ADHD Meds & Serious Side Effects

     In my last article on ADHD medication I talked about the problems inherent in using stimulants. In this article, we will discuss the specific side effects that popular ADHD medications can have. But let’s establish a few parameters first. To begin with we know that medication does not work for all ADHD symptoms. We also know that medication‘s do not affect everyone in  the same way. Finally, there are other alternatives that may work better and have no side effects; I believe that we can use a combination of supplements, behavior therapy and skills training to address most if not all of the ADHD symptoms. This is referred to as a multimodal approach. 

     I am a systems based therapist. I look at causality as being multiple and cyclical. By that I mean that  it is a gross oversimplification to think that A causes B. If you think in linear terms such as that, you eliminate many other possible solutions. Let’s take the common cold. We used to think that a germ caused a cold. We now know that a germ plus a receptive host, under the right set of circumstances, that repeats again and again is what actually results in the common cold. 

     It is the same thing with ADHD. We do not know exactly what causes ADHD. But we do know that each child is unique such that using a One Size Fits All approach is less likely to be effective. Treating ADHD with medication alone is such an approach.As such, it often fails. In addition most ADHD meds have serious side effects. As I mentioned in my previous article, https://mindweightwellnesspro.com/mentalhealthblog/2965qykwugi18bcbpnv3pwb2soowjc the medications most often used to treat ADHD are stimulants, non-stimulants and antidepressants.

STIMULANT ADHD MEDICATIONS 

Let’s start with the stimulants as they are the most popular. These drugs are believed to increase the levels of the neurotransmitters  in the brain that can improve focus . The problem as we saw in the first article is that they also come with many side effects. Nonetheless, the FDA has approved dozens of brand-name stimulants for ADHD. Although this sounds like a multimodal approach, the reality is that all of these medications contain  versions of only two different stimulants; methylphenidate and amphetamine.

Both of these drugs are dangerous, as evidenced by the fact that, Doctors don’t generally prescribe them for people with:

• Heart defects or heart disease

• High blood pressure

• Hyperthyroidism

• Glaucoma

• High levels of anxiety

• A history of drug abuse

There are two types of ADHD stimulants when it comes to their timing: short-acting (immediate-release) and intermediate or long-acting (extended-release).

The short acting stimulants usually begin working within 30-45 minutes of taking them and can last about 3-4 hours. They are prescribed for use two to three times a day. 

Examples of each kind of the short-acting stimulants include:

• Amphetamine: Adderall, Dexedrine, Evekeo, Zenzedi

• Methylphenidate: Ritalin and Focalin

Although the Amphetamines may be a little stronger than methylphenidate, and their effects may last a little longer, in general, both medicines are very similar.

     Intermediate and long-acting stimulants can last 6-8 hours, while long-acting stimulants can last 8-12 hours and sometimes up to 16 hours. You usually take these once a day although I have found in my practice that many people fail to understand how long the medication affects them and so they often take them more than once a day, and then are unable to sleep at night.         

     A commonly held belief is that long-lasting medicines are usually the best option because people with ADHD may have trouble remembering to take their medicine. I think the upshot of this is that they end up overmedicating.I generally recommend taking as little as possible for the shortest period of time necessary.

Examples of intermediate and long-acting stimulant include:

• Amphetamine: Adderall XR, Vyvanse, Dexedrine Spansule, Dyanavel XR, Adzenys XR-ODTC

• Methylphenidate: Concerta, Metadate CD, Ritalin-LA, Aptensio-XR, and Focalin XR

The problem with all of these stimulant medications is that they have significant side effects which include:

• Loss of appetite

• Upset stomach

• Feeling restless or jittery

• Racing heartbeat

• Trouble sleeping

• Irritability or mood swings

• Headaches

• Dizziness

• Depression

• Tics

 The long-acting medicines may have greater effects on appetite and sleep than short and intermediate-acting stimulants.They may also raise your blood pressure and heart rate. So I encourage individuals who must use these drugs to use short acting. You can always take a second dose but you can’t undo an overdose.

