Medication

Treating ADD–or any mental health condition–is based on science, but is ultimately an art of trial and error. Finding the right medication, in the right dosage, while trying to minimize negative side effects, is a process and does not happen overnight.

Types of Adult ADD Medication:

Psychostimulants are the most effective medications for treating adult ADD, with responsiveness rates in the 70%–80% range. Common psychostimulants include:

  • Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
  • Dexmethylphenidate (Focalin)
  • Amphetamine-Dextroamphetamine (Adderall)
  • Dextroamphetamine (Dexedrine, Dextrostat)
  • Lisdexamfetamine (Vyvanse)
dopamine
Dopamine

Ritalin, Concerta, Methadate, Daytrana, and Focalin are the most commonly used stimulant medications to treat adult ADD. These drugs increase the body’s level of dopamine (dohpuh-meen), a neurotransmitter, or “chemical messenger.” Adderall, Dexedrine, Dextrostat, and Vyvanse also treat adult ADD by blocking the re-absorption of dopamine and another neurotransmitter, norepinephrine (nawr-ep-uhnef-rin).

Both dopamine and norepinephrine affect mental and emotional function, as well as the brain’s “reward response“–the pleasure one feels in response to certain experiences.  Several studies have found dopamine neurotransmission problems in the ADD-affected brain, suggesting that lower dopamine receptor and transporter levels “may underlie core symptoms of inattention and impulsivity” (See The ADD Brain). This is where psychostimulants like Adderall and Vyvanse come in–by blocking the re-absorption of dopamine back into the brain cells, these drugs increases the level of dopamine in the brain.

For adults with ADD who cannot take stimulant medications or don’t experience any benefit from them, nonstimulants like guanfacine extended release (GXR), atomoxetine (ATX), and clonidine hydrochloride extended release, can be used instead.

Medication Adherence

Since ADD is a chronic (long-term) condition, people with ADD usually require long-term treatment. However, adherence to medication–whether a patient takes a medication as it was prescribed–can be a significant challenge. As one recent study reported, it is “fairly common” for people with ADD to stop treatment: “one-half of all patients fail to adhere to treatment guidelines or discontinue treatment within 2–3 years of starting” ADD medication. One study reported in 2014 that “although stimulant medication can reduce symptoms and lessen the degree of functional impairment associated with ADD, the adherence rate in adults diagnosed with ADD is reportedly [less than] 12 percent.”

There are many reasons why someone may not take their ADD medication as prescribed. Although there are limited studies on adults’ adherence to ADD medication, a recent study found that adherence decreased if patients took multiple daily doses, had a family history of ADD, experienced negative side effects or stigma, and if the medication was not effective. Adherence increased if patients used long-acting drugs (sometimes referred to as “extended release”), and if patients were also being treated for comorbidities like depression and anxiety. 

Positive Side Effects

Numerous studies since the 1960’s have documented the positive effects of stimulant medication to treat ADD, with improvement noted for up to 75% of patients in all age groups. Stimulants effectively relieve common ADD symptoms, including inattention, distractibility, impulsive behavior and restlessness. Two studies published in 2005 found that stimulants also improve cognition, reaction time, response inhibition, and short-term memory.

Studies also suggest that stimulant treatment may also have real life or death consequences: a population-based study of more than 17,000 men and women found that those who had been diagnosed with ADD were much more likely to be involved in car accidents compared to their non-ADD peers–but men had a 58% reduced risk of being in a car accident when they were on stimulant medication. The study, which followed its subjects from 2006-2009, estimated that between 41% – 49% of the accidents in male patients with ADD could have been avoided if they had been on treatment during the entire follow-up period.

Pills by The Javorac

Negative Side Effects

As David Anderson explains in his TED talk, ADD medications often don’t work well, since many have negative side effects. Severe negative side effects can make it difficult to adhere to medication and more challenging to function in day-to-day life. Possible stimulant side effects include decreased appetite and weight loss, sleep problems, fatigue, irritability, headaches, an increase in blood pressure and heart palpitations. Side effects can be so severe that they interfere with the ability to work, enjoy time with family and friends, and engage in other activities that are essential to overall health, including getting enough quality sleep, healthy eating and exercise.

Adult ADD Medication Use on the Rise

Adult ADD prescription sales surpassed pediatric ADD prescription sales for the first time in 2014.
Adult ADD prescription sales surpassed pediatric ADD prescription sales for the first time in 2014.

ADD medication use among adults in the United States is on the rise. As Bloomberg news reported in June 2015, prescriptions for adults with ADD accounted for 53 percent of industry-wide ADD medication prescriptions in 2014, compared to only 37 percent in 2007. The steady increase in the adult market-share for ADD drugs has been a boon for Shire, which has seen its sales of Vyvanse rise 18 percent to $1.4 billion last year.

