Adults who do NOT have ADHD

[WisNeuro]

Yeah but the paper doesn't actually say they are basing it on that question., which is a big problem. Under this definition if someone uses an extra IR due to a particular demanding day they have to say yes, and I lose zero sleep worrying about someone doing that. The definition of abuse is important because it gives us a sense of whether this is behavior that matters and has a meaningful negative impact or not

Could be, but usually when one might use that extra dose, they don't tend to crush and snort it, like the "vast majority" of those who reported abuse did. Also, the diversion questions are pretty clear. Could it have been better worded? Sure. Is it consistent with a large body of literature in the area? Yes.

---

Members don't see this ad.

 

[robellis]

What's the question behind the question?

It says you’re a psychologist but you seem eager to opine on discussions of pharmacology so I’m wondering if you prescribe medications

 

[WisNeuro]

It says you’re a psychologist but you seem eager to opine on discussions of pharmacology so I’m wondering if you prescribe medications

What's the question behind the question?

 

[clausewitz2]

Could be, but usually when one might use that extra dose, they don't tend to crush and snort it, like the "vast majority" of those who reported abuse did. Also, the diversion questions are pretty clear. Could it have been better worded? Sure. Is it consistent with a large body of literature in the area? Yes.

That question actually doesn't require insufflation, inhalation or injection. It gives those as examples, but actually just asks if you have used it other than as prescribed. That's the problem.

 

[WisNeuro]

That question actually doesn't require insufflation, inhalation or injection. It gives those as examples, but actually just asks if you have used it other than as prescribed. That's the problem.

Does that invalidate the broader research on a whole that shows similar findings?>

 

[clausewitz2]

Does that invalidate the broader research on a whole that shows similar findings?>

I don't know. How are abuse and diversion defined typically in those papers? If abuse can encompass the example I gave and giving your brother also diagnosed with ADHD your leftover Vyvanse because he forgot to fill his script again I am suspicious of how meaningful the high numbers are.

 

[WisNeuro]

I don't know. How are abuse and diversion defined typically in those papers? If abuse can encompass the example I gave and giving your brother also diagnosed with ADHD your leftover Vyvanse because he forgot to fill his script again I am suspicious of how meaningful the high numbers are.

This isn't a controversial finding in the ADHD community. These numbers are pretty consistent with what we found in the past when I managed a large ADHD longitudinal study. I am curious as to the reasons for the vociferous pushback, though.

 

[psychacad]

This isn't a controversial finding in the ADHD community. These numbers are pretty consistent with what we found in the past when I managed a large ADHD longitudinal study. I am curious as to the reasons for the vociferous pushback, though.

Most of us are aware that stimulants are abused. That's why we routinely check drug monitoring programs...etc. Frankly, I'm surprised that they are not more abused, going by the numbers you are citing. As mentioned though, if you have a patient with diagnosed ADHD the benefits still clearly outweigh the risk. That's what matters at the end.

 

[WisNeuro]

Most of us are aware that stimulants are abused. That's why we routinely check drug monitoring programs...etc. Frankly, I'm surprised that they are not more abused, going by the numbers you are citing. As mentioned though, if you have a patient with diagnosed ADHD the benefits still clearly outweigh the risk. That's what matters at the end.

Fair, and I haven't disputed that notion. Although I would add "correctly" before diagnosed in that statement.

 

[robellis]

This isn't a controversial finding in the ADHD community. These numbers are pretty consistent with what we found in the past when I managed a large ADHD longitudinal study. I am curious as to the reasons for the vociferous pushback, though.

You’re not understanding the pushback because I suspect you don’t prescribe stimulants, if you were on the front lines and understood the practicalities of clinical practice you would be more understanding

 

[WisNeuro]

You’re not understanding the pushback because I suspect you don’t prescribe stimulants, if you were on the front lines and understood the practicalities of clinical practice you would be more understanding

I'm not sure you're quite getting it.

 

[clausewitz2]

This isn't a controversial finding in the ADHD community. These numbers are pretty consistent with what we found in the past when I managed a large ADHD longitudinal study. I am curious as to the reasons for the vociferous pushback, though.

Okay, so genuine question. How are abuse and diversion operationalized in this scientific community? How were they operationalized in the study you managed? These questions have huge import for how serious a problem this is. I am not trying to pushback and am genuinely persuadable on this issue.

 

[WisNeuro]

Okay, so genuine question. How are abuse and diversion operationalized in this scientific community? How were they operationalized in the study you managed? These questions have huge import for how serious a problem this is. I am not trying to pushback and am genuinely persuadable on this issue.

There are various definitions, and it really depends on the question you are trying to explore. Some studies have the higher bar of the abuse needing to meet diagnostic criteria for SUD. Some define it as any repeated use above and beyond prescribed directions. Our studies looked at it different ways, but generally repeated misuse. Similar with diversion. We generally viewed diversion as a related, but separate category, at least as far as our research questions were concerned. We also examined that as repeated or not. Though, at least in our studies, those who diverted, were generally those who did it repeatedly. Frequent diversion, in those who did, was the rule, rather than the exception.

As an aside, these questions were a very small part of our studies. The larger goal was looking at neurobiological, genetic, and neuropsychological factors.