     But if that’s not scary enough, there are some other safety concerns when it comes to stimulants.Experts in the field, have pointed out that:

• We do not yet know what the long-term effects on people whose brains are still developing will be. 

• The risk of sudden death in people with heart conditions is higher. The American Heart Association recommends that all people, including children, have their heart evaluated before starting stimulants. I can tell you from my experience that this does not happen. 

• There is an increased risk for other psychiatric problems. Some people may have personality changes on stimulant medicines. For instance, stimulants may trigger or make worse symptoms of hostility, aggression, anxiety, depression, or paranoia. People who have a personal or family history of suicide, depression, or bipolar disorder may be at higher risk of this than other people and will likely be followed closely by their doctor while they’re taking stimulants. And many people on stimulant medication suffer from “Anodontia” or less loss of joy.

• Finally the potential for abuse is significant. A growing problem in schools and colleges is that teens and college students may abuse stimulants when they study for exams or when they want to lose weight.Those with prescriptions may share or sell their stimulant medicine to classmates. It is next to impossible to ensure that your child is taking their medicine and not sharing or selling it.

Non-Stimulant ADHD Medications 

 Let’s take a look now at the non-stimulant ADHD medications. About 15%-30% of people don’t respond to stimulants. If stimulants don’t work for you or you can’t tolerate the side effects of stimulants, non-stimulants may be an option. Your doctors may also prescribe these to take with stimulants because they can boost the effects. Non-stimulants are not controlled substances, so there’s less chance of abuse. They may also be a good option if you have had problems with drug abuse before. In addition, non-stimulant medications usually take a while to start working and they may not work as well as stimulants.

The U.S. FDA has approved four non-stimulants for the treatment of ADHD:

• Atomoxetine (Strattera)

• Clonidine (Kapvay)

• Guanfacine (Intuniv)

• Viloxazine (Qelbree)

     Atomoxetine (Strattera) and viloxazine (Qelbree) belong to a class of antidepressants called selective norepinephrine reuptake inhibitors (SNRIs). These medications increase your brain’s level of a neurotransmitter called norepinephrine. They may help improve the ability to concentrate and control impulses, but they may not work as well for symptoms of hyperactivity. You may not feel the effects until you’ve been taking them regularly for about 3-4 weeks, although they generally work for 12-24 hours.

     Because they are antidepressants, they may be a good option if you also have anxiety or depression. Atomoxetine is approved for children aged 6-17, and is also prescribed for adults. One benefit of these is that they don’t cause or worsen tics or other symptoms of Tourette’s syndrome.

     Guanfacine (Intuniv) and clonidine (Kapvay) belong to a class of high blood pressure drugs called alpha-2 adrenergic agonists. These were initially used “off label”  for ADHD for many years. Off-label is the term used when a doctor prescribes a medication for a condition for which it has not been FDA approved. Drug makers eventually made extended-release versions, and the FDA approved them as a treatment for ADHD

      Because these drugs are meant to lower high blood pressure, they have a calming effect, which may help with symptoms such as hyperactivity, the ability to control impulses, and feelings of aggression. Unfortunately they may not help as much in improving attention and focus.

The side effects of Atomoxetine and Viloxazine include:

• Stomach pain or upset stomach

• Nausea or vomiting

• Mood Swings

• Headaches

• Dizziness

• Sleepiness

     These side effects may cause insomnia and appetite suppression, but it’s less common than with stimulants. Adults may also have dry mouth, trouble peeing, and sexual side effects, such as erectile dysfunction. Atomoxetine may also cause high blood pressure, increased heart rate, and liver problems in some people.

     Rarely, SNRIs may increase the risk of suicidal thoughts and actions in some people, especially children and young adults who have bipolar disorder or depression. Again in my experience, no one is checking to see if the individual has bipolar disorder or even depression.

