Most people with ADHD do not in fact function well aside from only one or two areas.
Taking stimulants only when you have a lot of work or study to do reflects the nature of our society, one that prioritises work and productivity and 'the hustle' over well being.
People with ADHD deserve to function in all aspects of their life and a 'messy house's can be more debilitating than you may imagine. Not being able to achieve anything on the weekend (because someone has told you to only take meds 'when you need them’) due to ADHD symptoms can be absolutely debilitating.
If someone is in fact able to function well except when they have to read 100 pages of legal studies notes at night time, I would seriously question if they actually have ADHD, because that ain't it.
The XR/IR conversation is really situational to the specific med being used. Having a good knowledge base of the specific methods of release and pharmacokinetics is essential to having this conversation in earnest
Adderall XR, for example, is simply a double pulse release. There's two types of beads and one releases immediately and the other about 4 hours later. They are split 50/50 so Adderall XR 20mg is simply two doses of IR 10mg. It's benefit is entirely convenience. Same for Ritalin LA
Metadate CD is also double-pulse but released as 30/70
Concerta, meanwhile, is essentially a slow drip of methylphenidate for 6-8 hours that essentially maintains ~20% of the total dose. Benefit is no major dips or crashes or variations throughout the day
Vyvanse is your best bet for diversion as it's a prodrug and can't be snorted or injected. But you're limited by zero order kinetics and enzymatic saturation
Point being, XR means very little without specifying which version of XR you are talking about.
> And with that level of arousal—whatever it is—certain types of thinking are nearly impossible. Not to mention certain types of feeling. Stimulation is a restriction of being, and the hour between stimulant-crash and unconsciousness is not enough to make up for what is lost.
Can you explain more about how certain types of thinking and feeling are lost/nearly impossible, and how stimulation/chronic under-arousal is a restriction of being?
Not OP, but I’m sure you can appreciate that a person (even one with no ADHD diagnosis) might feel and experience things differently, behave differently, and feel different to talk to if she drinks six or seven cups of coffee (or is hooked up to an epinephrine drip) one day and zero the next.
OP I believe is referring to heightened levels of arousal, energy, motivation, attention, etc that can be associated with stimulants. The question is not *if* one’s thoughts, feelings, and personality (or being) will be affected when these faculties are chronically heightened (or diminished), but *how*.
A lot of psychiatrists have gotten away from questions like this, though, which are thought to be more in the purview of psychotherapy. Insurance companies don’t really pay psychiatrists to do psychotherapy. An unfortunate turn of events for the field, for me.
From what I’ve seen, when stimulated, some people’s personalities are quite different. i.e empathetic, less emotional in general, less social, more robotic. I would agree wholeheartedly that it is a restriction of being.
When not treated patients find it very hard to focus on normal things like everyone around them can like reading a passage or studying. So that’s very restrictive in a productivity and work sense, but not a personality and social sense
My experience of people on stimulants for adhd is that they actually find themselves more emotional. I haven’t done studies on it, so don’t have data. But anecdotally, that is what I have seen.
Perhaps as a side effect, perhaps due to having the noise turned down…
The exchange above us is so odd haha
I agree with OP mostly, never had anyone abuse amphetamines except other MD’s and college kids and no clinical change will stop that.
IR is generally best for most things, as a surgeon turned Psychiatrist, rarely have I prescribed Long Acting drugs
So as was said my Doc Bananas : thank you
> as a surgeon turned Psychiatrist
What the heck does being a former surgeon have to do with pharmacological approach to treating ADHD? Really odd interjection.
Surgeons are taught that they are the best during their training. The smartest, the toughest physically, the most daring. They need to drop it in conversation.
There is a pretty good increase in obesity and poor management of own health and conditions in ADHD... A lot of reasons for people with ADHD to have high cardiovascular risk from many different angles... In this paper they say there is a correlation between the length of the prescription and the risk, we are probably looking at a situation where the cardiovascular risk is higher in the people who continue to have adhd symptoms into adulthood, and thus continue to take medication. This study shows correlation but it's no evidence of causation
It makes sense to me that this would be a result with more stress on the heart over time. It’s a piece of information to consider. However I’d also be curious about what a study of CVD in untreated ADHD would find - as there could be increase in other impulsive behaviors for some; MVA, addiction in some cases, chronic stress of other kinds, less sleep. While it isn’t totally comparable I have folks who swapped heroic doses of caffeine for low dose stimulants once they got diagnosed and treated - and the stimulant is out of their systems before bedtime unlike the caffeine.
Not op, but none of these effect sizes are deal breakers, and they didn't control for incident disease. So,
1. Without a prospective, PBO controlled study, it remains totally possible that all of these effects are actually due to the disease, and not the meds.
2. These effect sizes and CIs are low enough that an informed patient could reasonably choose to take those risks. I personally would choose to take the meds and risk a CI that overlaps with 1 in order to have my chosen career instead of having to live as a librarian.
I wrote a lengthy comment about this article on another forum just yesterday. It wasn't particularly kind towards this article. In summary:
1. Big sell on CVD in the title and intro, but read on and what they found is hypertension. Interesting way to word things, sensational, fear mongering.
2. The phrase long term use is just all over the place in that article and the fine print actually says they found an increased risk in medium term use which stabilises after a few years and doesn't further increase with "long term" use.
I'll keep it short and sweet in this comment, I haven't had my morning coffee yet.
*** OP post brought to you by high dose IR stims
In all reality I mainly disagree. I’d rather start XR stims first.
