Addiction Medicine Made Easy | Fighting back against addiction

A Child Psychiatrist Schools Me on ADHD Meds in the Treatment of Addiction

• Casey Grover, MD, FACEP, FASAM

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Discover the transformative potential of ADHD medications in addiction treatment as we bring you a captivating discussion with Dr. Justin Mohatt, a renowned child and adolescent psychiatrist. Dr. Mohatt joins us to unravel the complexities of using ADHD medications to combat stimulant addiction, shedding light on how these drugs can make a difference. We'll explore a myriad of medications, including guanfacine, clonidine, and atomoxetine, and discuss their respective roles in addressing adult ADHD and substance use disorders. Learn the importance of a meticulous diagnostic process to distinguish ADHD from other mental health conditions like depression and anxiety, ensuring a tailored approach to treatment.

We navigate the nuanced landscape of ADHD in adults with a history of substance use, emphasizing the critical role of family insights to inform diagnoses beyond self-reports. The conversation underscores the careful application of stimulants for ADHD, even in those with stimulant use disorders, while presenting Vyvanse as a potentially safer choice. Non-stimulant medications like atomoxetine receive special attention for their dual role in treating ADHD and co-occurring anxiety, offering a glimpse into strategies for managing side effects and insurance hurdles. Hear how non-addictive alternatives could provide solutions for patients who haven't found success with traditional medications.

As we delve deeper into co-occurring ADHD and trauma, Dr. Mohatt discusses the potential benefits of alpha agonists and other non-stimulant options in treating complex cases involving PTSD and substance use disorders. Together, Dr. Mohatt and I affirm the importance of addressing ADHD within addiction treatment to foster recovery and improve cognitive function, offering a beacon of hope for those navigating these intertwined challenges.

To contact Dr. Grover: ammadeeasy@fastmail.com 

Speaker 1:

Hello, my friends. Welcome to the Addiction Medicine Made Easy podcast, where we take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. Dr Casey Grover here as your host once again. All right, everyone, I am so glad to have you back for another episode, If this is your first episode. My name is Casey Grover and I am an addiction medicine doctor working on the Central Coast of California. If you're a regular, welcome back. A little housekeeping before we start. Thank you, as always, to the Montage Health Foundation for their support of my quest to improve my podcast and produce fun and engaging education for healthcare providers on addiction. But if you're not a healthcare provider, I'm glad you're here too. Thank you also to the nonprofit Central Coast Overdose Prevention for partnering with my podcast to help me provide good education about addiction for the community.

Speaker 1:

Today we're going to do a follow-up to a previous episode, which discussed using ADHD medications to treat stimulant addiction. The conversation I had during that episode got me thinking. There really seems to be a lot of signal here. Could I be doing a better job with medications for my patients with stimulant use disorder? And the answer is yes, but unfortunately, my primary specialty is emergency medicine, so I was never trained on how to use ADHD medication. So I phoned a friend. I reached out to my friend and colleague who is a very well-respected psychiatrist at my hospital, Dr Justin Mohat, and I asked for his help and he joined me for a conversation. In this conversation we walked through all of the ADHD medication and try to see how we could potentially use them in addiction medicine.

Speaker 1:

Now, before we start, there are a lot of medication names in this episode and Dr Mohat and I flip-flop between brand and generic names quite a bit. So let's get on the same page with medication names. For each of the meds, I'll give the generic name first and then the brand. So we have guanfacine, also known as Intuniv. We have clonidine, also known as Catapress or Capve. We have adamoxetine, also known as Stratera. We have vioxazine, also known as Kelbree. We have bupropion, also known as Welbutrin. We have mixed amphetamine salts, also known as Adderall. We have methylphenidate, also known as Concerta or Ritalin. We have lisdexamphetamine, also known as Vyvanse, and finally, if you didn't know, we have methamphetamine, which is a prescription, known as Desoxen. That's the brand name. So this was an awesome conversation. I learned so much, so let's get started, All right. Well, thank you for making time with me this morning. I respect you enormously as a colleague and I'm so glad to learn from you today. Why don't you start by introducing yourself and tell us what you do?

Speaker 2:

Sure. Thanks, casey, happy to be here. I'm Justin Mohat. I am a child and adolescent psychiatrist and medical director here at Montage Health's Ohana Center, which is a youth mental health program serving the larger Monterey County and providing a variety of levels of care. I am the medical director in charge of our outpatient services and the sort of head of our innovation program.

Speaker 1:

Nice. So you know we're just talking before we started. So ADHD is not something I ever learned about. In the emergency department People would come in for Adderall refills occasionally. We usually accused them of drug seeking and then maybe gave a refill, maybe didn't. But I'm starting to see in my addiction practice so many of my patients have untreated ADHD and a lot of them self-medicate with methamphetamine and, I feel like, with psychiatry. Sometimes it's almost like picking out notes in wine. It's like subtle little points make me think. Well, maybe this is more of an ADHD picture versus an OCD picture. Talk to me about how you just pull out those clues about making a diagnosis of ADHD.