 

[Stagg737]

There are various definitions, and it really depends on the question you are trying to explore. Some studies have the higher bar of the abuse needing to meet diagnostic criteria for SUD. Some define it as any repeated use above and beyond prescribed directions. Our studies looked at it different ways, but generally repeated misuse. Similar with diversion. We generally viewed diversion as a related, but separate category, at least as far as our research questions were concerned. We also examined that as repeated or not. Though, at least in our studies, those who diverted, were generally those who did it repeatedly. Frequent diversion, in those who did, was the rule, rather than the exception.

As an aside, these questions were a very small part of our studies. The larger goal was looking at neurobiological, genetic, and neuropsychological factors.

The statement on diversion being a repeated offense is fair, but the percentage of prescriptions diverted and individuals actually diverting stimulants is relatively small and grossly overestimated by health professionals.

To the bolded, those definitions are still inadequate. What is "repeated use above and beyond prescribed directions"? Is it using an extra pill 2 days a month considered repeated use? Twice a week? Chronically repeating? What about someone started on 10mg BID who increases themselves to 15mg BID, and then when the plan is changed is stable and does not further increase that dose? Are we defining someone using a higher dose before therapeutic effect is reached abusing? Specifics of the definitions are important as they can significantly change the implications of the results.

 

[Old&InTheWay]

The statement on diversion being a repeated offense is fair, but the percentage of prescriptions diverted and individuals actually diverting stimulants is relatively small and grossly overestimated by health professionals.

To the bolded, those definitions are still inadequate. What is "repeated use above and beyond prescribed directions"? Is it using an extra pill 2 days a month considered repeated use? Twice a week? Chronically repeating? What about someone started on 10mg BID who increases themselves to 15mg BID, and then when the plan is changed is stable and does not further increase that dose? Are we defining someone using a higher dose before therapeutic effect is reached abusing? Specifics of the definitions are important as they can significantly change the implications of the results.

To add to that, is someone taking an extra dose to "get high" (i.e. feel good) actually harming themselves? Shouldn't something like "use of medications in a way likely to cause significant harm" be the endpoint of these studies?

 

[WisNeuro]

The statement on diversion being a repeated offense is fair, but the percentage of prescriptions diverted and individuals actually diverting stimulants is relatively small and grossly overestimated by health professionals.

To the bolded, those definitions are still inadequate. What is "repeated use above and beyond prescribed directions"? Is it using an extra pill 2 days a month considered repeated use? Twice a week? Chronically repeating? What about someone started on 10mg BID who increases themselves to 15mg BID, and then when the plan is changed is stable and does not further increase that dose? Are we defining someone using a higher dose before therapeutic effect is reached abusing? Specifics of the definitions are important as they can significantly change the implications of the results.

I'm relying on estimates provided by research. There are studies on perception of diversion and physician attitudes, of which physicians believe it is common, though that belief varies by specialty. With estimated diversion rates ranging from 15-25%ish, I'd say common is an apt descriptor.

 

[Stagg737]

To add to that, is someone taking an extra dose to "get high" (i.e. feel good) actually harming themselves? Shouldn't something like "use of medications in a way likely to cause significant harm" be the endpoint of these studies?

Imo that's the most clinically relevant endpoint, but actually defining what that means can vary significantly between individuals. So probably not the best metric to use if we're trying to create more concrete and objective data.

I'm relying on estimates provided by research. There are studies on perception of diversion and physician attitudes, of which physicians believe it is common, though that belief varies by specialty. With estimated diversion rates ranging from 15-25%ish, I'd say common is an apt descriptor.

Most of the larger studies I've seen show actual "outgoing" diversion rates <5% and the ones with larger diversion rates define "diversion" as both outgoing (selling/giving away) and incoming (inappropriately receiving) stimulants or don't adequately define diversion at all, which falsely elevates the form of diversion (outgoing) relevant to people prescribing the medications. Aka, us.

The perception that physicians have of diversion are that it occurs at much higher rates. Idk specific numbers, but 15-25% seems accurate, which is a gross overestimation compared to the actual data.

ETA: if you've got some studies available which show "outgoing" diversion rates much higher than 5% I'd be interested in seeing them this is significantly different from what I've seen.

 

[Mass Effect]

It is self-reported, but still fairly telling. Also telling that about 17% reported diversion of their script. It also references many other similar studies. It's not the be all, end all, but to have earlier claimed that the "vast majority" are only using as prescribed, is simply not true. I didn't comment on prescribing or not, just that perhaps people are willfully blind to the negatives.

The vast majority are not abusing it. That is a fact and it will remain a fact despite the weak paper.

This isn't a controversial finding in the ADHD community. These numbers are pretty consistent with what we found in the past when I managed a large ADHD longitudinal study. I am curious as to the reasons for the vociferous pushback, though.

Because you don't prescribe and your posts sound like you don't prescribe. That isn't meant to be rude, but the truth is that until you're prescribing and treating patients with these medications, your opinions about risk vs benefit and abuse vs not are likely going to be challenged.

 

[WisNeuro]

Because you don't prescribe and your posts sound like you don't prescribe. That isn't meant to be rude, but the truth is that until you're prescribing and treating patients with these medications, your opinions about risk vs benefit and abuse vs not are likely going to be challenged.

Ignoring the obvious logical fallacy in this sentence, I would wager that I have more experience with ADHD than everyone else in this thread. The "vast majority" of experts in the ADHD field are not prescribers. Do we throw out their research?