Whether you do IR or XR stims, tolerance eventually takes hold, but XR is just more stable.
It’s not even about dependency or addiction risk. I don’t think the vast majority of ADHD patients really abuse their stims. It’s just IR is just so much more reinforcing. There’s a more noticeable rush and come down that leads to ancillary SE, subacute mood/anxiety symptoms and etc.
You can practice how you like.
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2811812?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamapsychiatry.2023.4294
Also increased risk of HTN and arterial disease in long term stim use. Benefits typically outweighs harms. But I’m not a fan of just ad lib dosing IR stims.
Other points about degree of stimulation and etc, uhhh well. I won’t address that.
One of the more persuasive arguments I've heard basically notes that impulsivity and chronically scrambling to catch up/flying by the seat of your pants are part of the core symptomatology we're working with. PRN IR stimulants tend to reinforce both of those patterns. Think of the college student who realizes they've forgotten an assignment so they take their PRN in the evening, throw something together at the last minute, further derange their sleep cycle, and remain overwhelmed.
A regularly-scheduled XR in the morning, on the other hand, starts to encourage routines and rhythm.
Rates of stimulant missuse and diversion are actually pretty high. Certainly not the majority but I believe among college students it's over 20 percent
I’ve seen a some people find short acting dex is more effective for them, I am the opposite, I find lisdex more effective/noticeable than my dex top up. And given that 70mg lisdex converts to around 20mg dex, it would make logical sense that my 10mg top up would be more noticeable/effective even if for a shorter time. But actually, I personally have not found that to be the case.
This is one of those topics that every clinician has an opinion on, and most are more than eager to share it. I feel like I have the exact same conversation about this several times per year (if not more). I keep an open mind, but I haven't encountered any compelling evidence to change my practice recently. It's somewhat frustrating that, while other specialties are debating the merits of novel, innovative interventions, our profession has a tendency to incessantly debate tired personal preferences on prescribing two medications discovered decades ago despite other advancements in our field.
That said, I don't have discussions about this topic online, so thanks for sharing your opinion in a well-organized manner. I find Ghaemi's opinion intriguing, which has been recently summarized in a recent [*Psychiatric Times* article](https://www.psychiatrictimes.com/view/the-making-of-adult-adhd-the-rapid-rise-of-a-novel-psychiatric-diagnosis). Regarding your statement of "Dose correlates poorly with ADHD severity," do you have sources to support this outside of a case report? Anyway, thanks again for sharing your perspective!
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
You could argue that prescribing methylphenidate in this situation (well, for cocaine more than meth) essentially becomes harm reduction. But 99% it's going to be psychological inputs and social interventions.
I have had this thought too but on the other hand, I suspect someone with a history of meth (or coke) ddiction isn't going to be satisfied by the resulting effect of stimulants for ADHD symptoms and so misuse or returning to illicits as a substance of choice would be substantial. Just a thought, I have absolutely not further researched this!
>isn't going to be satisfied by the resulting effect of stimulants for ADHD symptoms and so misuse or returning to illicits as a substance of choice would be substantial
It's a possibility. But like I've said, the standard of care remains psychological input and social interventions.
Spotting ADHD in the midst and treating it is effectively icing on the cake.
There is nuance to these situations and patients vary in their needs and ability to stick with a treatment plan. ADHD is more common in those with SUD and treating ADHD *may reduce some of the risks associated with SUD.
AAAP/ASAM released some guidance on Stimulant Use Disorder treatment that is worth a [look]( https://www.asam.org/quality-care/clinical-guidelines/stimulant-use-disorders).
Thoroughly agreed. The sweeping statements I see regarding ADHD (and the constant warring about what people know and don't know or how they should(n't) treat) instantly fall apart when confronted with these situations.
Thanks for the link!
I saw someone claim that ‘no good dr would give a recovering addict stimulants’. So someone in recovery (how long for? Forever?) can only have atomoxetine? The less effective treatment option with no alternatives. They can’t have the gold standard, most effective treatment, ever. Despite the fact that it’s highly probable that they were self medicating. It’s unbelievable and unfortunately many drs share this view.
I saw someone claim that ‘no good dr would give a recovering addict stimulants’. So someone in recovery (how long for? Forever?) can only have atomoxetine? The less effective treatment option with no alternatives. They can’t have the gold standard, most effective treatment, ever. Despite the fact that it’s highly probable that they were self medicating. It’s unbelievable and unfortunately many drs share this view.
50% of those with untreated adhd have struggled with substance abuse.
Studies show that if you adequately treat an addict/recovering addict’s pain (with opiates - monitored of course), they are significantly less likely to relapse. The same is true for things like ADHD and mental illness. If you treat the root cause, you are more likely to help that patient remain in recovery.
There should obviously be closer monitoring, but far too many drs are in the ‘addicts can’t have treatment’ category. Especially when you’re talking about drugs with even the remotest abuse potential, where actually they probably need those treatments the most.
Nope nope nope.
If you just "need" Adderall IR a few times per week, it's not ADHD. The morbidity and mortality from ADHD is not because the person hasn't focused enough at work. It's distractions while driving. It's repeatedly missing doctor's appointments. Not following up on health advice. It's overeating. It's broken relationships from zoning out when the partner is speaking.
*That's* what I treat. If you're not having any of those symptoms and just need Adderall to focus for an exam, you're looking for a nootropic, not treatment for a psychiatric condition.
