non amphetamine stimulants

[bedrock]

I'm PMR/Pain and used stimulants both amphetamine based and others such as provigil when I treated traumatic brain injury (TBI) patients both in and outpatient during my PMR residency.

I now do Pain in the Rocky Mountains and 2 days a month I travel to a remote town and my best referrer there is asking for help with some mild TBI/CVA patients, and there is nothing but primary care in this very rural area.

I have a couple patients there who would benefit from a stimulant, but I'd like to stay away from adderall/concerta etc, and start with something like provigil, but I'm rather out of date as I finished residency a dozen years ago and have only practiced Interventional Pain since that time.

I'd to ask your thoughts on non adderall/ritalin/concerta type stimulants such as Provigil or others, and when you use them in psych patients and in particular to understand the common risks and side effects of the drugs. (Several of these patients have overlapping psych issues as well).

(if you can point me to a good review article, I'm happy to read it, but I thought I might also take advantage of the experience and wisdom of the group here on SDN)

Thanks

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[clausewitz2]

I'm PMR/Pain and used stimulants both amphetamine based and others such as provigil when I treated traumatic brain injury (TBI) patients both in and outpatient during my PMR residency.

I now do Pain in the Rocky Mountains and 2 days a month I travel to a remote town and my best referrer there is asking for help with some mild TBI/CVA patients, and there is nothing but primary care in this very rural area.

I have a couple patients there who would benefit from a stimulant, but I'd like to stay away from adderall/concerta etc, and start with something like provigil, but I'm rather out of date as I finished residency a dozen years ago and have only practiced Interventional Pain since that time.

I'd to ask your thoughts on non adderall/ritalin/concerta type stimulants such as Provigil or others, and when you use them in psych patients and in particular to understand the common risks and side effects of the drugs. (Several of these patients have overlapping psych issues as well).

(if you can point me to a good review article, I'm happy to read it, but I thought I might also take advantage of the experience and wisdom of the group here on SDN)

Thanks

For what it's worth Concerta and Ritalin are non-amphetamine stimulants and don't work by the same mechanism as amphetamines. What is it you are trying to stay away from?

 

[bedrock]

For what it's worth Concerta and Ritalin are non-amphetamine stimulants and don't work by the same mechanism as amphetamines. What is it you are trying to stay away from?

Agree. That was poorly worded on my part.

They have some GI interactions that I’d like to avoid and other issues.

Basically, I’m trying to understand uses, common side effects, and precautions when writing for modern prescription brain stimulants that aren’t in the family of adderal/Ritalin etc.

I’d rather not turn to adderal/ritalin unless they fail other options.

 

[aim-agm]

To clarify what you are looking for:
-What is the goal of the treatment (e.g. wakefulness, concentration, etc.)?
-What are the interactions and issues you want to avoid?

 

[clozareal]

Yeah I agree with the above about having some behavioral targets. Irritability/aggression with TBI is treated much differently than depression vs anxiety vs wakefulness vs memory vs concentration vs executive functioning vs mood dysregulation, all of which are neuropsychiatric sequelae of TBI.

For my TBI patients, I tend to go with donepezil for memory problems, methylphenidate for attention and apathy, amantadine for executive dysfunction, and beta blockers for irritability/aggression (although my last pt came to me on Abilify put on by the neurologist for this and did remarkably well).

A bit old, but I like this review article.

Neuropsychiatric problems after traumatic brain injury: unraveling the silent epidemic - PubMed

Despite the high incidence of severe consequences of TBI, there are scarce empirical data to guide psychiatric treatment. Some approaches that have been helpful include cognitive and behavioral therapy and pharmacologic treatment. The authors list specific research recommendations that could...

pubmed.ncbi.nlm.nih.gov

 

[romanticscience]

I found this article helpful for its discussion of non-ritalin/adderall options, particularly the discussion of treating co-morbidity.

Adult ADHD and comorbid disorders: clinical implications of a dimensional approach - PubMed

Attention-deficit/hyperactivity disorder (ADHD) in the adult population is frequently associated with comorbid psychiatric diseases that complicate its recognition, diagnosis and management.The prevalence of ADHD in the general adult population is 2.5% and it is associated with substantial...

pubmed.ncbi.nlm.nih.gov

For me, these drugs include bupropion, modafinil, nortriptyline/desipramine (TCAs), and tranylcypromine (MAOI).

 

[clozareal]

Modafinil doesn't seem to be effective in adults from the small number of trials for ADHD but it does seem to be effective in children/adolescents. Lower doses (50-100mg) tends to be better than higher doses in terms of acceptability (benefit vs tolerability).

