ADHD medications

There are three main ADHD medications: methylphenidate (i.e. Ritalin), dextroamphetamine (i.e. Dexedrine), and atomoxetine (i.e. Strattera).  I've tried all three.

The effect of methylphenidate(MPH) last for about four hours.  There are many different release mechanisms in order to have the effect of one pill last for a longer period of time.  I discussed APO MPH SR in a previous post.  I found MPH improved my impulse control (i.e. helped me hold my tongue I might loose my temper and say something I'd later regret), but found no difference with focus (I still had no interest in doing my tax returns).  It also didn't help with forgetfulness and distractability.  It's other benefits are that it's the cheapest ADHD medication, it is well studied (i.e. safe), and has an effect within 1-2hr of taking the medication.  Typical adult doses are 40-80mg/day.  I experienced negative side-effects at 80mg/day, though I am likely more sensitive since I have Aspergers.

Dexedrine has a slightly longer effect than MPH, but still needs to use an extended-release mechanism to last throughout the day.   15mg of dexedrine costs about $1 vs. 50c for 40mg of MPH (2x APO MPH-SR @25c ea).  I found 15mg of dexedrine dampened all my emotions.  I wouldn't loose my temper since I wouldn't get angry.  I also wouldn't laugh as loud watching my favorite comedies, and my wife noticed a negative effect on my libido (vs. MPH which seems to have made things even better in the bedroom).

Atomoxetine appears to have a very long-lasting effect (days), even though most of the drug is metabolized within 12hrs. "There was no evidence of symptoms rebound and no evidence of an acute discontinuation syndrome when discontinuing treatment."  It hasn't been around as long as MPH, so it doesn't have the same safety record.  My psychiatrist warned me that a very small minority of patients taking atomoxetine experienced suicidal thoughts. 40mg of atomoxetine is rather expensive at ~$3/pill.  I found a noticeable improvement in my irritability (things that used to bother me didn't any more).  I noticed negative sexual side-effects, so combined with the costs I decided to discontinue use.

Currently I'm not taking any ADHD medication.  When I started taking atomoxetine, I had also started B12 supplements.  My psychiatrist asked for a liver test before prescribing the atemoxetine, and the test results showed low B12; 229pmol/L.  As B12 is sometimes referred to as the stress hormone, I've decided to boost my levels to at least 400.  It seems to be helping.

Temper, Crime, and Stress

Stress is the uncomfortable feeling in your gut when your nervous system senses conflict.  We all feel stress at times, and much of this post applies to all human beings, not just people with ADHD.  The negative feeling of stress motivates people to act to end the conflict swiftly.  When that motivation is acted upon without pause for thought, bigger problems are usually created.

Barkley has talked about the issues of emotional regulation in ADHD. What I missed the first couple times I watched the video was the role the anterior cingulate plays in resolving CONFLICT.  Many times in the past when I have been insulted, I have reacted with a verbal counter-attack.  Like all other children, I was taught to be polite in the presence of adults, even if they behaved offensively.  When a child is five years old and an adult tells them the painting they just finished is ugly, few are surprised when the child responds "Well you are ugly!"  By twenty-five, that child is expected to behave like other adults.  When someone insults me, like many people, I instantly feel angry.  Anger motivates people to fight, and besides Barkley's physical example, the attack can be verbal.  Everyone has experienced times when they failed to suppress a verbal attack.  For people with ADHD it is much more difficult to suppress those motivations.  And as Barkley showed, this capability is limited by the physical characteristics of the brain.  Since it is invisible, people don't consider it when they set expectations like they do for visible capabilities.  We don't expect the small, weak child to carry the same weight of groceries as the stocky and strong child.  However, since nobody could see the size of my anterior cingulate, I was expected to control my temper the same as everyone else.

I read a family court case in Virginia that happened a few years ago.  A father lost his temper while arguing over custody of his daughter.  The judge ordered him to sit and be quiet.  He turned around to leave.  The judge ordered the bailiff to restrain the man.  The man swore at the bailiff and yelled, "I need to take a walk!"  In a matter of seconds, the judge summarily found the man guilty of criminal contempt and sentenced him to 10 days in jail.  What typically happens afterwards is the man is required to attend an anger management group after his release.  The group therapist will think that they can teach him to manage his temper, and if he doesn't respond he will be dismissed as being defiant and angry.  A few sociologist know ADHD is 4-8 times more prevalent in criminals and are able to recognize it.  However they are not licensed to make a diagnosis or prescribe medication, and in many jurisdictions they cannot make referrals to a psychiatrist.  Since social workers want to help people, they are going to look for ways they can help.  Since they can't help people with ADHD (or other psychiatric disorder for that matter), they aren't going to look for ADHD.

When I am able to suppress my urge to attack, the anger subsides and I'm left with a churning feeling in my gut.  I'm feeling conflicted since I know I shouldn't react despite the urge I'm feeling.  The capability to self-regulate is very important in this context.  Most people can easily use the anterior cingulate in their thinking brain to tell their emotional brain, "Shut up and stop making me feel like I'm going to puke up my lunch!"  When that doesn't work, it's a good idea to get up, go for a walk, and calm down.  However in situations where you are expected or required to stay like the man in court, the stress remains, making it even easier to blow up at the next irritating situation.