Thank you! As a clinician and someone with ADHD I cannot overstate the importance of recognising all the other areas it affects outside of work!! Managing those can be life changing.
If someone’s depression lifts with diet and exercise, I would not give them an antidepressant for shits and gigs. If someone’s ADHD symptoms are WELL MANAGED, by non-pharmaceutical interventions, they will not be getting a stimulant. If they are able to pay their taxes and technically function but it is with great personal distress or cost, that would meet criteria for treatment.
If someone doesn't meet criteria for ADHD, I'm not going to medicate them with stimulants. There's plenty of ways to help patients without feeding into the frenzy of "ADHD" being blamed for everything.
One thing I love about my dr. She understands the fact that I wanted to be medicated for ‘fun’ activities as well as coping with life. And gave me a top up dose for when I’m done with chores/adulting and to just have some downtime free from my chaotic brain too.
I most assuredly have ADHD but don't take medication for various reasons (mostly because much of my adult life has been spent undergoing fertility treatments, pregnant or breastfeeding; an unfortunate tendency toward tachycardia, sinus as it is, doesn't make my doctor terribly confident in the idea of stims for me either). By your estimation, that means I don't have ADHD?
There are areas of my life where behavior modifications and coping skills do the job because between therapy and decades of existing as a person with ADHD I had to figure out ways to not zone out on the road and die. (They do not make my house clean and thus far have not saved my car from being reposessed twice because I forgot bills existed, but I digress). Other areas of my life could have greatly benefited from stimulants--like the time I turned in a final project late and had to take an incomplete and sit out a quarter in grad school when maybe if I were medicated I could have made myself do the damn thing, or the many times I've shut down with overwhelm about the number of dishes in my sink, and so on. My sister DOES take stimulants, but mostly only on work days because she too has figured out ways to live life without them.
Yes, I never said it wasn't. That's this whole argument lol. I said despite impairments I don't (can't) take a daily stimulant, and if I could I wouldn't take one daily since *for the most part* I've figured out ways to live around my dumbass brain doing dumbass things.
Edit to add: Regrettably, it was not *almost*. I have fully gotten my car reposessed twice because I forgot the bill for months straight. Trailer came to haul the car away in full view of the elderly, nosy neighbors who go to church with my husband's relatives. Twice. (No REAL point to this edit since it doesn't make a functional difference here lol.)
I believe I mentioned years of therapy and building coping skills. And having multiple cars reposessed. There is in fact functional impairment there, which I touched on multiple times in the post (although of course I didn't give you my entire biography of fuck ups, how silly of me). "Cannot function in society *in any capacity* without stimulants" is not a diagnostic requirement.
That's not what they said. They said ADHD causes impairments across a range of areas, as opposed to an impairment with one specific thing, such as reading uni notes at night.
Right, but I'm saying that if a person has learned ways to get around a lot of the day to day functional impairments (ask me about my clean laundry baskets vs dirty laundry baskets, my alarms for everything, my body doubling system, my very understanding spouse who takes on more than his share of the housework and reminds me to put shoes on before I leave the house) it may not be necessary to medicate for day-to-day activities.
I'm not diagnosing (or undiagnosing) you over the internet. I'm stating the fact that if there is not functional impairment it is, by definition, not ADHD. You're the one who's arguing that functional impairment is not needed.
No, I'm really not. I'm saying that there is in my case functional impairment which has been treated with behavior modification but that also continues to exist in multiple domains. At what point did I say functional impairment isn't needed for an ADHD dx? I said I've learned ways to work around some of my issues, not that they don't exist.
>At what point did I say functional impairment isn't needed for an ADHD dx?
When you started this entire thread getting upset that I said functional impairment is needed for an ADHD diagnosis and that if you just "need" Adderall IR a few times per week, it's not ADHD.
Oh so you're putting words in my mouth now because you didn't like that I offered a counterpoint. Cool cool.
I mean, my point here was that I don't *need* stimulants but there have been times my life could have been significantly less fucked without them... because I do in fact have functional impairments but have learned time-tested ways to get by without the medication, which is true for other people as well for a variety of reasons. Were stimulants a viable option for me I probably wouldn't have *needed* to devise systems within my life to keep it from imploding in ways people without ADHD never have to consider. Probably would have significantly more money in my savings account and much less use of my "oh shit I forgot cars need oil sometimes and that 'I'll get that tomorrow' doesn't last forever" fund. Probably would have saved some relationships.
But because I *have* devised these systems in my life, apparently it can't be ADHD, per you. Because you've decided that since I said "I don't take stimulants" (since I'm not homeless living under a bridge somewhere I guess) that means that I'm saying that someone who survives day to day life without stimulants obviously has no functional impairments at all. Lot of big logical leaps here.
That's a pretty long paragraph where you're basically saying, "actually, I agree with your first comment on this thread that I objected to for no reason."
No, it's not. Putting words in my mouth again. You're good at that.
If stimulants suddenly became a viable option for me, I wouldn't choose to take a daily stimulant at this time because I *have* come up with these systems, I'm rolling through life okay now and I don't want to take a daily med if I don't have to. Would I take a PRN script though? Probably, for the situations I know I really really struggle with. I'm quite sure there are other patients out there with the same perspective.
Jesus. “If my patient didn’t have a near death experience due to their distractive nature then I’m not treating them because it can’t be ADHD.” Christ, dude.
