Tag: psychostimulants

Substance-Induced Psychosis vs. Primary Psychosis: Treatment, Prognosis, and the Cannabis Connection

Psychosis can emerge from a range of causes, but distinguishing between substance-induced psychosis (SIP) and primary psychotic disorders like schizophrenia is critical for effective treatment and prognosis. While the clinical presentation often overlaps—hallucinations, delusions, disorganized thinking—the underlying etiology, treatment approach, and long-term outcomes can diverge significantly.

Defining the Two

Substance-Induced Psychosis (SIP) occurs when symptoms of psychosis are directly caused by intoxication with or withdrawal from substances such as cannabis, amphetamines, alcohol, hallucinogens, or synthetic cannabinoids (e.g., spice or K2). The psychosis typically emerges during or shortly after substance use and resolves with abstinence.

Primary Psychosis, on the other hand, refers to psychotic disorders that are not directly attributable to substances or medical conditions. This includes schizophrenia, schizoaffective disorder, and brief psychotic disorder, among others.

Treatment: Overlapping Tools, Different Emphasis

1. Acute Management
Both SIP and primary psychosis are often treated with antipsychotic medications during acute episodes. The initial goals are the same: reduce agitation, manage delusions or hallucinations, and ensure safety.

  • Commonly used antipsychotics include risperidone, olanzapine, haloperidol, and quetiapine. In SIP, short-term use is typically sufficient.
  • In cases involving severe agitation or aggression, benzodiazepines (like lorazepam) may be used adjunctively, especially if stimulant intoxication is suspected.

2. Long-Term Strategy

  • SIP: After stabilization, the primary strategy is abstinence from the offending substance and psychosocial support (e.g., CBT, motivational interviewing, relapse prevention).
  • Primary psychosis: Typically requires ongoing antipsychotic treatment, often for life. Psychosocial interventions, supported employment, and cognitive remediation are also central to recovery.

Conversion to Schizophrenia: What’s the Risk?

One of the key concerns with SIP is whether the episode is a harbinger of an underlying primary psychotic disorder.

  • Approximately 20–50% of individuals with substance-induced psychosis later develop a primary psychotic disorder, such as schizophrenia.
  • Amphetamine- and cannabis-induced psychosis carry the highest risk of conversion, particularly when psychosis occurs in adolescence or early adulthood.
  • A meta-analysis by Niemi-Pynttäri et al. (2013) found that 46% of people with SIP later developed schizophrenia-spectrum disorders over a follow-up of 8 years.

Predictors of conversion include:

  • Younger age at first psychotic episode
  • Family history of psychotic illness
  • Persistent psychotic symptoms after substance clearance
  • Poor premorbid functioning

Do Antipsychotics Work in SIP?

Antipsychotics reduce acute psychotic symptoms in SIP, but their long-term utility is less clear.

  • Studies show rapid resolution of psychosis within days to weeks in most SIP cases when abstinence is achieved.
  • Long-term antipsychotic treatment does not reduce the conversion rate to schizophrenia in confirmed SIP, suggesting their role should be time-limited unless ongoing symptoms or risk factors emerge.
  • A 2020 review in Psychological Medicine emphasized that monitoring over the 6–12 months post-episode is essential for risk stratification and avoiding premature chronic medication exposure.

Cannabis: A Powerful Catalyst

Cannabis has become the most studied and most controversial substance linked to psychosis. Here’s what the evidence says:

  • Daily cannabis users are 3–5 times more likely to develop a psychotic disorder compared to non-users, especially with high-THC strains (≥10% THC).
  • A 2019 Lancet Psychiatry study by Di Forti et al. showed that strong cannabis use accounts for 12% of new psychosis cases in Amsterdam, and 30% in London.
  • Adolescents who use cannabis, particularly those with a family history of psychosis, are at dramatically increased risk.

Mechanistically, THC may dysregulate the dopamine system in vulnerable brains, tipping the balance toward psychosis. Cannabidiol (CBD), in contrast, may be protective, but commercial cannabis typically contains very little CBD.

