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Stimulants are without a doubt my most successful medications.  All except Provigil require a triplicate prescription, which is ironic because stimulants are seldom abused when properly prescribed. Approximately 10% of adults will abuse prescription medication but what they abuse is primarily pain medications, especially Hydrocodone (4 to 1 over stimulants and tranquilizers 2 to 1 over stimulants). Ironically, pain medications and tranquilizers are much less regulated and can be called in with refills whereas stimulant prescriptions have to be written each time. In what way does this possibly make sense? To paraphrase an old Bullwinkle cartoon, “are you familiar with government intelligence?” “It sounds like a contradiction in terms to me sir.”

The single most important thing for all ADHD patients on stimulants is ALL DAY coverage.

AMPHETAMINE PRODUCTS

Adderall XR primarily and Adderall tablets to a somewhat lesser extent rank #1 in my practice. Adderall is a type of amphetamine. Amphetamines have been studied in patients since 1936. The fact that we have more years of scientific study and clinical experience with this type of medication than any other we use in psychiatry is reassuring to me and many of my patients. There is no evidence of long term problems with Adderall or other amphetamines.

These medications help with staying calm and focused on what one chooses, not just what’s interesting. Adderall also tends to improve mood. It doesn’t usually decrease appetite but helps control weight because eating impulsively due to being bored or stressed is reduced. It is usually the best long term treatment for Bulimia-sometimes combined with an SSRI. The primary indication for Adderall XR and Adderall tablets is Attention Deficit Hyperactivity Disorder (ADHD).  Adderall was the first stimulant approved by the FDA to treat adult ADHD.

Adderall helps people to think about one thing at a time and to single out the important from the unimportant. The XR formula usually allows for once a day dosing although some people, especially those that want 16 hours of calm/focus and productivity, may take it twice a day. It has a low abuse potential because it takes 6 hours to reach maximum blood level, (3 hours for Adderall tabs). Abuse potential correlates highly with rate of onset of action.

Dexedrine is similar to Adderall and may be as effective for boredom or low motivation, but isn’t as calming.

Desoxyn (see below)

METHYLPHENIDATE PRODUCTS

Methylphenidate may be better than amphetamines for hyperfocusing. Moodiness may be a side effect, but it is less likely to affect blood pressure or erectile functioning. We have over 50 years of scientific study and clinical experience with methylphenidate and have no evidence of long term problems or loss of efficacy.

Daytrana patch is the most flexible and potentially longest lasting stimulant – up to 15 hours if removed at 12 hours or if left on for up to 24 hours.  It has a smooth onset of action and wears off 3 hours after it’s removed.

Concerta usually lasts 12 hours.   For patients who would do best on a methylphenidate product but who don’t like or can’t tolerate patches, Concerta is the best choice. 

Other forms of methylphenidate:

Ritalin and Methylin last 3-4 hours and rebound can be a problem. Methylin comes in chewable and liquid forms for children and adults that have trouble swallowing pills.

Focalin is the primary active ingredient in methylphenidate and may be better tolerated by a few patients.  It lasts 4-6 hours.

Focalin XR lasts approximately 8 hours and was the second stimulant approved by the FDA to treat adult ADHD.

Metadate CD is 30% release initially and 70% in 4 hours.  Ritalin LA is 50% immediately and 50% in 4 hours.  Both last around 8 hours.  Some people have a preference for one or the other.

WHY START WITH AMPHETAMINES?

Some people prefer methylphenidate and some prefer amphetamine products. In one study that compared methylphenidate to amphetamines, about 40% said either worked fine, 15% preferred methylphenidate, and 30% preferred amphetamine.  If the percentages are the same as the study and with no other factors to guide the decision, I feel patients are better off starting with Adderall XR. It will work well in at least 70% of people. If Adderall does not work, I would next try Daytrana.  This will get the success rate to 85%.

Pediatricians usually start with a methylphenidate product because they’re milder.  This is probably true.

There are a few patients that don’t tolerate Adderall, Dexedrine, Concerta, or other methylphenidate type stimulants. The most common side effects they complain of are nervousness and irritability. For these people Desoxyn (methamphetamine) usually works well. I have 15-20 patients who can’t tolerate other stimulants but who lead normal lives on this medication. Unfortunately, it is now only available in short acting tablets. It lasts 4-6 hours and is very expensive. Because it is the most likely of the stimulants to be abused it has to be monitored more closely. We have 60 years of clinical experience with this medication and there is no evidence of long term problems or loss of efficacy.

Provigil is a different type of stimulant. It does not require written triplicate prescriptions and basically has no abuse risk. Provigil was originally marketed for excessive daytime sleepiness associated with narcolepsy and has since added formal approval for daytime sleepiness associated with shift-work and sleep apnea.

Provigil primarily increases alertness but may also improve cognitive functioning and learning. In a study in mice, Provigil enabled old mice (equivalent to 70 year old humans) to learn a maze as fast as young mice. Without Provigil the old mice took twice as long to learn the maze.

Provigil is very well tolerated but occasionally causes headaches or dizziness when first starting. Dose reduction usually solves this problem. It doesn’t work on boredom or low motivation. There are studies showing benefit for ADHD in some patients but it’s not on the order of magnitude of benefit we see with Adderall XR or methylphenidate. It is sometimes added to other stimulants or to antidepressants. It is also useful for chronic fatigue from physical causes such as fibromyalgia. It is pricey and insurance companies frequently try not to cover it. But it is very safe and effective, and many patients find it useful. Although it has only been on the market for a few years, we have no evidence of any long term problems.

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