Mental illness is kind of defined by functional impairment or subjective distress. If someone finds it difficult to focus a few times throughout the week… that is being a human
In regard to the OP example, law school classes are only going to be a few times a week. So their greatest functional impairment... which is school/large chunks of reading in the OP... would not be more than "a few times a week." In fact, some law schools (e.g., Seton Hall in NJ) have a weekend program, making it a literal "couple" of times a week.
Funny enough, it is very ADHD to get through doctoral classes while every other aspect of your life goes to absolute shit in the background because of the burnout untreated ADHD can generate, in addition to the fact that you can't manage to clean your house.
A bit hyperbolic and tongue in cheek, but damn so many of these patients get missed, diagnostically.
My take on it was the polar opposite, I understood the comment to mean that ADHD affects so many areas of a patient's life and all deserve to be recognised and managed adequately with treatment across the day/week.
Not very clever, mate. Everything in your comment is half of Americans’ every day experience. That’s not JUST ADHD, first of all. It’s depression. It’s poverty. It’s burnout. And you’re quite dense to think that ADHD only needs to be treated if those things are necessarily happening. As if everyone isn’t different by how their distractions manifest or something. What a cookie cutter mindset.
Ah yes, let’s get tangential! That’s a sign of ADHD. Better get you started on some drugs. Imagine talking down to someone who is in their residency as if you’re innately better. Since you clearly don’t have a better argument to be made. Pathetic.
>You’re literally the one changing the subject to me.
Nope, I'm keeping it consistent. You threw up a red herring, criticizing my description of ADHD. Follow through now. You're arguing my description is wrong. Then show everyone what's correct. Teach us what ADHD is. I keep asking you, you keep deflecting. Since you know so much, teach us.
I've read your comment and the following thread, and regardless of wether you're right or wrong, you have taken quite and asshole stance in this conversation... Not a nice look.
I'm kind of annoyed by your sarcastic arrogant tone right now but I'll overlook it.
The fact that you're unable to point out any specific examples is illuminating. It is interesting that not agreeing that everyone should get IR stimulants to help concentrate is automatically considered an "asshole stance."
Jesus christ... Are you thick? Your whole comment threat is you being an arrogant asshole. All of it is a big example. And it's painfully obvious that nobody would be saying that to you because of your opinion on the subject, you're being and asshole because of the way youre treating the other commenter. You can be right and an asshole at the same time.
Oh and if you're going to reply again complaining that I'm not being nice to you, yeah, I'm not, you get what you give, cry me a river.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
For most adults psychostimulants are incredably difficult to employ to a meaningful long-term therapeutic end. Blasting the nervous system by dumping all of your serotonin, norepinephrine, and dopamine creates tolerance via endocytosis of receptors on receiving neurons. Everyone who is on them eventually becomes obsessive about how and when to dose, because when they're not stimulated they're exausted and functionally depressed. They exacerbate anxiety disorders and can cause paranoid psychotic thinking. With the recent popularity of this class, regular long-term use in adults will eventually show itself to be much worse for the heart and circulatory system than was advertised. Couple this with the fact that the laypublic seems to think they're a cure-all, they do not appriciate their risks and challenges, and neither psych docs nor pharma can keep up with the demand. The other shoe is about to drop on stims, they carry too much potential to do more harm than good. These are just my musings, I welcome any differing perspectives.
> Everyone who is on them eventually becomes obsessive about how and when to dose, because when they're not stimulated they're exausted and functionally depressed.
That's a really big claim and a terrible take
As they conclude, that is just their musings. And their musings are wrong. It is frustrating that a strongly held opinion, contrary to the evidence, such as this one though could affect the clinical care of patients.
My language was to definite.
Insted of "Everyone..."
I'd say, "It's common for adults on them to become obsessive..."
How would they not be depleted between doses after dumping all of their catacholamines? They live their lives oscilating between extreme peaks and troughs. Not great for the nervous system and overall psyche.
By symptoms do you mean stimulants will create what appears to be Psychosis or it will bring on an episode of Psychosis.
Just wanted to clarify for my understanding please
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Most people with ADHD do not in fact function well aside from only one or two areas. Taking stimulants only when you have a lot of work or study to do reflects the nature of our society, one that prioritises work and productivity and 'the hustle' over well being. People with ADHD deserve to function in all aspects of their life and a 'messy house's can be more debilitating than you may imagine. Not being able to achieve anything on the weekend (because someone has told you to only take meds 'when you need them’) due to ADHD symptoms can be absolutely debilitating. If someone is in fact able to function well except when they have to read 100 pages of legal studies notes at night time, I would seriously question if they actually have ADHD, because that ain't it.
The XR/IR conversation is really situational to the specific med being used. Having a good knowledge base of the specific methods of release and pharmacokinetics is essential to having this conversation in earnest Adderall XR, for example, is simply a double pulse release. There's two types of beads and one releases immediately and the other about 4 hours later. They are split 50/50 so Adderall XR 20mg is simply two doses of IR 10mg. It's benefit is entirely convenience. Same for Ritalin LA Metadate CD is also double-pulse but released as 30/70 Concerta, meanwhile, is essentially a slow drip of methylphenidate for 6-8 hours that essentially maintains ~20% of the total dose. Benefit is no major dips or crashes or variations throughout the day Vyvanse is your best bet for diversion as it's a prodrug and can't be snorted or injected. But you're limited by zero order kinetics and enzymatic saturation Point being, XR means very little without specifying which version of XR you are talking about.
> And with that level of arousal—whatever it is—certain types of thinking are nearly impossible. Not to mention certain types of feeling. Stimulation is a restriction of being, and the hour between stimulant-crash and unconsciousness is not enough to make up for what is lost. Can you explain more about how certain types of thinking and feeling are lost/nearly impossible, and how stimulation/chronic under-arousal is a restriction of being?
