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Thursday, December 5, 2013
Attention Deficit Hyperactivity Disorder
Midlife and finally addressing the problem
But I am worried. I am 40 and just prescribed methylphenidate at 10mg in the morning and at noon. I took the morning one and noticed nothing. After the noon dose I realized it was working. I indeed felt more focused, motivated and able to get things done unlike before. My worry is this though: When the medicine wore off in just a couple hours I had a very old, but familiar sensation. For the first time in the nearly 20 years since I last touched the stuff I had a craving for cocaine. It was identical to the sense I would get when using cocaine that I must have more. It is accompanied by a frustration and a feeling of generally DOWN. That comes and goes for a couple hours until it`s gone. I did not like that feeling. Is that normal??? Do I have any options?
You are not alone in this worry. Methylphenidate and cocaine (and also amphetamine, the other major stimulant medicine) do work on the same receptors with somewhat similar effects, and this issue is the target of much research, including at the National Institute on Drug Abuse. For years many experts have worried that therapeutic use of stimulants might lead to addiction. At our current state of knowledge this appears to be a mistaken impression resulting from the fact that people with ADHD, whether or not they received treatment with stimulants, have a higher risk of drug and alcohol abuse. Some have theorized that unmedicated individuals with ADHD self-medicate with substances of abuse/dependence, especially nicotine and alcohol. A few have even claimed from a small naturalistic study that medication with stimulants protects from substance abuse. The best scientific data currently available on this issue is that treatment with stimulants does not affect the risk of later substance abuse either direction: it neither raises the risk nor protects from it.
For your individual case, you might want to discuss with your doctor some alternative medications: For example, the very same medication in a different form, such as an extended-release oral formulation or a skin patch could smooth out the ups and downs you describe. There are also 2 nonstimulants approved by the FDA for treatment of ADHD. One is atomoxetine (trade name Strattera). It does not work as quickly as a stimulant, so you have to be patient, and it has some different side effects; it has to be slowly titrated up from a low beginning dose. If you try it, you should give it a month at full dose before deciding whether it helps. A more recently approved one is guanfacine (trade names Tenex and Intuniv); this one has been on the market for decades and was used "off label" for ADHD, but recently has received FDA approval for ADHD.
Importantly, there are other things you could do to help yourself besides medication. These include behavioral treatments, coaching in organizational skills and schedule-keeping, good nutrition (including adequate omega-3 polyunsaturated fatty acids, balanced diet, and possibly a RDA/RDI multivitamin-mineral pill), exercise, a full night's sleep, and forming good habits one at a time. Habit formation is the key to living with ADHD. Once you have a habit, you don't have to pay attention to it any more; it just runs on autopilot. The more good habits you have, the less of a problem inattentiveness becomes. You can find more details in "A Family's Guide to Attention-Deficit/Hyperactivity Disorder", 2004, Handbooks in Health Care, 3 Terry Drive, Newtown, PA 18940 (http://www.hhcbooks.com/).
L Eugene Arnold, MD, MEd
Professor Emeritus of Psychiatry
College of Medicine
The Ohio State University