 

[Mass Effect]

Ignoring the obvious logical fallacy in this sentence, I would wager that I have more experience with ADHD than everyone else in this thread. The "vast majority" of experts in the ADHD field are not prescribers. Do we throw out their research?

I'm sure you do have more experience with ADHD than I do and I have no doubt I could learn from you with regard to ADHD, the condition. But the medication part is what I do on a daily basis, not just with stimulants but all medications. I assess risk versus benefit, I look at the literature, I read about them, and I make an informed decision for my patients. Stimulants are hardly a dangerous medication, relative to all the other stuff we prescribe. When I put someone on stimulants, I weigh the pros and cons, knowing that it can be addictive and in every follow up visit, I address these issues with my patients. I evaluate very carefully the necessity of the medication, the change it's made in my patients' life, the abuse potential (or current abuse/misuse), and take all the factors already mentioned into consideration. So yeah, you're going to get pushback when you cite a weak article about abuse in order to contradict my statement that the vast majority of patients are not abusing this med and that fear of potential abuse in patients not currently abusing is no reason to not prescribe. I stand by my statement that failing to prescribe when it's indicated without a legitimate contraindication is bad medicine.

 

[WisNeuro]

I'm sure you do have more experience with ADHD than I do and I have no doubt I could learn from you with regard to ADHD, the condition. But the medication part is what I do on a daily basis, not just with stimulants but all medications. I assess risk versus benefit, I look at the literature, I read about them, and I make an informed decision for my patients. Stimulants are hardly a dangerous medication, relative to all the other stuff we prescribe. When I put someone on stimulants, I weigh the pros and cons, knowing that it can be addictive and in every follow up visit, I address these issues with my patients. I evaluate very carefully the necessity of the medication, the change it's made in my patients' life, the abuse potential (or current abuse/misuse), and take all the factors already mentioned into consideration. So yeah, you're going to get pushback when you cite a weak article about abuse in order to contradict my statement that the vast majority of patients are not abusing this med and that fear of potential abuse in patients not currently abusing is no reason to not prescribe. I stand by my statement that failing to prescribe when it's indicated without a legitimate contraindication is bad medicine.

I'd like to know where I, at any point, discount the notion that stimulants are helpful, as people seem to think for some reason. However, the abuse and diversion literature is pretty extensive at this point, not just one article, and fairly consistent. That's where I am interested about the feedback. Of course, if someone would like to write a review article that attempts to rebut that entire body of literature, I'd be interested in reading it.

 

[Mass Effect]

I'd like to know where I, at any point, discount the notion that stimulants are helpful, as people seem to think for some reason. However, the abuse and diversion literature is pretty extensive at this point, not just one article, and fairly consistent. That's where I am interested about the feedback. Of course, if someone would like to write a review article that attempts to rebut that entire body of literature, I'd be interested in reading it.

No one is saying there isn't literature about abuse and diversion. We know there is. What's being discussed is if that should prevent prescribing because a poster (an MD) said they don't prescribe stimulants first line unless the patient is unsafe. We're arguing this is bad from a prescribing standpoint. You coming into the discussion to cite literature in order to contradict the fact that the majority of patients are in fact not abusing this drug is going to get pushback. You asked the question. I'm answering.

 

[WisNeuro]

No one is saying there isn't literature about abuse and diversion. We know there is. What's being discussed is if that should prevent prescribing because a poster (an MD) said they don't prescribe stimulants first line unless the patient is unsafe. We're arguing this is bad from a prescribing standpoint. You coming into the discussion to cite literature in order to contradict the fact that the majority of patients are in fact not abusing this drug is going to get pushback. You asked the question. I'm answering.

Actually, you and others questioned the numbers on abuse and diversion. Which, if you read the literature as you said you did, you would have been aware of it. We always weigh pros/cons when delivering services, that's what we're supposed to do. But, we can't just ignore literature that doesn't conform to our myopic view of something. Considering the previous poster, they have a point that is to be considered. Looking at the middiagnosis literature, in conjunction with abuse/diversion literature, there are a lot of inappropriate prescriptions. Pair that again with mild cases who also probably do not need medication and you magnify the potential issues. Dismissing that poster outright is simply being willfully blind to the nuance of the issue.

 

[Mass Effect]

Actually, you and others questioned the numbers on abuse and diversion. Which, if you read the literature as you said you did, you would have been aware of it. We always weigh pros/cons when delivering services, that's what we're supposed to do. But, we can't just ignore literature that doesn't conform to our myopic view of something. Considering the previous poster, they have a point that is to be considered. Looking at the middiagnosis literature, in conjunction with abuse/diversion literature, there are a lot of inappropriate prescriptions. Pair that again with mild cases who also probably do not need medication and you magnify the potential issues. Dismissing that poster outright is simply being willfully blind to the nuance of the issue.

Actually, what I said was the vast majority don't abuse. You, for some bizarre reason, took an issue with the phrase "vast majority". I'm familiar with the literature and that article you sent is weak with inflated numbers. I don't have a myopic view of anything; I just think it's a rich for a non-prescriber to tell prescribers how to prescribe and then be shocked that he's getting pushback.

 

[WisNeuro]

Actually, what I said was the vast majority don't abuse. You, for some bizarre reason, took an issue with the phrase "vast majority". I'm familiar with the literature and that article you sent is weak with inflated numbers. I don't have a myopic view of anything; I just think it's a rich for a non-prescriber to tell prescribers how to prescribe and then be shocked that he's getting pushback.