I like the TCAs for anxiety/mood, ADHD, and for children, enuresis. If they have all three, it's a trifecta treatment all in one pill even though TCAs don't show evidence of benefit for depression in the pediatric population.

 

[littlefred]

Agree. That was poorly worded on my part.

They have some GI interactions that I’d like to avoid and other issues.

Basically, I’m trying to understand uses, common side effects, and precautions when writing for modern prescription brain stimulants that aren’t in the family of adderal/Ritalin etc.

I’d rather not turn to adderal/ritalin unless they fail other options.

You've been posting on the psych forums with some rather interesting questions.
Are you leaving your practice and doing mental health on the side?

 

[deleted1100659]

Yeah I agree with the above about having some behavioral targets. Irritability/aggression with TBI is treated much differently than depression vs anxiety vs wakefulness vs memory vs concentration vs executive functioning vs mood dysregulation, all of which are neuropsychiatric sequelae of TBI.

For my TBI patients, I tend to go with donepezil for memory problems, methylphenidate for attention and apathy, amantadine for executive dysfunction, and beta blockers for irritability/aggression (although my last pt came to me on Abilify put on by the neurologist for this and did remarkably well).

A bit old, but I like this review article.

Neuropsychiatric problems after traumatic brain injury: unraveling the silent epidemic - PubMed

Despite the high incidence of severe consequences of TBI, there are scarce empirical data to guide psychiatric treatment. Some approaches that have been helpful include cognitive and behavioral therapy and pharmacologic treatment. The authors list specific research recommendations that could...

pubmed.ncbi.nlm.nih.gov

Used to I used to see aricept widely prescribed, and used it myself quite often, but the studies I looked at, it didn't seem like it had a substantial effect in terms of memory for patients with a neurocog disorder. Whats your thoughts on it?

 

[whopper]

The APA has online lectures on use of Modafinil for ADHD, but it never got an FDA approval. I've seen Modafinil work very well on some patients for ADHD and even better, sometimes, than other options. Just like any med some meds work better, some work worse. I only try Modafinil, however, if patients don't get a good response to either of the main FDA approved simulant families. There are some exceptions. Modafinil has less abuse potential and can be prescribed for more than 3 months at a time.

For TBI, and I've never seen any published data on this, the medication I've seen consistently do the best is Lamotrigine. Every single TBI patient I had it was the old throw something and see if something sticks (works). After about the 5th patient in a row where Lamotrigine worked well I just start off with this now. Eventually that sample size went into the dozens with Lamotrigine usually working well for mood and impulsivity.

 

[hallowmann]

Yeah I agree with the above about having some behavioral targets. Irritability/aggression with TBI is treated much differently than depression vs anxiety vs wakefulness vs memory vs concentration vs executive functioning vs mood dysregulation, all of which are neuropsychiatric sequelae of TBI.

For my TBI patients, I tend to go with donepezil for memory problems, methylphenidate for attention and apathy, amantadine for executive dysfunction, and beta blockers for irritability/aggression (although my last pt came to me on Abilify put on by the neurologist for this and did remarkably well).

A bit old, but I like this review article.

Neuropsychiatric problems after traumatic brain injury: unraveling the silent epidemic - PubMed

Despite the high incidence of severe consequences of TBI, there are scarce empirical data to guide psychiatric treatment. Some approaches that have been helpful include cognitive and behavioral therapy and pharmacologic treatment. The authors list specific research recommendations that could...

pubmed.ncbi.nlm.nih.gov

Are you really seeing that much benefit with donepezil and amantadine? For the former, I honestly have not, and for the latter, I simply haven't used it enough to form an opinion. Completely agree with the use of stimulants (most often methylphenidate) and beta blockers for the indications you have cited, as well as lamotrigine as below.

The APA has online lectures on use of Modafinil for ADHD, but it never got an FDA approval. I've seen Modafinil work very well on some patients for ADHD and even better, sometimes, than other options. Just like any med some meds work better, some work worse. I only try Modafinil, however, if patients don't get a good response to either of the main FDA approved simulant families. There are some exceptions. Modafinil has less abuse potential and can be prescribed for more than 3 months at a time.

For TBI, and I've never seen any published data on this, the medication I've seen consistently do the best is Lamotrigine. Every single TBI patient I had it was the old throw something and see if something sticks (works). After about the 5th patient in a row where Lamotrigine worked well I just start off with this now. Eventually that sample size went into the dozens with Lamotrigine usually working well for mood and impulsivity.

I will second the lamotrigine suggestion for mood and impulsivity. I have seen this work for a handful of TBI patients as well, although others had surprisingly OK management with lower dose SRI and methylphenidate.