Speaker 2:

I think the challenge, particularly if your population is largely adults as opposed to younger patients, is that it requires pretty precise longitudinal history and it's harder to get that with your adult patients, but certainly worth pursuing, because there's a lot of talk about adult ADHD, but there isn't really adult ADHD in the sense of someone developing true ADHD in adulthood with having had ADHD as a kid. Establishing that can be really hard, though. If you have a 45-year-old in your office and you're like do you have your elementary school report cards to show me, although I have asked for that. If somebody is like yeah, my parents still have all my stuff, give it to me. So I think, when it comes to teasing apart the different things that can mimic ADHD or share symptoms, it just is about taking the time to do a detailed history and trying to understand the timeline that things came on board.

Speaker 2:

So someone may be struggling with a lot of symptoms of inattention, distractibility, inability to complete work, get started on things, and the question is that part of depression Is it that they're anxious and their brain's too full of anxious thoughts that they can't focus? Is it true distractibility where they are sitting around daydreaming, their mind wanders, their mind's more blank as opposed to overcrowded with anxious thoughts. And then, really importantly, that distractibility or that inattention. How long has that been there and did it predate the depression that they have or did it predate the anxiety that they have? These things are frequently co-occurring. About 60% of patients with ADHD will experience anxiety. Makes perfect sense, and you know about half depression, roughly speaking. So it's not often an either or and it's important to tease apart what came first, because if there was no inattention before they got depressed, then it's probably difficulty concentrating related to their depression, but they may have had longstanding inattention from ADHD, which is a risk factor for developing depression, right?

Speaker 1:

So kind of this is how it looks for me in clinic. Somebody comes to me let's say they're 50 years old and they've got a history of methamphetamine use and you know I don't have any formal training in psychiatry. Mental health was always an interest of mine in emergency medicine, given my own history with self-harm and eating disorder and depression. So I paid attention and I loved my psychiatry rotation. But that's one of the reasons I'm talking to you today. A lot of what I ask is talk to me about your employment history. Talk to me about your grades in school. I kind of observe them during the encounter. Can they make eye contact. Talk to me about how you would say or how you would interpret someone's high school or middle school performance as what it means for them when they're in their 40s and 50s.

Speaker 2:

So I guess what I would say is that when you are getting that long history, what I'm looking for are certain pain points where someone with ADHD might start to experience difficulty, and it can be anywhere along the way, depending often on how bright somebody is. If you're really bright and can just get by on pure horsepower without having to do a lot of work, you can often get by longer. But the classic story are the kids who, very early on, are really hyperactive and impulsive and inattentive, and they get identified early. But there are a lot of kids that don't come to attention until later on Sometimes it's third or fourth grade, depending on the school system that they're in.

Speaker 2:

When learning changes or school changes and it goes, for instance, from learning to read to reading to learn, which is a different skill set and kids will start to struggle. Transition to middle school, when they're suddenly expected to manage multiple teachers in multiple classrooms and be more independent in their functioning Another version of that with the start of high school. So those are actually specific questions that I'll ask about. So what happened in middle school? When did you start having trouble with this? Technically, with ADHD, you have to start having symptoms that cause impairment before the age of 12.

Speaker 1:

Okay.

Speaker 2:

So when you have a 50-year-old in your office, that can be challenging to establish, but not impossible. Perhaps more challenging in a population of patients with stimulant use disorder, where you're worried about, are they trying to get stimulants from you? Kind of separate from that dynamic patients are usually pretty clear about how they felt about school, and so early academic failure isn't synonymous with ADHD, but it certainly would be a trigger for me to wonder if there was ADHD. Math is often a real challenge for kids with ADHD. If you can imagine. It's one of the things that really builds on itself over time, and so kids with ADHD who have struggled to pay attention in those early years of learning basic math facts, when they get to more complicated math they just can't do it because they didn't get the basics, versus other things where they don't build on each other quite the same way, and I think that their experience of school often is a lot of frustration. Untreated ADHD is highly correlated with academic failure, along with a lot of other long-term risks, of course.

Speaker 1:

So you know and this pivots into what we were going to talk about, which is the treatment of ADHD and how it intersects with stimulant addiction so a lot of my patients come to me and say meth calms me down, and for years I thought they were just lying. And then someone pointed out to me ADHD is treated with a stimulant and it calms hyperactive people down and a little light bulb went off. And so when someone tells me that meth calms them down, I am very willing to try them on a non-stimulant ADHD med because it's non-scheduled. So I'll try Stratera, guanfacine, welbutrin, kelbury, which is biloxazine, but I feel like I'm not 100% right on the diagnosis. It's more just that stimulants calm me down. Let's try it. Do you think that sounds like a reasonable approach? Because that's what I'm doing.