Final Thought: Clinicians must balance vigilance and restraint—treating psychosis aggressively when needed but also avoiding unnecessary chronic antipsychotic exposure in what may be a reversible, substance-driven episode.

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Olanzapine vs. Quetiapine for Stimulant Psychosis: Is One the Clear Winner?

There is limited high-quality randomized controlled trial (RCT) evidence specifically comparing Zyprexa (olanzapine) or Seroquel (quetiapine) for the treatment of stimulant-induced psychosis (SIP), including cocaine-induced psychosis. However, some RCTs and observational studies provide useful insights:

Olanzapine (Zyprexa)

  • RCT Evidence:
    • A 2022 meta-analysis of antipsychotic treatments for stimulant-induced psychosis included olanzapine and found it to be effective in reducing positive psychotic symptoms, often comparable to haloperidol but with a better side effect profile (less extrapyramidal symptoms) 11.
    • A double-blind RCT comparing olanzapine vs. haloperidol in methamphetamine-induced psychosisfound that both were effective at reducing PANSS (Positive and Negative Syndrome Scale) scores, but olanzapine was associated with better tolerability 22.
    • Another RCT in methamphetamine-induced psychosis compared olanzapine and risperidone, showing similar efficacy but better tolerability with olanzapine 33.

Quetiapine (Seroquel)

  • RCT Evidence:
    • A small RCT in methamphetamine-induced psychosis found that quetiapine was effective but tended to require higher doses to achieve symptom resolution 44.
    • A retrospective study on cocaine-induced psychosis suggested that quetiapine may help reduce symptoms, but data is weaker compared to olanzapine or risperidone 55.
    • Quetiapine has also been studied as an option for reducing cocaine cravings, but results are mixed and it is generally less preferred for acute agitation compared to faster-acting options like olanzapine.

Head-to-Head Comparison

There is no direct RCT comparing olanzapine vs. quetiapine for stimulant-induced psychosis, but based on available data:

  • Olanzapine is generally preferred for acute agitation and psychosis because of its faster onset and greater D2 blockade.
  • Quetiapine may be useful in milder cases or for individuals needing sedation, but higher doses are often required.

Clinical Implications

  • For acute stimulant-induced psychosis, olanzapine (5–10 mg IM or PO) is a common first-line option due to rapid onset and favorable side effect profile.
  • Quetiapine (200–400 mg PO) can be considered, particularly for patients needing sedation or those with comorbid conditions like bipolar disorder.
  • Other antipsychotics with strong evidence include risperidone and haloperidol (though the latter has more extrapyramidal risk).

After reviewing the available literature, direct randomized controlled trials (RCTs) comparing olanzapine (Zyprexa) and quetiapine (Seroquel) for stimulant-induced psychosis (SIP), including cocaine-induced psychosis, remain scarce. However, some studies provide relevant insights:

Olanzapine (Zyprexa):

  • Efficacy: A randomized, double-blind trial compared olanzapine and haloperidol in patients with amphetamine-induced psychosis. Both medications effectively improved psychotic symptoms in the short term, with olanzapine showing a faster onset of action.

Quetiapine (Seroquel):

  • Efficacy: A double-blind RCT compared haloperidol and quetiapine for methamphetamine-induced psychosis. While both medications reduced psychotic symptoms, quetiapine appeared to have a more favorable profile in reducing certain symptoms over time. 

Indirect Comparisons:

  • First-Episode Psychosis: A 52-week randomized, double-blind study evaluated olanzapine, quetiapine, and risperidone in early psychosis patients. All three antipsychotics demonstrated comparable effectiveness, as indicated by similar rates of treatment discontinuation.

Conclusion:

While direct RCT evidence comparing olanzapine and quetiapine specifically for stimulant-induced psychosis is limited, existing studies suggest that both medications are effective in managing such conditions. Olanzapine may offer a faster onset of symptom relief, whereas quetiapine might present a more favorable side effect profile. Clinical decisions should be individualized, considering factors such as patient history, specific symptomatology, and potential side effects.

