Vyvanse, the new ADHD medicine, has a unique prodrug delivery system developed to prevent abuse.  In addition to marked reduced abuse and misuse, studies have shown other major advantages over Adderall XR – the most prescribed medication for ADHD.  Vyvanse has been found to be more consistent in its effect, more effective, especially for attention, longer acting and to have less rebound symptoms in the afternoon.    

 How is Vyvanse different from Adderall?

• Adderall is 75% dextroamphetamine (dexedrine) + 25% levoamphetamine (mostly effects norepinephrine) 
• Vyvanse is 100% dextroamphetamine as the active ingredient but it is bound to an amino acid, L lysine.  Because the amino acid has to be removed by a protease enzyme located  primarily in the intestine before it works, it is designated as a "prodrug".

Note:  The additional norepinephrine effect of Adderall may help alertness and distractibility but it is also responsible for most of the risks and side effects of Adderall.  Many patients taking Adderall do better taking it with Tenex. www.askdrjones.com/  Men on Adderall XR are more likely to have erectile dysfunction and need Viagra type medication.  Some people, especially older men have trouble urinating when taking Adderall XR and may need Flomax.  Patients switching to Vyvanse have been less likely to have these side-effects. 

  Other side-effects related to norepinephrine include:

• dry mouth
• muscle tightness
• nervousness
• stomach aches
• cardiovascular effect (so less risk of increasing blood pressure)

Vyvanse is much more consistent than Adderall XR from day to day and patient to patient.  Vyvanse consistently reaches peak blood levels in 3 1/2 to 5 hours at a concentration of 100-175 ng/ml for a 70mg capsule.  Adderall XR has 400% variability – it peaks anywhere from 3 to 12 hours at levels of 70-300 ng/ml for a 30mg capsule.

Acidity levels in the stomach and small intestine and levels of gastrointestinal motility significantly impact absorption of XR but not Vyvanse.  Food, especially fat in the stomach or intestine can delay Adderall XR up to 2 1/2 hours but maximum delay of Vyvanse absorption is less than an hour.  Since it takes 3 hours to digest a fatty meal, forgetting to take XR before eating can result in significant stretches of time with reduced focus and productivity.

Vyvanse may be more likely to increase insomnia, decrease appetite, and increase weight loss – probably because it has a longer duration of action.

In a study where patients took alternately Adderall XR and Vyvanse almost 75% did much better.  However, twice as many patients on Vyvanse did very much better.

"Effect size" is a statistical measure of efficacy when comparing different studies.  The effect size for Vyvanse was significantly higher than any other medication ever studied for ADHD.  Also, when tested in known stimulant abusers it was significantly less likable than oral or IV dexedrine which means it is less abuse prone.

I have tried Vyvanse in approximately 200 patients – these were mostly patients taking Adderall.  Almost everyone that switched prefers Vyvanse.  One woman said that Adderall made her nervous and jittery which caused her to smoke more.  On Vyvanse she’s not smoking.  I still have a few patients that prefer Adderall.  Some probably prefer the increased mood or likability effect.  Some probably need the norepinephrine effect.

My prediction:  Vyvanse will rapidly become the number one medication for ADHD.

 Related ADHD article: www.askdrjones.com/2007/09/06/only-13-of-adhd-kids-are-being-consistently-treated-why-are-we-not-taking-better-care-of-our-greatest-resource/

These scans looking down on the brain are measuring dopamine activity in the nucleus accumbens and reflect levels of interest, drive and motivation. 

A recent research finding is that people who are born with below average receptors (D2) in this area are more likely to develop behavioral and/or substance addictions.

Conversely, people born with above average numbers of these receptors are relatively protected from developing addictions.

The function of this area of the brain is to learn what is pleasurable and then fire to activate our systems of pursuit.  Mother nature wants us to be motivated to eat and have sex.  These are natural activators of the nucleus accumbens.

In addictions this part of the brain is "hijacked" by some behavior, like gambling or alcohol/drugs.

Tolerance frequently develops to addictive substances and results in a depletion of dopamine.  Low dopamine causes craving for substances that have powerful effects on the dopamine system – like speed, cocaine, or alcohol.

One of the major themes of this year’s APA was the neurobiological basis of addictions. 

First it was schizophrenia, then manic and depressive disorders, then the anxiety disorders, then attention deficit disorders – These all became much better understood not just as abnormal behavior or feelings but as complex medical disorders with genetics and physiology. 

Science of mind is making possible much more effective treatments – not to replace psychological and social dimensions but to enhance them. 

Most recently, advances in understanding the science of addiction is beginning to help us treat these disorders more effectively.  How many D2 receptors were you born with?  It makes a difference. (see pictures of addiction)

One of the personalities that stood out at this years APA was Dr. Nora Volkow, Director of the National Institute of Mental Health Division for Addictions.  Dr. Volkow is a wiry, hyper, opinionated woman with a strong Germanic accent which seems to add force to her dynamic personality.  Her favorite thing to say is, "I like to be provocative."  She occasionally apologizes for dominating the stage and microphone but is not able to stay silent very long. 