Speaker 2:

I need to know if this is the right thing sometimes you end up having to do an empirical trial of medication because you just can't get the collateral history and maybe you can't get those sort of early things that I was talking about. But often you can if the patient's willing to let you get a certain amount of collateral information that could give you some answers. Adults, depending on their age, still have parents that are around and I've definitely asked my adult patients are you okay if I talk to your parents about what it was like when you were a kid? Interesting Okay, and more often than not they're fine to let me do that.

Speaker 2:

Spouses, partners, their own grown children, like there are lots of people in their lives. If they're willing to let you talk to them, they can help you establish what is this individual like, separate from their report of it, and I try to get at least one other person's perspective so that I'm building essentially a story of symptoms and without relying only on the individual's self-report and self-report screening measures are essentially a list of all the ADHD symptoms and I use them more to track response than to feel confident about making a diagnosis.

Speaker 1:

Yeah, my understanding is the non-stimulant ADHD meds are a lot less effective for ADHD. So when someone tells me meth calms them down or they've identified that they only use methamphetamine, I will try the non-addictive ADHD meds and then, if I get a lukewarm response, I question am I going the right direction? So let's start with the non-addictive ADHD meds, because I feel like and from what I've read on the topic as well they just don't work as well. But they're there for a reason, which is that certain patients may benefit from them, or if a patient has a problematic history with stimulants, they're available.

Speaker 2:

If it's okay with you, I first want to just address the question of stimulants in patients with stimulant use disorders.

Speaker 1:

Let's do it, let's do it.

Speaker 2:

I think that we've come a long way, certainly from when I got out of training. I remember early on in my practice when I would have patients not necessarily even with a stimulant use disorder, but with any substance use disorder, and the belief was that you couldn't treat them with any kind of stimulant medication. That in fact, I sent some patients to substance abuse treatment where the treatment program took them off all their psychiatric medications because they were mood-altering substances, which was really problematic. I think we've come a long way in the field in understanding things and in fact the current practice guidelines for treating patients with stimulant use disorder who have co-occurring ADHD explicitly say you can use stimulants and you should use stimulants if the risks don't outweigh the benefits of it. Right, so I think you have to make your clinical judgment about whether you feel like for a given patient you just can't go the stimulant route. But to your point, the stimulants are by far the most reliably effective medications we have for ADHD. Stimulants are by far the most reliably effective medications we have for ADHD and if you don't aggressively treat somebody's ADHD symptoms, their risk of relapsing in terms of impulsively using substances is going to be higher, of course. So I'm not going to tell you you should use stimulants in all your patients with stimulant use disorder, but I would be less shy about it. As long as you feel like for a given patient, you can monitor it, have a treatment contract, all the appropriate things, and see if it helps. Because around 70 to 80% of patients with ADHD that's an accurate, well-established diagnosis will respond to the first stimulant that you. And if you take the rest that didn't and you do a trial of a second stimulant, 70 or 80% of those will respond to that stimulant, which is much different than some of our non-stimulants, right?

Speaker 1:

Yeah, we did this. So you know, our patient agreement says we do not prescribe stimulant medications and that's partly because the other addiction doctor, my lovely bride, dr Close, and I didn't have a lot of experience with this. And we had one patient came to us. She was long period of sober, time off of meth and just miserable. Couldn't focus, felt very unproductive, easily distractible, like her family was noticing she was committed to sobriety and I wrote up a special agreement just for her.

Speaker 1:

And then it's every two weeks with urine drug testing every two weeks, and I'll probably loosen the tightness of my reins or how short the leash is as time passes. But yeah, I'm open to it, but I don't have a lot of experience with it and I also wanted to learn some of the nuances of the ADHD meds and ultimately the one I chose for her was Vyvanse, which I think is lisdexamphetamine. Did I say it right? Okay, lisdexamphetamine, and my understanding is it has a side group which makes it get absorbed differently, so it's less euphoric, which is why I chose it and the patient was doing relatively well.

Speaker 2:

Yeah, vyvanse is meant to be. When it came out it was marketed as having a lower risk of abuse, and it probably does, because you know essentially what it is dextroamphetamine with a lysine molecule attached to it. You absorb it in your gut. It gets metabolized, kind of first pass metabolism in your gut to cleave off the lysine and then you get the active amphetamine. And so the idea was you can't snort it, you can't get the same and that's a rate limiting step, so you can't get the same rush that you would get with others. It's still abusable and patients can take high doses and get euphoric from it, but it is definitely one of the safer options and I appreciate that you would want to understand and it's important to understand what your other alternatives are and what the pros and cons of them are and how to use them.

Speaker 1:

Yeah, the way this started for me is I started learning that a lot of my patients had ADHD and I had one other patient and there were a lot of other issues. There were other substances being used and we did a trial of actually Adderall and I just felt like I didn't have enough experience. There were other substances involved and I got nervous and pulled the plug and the patient actually responded very well to Adderall and had a negative urine drug test for methamphetamine and I think it was my feeling very inexperienced and I will probably reach out to this patient again to say I've learned more, let's reconsider. But yeah, I think this is why I have the podcast. Is I have a clinical question? I don't know the answer, so I either go to the research excuse me, I go to research the literature or I phone a friend and here we are.

