Medication Challenges and Risks for Adult ADHD Treatment

Theresa R. Cerulli, MD: Keeping in mind approved drugs for treating ADHD [attention-deficit/hyperactivity disorder], what are some of the challenges in the adult population? What are some of the risks that you’re thinking about?

Birgit H. Amann, MD: I’ll jump in. On a practical level, in the office, 1 of the biggest frustrations is that even though we’ve made tremendous progress over the last 2 decades in our stimulant options and a little in our nonstimulant options—I deal with this all day every day—a long-acting product isn’t approved for adults. Although we’ve improved upon the number we have, we deal with rejections from insurance and different frustrations like that. So on my wish list are products that come out off the bat for ages 6 and older. That includes adults. Because even my 16- and 17-year-olds who I’ve had on viloxazine are going to turn 18 or already have, and I have to sample a lot in anticipation of the adult indication.

Rakesh Jain, MD, MPH: Theresa, there are some frustrations in addressing the needs of our patients with adult ADHD. But I want to hasten to add that we’re expressing these frustrations with the background of how glad we are. In many ways, it’s easy to treat adult ADHD. There are profoundly large effect sizes of many of our treatments. Even though we’re talking about the details of some of the challenges, let’s not for a second forget that overall, it’s a very good world out there for someone with adult ADHD.

Perhaps as many as a third of adult patients don’t want a stimulant, no matter how long-acting it is, no matter what indication it has. They have their own reasons for not wanting stimulants. There’s a substantial number of patients who we don’t want to expose to stimulants. They might have a challenge with sleep or an anxiety difficulty, or perhaps real concerns about diversion or addiction. They may have their own reasons. That’s why having this broad array of treatment options in the world of stimulants and nonstimulants is a good thing. Things are good with ADHD. Things will get better with ADHD in adult ADHD with a greater number of treatment options, as you’ve been hearing from us. I’m curious to hear, Theresa, your response to the very good question you asked. I want to hear, what do you see as the risks or benefits? What do you think about adult ADHD treatment?

Theresa R. Cerulli, MD: Thanks for asking, Rakesh. I’m not a 1-size-fits-all practitioner. I’m very much about individualized and collaborative care. Collaborative with not just my colleagues but the patients themselves. One risk that hasn’t been brought up that I’d like to weigh in on is the risk of substance abuse and the many forms that can take with stimulant medications. I heard you say diversion. I realize that we’re all behavioral health practitioners, but how much greater that risk goes up in a primary care setting where they perhaps don’t have the ability to closely monitor patients once the prescription leaves our hands. I’m thinking of my primary care colleagues and the challenge for them around this risk with substance abuse with stimulants. We still have that as an unmet need. As you said, a highly efficacious medication, full-day coverage, and less risk would be an unmet need in my practice.

David W. Goodman, MD: That goes into another issue. One-third of the patients for adult ADHD don’t necessarily respond up to the maximum dose in the package insert. The basis for this is the OROS [osmotic-release oral system] methylphenidate study, which is a dose optimization study I was involved with 25 years ago. In the study, we were allowed to optimize dosing up to 108 mg. Now the OROS methylphenidate package insert max dose is 72 mg. Yet in this trial, on dose optimization with a 30% reduction in symptoms as the basis of dose optimization, one-third of the patients were taking over 72 mg—more than the max dose in the PI [proteasome inhibitor].

Part of the unmet need for those patients who don’t respond within the drug range guidelines is that they’re being underdosed. The question then becomes: is this patient being underdosed in need of a higher dose for optimal treatment of their ADHD? Or in the clinician’s mind, is this someone who’s goosing the prescription for unnecessarily high doses? How would you distinguish somebody who’s abusing the drug vs that person who needs to be on supertherapeutic doses?

Theresa R. Cerulli, MD: Absolutely. Any other thoughts on this topic before we move to emerging treatments, which I’m excited to hear about?

David W. Goodman, MD: One other thought of concern for clinicians is they’ll all sit and watch this and say “Yes, I understand.” We need to assess for this, but what do I do with people who come in trying to fake ADHD? Those people develop the story. They go online. If you type “ADHD faking” into Google, you’ll get millions of sites that will tell you what story to tell and how to convince them, and the clinicians are concerned. Am I being deceived in writing these prescriptions? How do I sort out people who need the medicine from people who are fakers and just looking for a prescription?

Greg Mattingly, MD: David, in that group, avoid the short-acting-stimulant trap. The people are coming in faking a diagnosis, and you and I have both worked with a number of professional athletes and some athletic organizations. The people usually faking or looking for short-acting stimulants, like short-acting amphetamine and short-acting methylphenidate, do not have an FDA indication for adult ADHD. If somebody says, “I tried my buddy’s short-acting amphetamine, and it really worked—it made me concentrate,” that’s a person you should never give a short-acting stimulant to. If you have any suspicions, if the alarm bells are going off, don’t use short-acting stimulants. Use medicines that have FDA indications for adult ADHD and the long-lasting once-daily medicines, and you’re going to avoid a lot of the pitfalls of those people who are doctor shopping, looking for short-acting stimulants.

David W. Goodman, MD: I’ll often suggest a nonstimulant medication if I have some concerns. Then I wait for the patient response to see if they’re treatment seeking or drug seeking. That might give me some sensitivity as to what I’m going to prescribe, but it’s an issue for clinicians. As much as we advocate the identification, assessment, diagnosis, and treatment, we have to be mindful of clinicians who are shaking their head and going, “You guys don’t understand the population I’m taking care of.” I’m happy to treat the ADHD people, but I don’t want to risk my license with the DEA [Drug Enforcement Administration] because I’m writing prescriptions for people who are just selling it down the street.

Birgit H. Amann, MD: We’ve had a few clinics in Michigan, family practice or internal medicine, that have opted not to treat anymore with federally controlled medications. They refer to specialist psychiatry. When we talked about nonstimulants, what’s so critical is to educate on the difference in how those medicines work that they must take it once a day, every day. In the case of clonidine, it’s twice a day. But in general, they can’t skip doses. They’re not going to build the level often so that group is written off unnecessarily, simply because they thought they could skip it on the weekends because they were used to doing that from stimulants.

Theresa R. Cerulli, MD: What popped into my head is that it’s not just the psychoeducation about ADHD. We have to do a lot of psychoeducation about how to properly use the medications because there’s such a misunderstanding among not just the kiddos and adolescents but also the adults. We get those questions all the time: what do you mean I couldn’t stop it on the weekend? That’s what I always did with my ADHD meds. Very good point.

Transcript Edited for Clarity