One of her lectures was titled "Addictions and Free Will."  Free will is one of the things between stimulus and response.  Is this response a good idea?  What happened last time?  What are the possible consequences, options…etc.?

Unfortunately, the addictive brain may not access these thoughts.  Control is reduced or absent.  Fortunately we’re starting to understand why, and we’re starting to find treatments that give addicts new controls and options.

Two thunderous standing ovations highlighted this year’s APA meeting. They were as different as you could imagine. An intimate conversation with Brooke Shields about her battle against nature’s cruelest mood disorder – postpartum depression – and Dr. John Nash (A Beautiful Mind) reading a paper he wrote in which he describes his battle against schizophrenia through metaphors of economic theory and the complex mathematics of game theory (for which he received a Nobel prize). Each presentation was in front of hundred’s of physicians and other professionals. One was alternately funny and gut wrenching.  The other was a mind twisting exercise in obfuscation.

What they had in common was each individual had the courage and strength to open their heart and soul to the professional world so that their stories could help us help others.

Dr. Nash’s presentation was interesting at times and touching at times but mostly unemotional.  I wish he had been interviewed in front of the audience instead.

He likened becoming psychotic to part of his mind going on strike. The most provocative thing he said was that to him his new insight into mathematics and his paranoia were both novel ideas not shared by anyone.  The only difference was that one was true, was labeled genius, and was rewarded with the Nobel prize.  The other was not true, was labeled insanity, and got him committed to a locked psychiatric ward.

The schizophrenic mind can’t tell the difference. Of course sometimes ideas are true but sound crazy.  And for various reasons society is not ready for them and may even persecute those who dare to challenge the current version of truth (like the earth is the center of the universe).

I was the most moved by Brooke Shields. Maybe because I have helped women who struggle with postpartum depression for over 40 years. 

What can possibly be a more joyous time than having a new baby – looking into your eyes, cooing, and responding to your love?  What can be more painful than when you as a mother feel nothing, or rejection, or thoughts of harming this poor helpless creature?  What could be more shameful and guilt producing? 

Everyone is saying how cute and precious your baby is, and you’re thinking "I wish you would shut up," or maybe even, "Please take this baby with you."  And if you do share that you’re not feeling right they say, "Oh, it’s just ‘baby blues.’  It will pass. it’s normal." 

And you’re thinking, "You don’t understand. I want to die. I feel empty, hopeless, inadequate, overwhelmed."  Or if they suggest medication, what you hear is you’re weak or crazy or both!  When you’re a celebrity with fame and fortune, a loving husband, and all the trappings of a perfect life, but you feel like a total failure, you see no hope for even being o.k. again and thoughts of suicide come to mind.

As Brooke Shields discussed this torturous beginning to motherhood, the pain of her experience was palpable throughout the ballroom.  The first turning point occurred for her when she had sent her husband to get a changing table, but he returned empty handed.  He sat on the bed and broke down.  She had never seen him cry.  He said "I went to the store and there were all these mothers and babies and families, and they were so happy.  Why aren’t we happy?" 

I almost lost it, in fact it took several tries before I could comment to my wife without getting choked up.

She went on to describe how she got on an antidepressant and felt better.  She went back to California and stopped the meds and crashed again.  She describes driving in her car with the baby in the back and thinking, "I could speed up to 80 mph and run into a concrete wall and all this would be over."  Fortunately she called a girlfriend and told her how she was feeling, and her girlfriend made a date with her for lunch the next day. She said her girlfriend was so manipulative because she knew Brooke was compulsive about keeping her commitments and would have to wait until after lunch tomorrow to drive into a wall.  

Brooke called her  doctor who asked if she had stopped her meds.  She said yes and he asked, "Why?"  She thought, "Did I sleep through my 4 years at Princeton?"

So, she went back on meds, had some side effects, changed meds, and eventually, everything was okay. 

3 years ago she went through a 2nd pregnancy without all the stressors of her first pregnancy, which included 7 in vitro fertilizations, miscarriages, death of her father (prostate cancer), an emergency C-section, being away froms support people, and being clueless with expectations of being the perfect mother. 

She described how different this 2nd experience was.  When the OB handed her the baby in the delivery room, her husband was thinking "Please don’t start sobbing," but she felt joyous, relieved, then elated.  She said, "I started telling my girlfriends they could have some of my husband’s sperm (in vitro) if they needed it."  A happy ending.

She tells her story in the recent book Down Came the Rain.  She has done way more than her share in making women aware of what can happen and that treatment is available.  I felt so much respect and appreciation for what she has done.  Then I thought about Tom Cruise (see previous article). I wondered how many women were on the fence about mood disorders, psychiatry, and medication.  How many were influenced by him to not seek help?  How many mothers suffered unnecessarily, and how many babies didn’t bond with their mothers during those early critical developmental weeks and whose lives will be adversely affected forever?

At the same moment I wanted to sing Brooke Shields praises and kick Tom Cruise’s ass.