Guanfacine and Clonidine side effects include:

• Nausea, stomach pain, or vomiting

• Loss of appetite

• Headaches

• Dizziness

• Sleepiness, fatigue

• Dry mouth

One last issue is that these medications cannot be discontinued suddenly as it can cause a rapid rise in your blood pressure and heart rate.

Off-Label Antidepressant ADHD Medications

     Other than the two SNRIs already mentioned, the FDA has not approved any other types of antidepressants for ADHD treatment. However, there are some other medications that are used off label for this purpose, especially for people who have ADHD as well as depression or anxiety. This may also be an option for when stimulants don’t work, or for those who can’t tolerate stimulants. Finally, this may be an appropriate choice for those  with a history of drug abuse.

     The most common antidepressant prescribed off-label for ADHD is bupropion (Wellbutrin). Bupropion belongs to a class of antidepressants known as norepinephrine and dopamine reuptake inhibitors (NDRIs). It works by increasing the neurotransmitters norepinephrine and dopamine in your brain, which can help you improve your ability to concentrate.I have had very good luck with this medication because the side effects are so minimal.

     If other ADHD drugs haven’t worked out for you, your doctor may suggest a tricyclic antidepressant, such as imipramine (Tofranil) or nortriptyline (Pamelor/Aventyl). Tricyclics are an older class of antidepressants. They can have challenging side effects, so your doctor will usually only try these if you have no other options left to try.

Bupropion side effects include:

• Nausea, stomach pain, or constipation

• Weight loss

• Dry mouth or a sore throat

• Headaches

• Dizziness

• Insomnia

• Increased heart rate

    Some people may have more challenging side effects, such as anxiety, ringing in the ears, and changes in vision or heart and lung function. Adults may also have sexual side effects. Bupropion may also increase the risk of suicidal thoughts in people aged 18-24 years old.

Imipramine and nortriptyline side effects include:

• Constipation

• Increased appetite and weight gain

• Dry mouth

• Dizziness

• Blurred vision

• Confusion

• Seizures

• Increased heart rate Not being able to empty your bladder fully when you pee, peeing a little bit many times over the day, or feeling like you have to pee but not being able to

• Increased sweating

• Sexual dysfunction, including libido changes and impotence

     Like all tricyclic antidepressants, both imipramine and nortriptyline can change your heart rhythm. Both may also increase the risk of suicidal thoughts in people aged 18-24 years old. Again, don’t stop taking nortriptyline suddenly because you can have withdrawal symptoms, such as nausea, vomiting, anxiety, headaches, dizziness, and restlessness. If you want to stop taking it, your doctor will decrease your dose over time to wean you off safely.

How SAFE ARE ADHD Medicines?

     Many ADHD medications are controlled substances. The most common ADHD medicines are stimulants, so they have a high potential for misuse, abuse, and addiction. People who don’t have ADHD may misuse the medicines to feel more alert, curb their appetite to lose weight, or to feel “high.”Some people may intensify the effects of the drug by taking higher doses or even crushing and injecting, smoking, or snorting them. This can cause serious side effects, including:

• Dangerously high body temperature

• Fast heartbeat

• High blood pressure

• Panic attacks

• Paranoia

• Psychosis

• Violent behavior

• Seizures

     Because of the risk of misuse and abuse, the U.S. Drug Enforcement Administration (DEA) classifies stimulants as Schedule II Controlled Substances. This means that while there’s a medical use for them, there’s also a high potential for them to be abused. To help cut down on the misuse of these drugs, Schedule II Controlled medicines are harder to get because they can’t be refilled. Your doctor must write a new prescription for the medicine each time.

     As of May 2023, the FDA requires makers of stimulant drugs to put “boxed warnings” on the labels to warn people of the risk of abuse, misuse, addiction, and overdose. Boxed warnings, also called black box warnings, are the most serious warning given by the FDA for an approved medicine. These warnings let the public and health care providers know they may cause serious side effects, such as injury or death. I think that kind of says it all.

     In the article to follow, I will describe other methods of treatment that I have found to be highly effective and without the risks inherent in the most popular ADHD medications mentioned above.