STIMULANT MEDICATION USE DURING PREGNANCY

IN REVIEWING INFORMATION ON THE USE OF STIMULANT MEDICATION [ADDERALL, DEXEDRINE AND METHYLPHENIDATE] DURING PREGNANCY, THERE ARE A NUMBER OF REFERENCES TO STUDIES ON MICE LEADING TO MISCARRIAGES AND BIRTH DEFECTS. THESE WERE ASSOCIATED WITH A SIGNIFICANT OVERDOSE OF THE MICE COMPARED TO DOSES TAKEN BY HUMANS. IN ADDITION, THERE HAVE ALSO BEEN MENTION OF HEART DEFECTS RELATED TO AMPHETAMINE USE DURING PREGNANCY AND YET A STUDY OUT FROM HARVARD BY LEAD AUTHOR KRISTA HUYBRECHTS INVOLVING A VERY LARGE NUMBER OF PREGNANT WOMEN [IN JAMA PSYCHIATRY 2018 FEB; 75(2): 167-175] FOCUSED ON THE SAFETY OF METHYLPHENIDATE AND AMPHETAMINES [ADDERALL AND DEXEDRINE] FOR PREGNANT WOMEN DURING THE FIRST TRIMESTER OF THEIR PREGNANCY.  THERE WERE NO CARDIAC MALFORMATIONS OR OTHER MALFORMATIONS RELATED TO THE AMPHETAMINES, HOWEVER, THERE WAS A 28% INCREASE IN CARDIAC MALFORMATIONS AND AN 11% INCREASE IN BIRTH DEFECTS FOR PREGNANT WOMEN TAKING METHYLPHENIDATE WITH THE CONCLUSION THAT THERE IS A SMALL INCREASE IN THE RISK OF CARDIAC MALFORMATIONS AND EVEN SMALLER RISK FOR BIRTH DEFECTS FOR PREGNANT WOMEN TAKING METHYLPHENIDATE.

A 2007 ARTICLE ENTITLED "EXPOSURE TO ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD] MEDICATIONS DURING PREGNANCY", IN THE CANADIAN FAMILY PHYSICIAN JUL; 53(7):1153-1155, SUMMARIZES RESEARCH RELATED TO TAKING AMPHETAMINE TYPE MEDICATIONS FOR ADHD DURING PREGNANCY. IN THEIR REVIEW THEY REPORT THAT THERE IS NO EVIDENCE FOR AN INCREASE IN MALFORMATIONS USING THERAPEUTIC DOSES. THEY ALSO REPORT THAT ABUSE OF AMPHETAMINES DURING PREGNANCY HAS BEEN ASSOCIATED WITH LOW BIRTH WEIGHT, PREMATURITY, AND INCREASED MATERNAL AND FETAL MORBIDITY.  THIS WAS CONNECTED WITH USE OF COCAINE AND MAY REFLECT PLACENTAL VASOCONSTRICTION.  HOWEVER, THERE WERE OTHER CONFOUNDING FACTORS SUCH AS POLY DRUG ABUSE, POSSIBLE ALCOHOL ABUSE, AND OTHER MEDICAL PROBLEMS ASSOCIATED WITH LIFESTYLE CHOICES. ANY OF THESE COULD HAVE CAUSED THE PROBLEMS NOTED.  ADDITIONALLY, THERE IS A REPORT OF A MILD [100-400 GRAMS] WEIGHT LOSS FOR INFANTS BORN TO WOMEN WHO WERE PRESCRIBED DEXTROAMPHETAMINE FOR WEIGHT CONTROL. THE SIGNIFICANCE OF THIS IS NOT CLEAR AS THERE WERE A NUMBER OF CONFOUNDING VARIABLES IN THIS STUDY AS WELL.  INTERESTINGLY, A PROSPECTIVE STUDY EVALUATED THE RISK OF CONGENITAL ANOMALIES OF INFANTS BORN TO 1694 WOMEN WHO WERE USING AMPHETAMINES AS ANORECTICS [FOR WEIGHT LOSS] WITH NO INCREASE IN MALFORMATIONS. SO, IT APPEARS THAT EVEN WHEN AMPHETAMINES ARE USED [ABUSED?] TO LOSE WEIGHT, THERE ARE NO MALFORMATIONS IN THEIR INFANTS. 

MORE RECENT REVIEWS GO OVER THE STUDIES MENTIONED ABOVE.  THEY CONCLUDE THAT THERE IS NO EVIDENCE OF MALFORMATIONS WITH THE USE OF AMPHETAMINES [INCLUDING ADDERALL] DURING PREGNANCY BY WOMEN WHO HAVE ADHD AND YET WILL OFTEN STILL RECOMMEND STOPPING THE AMPHETAMINE. THIS IS POSSIBLY BECAUSE OF OLDER STUDIES WHERE PREGNANT MICE WERE SIGNIFICANTLY OVERDOSED ON AMPHETAMINES AND HAD SOME MALFORMATIONS IN THEIR INFANTS.