I am now completely against birth control pills. I’m also against hormone replacement with oral estradiol. Estradiol (in every birth control pill) taken by mouth goes through the liver and causes problems with thyroid, testosterone, and the most effective form of estrogen.

In anyone with a history of depression and/or stress reactivity, this can be a major contributing factor to their functioning and quality of life.

For premenopausal women the NuvaRing seems to be the best option. This is because the hormone blood levels are about 1/3 of what they are with the weakest birth control pill.

Controversy continues regarding hormone replacement in postmenopausal women. However, for most women, the benefits outweigh the risks – especially for brain function (mood & memory). Using the right types of hormones and the right dose is essential. The best options are Premarin or Cenestin tablets and/or estradiol by patch or gel.

Remember, estrogen x thyroid x brain transmitters = mood in women.

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Recently, one of my pharmaceutical reps asked me a question she’d been asking other doctors.  "If you only had 5 medications to work with, which ones would you choose?"  For me it was easy.

1. Adderall XR

Has the best batting average.  Batting average = how often patients say, "This med is great.  It changed my life and has no significant side effects."  And they’re still saying it after a year.

2. Alprazolam (Xanax or Niravam)

Helps people take back control of their lives.  Was the most prescribed med for stress last year.

3. Ambien CR

Safe sleep medication which gives you normal sleep.  Normal sleep = foundation for health.

4. Effexor XR

Has the most flexibility (SSRI at low doses, dual agent at higher doses), works the fastest, and has no significant drug/drug interactions.

5. Abilify

Best mood stabilizer.  Was the 1st of the new generation of atypicals.

I no longer take insurance.  To be successful I have to use the meds that work the best.  My goal for each patient is to find "the right medication at the right dose."  All of these "Top 5" have alternatives that I often use.  The bottom line is that with these meds I have seen the best long term results.

ADHD and to a lesser extent anxiety disorders are frequently unrecognized and untreated.  As a result millions of adults in the U.S. have a reduced quality of life and chronic stress symptoms that gradually take their toll on physical health.

Adults who have mood and anxiety disorders can also be ADHD.  The National Comorbidity Study (NCS) found ADHD occurs in

• 32% of  patients with a depressive disorder
• 21.2% of patients with bipolar disorder
• 9.5% of patients with an anxiety disorder

However, a large managed care data base reported the following treatment rates for co-occurring ADHD in adults with mood and anxiety disorders:

•  2.5%   in patients with bipolar disorder
•  1.7%   in patients with a depressive or anxiety disorder

New diagnoses for mood and anxiety disorders =

• 12,036,905 new depressive disorders
• 6,573,576 new anxiety disorders
• 1,148,175 new bipolar disorders

New diagnoses for ADHD = 900,897

This means that of 12 million patients diagnosed with a new depressive disorder almost 4 million also were ADHD but only 200,000 were being treated (4%) of the total here.  Approximately 100,000 of 600,000 patients with an anxiety disorder were being treated for ADHD (16%).  Only 250,000 bipolar patients (11%) were being treated for ADHD. 

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

The National Comorbidity Study (NCS) directed by Dr. Ronald Kessler is accepted as the most reliable study of the U.S. population.  Two hour assessments of all adults in selected households were randomly chosen from all over the country to establish prevalence. 

The NCS also found that anxiety disorders were the most prevalent mental health problem.  Social anxiety disorder was the single most common (8%) of the population followed by post traumatic stress disorder, generalized anxiety disorder, panic disorder and OCD.

Since anxiety disorders are 50% more prevalent than depressive disorders the managed care data base reflects that 2/3’s of anxiety disorders were not being treated.  The most likely explanation is that they usually weren’t diagnosed. 

If anxiety disorders are more common, how do you explain the fact that almost twice as many patients in the managed care data base were treated for depressive disorders (12 million) than anxiety disorders (6.5 million)? 

Other studies have found that doctors, including psychiatrists are much less likely to recognize and treat anxiety disorders.  This is partly because patients don’t have insight into the nature of their symptoms, or, especially in social anxiety and OCD, they are too embarrassed to bring it up.  Many doctors are not proactive in asking about each group of symptoms.  In managed care, reimbursement is a set rate.  It’s more economically effective to keep it simple and focus primarily on the presenting complaint. 

The saddest reality is that the success rate of treatment is appallingly low.  The NCS found that in any given year 30% of Americans will suffer from a mental health disorder, and those with a disorder will have on average 2 co-occurring disorders.  Successful treatment requires identification of all the existing problems and understanding of how each relates to the others.

It’s ironic that ADHD is the most frequently missed diagnosis since it is the most easily and effectively treated.   Anxiety disorders are probably the second most missed.  Although harder to treat than ADHD, they are not as complicated as depressive disorders, especially bipolar type.

The managed care data base didn’t include alcoholism and drug abuse.  Addictive disorders have the highest rate of co-occurring ADHD, but doctors are  reluctant to give the most effective treatment (stimulants) to this group of patients – even though studies show that usually they are safe and effective.

Change begins with awareness.  Our medical system is broken.  The impetus is going to have to come from the people suffering the consequences of the system.

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. 

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.