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The Twin Epidemic: Rising Co-Prescriptions of Opioids and Stimulants in the U.S.

A recent 10-year longitudinal cohort study has unveiled concerning trends in the co-prescription of opioids and stimulants, shedding light on the escalating “twin epidemic” in the United States.

Key Findings:

  • Prevalence of Co-Prescription: Approximately 5.5% of patients received both opioid and stimulant prescriptions during the study period. 
  • Increased Opioid Dosage: Patients co-prescribed stimulants were more likely to escalate their opioid doses over time, with the highest doses observed in the South and West regions.
  • Associated Conditions: Common diagnoses among these patients included depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), and chronic pain

Implications:

The concurrent use of opioids and stimulants poses significant risks, including increased chances of overdose, cardiovascular events, and mental health complications. This study emphasizes the need for healthcare providers to carefully consider the implications of co-prescribing these medications and to monitor patients closely.

Call to Action:

It’s crucial to raise awareness about this emerging twin epidemic. Healthcare professionals, policymakers, and patients must collaborate to develop strategies that mitigate risks associated with co-prescriptions and ensure safer prescribing practices.

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New ASAM and AAAP Guidelines for Stimulant Use Disorder: Key Updates

The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) recently released updated guidelines for the treatment of stimulant use disorder (SUD).

  1. Comprehensive Assessment: The guidelines emphasize a thorough assessment of patients, including the use of validated screening tools to diagnose SUD, assess severity, and identify co-occurring mental health disorders.
  2. Evidence-Based Psychosocial Interventions: Behavioral therapies remain the cornerstone of treatment. Cognitive-behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) are recommended due to strong evidence of their efficacy.
  3. Pharmacological Treatments: While no medications are currently FDA-approved specifically for stimulant use disorder, the guidelines discuss off-label use of medications like bupropion and naltrexone, which show promise in reducing stimulant use and cravings in some patients.
  4. Harm Reduction Strategies: Recognizing the importance of harm reduction, the guidelines support interventions like needle exchange programs and education on safer use to reduce the risk of infectious diseases and other health complications.
  5. Integrated Care Models: The guidelines highlight the importance of integrated care that combines medical, psychiatric, and social support services, aiming to provide holistic care tailored to individual patient needs.
  6. Special Populations: Specific recommendations are provided for treating special populations, including pregnant individuals, adolescents, and those with co-occurring mental health disorders, recognizing the unique challenges these groups face.
  7. Recovery Support: Emphasis is placed on long-term recovery support, including peer support groups, vocational training, and housing assistance, to help individuals maintain recovery and improve their quality of life.

These guidelines represent a significant step forward in the standardization of care for individuals with stimulant use disorder, aiming to improve outcomes through evidence-based, patient-centered approaches. For clinicians, staying informed and implementing these recommendations can greatly enhance the quality of care provided to this population.

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Mindfulness and Meditation for ADHD: A Natural Boost for Focus and Calm

ADHD often brings challenges like racing thoughts, impulsivity, and difficulty staying focused. Mindfulness and meditation are powerful tools that can help individuals with ADHD calm their minds, enhance focus, and reduce stress. Backed by research, these practices are accessible and adaptable to everyday life.

What is Mindfulness?

Mindfulness is the practice of paying attention to the present moment without judgment. It involves observing your thoughts, feelings, and surroundings with curiosity and acceptance.

For individuals with ADHD, mindfulness can help manage the constant stream of thoughts and improve attention regulation.

Benefits of Mindfulness and Meditation for ADHD

  1. Improved Focus: Regular mindfulness practice helps train the brain to redirect attention back to the task at hand.
  2. Reduced Impulsivity: Mindfulness strengthens self-awareness, helping individuals pause before reacting.
  3. Lower Stress Levels: Deep breathing and meditation activate the relaxation response, countering ADHD-related anxiety.
  4. Better Emotional Regulation: Mindfulness helps identify and manage strong emotions before they escalate.