Speaker 2:

Well, I think most people feel more comfortable prescribing a non-stimulant.

Speaker 1:

Of course.

Speaker 2:

It's also a lot easier if it works right, because you're not going to just give your patient with stimulant use disorder unfettered access to their stimulant, whereas if you're giving them adamoxetine or Calvary, you can just write them a prescription and not worry that they're going to do anything untoward with it.

Speaker 1:

So when you're choosing a stimulant for ADHD, I believe there's three right. There's mixed amphetamine, salts or Adderall, and there's various formulations instant release, extended release. There's methylphenidate, which is Ritalin or Concerta, and then there's Lisdexamphetamine.

Speaker 2:

How do you choose? Yeah, the way I conceptualize it is essentially there's methylphenidate and a whole variety of preparations of methylphenidate, that being the base medicine of Ritalin Right. And then there are the amphetamines, and within the amphetamine class, there's a variety of them dextroamphetamine, mixed amphetamine salts, which is Adderall, listexamphetamine, which is Vyvanse, but they're all amphetamines, right. Also dozoxin, which is methamphetamine.

Speaker 1:

Yes, it is, I got duped into prescribing that once in the ER at 2 am.

Speaker 2:

FDA approved for six years old and above for ADHD. I've never used it. So it's really methylphenidate and amphetamines and the question is how do you choose which side of that to start with? There's no head-to-head trial that indicates that it's more appropriate to start with one or the other. Clinically, I think everyone has the experience that some patients respond to methylphenidate better, some patients respond to an amphetamine better, and you just can't predict ahead of time which it's going to be. And so I always prepare patients that we're going to start with one and if you don't have a good response to it, we're going to try the other class and see you might be somebody who responds better to the other class. I typically start with a methylphenidate preparation, but that's just my personal kind of choice.

Speaker 2:

I can explain why I do it but, there's no right or wrong, I just mean it would be defensible to do either. So, for what it's worth, I start with a methylphenidate preparation because if you think about the mechanism of action of the two classes mechanism of action of the two classes Methylphenidate increases dopamine by reducing reabsorption of dopamine from the synaptic cleft. Amphetamines decrease reabsorption and also cause an increase in release of dopamine. So in some ways I think of them as more powerful. They have a dual action and additionally I think anecdotally I find that the amphetamines can be more moodogenic in a way, in the sense of cause more irritability and moodiness for some patients. So I typically start with a methylphenidate preparation, a long-acting version, and then, depending on how that works, if there's just not a good response to it, I'll try an amphetamine.

Speaker 2:

I have colleagues who do work in ADHD specialty clinics who have actually a process where they give every new patient with an established diagnosis of ADHD both a prescription of an amphetamine and a prescription of methylphenidate and say I want you to try this for a few days and try this for a few days and then we'll figure out which one works best for you and then we'll go with the one that works best. How do you measure success? Oh, that's a good question. I think most people do it just by patient and in younger kids' parent self-report of how things are going, getting teacher reports with adults. It's a lot of just self-report of how things are going. But again, if you can get a partner, spouse, somebody else to say, that's going to be much more reliable. There are standardized measures for kids like the Vanderbilt assessment scales and the SNAP-4. They're free and in the public domain and the SNAP in particular provides scores so you can track it over time and see is your score changing in terms of ADHD symptoms.

Speaker 1:

With my patients with addiction. I think about function. Are you able to parent, Are you able to work? Is that what you're asking as well around this?

Speaker 2:

Yeah, parent work. Are you getting into less sort of arguments at work? How's your road rage doing? Because you know you think about impulsivity in kids. You think about the little kid climbing the wall and all over the furniture. In adults it doesn't look like. I mean, if I have an adult that's climbing the furniture, I think of something other than ADHD, than ADHD, but if they are, if for adults, I'm asking about emotional impulsivity like rage episodes, anger, conflict with partners, friends, colleagues, bosses, driving impulsively, impulsive, risk-taking behavior that isn't episodic, you know, like not bipolar disorder where it's an episodic thing, but just chronic kind of impulsive behavior.

Speaker 1:

For patients who are engaging in high-risk sexual encounters. Does that get better when their ADHD gets treated?

Speaker 2:

If it's from their ADHD, yeah, interesting.

Speaker 1:

Yeah, it makes sense. Okay, so it sounds like you probably, and I know UpToDate gives recommendations on starting doses. How do you choose to up-titrate the dose versus change classes with the stimulants?

