Download Stimulant fact sheet

ALEXANDER LERMAN, M.D.
Adult, Child & Adolescent Psychiatry
250 North Bedford Road | Chappaqua Ny 10514
TEL. (914) 238-0566 | FAX (914) 914/238-0567 | E-MAIL: [email protected]
STIMULANT FACT SHEET
Stimulants are safe and effective medications that have been in use or more than five
decades. Stimulant drugs in common use include

Methylphenidate (marketed under the names Ritalin, Ritalin SR, Ritalin LA, Focalin,
Metadate, and others)

Concerta, a unique time-release preparation of methylphenidate;

Amphetamine, and it's almost-identical sister Dextroamphetamine (Adderall,
Adderall XR, Dexedrine, Dextrostat
These drugs are classified as narcotics, and are prescribed under the restrictions specified
by state and federal law. They are approved by the Food and Drug Administration to treat
Narcolepsy, a relatively rare disorder which causes people to fall asleep unpredictably; and
Attention Deficit Hyperactivity Disorder (ADHD or ADD)
Non-FDA approved “off label” uses include use of these drugs includes use as ancillary
agents in the treatment of Depression, and in the treatment of cognitive problems following
stroke and other brain trauma.
Effectiveness And Means Of Action
The principal effect of low doses of these drugs is

Improved memory, concentration, and mental task-performance

diminished fatigue

reduced restlessness and impulsivity
Response is variable. For some people suffering from Attention Deficit Disorder, the effect
can be dramatic, particularly when a problem with short-term memory or concentration is
decisively alleviated by the medication. Global improvements in academic and social functioning,
sometimes persisting even when the medication is not in use result. In my practice, this kind of
response occurs in about 20% of patients I treat. Many people experience similar, but less
extraordinary improvements.
All of these medications work by activating dopamine and norepinephrine pathways in the
brain, by either stimulating increase release of these molecules by brain cells (methylphenidate)
or imitating their effect at brain cell junctions (amphetamine). Methylphenidate is theoretically the
milder drug — but individual responses to medications are extremely variable.
Unlike many medications, stimulant drugs are active within minutes of taking them, and
required no induction period to gain effectiveness.
A reasonable comparison can be made to taking a cup of coffee, in which the effect (and
side-effects) of the stimulant caffeine is noticeable within minutes to having a cup, and less for
several hours.
Duration of Action
Different stimulants preparations have different potencies and duration of action
Drug
Usual Dose
Duration
Doses Daily
Methylphenidate (Ritalin)
5 -20 mg
4 hours
2-4
4 – 6 hours
1-3
Amphetamines (Adderall) 2.5 to 20 mg
Adderall XR
10-30 mg
6 – 8 hours
1
Concerta
18 – 54 mg
12 hours
1
In theory, someone taking a stimulant “washes out” at the end of the day, with no lingering
effect of the drug. This isn’t always true, particularly at higher doses or when stimulants are
abused to produce a “high”. Long-term stimulant use at high doses, especially in a setting of
stimulant abuse, can lead to a syndrome of exhaustion, mood instability, and loss of creativity.
Side Effects And Risks Of Stimulant Medication
Short Term Side-Effects
At low to moderate doses, stimulants may have either no ill effect, or a number of usually
minor side affects, which vary in their frequency and severity from person to person. Adjustments
in dose and type of medication can often lessen side-effects. Problems can include

HEADACHE – usually mild and less frequent over time.

STOMACH PAIN (more common in children). Usually mild. Alleviated by giving
medication with food.

INSOMNIA – Often treated with low doses of melatonin, Benadryl, or clonidine

LOSS OF APPETITE AND WEIGHT LOSS Variable. At times significant. Afterhours eating, as medication wears off, should be permitted by parents. Medication
can in many cases be skipped on weekends and holidays. Weight should always
be monitored when children are receiving stimulant medication.

HYPERACTIVITY AND EXCITATION (though these symptoms are usually reduced
by medication)

“REBOUND IRRITABILITY” occurring at the end of the day when the medication
wears off.

DROWSINESS (a so-called “paradoxical reaction”).

