medications

John J. Ratey, M.D. discusses ADD medications

cont.

Side effects with the Phychostimulants

Side effects with the Phychostimulants, on the whole are low as compared to other psychoactive agents that psychiatrists and neurologists use. Major complaints involve appetite suppression, insomnia or multiple varieties of sleep disturbance such as waking up in the middle of the night and interference with dreams. Ten percent of patients on Ritalin complain of headaches, and the clinician must watch blood pressure and pulse when either psychostimulant is used.

A more important issue in prescribing Phychostimulants is the difficulty in achieving a therapeutic dose of medication. Sometimes a patient needs very little medication, for instance we have those in our practice who find that as little as 1/4 mg Ritalin or Dexedrine a few times a day provides them with the necessary enhancement of focusing ability.

Others need much higher doses to sustain an effect, and require levels well beyond the recommended upper limit of 60 mg/day of Ritalin. Gittleman-Klein has stated that the most commonly made error in the treatment of ADHD is inadequate dosing (Gittleman-Klein, 1987).

This is most likely due to a cookbook dogma that deflates the role of the patient's report as the primary measure of drug response.

For these individuals there is the problem of maintaining an adequate dose of medication. The drug is available in 5 mg tablets, and adults may need 20 mg per dose to get a calming, focusing effect, and this lasts only 3-4 hours. For many people there is a limit to the number of pills that one can take or will remember to take.

We sometimes use a slow release stimulant to counter this problem, particularly in individuals who are likely to forget to take a 2nd or 3rd dose of medication; however, it has been our observation that Cylert generally does not induce as dramatic results as Ritalin or Dexedrine. Dexedrine slow release, which is available in 10 mg spansules, seems to be more effective than slow release Ritalin.

It would be wonderful to have a long acting stimulant, but currently there is not a clinically efficacious one available. Scientists have discovered a way to chemically purify Ritalin into a more effective drug with fewer side effects; however, the development of this specifically targeted drug is pending funding (Jaffe, 1992).

Another frequently encountered problem in prescribing Phychostimulants is negotiating with pharmacists. There is a persistent dark cloud hanging over the use of stimulants because of their tarnished history as drugs of abuse.

Even in the most enlightened states it is difficult to prescribe Phychostimulants for adults due to the prevailing myths that ADHD is

1 not a disorder but merely moral corruptness
2 something that disappears in adolescence.

It is thus often thought that adults who are taking prescription Phychostimulants are simply looking for their next high. In many cases, the physician must call the pharmacy before the drug will be dispensed. This brings up the issue frequently faced by mental health professionals, parents, and concerned others of whether it is wise to use stimulant medication in individuals with a history of drug or alcohol abuse. This is fraught with anxiety on everyone's part; however it has been our experience that an adult with a history of drug and/or alcohol abuse who has been diagnosed with ADHD is committed to changing his/her life will not use the medication in an illegal or abusive fashion. This obviously presupposes a very strong therapeutic relationship with the prescriber as well as with other involved mental health professionals.

Further, Huessey has written that no cases of psychostimulant abuse in ADHD adolescents have been reported because the drugs are not used to "tune out" of the environment as are most recreational drugs, but to "tune in" (Hussy, 1985).

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