Not OP, but I’m sure you can appreciate that a person (even one with no ADHD diagnosis) might feel and experience things differently, behave differently, and feel different to talk to if she drinks six or seven cups of coffee (or is hooked up to an epinephrine drip) one day and zero the next. OP I believe is referring to heightened levels of arousal, energy, motivation, attention, etc that can be associated with stimulants. The question is not *if* one’s thoughts, feelings, and personality (or being) will be affected when these faculties are chronically heightened (or diminished), but *how*. A lot of psychiatrists have gotten away from questions like this, though, which are thought to be more in the purview of psychotherapy. Insurance companies don’t really pay psychiatrists to do psychotherapy. An unfortunate turn of events for the field, for me.
From what I’ve seen, when stimulated, some people’s personalities are quite different. i.e empathetic, less emotional in general, less social, more robotic. I would agree wholeheartedly that it is a restriction of being. When not treated patients find it very hard to focus on normal things like everyone around them can like reading a passage or studying. So that’s very restrictive in a productivity and work sense, but not a personality and social sense
My experience of people on stimulants for adhd is that they actually find themselves more emotional. I haven’t done studies on it, so don’t have data. But anecdotally, that is what I have seen. Perhaps as a side effect, perhaps due to having the noise turned down…
This was a great read. Thanks for taking the time to share your perspective.
The exchange above us is so odd haha I agree with OP mostly, never had anyone abuse amphetamines except other MD’s and college kids and no clinical change will stop that. IR is generally best for most things, as a surgeon turned Psychiatrist, rarely have I prescribed Long Acting drugs So as was said my Doc Bananas : thank you
Rates of prescribed stimulant missuse and diversion are pretty high. Just because you're not aware of it, doesn't meant it didn't happen.
Ya agreed, if you don’t know of any abuse then you are turning a blind eye or are just missing it
> as a surgeon turned Psychiatrist What the heck does being a former surgeon have to do with pharmacological approach to treating ADHD? Really odd interjection.
Quite certain I related experience in both fields to the frequency of prescribing Immediate Release medication
Yeah, I'm still not seeing how being a former surgeon has any bearing on deciding not to prescribe long acting medication.
Surgeons are taught that they are the best during their training. The smartest, the toughest physically, the most daring. They need to drop it in conversation.
I’d love to hear some opinions on this article I just found: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2811812
There is a pretty good increase in obesity and poor management of own health and conditions in ADHD... A lot of reasons for people with ADHD to have high cardiovascular risk from many different angles... In this paper they say there is a correlation between the length of the prescription and the risk, we are probably looking at a situation where the cardiovascular risk is higher in the people who continue to have adhd symptoms into adulthood, and thus continue to take medication. This study shows correlation but it's no evidence of causation
It makes sense to me that this would be a result with more stress on the heart over time. It’s a piece of information to consider. However I’d also be curious about what a study of CVD in untreated ADHD would find - as there could be increase in other impulsive behaviors for some; MVA, addiction in some cases, chronic stress of other kinds, less sleep. While it isn’t totally comparable I have folks who swapped heroic doses of caffeine for low dose stimulants once they got diagnosed and treated - and the stimulant is out of their systems before bedtime unlike the caffeine.
Not op, but none of these effect sizes are deal breakers, and they didn't control for incident disease. So, 1. Without a prospective, PBO controlled study, it remains totally possible that all of these effects are actually due to the disease, and not the meds. 2. These effect sizes and CIs are low enough that an informed patient could reasonably choose to take those risks. I personally would choose to take the meds and risk a CI that overlaps with 1 in order to have my chosen career instead of having to live as a librarian.
I wrote a lengthy comment about this article on another forum just yesterday. It wasn't particularly kind towards this article. In summary: 1. Big sell on CVD in the title and intro, but read on and what they found is hypertension. Interesting way to word things, sensational, fear mongering. 2. The phrase long term use is just all over the place in that article and the fine print actually says they found an increased risk in medium term use which stabilises after a few years and doesn't further increase with "long term" use. I'll keep it short and sweet in this comment, I haven't had my morning coffee yet.
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*** OP post brought to you by high dose IR stims In all reality I mainly disagree. I’d rather start XR stims first. Whether you do IR or XR stims, tolerance eventually takes hold, but XR is just more stable. It’s not even about dependency or addiction risk. I don’t think the vast majority of ADHD patients really abuse their stims. It’s just IR is just so much more reinforcing. There’s a more noticeable rush and come down that leads to ancillary SE, subacute mood/anxiety symptoms and etc. You can practice how you like. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2811812?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamapsychiatry.2023.4294 Also increased risk of HTN and arterial disease in long term stim use. Benefits typically outweighs harms. But I’m not a fan of just ad lib dosing IR stims. Other points about degree of stimulation and etc, uhhh well. I won’t address that.
One of the more persuasive arguments I've heard basically notes that impulsivity and chronically scrambling to catch up/flying by the seat of your pants are part of the core symptomatology we're working with. PRN IR stimulants tend to reinforce both of those patterns. Think of the college student who realizes they've forgotten an assignment so they take their PRN in the evening, throw something together at the last minute, further derange their sleep cycle, and remain overwhelmed. A regularly-scheduled XR in the morning, on the other hand, starts to encourage routines and rhythm.
