Stimulants- The Explosion, The Reasons, The Risk

Ritalin (Photo credit: Wikipedia)
Stimulants- The Explosion, The Reasons, The Risk

Stimulants are a group of drugs whose most famous example is Ritalin.

We are currently living at a time when the use of these drugs is truly epidemic, so it makes sense to take a moment and look at why they are so popular, and whether there is any risk (there is).

The Basics of Stimulant Chemistry 
Let's begin with a few basics about these drugs.   All stimulants can trace their chemistry back to the king of all stimulating chemicals- adrenaline, also known as epinephrine.   Many of us are familiar with what adrenaline can do- it causes excitement.  Adrenaline makes your heart race, your mind clear, your breathing go deeper, your alertness soar, and overall makes you very, very excited.   But if you eat adrenaline, nothing happens, the gut destroys it before it can do anything.

For the last 5,000 years, the herb ma-huang has been used in China to give people the boost of adrenaline in an oral form.  The chemical in the herb is ephedrine, and it was from this chemical that in 1887 a chemist created a new chemical, amphetamine.  Amphetamine was not used in people until 1927, but it really took off.  Various forms of amphetamine were widely used by German, British, and American military during World War II.  Near the end of the war, in 1944, a chemist created a related chemical, methylphenidate, and he gave it to his wife to increase her low blood pressure.  His wife's name was Rita, so he called the new drug Ritalin.

Today, these two drugs, amphetamine and methylphenidate, account for nearly all the stimulant drugs used to treat people who struggle with paying attention.  They both work by stimulating the activity of various networks of nerves in the brain.  Each of these networks help control and manage a wide range of functions in the human mind.  The key network the stimulants stimulate is the dopamine network.   The nerves in the brain that use dopamine to communicate with each other are very much involved in the overall alertness of the brain, as well as a sense of reward and pleasure.   

Like many drugs, the chemicals amphetamine and methylphenidate are sold under many brand names.
Amphetamine is sold under two main brands today:  Adderall and Vyvanse.   Adderall is straight and pure amphetamine.  Vyvanse is amphetamine with an amino acid attached.  As long as the amino acid remains on, this drug will be inactive.  But if you swallow a pill of Vyvanse, your gut will cut off the amino acid leaving you with straight amphetamine, now activated and ready to go.  Therefore, Vyvanse (once digested) really is very much the same drug as Adderall.

In the methylphenidate side of the stimulants, there are a few more brands.  They include:  Ritalin, Concerta, Methylin, Metadate, Daytrana, and Focalin.  Focalin is what's called an isomer of methylphenidate.  It turns out most drugs and many chemicals in the body are like our hands, they come in right and left handed forms.  Both forms are identical in structure in all ways, but physically are mirror images of each other.  Focalin is the right-handed version of methylphenidate.   All the other  methylphenidates have both right and left handed versions of the drug in the pill.  So a 20 mg pill of Ritalin has 10 mg of Focalin in it (the right handed form of  methylphenidate) and 10 mg of the left handed form of  methylphenidate.  So aside from Focalin, all the other brands of  methylphenidate are exactly the same.  So 30 mg of Ritalin has exactly the same drug in it, really is the same thing,  as 30 mg of Concerta, or Methylin, or Metadate, or Daytrana.

Lots of Kids are On These Drugs
Recent surveys reveal that lots of kids are on these drugs.  Some years ago, one survey found that in the United States, 10% of boys age 10 take stimulants to get their homework done and do well in the classroom.

Just recently, an anthropologist conducted a study of undergrads at Case Western Reserve University.  The question was how many college students take the stimulant Adderall during midterm or finals weeks?
The answer reflects a new reality in the lives of our children- 93%.  That's right, nearly every college student at Case feels compelled to take the powerful drug Adderall in order to succeed.

What makes this incredible rate so amazing is that for the vast majority of these students, their use of Adderall is highly illegal.  Use of Adderall without a prescription is no different than scoring speed off the corner.  If the DEA finds out, you can easily spend many years in jail.  And yet, 93% of college undergraduates are using this drug, most without a prescription.

And, just in the last few years, we have seen the number of kids being prescribed stimulants really taking off.  The 10% of all American 10 year old boys is a rate quoted from several years ago, but that number is surely much higher now.  In our office, we are seeing many, many children being referred by their teachers to us, with the express directive to see about starting their child on stimulants to succeed in school.