The Evidence: Mindfulness for ADHD

Research supports mindfulness and meditation as effective interventions for ADHD:

  • A 2018 meta-analysis found that mindfulness-based interventions significantly improved attention, impulsivity, and emotional regulation in children and adults with ADHD.
  • A 2016 RCT published in Journal of Attention Disorders reported that mindfulness training reduced ADHD symptoms and improved executive functioning in adults.

How to Start a Mindfulness Practice for ADHD

1. Breathing Exercises

  • What to Do:
    • Sit comfortably.
    • Focus on your breath as it flows in and out.
    • If your mind wanders, gently bring your focus back to your breath.
  • Duration: Start with 2–5 minutes and gradually increase to 10–15 minutes.
  • Why it Works: Deep breathing calms the nervous system and anchors attention.

2. Body Scan Meditation

  • What to Do:
    • Lie down or sit comfortably.
    • Close your eyes and focus on each part of your body, starting from your toes and moving upward.
    • Notice sensations, tension, or relaxation.
  • Duration: 5–10 minutes.
  • Why it Works: Increases body awareness and reduces physical restlessness.

3. Mindful Walking

  • What to Do:
    • Walk slowly and focus on the sensations of your feet touching the ground.
    • Pay attention to the rhythm of your steps and the sounds around you.
  • Duration: 5–10 minutes during breaks or daily walks.
  • Why it Works: Combines movement with mindfulness, making it ADHD-friendly.

4. Guided Meditations

  • What to Do: Use mindfulness apps like Calm, Headspace, or Insight Timer for ADHD-specific guided sessions.
  • Duration: Sessions range from 5 to 30 minutes.
  • Why it Works: Guided meditations provide structure, making it easier to stay engaged.

5. One-Minute Check-Ins

  • What to Do:
    • Pause for one minute during the day to notice your breath, thoughts, or surroundings.
    • Ask yourself, “What’s happening right now?”
  • Why it Works: Quick mindfulness breaks ground your attention and reduce overwhelm.

Tips for Success

  • Start Small: Begin with short sessions and gradually increase as your comfort grows.
  • Be Patient: It’s normal for the ADHD mind to wander. The goal is to notice and gently refocus.
  • Practice Consistently: Aim for 3–5 sessions per week to build the habit.
  • Integrate into Daily Life: Use mindfulness during daily tasks, like eating or brushing your teeth, to stay present.
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Evidence-Based Strategies to Reduce Distractions in ADHD

Managing distractions is a core challenge for individuals with ADHD and even for those without. Research-backed strategies, including environmental adjustments, behavioral techniques, and technological tools, have shown promise in helping individuals stay focused and minimize interruptions

1. Environmental Modifications

Declutter and Organize Your Space

  • Why: Visual clutter increases cognitive load and distractibility in ADHD.
  • Evidence: Studies show that simplified, organized environments improve task performance and reduce overwhelm.
  • Implementation:
    • Create a designated workspace with minimal visual and auditory distractions.
    • Use storage bins or labeled organizers to keep items out of sight.

Sound Management

  • Why: Background noise can be highly distracting for individuals with ADHD.
  • Evidence: RCTs indicate that white noise or low-level background music can enhance focus in some ADHD individuals.
  • Implementation:
    • Use white noise machines or apps (e.g., “Noisli”).
    • Experiment with instrumental music or nature sounds to find what works best.

2. Structured Task Management

The Pomodoro Technique

  • Why: Short, timed intervals of work followed by breaks improve sustained attention.
  • Evidence: Studies show that structured time management strategies reduce procrastination and improve productivity in ADHD.
  • Implementation:
    • Work for 25 minutes, then take a 5-minute break. Adjust intervals based on your focus capacity.
    • Use timers or apps like “Forest” to track intervals.

Chunking Tasks

  • Why: Breaking tasks into smaller steps prevents overwhelm and promotes task completion.
  • Evidence: Behavioral interventions involving task segmentation show significant benefits in ADHD.
  • Implementation:
    • Divide projects into 3–5 actionable steps.
    • Write each step on a checklist and celebrate small wins.