As Shire CEO Flemming Ornskov explains, “we’ve shifted more effort into the adult AD/HD market, which is now more than half of the overall market and has the highest growth…it’s growing fast, almost twice as fast as the overall market.”

Bloomberg news reports that the increase in adult ADD prescription drug use has occurred in part due to growing awareness that ADD is heritable and can persist into adulthood. However, the increase in prescription drug use also reflects the incentives ingrained in the U.S. health care system: insurance companies are more willing to pay for medication than more time-intensive, behavioral treatments such as cognitive behavioral therapy, while general practitioners have little incentive to spend time counseling their ADD-affected patients about the benefits of sleep hygiene and exercise.

This phenomena may also stem from increased pressure to perform in the workplace. While reliable data on how many workers abuse stimulant medications are not available, the New York Times found that “dozens of people in a wide spectrum of professions said they and co-workers misused stimulants like Adderall, Vyvanse and Concerta to improve work performance.” Most reported that they accessed ADD medication by feigning ADD symptoms “to physicians who casually write prescriptions without proper evaluations.”

ADD Medication and Substance Use Disorder

Historically, ADD treatment among patients with substance use disorder (SUD) has been considered “complex and controversial,” since first-line treatment includes stimulant drugs that are prone to abuse. Current guidelines recommend nonstimulant medication as first-line treatment for patients with both ADD and SUD, but “these agents have not been demonstrated to have comparable efficacy to the psycho-stimulants.” Meanwhile, there is limited research on stimulant ADD medication among adults with SUD. Available studies suggest that stimulants can be safe and effective for many adults with ADD and SUD, but:

  • Careful monitoring is needed to ensure that ADD medications do not make patients’ substance abuse even worse
  • Treatment can be challenging due to patients’ “poor engagement with clinical services and poor compliance”
  • Medication treatment alone does not appear to be particularly effective in treating SUD in currently active substance abusing individuals with ADD

For example, a promising study published in 2014 examined long-term outcomes among 60 adult men with ADD, SUD and a “history of violence” or other psychiatric illness–half of whom received ADD medication, and half of whom did not.  The study found that the men who had received medication for ADD had fewer substance abuse relapses, a higher unemployment rate, and were more frequently accommodated in supportive housing or a rehabilitation center.

Echoing previous studies that found that medication treatment led to a “decrease in criminality, a reduction in relapses, and better long-term functional outcomes” among adults with ADD and SUD, this study concluded that under close monitoring, ADD medication may decrease the risk of relapse among individuals with severe SUD, and “increase these patients’ ability to follow a non-pharmacological rehabilitation plan, thereby improving their long-term outcomes.”

ADD Medication and Pregnancy

Women with ADD may need to consider whether to take ADD medication during pregnancy. Dr. Marlene Freeman wrote in 2014 that more data are needed to understand possible short-term and long-term risks. “While most women can successfully avoid the use of stimulant medication during pregnancy,” Freeman writes, “there are cases in which the benefits of stimulant treatment outweigh known and putative (negative) risks.”

Maternity curves_Seth McGrath

Evidence-based guidelines published in 2014 also emphasize that “both continuing and stopping drug treatment carries risk.” While stopping ADD drug treatment removes the risk of medication causing harm during pregnancy, it may increase the risk of harmful behaviors related to the mother’s mental health. These may include “poor risk management, such as dangerous driving or the use of illicit drugs, alcohol or tobacco during the pregnancy; increased stress levels; and self-injurious behavior.”

In addition to considering medication during pregnancy, the guidelines advise that “it is also important to explore non-pharmacological treatment strategies” such as psychotherapy (See Cognitive Behavioral Therapy).

While women with ADD may want to stay on medication after delivery, there are risks and benefits that should be evaluated on a case by case basis. Since “little is known of the effects of ADD medications reaching the child through breastfeeding,” the guidelines advise that “the effects of the drug on the child’s development should be monitored and the child’s pediatrician should be informed of any changes in medication dosage or formulation.”

Talking to Your Mental Healthcare Provider

It is important to share side effects with your mental health care provider, and discuss ways to manage these side effects. Your mental health care provider might suggest behavioral solutions (i.e. improving your quality of sleep) or try a different dosage of the medication suspected of causing the negative side effects, or recommend a different medication altogether. The important thing to remember is that a mental health care providers are only as good as the information you give them–if they do not know you are suffering from negative side effects, they won’t be able to help address them.

Advertisements