Psychostimulants…the Good the Bad and the Ugly.

Stimulants first arrived on the market back in the 1950’s. Prior to that they were given to soldiers in World War II in order to keep them awake and focused. There’s a great novel- ADHD Nation- that outlines the history of stimulants so I will not go into that here. What I do want to talk about is my clinical experience in prescribing stimulants.

I have a lot of thoughts about ADHD as outlined here. For this blog post I’m going to try and stay off my soap box and stick to clinical experience only.

The Good. 

I don’t prescribe Adderall. I will limit my discussion to Ritalin LA, Ritalin (methylphenidate), Focalin XR, Focalin, Vyvanse, and Concerta. There are short acting stimulants (Methylphenidate and Focalin are the ones I prescribe most, however I have also prescribed Dexedrine) and long acting stimulants (Concerta, Vyvanse, Focalin XR, Ritalin LA). There is also a patch called Daytrana- I have never prescribed it. I know prescribers who have and they report mixed results. The good about Concerta is that it’s cheap and usually covered by insurance. The good about Vyvanse is it is less addicting and has a slower onset as well as less of a crash. Focalin XR I’ve had mixed results with, it doesn’t last as long as Vyvanse or Concerta but when it works it does really work for people. Some people who couldn’t tolerate Vyvanse or Concerta were able to tolerate Focalin XR. Ritalin LA same results, doesn’t last as long but generally well tolerated when it works. The benefits of stimulants for teenagers with ADHD can be quite astounding. They report feeling like they can focus better, having improved short term memory, improved organizational skills, and many of my clients report feeling better and more confident socially. To be clear, these are all subjective reports from my clients and what I have observed in my practice. None of the above should be substituted for your own practitioner’s recommendations and clinical experience.

The Bad.

They all reduce appetite and I’ve had to stop them or not even be able to start them in teenagers who are already underweight. There often is a crash of some sort. People report feeling very tired when it wears off or having onset of significant headaches. Some people just don’t tolerate long acting stimulants in general and feel crappy and in a fog when they take any of them. They can cause hypertension, and yes I’ve seen that happen in multiple cases hence why I check blood pressure. They can cause increase in irritability and anger. They can interfere with sleep. The worst is when a teenager is taking a stimulant and doing much better in school, and then they start to not be able to sleep. They come in for a medication visit with their parent and they both ask for a sleep aide. This is something I don’t do. I’m not going to prescribe an “upper” during the day and a “downer” at night to mitigate the side effects of the “upper”. If there are adverse effects such as poor sleep then we need to take a break from the stimulant. Many people do not like this answer.

The Ugly. 

Stimulants (and non-stimulant Strattera) can cause auditory and tactile hallucinations. I have seen this in clinical practice and it’s very scary for the client and their family. Stimulants can stunt growth. I’ve had clients on stimulants throughout their adolescence who grow to be over six feet. I’ve also had clients in their adolescence who stop growing and who need to be off stimulants and obtain growth hormone injections in order to reverse these effects. The growth stunting is very rare, but I’ve only been prescribing for four years and I’ve seen it happen. There is no predicting who will be in which category. Stimulants are absolutely addictive and they have a street value and you can snort them. I’ve even had clients who injected them.

The ugliest part of stimulants to me as a prescriber are instances when they are sought for the wrong reasons. I’ve done intakes on kids who are absolutely brilliant. They are referred by teachers for being “too fidgety” or “off in space” but they are getting straight A’s. These kids are bored. They need more challenging work at school, but in a class of 25-30 kids the teacher teaches to the average or below average so the kid only has to pay attention for the first five minutes to understand the lesson. I don’t prescribe to these kids, but their parents can easily take them to some one who will. Or the kids who are angry all the time and acting out at home so they must have ADHD. Then you talk to the kid and find out about a trauma history. These kids don’t need stimulants they need trauma therapy. The worst are the drug addicts who seek them to abuse or to sell or both. The addiction to psychostimulants is rampant and it’s something that no one talks about because drug companies are making billions of dollars.

Fun fact- the volume of Adderall that can be produced in a single year is regulated by congress. Guess who endorses the continued increase in the volume of Adderall that can be produced yearly? Our representatives and senators in congress. In one breath our politicians are speaking out against opiate addiction while in the next they are advocating for increase in production of stimulants. As a prescriber who sees the abuse of these medications daily I feel this is a problem.

My take home message is there can be vast benefits for people who truly suffer from ADHD and for who it is impairing their functioning socially and academically. But there are also adverse effects, long term effects, and addiction which all need to be considered carefully before writing out a prescription.

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