By that same logic, I could claim that it's rich for someone not trained in research to criticize research. Specifically when the article is not inflated as it is very consistent with a larger literature base spanning decades.

 

[Mass Effect]

By that same logic, I could claim that it's rich for someone not trained in research to criticize research. Specifically when the article is not inflated as it is very consistent with a larger literature base spanning decades.

Medical/graduate medical education involves research. Even if you don't actually do research (and I have done clinical research), you don't get out without learning how to interpret it.

 

[WisNeuro]

Medical/graduate medical education involves research. Even if you don't actually do research (and I have done clinical research), you don't get out without learning how to interpret it.

And my education involves multiple courses in neuroscience and psychopharmacology.

 

[Stagg737]

Looking at the middiagnosis literature, in conjunction with abuse/diversion literature, there are a lot of inappropriate prescriptions. Pair that again with mild cases who also probably do not need medication and you magnify the potential issues.

You're adding confounding variables. Misdiagnosis vs abuse are two completely separate issues, one which the physician is responsible for and one which the patient is responsible for. Yes, we take both into account when prescribing, but someone can take the prescription "correctly" even if they're not appropriately diagnosed. Again, definitions matter.

I also don't see anyone arguing that mild cases may be better treated through means other than medications (specifically stimulants), though one could certainly make the argument that stimulants should still be used.

 

[WisNeuro]

You're adding confounding variables. Misdiagnosis vs abuse are two completely separate issues, one which the physician is responsible for and one which the patient is responsible for. Yes, we take both into account when prescribing, but someone can take the prescription "correctly" even if they're not appropriately diagnosed. Again, definitions matter.

I also don't see anyone arguing that mild cases may be better treated through means other than medications (specifically stimulants), though one could certainly make the argument that stimulants should still be used.

They are not wholly orthogonal variables in the current discussion. They both overlap in terms of inappropriate use of medication. The etiology is different, but the potential negative effects are the same.

 

[meow1985]

The issue is that while you think ADHD isn't a significant enough to be an emergency, it can drastically change someone's life. They don't have to be failing out of school or be totaling their car every other day to feel the effects and benefit from a stimulant. If a patient is having trouble and they meet criteria, I never try to convince them things aren't so bad and maybe they don't need a med.

I think we need to stop teaching residents stimulants=wrong. Stimulants can be life-changing and the vast majority of patients are not going to abuse them. The fear that residents/new attendings have is overblown imo.

Is there any literature out there on people abusing their sertraline? (Semi-serious question).

I don't dispute that stimulants can be very helpful, but I doubt a couple weeks to confirm things is going to make or break things. A stimulant is not on the table, typically, on the first visit, but once things are confirmed it's fair game. Some people also don't want a stimulant. Not everyone wants to deal with all the rules of being on controlled substances, and I present that as part of my pros and cons discussion.

Of course, my training at an academic institution, much like OP's, was to be very conservative with stimulants. "Never prescribe stimulants on a first visit, always get collateral" was our mantra. The idea about ADHD not being an emergency unless there's a safety concern is also from my training. Thanks to this forum, yesterday I did step on myself and prescribe a small supply of stimulant to a new patient with reasonably classic ADHD who is treatment naïve, so I suspect this is just something to get used to.

I also, fun fact, have come a long way in terms of challenging my countertransference about ADHD. There was a time, long ago back in med school/early residency, when I quietly "didn't believe in" ADHD. Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy." After all, behavioral interventions are first line for kids, aren't they, and for adults, behavioral interventions are key as well. So I thought that a large part of the disorder was due to a failure of others to discipline kids and people to discipline themselves.

To be clear, I don't think that way anymore. I realize many cases of ADHD are too severe for behavioral interventions, and if opportunities for behavioral training in childhood were missed, there's only so much that can be done to make up for it.

 

[Stagg737]

They are not wholly orthogonal variables in the current discussion. They both overlap in terms of inappropriate use of medication. The etiology is different, but the potential negative effects are the same.

They aren't, but it also depends on what outcomes we're trying to look at. If we're looking at negative clinical outcomes, then they are certainly both relevant. If we're talking about "inappropriate use", then we also need to define that. Does that mean that the patient is taking it or using it an a way other than how they are prescribed or does it mean that they are taking it in a way not indicated for their true diagnosis regardless of their adherence to prescriber instructions? One of these is suggestive of abuse, while the other is much more suggestive of prescriber incompetence and not related to any fault of the patient.

The relevance here is that the conversation has been about "abuse", which I define as something the patient is largely responsible for. If we're talking about negative effects, that's a whole other conversation with far more factors than what we've been discussing. I don't think you're intentionally moving the goalposts, but this is why language and definitions are so much more important than we realize. We can't get anywhere in discussion if we can't understand what the other person is arguing and we just end up talking past each other.

 

[meow1985]

Also, to the point about stimulant utility and addictive potential, stimulants hijack the dopamine reward system. Sertraline does not. That makes me skeptical about whether people can make rational decisions and assessments of how effective and important stimulants are to their function. That's not a reason not to prescribe, but when assessing how life-changing they are, I would argue that quantitative measures and tying follow up assessments to very specific aspects of function are just as crucial.