INCREASED “STEREOTYPICAL ACTIONS” such as finger chewing, lip-biting,
scab-picking.

STIMULATION OF MOTOR TICS (most commonly blinking, occasionally far more
significant).

DECREASED SOCIABILITY (while other people become more sociable due to
improved powers of concentration and ability to pick up social cues)

INCREASED BLOOD PRESSURE AND HEART RATE (more common in adults).
Vital signs should always be monitored when people are taking stimulant
medication.
Long Term Side-Effects
All of these effects are fully reversible when the medication is stopped. Longer-term ill
effects are rarer, and more controversial. They include

GROWTH SUPPRESSION – a limited number of long-term studies of children
maintained on medication for several years at high dosage, found an average
shorter stature by 1 - 2” among the children taking medication. The wider
applicability of these results is a matter of controversy and uncertainty. Growth
charts should always be monitored when children are taking stimulant
medication.

INCREASED RISK OF DEPRESSION AND MOOD CHANGES, including possible
“induction” of bipolar disorder. This is a matter of controversy, made more
complicated by the likelihood that some children presenting with ADHD symptoms
will probably later develop mood symptoms whether they take medication or not. I
have found incidence of significant mood problems quite low in my practice. People
taking stimulants should always be monitored for depression and other mood
disorder symptoms.

INCREASED RISK OF ILLICIT DRUG ABUSE - As a population, children
diagnosed with ADHD in elementary school years are at increased risk of substance
abuse problems in high school and college. In my view — and that of many experts
— this finding reflects the risk of ADHD impairing academic achievement and selfesteem, not of stimulant medication. Good treatment interventions, including but by
no means limited to stimulant medication, probably reduce risk of substance abuse
and other problems.

STIMULANT ABUSE AND ADDICTION - This is virtually impossible if the
medication is taken as prescribed, but represents a significant risk if the medication
is abused, i.e. taken at high doses to produce a “high”. At high doses, usually far
beyond medical limits, most stimulants can induce euphoria, personality changes,
chronic sleep deprivation, paranoia, and even psychosis. People receiving
stimulant medication should always take the medication as prescribed, and
never casually share medication with people for whom it has not been
prescribed. This is a matter of particular concern among college students and older
adolescents. Stimulants should not be mixed with illicit drugs or alcohol, and
prescribed with caution to adolescents and adults who use such substances.
Other Safety Controversies

INDUCTION OF TOURETTE’S DISORDER - This was a matter of controversy
some years ago, based on the experience that a) stimulants intensify motor tics in
the short run, and b) some children treated with stimulants went on to develop more
serious tic disorders including Tourette’s Disorder. Considerable research effort has
tended to support the view that such children were on the way to developing
Tourette’s Disorder with or without stimulant medication, and that the hyperactivity
that elicited the stimulant treatment was part of the Tourette’s Syndrome. Many
child psychiatrists (including me) now cautiously include stimulants among
medications used to treat Tourette’s Disorder.

SUDDEN CARDIAC DEATH - Canadian regulators withdrew approval for Adderall
XR in 2005 after about 20 sudden cardiac deaths in children and young people over
several years came to light. This is an extremely difficult risk to evaluate, given that
— tragically — about four per million children die suddenly of cardiac arrhythmias
each year. The fatalities in the Canadian report included cases of overdose,
congenital cardiac disease, and other unusual factors — all of which make it
impossible to decisively answer the question of whether Adderall XR or other
stimulants increase the risk of cardiac death. While I favor erring on the side of
safety, the present data are insufficient in my opinion (and in that of the experts I
trust) to warrant withholding Adderall XR and other stimulants from healthy children.
All children should be evaluated for family histories of cardiac malformations,
cardiac arrhythmias, and sudden cardiac death. (Family history of cardiac death
due to coronary artery disease — a leading cause of death in the western world —
does NOT count as a risk factor.)

ANOREXIA NERVOSA - Stimulant medications, as described above, suppress
appetite. These medications should be used with extreme caution in persons
with a history of anorexia or related eating disorders.
Pharmaceutical Promotions
Dr. Lerman does not accept gifts, honoraria, free samples, investment schemes, or other
forms of payment from drug companies.