Speaker 2:

Well, for me it's about are you seeing any benefit? So if you're seeing improvement and it's just not adequate, then I'll go up. But I'm also always telling patients that with the stimulants there is essentially an upside down U curve of effectiveness and that more isn't always better. So we may get to a dose where we go higher and it actually is less effective, and so I'm always looking for that to happen, because, you're right, there isn't weight-based dosing for these or anything like that, so you're dosing to effect. If I'm getting up to a dose that seems like a reasonable dose and the person's just saying I don't feel anything, it's not doing anything, instead of going higher, that's when I would say let's just try a different class. But if they're saying, yeah, it's helping, it's just not helping enough.

Speaker 1:

That's when I think about titrating. The dose Makes perfect sense. So in your practice, do you use any of the non-addictive ADHD meds?

Speaker 2:

Yeah, I use a lot of them, some more than others. I would say that I use adamoxetine and the alpha agonists the most, so guanfacine and clonidine more guanfacine than clonidine because it's less sedating and usually the long-acting versions of those. So, and for different reasons, right, so let's just maybe take them one at a time. So strutera or adamoxetine, which is a norepinephrine reuptake inhibitor. It is something that I think it came out around 2003. And I think most of us were not particularly impressed.

Speaker 1:

That's been my experience. A lot of patients don't notice a huge difference.

Speaker 2:

I think that part of what's happened since it came out is an appreciation that the initial dosing guidelines were probably low, and so I, in more recent years, have been using it more, in particular because of the group of patients I tend to treat, which are patients with OCD, anxiety and often co-occurring ADHD, and I'll get into why. But what I've started doing is more aggressively dosing it so Name an example. I think if you look at the packaging insert, it's supposed to be somewhere between 1.2 and 1.4 milligrams per kilogram per day, up to a max of 100 milligrams a day, and this is more apropos to treatment of younger patients. But I'll go as high as 1.8 milligrams per kilogram per day and I see much more benefit at higher doses. Again, this is anecdotal, but it's also something that is very common now in practice to go above that 1.4 milligrams per kilogram per day. Per day.

Speaker 2:

I also have found that sometimes for my older patients, my adult patients, 100 milligrams a day, which is the max even for adults, is not adequate on its own, and so I've definitely had patients where I'm actually thinking of a patient of mine who had cocaine use disorder who, when he was just on stimulants, we couldn't safely do it. He just was not able to do it adequately and safely and so I switched him over to adamoxetine. He did great on adamoxetine, was sober for years, but at one point it's just not quite adequate. And we were able to start him back on a little bit of Adderall in addition to the ademoxetine and he was able to be safely on that sort of indefinitely without any issues because the strateria had done enough to treat his ADHD. It just wasn't quite enough.

Speaker 1:

It's interesting I've been dosing like 25 to 30 for a week and then doubling it to 50 to 60 for a week, Because my understanding is people can get a lot of gastrointestinal side effects and that's the main issue with adamoxetine.

Speaker 2:

Absolutely, without a doubt. That's the main issue. I get around it by either you can split the dose and do BID dosing. The other way to do it is to always have it with food and to take it at night so that the peak blood level is at night when you're sleeping, because that's when people experience the most nausea. So actually, this patient I was just referring to got a lot of GI upset at 100 milligrams, but taking it at dinner time took care of that completely because he was asleep and you'd say I still get upset stomach, but it's not an issue because it's not happening during the day and I and I'm okay. So that's definitely the biggest limiting factor for a lot of patients. So I usually dose it at night just to try and avoid that. Since it is supposed to work 24 hours a day. It's not like the stimulants that wear off after a certain amount of time and so it's also a good one to think about if you have a patient with co-occurring anxiety.

Speaker 1:

Which is like all my patients.

Speaker 2:

Yeah, there's some evidence that Stratera can help treat anxiety as well, and it makes sense if you think about the fact that it helps treat anxiety, and so I use it a lot in my anxious ADHD patients patients. And in fact, if I have a patient with so much anxiety that I'm worried that the stimulant is actually going to worsen their anxiety, I'll start with Stratera, or you could start with Kelbree. So Kelbree is just another NRI like adamoxetine. It has certain advantages in that it is, I guess, easier to dose, although, I'll be honest, I'm still learning how best to use it. The dosing seems a bit mysterious because they say start at 100 milligrams and then you can go as high as 400 or 600, depending on the age of somebody, but there's no weight-based component to it. I've had some good luck with it when I've used it. The challenge at this point the biggest challenge, is getting insurance to cover it.

Speaker 1:

Or authorizations for sure.

Speaker 2:

I've only succeeded in getting it covered when a patient has failed multiple other medications, usually one of each stimulant class, an alpha agonist they really want to see that you've tried and adamoxetine, since it's the same mechanism and generic at this point and the generic of Calpre is a vialoxazine.

Speaker 1:

Yeah, okay, yeah. What my experience has been is my patients come to me. We start talking about ADHD because of their stimulant use. I don't consider them a good candidate for stimulants right away, so I try them on adamoxetine and usually guanfacine, maybe Welbutrin because it does have some evidence that it can reduce stimulant use, and by the time we're not making any progress they've failed so many classes. I get the PA approved pretty quickly.