 

[WisNeuro]

They aren't, but it also depends on what outcomes we're trying to look at. If we're looking at negative clinical outcomes, then they are certainly both relevant. If we're talking about "inappropriate use", then we also need to define that. Does that mean that the patient is taking it or using it an a way other than how they are prescribed or does it mean that they are taking it in a way not indicated for their true diagnosis regardless of their adherence to prescriber instructions? One of these is suggestive of abuse, while the other is much more suggestive of prescriber incompetence and not related to any fault of the patient.

The relevance here is that the conversation has been about "abuse", which I define as something the patient is largely responsible for. If we're talking about negative effects, that's a whole other conversation with far more factors than what we've been discussing. I don't think you're intentionally moving the goalposts, but this is why language and definitions are so much more important than we realize. We can't get anywhere in discussion if we can't understand what the other person is arguing and we just end up talking past each other.

True, the conversation thus far has been about abuse and diversion, but I've always conceptualized it in terms of negative consequences. Perhaps because my general interactions have been more on the side of diagnostics, of which there are a huge amount of misdiagnoses. Again, I have never disputed the need for some people to have this medication, I've just been more concerned about the sweeping under the rug of the negative consequences by quoting the greater good. These are not mutually exclusive, we can minimize harm and maximize benefit, and an understanding of the scope is a good starting place, especially when there is already a good deal of this literature out there.

 

[clausewitz2]

They are not wholly orthogonal variables in the current discussion. They both overlap in terms of inappropriate use of medication. The etiology is different, but the potential negative effects are the same.

I don't think this is true. If misdiagnosis leads to someone taking therapeutic doses of a stimulant as prescribed, you have a totally different set of "harms" than if someone is snorting 400 mg of dexedrine on the daily. In the first case, for instance, unless they have specific rare heart problems, they are vanishingly unlikely to have meaningful ill effects.

I am not trying to endorse nootropic type approaches to prescribing medications (reasonable people can disagree about that) but if we are worrying about harm let's get real. 20 mg of adderall once a day is about as harmful as someone taking 600 mg of ibuprofen once a day. honestly the later probably leads to more medical complications in the long-run.

 

[clausewitz2]

Also, to the point about stimulant utility and addictive potential, stimulants hijack the dopamine reward system. Sertraline does not. That makes me skeptical about whether people can make rational decisions and assessments of how effective and important stimulants are to their function. That's not a reason not to prescribe, but when assessing how life-changing they are, I would argue that quantitative measures and tying follow up assessments to very specific aspects of function are just as crucial.

I tell everyone I prescribe stimulants to to figure out a set of objective benchmarks, i.e. what are the specific tasks and responsibilities you struggle with now that you are hoping you will be able to do better with. I then tell them we are going to judge the utility of this based on those benchmarks. What we are not going to do, I inform them, is go based off subjective feelings of being able to concentrate or focus because regardless of the dose of these stimulants that subjective sense of well-being/attentiveness/productivity is going to go away after a while but it does not mean that the medication is not working. People are usually on board for this, and it only takes a couple of appointments of gently re-directing them back to their actual level of functioning instead of whether they feel scattered to get on the right track.

 

[WisNeuro]

I don't think this is true. If misdiagnosis leads to someone taking therapeutic doses of a stimulant as prescribed, you have a totally different set of "harms" than if someone is snorting 400 mg of dexedrine on the daily. In the first case, for instance, unless they have specific rare heart problems, they are vanishingly unlikely to have meaningful ill effects.

I am not trying to endorse nootropic type approaches to prescribing medications (reasonable people can disagree about that) but if we are worrying about harm let's get real. 20 mg of adderall once a day is about as harmful as someone taking 600 mg of ibuprofen once a day. honestly the later probably leads to more medical complications in the long-run.

This isn't true, or at least emerging literature would not support this. The early literature pretty much only looked at cardiovascular risk in children and adolescents, and by and large found measures of risk to be fairly small. Longer term effects in adults has only recently been looked at in a systematic way, finding much more in the way of potential adverse cardiovascular changes. More work and longer follow-up needs to be done to see how these modest changes actually affect morbidity, but they are by no means vanishingly rare. I don't think we should be approaching medicine in the vein of "X is worse for you, so what the hell?" Best practices are the ideal and often hard to attain, but it's hardly a reason to throw your hands in the air and pretend that the issue does not exist in the first place.

 

[clausewitz2]

This isn't true, or at least emerging literature would not support this. The early literature pretty much only looked at cardiovascular risk in children and adolescents, and by and large found measures of risk to be fairly small. Longer term effects in adults has only recently been looked at in a systematic way, finding much more in the way of potential adverse cardiovascular changes. More work and longer follow-up needs to be done to see how these modest changes actually affect morbidity, but they are by no means vanishingly rare. I don't think we should be approaching medicine in the vein of "X is worse for you, so what the hell?" Best practices are the ideal and often hard to attain, but it's hardly a reason to throw your hands in the air and pretend that the issue does not exist in the first place.

I defer to my cardiology colleagues who universally do not give a great godd*mn about someone taking stimulants unless they have a significant arrhythmia. If the heart experts don't think this really matters, why should I? I think there is a middle ground between throwing our hands in the air and clutching at our collective pearls about this. The issue obviously exists, nobody in the thread is saying that we should have Ritalin vending machines, but how big a deal you think it is determined whether you are going to spend hours combing through the life history of anyone reporting an ADHD diagnosis with a fine-toothed comb and calling all of their blood relations for collateral before prescribing anything, or whether you are going to do a systematic assessment you might actually be able to complete in a 60 minute intake and do your best to get corroboration but not refuse to treat people if you can't raise their 2nd grade teacher.

