HOW DO AMPHETAMINES HELP PEOPLE WHO HAVE ADHD?

I have prescribed amphetamines [Adderall, Vyvanse, Dexedrine, Ritalin, Concerta, Focalin, Evekeo and others] for thousands of people of all ages that I have diagnosed with ADHD. To diagnose ADHD I require that current symptoms meet the current DSM criteria for ADHD as they are self-reported using a scale that has been shown to be reliable and valid, comparing results to clinician determined results as part of a blinded research study. I also require that symptoms be present before 6 years of age and also have corroboration of symptoms by a spouse, parent or at times an employer. Finally, I do not prescribe these medications to people with addictions unless they have been free of addictive behaviors for more than a year. I also look for other problems separate from ADHD symptoms and will frequently treat those problems before the ADHD as people often believe that Rx for ADHD will reduce distractibility no matter what is causing it. This is not the case as other causes of distractibility that are not directly connected to poor focusing and concentrating will not be helped by medication prescribed for ADHD. An example would be that depression is often distracting and Rx for ADHD will not reduce this and will not improve mood. However, stress associated with poor focusing and concentrating can lead to brief episodes of depressed feelings that can be overwhelming and treating the ADHD can eliminate these depressed feelings and yet this is not the same as significantly reducing depressive symptoms. I believe that one reason that antidepressants have been shown to improve ADHD symptoms is that the distractibility due to the depression is reduced or eliminated and this is considered an improvement in ADHD when it is actually an improvement in mood. 

I have very frequently found that people who have their focus and concentration helped by amphetamine based medications experience very significant changes in their lives as they are able to concentrate and focus and therefore have more access to their brains, they feel more motivated as they can finish tasks now and they experience a sense of accomplishment that leads to improved self worth. Another important benefit of medication enhancing concentration and focus is that now it is possible to reflect on what they are doing and this reflection can lead to improved self esteem as they are able to recognize what they are accomplishing. 

There are still misunderstandings of the way that amphetamine based medications help concentration and focusing. People frequently assume that people with ADHD respond to the medications like other people who do not have ADHD respond to amphetamines with increased energy, very poor appetite, reduced sleep and irritability. This would make concentrating and focusing much worse even though one might feel a lot of energy and think that they are focused when they are not. This latter might be why people without ADHD abuse amphetamines to get the increased energy and the illusion of increased focusing. If people with ADHD has this reaction to the amphetamine medications their concentration and focusing would be much worse. Instead, people with ADHD respond to amphetamine medications by being more focused, having more sustained concentration, being less anxious, are more able to finish tasks and able to reflect on what they are accomplishing. 

Occasionally, one of my patients will respond to one type of the amphetamine based medications with continuing poor appetite, poor sleep, irritability and no improvement in focusing or concentration. I will then switch them to another kind of amphetamine based medication such as changing from methylphenidate [Ritalin] medication to dextroamphetamine mixed salts [Adderall type]. They will then respond to the new medication with improved concentration and attention span. For each person that I diagnose with ADHD and prescribe amphetamine type medications the dose has to be optimized. Part of this optimization process is to be sure that the concentration support does not wear off or be diminished before the next dose as many people with ADHD will require three doses a day of the immediate release form of these medications and often two doses a day with the long acting form of these medications.  It is also important to carefully titrate the optimum dose of these medications because a dose that is to high dose can lead to them becoming stuck on one focus and having significant difficulty switching focus.

Because people with ADHD [or ADD] respond to amphetamines with improved concentration, focusing,alertness and feeling calm which is so different from how people without ADHD respond to these medications, this is likely why none of my thousands of patients who have ADHD became addicted to the amphetamines that I had prescribed for them. This is important as there is still concern by many people [including some physicians and pharmacists] that prescribing amphetamines to people with ADHD puts them at risk of becoming addicted. While there seems to be virtually no risk of addiction if amphetamines are prescribed for people with ADHD, there is a risk associated with others using amphetamines who do not have ADHD and this risk is a health concern in the United States. 

IS LONELINESS AT THE HEART OF ADDICTION?

Recently I listened to a TED talk by Rachel Wurzman entitled: "How isolation fuels opioid addiction." She discribes her experience of having tics [Tourettes Disorder] that she calls "unvoluntary." Dr. Wurzman experiences her involuntary tics as unvoluntary meaning that she feels like she is doing the tic movement and not an external force. However, Dr. Wurzman recognizes that her tics are not related to her conscious intentions or attention. Dr. Wurzman then makes the point that we all have things that we do in healthy ways and other things that are not healthy and this can help us to understand what others are experiencing, including those with tic disorders and addiction. So, why is it important that we can understand each other? Dr. Wurzman goes on to talk about the opioid epidemic and it's connection to being lonely. She states that this epidemic is killing 91 people every day and it is getting worse. Dr. Wurzman understands that addiction is a medical, neurobiological problem and yet she feels that we can help people with addictions by changing how we respond to them. To change how we respond to people with addictions she feels that it is helpful if we understand how and why our brains cause behaviors like urges to use substances. Dr. Wurzman's research suggests that loneliness may be reinforcing the brains of addicts to seek comfort from substances as their striatum's are seeking things that have most frequently been associated with reducing their feelings of loneliness. These responses [seeking things] are like they are on autopilot, so that when there is a stimulus there is then a very rapid and automatic response from their brains. 

Importantly, according to Dr. Wurzman, feeling socially connected to others is part of what the striatum does. The experience of feeling pleasure in social interactions is modulated by opioid receptors in the striatum. If some one is experiencing intense loneliness the opioid receptors are sensitized so that anything that reduces this sense of loneliness, such as taking opioids, is intensely and very rapidly sought. Therefore, loneliness may keep people addicted and social connections may help people not be addicted. However, those social connections need to be strong enough to convince the striatum that it is safe to let go of the immediate and reliable relief that taking opioids [and other drugs] represents. Dr. Wurzman also believes that to establish powerful social connections, it is better to connect with each other not focused on one aspect of ourselves/others [like addictive behavors] but recognize how we all have unvoluntary or automatic type behaviors. This helps us to realize that we are connected to people who happen to have different unvoluntary or automatic type behaviors. 

After listening to Dr. Wurzman, I wondered about a connection between the social isolation experiences of people with addictions and those who suffer from Post Traumatic Stress Disorder [PTSD]. If so, then does the isolation theory apply to people who have PTSD? And how would this influence treatment of PTSD?

What do you think?