Medication

While Ritalin (methylphenidate) is the most common one used, there are other drugs that can be used. Sometimes the effects and side effects differ so much that another drug is chosen. To the right drug and optimal dosage can say one looks at the effects in combination with the side effects. If side effects occur you can look how this compares to the beneficial effects. Sometimes the positive results have lead to adverse side effects can be eliminated. In other cases, such adverse affects that one feels rather have taken a step backwards instead of forward. In other cases, people experience no results. Both children and adults with severe ADD psychostimulants are the most important medicines used for treatment. For milder forms of ADD are other drugs including the newer antidepressants have proven effective.

 

Medication can be a good way to regulate behavior. But medication is not the dominant solution for autism and / or ADD. Medication should be seen as treating the symptoms. If you stop taking medication, these symptoms will come back again. Besides medication, it is also important to have a good balance and holding it. Finding structure is very important. If you are considering medication it is always good to have an expert to be inspected.

RITALIN

Because Ritalin have at 70 percent a favorable result, means it is often the first choice. If this turns out to have little effect will be looking for other means. For one, the first choice has the right solution, for others this may be a quest of one year or longer. Ritalin is the most widely used drug in the fight against ADD symptoms. In Belgium, the drug known as Ritalin, but there are also generic versions in circulation that are usually only marked "Methylphenidate" . The drug consists of the active ingredient methylphenidate that has been registered since the early sixties. The drug is related to amphetamine-like substances, however, there are also major differences. The comparison with drug types such as speed and cocaine are very far-fetched and misleading. Research has shown that this drug in more than 70 percent of children and adults with ADD have proven effective . Ritalin or the generic form consists of tablets of 10 mg and will work for three to four hours. To achieve the effect you want, the manufacturer recommends 10mg per 10 kg body weight. Nevertheless, there are people who experienced satisfactory with lower doses.

  • Max. blood levels after 1.5 to 2 hours, stop working after 2-4 hours 
  • Start with 4 x 10 mg, one tablet every four hours, from 8:00 to 20:00  
  • Use timer or cell phone with alarm 
  • Rebound = increased anxiety, impulsivity, irritability, decreased concentration after dose stop working
  • After 1 and 2 wk evaluation dosage time and side effects 
  • Dosing every 2-3 hours by rebound, often to 23.00 
  • Dose children dependending  of impact and weight • Average adult dose: 60 mg  
  • Max . adult dose of 1 mg / kg / day

 

These days there are numerous websites and media reports emerged with much criticism. Unfortunately, most of the stories are very suggestive and scientifically ill-founded. Methylphenidate for example, would cause serious heart arrhythmias and an increase in suicide among young people. Let me stress that in the United States, many people suffer from obesity, high cholesterol and subsequent cardiovascular disease. The effect of methylphenidate for this group of people indeed is at risk and it is desirable to exclude potential health risks through a medical examination. In the Netherlands this is done by too few doctors and a standard protocol would have to come to these risks as much as possible. In addition, blood pressure should be monitored regularly. f you have doubts about your health and the possible risks, you may always ask for an additional investigation. Remains for me to say that the pharmaceutical industry has become an one billion industry  and have a lot of economic interests. Suppliers of new and alternative medicines have an interest in that concern arises about a drug as Ritalin. The user will then be easier choose to persuade their medicine.

Ritalin stimulates the brain cells to create and release certain neurotransmitters which are necessary for the proper incentive transfer. In people who do not have ADD or ADHD, this would just cause an overproduction that causes additional turbulence. Nevertheless, frequent abuse of this product take place in the nightlife. It gives people an extra boost when they when they want to sustain longer at night. While their brains are preparing for hibernation. In this sleep mode, the brains have the opportunity to create new resources and put the release of certain substances to the back ground. Prolonged abuse, the brains will stop working on their own so an addiction occurs. Also, symptoms of paranoid thoughts, fears and feelings of extreme anxiety occur. When there is indeed ADD or ADHD, these problems do not occur soon because then Ritalin / Methylphenidate ensures that there will occur a natural and harmonious balance in the functioning of brain cells. As mentioned there are also generic versions of Ritalin and the substance Methylphenidate ensures the working. Each tablet, brand or form, contains 10 mg of methylphenidate. Yet there are plenty of stories of people who experienced differences. This would not be possible in theory, and some pharmacists and doctors will try their best to convince you. It's your right to ask for your preference and they can not refuse. The past ten years the number of people who use Ritalin has increased substantially. Especially in the United States, this leads to much debate between supporters and opponents.