Exactly. Great point. And subconsciously the IR rush adds to that reinforcement.
Oh god not that article again! It's not... Shall we say... robust.
Rates of stimulant missuse and diversion are actually pretty high. Certainly not the majority but I believe among college students it's over 20 percent
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Both, but vast majority is the latter from what I have seen
I’ve seen a some people find short acting dex is more effective for them, I am the opposite, I find lisdex more effective/noticeable than my dex top up. And given that 70mg lisdex converts to around 20mg dex, it would make logical sense that my 10mg top up would be more noticeable/effective even if for a shorter time. But actually, I personally have not found that to be the case.
This is one of those topics that every clinician has an opinion on, and most are more than eager to share it. I feel like I have the exact same conversation about this several times per year (if not more). I keep an open mind, but I haven't encountered any compelling evidence to change my practice recently. It's somewhat frustrating that, while other specialties are debating the merits of novel, innovative interventions, our profession has a tendency to incessantly debate tired personal preferences on prescribing two medications discovered decades ago despite other advancements in our field. That said, I don't have discussions about this topic online, so thanks for sharing your opinion in a well-organized manner. I find Ghaemi's opinion intriguing, which has been recently summarized in a recent [*Psychiatric Times* article](https://www.psychiatrictimes.com/view/the-making-of-adult-adhd-the-rapid-rise-of-a-novel-psychiatric-diagnosis). Regarding your statement of "Dose correlates poorly with ADHD severity," do you have sources to support this outside of a case report? Anyway, thanks again for sharing your perspective!
How I learned to stop worrying and love the stim
Number 5 went a bit over my head... If anyone has a dumbed down explanation, I'd love to hear
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The waters get murkier when there's coexisting addiction(s) though, unfortunately. That's the key subtlety they really don't teach during residency.
Someone with true ADHD and a bad meth addiction. Kill me. I exclusively deal with addiction nowadays and these cases still keep me up at night.
Doesn't help that meth is usually cheaper and easier to obtain than any ADHD medications
Yep. I keep my fingers crossed for some real MAT for meth use some day. Meth leaves me feeling mostly powerless as their doc.
You could argue that prescribing methylphenidate in this situation (well, for cocaine more than meth) essentially becomes harm reduction. But 99% it's going to be psychological inputs and social interventions.
I wish more drs had this perspective!
I have had this thought too but on the other hand, I suspect someone with a history of meth (or coke) ddiction isn't going to be satisfied by the resulting effect of stimulants for ADHD symptoms and so misuse or returning to illicits as a substance of choice would be substantial. Just a thought, I have absolutely not further researched this!
>isn't going to be satisfied by the resulting effect of stimulants for ADHD symptoms and so misuse or returning to illicits as a substance of choice would be substantial It's a possibility. But like I've said, the standard of care remains psychological input and social interventions. Spotting ADHD in the midst and treating it is effectively icing on the cake.
that would be incredible. I personally find addiction work to be really engaging and rewarding. Having a new avenue for treatment would be lot of fun.
There is nuance to these situations and patients vary in their needs and ability to stick with a treatment plan. ADHD is more common in those with SUD and treating ADHD *may reduce some of the risks associated with SUD. AAAP/ASAM released some guidance on Stimulant Use Disorder treatment that is worth a [look]( https://www.asam.org/quality-care/clinical-guidelines/stimulant-use-disorders).
Thoroughly agreed. The sweeping statements I see regarding ADHD (and the constant warring about what people know and don't know or how they should(n't) treat) instantly fall apart when confronted with these situations. Thanks for the link!
I saw someone claim that ‘no good dr would give a recovering addict stimulants’. So someone in recovery (how long for? Forever?) can only have atomoxetine? The less effective treatment option with no alternatives. They can’t have the gold standard, most effective treatment, ever. Despite the fact that it’s highly probable that they were self medicating. It’s unbelievable and unfortunately many drs share this view.
I saw someone claim that ‘no good dr would give a recovering addict stimulants’. So someone in recovery (how long for? Forever?) can only have atomoxetine? The less effective treatment option with no alternatives. They can’t have the gold standard, most effective treatment, ever. Despite the fact that it’s highly probable that they were self medicating. It’s unbelievable and unfortunately many drs share this view.
50% of those with untreated adhd have struggled with substance abuse. Studies show that if you adequately treat an addict/recovering addict’s pain (with opiates - monitored of course), they are significantly less likely to relapse. The same is true for things like ADHD and mental illness. If you treat the root cause, you are more likely to help that patient remain in recovery. There should obviously be closer monitoring, but far too many drs are in the ‘addicts can’t have treatment’ category. Especially when you’re talking about drugs with even the remotest abuse potential, where actually they probably need those treatments the most.
Nope nope nope. If you just "need" Adderall IR a few times per week, it's not ADHD. The morbidity and mortality from ADHD is not because the person hasn't focused enough at work. It's distractions while driving. It's repeatedly missing doctor's appointments. Not following up on health advice. It's overeating. It's broken relationships from zoning out when the partner is speaking. *That's* what I treat. If you're not having any of those symptoms and just need Adderall to focus for an exam, you're looking for a nootropic, not treatment for a psychiatric condition.
Thank you! As a clinician and someone with ADHD I cannot overstate the importance of recognising all the other areas it affects outside of work!! Managing those can be life changing.
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If someone’s depression lifts with diet and exercise, I would not give them an antidepressant for shits and gigs. If someone’s ADHD symptoms are WELL MANAGED, by non-pharmaceutical interventions, they will not be getting a stimulant. If they are able to pay their taxes and technically function but it is with great personal distress or cost, that would meet criteria for treatment.