3. Technology-Based Interventions

Digital Focus Tools

  • Why: Apps that block distractions and guide focus provide real-time support.
  • Evidence: RCTs on apps like “Focus@Will” and browser extensions like “Freedom” show improvements in task engagement for ADHD.
  • Implementation:
    • Use website blockers to eliminate access to social media or other distractions during work.
    • Try ADHD-specific productivity apps like “TaskTuner” or “Asana.”

Timed Alerts and Reminders

  • Why: Timers and reminders keep individuals on track and prevent attention drift.
  • Evidence: Digital prompts have been shown to improve task adherence in ADHD.
  • Implementation:
    • Use phone alarms or apps like “Remember The Milk” for task reminders.
    • Schedule alerts for transitions or breaks.

4. Behavioral Techniques

Mindfulness Training

  • Why: Mindfulness helps individuals recognize and redirect wandering attention.
  • Evidence: RCTs show that mindfulness-based interventions improve sustained attention and reduce impulsivity in ADHD.
  • Implementation:
    • Practice 5–10 minutes of mindfulness meditation daily using guided apps like “Headspace.”
    • Incorporate brief mindfulness exercises before starting tasks.

Behavioral Reinforcement

  • Why: Positive reinforcement encourages task focus and reduces distractions.
  • Evidence: Token systems and reward strategies have proven effective in ADHD-focused behavioral studies.
  • Implementation:
    • Set up a reward system (e.g., complete 3 tasks to earn 15 minutes of free time).
    • Track progress with visual aids like charts or checklists.

5. Workplace or School Accommodations

Flexible Seating and Movement Breaks

  • Why: ADHD individuals focus better when they can move or choose a seating arrangement.
  • Evidence: Studies on flexible classroom setups and “active learning environments” report improvements in ADHD engagement.
  • Implementation:
    • Use standing desks or fidget tools to incorporate movement.
    • Take brief movement breaks every 20–30 minutes.

Noise-Canceling Headphones

  • Why: Blocking environmental noise improves focus on tasks.
  • Evidence: RCTs demonstrate that noise-canceling headphones significantly reduce distractions in ADHD.
  • Implementation:
    • Use headphones during work or study sessions to minimize auditory interruptions.

6. Diet and Lifestyle Adjustments

Nutrition for Focus

  • Why: Stable blood sugar and adequate nutrition reduce mental fatigue and improve concentration.
  • Evidence: Studies suggest that diets high in protein and low in refined sugar reduce distractibility in ADHD.
  • Implementation:
    • Eat balanced meals with complex carbs, proteins, and healthy fats.
    • Avoid high-sugar snacks during focus-intensive tasks.

Exercise and Movement

  • Why: Physical activity improves attention and executive function in ADHD.
  • Evidence: A 2018 RCT found that 20 minutes of moderate aerobic exercise improved focus in children with ADHD.
  • Implementation:
    • Schedule exercise breaks or mini workouts during the day.
    • Use movement as a tool to reset focus between tasks.

7. Cognitive Behavioral Therapy (CBT) for ADHD

Why: CBT addresses thought patterns and behaviors contributing to distractibility.

Evidence: Multiple RCTs demonstrate the efficacy of CBT in improving attention and task persistence in ADHD.

Implementation:Work with a therapist trained in ADHD-specific CBT.Practice CBT strategies like identifying and reframing negative thoughts about distractions.

Conclusion

Reducing distractions in ADHD involves a combination of environmental modifications, structured strategies, and personalized interventions. These evidence-based approaches can help individuals focus, complete tasks, and thrive in daily life. By experimenting with these methods and tailoring them to your needs, you can find a system that works best for you.

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Evidence-Based Diets for ADHD: Insights from Randomized Controlled Trials (RCTs)

Diet plays a significant role in brain health and behavior, making it a promising area for ADHD symptom management. While dietary changes are not a substitute for standard treatments, several dietary interventions have shown evidence-based benefits in improving ADHD symptoms.