 

[WisNeuro]

I defer to my cardiology colleagues who universally do not give a great godd*mn about someone taking stimulants unless they have a significant arrhythmia. If the heart experts don't think this really matters, why should I? I think there is a middle ground between throwing our hands in the air and clutching at our collective pearls about this. The issue obviously exists, nobody in the thread is saying that we should have Ritalin vending machines, but how big a deal you think it is determined whether you are going to spend hours combing through the life history of anyone reporting an ADHD diagnosis with a fine-toothed comb and calling all of their blood relations for collateral before prescribing anything, or whether you are going to do a systematic assessment you might actually be able to complete in a 60 minute intake and do your best to get corroboration but not refuse to treat people if you can't raise their 2nd grade teacher.

It's definitely a continuum. Some people get a comprehensive eval, some people talk to their PCP for 2 mins and get a script. I get the need for practicality, but I reject the notion of pretending research doesn't exist because you'd rather not consider the reality. Again, this is not a binary issue, but rather, how can we make things better. Presenting it as a false dichotomy rarely does any good in healthcare policy.

 

[sloh]

This isn't true, or at least emerging literature would not support this. The early literature pretty much only looked at cardiovascular risk in children and adolescents, and by and large found measures of risk to be fairly small. Longer term effects in adults has only recently been looked at in a systematic way, finding much more in the way of potential adverse cardiovascular changes. More work and longer follow-up needs to be done to see how these modest changes actually affect morbidity, but they are by no means vanishingly rare. I don't think we should be approaching medicine in the vein of "X is worse for you, so what the hell?" Best practices are the ideal and often hard to attain, but it's hardly a reason to throw your hands in the air and pretend that the issue does not exist in the first place.

Do you think there might be any potential adverse outcomes on the brain? Something like decreasing IQ or contributing to a faster cognitive decline.

 

[WisNeuro]

Do you think there might be any potential adverse outcomes on the brain? Something like decreasing IQ or contributing to a faster cognitive decline.

Effects of stimulants on the brain? If that's the question, the answer is, we don't know, but potentially. At least in the longitudinal adult studies, almost all of the stimulant/cognition literature is on pretty heavy abuse, in which there are fairly significant adverse effects. Although there are some limitations here, hard to get good case-controls in some studies. Most of the child lit would suggest a beneficial effect on IQ testing with prescription use, not because it actually changes IQ, but it allows the to actually use their working memory capacity in an effective way. So, there may be some middle ground of dose/chronicity to use in which the benefit/cost bends to the negative, we just don't have enough long-term adult stuff to know at the moment.

 

[Stagg737]

Is there any literature out there on people abusing their sertraline? (Semi-serious question).

I actually think this is an interesting question, so I did a brief dive and turns out there is some scant research on it. If you just google "Zoloft Addiction" you'll get pages of substance treatment centers talking about "detoxing" from SSRIs, their "addictive" properties, and withdrawal. None of them cite any actual research, but it's apparently a thing at more than a few rehab facilities.

In terms of actual research, I found a single case report from the UK about a guy using 11g per day to experience euphoria, excitement, and hallucinations. Also found a review article which did a general review on the available literature of abuse of antidepressants as a whole and dose include some case reports of SSRI/SNRI abuse to experience euphoria or other forms of an actual high. I also didn't know that abuse of TCA's to get high was apparently not uncommon in the 70's and there's a few studies showing that a decent percentage (25% in the one they quote) of patients in methadone clinics were abusing TCAs to get high. Here's a link to the larger review:

Abuse and misuse of antidepressants

Rates of prescription drug abuse have reached epidemic proportions. Large-scale epidemiologic surveys of this under-recognized clinical problem have not included antidepressants despite their contribution to morbidity and mortality. The purpose of this ...

www.ncbi.nlm.nih.gov

I can't link the case report but it is a correspondence article called "Abuse of Sertraline" (yes, very original) from the "Journal of Clinical Pharmacy and Therapeutics" from 1996, issue 21 pg 359-360. Quick but interesting read if you can access it (I did through Wiley)

 

[clausewitz2]

I actually think this is an interesting question, so I did a brief dive and turns out there is some scant research on it. If you just google "Zoloft Addiction" you'll get pages of substance treatment centers talking about "detoxing" from SSRIs, their "addictive" properties, and withdrawal. None of them cite any actual research, but it's apparently a thing at more than a few rehab facilities.

In terms of actual research, I found a single case report from the UK about a guy using 11g per day to experience euphoria, excitement, and hallucinations. Also found a review article which did a general review on the available literature of abuse of antidepressants as a whole and dose include some case reports of SSRI/SNRI abuse to experience euphoria or other forms of an actual high. I also didn't know that abuse of TCA's to get high was apparently not uncommon in the 70's and there's a few studies showing that a decent percentage (25% in the one they quote) of patients in methadone clinics were abusing TCAs to get high. Here's a link to the larger review:

Abuse and misuse of antidepressants

Rates of prescription drug abuse have reached epidemic proportions. Large-scale epidemiologic surveys of this under-recognized clinical problem have not included antidepressants despite their contribution to morbidity and mortality. The purpose of this ...

www.ncbi.nlm.nih.gov

I can't link the case report but it is a correspondence article called "Abuse of Sertraline" (yes, very original) from the "Journal of Clinical Pharmacy and Therapeutics" from 1996, issue 21 pg 359-360. Quick but interesting read if you can access it (I did through Wiley)

I am not shocked, sertraline specifically has a fair degree of affinity as an antagonist for DAT so it makes sense that big enough doses would get the job done of you were really desperate to get high.