Why Are Stimulants Being Used So Much Now?

There is no doubt at all, as noted above, that the use of stimulants is galloping ahead.  Why is that happening?

The most important reason is that they work.   There is little mystery about this fact.  It is a fact that if you stimulate or arouse the brain, it simply works better.  This is likely a fact for all animals, but is certainly how we humans are built.

It makes a lot of sense.  If you find yourself in real danger, your mind gets a little bath of adrenaline, and that causes it to get very excited.  Once aroused, the mind has the energy and resource to become amazingly focused, to laser in on the task at hand and put all mental resources on getting the job done, thoughts fly faster and with more purpose.  Think about a tiger suddenly jumping at you, all of a sudden your mind instantly organizes all thoughts and actions towards escape.  The level of focus created by this excitement is intense and extremely effective.  From the point of view of evolution, all humans whose minds do not focus at moments of danger tend to have a lot fewer kids than those whose minds do focus in response to a threat.

One could argue that all of us are descendants from humans whose brains got going and got focused when threatened.  And so our minds have this response to arousal and stimulation.  Of course, too much excitement and we move from focus to agitation, losing ability to get good work done.

We see the same thing happen with coffee.  A cup or two seems to help nearly everyone wake up, be more alert, and be more productive.  But too much coffee and our minds are whizzing into chaos.

So it is with the stimulants.  A bit of Concerta, or Adderall, or Ritalin, will improve the focus and efficacy of 80% of any group of people!  That's right, these drugs help nearly everyone do better work.

This has nothing to do with ADHD.  Yes, about 80% of people with ADHD who take stimulants will produce better work and get better grades.  But the point is that about 80% of all people, will do better work and get better grades when they take stimulants.

So the main reason that the use of stimulants is exploding is that they work.

The other reason is more cultural and complex.  The drugs work, but they have always worked, and known to work since the 1950's.  So why now in the 2010's is use booming so dramatically?   I suggest that one reason is the move towards describing our problems in thinking as medical conditions.  Another is the rise in complexity of thinking required to get good grades or do good work.

Going Medical
Consider a 6th grade boy named John.   He is doing OK in school, but he is not doing as well as he could.  He turns out to be a very, very bright young man, but seems bored in school.  He is often seen not paying attention in class, even looking out the window most days.  Parents find getting him to complete his homework is a great struggle.  Lately his grades have been slipping from mostly B's to more and more C's.
His teacher meets with the parents, and although stating she cannot diagnose medical conditions or advise on medical therapies, she suggests they look at the issue of ADHD and the option of medicating the child.
The parents go to their doctor and let him know the school is worried about his ability to focus and ask if he has ADHD.  A questionnaire is given to the parents and teachers and they confirm that he has many symptoms of ADHD, he is duly diagnosed with this mental health disorder or condition, and started on a stimulant.  He suddenly improves dramatically, now a model student with all straight A's.

This is very, very common story in America today.  But if you look at the story carefully, one could conceivably think of this in a different perspective.  Not that long ago, one could have thought about this as a case of boredom, or mismatched interests.  One could make the case that this 6th grader dislikes the subjects at hand and is defying the authorities in his life who want him to buckle down and do the assignments.  I am not going to say which perspective is right in this case, only that it is conceivable that an explanation other than a medical condition is possible to explain at least some situations where our children underperform.

Are Stimulants Addictive?  Can you stop taking them easily?  Do people tend to use them for a short time or long time?
The stimulants are addictive.  They tend to activate addiction when taken in high doses, high enough to get high, that is.  We do not see addiction develop very often in children taking them to enhance performance in school.  The doses are low enough to avoid causing a high.
If addiction is not activated it is a very simple matter to stop, one simply stops taking the pills.  Normally very little if anything happens when you stop taking stimulants, even after many years.

Yet, curiously, most people who take stimulants for better focus tend to take them for many years, often many decades.  Again, the reason is likely obvious.  If you take a medication and on it you find your grades and work success soar, why would you stop?  Why return to days of failure?  The answer is for most people, not to return to failure, but to keep taking the stimulant.

If Stimulants Work, Doesn't that Prove ADHD is present?
But what about the fact this child's work got so much better on the medication?  Doesn't that prove he has ADHD?  The full answer is, no.
Remember, as noted above, about 80% of all humans will find their brain working better, often dramatically better, on these medications, whether they have ADHD, or not.