CONCERTA

Like Ritalin Concerta is also a brand name and also contains the same active ingredient methylphenidate. Concerta has a specific delay mechanism for the release of methylphenidate, with rising blood levels, spread over approximately 12 hours. The advantage of Concerta is that you only have to take one capsule once a day. The distribution of the drug is gradual, unlike Ritalin, which has a peak four times a day. A disadvantage of Concerta is that insurance companies reimburse poorly, so the monthly costs can amount. Doctors often start first with the prescription of Ritalin for the correct dosage to be determined. Ritalin is more quickly developed and can be halved to 5 mg. When the correct dosage is known and there are and not too bothersome side effects than can pass on Concerta. 

18 mg = 3 x 5 mg methylphenidate 36 mg = 3 x 10 mg methylphenidate 54 mg = 3 x 15 mg methylphenidate An adult use: 18 to 108 mg / day Duration of 10-12 hours once daily dosing if necessary evening dose short-acting methylphenidate Hard capsule prevents Methylphenidate abuse dissolved in gel Less or no rebound: less likely to forget, better patient compliance, greater efficiency in traffic Safer Safer More expensive in addiction, is not yet reimbursed (NL)

  • 18 mg = 3 x 5 mg methylphenidate 
  • 36 mg = 3 x 10 mg methylphenidate 
  • 54 mg = 3 x 15 mg methylphenidate 

An adult use: 18 to 108 mg/day

  • Duration of 10-12 hours 
  • once daily dosing 
  • if necessary evening dose short-acting methylphenidate 
  • Hard capsule prevents abuse 
  • Methylphenidate dissolved in gel 
  • Less or no rebound: less likely to forget, better patient compliance, greater efficiency 
  • Safer in traffic 
  • Safer in addictionMore expensive
  • is not (yet) reimbursed (NL)

 

Concerta is composed of a number of segments within. After ingestion it creates an opening which the active ingredient gradually be issued. Because of this system it is hardly possible to abuse this medicine and to use it for other purposes.

 

In this diagram you can see the difference between Ritalin and Concerta. The blue line is Ritalin, the other two are Concerta in  two different application forms.

STRATTERA

How does Strattera works?

Everyone has chemicals in their brains that help to pass signals between nerve cells. These substances are called neurotransmitters. An example of a neurotransmitter substance is noradrenaline. Researchers believe that patients with ADHD have, in some areas, a shortage of the substance noradrenaline. Strattera helps the amount of noradrenaline to maintain, wich the transmission of signals is more effective.

 

What makes Strattera special?

Strattera is a new drug for treating ADHD. The special thing about Strattera is the fact that, unlike other drugs for ADHD, it is working not a few hours, but the whole  day. Strattera has to be taken just once a day and will working of the time up until bedtime. After starting treatment it takes some time before improvements are visible: It usually takes about six weeks before the effect of Strattera can be evaluated.

Another reason why Strattera is special, is because unlike other ADHD drugs it is not derivative of amphetamine and therefore not covered under the Opium Act. It does not work on those parts of the brains associated with feelings of euphoria and addiction, but only those parts of the brains that are important for reducing the symptoms of ADHD.

 

How long does it take for Strattera to work?

Although the efficacy of Strattera in ADHD throughout the day continues, it will take after starting treatment about six weeks before the effect is clearly visible. This means that it is important to be patient in the beginning of treatment. So evaluate the effect of treatment with Strattera after 6 weeks with the treating physician.

MEDIKINET CR

Since September 1, 2007, there is a new long-acting methylphenidate (mph) for children with ADHD in the Dutch market: Medikinet CR, together with short-acting Medikinet. Medikinet CR works 8 hours and contains 50% white balls mph, with immediate release, and 50% blue balls mph with sustained release. The effect occurs within 30 minutes of ingestion. Rebound (development of the drug leading to more unrest temporarily) at the end of the day can be absorbed with additional short-acting mph. There are capsules of 10, 20, 30 and 40 mg Medikinet CR. Medikinet CR needs to be taken during or after a meal (breakfast) to prevent rapid absorption and thus insufficient duration of action. The capsules should not be chewed, but may be opened to the content, for example taking into applesauce. The medicine contains sucrose. Short-acting Medikinet is launched in tablets of 5, 10 and 20 mg,  a lower or higher short-acting dose is feasible. 

 

Compensation 

Still there is no long-acting medication for ADHD / ADD completely covered in the basic and only the (low) cost of an equivalent amount of Ritalin are reimbursed. Medikinet CR will be, by the same additional compensation insurance packages, reimbursed as other long-acting ADHD / ADD drugs.