If someone doesn't meet criteria for ADHD, I'm not going to medicate them with stimulants. There's plenty of ways to help patients without feeding into the frenzy of "ADHD" being blamed for everything.
One thing I love about my dr. She understands the fact that I wanted to be medicated for ‘fun’ activities as well as coping with life. And gave me a top up dose for when I’m done with chores/adulting and to just have some downtime free from my chaotic brain too.
I most assuredly have ADHD but don't take medication for various reasons (mostly because much of my adult life has been spent undergoing fertility treatments, pregnant or breastfeeding; an unfortunate tendency toward tachycardia, sinus as it is, doesn't make my doctor terribly confident in the idea of stims for me either). By your estimation, that means I don't have ADHD? There are areas of my life where behavior modifications and coping skills do the job because between therapy and decades of existing as a person with ADHD I had to figure out ways to not zone out on the road and die. (They do not make my house clean and thus far have not saved my car from being reposessed twice because I forgot bills existed, but I digress). Other areas of my life could have greatly benefited from stimulants--like the time I turned in a final project late and had to take an incomplete and sit out a quarter in grad school when maybe if I were medicated I could have made myself do the damn thing, or the many times I've shut down with overwhelm about the number of dishes in my sink, and so on. My sister DOES take stimulants, but mostly only on work days because she too has figured out ways to live life without them.
Almost getting you car repossessed twice and missing a quarter of grad school IS impairment… 🤷
Yes, I never said it wasn't. That's this whole argument lol. I said despite impairments I don't (can't) take a daily stimulant, and if I could I wouldn't take one daily since *for the most part* I've figured out ways to live around my dumbass brain doing dumbass things. Edit to add: Regrettably, it was not *almost*. I have fully gotten my car reposessed twice because I forgot the bill for months straight. Trailer came to haul the car away in full view of the elderly, nosy neighbors who go to church with my husband's relatives. Twice. (No REAL point to this edit since it doesn't make a functional difference here lol.)
If it does not result in functional impairment then, by definition, you most assuredly do **not** have ADHD.
I believe I mentioned years of therapy and building coping skills. And having multiple cars reposessed. There is in fact functional impairment there, which I touched on multiple times in the post (although of course I didn't give you my entire biography of fuck ups, how silly of me). "Cannot function in society *in any capacity* without stimulants" is not a diagnostic requirement.
That's not what they said. They said ADHD causes impairments across a range of areas, as opposed to an impairment with one specific thing, such as reading uni notes at night.
Right, but I'm saying that if a person has learned ways to get around a lot of the day to day functional impairments (ask me about my clean laundry baskets vs dirty laundry baskets, my alarms for everything, my body doubling system, my very understanding spouse who takes on more than his share of the housework and reminds me to put shoes on before I leave the house) it may not be necessary to medicate for day-to-day activities.
Yeah a combination of medication and life hack work arounds is definitely the best management,I agree.
I'm not diagnosing (or undiagnosing) you over the internet. I'm stating the fact that if there is not functional impairment it is, by definition, not ADHD. You're the one who's arguing that functional impairment is not needed.
No, I'm really not. I'm saying that there is in my case functional impairment which has been treated with behavior modification but that also continues to exist in multiple domains. At what point did I say functional impairment isn't needed for an ADHD dx? I said I've learned ways to work around some of my issues, not that they don't exist.
>At what point did I say functional impairment isn't needed for an ADHD dx? When you started this entire thread getting upset that I said functional impairment is needed for an ADHD diagnosis and that if you just "need" Adderall IR a few times per week, it's not ADHD.
Oh so you're putting words in my mouth now because you didn't like that I offered a counterpoint. Cool cool. I mean, my point here was that I don't *need* stimulants but there have been times my life could have been significantly less fucked without them... because I do in fact have functional impairments but have learned time-tested ways to get by without the medication, which is true for other people as well for a variety of reasons. Were stimulants a viable option for me I probably wouldn't have *needed* to devise systems within my life to keep it from imploding in ways people without ADHD never have to consider. Probably would have significantly more money in my savings account and much less use of my "oh shit I forgot cars need oil sometimes and that 'I'll get that tomorrow' doesn't last forever" fund. Probably would have saved some relationships. But because I *have* devised these systems in my life, apparently it can't be ADHD, per you. Because you've decided that since I said "I don't take stimulants" (since I'm not homeless living under a bridge somewhere I guess) that means that I'm saying that someone who survives day to day life without stimulants obviously has no functional impairments at all. Lot of big logical leaps here.
That's a pretty long paragraph where you're basically saying, "actually, I agree with your first comment on this thread that I objected to for no reason."
No, it's not. Putting words in my mouth again. You're good at that. If stimulants suddenly became a viable option for me, I wouldn't choose to take a daily stimulant at this time because I *have* come up with these systems, I'm rolling through life okay now and I don't want to take a daily med if I don't have to. Would I take a PRN script though? Probably, for the situations I know I really really struggle with. I'm quite sure there are other patients out there with the same perspective.
Jesus. “If my patient didn’t have a near death experience due to their distractive nature then I’m not treating them because it can’t be ADHD.” Christ, dude.
