Treatment. Drugs
24 Feb 2020
The evidence documenting the individual and social impact of ADHD is the most important justification for treatment.

Various treatment approaches aiming to reduce ADHD core symptoms have been evaluated:
✔ pharmacological treatments;
✔ behavioral and psychosocial treatments;⠀
✔ cognitive training;⠀
✔ neurofeedback.

Furthermore, numerous meta-analyses published in the last few years have assessed the efficacy of pharmacological, non-pharmacological, and combined treatment for managing ADHD. No consistent evidence has been found for any one particular therapy that would provide meaningful benefits in the long-term for children and adolescents with ADHD.

Let's talk about drugs.
Drugs approved by the FDA for treating ADHD and around 90% of children with ADHD eventually receive medication as treatment.
The most widely used medications are two psychostimulants, methylphenidate (MPH) and the amphetamines (AMP), they reduce symptoms in approximately 70% of patients.
Treating ADHD with stimulants decrease anxiety disorders and reduce aggression and antisocial behavior in individuals with ADHD. Children become more attentive, less hyperactive, they have fewer problems at school and at home.

The psychostimulants improve the severity of ADHD symptoms in the short term but did not improve retention to treatment.

Important information: stimulants have a high potential for abuse and dependence!

By the way, such medications cause many side effects. The long-term therapeutic use can lead to severe sleep problems, decreased appetite and weight loss, increased blood pressure, dizziness, hallucinations, paranoia, rebound (irritability when the medication wears off), moodiness, irritability and even neurological events (amphetamines may increase the risk of seizures).

So, the main question is: psychostimulant treatment is a safe and effective treatment for ADHD symptoms, but is it also effective in curbing drug use in this co-morbid population?
In such a way, despite the fact that stimulants are effective in controlling ADHD symptoms, their use is not a solution, it's only the way to put off the issue.

This is a very big problem in the scope of prescription stimulants.
Close to 50 million prescription stimulant drugs like Adderall were dispensed in 2011 to treat symptoms of ADHD. This represents an almost 40 percent rise in these prescriptions since 2007 (Drug Enforcement Administration, DEA ). And from 2006 to 2016 amphetamine use increased 2.5 fold (7.9 to 20.0 tons).

The use of stimulants, often lifelong, has raised several concerns and controversies over the years because amphetamines and methylphenidate are ranked as 6th and 12th for substances known to cause physical harm (alcohol and tobacco are 11th and 14th) and 8th and 13th for substances known to cause dependence (cannabis and LSD are 11th and 14th).
Isn't it a reason for thinking about it?

Although stimulants are considered first-line agents, they may not be suitable for nearly 30% of ADHD patients.
Nonresponsiveness or partial responsiveness to stimulants; intolerance to their side effects; the presence of medical issues such as psychiatric, cardiovascular, or tic disorders; and family aversion to controlled substances may require alternative agents categorized as non-stimulants – atomoxetine, guanfacine, clonidine, bupropion, tricyclic antidepressants.

The non-stimulant atomoxetine (Strattera) first gained approval for the treatment of patients aged 6 years in the USA in 2002, and has been authorized for use in 97 countries throughout the world, including most European countries. With regard to safety, the European SPC (summary of product characteristics, SPC) and US label for atomoxetine have been updated on numerous occasions over the past decade. For example, in the European SPC and US label, a number of warnings or contraindications have been updated, including contraindication for atomoxetine in patients with severe cardiac or vascular disorders, such as severe hypertension, and warnings have been included about treatment-emergent suicidality.

All of these medications except atomoxetine have been the most widely used off-label medications to treat ADHD for monotherapy; the long duration of action of the antidepressants, no risk of abuse potential, and ability to overcome depression and tics were touted as distinct advantages over stimulants.

Nonstimulants are believed to possess a less-robust effect than stimulants.
The effects of ADHD medication, however, are short-lived, and benefits of medication are generally maintained only if medication is continued.

Piper, B. J., Ogden, C. L., Simoyan, O. M., Chung, D. Y., Caggiano, J. F., Nichols, S. D., & McCall, K. L. (2018). Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016. PLOS ONE, 13(11), e0206100. doi:10.1371/journal.pone.0206100

Sharma, A., & Couture, J. (2013). A Review of the Pathophysiology, Etiology, and Treatment of Attention-Deficit Hyperactivity Disorder (ADHD). Annals of Pharmacotherapy, 48(2), 209–225. doi:10.1177/1060028013510699

Castells, X., Blanco-Silvente, L., & Cunill, R. (2018). Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd007813.pub3

Rajeh, A., Amanullah, S., Shivakumar, K., & Cole, J. (2017). Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies. Asian Journal of Psychiatry, 25, 131–135. doi:10.1016/j.ajp.2016.09.005

Mattingly, G. W., Wilson, J., & Rostain, A. L. (2017). A clinician's guide to ADHD treatment options. Postgraduate Medicine, 129(7), 657–666. doi:10.1080/00325481.2017.1354648

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