Speaker 2:

Yeah, yeah, I think I've had good luck with it. Like I said, it doesn't cause the GI upset that adamoxetine does, so that's a definite advantage. And for patients who have trouble swallowing pills for whatever reason, it can be opened and put in a little bit of pudding or applesauce, so that's another way I've gotten it approved is when I have kids who just can't swallow pills and they've failed other things Makes sense.

Speaker 1:

Yeah, I think of atomoxazine and valoxazine is basically. I start with the atomoxazine because it's easier to get approved, and if they can't tolerate it for GI symptoms do I switch to the valoxazine. Yeah, that seems very appropriate. Let's talk about guanfacine. So I usually dose it at bedtime and I use the 24-hour release version and a couple of folks get really sleepy on it. When do you pick that one specifically?

Speaker 2:

So I think you indicated one of the reasons. So if somebody has difficulty with falling asleep, that's a reason to consider it. It's not super sedating, so unlike clonidine that tends to be more sedating, even in its long acting form, guanfacine is less, but it might help with that. It also may have some anti-anxiety effects. I think about it in patients who have ADHD and trauma, because the alpha agonist can be really helpful for that trauma-related hypervigilance and anxiety, and the stimulants can sometimes be activating for patients with trauma and counterproductive. So it rises much higher on the list in the context of PTSD.

Speaker 1:

So many of my patients have PTSD. Can you mix it with prazosin, since they're both alpha-2 agonists? I haven't.

Speaker 2:

I usually pick one or the other, but mostly because I'm a little chicken Okay.

Speaker 1:

I had one patient poor man's in residential right now and I went to put him on clonidine, prazosin and guanfacine and I went no, I can't do three. So I've been tinkering with his meds. He's actually doing the best on clonidine. He has a PTSD history.

Speaker 2:

I interrupted you Go ahead. The trauma piece is a big part of it. The other time it rises much higher in the hierarchy is if I have a patient with co-occurring tick disorder, because alpha agonists are a treatment for ticks and Tourette's. And it also rises higher if there's much more prominent hyperactivity and impulsivity, because they tend to be very effective for that. And then in the pediatric population the alpha agonists are used to help with aggressive behavior and such. So those are the things that would make me maybe lean quickly to that, but I still go to a stimulant most of the time first.

Speaker 2:

The other non-stimulants are well, actually, in terms of the alpha agonists. There's also CAPVE, which is Luang-acting clonidine which is FDA-approved for ADHD. I did not know that existed. It's not as long-acting as guanfacine, so instead of once-a-day dosing it's BID dosing. But that's still better than short-acting clonidine that needs to be given four times a day and puts everyone to sleep. So CAPVE is definitely less sedating than short-acting clonidine, but it is a. You have to give it in the morning and at night, so that's another option.

Speaker 2:

I'm always a little cautious as kids get older with the alpha agonist. There's less research about their effectiveness and safety in older patients and adults and they have more blood pressure effects in adults than they do in kids. So I'm always we monitor that every visit anyway, but I'm just more cautious about it, of course. And then those are. If you think about the non-stimulant ADHD medicines, those are the FDA-approved ones. Then you get into non-FDA-approved medications that have been found to maybe be helpful for ADHD, like Welbutrin or Bupropion. Yeah, the tricyclic antidepressants were used to treat ADHD for many years Interesting but have kind of fallen out of favor as we have easier-to-use, safer medications now.

Speaker 1:

I took care of a TCA overdose in residency. That was a harrowing experience.

Speaker 2:

Yeah, no, there are reasons that the tricyclics have fallen by the wayside, and they were never the most effective treatment either, so we have much more effective treatments now.

Speaker 1:

So let's talk about Welbutrin. So there's in the addiction world. We're hearing about tapiramate or Topamax and bupropion or Welbutrin as potential treatments for stimulant use disorder, and I have a couple of patients that when they take their Welbutrin they really don't want to use stimulants. What's your experience with using bupropion or Welbutrin for ADHD, I think?

Speaker 2:

if it's just pure ADHD, I don't reach for it until I've tried lots of other things, because it's just not as reliably effective. The research isn't there. However, if somebody has co-occurring depression and ADHD and they don't have co-occurring anxiety, that's important.

Speaker 1:

Yeah, it's very activating yeah.

Speaker 2:

So in the presence of pure unipolar depression and ADHD symptoms I'll reach for it much more quickly. And I do think in patients with co-occurring substance use disorders and if they have nicotine addiction it's a good thing to reach for because it is FDA approved for smoking cessation and you talk to patients and I wonder if it's somewhat a similar mechanism with your stimulant use disorder patients. The appeal of smoking really goes down for a lot of patients with bupropion.