WHEN EVALUATING ANY STUDIES RELATED TO AMPHETAMINES AND PREGNANCY, IT IS IMPORTANT TO BE SURE THAT THE DATA IS FROM WOMEN WITH ADHD WHO ARE PREGNANT. IT IS CLEAR TO ME AFTER TREATING THOUSANDS OF PEOPLE WITH ADHD THAT PEOPLE WITH ADHD DO NOT RESPOND TO AMPHETAMINES LIKE PEOPLE WHO DO NOT HAVE ADHD. TAKING THE AMPHETAMINE TYPE MEDICATION, PEOPLE WITH ADHD ARE CALMER, MORE ALERT, MORE FOCUSED, NOT IRRITABLE AND DO NOT EXPERIENCE SUSTAINED SLEEP OR APPETITE DISTURBANCE.  IF THEY ARE MORE IRRITABLE, MORE HYPERACTIVE AND HAVE REDUCED APPETITE AND SLEEP, THESE ARE SIDE-EFFECTS AND OFTEN MEAN THAT THEY WILL NEED TO CHANGE TO ANOTHER AMPHETAMINE TYPE MEDICATION. 

FINALLY, A STUDY BY JM COHEN, ET AL. OBSTET GYNECOL. 2017 DEC; 130(6): 1192-1201 WITH DR. HUYBRECHTS AN AUTHOR ON THE STUDY, LOOKING FOR RISK FOR PLACENTAL-ASSOCIATED ADVERSE OUTCOMES IN PREGNANT WOMEN TAKING PSYCHOSTIMULANT [INCLUDING ADDERALL] MEDICATIONS, FOUND THAT IN A COHORT OF 1.5 MILLION PREGNANCIES THERE WERE 5000 PREGNANCIES EXPOSED TO STIMULANT MEDICATION AND THERE WAS A SMALL INCREASED RELATIVE RISK OF PREECLAMPSIA AND PRETERM BIRTH. THE RISK WAS SMALL ENOUGH THAT THE AUTHORS DID NOT RECOMMEND STOPPING THE STIMULANT MEDICATION IF IT WOULD HAVE AN IMPACT ON THE MOTHER’S FUNCTIONING. ALSO, THERE WERE SOME CONFOUNDING VARIABLES THAT COULD HAVE INFLUENCED THE FINDINGS OF THIS SMALL RISK.  THESE WERE THAT THERE WERE MOTHERS WHO DID NOT HAVE ADHD WHO TOOK THE STIMULANT MEDICATION AND THERE WERE MOTHERS IN THE CONTROL GROUP WHO HAD ADHD WITHOUT MEDICATION AND THESE MOTHERS WERE FOUND TO HAVE A TWO FOLD INCREASED RISK OF PRETERM BIRTH IN A STUDY BY SP BRO, ET AL. IN CLIN EPIDEMIOL. 2015;7:139-47. 

IN SUMMARY, A NUMBER OF STUDIES OF PREGNANT WOMEN WITH ADHD TAKING ADDERALL HAVE FOUND NO EVIDENCE OF MALFORMATIONS [INCLUDING HEART MALFORMATIONS] IN THEIR INFANTS OR ANY OTHER BIRTH COMPLICATIONS. HOWEVER, A STUDY OF PREGNANT WOMEN TAKING METHYLPHENIDATE HAS FOUND HEART MALFORMATIONS AND OTHER BIRTH COMPLICATIONS. I DO NOT BELIEVE THAT THIS STUDY HAS BEEN REPLICATED YET.  ALSO,THERE WAS ANOTHER STUDY THAT FOUND A SMALL RELATIVE RISK FOR  PREECLAMPSIA AND PRETERM BIRTH BUT NOT ENOUGH TO REQUIRE STOPPING THE MEDICATION IF THE MEDICATION HAD AN IMPACT ON THE MOTHER’S FUNCTIONING.

EXTERNALIZING COSTS: MAKING EVERYBODY PAY FOR WHAT OTHERS ARE DOING

Cost externalization or externalized costs usually refers to producers [often corporations] that off-load indirect costs, called negative externalities, to a third party [often all of us] in order to maximize their profits. An example would be a corporation not taking financial responsibility for the polution that they produce or paying their employees low wages and thus requiring them to use food stamps and other forms of public assistance that we all pay for through our taxes. The UN is currently studying the cost of polution and other environmental damage by the world's top 3,000 corporations. The price tag is $2.2 trillion. That represents 1/3 of the profits for these corporations. So, for the sake of more profit, these corporations are willing to contribute to the end of our planet as they put the burdon of this pollution on the rest of the world. Does it seem right that a very small percent of the world's population gets money at the expense of the rest of us. I believe that everbody would agree that this is very wrong. It is not part of a fair capitalistic system as externalizing costs can allow a corporation to lower the cost of their products giving them an unfair advantage over other corporations making the same type of product. It is not right. It is morally wrong and all of us know this. So why do we tolerate this? It may be because we are also guilty of externalizing our costs by: purchasing things that are cheap because of the manufacturer externalizing costs; by polluting [not carbon neutral, not recycling, etc.]; buying stocks of corporations that externalize costs; by electing people who promote externalization of costs; etc. So, many of us externalize costs. If we want those corporations to stop externalizing costs then it might be helpful for all of us to do likewise. This might increase our awareness and sensitivity to this problem and help all of us to work together to treat each other with more respect as we take responsibility for our own problems and help others to take responsibility for theirs.