If Stimulants Work so Well for So Many, Why not Have Everyone on Them?
This is a very important question.
If these drugs were truly perfectly safe, I would be in favor of their very wide use.  I would actually have no problem with 93% of college students taking them during exam week.  They would turn out to be simply a stronger version of stimulants like coffee, just as safe, and more effective.

Sadly, the stimulants are not free of serious risk.
All stimulants carry a set of minor and major risks.   Minor side effects are only minor because they go away if you stop use of the medication.  Major side effects are major because they tend to be permanent.
The key minor side effects are:  loss of appetite with real weight loss, disrupted sleep, headache, stomach ache, sensation of altered mind.
The three key major side effects are:  Diminished final adult height, tics, and cardiac effects.
  • Height  It is estimated that a number of kids (not an issue if you are already fully grown) will lose 1-2 inches of final adult height if they take a stimulant regularly over time.
  • Tics  Tics are twitches of one or several sets of muscles.  They can be very small, like a very partial wink of one eyelid every few days, or very severe, involving arms and legs and vocalizations every few seconds.  Although proof is not yet complete, there are indications that use of stimulants can increase the chance of a person developing tics, permanently.  
  • Cardiac effects There are two very serious risks here, these are the most dangerous aspects of use of stimulants.  The chair of the Cleveland Clinic Department of Cardiology is Dr. Steven Nissen.  Widely regarded as one of the world's top cardiologists, Dr. Nissen voiced his concerns about the impact use of stimulants would have on a heart as chair of an FDA Panel looking into this concern.  His perspective was published in the world's leading medical journal, the New England Journal of Medicine   http://www.nejm.org/doi/full/10.1056/NEJMp068049
    • Sudden Death.  There are a number of children and adults who suddenly died after taking a dose of stimulant medication.  This appears to be an event limited to individuals with rare abnormalities of their heart's electrical conduction system.  The problem is that most people with these rare electrical conduction systems do not know they have them.  A screening EKG prior to use of these medications could help prevent some, but not all of these tragic events.
    • Long-term Wear and Tear- the Risk of Congestive Heart Failure later in life  Those who study how congestive heart failure develops use the fact that simply dripping amphetamine on an animal heart long enough will create congestive heart failure.  There are reports in the medical literature of some older adults developing heart failure when used with amphetamine.  Of much greater concern is that we are currently embarked on a rather worrisome experiment.                         As noted above, people who benefit from use of stimulants (about 80% of everyone who might try them), tend to stay on them for many years, even decades.  We now have placed millions and millions of children on stimulants, and they will likely be taking them daily for many, many years.  No one, including myself, who is currently prescribing these medications to children, will likely be in practice or even alive, when these children grow into later middle age.  We simply do not know what the rate of heart failure will be in this group of many millions of children once they turn 40, 50, or 60, or more years old.  But the experience with animal research clearly establishes the possibility that long-term, daily use of stimulants could set up a very real risk of very serious heart disease later in life.
Bottom Line
  • The use of stimulants is rising, very rapidly, and across populations that have nothing to do with ADHD
  • The notion that children who do not pay attention in school have a medical condition has grown and continues to increase dramatically
  • Stimulants come in two major forms- amphetamine and methylphenidate.  They have a known set of side effects
  • Stimulants work very well, for everyone.  In any group of people, about 80% will see improvements in their life when they use stimulants.
  • The biggest question mark on the risk of using stimulants is their long term impact on the heart.  We do not know what that might be, but the chance that it could be very significant needs to be answered.
Putting all this together, at Advanced Pediatrics we only prescribe stimulants with the greatest of care.  We take the following steps to ensure your children are exposed to the risk of stimulants only when necessary and only with your awareness of the risk:
  1. We try to only use stimulant medication for the diagnosis of ADHD.  If a child has trouble in school, we start with finding out why, not with a therapy.  Causes might include other cognitive dysfunctions (e.g., dyslexia), emotional troubles, relationship concerns, or other problems.  So first, see if the problem is really ADHD or some other cause.
  2. We try to use interventions free of side effects first.  Options include ADHD coaching, counseling, and cognitive training programs.
  3. Use of stimulants should be used only if the impairment is very serious.
We live in an era when 93% of some college's students use Adderall to get a good grade!  But these medications are not entirely free of risk.  Advanced Pediatrics will continue to keep you informed as we learn more about how the brain works and how we can most safely improve how our children's minds work.

Dr. Arthur Lavin

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.
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