Prescription amphetamines or similar

[nexus73]

I'll go with psychosis as a theoretical possibility. Let's say you've got some mild propensity towards psychosis, you combine this with therapeutically dosed amphetamines and sleep deprivation and… psychosis!

you don’t even necessarily need the amphetamines in this scenario

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[PikminOC]

Can you back that up with any research outside case reports? Especially related to strokes

Pls look at the pi and pubmed

 

[PTPoeny]

“Does anyone know any major downsides to prescription stimulants other than minor BP increase?”

Yes, there are many major (potential) downsides to prescription stimulants. I won’t bore the readers of this thread by listing them.

Instead, I’ll say that when I started having thoughts like the OP, it was the beginning of the end of EM for me. I soon realized EM had pushed me near the brink and I had to get out before EM did irreparable harm to me.

Would you mind expanding how you decided to get out of EM rather than find a new job?

 

[dchristismi]

You're apparently new to the EM forum, although clearly not to SDN. Birdstrike's story is one for the ages... he's one of the first of us to escape the Pit. (Many have followed his breadcrumbs, myself included.) In fact, it's probably stickied around here somewhere. If not, it probably should be for easy reference...

And basically, the same things happened - the slow realization that the water in the pot was slowly rising to a simmer, and it was jump out of the pot or suffer a slow, agonizing death.

 

[Birdstrike]

Would you mind expanding how you decided to get out of EM rather than find a new job?

You've got 13 years of SDN-EM forum back reading to do. But I'll give you the uber-summary, since I'm lying in bed, sick with the flu and nothing else to do until I pass out and go to sleep super early.

1-I realized EM was build on a series of lies, that I was told, believed, told myself, and heard repeated many times by others in the pit (there are too many to list here). Even the people on your textbooks, who you think you could look up to, give false testimony against other EM doctors for cash, working for lawyers who sue ER docs. It runs that deep.

2-I realized the abuse of EM staff isn't accidental, but the flames actively fanned by those in control EM careers. That doesn't include patient abuse of EM staff, which pales in comparison to the impact of that by the EM powerbrokers.

3-I realized every hours spent working as a doc in ED takes the toll of 2 hours working in any other specialty in Medicine and 3 hours, compared to any non-medical job (soldiers and first responders aside). I used to say it was a factor of 1.5, but realize now, it's grown closer to x 2-3.

4-I realized EM isn't a lifestyle specialty it's the hardest specialty in all of Medicine. Yes that includes neurosurgery, trauma surgery, ICU and whatever your currently think the hardest specialty is. It's not hyperbole. It's true. And you don't believe me. But you will, in time.

5-No amount of EM selling points (see reason #1) can counteract the amount chronic circadian-rhythm dysphoria, will bleed into that oft-glorified EM "free time" and make that free time work.

6- I decided not to job hop, because I saw no less than 15 partners of mine leave my group for the "perfect job" over the 8 years I worked as an EM attending, 14 of the 15 left those "perfect" jobs within very short periods of time. The 15th, who held out the longest, eventually left that perfect job, because that job lost its contract, proceeded to be a sucky job and that guy now works for an insurance company in a role of denying patients access to healthcare. "New jobs" were nearly alway mirages, from what I saw. Multiple promises made, very few kept. All jobs desperate to replace the last 2 docs who burned out and by the time they hire you and another to replace them, volume jumps up enough you're two docs short again. That burns two more out, they quit, you're short, hating life and more people quit. Repeat cycle.

Any specialty in medicine, where you can have a normal life, work normal hours, work no nights weekends, holidays or take meaningful call is lightyears better than EM, no matter how boring, dirty, frustrating or unsexy it seems now.

 

[Apollyon]

You've got 13 years of SDN-EM forum back reading to do.

Nah, you made that easy by deleting most of what you have ever written. I still don't understand that.

 

[Arcan57]

OP, once you've moved past caffeine on the stimulant chart or melatonin/anti-histamines on the sleep chart it starts becoming a slippery slope. It's not uncommon for stuff that starts off as performance enhancing to quickly become necessary just to maintain.

In regards to your exercise regimen, are you taking days off to recover? If you're fatiguing earlier in the set or with lower weights, the question usually isn't "what can I do to push past this?" but "how do I support my body and recover without injury?"

 

[hebel]

I recommend giving this a read. Written by a psychiatrist.

