by Larry B. Silver, M.D.
ADHD is a neurological disorder resulting from a deficiency of a specific neurotransmitter in specific areas of the brain. This transmitter is norepinephrine or one of its building blocks, dopamine or dopa. Any medication that increases the level of this neurotransmitter in the areas of the brain involved with ADHD will significantly reduce the behaviors associated with ADHD. This article reviews the medications currently available to treat ADHD.
The group of medications called “stimulants” are most successful in treating ADHD. (They are called stimulants because they stimulate nerve cells to produce more of the deficient neurotransmitter not because they stimulate or arouse the individual.) There are a few non-stimulant medications that might be used if the stimulants are not successful. The stimulant medications are most frequently used and will be reviewed in this article.
The Specific Stimulant Medications
There are so many medications advertised for ADHD that parents can easily become confused. Thus, it is helpful to explain the many medications available.
There are three main medications within this group of stimulant medications: methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and a mixture of several amphetamine salts (Adderall). Each comes in different strengths and different release mechanisms. The confusion for parents is that each new product is given what is called a “trade name,” suggesting that it is a new medication. And, each pharmaceutical company advertises their specific product as the best treatment.
Each of these medications may be available as a four-hour tablet, an eight-hour tablet, and an eight-hour capsule. One comes in a twelve-hour capsule. Each may be given a different name by the company making it. Then, there are generic forms of each medication, each of which may have its own name. Methylphenidate is also available in a trans dermal patch, Datrana. Adderall is also available in a form that modifies how it is absorbed and activated, Vyvance.
Another confusion relates to what is referred to as the polarization characteristics of each medication. When crystals of a medication are looked at through polarized light, two different images are seen. The right image is called the “dextro” form and the left image is called the “levo” form of the medication. For example, when the amphetamine medications were studied, it was found that the dextro form was potent and that the levo form had little effectiveness. Thus, dextro-amphetamine became the medication of choice. Later, a pharmaceutical company decided to mix the dextro and levo forms of amphetamine with “other salts,” creating Adderall. (It is unclear if Adderall is more effective than dextro-amphetamine.) Another example: methylphenidate (Ritalin) was analyzed with polarized light. The dextro form of the medication was found to be potent and the levo form found to be much less potent. Thus, a pharmaceutical company patented dextro-methylphenidate as a new product, Focalin.
This product has always been available in a tablet form, each lasting about four hours. These tablets might come in the brand name (Ritalin) or in the generic form (methylphenidate). There is an 8-hour tablet (called Metadate CD) and an 8-hour capsule (called Ritalin LA). The tablet must be taken whole; it cannot be cut or crushed. The capsule can be opened and sprinkled on food if needed. Methylphenidate comes in a 12-hour capsule called Concerta and in a trans-dermal patch called Datrana. Methylphenidate also comes in a chewable tablet (Methylin Chew) and a liquid (Methylin Oral). The more potent form of methylphenidate, Focalin, comes in a four-hour tablet and an eight-hour capsule.
- Four-hour tablets: Brand name Ritalin; generic name methylphenidate come in 5, 10, and 20 mg strengths
- Eight-hour tablet (Metadate CD) comes in 10, 20, 30, 40, 50, and 60 mg strengths.
- Another product is Ritalin SR and only comes in 20 mg strength.
- Concerta comes in 18, 27, 36, and 54 mg strengths
- Datrana Patch comes in 10, 15, 20, and 30 mg strengths.
- Eight-hour capsules (Ritalin LA)
The brand-named product, Dexedrine, is phasing off of the market, leaving primarily the generic forms. The four-hour tablets might be called dextroamphetamine or dextrostat. They can come in 5 mg, 10 mg, and 20 mg strengths. The eight-hour capsules may come in the brand name, Dexadrine Spansules, or in various generic names. These capsules come in 5 mg, 10 mg, and 15 mg strengths.
The four-hour forms are called Adderall and come in 5, 7.5, 10, 12.5, 15, 20, and 30 mg strengths. The eight-hour capsules come as Adderall XR and come in 5, 10, 15, 20, 15, and 30 mg strengths. The tablets are now available in generic form. Vyvance comes in 20, 30, 50, and 70 mg strengths.
One Other Confusing Factor
The number used in the label may not reflect the amount released into the body. The number must reflect the total amount of the medication in the product. The number for the four-hour tablets does clarify the amount released. For example, one methylphenidate 5 mg tablet releases 5 mg over the four hours. But, the eight-hour forms must identify the total amount of the medication in the product. Thus, Ritalin LA20 does not release 20 mg. It releases 10 mg initially and 10 mg about four hours later for a total of 20 mg. Adderall XR 30 releases 15 mg initially and 15 mg about four hours later.
Concerta is confusing. This product consists of a capsule with only one tiny release site. The bottom of the capsule consists of a sponge and the top of the capsule contains the methylphenidate. As the sponge absorbs moisture and expands, it slowly releases the product through a tiny hole at the top. It takes time for the sponge to saturate and then begin to expand. Thus, a small amount of methylphenidate is released to cover the time before the medication inside the capsule is pushed out. The number reflects the amount of methylphenidate inside the capsule for slow release plus the amount that is immediately released. Thus, Concerta 18 releases 5 mg progressively over about 12 hours; Concerta 27 releases 7.5 mg over the 12 hours. Concerta 36 releases 10 mg and Concerta 54 releases 15 mg over about 12 hours.
Using the Stimulant Medications
There is no one medication that should be used first. Each physician might have his or her own preference. Once medication is started, there are three steps in the process of finalizing the medication treatment plan:
- What dose does the individual need? Unlike many medications, the dose is not based on age or body weight. It seems to be related to how quickly it is absorbed into the blood stream and how quickly it passes through the blood-brain barrier into the brain. Usually, the individual is started at the lowest dose, for example, methylphenidate 5 mg. After five to seven days, the dose might be increased to 10 mg and later to 15 mg or 20 mg until the maximum benefits are noted.
- How long does the medication last? Depending on the form used, each dose should last the time noted for the product: 4 hours, eight hours, 12 hours. However, the length of effectiveness might vary with individuals and last a shorter time or a longer time. Based on this observation, the periods of the day to be covered is determined. For example, the individual might take an eight-hour capsule before going to school and a four-hour tablet at about 4:00 P.M. to cover the afternoon/evening.
- Are there side effects that need to be addressed? The stimulant medications might cause a reduction in appetite or difficulty falling asleep at night. Each negative effect must be addressed. The individual should not be expected to live with either. If the individual has (or has a predisposition to) difficulties with anxiety, depression, anger control, obsessive-compulsive disorder, or a tic disorder, the stimulant medications might exacerbate them. If so, this problem must be addressed.
Ideally, the right medication and dose is worked out. Any side effects are addressed. And, the individual functions well in all settings. If there are problems reaching this ideal level, it may be helpful to consult with someone who specializes in ADHD (Child and Adolescent Psychiatrist, Behavioral Pediatrician.)
Medication alone is not the treatment of choice. Along with medication, behavioral counseling may help the individual. Family education and counseling may help the parents. Adults might benefit from help provided by an ADHD Organizational Coach.
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Larry B. Silver, M.D., is a child psychiatrist in private practice in the Washington, DC area. He is a past president of LDA and is currently serving on the Board of Directors.