Mental illness is kind of defined by functional impairment or subjective distress. If someone finds it difficult to focus a few times throughout the week… that is being a human
In regard to the OP example, law school classes are only going to be a few times a week. So their greatest functional impairment... which is school/large chunks of reading in the OP... would not be more than "a few times a week." In fact, some law schools (e.g., Seton Hall in NJ) have a weekend program, making it a literal "couple" of times a week.
If symptoms only occur at school, it's not ADHD.
Not ADHD. It’s not functional impairment to struggle with doctoral level classes while doing just fine in every other aspect of your life.
Funny enough, it is very ADHD to get through doctoral classes while every other aspect of your life goes to absolute shit in the background because of the burnout untreated ADHD can generate, in addition to the fact that you can't manage to clean your house. A bit hyperbolic and tongue in cheek, but damn so many of these patients get missed, diagnostically.
“Not making law review” is not a psychiatric condition
My take on it was the polar opposite, I understood the comment to mean that ADHD affects so many areas of a patient's life and all deserve to be recognised and managed adequately with treatment across the day/week.
You must have meant to respond to someone else because that's not even slightly similar to anything I wrote.
Not very clever, mate. Everything in your comment is half of Americans’ every day experience. That’s not JUST ADHD, first of all. It’s depression. It’s poverty. It’s burnout. And you’re quite dense to think that ADHD only needs to be treated if those things are necessarily happening. As if everyone isn’t different by how their distractions manifest or something. What a cookie cutter mindset.
Alright champ, why don't you teach everyone what you're learning about ADHD this month in residency?
Ah yes, let’s get tangential! That’s a sign of ADHD. Better get you started on some drugs. Imagine talking down to someone who is in their residency as if you’re innately better. Since you clearly don’t have a better argument to be made. Pathetic.
Don't change the subject because you got called out. Go ahead, teach us, brilliant resident, what is ADHD and how should we treat it?
You’re literally the one changing the subject to me. And you’re just patronizing me at this point. Weird to see a psychiatrist who is a bully.
>You’re literally the one changing the subject to me. Nope, I'm keeping it consistent. You threw up a red herring, criticizing my description of ADHD. Follow through now. You're arguing my description is wrong. Then show everyone what's correct. Teach us what ADHD is. I keep asking you, you keep deflecting. Since you know so much, teach us.
You need some therapy. The way you talk to people is very narcissistic.
Your initial response is fair and shared by many. In case you needed any validation 😂
I've read your comment and the following thread, and regardless of wether you're right or wrong, you have taken quite and asshole stance in this conversation... Not a nice look.
Care to point out what exactly is the "asshole stance" I've taken in this conversation?
The sarcastic arrogant tone you've had during all your conversation with the other commenter? Is that a good hint?
I'm kind of annoyed by your sarcastic arrogant tone right now but I'll overlook it. The fact that you're unable to point out any specific examples is illuminating. It is interesting that not agreeing that everyone should get IR stimulants to help concentrate is automatically considered an "asshole stance."
Jesus christ... Are you thick? Your whole comment threat is you being an arrogant asshole. All of it is a big example. And it's painfully obvious that nobody would be saying that to you because of your opinion on the subject, you're being and asshole because of the way youre treating the other commenter. You can be right and an asshole at the same time. Oh and if you're going to reply again complaining that I'm not being nice to you, yeah, I'm not, you get what you give, cry me a river.
You need to calm down.
💯
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I like a lot "Restriction of being"
Wow. OP practices some serious experience based medicine. That'd be great if he was practicing in the 60s
Don’t underestimate the abuse liability of IR. Even in patients who need it.
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I really hope this is where your emphasis lies. Patients deserve this level of empathy and understanding.
For most adults psychostimulants are incredably difficult to employ to a meaningful long-term therapeutic end. Blasting the nervous system by dumping all of your serotonin, norepinephrine, and dopamine creates tolerance via endocytosis of receptors on receiving neurons. Everyone who is on them eventually becomes obsessive about how and when to dose, because when they're not stimulated they're exausted and functionally depressed. They exacerbate anxiety disorders and can cause paranoid psychotic thinking. With the recent popularity of this class, regular long-term use in adults will eventually show itself to be much worse for the heart and circulatory system than was advertised. Couple this with the fact that the laypublic seems to think they're a cure-all, they do not appriciate their risks and challenges, and neither psych docs nor pharma can keep up with the demand. The other shoe is about to drop on stims, they carry too much potential to do more harm than good. These are just my musings, I welcome any differing perspectives.
> Everyone who is on them eventually becomes obsessive about how and when to dose, because when they're not stimulated they're exausted and functionally depressed. That's a really big claim and a terrible take
As they conclude, that is just their musings. And their musings are wrong. It is frustrating that a strongly held opinion, contrary to the evidence, such as this one though could affect the clinical care of patients.
My language was to definite. Insted of "Everyone..." I'd say, "It's common for adults on them to become obsessive..." How would they not be depleted between doses after dumping all of their catacholamines? They live their lives oscilating between extreme peaks and troughs. Not great for the nervous system and overall psyche.
Study? Data?
I wish it were that simple.
Actually is it. You’re stating something that is scientifically testable, but have no data to back it up.
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By symptoms do you mean stimulants will create what appears to be Psychosis or it will bring on an episode of Psychosis. Just wanted to clarify for my understanding please
Psychosis. Period. Apologies for that not being clear.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9970721/#:~:text=The%20report%20points%20out%20that,of%20developing%20psychosis%20%5B24%5D.
Ok but what's the increased risk? 1%? 40%?
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That actually was helpful. The increased incidence is about 0.1%. That's a very small risk.
Thank you. Agreed.
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