Archive for the ‘ADHD’ Category

HAPPY NEW YEAR 2014!!!!!

 

Happy New Year to all my fellow ADHD friends. Remember, you DO NOT have a disorder. I hate that. You have a very unique temperament and many gifts. The major problem is that this temperament is created in the prefrontal cortex of your brain. That controls “executive functioning”.. that means mainly the things you hate to do you probably won’t, because you have to have stimulation to make your brain increase dopamine, which drives us. So….when possible, delegate out the things that need to be done, but you hate to do and always procrastinate. Learning to compensate for our areas we lack interest in (or feel inadequate about, for that matter) is a SMART thing to do. Some people get down on themselves because of this.

 

Instead of being bummed about the things you don’t do, concentrate on your strengths. Embrace what you are good at and do it! Most people with ADHD are creative, likely to be entrepreneurs, innovators, challengers of the system, and passionate with their interests, whatever they are!

 

If you don’t have a person that is your own “personal secretary”, BARTER out your boring stuff!

 

Some of the people I love most dearly in the world have ADHD….So Happy New Year to all of you!!!!!!!

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ADHD Resources

Book/Audio Suggested Reading:

  • Shadow Syndromes, by John Ratey, M.D.
  • Driven to Distraction, by Edward Hollowell, M.D.
  • Women With Attention Deficit, by Sari Solden
  • Crazy Busy, by Edward Hollowell, M.D.
  • Taking Charge of Adult ADHD, by Russell Barkley, PhD
  • Straight Talk about Psychiatric Medications for Kids, by Timothy Wilens, M.D.

Online resources:
http://www.chadd.org/
http://www.add.org/
http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
http://www.mayoclinic.com/health/adhd/DS00275
http://www.russellbarkley.org/
http://www.drhallowell.com/

 

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Perspectives by Penny – ADHD

ADHD… Perspectives by Penny

I hope I can accomplish through the privilege of writing this blog helping someone gain more insight into understanding the challenges of living with ADHD every day.

And I have to put this disclaimer in: these are all my opinions, not those of Dr. Jones.

“Our future lies in the hands of the creatively maladjusted” Martin Luther King Jr.

04-30-2013

Blog Entry 1 Introduction

I have worked with Dr. Jones for 17 years, gone to most of the CME courses he attends (continuing medical education), which has been literally hundreds of hours, and have a bachelors degree in Psychology and Marketing. I have developed slides for his presentations, as well as edited and help write his newsletters and website. I have also been on the board of directors of the Dallas chapter of CHADD which is a national ADHD organization. Their website is: http://www.chadd.org/

I think I have an extremely unique, multi-faceted slant on ADHD and stress related mental health issues. (I have also seen the pharmaceutical company industry very up close and personal concerning neuropsychiatric drugs.) So, I am starting my first blog with that subject specifically.

I have known and interacted with many physicians that treat ADHD. I have also had direct contact with the pharmaceutical companies all the way down the chain of hierarchy from their ivory tower corporate executives (they get the really big money), the specialists with “big credentials that answer questions for the few doctors that inquire”, the regional managers, and then the pharmaceutical reps that really work in the trenches with doctors and see the real world that clinical physicians deal with everyday.

I have attended countless meetings and conferences, including: data and research updates on new drug studies, pharmaceutical company “launches” of new products, physician speaker training meetings, and reviewed endless studies of medications relevant to treating psychiatrically related issues.

Because of negative press, the pharmaceutical industry has made an attempt to “self police” by creating PhRMA (Pharmaceutical Research and Manufacturers of America). This self-regulatory group was created by the pharmaceutical industry as an attempt to try to avoid complete control by the FDA (Food and Drug Administration)… (They would probably deny that observation, however).

The fact of the matter is, the reason pharmaceutical companies exist in the first place is capitalism, (which translates ultimately into profits made for the shareholders). This industry is unique because the “products” they produce effect real people in a very personal, crucial, and sometimes “life or death” way. This makes them extremely vulnerable to regulation, and public criticism and scrutiny. It also causes dissonance, and conflicts of interest between the industry, the consumers that use their products, and their shareholders. And, of course, there is a strong, hungry, greedy segment of the legal industry that is just salivating at the chance to sue them for some drug that proves to have a negative outcome because of unforeseen adverse side effects, (or, god forbid, deception through hiding adverse data in studies of bad or life-threatening findings.)

However, I am still NOT against capitalism, and that includes the pharmaceutical industry. One of the great freedoms we have living in America is that anybody can go from complete poverty to billionaire, and the only thing stopping any of us is our own drives and talents (in a perfect world we could also add “integrity” to drives and talent) .

I want to challenge anyone to tell me who else would bother to spend millions and millions of dollars trying to develop new medications that might end up proving through complex research and studies to be a wash, or, could possibly help people function and contribute to society, find cures for disease and illnesses, and even give someone more years to live than they would have had otherwise. The answer to that question is NO ONE I can think of. So without them, even with all the good and bad, they play an extremely important role in our lives because they research and study new and novel ways to, yes, make a profit, but also to literally save lives, and make life bearable/and or functional for those that often desperately need help.

