Just five years ago, one study found that 93 percent of adult psychiatry residences did not touch ADHD once, and an astounding half of all pediatric residences also did not cover ADHD in their medical training. What this means: Your doctor may not know enough about ADHD or your first-line treatment, stimulant medications. That puts the burden of knowledge on you – the patient or the parent.
Why the medication?
Stimulant medication is the most recommended form of treatment for ADHD for a simple reason: studies show that it is more effective. “When adults ask me questions about why they should try medications to manage their ADHD, my response always comes down to two words: Medication works,” says Russell A. Barkley, Ph.D., clinical professor of psychiatry and pediatrics At the Medical University of South Carolina. “When you find the right medication, you can experience substantial improvements in your ADHD symptoms.”
Clinical practice guidelines developed by the American Academy of Child and Adolescent Psychiatry (AACAP) recommend medication as the first-line treatment for ADHD, citing a formal review of 78 studies on the treatment of ADHD, which “consistently supported superiority Of the stimulant on non-pharmacological treatment “.
Even the widely cited Multi-Modal MTA Cooperative Group Study, which concluded that medication combined with behavioral therapy is the optimal treatment of ADHD in school-age children, acknowledged that “a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. ”
What is stimulant medication?
The key neurotransmitters deficient in ADHD brains are norepinephrine and dopamine. The main medications used to treat ADHD stimulate specific cells within the brain to produce more of these deficient neurotransmitters – thus the descriptive label “stimulants”.
The FDA has approved 29 stimulant medications to treat ADHD in the United States. “All 29 are just different ways to administer just two molecules: methylphenidate and amphetamine. There is no evidence to indicate that one molecule is inherently better than the other,” explains board-certified psychiatrist Dr. William Dodson.
Stimulants based on methylphenidate include Ritalin, Concerta, Daytrana, Qullivant and Quillichew. Amphetamine-based stimulants include Adderall, Vyvanse and Evekeo.
“The response rates for methylphenidate and amphetamine are about the same,” says Dodson. “When you try methylphenidate and amphetamine, you get about 80-85 percent sturdy response rate, which means that if you do not get a good response with whatever medicine you’re trying, do not give up.
Most people do well on methylphenidate or amphetamine, but not on both. Dr. Dodson begins by trying both types with each patient, to ensure that the patient is getting the best possible result with ADHD medication. It also recommends long-acting stimulant formulations instead of short-acting formulations. For most patients, long-acting formulations require only one pill a day, provide more even and uniform coverage throughout the day, and disappear more gradually.
What is the correct dose?
No test can predict what dose of what drug will give a patient the optimal level of benefits without side effects. What worked best for your brother might be ineffective for you, and vice versa. The dose of each patient is determined by trial and error.
Genetic testing to measure alleles that metabolize a drug can not predict the dose a person will need. Many pediatricians are trained to prescribe a certain number of milligrams per kilogram of weight of a patient, but there is no evidence that an ideal dose of ADHD medication correlates in any way with weight, age, sex, scores Of the scale or severity of the impairment.
This is what determines the optimal dose of a patient or ADHD medication:
Individual Metabolism – How medications are absorbed by the gastrointestinal tract. This is constantly changing for children under the age of 16, so your child’s dose should be adjusted once a year in August just before the start of school.
Individual Neurochemistry – How effectively molecules of a drug cross the blood-brain barrier from the bloodstream to the brain.
Think of medications for ADHD as you would with glasses. An individual who can not focus on his vision needs to wear glasses; An individual who can not concentrate their attention and control their impulses may need medications for ADHD. Two people can not exchange glasses because each recipe is personalized to the individual and their unique vision challenges. The notion of high dose graduated glasses versus low dose prescription glasses is quite absurd. What we want is the correct dose for each individual, and when the correct prescription is achieved, then the individual sees with 20/20 vision, with virtually no side effects.
“Medication for ADHD is more than just school,” says Dodson. “It’s about being able to be social, get along with your family, do your homework, meet expectations at work, drive a car at night, and be sure.” The current recommendation is that you take the medication wherever there is Impairment of ADHD. ”
What is the wrong dose?
Optimal dosages vary greatly from person to person. The dosage range approved by the FDA for most ADHD medications covers only half of all people. Approximately 6 to 8 percent of children, adolescents and adults optimize at lower doses than the lowest doses. Up to 40 percent of people optimize at doses higher than those studied and approved by the FDA, according to Dr. Dodson.
“Physicians should stop seeing the dosage from a high vs. low dose perspective, and instead focus on adjusting a dose for the single individual.” Putting Vyvanse in water, for example, or using liquid formulations such as Quillivant XR, doctors can adjust the dose to a lower than the lowest dose done if someone responds well to a small amount, “Dodson says.
Where dosage goes wrong: Patients expect them to feel stimulated or different in some way.
The rule: The right molecule in the correct dosage should return a person to normative levels of functioning, not to some artificial amped-up state, and without side effects.
If a person feels different, the dose is too high or too low. “When the dose is off,” says Dodson, “hyperactive people tend to be reduced to a drag – this is commonly referred to as” zombie syndrome. “Other people get over stimulation with the wrong dose, and this is called” Of Starbucks. “If a patient is experiencing personality changes or feels revved or slowed, the dose is typically too high and needs to be decreased. Traditionally, doctors were trained to give the highest dose a person could tolerate. Research shows that this “higher dose” is too high; the optimum is typically at least two doses weaker than this threshold, “says Dodson.
What happens if stimulant medications do not work?
About 15 percent of children and adults with ADHD do not respond or do not tolerate stimulant medications. For these people, physicians should turn to second-line medications for ADHD: non-specific ADHD stimulants clonidine and guanfacine. They are alpha-agonists initially developed to treat high blood pressure but now approved for treating ADHD. They have more time to get results than stimulant medications.
The American Academy of Child and Adolescent Psychiatry calls the non-stimulant Straterra specific for ADHD a third medication option as it is moderately effective for children of elemental age with ADHD but barely detectable in adolescents and especially in adults. The structure of Strattera, action patterns, length of time needed to work, and side effects are, in many ways, similar to a group of depression medications and other disorders called “selective serotonin reuptake inhibitors” or SSRIs. In fact, Straterra was first studied as a treatment for depression. When it was not found to be successful, it was treated as ADHD. Strattera is approved for use with children six years and older, as well as with adolescents and adults who have ADHD. Safety and efficacy have not been established in patients younger than six years of age.
Finally, there is an alternative category of medications sometimes used to treat ADHD, commonly referred to as “off the label” because they were not specifically approved to treat ADHD. These include Bupropion (Wellbutrin), Modafinil (Provigil), tricyclic antidepressants and Amantadine. These are not approved by the FDA for the treatment of ADHD, but some studies support its effectiveness in cases where first, second and third line treatments have failed.