You'd never leave the bathroom and have no sex life to speak of, but people face tradeoffs I guess.

 

[Old&InTheWay]

I am not shocked, sertraline specifically has a fair degree of affinity as an antagonist for DAT so it makes sense that big enough doses would get the job done of you were really desperate to get high.

You'd never leave the bathroom and have no sex life to speak of, but people face tradeoffs I guess.

You can still have sex if you take it with a bottle of bupropion. Unfortunately, you are seizing the entire time and don't remember it.

 

[clausewitz2]

You can still have sex if you take it with a bottle of bupropion. Unfortunately, you are seizing the entire time and don't remember it.

Man if you have a bottle of them Welly B's why are you wasting your time with Zoloft? Grab a handful of'em and straight up your nose, get a proper high going.

 

[Mass Effect]

It's definitely a continuum. Some people get a comprehensive eval, some people talk to their PCP for 2 mins and get a script. I get the need for practicality, but I reject the notion of pretending research doesn't exist because you'd rather not consider the reality. Again, this is not a binary issue, but rather, how can we make things better. Presenting it as a false dichotomy rarely does any good in healthcare policy.

I didn't see anyone in this thread pretend research doesn't exist.

 

[Mass Effect]

Is there any literature out there on people abusing their sertraline? (Semi-serious question).

I don't dispute that stimulants can be very helpful, but I doubt a couple weeks to confirm things is going to make or break things. A stimulant is not on the table, typically, on the first visit, but once things are confirmed it's fair game. Some people also don't want a stimulant. Not everyone wants to deal with all the rules of being on controlled substances, and I present that as part of my pros and cons discussion.

The question about Zoloft was already answered, so I'll move on.

With regard to stimulants, no one said a couple of weeks is going to make or break things (though depending on the situation, it's also something you need to rule out). That was never anyone's objection that I saw. The objection was to your claim that stimulants are never first line unless the person was unsafe. I also get from the way you word things that you actively try to dissuade patients from this class of meds which I personally think is wrong given that it is considered first line and most effective treatment for genuine ADHD.

Of course, my training at an academic institution, much like OP's, was to be very conservative with stimulants. "Never prescribe stimulants on a first visit, always get collateral" was our mantra. The idea about ADHD not being an emergency unless there's a safety concern is also from my training. Thanks to this forum, yesterday I did step on myself and prescribe a small supply of stimulant to a new patient with reasonably classic ADHD who is treatment naïve, so I suspect this is just something to get used to

Right, it does take getting used to, which is why I made the comment that residencies need to stop teaching their residents to fear stimulants. They should never be given out like candy, but it's a legitimate medication with a legitimate purpose for a legitimate illness. ADHD is an illness, just like depression, anxiety, and everything else we treat. It isn't the patient's fault that while their Prozac may not be addictive so we give it out without much worry, we'll let them suffer with ADHD which can cause just as many problems for the patient as anxiety or depression. Of all the meds we prescribe, stimulants are relatively safe when used appropriately.

I also, fun fact, have come a long way in terms of challenging my countertransference about ADHD. There was a time, long ago back in med school/early residency, when I quietly "didn't believe in" ADHD. Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy." After all, behavioral interventions are first line for kids, aren't they, and for adults, behavioral interventions are key as well. So I thought that a large part of the disorder was due to a failure of others to discipline kids and people to discipline themselves

Behavioral interventions are definitely a thing and should be explored, but ADHD is definitely a thing and the first time you see a severe case of it, you'll never doubt that again.

To be clear, I don't think that way anymore. I realize many cases of ADHD are too severe for behavioral interventions, and if opportunities for behavioral training in childhood were missed, there's only so much that can be done to make up for it

This. It's amazing how many adults never get the diagnosis or get the diagnosis and parents don't want them on stimulants. Some of those people are just fine. Others walk through life a mess and when they start a stimulant, they're not suddenly superstars, but they're normal.

 

[meow1985]

The question about Zoloft was already answered, so I'll move on.

With regard to stimulants, no one said a couple of weeks is going to make or break things (though depending on the situation, it's also something you need to rule out). That was never anyone's objection that I saw. The objection was to your claim that stimulants are never first line unless the person was unsafe. I also get from the way you word things that you actively try to dissuade patients from this class of meds which I personally think is wrong given that it is considered first line and most effective treatment for genuine ADHD.



Right, it does take getting used to, which is why I made the comment that residencies need to stop teaching their residents to fear stimulants. They should never be given out like candy, but it's a legitimate medication with a legitimate purpose for a legitimate illness. ADHD is an illness, just like depression, anxiety, and everything else we treat. It isn't the patient's fault that while their Prozac may not be addictive so we give it out without much worry, we'll let them suffer with ADHD which can cause just as many problems for the patient as anxiety or depression. Of all the meds we prescribe, stimulants are relatively safe when used appropriately.



Behavioral interventions are definitely a thing and should be explored, but ADHD is definitely a thing and the first time you see a severe case of it, you'll never doubt that again.