Equal is Not Fair

Before I was diagnosed with ADHD, I heard someone say, "Fair is not equal."  I think it was something a teacher said to one of my children in school. I didn't think about it much, however it obviously stuck in my head.  Now I'd like to turn that around and say, "Equal is not fair."

What do I mean by that?  I think a story is the easiest way to explain.

A high school has a rule that says that when a student hits another, they get detention.  In that school, Mike is talking to a Amy, girl he likes.  A group of boys walks by and John says, "Hey looser, did mommy stop buying you clothes?  Guess there's not many tricks to be had for an old ho!"  Mike turns and punches John.  A teacher happened to be walking down the hall behind Mike and saw Mike hit John, so Mike gets detention. 

John wants to settle the score with Mike, so he's waiting for his opportunity.  A few days later Mike is running down the hall, late for class.  John comes around the corner, sees the hall is empty but for Mike, and sucker punches him in the gut.  Mike drops his books and falls to the floor unable to breathe.  John says, "Payback's a bitch." and walks away with a big smile on his face.

I think most people can recognize the unfairness, and how a rule intending to treat offenders equally contributes to the unfairness (especially if Mike has ADHD).  Where I think most people go off track is the next question they ask is "How do we fix the rule then?"  When you ask the wrong question you aren't going to solve the problem.  See, we want to fix the problem, not the rule.  Removing the rule helps fix the problem since Mike wouldn't get punished twice.  I agree it's not good to let kids get away with hitting others, but society already has a way of dealing with that: assault.  And our system of law has already considered the dilemma of John and Mike.  The courts consider the intent of the offender.  School rules don't.

"So we do nothing?" No, the school can refer assault cases to the police, who in turn can decide to lay charges under the same rules the kids are subject to outside school.  And the schools could start demonstrating compassion.  Make the goal helping instead of punishing.  So if you are the vice-principal who walks around the corner and sees Mike on the floor, don't ask, "Who punched you?"  Say, "Here, let me help you up."

is ADHD a gift or a curse?

Russell Barkley has said ADHD is not a gift.  He's right, however there still can be positives to ADHD.

His argument is understandable given his clearly stated motivations.  His goal is to get help for people with ADHD, and pointing out the positives frustrates that goal.  I think we can still work to get accommodation for the disability even while recognizing there are some positive aspects to ADHD.  The first analogy that comes to mind is that we can recognize the problems that stairs and steep inclines are for people in wheelchairs while recognizing that on a gentle decline people in wheelchairs move easier than people walking.

So what are the positives?  Some of the time I like the distractability.  I naturally notice changes better than the average person.  For example I may notice the new car in your driveway, or the rabbits eating the dandelions (or the tulips!) on your lawn.  The problems with emotional regulation is the biggest negative for me, and the reason I choose to take medication.

Barkley calls ADHD a blindness to the future.  I think this contributes to my natural optimism.  Humans assign a greater weight on negatives than they do positives.  I tend to think about now instead of the future.  When picking courses in university I would pick ones I liked.  Most of my fellow students would worry about their GPA, so they would narrow it down to the easy courses first, then pick the one they liked the most.  When I pack for a trip I take what I need instead of packing for every possible scenario I might encounter.  I have significantly less anxiety than average.  By anxiety I mean fear about possible negative events in the future.  I don't see as far into the future, so I don't see many possible negative events in my future.

So where does that leave the gift or curse question?  Well, the question is wrong since it restricts the possibilities to a gift or a curse.  In reality the possibilities are ... endless! :-)

ADHD and Exercise

Prior to my ADHD diagnosis, I found that my symptoms were reduced after exercise.  On a day when I took no medication, I did vigorous exercise for half an hour.  An hour later I did a PASAT.  The results were similar to my results on medication.

Although it was done on rodents, I think tests showing chemical changes in the brain after exercise are applicable to humans too.  I think it also make sense that the genetic basis of ADHD makes us want to get up and go, and when we do we feel better.

I think I'll try doing a few minutes of exercise in the mornings before my meds kick in.  It will help my symptoms a bit, and it's good for my health!

drug dosing

Determining the best dose and timing of ADHD drugs requires work.  I think the primary appeal of drugs like Concerta is that they simply it.  For myself though, I find Concerta lacking.  In adults taking Concerta, blood levels typically drop to half of the peak 9.6 hours after taking it.  So when you take it at 6:30am, the effect is disappearing around 4pm.  I want the benefit of medication from the morning as I get my kids ready for school, through the day, and the evening until my kids are in bed.

To figure out my desired dosing, I downloaded the product monograph for APO 20mg methylphenidate-SR from Health Canada.  Using the monograph, I estimated the hourly blood levels and recorded them in a spreadsheet.  With that I was able to calculate and graph the levels obtained for different drug dose timings.

drug costs

There is a wide range in price between different ADHD drugs, and even in the price for the same drug from different pharmacies.  Here are some examples:
Concerta 54mg, 30 tablets: 123.90 at Superstore pharmacy vs. $111.32 at Costco
The manufacturer is distributing co-pay benefit cards through doctors and pharmacies which covers the difference in cost between Concerta and the generic version.  For the Superstore, this difference was $36.56, bringing the price down to $87.34.
MPH-SR(generic Ritalin-SR) 20mg, 90 tablets: 37.39 at Superstore pharmacy vs. 26.42 at Costco.