Speaker 1:

Yeah, when I was starting to get into the addiction space, I remember and I love my naive brain at the time this was like eight, nine years ago thinking it's all about the dopamine. And actually Dr Lee Goldman bought me a t-shirt that says follow the dopamine, and so I was researching which meds are active in increasing dopamine levels, and bupropion is one of the only ones and it seems like that's why it's helpful for dopamine things like binge eating disorder and smoking and addiction. So I don't know, I'm pretty liberal with bupropion. The only issue I always ask is have you ever had a seizure? Because obviously that's an issue. But yeah, I'm pretty liberal and I tend to use the extended release formulation. I usually start at 150 and then bring them up to 300. People get a little bit jittery at 450, but I've got a couple of patients there.

Speaker 2:

Yeah, that's how I would do it as well and agree. The main thing is asking about a seizure history. The other thing that's worth asking about is if there's any active eating disorder symptoms, particularly binge eating, or more bulimia with purging, because there is some association historically between propion and seizures in patients with bulimia. I think it's not a super strong, it was like one study, but enough that it's still talked about and a worthwhile question. Yeah, absolutely.

Speaker 1:

I think for me what I'm trying to get a sense of is when I'm going to feel comfortable starting a stimulant when someone has a history of stimulant use disorder and I feel like it's kind of I know that they're motivated to stay sober and that there's not other active addiction issues. So let's say somebody has trouble with alcohol and opiates and stimulants, I'm going to be more hesitant to start a stimulant in that person as opposed to somebody who's really stimulant is their only drug of choice and they're in residential or they've had three months of sober time and they've got a supportive spouse. So I think that was this one patient that I mentioned earlier. That was my issue is just there were so many other issues. I just felt very vulnerable giving a schedule two medicine and a stimulant to somebody with multiple active addiction issues. But you know I may be wrong on that because this person I prescribed them Adderall and they had their first negative urine for meth and I was really impressed and then I got nervous.

Speaker 2:

Yeah, and I'm not sure that I would wait for three months of sobriety to start, because you might actually be setting them up for relapse because they're sitting there with their untreated ADHD, impulsively doing risky things and not thinking before they act essentially. So, whether it's with a stimulant or a non-stimulant, I'd be trying to aggressively treat their ADHD early.

Speaker 1:

With the non-stimulant meds I am very aggressive, Like my first appointment. I'll start, usually adamoxetine and guanfacine, yeah yeah. So I wish this were a thing In the world of addiction and actually in psychiatry as well. We have the long-acting injectable meds. I would love a long acting injectable amphetamine. I would start someone on that day one because it's under their skin, they can't misuse it, but they get their ADHD treated. And I actually went to the makers of Sublocade, which is in Divier, and I was like can you please make me the equivalent of Sublocade with an amphetamine, Because I would feel much more comfortable. They'd get relatively constant levels. It might interfere with sleep, obviously.

Speaker 2:

I was going to say 24-hour-a-day stimulant might pose some challenges.

Speaker 1:

Well, but I just maybe I'm pie in the sky here, but I just I struggle because with many of these addictions you don't have anything to give back but that drug of choice. So, benzodiazepine use disorder all we can do is put it back on benzos and wean. Stimulant use disorder we have ADHD meds, but if they don't respond to the non-addictive ones, then we have the stimulants and with opioids we have buprenorphine, which is amazing because it's a different opioid. You can't overdose on it. It's less euphoric. So that's what I've tried in my practice is to say I think of adamoxetine and guanfacine like buprenorphine for my stimulant patients, and I keep joking, I need a methaboxone. So I'm curious if you're aware of any emerging research around new pharmaceuticals and ADHD that might be useful in the future.

Speaker 2:

Everything that's come out in the recent years is similar to the antidepressants. They're kind of me-too drugs. Yeah, of course, slight tweaks on something and some of them are meaningful tweaks in terms of a longer duration of action, or a patch versus a liquid versus a pill, so that different you know patients with different challenges can get the medication. But there haven't been any big earth-shattering changes and I don't know of any on the horizon, although I'm not necessarily in the loop in terms of what's going on in R&D.

Speaker 1:

But even in infectious disease. They're starting to make long-acting injectable HIV meds, which is the same reason we have long-acting buprenorphine and in psychiatry we have the long-acting antipsychotics. It's just the compliance is so much better.

Speaker 2:

I think that because adherence to medication regimens is so hard for patients with ADHD which is the other thing their ability to remember to take their medicine is often not the best. What I imagine would come along before any kind of long-acting injectable stimulant would be potentially just like we have once a week Prozac, some sort of longer acting non-stimulant ADHD medicine that you only have to take once a week or something like that, or, I suppose, an injectable non-stimulant ADHD medicine. But I think the challenges of having a 24-hour-a-day stimulant in your system might preclude Point taken. One of the hardest things in treating ADHD for kids is the fact that the stimulants are the most effective medications and then they wear off and the teacher gets the best of the day and the parents get the worst of the day at the end of the day, and you're always trying to tinker with how can you tread the line between maybe like boosters after school or moving the timing of things so that you get as much coverage into the evening for families as possible without messing sleep up.