As an aside, they also have many patient assistance programs that they should be recognized for. Most of them will supply free medications to patients in low income categories. A good source to find out if you are eligible for these programs is: http://www.needymeds.org/. This industry is in no way perfect, but they do not deserve to be “thrown under the bus completely” in my opinion.

My hope is that we can all put biases and blame aside and just at least listen to each other’s opinions and experiences. I certainly don’t have all the answers, but I do have insights into my own unique world that I hope you can at least consider. I want to always be open to new knowledge that will allow me to have a “shift of paradigm” if another point of view can sway my stigmas and biases. I think the rigidity and prejudices that continually cause us all pain and injustice need to be challenged. I don’t think any of us have all the answers to everything (to think otherwise is delusion and/or arrogance), and my personal goal is to grow and learn and be open to new ideas…and I hope that is your goal.

All of my blogs are dedicated to Jeff, Melissa, and Wayne, and ….Madison and Brooklyn, and of course Unkie, Kirsten and Will!

I love you all dearly!

Penny

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COMPARISON OF VYVANSE AND ADDERALL

(more…)

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Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.

Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.
In his book, Adult ADHD (2010), he details a study where he followed a group of non-ADHD young kids to age 30 and compared them to a group of ADHD kids. There were about 100 kids in each group.
The most striking finding in this study is that untreated ADHD impairs functioning in every area of life. They are less likely to be employed, and if employed, make less money, have had more jobs, have less education, worse grades, or took longer to get through school. They were also in greater debt, had more relationship problems, worse health, more traffic tickets, and other legal problems.
In my clinical experience over the past 40 years I have seen more people’s lives dramatically improve with ADHD treatment than any other mental health condition I treat, usually by prescribing a stimulant.
Long-term adherence to treatment is a problem with all medical and mental health problems, but many times it is because patients did not get the right medication(s) at the right dose(s). Sometimes cost is the primary problem but adequate generic medications and sometimes patient assistance programs can solve that issue.
We ADHD personalities are driven by interest rather than importance. We tend to be easily distracted and have way too many things on our mind at any given moment. ADHD medications can help us be calm and focused, and not only cope with our rapidly changing modern world, but actually thrive.

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Can stimulants permanently stunt growth in children?

I have not seen previous reports of permanent growth suppression from long-term use of stimulants during childhood.  Expert consensus and my clinical experience is that height may be slightly delayed but is genetically determined (assuming adequate nutrition).

The package insert for methylphenidate products (Ritalin, Concerta, Focalin, Daytrana, Metadate), cautions that daily use in a controlled study versus a controlled group did show on average 2cm less height after 3 years – but it is assumed to eventually catch up.

Kids who don’t take medication on weekends or during summer don’t show this delay.  The presumed mechanism of the delay is that norepinephrine (increased by methylphenidate) leads to a decreased release of growth hormone during deep sleep, (normally in the first 3 hours).  This suppression of growth hormone can probably be prevented by use of Clonidine or possibly Guanfacine  taken at bedtime.

In the reader’s comment amphetamines were referenced but the statement was also made that the person referred to was treated with methylphenidate.  Of course both are stimulants but are significantly different.

The package insert on amphetamines (including Adderall and Vyvanse) cautions about below average weight gain over a one year period of daily use.  In the Vyvanse study the evidence was that at the beginning of the study the average child was at the 62nd percentile of body weight – since food is a natural booster of dopamine in the nucleus accumbens, patients on amphetamines are less likely to eat out of boredom and they usually lose weight.

In fairness, we do have more studies using methylphenidate in kids than amphetamines.  The longest controlled study ever, the MTA study was also predominantly methylphenidate.  Intuitively it would make sense that amphetamines would raise norepinephrine levels even more since they increase release in addition to blocking reuptake.  Empirically however, methylphenidate is associated with increased excretion of norepinephrine and amphetamines are associated with a decrease.  Presumably amphetamines are more likely to down regulate, ie, modulate norepinephrine levels.

The hardcore science for all of this is in its infancy.  We will undoubtedly find that there are “outliers”, but at this time with all the evidence I know of the long-term benefits outweigh potential risks for the spectrum of Attention Deficit Hyperactivity Disorder.

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I took Adderall for ADHD. I then switched to Vyvanse for 2 months. It stopped working. I have anxiety and moodiness on it…which makes the ADHD worse. I can’t concentrate and am going back to the doctor. What do you recommend and should I take Tenex?

What does it mean when stimulants stop working and/or start causing anxiety or moodiness?  Stimulants usually have a stronger effect when they are first started and then the dose has to be increased to achieve a good response.  Some patients will become tolerant to at least some of the stimulant effects and have to increase the dose gradually over time.  This is not a major problem as long as the total daily dose doesn’t exceed the maximum.

