Margaret V. Austin, Ph.D., edited by C. E. Zupanick, Psy.D.
Within the stimulant drug category, there are three basic types:
1. Methylphenidates: This family of stimulants is used to treat both ADHD and narcolepsy. Brand names are: Ritalin®, Concerta,® Metadate®, Focalin®, Daytrana®. 2. Dextroamphetamines: Brand names are: Exedrine®, Vyvanse®. 3. Amphetamines: These drugs were once approved by the FDA in the 1960's for the treatment of obesity and ADHD. The most common brand is Adderall®.
Ritalin, a methylphenidate, is the most commonly prescribed medication for ADHD. The initial prescribed dosage is 5 mg of the short-acting variety for young children; and, 10 mg for older children, adolescents, and adults. Most people take a morning and a lunch dose. Some individuals also require a mid-afternoon dose in order to complete homework or other necessary tasks. Patients (and caregivers) are encouraged to track response to medication and report back to the prescribing healthcare provider. If side effects are minimal, the provider will gradually increase the dosage until the patient notices improvement. Children and their caregivers should not increase the dosage without consulting with their healthcare provider. The maximum recommended dosage of Ritalin is 60 mg per day. This higher dose is typically tried before switching to a different medication.
If Ritalin is effective, and an optimal dose has been determined, the provider may suggest switching to a long acting (LA) formula. This eliminates the need for more than one dose per day. Ritalin LA is formulated with 50% immediate release, and 50% delayed release. This two-tiered release extends the drug's effectiveness for up to eight hours. This produces two equal phase dosages, one in the morning and one in the afternoon. This works well for many people, but not all. Finding the most effective dose may require patience and flexibility as different strategies are tested.
Focalin is a very strong type of methylphenidate. It has only been around for about ten years. A powerful drug action can be very helpful in some cases; for instance, some adults or very large people. However, it may be too strong for young children and may cause too many side effects. Focalin comes in a capsule with 50% immediate release, and 50% delayed release. It lasts 12 hours.
Another option is Daytrana, which is a methylphenidate patch. Basically, the patch has medication that's embedded in the adhesive. You peel off the liner, and the adhesive holds it next to skin. Then the medication is absorbed through the skin, directly into the bloodstream. A patch provides a more even and steady dose than medications absorbed through the intestinal track. However, it takes longer to take effect. Nonetheless, once a therapeutic level is obtained, the medication level stays very constant for about 9 to 10 hours or until the patch is removed. Blood levels return to baseline about an hour and a half after removing the patch.
If Ritalin does not prove effective, Dexedrine, a Dextroamphetamine, is the next most likely candidate to try. About 12% of people with ADHD are treated with this medication. In addition to impacting dopamine levels, Dexedrine also affects norepinephrine levels. Norepinephrine is another neurotransmitter that affects our ability to pay attention and focus.
This medication decreases fatigue; increases motor activity and mental alertness; and produces mild euphoria. The side effects of using Dexedrine include increased heart rate, blood vessel constriction, and bronchial dilation. However, the primary concern regarding its use is related to its potential to be resold as a street drug. It is twice as powerful as Ritalin, and is highly valued in the underground drug trade.
A 5 mg dose generally lasts 5 to 6 hours. The use of Dexedrine adds flexibility to a treatment regimen because there are 3 strengths of slow-release tablets. Although these are more reliable than slow-release Ritalin, they are harder to obtain because they are more closely monitored by the DEA.
Vyvanse is another amphetamine but it also contains a compound called lysine. Lysine attaches itself to the active ingredient in Adderall, an amphetamine. To metabolize this drug, an extra step is needed to break apart Lysine from Adderall. This additional process ensures that Vyvanse lasts a very long time-up to 14 hours. Although this length of time could easily be too long for a young child, it could be ideal for people in high school or college, or an adult. It's a powdered medicine so it will have a consistent release, without peaks and troughs.
Adderall is an immediate-acting amphetamine. Its effect will last for 3 to 4 hours. Adderall XR (extended release) is a mixture of both immediate and slow-release forms. The XR form lasts up to 10 to 12 hours (twice as long as Dexedrine). The advantage of the XR form is it usually requires only one dosage per day. Both objective performance measures (e.g., grades, tests) and subjective measures (e.g., teacher ratings) indicate both forms of Adderall are effective. The side effects of Adderall are similar to Dexedrine. The recommended dose for children is 5 to 60 mg. This wide range indicates the different responses of individual children as a result of size, metabolism, and age.
The Federal Drug Administration (FDA) is a governmental agency in the United States responsible for drug regulation. In 2005, the FDA released a warning about the use of Adderall in response to 12 pediatric deaths. With further investigation, extenuating circumstances were found in each case. These included heat exhaustion, Type I diabetes, dehydration, and extremely vigorous exercise. Furthermore, several children had underlying heart conditions that contributed to their death. The FDA compared the rate of sudden death for these cases of pediatric Adderall users, against the sudden death rate in the general pediatric population. This comparison revealed similar rates. As a result, the FDA is continuing to investigate the relationship between Adderall and sudden death. However, the FDA has not removed Adderall from the marketplace. Currently, there are no further restrictions on Adderall, other than a warning that people with an underlying heart condition are at particular risk.