 

[NickNaylor]

I found this article helpful for its discussion of non-ritalin/adderall options, particularly the discussion of treating co-morbidity.

Adult ADHD and comorbid disorders: clinical implications of a dimensional approach - PubMed

Attention-deficit/hyperactivity disorder (ADHD) in the adult population is frequently associated with comorbid psychiatric diseases that complicate its recognition, diagnosis and management.The prevalence of ADHD in the general adult population is 2.5% and it is associated with substantial...

pubmed.ncbi.nlm.nih.gov

For me, these drugs include bupropion, modafinil, nortriptyline/desipramine (TCAs), and tranylcypromine (MAOI).

Thanks for sharing - much appreciated.

 

[GHPA]

CAP here, so the population I serve is ery different than yours. Here is some personal experience/preference,

1. Clonidine / Guanfacine works well for impulsivity, OK with hyperactivity, but almost no effect with inattention. Since ADHD hyperactivity is kind of rare in adult, we rarely use them in adult
2. Stimulant is for sure the first line treatment for ADHD in children and adult.
3. Methylphenidate (Concert, Ritalin, Focalin etc) tends to tolerate better in younger kids. They mostly focus on NE
4. Amohetamine (Adderall, Vyvanse, Mydayis etc) tends to work better in older teen and adult. They work through NE and DA, clearly more on DA then Methylphenidate.
5. Strattera (Atomoxtine) has FDA approval for ADHD, relatively unique mechanism. Much less potent and less convienent as pt has to titrate up and then wait for 4-8 weeks to see effect. But I used in some TBI patients with mild to moderate success.
6. A new player got approved for Adult ADHD, after being approved for child 2 yrs ago. Qelbree. Personally I never used it.
7. Amantadine has been used in Autim kids for aggression, too small smples in several studies.
8. Abilify and Risperidone are FDA approved for aggression in ASD kids, we sometimes use in TBI patient also. Questionable pro vs con.

My 2 cents

 

[calvnandhobbs68]

For TBI, and I've never seen any published data on this, the medication I've seen consistently do the best is Lamotrigine. Every single TBI patient I had it was the old throw something and see if something sticks (works). After about the 5th patient in a row where Lamotrigine worked well I just start off with this now. Eventually that sample size went into the dozens with Lamotrigine usually working well for mood and impulsivity.

Interesting is this mostly mild or severe TBIs? I’ve got a couple teenagers who got sent to me with prolonged depressive/anxiety/vague somatic symptoms after mild concussions that didn’t respond to a bunch of post concussive therapies that I’m working on….one of them has persistent anxiety about mild somatic symptoms/cognitive complaints that hasn’t responded to to Zoloft/Prozac/Cymbalta/Amitriptyline, I was about to go to methylphenidate next just to see if it helps.

And yes I tell them they need to be in psychotherapy consistently haha.

 

[clozareal]

Are you really seeing that much benefit with donepezil and amantadine? For the former, I honestly have not, and for the latter, I simply haven't used it enough to form an opinion. Completely agree with the use of stimulants (most often methylphenidate) and beta blockers for the indications you have cited, as well as lamotrigine as below.

I will second the lamotrigine suggestion for mood and impulsivity. I have seen this work for a handful of TBI patients as well, although others had surprisingly OK management with lower dose SRI and methylphenidate.

I see more benefit with amantadine than donepezil. I've used donepezil mostly for more moderate/severe memory impairment and even then, it's more to stave off worsening decline in memory/functioning if I find progression based on the MOCA.

 

[whopper]

Interesting is this mostly mild or severe TBIs? I’ve got a couple teenagers who got sent to me with prolonged depressive/anxiety/vague somatic symptoms after mild concussions that didn’t respond to a bunch of post concussive therapies that I’m working on….one of them has persistent anxiety about mild somatic symptoms/cognitive complaints that hasn’t responded to to Zoloft/Prozac/Cymbalta/Amitriptyline, I was about to go to methylphenidate next just to see if it helps.

And yes I tell them they need to be in psychotherapy consistently haha.

For TBIs where there was noticeable symptoms or signs after the TBI.

And while we're on the topic of TBI I also tend to recommend Melatonin or Ramelteon if they can't sleep well which I also often times see. I have a theory that there's a disruption of circadian rhythms with TBI in several of these patients. The circuits of at least melatonin release have been identified and anyone with a TBI with permanent repercussions can obviously disrupt that circuit. Add to this if the TBI is relatively recent good sleep is a very important factor in the recovery process.

 

[milesed]

What about Qelbree? It's similar in my experience to Strattera in efficacy and side effect profile.