Dosing chart:

Your problem may just be an inadequate dosing issue.

The anxiety and moodiness that you are having may be a side-effect or a rebound effect depending on when it is occurring.  If your mood symptoms are at their worst between 3 1/2 to 5 hours of taking Vyvanse it is probably a side-effect.  If they are  occurring later it more likely is rebound and you need a second dose – probably around lunch time.  Rebound symptoms are more likely with Adderall XR than Vyvanse – short acting Adderall or Dexedrine tablets are even worse.

The majority of my patients have done better on and preferred Vyvanse.  There are some patients however who do better on Adderall XR, presumably because they need the added norepinephrine effect.  More patients on Adderall need to add Tenex, but it can also be helpful with Vyvanse.

Anxiety and moodiness starting after taking stimulants for a while can also be due to underlying genetics of mood disorder, especially bipolar.  Any significant family history of major mood disorder increases the risk.  Patients with ADHD and bipolar genetics do best on a combination of a mood stabilizer and a stimulant.

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My doctor prescribed methylphenidate for weight gain from Effexor and Lexapro. It makes me sleepy/drowsy. Is there a better drug for appetite suppression?

There are occasional patients who become sluggish or sedated with methylphenidate for reasons that aren’t clear.  If you are taking Effexor or Lexapro in the am then these could interfere with the activating effects of the stimulant.  Lexapro and Effexor are usually taken in am when first started, but after a few weeks they generally work better taking them at night (Lexapro) or supper (Effexor XR), and this is especially true when combining with stimulants. 

See how to take Effexor: http://test.askdrjones.com/2005/12/29/how-to-take-effexor/

The most effective stimulant for appetite suppression and weight loss is Dexedrine (Vyvanse is the most effective form).  Adderall is the next best.  Methylphenidate is the least effective for appetite/weight.

In general, using stimulants to lose weight needs to be a long term commitment.  If the stimulant is stopped the weight is almost always regained – usually with 5 extra pounds for good measure.  This is not usually the case if weight gain only occurred on an antidepressant and the antidepressant is no longer being taken.  All antidepressants except Wellbutrin are sometimes associated with weight gain, but may not occur until several months of being on the medication.  Weight gain is partly due to changing set points for serotonin receptors that help regulate carbohydrate intake.  Another possible mechanism is that serotonin up regulation by antidepressants can down regulate dopamine and eating is one way to stimulate the dopamine system.  Stimulants, especially amphetamines (Dexedrine, Vyvanse, Adderall) increase dopamine release to counteract the serotonin effect.

 

 

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My brother is 16 and he has ADHD. What is the right starting dose for medication?

It is usually better to start low and increase until no additional benefits or side-effects.

Weight can be used to determine maximum dose, 2mg/kg for methylphenidate and 1.5mg/kg for amphetamines.  The following chart was published by Biederman and Wilens at the Harvard department of psychiatry.

More people prefer amphetamines.  Only 16% prefer methyphenidate.  This fits my clinical experience over the past 40 years.  The following chart shows a meta-analysis study that was done that confirms this.

So, if your brother weighs 150 pounds (or 70kg) he may need doses of methyphenidate up to 140mg, or Concerta 54mg 3x per day, or 1-2 Daytrana patches, or 90-150mg Adderall, or Vyvanse 70mg 3x per day for optimal effect.

Over the past several weeks I have tried Vyvanse in over 300 patients, many of whom were previously on Adderall.  The majority of patients prefer Vyvanse – they report that it is smoother, has less side-effects, less rebound in the afternoon, and more efficacy throughout the day.  Vyvanse has less risk to blood pressure or the cardiovascular system and has a mode of action that prevents using it to get high.  There are still some patients that prefer and do better on Adderall.  The lowest dose of Vyvanse is 30mg, which is equal to 10mg of Dexedrine or 20mg of Ritalin (methylphenidate).

How much medication should your brother take?

Enough, not too much.   It takes time and trial and error to find the best dose for each individual.

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I have Mitral Valve Prolapse and also have ADD. I have just been prescribed Vyvanse. In the afternoon I have experienced difficulty getting a deep breath and also tiredness in my left arm. I have also had pain in my lower abdomen. I take Toprol for the MVP. I have been taking Vyvanse for 2 weeks. Could the Vyvanse be causing these side-effects?

Vyvanse has less effect on the cardiovascular system than Adderall but all stimulants have possible cardiovascular side-effects.  You should stop taking it and see if the symptoms go away.  If not you need to see your cardiologist or internist.  If the side-effects do go away you may want to discuss options with your doctor. 

Generic Tenex helps with distractibility test.askdrjones.com/2006/11/07/tenex/ and can be taken with Toprol if it doesn’t lower the blood pressure too much.  You may tolerate a lower dose of Vyvanse, possibly with Tenex or you may do better on one of the forms of methylphenidate, or possibly Provigil.

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