Adderall Risks: Much More Than You Wanted To Know

A little section of the summary:

My impression is that the risks of proper, medically supervised Adderall use are the following:

1. High risk of minor short-term side effects that might make you want to stop taking the medication with no long-term issues
2. Extremely low risk of serious medical side effects like stroke or heart attack, except maybe in a few very vulnerable populations
3. Maybe one percent risk, but not literally zero risk, of addiction if patients are well-targeted by their doctors and use the medication responsibly.
4. Perhaps one in five hundred risk, but not literally zero risk, of psychosis. Some anecdotal evidence suggests it is more common than this. Most of these cases will be mild and resolve quickly. Some people find a very small number of cases of stimulant-induced psychosis may be permanent, though I still find this hard to believe.
5. Some evidence for tolerance after several years, though most patients will continue to believe it is helping them. No sign of supertolerance where it actually makes the condition worse.
6. Plausibly 60% increased relative risk (+~1% absolute risk) for Parkinson’s disease with long-term use.
7. Unknown unknowns.

 

[Birdstrike]

Nah, you made that easy by deleting most of what you have ever written. I still don't understand that.

You do have a point there.

But I’m amazed you’re still bothered by this. It’s been about ten years, since I deleted those. Plus, I found and reposted most of the good ones.

You weren’t really going to go back and read my angry, rant-misery posts from 12-13 years ago, were you?

 

[TooMuchResearch]

OP, once you've moved past caffeine on the stimulant chart or melatonin/anti-histamines on the sleep chart it starts becoming a slippery slope. It's not uncommon for stuff that starts off as performance enhancing to quickly become necessary just to maintain.

In regards to your exercise regimen, are you taking days off to recover? If you're fatiguing earlier in the set or with lower weights, the question usually isn't "what can I do to push past this?" but "how do I support my body and recover without injury?"

I have about 6-7 hours of dedicated exercise time on the calendar weekly, give or take a bit based on schedule/life. I would prefer to up it a bit, but now isn't the time. I don't think any form of overtraining is an issue in my case.

That's the problem with exogenous molecules. Are there any that don't require cycling, alternating, or step wise adjustments upwards forever? None come to mind. Caffeine is quite effective, but only for a short time after cycling off it altogether for a month.

 

[PikminOC]

I recommend giving this a read. Written by a psychiatrist.

Adderall Risks: Much More Than You Wanted To Know

A little section of the summary:

My impression is that the risks of proper, medically supervised Adderall use are the following:

1. High risk of minor short-term side effects that might make you want to stop taking the medication with no long-term issues
2. Extremely low risk of serious medical side effects like stroke or heart attack, except maybe in a few very vulnerable populations
3. Maybe one percent risk, but not literally zero risk, of addiction if patients are well-targeted by their doctors and use the medication responsibly.
4. Perhaps one in five hundred risk, but not literally zero risk, of psychosis. Some anecdotal evidence suggests it is more common than this. Most of these cases will be mild and resolve quickly. Some people find a very small number of cases of stimulant-induced psychosis may be permanent, though I still find this hard to believe.
5. Some evidence for tolerance after several years, though most patients will continue to believe it is helping them. No sign of supertolerance where it actually makes the condition worse.
6. Plausibly 60% increased relative risk (+~1% absolute risk) for Parkinson’s disease with long-term use.
7. Unknown unknowns.

How many years in practice had he been when he wrote this? He already had to strike out his incorrect thoughts about Ritalin from this article.

 

[Apollyon]

You do have a point there.

But I’m amazed you’re still bothered by this. It’s been about ten years, since I deleted those. Plus, I found and reposted most of the good ones.

You weren’t really going to go back and read my angry, rant-misery posts from 12-13 years ago, were you?

I'm not bothered by it. Recollection does not equate to irritation. I was just factually recalling. I guess it's my curse for having somewhat of a good memory.

 

[dozitgetchahi]

I'd suggest that if one is looking to stimulants (other than coffee) to function on shift and in life, then it may be a good time to switch careers and/or significantly decrease the hours worked.

Exactly.

I’m rheumatology. Needless to say, I see a fair share of referrals for “fatigue” etc. The ddx is very broad:

- Sleeping horribly? What’s your sleep latency like? Snoring? How about sleep hygiene etc (do you need a sleep study for OSA etc)?

- Short of breath? Pedal edema, palpitations etc? (Arrhythmias, pulm HTN, ILD, HF etc)

- Are you inflamed? Do you have inflammatory polyarthritis symptoms, etc (inflammation takes a LOT of energy and leads to big time fatigue until it’s properly controlled).

- Any other general medical symptoms? Anemia, occult malignancy, etc etc?