1. Omega-3 Fatty Acid Supplementation

  • Why: Omega-3 fatty acids, particularly EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), are crucial for brain development and function.
  • Evidence:
    • A 2018 meta-analysis of RCTs found that omega-3 supplementation improved attention and reduced hyperactivity in children with ADHD.
    • Higher EPA-to-DHA ratios (e.g., 3:1) were more effective.
  • How to Implement:
    • Include fatty fish (e.g., salmon, mackerel, sardines) 2–3 times per week.
    • Consider omega-3 supplements (1–2 grams daily with a high EPA content).

2. Elimination Diets

  • Why: Some children with ADHD may react adversely to specific foods or additives, exacerbating symptoms.
  • Evidence:
    • The Restricted Elimination Diet (RED), such as the oligoantigenic diet, has been tested in RCTs. A 2011 RCT published in The Lancet found significant symptom reductions in 64% of children who followed a restricted diet for 5 weeks.
    • Foods commonly eliminated include dairy, wheat, soy, eggs, and food additives.
  • How to Implement:
    • Work with a healthcare provider or dietitian to guide the process.
    • Reintroduce foods one at a time to identify triggers.

3. Additive-Free and Preservative-Free Diets

  • Why: Artificial food colorings, preservatives, and sweeteners may worsen hyperactivity in some children.
  • Evidence:
    • A meta-analysis published in Pediatrics (2012) found that artificial food coloring elimination reduced ADHD symptoms in a subset of children.
  • How to Implement:
    • Avoid processed foods with artificial dyes (e.g., Red 40, Yellow 5).
    • Read ingredient labels and choose whole, minimally processed foods.

4. Mediterranean Diet

  • Why: The Mediterranean diet is rich in nutrients critical for brain health, such as omega-3s, antioxidants, and vitamins.
  • Evidence:
    • A 2017 study in Pediatrics suggested that children who adhered to a Mediterranean diet had fewer ADHD symptoms compared to those with poor adherence.
  • How to Implement:
    • Focus on fruits, vegetables, whole grains, nuts, seeds, fish, and olive oil.
    • Limit red meat, processed foods, and added sugars.

5. Low-Glycemic Index (GI) Diet

  • Why: High-GI foods (e.g., sugary snacks) cause rapid blood sugar spikes and crashes, which may worsen hyperactivity and inattention.
  • Evidence:
    • A small RCT found that a low-GI diet improved behavior in children with ADHD by stabilizing energy levels and focus.
  • How to Implement:
    • Choose whole grains, legumes, and non-starchy vegetables.
    • Avoid sugary drinks, white bread, and refined snacks

6. High-Protein Diets

  • Why: Protein supports the production of neurotransmitters like dopamine, which is often dysregulated in ADHD.
  • Evidence:
    • Some studies suggest that protein-rich breakfasts improve attention and reduce impulsivity during the day.
  • How to Implement:
    • Include protein-rich foods (e.g., eggs, yogurt, lean meats, nuts) in each meal.
    • Avoid skipping breakfast to maintain consistent energy levels.

Micronutrient Supplementation

  • Why: Nutrient deficiencies (e.g., zinc, magnesium, iron) are linked to ADHD symptoms.
  • Evidence:
    • RCTs show that zinc and magnesium supplementation improves hyperactivity and impulsivity, particularly in children with low baseline levels.
    • Iron supplementation benefits those with low ferritin levels.
  • How to Implement:
    • Have nutrient levels tested by a healthcare provider.
    • Include nutrient-rich foods like spinach (iron), nuts (magnesium), and seafood (zinc).

Recommendations

  1. Prioritize Whole Foods: Focus on unprocessed, nutrient-dense foods.
  2. Limit Sugars and Additives: Avoid foods with high sugar content, artificial sweeteners, or additives.
  3. Monitor Responses: Keep a food and symptom journal to identify potential triggers or improvements.
  4. Consult Professionals: Work with a dietitian or healthcare provider to ensure nutritional adequacy and tailor dietary changes to individual needs.

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ADHD in Later Life: A Surge in Diagnoses Among Older Americans

🤣 What a perfect time for this article considering ADHD is my topic of choice this week.

