Primary Care Physician
Dr. Orrange received her BA in Biology at the University of California, San Diego, and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health. She received her MD from the USC Keck School of…
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Medicated Forever? When It Comes To Adult ADHD Stimulants, When Does It Stop?
Posted in ADHD / ADD by Dr. Sharon Orrange on Dec 29, 2010
The use of medications to treat ADHD in adults increased 90% from 2002 to 2005 in the United States. This was a dramatic increase, and adults now receive one third of all prescriptions for ADHD medications, a pattern that is not seen in other countries. You may or may not know that the bulk of the available data on the treatment of ADHD come from studies in children, which limits the ability to make evidence-based recommendations for adults.

I am often asked by my patients who are in undergraduate or graduate school whether they should be taking these medications, since “all of their classmates are.” Many of their friends weren’t diagnosed as children but rather started on stimulant medications upon entering college or graduate school. Without making this a blog about diagnosis of Adult ADHD, understand that for primary care physicians, the number of patients who self-diagnose ADHD far exceeds the number of people who fit DSM-IV criteria for ADHD, shown in studies to be 2.5- 4% depending on which criteria you use.

Many patients read the Utah criteria for ADHD in adults and believe they fit it: hyperactivity and poor concentration along with two of the following: affective lability (mood all over the place), hot temper, inability to complete tasks and disorganization, stress intolerance and impulsivity. Remember, there is no single "gold standard" diagnostic test for ADHD in adults

Okay, so why does pharmacotherapy for ADHD, most of which is stimulant medication, make primary care doctors nervous. Well, the addicting nature of stimulants, the chronicity of ADHD (do we treat patients with stimulant medications until they are 70?), and the large number of medical conditions that arise in adults which will be worsened on stimulants are a few reasons. Not to mention the warnings issued along with Adderall, Ritalin, and Vyvanse which acknowledge that women of reproductive age should not take these stimulant medications. Use of stimulant medications during pregnancy may lead to increased risk of premature delivery and low birth weight, infants may experience symptoms of withdrawal, and birth defects have been reported with women taking Adderall during the 1st trimester.

The cardiovascular effects of these stimulants (Ritalin, Vyvanse, and Adderall) are of potentially greater concern in adults than in children. Stimulants increase heart rate and blood pressure and both need to be closely monitored, and yes there are reports of sudden death with the use of stimulants in both adults and children. Abuse potential exists and this is different for adults who require larger doses of stimulants than those prescribed to children.

Many people feel better on stimulants, so realize the difficulty of weaning someone off them. They may feel the “normal” periods of fatigue during the day, and may not feel as productive as they did while on them. Stimulants improve cognitive function in most people. For example, methylphenidate (Ritalin) has been found in studies to reduce driving errors in all adults, not just adults with ADHD. Thus, a person’s response cannot be used to confirm or exclude the diagnosis of ADHD.

When adults have been started on ADHD medications by their psychiatrist or another doctor, those of us in primary care need to wonder: what is our endpoint for treatment? Do we treat you into your 50’s and 60’s if you have high blood pressure, high cholesterol, and high blood sugar? Do we continue to treat women in their 20’s-early 40’s with stimulant medication for ADHD and warn them of known complications during 1st trimester use? Young women will need to stop them during pregnancy and breastfeeding for sure, but do we stop the medications during the reproductive years anyway?

There is currently no consensus on this in the adult medicine literature... what are your thoughts?

Dr O.



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7
Take a look at narcophobia.com for a relative discussion of the real truths about opiate abuse and how most doctors and nurses failed so badly when questioned about their knowledge of pain management that the federal government had to intervene.
By Collinsrss  Jan 13, 2011
6
Only comment if you agree with them or they will delete your opinion. :)
By Pennyphone  Jan 02, 2011
5
Yup, we treat them into their 70s. I was put on Vyvanse at 69 and with Nuvigil had the first undepressed year of my life. I use Ritalin Brand name winters or afternoon crashes, and have no trouble getting off at all. Addictive, I don't agree.
By mwgli  Jan 01, 2011
4
Jpix of course I dont feel that people over the age of 50 are not productive members of our society, thats crazy. The risks of these medications may start to outweigh the benefits at that age (people over 50 tend to have more comorbid conditions like hypertension, high cholesterol, diabetes, atrial fibrillation, etc etc) and the stimulant medications have NOT been tested on this age group...ever! Psychiatrists in the community where I live are now routinely sending their patients over 40 on stimulants to their internist to be "cleared" for the use of these medications...in other words the Internist like myself signs off on the accepted risks and benefits. You have to see that these medications have not been looked at in adults and especially for use long term.
Dr O.
By DrOrrange  Dec 31, 2010
3
Hi Dr. O,
Thanks for inviting comments. I can understand concerns of Ritalin use in women of reproductive age and where significant health risk is a concern. Giving up ADHD meds for unborn children is a no-brainer and the impact of use during pregnancy should be highly considered if not mandated illegal.

For significant health issues if there is a direct relationship in older folks then discussions should continue. Taking PRN's, taking less, finding alternatives
perhaps?

For 50+ adults with ADHD that know the difference in productivity your article (to me) seems to discount "elders," as human beings who can contribute to our society. If health is a concern, that is one thing; if not what are you really asking? At what age is a MD too old to practice? 40? 50? 70? The stress of an
internists schedule is hectic, maybe an age limit should be considered.
By jpix  Dec 31, 2010
2
I want to know what happened to my comment?
By Pennyphone  Dec 30, 2010
1
Adderall is prescribed by my pdoc who thinks I have adult ADD.
More: I've had many bouts of major depression for over 25 years & have developed a resistance to a few of the ADs that used to help. At first I HATED taking it, one time my depression was so bad that the 5 mgs of adderall totally freaked me out, I was TOO depressed to take it (already anxious, not eating).

More: I have MCTD, an autoimmune disease. I live with fatigue. It's a symptom of the disease that makes a huge negative impact in my life. The adderall helps alot w/ the fatigue. My ins won't cover Provigil. I'd love to try a sample tho, I'll ask my doc. I'm very curious, if it has the same effect then I'd MUCH rather take the Provigil.

I wish I could sign this anonymously, I think I'll need to change my login name if possible.
By carolhop  Dec 29, 2010
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