DEXTROAMPHETAMINE

Dextro-amphetamine like Ritalin / Concerta is an amphetamine-related drug also used to treat ADD. Therefore this medicine is on the list of opiates. After methylphenidate Dextro-amphetamine is coming in second place when it comes to the pharmaceutical treatment of ADD. It does not inhibit the reuptake of the neurotransmitters, but allows more neurotransmitters available. Although the effects and side effects are almost appears the same, Dextro-amphetamine is often better working with people with ADD. Like Ritalin Dextro-amphetamine should also be taken throughout the day . This drug has a longer duration (4-5 hours) than Ritalin and is also stronger. The dose is usually half of what they were accustomed to Ritalin. It must be prepared by the pharmacy in doses of five or ten milligrams at the request of the physician. There is no longer acting form produced such as methylphenidate. Methylphenidate and dextro-amphetamine are among the group of Wekaminen. Wekaminen derive their name from the "wake effect", that means, the fatigue is suppressed, and one feels energetic, cheerful and alert. Often leads to overconfidence and the tendency to talk a lot. Wekaminen inhibit appetite, difficult to sleep and reduce sleep depth. Other effects include blood vessel constriction (thereby increasing blood pressure) and an accelerated heart action.

 

EFFEXOR

Efexor is a antidepresivum also more often prescribed for people familiar with ADD. Often a combination of problems such as ADD with anxiety and panic symptoms. The action of the substances that Efexor hold, is a similar effect on the brains like the stimulants at Ritalin and Concerta. Effexor enhances mood and reduces anxiety. It regulates the amount of serotonin in the brains. This naturally occurring substance plays a role in emotions and moods. In higher doses above 150mg per day, Effexor has a slight effect on norepinephrine and dopamine, two other natural substances that may affect the mood. 

Lower doses of Efexor only affects the amount of serotonin, and does it indeed works on anxiety and tension. Efexor reduces overall anxiety and tension. This reduces the physical symptoms like palpitations, stomach pain, trembling and sweating, often accompanied by anxiety and tension. Efexor is a temporary help for these symptoms. It doesn't solves the cause of your anxiety, however. Effexor also has disadvantages, making prolonged use inadvisable, but it also applies to other resources that I mention. The mechanism of Efexor is the same as Prozac, Paxil, and sertraline. Seroquel on the other hand is an anti-spychoticum  and is used in psychoses and schizophrenia, and has no effect in anxiety disorders.

 

INSURANCE

All insurance companies apply different fees for medications such as Concerta and Strattera. Often one additional policy will be closed. Some insurers promise 100% fee but with a maximum amount per year. With some additional policies there are still some disadvantages. Besides the extra premium you pay a deductible of 150 euros per year. 

THE OPPONENTS

There is already spoken and written a lot about Ritalin and Concerta. Due to the explosive growth in the number of prescriptions are also critical voices. Sometimes the arguments are well supported but there are enough stories that are not really based on truth and only make unnecessary trouble. The drugs used to treat ADD in adults are the same as in children. Normally, first the stimulant medications will tried: methylphenidate (Ritalin / Concerta) or Dextro-amphetamine. Some clinicians avoid stimulant medication because they are under the Opium Act. Sometimes they think you're looking for the ADD diagnosis to get this medicines.An answer on that is, that the doses given for ADD are very low compared to what a drug user could take. In general, ADD-ers have the opposite effect when the use stimulant medication. Instead of getting "high", like the addict wants, ADD-ers are getting very calm. ADD-ers with a history of drug abuse - alcohol, marijuana and cocaine are the most common - often find that their desire for these drugs is gone when they use medication for ADD.

 

Experts believe that drug abuse in these cases probably are cases of self-medication which has gotten out of hand, and at therapy is no longer required. Study of young people on stimulant medication for ADD shows that drug abuse among them is less frequently than their peers. Ritalin, the most widely used medication for ADD is fifty years in use and is very safe when taken as directed. Dr. Hallowell (USA) states that it is actually safer than aspirin.

 

Research on Ritalin over the past 50 years in children with ADHD has shown that this drug brings significant improvements for the most ADD-ers  (For Ritalin helps it for 70% of those with ADD diagnosis, provided that the correct dose is given.)

 

It is still not known how Ritalin or other stimulants medicines work, but it is strong evidence that these medicines help most of our ADD-ers to function better - ranging from mild to dramatic improvement. Again, medical science suggests that these drugs are prescribed in doses that are not harmful to us.

