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.


The Challenges of Treating ADHD as a Prescriber

I receive around two or three calls weekly for evaluation of ADHD in children and adults. Generally people have done some sort of questionnaire online and self diagnosed after answering six general questions. Or they have been receiving stimulants from their pediatrician, PCP, or other psychiatrist or APRN who is now requesting they transition care to psychiatry for whatever reason. They could have been on stimulants for years, having only completed a basic questionnaire at the time of the first prescription.

Diagnosing ADHD is hard. There are a lot of false positives because our brains and bodies are not supposed to sit for eight hours a day listening to lectures or working on a computer. So kids in high school and college who find lectures challenging often come to me stating they can’t pay attention to a three hour lecture. I’m thinking yeah but who can?

Depression is pretty straightforward. For a true severe depressive episode there is weight loss/gain, poor ability to function in daily life (decrease in showering, poorly groomed, missing work etc.), sleep increase or decrease, irritability…the list goes on. I’ve sat with enough depressed people on the spectrum from mild to severe with psychotic features that it in general fits a picture and there is overt evidence of impairment in functioning of the individual.

ADHD, especially in adults, is more subjective. Sometimes it takes a few sessions for me to see the full disorganization of their thought process. These are people who could be getting a 3.5 GPA telling me they can’t focus and can’t organize themselves. It’s hard for me to believe that when they are doing well academically. There’s also a lot to rule out. Anxiety disorders often present with difficulty focusing as do depressive disorders. Bipolar disorder has a high co-morbidity with ADHD and many times when bipolar patients are treated with mood stabilizers their focus improves. Trauma/abuse in children presents often as behavioral difficulties and difficulty focusing. I can’t tell you the number of kids I’ve assessed who have been diagnosed with ADHD but no one asked them about being sexually assaulted and how that is on their mind all the time making it impossible to focus.

I have adults who come to see me who are working two or three jobs, raising kids, getting maybe four hours of sleep per night telling me they have trouble concentrating and completing tasks. Chronic sleep deprivation can cause cognitive impairments. In other words without enough sleep you can’t think straight. Taking a stimulant would enhance anyone who is chronically tired. Taking a stimulant honestly would enhance anyone in general too.

What I look for in an assessment is thorough testing of some sort. Neuropsychiatric evaluation, or at the most basic a Conners Behavioral Rating Scale. Anything beyond a Vanderbilt really. Then I need to figure out how functioning is impaired. It needs to be impaired for me to offer medication. In the midst of all of this I have to assess for those who are drug seeking: those who would potentially sell their medications to others, and any other co-morbid substance abuse issues.

Then if I get through all of that and decide this person could benefit from some sort of medication for ADHD I have to warn about all the adverse effects. Because they exist. For real. I’ve seen stimulants make kids psychotic (visual hallucinations), more angry, irritable, lose weight due to decrease in appetite, stunt growth (yes I measure height and weight at every visit and rarely kids have needed Growth Hormone injections), and yes I’ve seen people who are addicted to stimulants. It’s a real thing.

Then we have to pick the stimulant to trial. There’s a bunch. I point blank don’t prescribe Adderall- it has a high, then a crash, and a wicked withdrawal, it also had a major street value and is the “most addicting”. Yet Adderall is the cheapest and the one all insurance companies want me to prescribe first. So for every stimulant prescription I write that’s a new prescription, new medication, I have to do a prior authorization. It’s a pain in the ass.

This is a side note. Adderall is supposedly the “cheapest” available. But Ritalin has been out on the market since 1952. So I’m confused as to why it is still wicked expensive. It’s generic now, yet pharmaceutical companies keep the price of stimulants jacked up. Read ADHD Nation. It’s a good book.

So, I do a thorough assessment, I provide drug education for my patient and/or their parents, I potentially send a urine toxicology screen, I fight the insurance company to cover the stimulant I feel is safest to prescribe. I call the pharmacy and the patient to tell them they can now pick up the stimulant. They try it. We do a follow-up. They don’t like it. “I just don’t feel like me.” “It makes me too tired.” “I have no appetite.” “It makes me angry.” “It makes me cloudy.” “My friends notice something’s not right.” The list goes on.

Round 2. We try another one. I have to do another prior authorization. I have to do more education. If it’s a college kid I have to make sure they get the old stimulant out of their dorm room and off the college campus to a place that destroys old medication.

Potential success with second medication trial. Or we go onto the third.

In my experience it can take 1-3 tries to find the right ADHD medication. I do prescribe non-stimulants as well.

We find the right medication. Then we have to taper to the right dose. Then it’s only lasting 6 hours they want it to last 8 or 10 or 16.

Then we have to have the discussion- my goals are to medicate someone to last a school day. My goal is not to have a person’s brain on a stimulant for sixteen hours a day. That’s not healthy. Then we may have to have the discussion of why they are running out of their medication early- because they are doubling their dose, or taking an added afternoon or evening dose to get through work or night classes. Then we have to revisit goals of treatment, misuse of medication….it goes on.

I don’t want people to think I don’t love treating ADHD. Because I do. When a thirteen or fourteen year old comes to me and is suffering and being made fun of at school and says the one thing they want to fix with medication “is to give me friends” well that just about breaks me and when I see them respond to ADHD medication and therapy and a year or two down the line they are functioning beautiful teenagers with friends and a social life and good grades, well that’s just about the best feeling in the world.

I’ve been in outpatient practice now for three and a half years. Some of the patient’s have been with me since day one. I started treating them as gangly and awkward thirteen year olds and they are now applying for college and asking me advice about sex and if they can smoke pot with their medications. It’s frightening watching these babies turn into men and women but it’s also amazing forging relationships with them and being a safe space for them to ask any question about anything. It’s also heart-melting to see them now have friends when a few years ago they felt like the most lonely kid in the world.

Those are my success stories and those are the reasons I still treat clients with ADHD. But there have been a lot of problems along the way too. I’ve seen clients who became irate and verbally aggressive because I wouldn’t prescribe them stimulants, specifically their Adderall. I now screen clients over the phone for intakes and am clear that I don’t prescribe that particular medication to weed out those issues.

Prescribing psychiatric medication is hard. Diagnosing psychiatric illness is hard. I take that responsibility very seriously and I try and be exceptionally thorough. Because for those suffering with ADHD I do want to help. But it can be exhausting and it is one of the few fields where patients come often thinking they know more than their healthcare provider about their diagnosis and course of treatment because of the tests they’ve taken online and subsequent research (many pharmaceutical companies are tricky and link ADHD questionnaires with websites about stimulants- you have a problem? Here’s the answer!).

For those truly suffering from ADHD I’m not trying to invalidate your experience. Because like I said, there are clients I treat with true ADHD who improve with therapy and medication and allowing me to be part of their journey is an honor. But to everyone else, you may not have ADHD- don’t jump to conclusions and please ask for a thorough evaluation before agreeing to the diagnosis. Also note that behavioral and cognitive therapy does help ADHD in addition to medication. Naturopath doctors also are around who treat ADHD if you are looking for an alternative approach.

Read legitimate sources and articles. ADHD Nation is great, the American Journal of Psychiatry has excellent articles about ADHD. Don’t depend on WebMD and pharmaceutical company websites. Be truly informed and don’t get mad when your healthcare provider recommends a thorough evaluation before jumping to a stimulant. Instead be thankful.