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Let's Get More Kids on Stimulants: The Under Diagnosis of ADHD [Part II]

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adhd-drug-concerta-methylphenidate-e1446580142896.0.jpg

I'm not 100% sure how much my own personal biases affect my research about the safety and effectiveness of stimulants. But for me, the fact that this article exists is a testament to how well they work.

For comparison's sake, I was applying to Game Informer magazine during my semester off last fall (prior to being diagnosed with ADHD). It took me one month to write a single game review, and quite honestly, the piece sucked.

In the last week I have written six pieces, all of which are either on my blog or The Verge's forum. There are other factors of course that I'm sure influenced this, but when I hit the right dose for stimulants, it was like putting on glasses for the first time. I was able to see my goals more clearly and just as important, pursue them more effectively.

In terms of why people dislike the prescription of stimulants, there isn't really a single particular thing I hear. It mostly comes down to this: "I don't think it is a great idea to give the equivalent of medical cocaine to five year olds."

I am getting some side effects as I am typing this actually, slight muscle tightness in my neck, small increases in anxiety, but these are minuscule problems compared to the huge gains in regulating the worst effects of ADHD.

I hope no one is swayed by what I have just typed however as the mind is a complicated mechanism. My experience with a substance does not necessarily translate to a broader scale. I just gave the personal part where I appeal to everyone's emotions. Now I hope to try to bring home the point in a way that isn't as subjective.

First I want to talk about why stimulants are even needed for people with ADHD at all. Since it is a mental health problem, wouldn't talking to a therapist help just as much?

Remember what I talked about in my previous column, ADHD has never been a problem with knowledge. As a matter of fact, people with the disorder have no marked impairments in IQ compared to the rest of the general population. ADHD is a neurological disorder that is overwhelmingly genetic in origin and impairs certain parts of brain functioning, mostly in the executive (frontal) brain. Telling someone with ADHD to focus is quite similar to telling someone in a wheelchair to simply walk. Medication is the only tool we have that improves executive functioning directly at the source -€” the brain. Hence it is by far the best tool for relieving executive functioning deficits.

Ritalin was first prescribed to patients in the 1960s, the amphetamine salts in Adderall were given out to soldiers in WWII to help improve alertness on the battlefield

Before I go on though, I am going to guess there are a few people who will read this and look for it as validation for their own illicit use of stimulants. As a general rule of thumb, we are generally the absolute worst at knowing what we need medicine-wise. Medical professionals very familiar with the pharmacology of their own medicine still go to another doctor to review side effect profiles.

If a doctor needs to do that, than so do you. Please do not use stimulants without first going to a professional. I'm not just trying to be PC here or cover my bases so I don't get sued, I totally mean it. Stimulants can become unsafe very quickly if not taken properly.

Ok, glad I got that out of the way. Now I am going to talk about why stimulants are perfectly safe when taken correctly at proper doses, for all age ranges.

Dependence on Ritalin or Adderall is virtually unheard of when taken orally and at the therapeutic level

It should be mentioned that both Ritalin and related brands of methlyphenidate (Focalin, Medidate, Concerta) along with Adderall and related forms of amphetamine (Vyvanse, Dexedrine) have been around for an extremely long time. Ritalin was first prescribed to patients in the 1960s, the amphetamine salts in Adderall were given out to soldiers in WWII to help improve alertness on the battlefield. As a result, researchers are extremely well aware of the various side effects that these drugs cause, and how they cause them. These two drugs are probably some of the most well-understood medications out there.

In terms of why people dislike the prescription of stimulants, there isn't really a single particular thing I hear. It mostly comes down to this: "I don't think it is a great idea to give the equivalent of medical cocaine to five year olds."

Fair enough. I mean the actual chemical name for Ritalin is methylphenidate, and for Adderall it usually just says amphetamine salts. Hardly reassuring names for a parent. And honestly, both these substances are similar in many ways to the harder drugs on the illicit markets.

There are a few critical distinctions though which make this train of thought not so reasonable under close scrutiny. The therapeutic dose range for the ADHD stimulants are significantly lower than those in the recreational use of cocaine. People take cocaine to feel a rush and/or euphoric, people are given Ritalin or Adderall to relieve their effects of ADHD. I would not be happy if these stimulants were revving me up everyday, I just want to be myself without the various symptoms of ADHD.

