pressure. The MTA study showed that medication is by far the most effective type of treatment. Just as it is in managing high blood pressure, patient education and cognitive behavioral changes are an essential component.