 

ADD is a neurobiological disorder. People with ADD have a deficiency of one or more substances (still not clear which) in the brains in the right quantities at the right places, and at the right times. We sometimes have these substances in the right quantities at the right place, but not always, and not always when we want to  - that is why the concentration and focus is so arbitrary. If these substances are not present as they should - as in people without ADD - it becomes ADD.

 

Dr. Daniel Amen, MD, an ADD specialist in Fairfield (CA, USA), says that the brains of those with ADD or ADHD benefit from stimulant medications because they have more blood flow to the frontal lobes. Those who treat ADD know that not treating ADD is doing more damage - emotionally and socially - than what possible side effects of medication whatsoever can arise. Unfortunately this is not appreciated by the public  and the media often do everything possible to the fear of that audience for ADD medications continue to stir. 

Some practitioners continue to enlarge the dose until the desired effect is reached or when there are too many unwanted side effects such as agitation, stomach or headaches that are not within a few weeks gone. Some prescribe antacids for treating patients who have stomach pain by helping the adjustment.

How do you determine whether a medication works, or what you use is the best for you, and the best dose and dosing schedule?

Thomas Phelan (Ph.D.) suggests that all patients try a second or even third stimulant medication. People differ in their response properly. He starts with for example Ritalin and keeps track of the results at any dose. Then he shows the patient two othermedicines to try.  again he keep an eye on what will work best at what dose. Then he and the patient together deciding what medication and what dosage is best. The idea is that although you can be treated for ADD, but if you can not compare to what works best for you, you will never know if it can´t be (much) better. 

It is therefore very important that you seek out a therapist who understands ADD and is open to work (with you) and doesn't dictate you. You need a therapist who is aware of the changes that medication can caused to the functioning of an ADD-er and who knows that it is not a condition where a drug in a fixed dose for all would be the answer. On the other hand, you, the patient, has to learn what changes in your work you should pay attention to when you are on medication. Sometimes you need someone else in your environment that noticed these changes, because ADD-ers are often poorly at self-perception.

What specific changes can you expect from medication?

If you on medication it is possible that you still involved in a conversation or a completes a task. before going on to something else, or you remember something that needs to be done. You can noticed that social situations are more relaxed, or that you have less trouble to sit in a meeting. 

Dr. Theodore Korn Mandel from Seattle says that ADD-ers on (good set) medication improve the attention, concentration, memory, motor coordination, mood and ability to complete tasks. Simultaneously it reduces the tendency to daydream and to wander (and with ADHD, the hyperactivity in, anger, and challenging or difficult behaviors). The treatment let intellectual possibilities that existed allready function better. 

 

If medication is used the right way, patients experience a considerable increase of control. Objective observers see a better control of attention, concentration, and ability to finish something. Many are much better able to cope with stress, with less frustration. The social interaction Improves and relaxes. If there is restlessness it will decreases also.

 

He goes on to say: "It is very important to remember what medication does and what it does not. Medication is like putting on glasses if you're nearsighted. It allows you to function better. But with glasses you don't automatically behave differently, or even write a report on time or get in time out of your bed in the morning. They make your eyes are able to function better if you choose to open them! You are still in charge of your vision. Or open your eyes, and what you watch is up to you. Medication allows your nervous system to be better able to send messages, and ensures a better use of your skills and knowledge. Medication does not give you skills or motivation to do something. 

ADD-ers often complain that they forget appointments, that their work is not complete, make mistakes and daydreaming. With medication these things improve quite often. Go to bed and discover that most of the day went as you planned, it is no longer an unattainable dream. 

 

Dr. Gross from Santa Clara (CA USA) suggests that one wonders whether the medication you use will help you with the following problems: 
(This list is for both ADHD and ADD, ADHD most features are on ADHD) 

  • Underachievement in school / training and inattention
  • Hyperactivity or excessive fidgeting / wobble 
  • Verbal impulsivity and / or impulsivity in behavior (loud interrupting others, do before thinking) 
  • Difficulty falling asleep 
  • Difficulty in getting up 
  • Excessive irritability without any cause and / or quickly frustrated 
  • Bedwetting 
  • Dyslexia 
  • Periods of flammable, emotional outbursts, or tantrums 
  • Unexplained and persistent emotional negativity 

If it does not, ask for change of dosage or medication type. It is not enough when medication, only relieved one symptom - such as difficulty falling asleep, but no other. 

It may take time to be find a good clinician and appropriate medication, but if you persist, the efforts amply rewarded. Good luck with your search! 

NOTE: none of the foregoing should be construed as medical advice and should not be used as a substitute for medical advice. Much of the above material is adapted from Paul Jaffee, NY, USA.