This. It's amazing how many adults never get the diagnosis or get the diagnosis and parents don't want them on stimulants. Some of those people are just fine. Others walk through life a mess and when they start a stimulant, they're not suddenly superstars, but they're normal.

Of course, my training at an academic institution, much like OP's, was to be very conservative with stimulants. "Never prescribe stimulants on a first visit, always get collateral" was our mantra. The idea about ADHD not being an emergency unless there's a safety concern is also from my training. Thanks to this forum, yesterday I did step on myself and prescribe a small supply of stimulant to a new patient with reasonably classic ADHD who is treatment naïve, so I suspect this is just something to get used to.

I also, fun fact, have come a long way in terms of challenging my countertransference about ADHD. There was a time, long ago back in med school/early residency, when I quietly "didn't believe in" ADHD. Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy." After all, behavioral interventions are first line for kids, aren't they, and for adults, behavioral interventions are key as well. So I thought that a large part of the disorder was due to a failure of others to discipline kids and people to discipline themselves.

The statement about it not being first line was more of a reference to first line treatment for someone I just met. I was taught not to give a stimulant first visit unless the case is so clear cut and so severe as to cause safety concerns. I was also taught to have a higher bar for diagnosing ADHD than depression per se because people may be lying and angling for a stimulant. In theory anything is abusable, but who in the general population knows that sertraline in big enough amounts gets you high? Whether that’s good or bad training is another question.

I tell people that I want to confirm the diagnosis and rule out a couple things, and subject everyone to the same process. I tell them they can try bupropion or strattera if they want something today, and a stimulant once collateral is back. I have recently changed it to offering a small supply of stimulant on first visit, with more contingent on getting collateral/labs done, but I’m still haunted by the notion of the patient absconding with it, selling it on the corner, and me never hearing from them again.

 

[erg923]

There was a time, long ago back in med school/early residency, when I quietly "didn't believe in" ADHD. Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy." After all, behavioral interventions are first line for kids, aren't they, and for adults, behavioral interventions are key as well. So I thought that a large part of the disorder was due to a failure of others to discipline kids and people to discipline themselves.

Oh, for goodness sakes! Of course many of us think (and say) this. Stop being so coy. No shame here, son.

It is actually very, very reasonable to assume this/these fact vs the other. In fact, many, many people are indeed lazy. Only some of those lazy people will have an actual psychiatric disorder. If we have to rely on a cognitive heuristic ….. I would bet on "lazy" vs "psychiatrically disordered" anytime.

Further, is it statistically probable that 30% of your peds Medicaid population have the same (neurodevelopment) psychiatric disorder that is about estimated to be about 3-5% of the general population per extensive DSM survey research? If you believe that? Or maybe ****ty parents = ****ty behaving kids? I mean, come on folks?

 

[Mass Effect]

I tell people that I want to confirm the diagnosis and rule out a couple things, and subject everyone to the same process. I tell them they can try bupropion or strattera if they want something today, and a stimulant once collateral is back. I have recently changed it to offering a small supply of stimulant on first visit, with more contingent on getting collateral/labs done, but I’m still haunted by the notion of the patient absconding with it, selling it on the corner, and me never hearing from them again.

There is nothing wrong with being careful as you get to know a patient, but why are you haunted by someone selling it on a corner and you never hearing form them again? I mean a 2-week supply (or even a 30-day supply) of 20 mg of Adderall shouldn't keep you up at night. For one thing, most patients are not going to leave and sell it on a corner. For another, if they did, that's their issue and if you see them again, you deal with it and if you don't, then move on. If there's even a hint of diversion, I cut patients off, but most patients don't divert. I personally don't get collateral unless I need to (if the case isn't clear). But as I said earlier in the thread, I'm getting some former peds patients with classic ADHD. I don't call moms or collect school records. You actually don't have to. But if it makes you more comfortable, knock yourself out.

 

[meow1985]

There is nothing wrong with being careful as you get to know a patient, but why are you haunted by someone selling it on a corner and you never hearing form them again? I mean a 2-week supply (or even a 30-day supply) of 20 mg of Adderall shouldn't keep you up at night. For one thing, most patients are not going to leave and sell it on a corner. For another, if they did, that's their issue and if you see them again, you deal with it and if you don't, then move on. If there's even a hint of diversion, I cut patients off, but most patients don't divert. I personally don't get collateral unless I need to (if the case isn't clear). But as I said earlier in the thread, I'm getting some former peds patients with classic ADHD. I don't call moms or collect school records. You actually don't have to. But if it makes you more comfortable, knock yourself out.

I'm not literally haunted by them selling it on a street corner. That was an exaggeration meant to be funny. I have that thought, but I recognize it as irrational. I mostly brought that up to illustrate that I do have level of discomfort prescribing stimulants first visit that I don't have with other meds. I feel more comfortable being thorough at this point. I don't call anyone anymore; I just have them complete symptom questionnaires. I also don't like it when someone is misdiagnosed with ADHD after a 10-minute conversation with their PCP when in fact it *is* just a kid misbehaving in a chaotic home, a person with hypersomnia who's always tired, or someone who's using substances and whoever evaluated - even tested! them - completely didn't take this into account. (shoutout to @WisNeuro, I feel your pain).

I'm also starting to change to offering stimulants at first visit, even as I still dot the i's and cross all the t's. So this forum has made a difference.