🧠 A nuanced debate surrounds the rise in ADHD diagnoses, particularly among adults. While underdiagnosis and increased awareness contribute to this trend, it’s not the sole explanation. ADHD, often linked to developmental delays, may require continued medication into adulthood for some individuals with persistent symptoms

➡️ However, the necessity for lifelong medication in all or most cases is questionable

➡️ The surge in first-time ADHD diagnoses among adults aged 30’s-40’s, often without prior documented history, raises important questions

💡 While some cases may have been previously overlooked, it’s crucial to consider:

⚡ Co-occurring disorders like depression and anxiety, which can cause similar cognitive issues

⚡ Societal factors: Increasing demands for productivity and competitiveness in modern society

⚡ The potential misuse of performance-enhancing drugs in high-pressure environments

💡 It’s essential to approach each case individually, considering both the benefits of treatment and the risks of overdiagnosis. A comprehensive evaluation, including assessment of co-existing conditions and life circumstances, is crucial for accurate diagnosis and appropriate treatment plans

Link to NYT article: https://www.nytimes.com/2024/12/11/well/mind/adhd-diagnosis-older-middle-age.html

#ADHD #ADHDawarness #ADHDtreatment #ADHDtips #ADHDlife #mentalhealth #mentalhealthmatters #mentalhealthishealth #psychiatry #psychiatrist #doctor #stimulants #stimulantmedication

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Give Me Stimulants—Just Don’t Make Me Come to the Office

A JAMA study found a significant rise in stimulant prescriptions between 2019 and 2022, with a 37.5% increase in total volume. This trend was particularly noticeable through telehealth, where stimulant prescriptions soared from 1.4% to 38.1%, peaking at 51.8% in mid-2020. The shift was largely influenced by COVID-19 pandemic policies, which eased telehealth restrictions. While antidepressant prescriptions also rose, opioid prescriptions declined by 17.2%. The study emphasizes the need to balance access with monitoring for potential misuse as telehealth policies evolve​

Link to Article: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2823646?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamanetworkopen&utm_content=wklyforyou&utm_term=091324&adv=null

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Are Stimulants Neurotoxic?

Introduction:

The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) is well established in the field of psychiatry. Not only is it well accepted, but ADHD has dramatically increased over the past 10 years. Some would even say it’s an epidemic in its own right. The use of psychostimulants as a treatment is common practice, and today we are here to discuss the risk of neurotoxicity with ADHD medication.

What Are Psychostimulants

Psychostimulants include methylphenidate (MPH) and mixed amphetamine salts such as Adderall. These remain the most effective and widely used medications for the treatment of ADHD. These medications function by blocking the dopamine reuptake transporter and increase dopamine stimulation at the postsynaptic receptors. These medications work to increase attention and reduce impulsivity but the long-term implications of consistent use are largely unknown. 

Substance Use and Stimulant Prescribing

Most lines of evidence in the literature indicate that these medications do not promote substance use later in life and may even decrease the potential for future substance abuse. I’ve also found lines of evidence that indicate the opposite, but the general consensus in the field is that there is not increased risk for future substance abuse. We do know that drugs that function in a similar manner to these medications result in molecular and structural changes to neurons. It is unknown if this also occurs with stimulant medications used to treat ADHD. 

Neuronal Effects of Amphetamine

Methamphetamine is a known neurotoxin and several studies have indicated this in animal models. Recently exposure to amphetamine has been sown to cause impairments on the development of dendritic branching up to 3 months after stopping methylphenidate. In mice there is evidence that MPH use causes loss of dopamine neurons in the substantia nigra which may increase the risk of Parkinson’s disease. Other groups have shown alterations in nerve growth factors and brain derived neurotrophic factor in the frontal cortex after chronic MPH use. When neurons from the prefrontal cortex are exposed to MPH it alters their electrical activity. MPH was found to reduce electrical activity and it persists in a dose dependent fashion even 10 weeks post exposure. In rats the use of MPH is associated with decreased response to normal stimuli and increased response to adverse stimuli. We need to be careful extrapolating this information to humans as these studies were conducted in animal models. 

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