Medications for ADHD

1. Treatment?Drug companies say that a pill is the cure, but pills don’t teach skills and may make addicts ill!

2. Medications for ADHD • Stimulants • Methylphenidate (Ritalin, Concerta, Daytrana) • Dexmethylphenidate (Focalin) • Amphetamine/dextroamphetamine (Adderall) • Dextroamphetamine (Dexedrine) • Lisdexamfetamine (Vyvanse) • Modafinil,amodafinil (Provigil/Nuvigil) • Antidyskinetic/Antiviral • Amantadine (Symmetrel) • Alpha agonists • Clonidine, Guanfacine (Kapvay, Intuniv) • Non-stimulants • Atomoxetine (Strattera) • Buproprion (Welbutrin) • Tricyclics • Imipramine, Desipramine, Nortriptylene • SSRIs/SNRIs • Fluoxetine (Prozac) • Venlafaxine (Effexor) • Mood Stabilizers/Antipsychotics

3. Why not use stimulants?

5. Description Amphetamine is a stimulant that is primarily used to treat narcolepsy and attention-deficit hyperactivity disorder. It is also used recreationally as a club drug and as a performance enhancer. Prescription amphetamines are subject to diversion and are one of the most frequently- abused drugs in high schools and colleges. A Schedule II drug is classified as one that has a high potential for abuse, has a currently-accepted medical use under severe restrictions, and has a high possibility of severe psychological and physiological dependence.

6. Effects of Drugs on Dopamine Release COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine NICOTINE MORPHINE 250 Accumbens 250 Dose (mg/kg) 200 Accumbens 0.5 200 Caudate 1.0 % of Basal Release 2.5 150 % of Basal Release 10 150 100 0 1 2 3 hr 100 0 1 2 3 4 5 hr 0 0 0 1 2 3 4 5hr Time After Nicotine Time After Morphine Di Chiara and Imperato, PNAS, 1988

7. Would increasing enhance activity in the OFC? CG CA PreF Striatum PUT Would these responses differ between controls and addicted subjects? OFC nucleus accumbens VTA/SN Compared the response to IV MP (methylphenidate given in 2 sequential doses of 0.5 and 0.25 mg/kg) in 15 controls and 21 cocaine abusers using FDG and PET to measure regional brain glucose metabolism

8. 10 10 8 8 6 6 4 4 2 2 0 0 Controls Abusers Controls Abusers Self Reports of Drug Effects After MP in Controls and in Cocaine Abusers baseline First MP Second MP Self Report High Self Report Craving (0-10) (0-10) P < 0.001 P<0.001

9. 1.30 1.25 1.20 1.15 OFC 1.10 0.3 1.05 0.2 1.00 0.1 Controls Abusers 0.0 -0.1 -0.2 -4.0 -2.0 0.0 2.0 4.0 6.0 8.0 10.0 Baseline MP Abusers > Controls p = 0.001 Rectal Gyrus/Brain p < 0.01 (MP - Placebo) Rectal Gyrus p < 0.005 Craving

10. How Much of the Differences Between Controls and Cocaine Abusers Reflect their Past Experience with Drugs? Effects of Expectation on the Brain Metabolic Responses To iv MP in Cocaine Abusers

11. 10 10 8 30 8 6 6 25 4 4 2 2 20 0 0 Pl/PL PL/MP MP/PL MP/MP Pl/PL MP/MP PL/MP MP/PL 15 10 10 10 8 8 6 6 5 4 4 2 2 0 0 0 MP/MP Pl/PL PL/MP MP/PL Pl/PL PL/MP MP/MP MP/PL Effects of Expectation on the Response to MP on Brain Glucose Metabolism and Behavior Feel Drug High % Change Restlessness Like Drug Expected MP Unexpected MP Expected MP Got Placebo “High” Was About 50% Greater When MP Was Expected Than Unexpected Increases in Metabolism Were About 50% Larger When MP Was Expected Than Unexpected Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.

12. Where the Rubber Meets the RoadData from Dr. Lloyd Gordon from the treatment of patients at COPAC Information obtained from CAPTASA 2012 website • Two interviewers had to agree with diagnosis (MD, PhD, PNP) • Hx of stimulant abuse not exclusionary unless DOC • Initial poor outcomes on Adderall led to switch to “safer” drugs (e.g. Concerta, Vyvanse) • One psychiatrist did all med. adjustments • Inclusion • No discussion on unit • 1 year enrollment in treatment • Leaving treatment meant no follow-up from providers • 1+ prior CD treatments • All had CBT manually/workbook driven and special groups with psychiatrist and psychiatric NP • Behavioral problems resulted in one verbal warning, then behavioral contract, then discharge • N=43 • Ages 18-55

13. AGE DISTRIBUTION CONTROL VS STIMULANT

14. RELAPSE AND LOST TO FOLLOW UP FOR STIMULANT TREATMENT OF ADHDBY QUARTER100%(43/43)

15. Results and Conclusions of COPAC Study • 100% (43/43) participants were relapsed and/or lost to follow-up. • 31% of controls (12/39) relapsed and/or were lost to follow-up • Only 25% of the stimulant group had abused stimulants in the past • There were many more behavioral discharges in the stimulant vs. control groups though the disease severity was equal. (Some of the control group participants were given Welbutrin or Clonidine. Strattera was not available at the time of the study.) • Stimulants do not work in the 1st year of treatment.

16. The Challenges • ADD is very difficult to diagnose • There is no distinct profile on testing, most of what is used in adults is self-report, and even sophisticated testing can be “fooled” • Expectancy effects on self-report of symptoms and treatment (with stimulants) are large • Because a person likes having more energy and can “get more done” on stimulants, it does not mean they have ADD. • Most experienced practitioners, if they are brutally honest, will probably admit that they are almost never sure about the diagnosis. • The best predictor of the likely diagnosis of ADD is the patient deciding they have it. • The greatest disability that can be directly linked to the diagnosis is academic difficulty. • ADD symptoms and personality traits are difficult to differentiate. • People want a quick fix.

17. The Benefits of Recovery • Living in the solution • One day at a time, easy does it, first things first, keep it simple • Acceptance • Utilize tools such as smart phones • Delegate • View the energy and creativity as wonderful gifts • Consider safe medications, but don’t expect to be “normal” (False expectation of stimulants as cure.)