- Depressed mood?

- Work schedule, shift work, etc etc?

And so on.

“I feel tired, how bout amphetamines” skips like 50 steps, may not even work, might miss a latent medical issue that needs to be addressed, and just isn’t the right idea in general. It’s not 1965 anymore (even if we actually hand out more amphetamines now for vague purposes than we did then).

 

[PikminOC]

I'll go with psychosis as a theoretical possibility. Let's say you've got some mild propensity towards psychosis, you combine this with therapeutically dosed amphetamines and sleep deprivation and… psychosis!

As it is a DEA level 2 controlled sub, people get tolerant to it and need more and more of it. I've seen psychosis several times from it

 

[nexus73]

The adverse cardiovascular effects seem like such a low base rate it's likely hard to study. Best, most recent meta analysis I found shows not much to be concerned about. Risk of Cardiovascular Diseases Associated With ADHD Medications

I see psychosis with stimulants when people are using meth off the streets. I don't think I've ever seen an adult on Rx stimulants within FDA dose range develop psychosis, with possible exception of someone with schizophrenia who someone put on a stimulant, in which the stimulant is more unmasking what's there. I did have one older patient on Wellbutrin and Requip at a pretty high dose having some odd visual phenomenon, which could have been hallucinatory in nature, and resolved off the mds.

In general, I think these concerns are likely overblown. Aspirin and NSAIDs have adverse effects, and could ask what is the annual mortality from ASA vs Adderall XR? And if you have ADHD, Adderall XR confers significant benefit. An interesting hypothesis could be once someone with ADHD is treated with a stimulant, their overall level of psychological stress reduces, and that could actually have a risk reduction effect on CV events. And if you have someone on a stimulant, standard of care is monitoring BP and HR, and if someone's on Vyvanse and ticking along at 120 bpm and 165/100, you shouldn't just let it ride.

But at the end of the day it's risk/benefit like all medical decisions.

 

[PikminOC]

The adverse cardiovascular effects seem like such a low base rate it's likely hard to study. Best, most recent meta analysis I found shows not much to be concerned about. Risk of Cardiovascular Diseases Associated With ADHD Medications

I see psychosis with stimulants when people are using meth off the streets. I don't think I've ever seen an adult on Rx stimulants within FDA dose range develop psychosis, with possible exception of someone with schizophrenia who someone put on a stimulant, in which the stimulant is more unmasking what's there. I did have one older patient on Wellbutrin and Requip at a pretty high dose having some odd visual phenomenon, which could have been hallucinatory in nature, and resolved off the mds.

In general, I think these concerns are likely overblown. Aspirin and NSAIDs have adverse effects, and could ask what is the annual mortality from ASA vs Adderall XR? And if you have ADHD, Adderall XR confers significant benefit. An interesting hypothesis could be once someone with ADHD is treated with a stimulant, their overall level of psychological stress reduces, and that could actually have a risk reduction effect on CV events. And if you have someone on a stimulant, standard of care is monitoring BP and HR, and if someone's on Vyvanse and ticking along at 120 bpm and 165/100, you shouldn't just let it ride.

But at the end of the day it's risk/benefit like all medical decisions.

Yes if you have ADHD. And there are lots of other treatments.

 

[TooMuchResearch]

The adverse cardiovascular effects seem like such a low base rate it's likely hard to study. Best, most recent meta analysis I found shows not much to be concerned about. Risk of Cardiovascular Diseases Associated With ADHD Medications

I see psychosis with stimulants when people are using meth off the streets. I don't think I've ever seen an adult on Rx stimulants within FDA dose range develop psychosis, with possible exception of someone with schizophrenia who someone put on a stimulant, in which the stimulant is more unmasking what's there. I did have one older patient on Wellbutrin and Requip at a pretty high dose having some odd visual phenomenon, which could have been hallucinatory in nature, and resolved off the mds.

In general, I think these concerns are likely overblown. Aspirin and NSAIDs have adverse effects, and could ask what is the annual mortality from ASA vs Adderall XR? And if you have ADHD, Adderall XR confers significant benefit. An interesting hypothesis could be once someone with ADHD is treated with a stimulant, their overall level of psychological stress reduces, and that could actually have a risk reduction effect on CV events. And if you have someone on a stimulant, standard of care is monitoring BP and HR, and if someone's on Vyvanse and ticking along at 120 bpm and 165/100, you shouldn't just let it ride.

But at the end of the day it's risk/benefit like all medical decisions.

Thanks for the paper.