The actual fact that the drugs work, and that they are perhaps the best drugs for treating a disorder in all of psychiatry almost seems like an afterthought.

This also ties into the second and most important distinction: delivery mechanism. Everyone who has seen the myriad of gangster shows over the last decade knows how people take cocaine, they snort it. In addition to a crazy high dosage, this guarantees that it all goes directly and immediately to the brain. Taking a drug this way supposedly feels incredible, and is also one of the worst things you can do for your body. It causes drug dependence, dopamine depletion, all sorts of bad things that are probably not worth the rush.

ADHD medication is never taken this way -€” it is usually taken orally. A vast majority of those on Ritalin and Adderall take their meds in pill form (some use a patch). This significantly slows down the rate of dopamine absorption into the body and release and thus prevents the drugs from causing addiction and all the nasty side effects of recreational cocaine. Dependence on Ritalin or Adderall is virtually unheard of when taken orally and at the therapeutic level. I could stop my drugs tomorrow and would experience little to no side effects. Sudden death, heart attacks, seizures, all of these simply do not happen to those taking stimulants properly, period.

But children are not to be trusted, especially those with ADHD since they are prone to impulsivity. Who can deny that some child somewhere is going to try to take more meds than they are prescribed, or even worse, break up their medication and snort it or inject it?

Even here there is good news. Recently, a variant of Adderall known as Vyvanse has entered the market. It works by effectively locking the drug with a chemical compound and will only release the amphetamine if combined with certain enzymes in the stomach and intestinal wall. Try to snort it? You are out of luck, it won't do anything.

vyvanse-for-adderall-color1.0.jpg A photo of a Vyvanse pill that was used in a story to demonstrate the out of control usage of stimulants on college campuses. Whoever snorts this will not feel any of the drug's effects and is probably in for a disappointing Saturday night.

The same is true with Concerta, a version of Ritalin housed in a miniature water-based pump. When swallowed, it squeezes out the Ritalin slowly as water is absorbed into the capsule (the pump). Parents who are concerned about their children possibly abusing the stimulants prescribed should consider Concerta or Vyvanse. Beyond the locking or delivery mechanisms, Vyvanse is identical to Adderall (amphetamine) and Concerta is essentially Ritalin (methylphenidate). As a quick side note, I take Concerta and it is also great because it only needs to be taken once a day, standard Ritalin only lasts four hours.

Blatant attempts to simply take more pills than prescribed are unlikely to succeed. Stimulants are tightly controlled and a doctor must authorize every single refill, every month. It would quickly be obvious if a person wasn't taking the prescribed amount as they would be going through their prescribed amount far too quickly.

Not to mention, overdosing is a problem with over the counter drugs as well and is not a unique problem to stimulants. There is a case to be made that overdosing on Advil poses more serious risks to an individual than overdosing on a stimulant (even though Advil is very safe at normal levels). Moral of the story: any parent should be keeping medications out of reach of children; this applies to drugs well beyond Ritalin and Adderall.

Hopefully I have made a plausible case that ADHD medicines are quite safe when used in the right way, and that there are a multiple safeguards to ensure that they are. The actual fact that the drugs work, and that they are perhaps the best drugs for treating a disorder in all of psychiatry almost seems like an afterthought. People have a tendency to be caught up more in the seeming absurdity of stimulants in children and their own perceptions of ADHD rather than looking beyond what seems so obvious.

And it's hard to blame any of these people. I quite honestly would have never read anything about ADHD if I hadn't gotten diagnosed myself. All the immediate signals of the disorder such as the name, the fact that it uses a seemingly extreme medication to treat it, etc, seem to show a lot of smoke without a fire. People should be skeptical about what doctors tell them, they should see the evidence for themselves and then decide.

But as I have said and will say many times again, good intentions can lead down some bad roads. For those suffering with ADHD, the fact that so many have not examined scientific literature on this subject has caused unnecessary feelings of inferiority and self blame. I know far too many individuals who are unwilling to treat their ADHD because they are worried about what others might think or see it as a sign of a weakness. That honestly just sucks.

Nonetheless, I remain optimistic that the legitimacy of mental disorders is slowly getting accepted into the mainstream. As this continues, ADHD's validity is very likely to move along with the changing tide. Here's to this small article series accelerating that process in some way.