Does this make sense?

UNALIENABLE RIGHT TO LIFE, LIBERTY AND THE PURSUIT OF HAPPINESS AND TO OWN ANY AND ALL THE GUNS THAT WE CHOOSE?.

I've read that the ancient Greek democracy failed because it did not protect the individual from the majority. If we believe that all life is sacred [precious, etc.] then we must protect the rights of the individual from the majority. So, something being good for most people does not justify it being imposed on the individual. Or does it? If we see that the right to life is being taken away from some people by individuals with assault style weapons then does any individual have the right to those weapons when exercising their right can take away the right to live for innocent people? So where do our individual rights end and the majority's rights begin? 

We as individuals are guaranteed by our constitution to be free to pursue our lives. So, any thing that interferes with our ability to pursue our lives interferes with our individual rights. But what about the rights of others, such as the rights of children and adults to not be killed by a male with an assault rifle. Their right to pursue their lives is over. So, is it right to pursue our lives if it can result in the right of others to pursue their lives be taken from them? It has been argued that it is wrong to take assault rifles from people who have not killed anyone and yet the fact of and availability of these weapons has taken the right of many to be alive to pursue their lives. I believe that it is our responsibility to protect the lives of those innocent people.  If this is true regarding guns then it must be true for protecting those innocent people from the hate being promoted on line or anywhere else. We are free to speak what we believe but not free to take away the rights of others to pursue their lives.

What do you think?

DOSING OF ADHD MEDICATIONS

Questions are sometimes raised about exceeding the maximum recommended doses of medications used to treat ADHD. I have reviewed the research studies for these medications and it is clear that the studies were to determine efficacy and were not dosing studies.  Specific doses were chosen to assess the benefit and minimize risk of side-effects.  Once efficacy was determined the study ended and there was no motivation to do further studies addressing the range of doses that were therapeutic. Thus, doses involved in efficacy studies can be mistakenly seen as being studies to determine limits of what is therapeutic. The studies could not recommend a different dose because they did not assess different [higher] doses.  Also, each person is unique and this uniqueness can include how they respond to medications with some people responding to higher doses and others to lower doses. The U.S. Food and Drug Administration recognizes this when they state “the dosing regimen [for stimulant and related medications] is adjusted according to a patient’s individual response to pharmacotherapy."

I believe that it is important to work with my patients to assess their response to medications and in collaboration with them determine an optimal dose. At times this dose may be higher than is “recommended.”  I hope that it is clearer now why this is the case and why it is necessary to prescribe higher doses for these patients.

WHITE PRIVILEDGE

It is so sad that Whites continue to be priviledged at the expense of others, mostly African-Americans. The priviledge is a weight on whites as we suffer from the abuse that is perpetrated in our name whether we agree with it or not. Our country grew up supporting racism and white priviledge and it is woven into our culture and to change this we must choose to see the priviledge for the abuse that it represents whether by financial institutions refusing loans or having higher interst rates, maintaining segregation through realestate practices or by promoting Whites only charter schools. According to Resmaa Menakem [My Grandmother's Hands] Whites suffer in their bodies from a long pattern of reacting to African-Americans as a threat and yet are also frequently dependent on them. Mr. Menakem feels that Whites need to become aware of their bodies response to African-Americans and change it so that they can process and then dismiss their emotional reactions and begin to see them as like themselves and not a threat. Mr. Menakem sees the police as needing a lot of support to overcome their frequent automatic response as if African-Americans are dangerous with the increased risk that lethal force will be used inappropriately.  Support to help the police to manage traumatic experiences that they have as well as help people they are responsible for keeping safe to resolve any traumatic experiences that they might have. Finally, Menakem also sees African-Americans as needing to stop their automatic response of defering to Whites and feeling responsible for them. If we all can overcome our rapid, automatic and destructive body responses to others we will be free to experience our common humanity and not need to live in fear or with the weight of prejudice and judging others. 

I believe that what Menakem is describing is similar to patterns of behavior that develop related to our automatically perceiving people or situations to be dangerous because of past traumatic experiences. Our behaviors are meant to protect us from the danger that we [or our ancestors?] had experienced in the past . The human brain is capable of storing patterns of behavior and accessing them instantly [in a nanosecond which is a billionth of a second] to protect us. We are reacting before we are even aware that we are. This makes changing these patterns of behavior much more difficult, even if we actually no longer need to be afraid or react to what is no longer a threat to us. According to Menakem, we all need to be aware of changes in our bodies that indicate we are recalling past threats and need to calm ourselves down to avoid reacting. This is especially important if we by the nature of our work, carry guns. Menakem recommends therapeutic support for police officers who are exposed to violence or participate in violence. It is important for all of us to develop this awareness of changes in our bodies that can activate old patterns of behavior that we no longer need and can lead to conflicts in our relationships with others. Then we need to learn ways to diffuse these reactions so we do not get triggered and thus do not react to them. How do we learn ways to diffuse our reactions?

What do you think?