Speaker 2:

But that's often another reason we end up going to non-stimulants. Is that just either the before the medicine starts working in the morning is too hard, or when it wears off at night is too hard and we can't figure out a way to bridge that. Honestly, there is a methylphenidate preparation, Jornay, which I don't know if you've ever used. That is a time-release, long-acting methylphenidate that is taken at night so that it starts working in the morning before the kid's up and then works throughout the day. And for kids who are really struggling and this could be adults as well with the morning routine and getting out the door in time, getting to work on time, having something that you take at night that's already working when you get up in the morning can be really helpful. Makes perfect sense, Do you?

Speaker 1:

use any of the wakefulness agents, like Provigil, nuvigil, in your practice as a part of ADHD management.

Speaker 2:

Not often I have, but I usually don't have to get to that place. I end up using things like Provigil more often in patients with like chronic fatigue from depression Got it from depression that isn't getting better or as an antidepressant augmenting agent. I have used it for ADHD in the past, but rarely.

Speaker 1:

Yeah, and my understanding to your point about drug levels is that for somebody with ADHD, they really need to be on an extended release formulation, because otherwise you get spikes of medicine and they focus and they feel better and then they crash and they're disorganized again.

Speaker 2:

Yeah, yeah, I think that the old way of starting stimulants was to start somebody on short acting, find the right total dose and then transition over to a long acting form. Now that we have so many long acting forms and the ease of giving it reliably and staying on it reliably is so much better with the long-acting, there's really no reason to start with a short-acting medication. And so the recommendations typically are always start with a long-acting and definitely for patients with stimulant use disorder to use a long-acting because you don't get the same rush necessarily that you get from boluses of short acting throughout the day.

Speaker 1:

It's funny. As you mentioned, the issue with compliance with medications with ADHD reminds me of one of my patients doing wonderful on opioids. I have this individual on Sublocade, which is the long-acting injectable buprenorphine. Comes to see me once a month, gets a shot, does great, can never remember to take her meds and then slips up on meth. And I have her on Welbutrin. When she takes it she does great. I may take her with her meds a little bit and try some more of a dedicated ADHD med and see how she does.

Speaker 2:

Yeah, it's worth a try, and then I think you just have to figure out for a given patient what are all the guardrails you put on to feel safety.

Speaker 1:

Yeah. So again, and I think it's like we were saying if somebody comes to me, visit one and they can still be using methamphetamine, I am 100% on board with trying the non-addictive ADHD meds, the non-scheduled ones. I'm going to have to chat with my team about a protocol about when we feel like we can try the stimulant ADHD medications and a lot of my patients really try hard but they just feel so just out of it, you know, disorganized, they struggle, they're so distractible off of a stimulant and the non-scheduled meds are okay. But I think I've also been underdosing my adamoxetine, so I will definitely start that next week.

Speaker 2:

Yeah your patients are typically adult right, and so I think most of them probably need to be on 100 milligrams of atomoxetine if they can tolerate it. That, ultimately, is the question. I've been way underdosing and obviously you go up. I go up weekly just to try and get somebody up to a good dose as quick as possible, unless they're having side effects. I tend to be fairly aggressive in getting people up to the right dose instead of waiting around.

Speaker 1:

Yeah, so we were chatting earlier this week about this podcast and you had mentioned that you were really glad that I was prescribing stimulants for ADHD and we had talked about seeing if you could change my mind. How do you think you did? I'm not sure. What I can tell you is I am learning, and this is one of the reasons why I wanted to chat with you. There's a time and a place for stimulants for ADHD, and I just have to think about how to take the appropriate precautions.

Speaker 1:

As you know, addiction medicine is one of the specialties that the DEA is traditionally targeted, so I think I just have to do my due diligence, write up a protocol. I have a general patient agreement that everyone signs. The one patient I have on Vyvanse I have a very specific consent for her that this is not something we do regularly. We're going to take extra precaution here, and the outcomes have been really great, and so I have to say I think you actually did change my mind. I'm just a little nervous. I just got to figure out the way to do it.

Speaker 2:

Yeah, I think you have to do it in a way that feels okay to you and safe, and it's going to be different for each patient. So you know your patients best and you know the ones that the risks do seem to outweigh the benefits and then you don't do it. So it's not to say you should always use a stimulant, but I would probably use them, maybe more than you have been. Well, I have one and you have a lot to back you up. Again, the guidelines that just came out this year from ASAM and AAAP say just what we were talking about in terms of using stimulants to treat ADHD and stimulant use disorder, the key being to treat ADHD and stimulant use disorder right, as opposed to trying to treat the stimulant use disorder by giving a stimulant.

Speaker 2:

Right, yes, unlike buprenorphine, where you're treating the opiate disorder by giving something to you know, or methadone, let's say that's a better.

Speaker 1:

Yeah, in my mind, essentially it's untreated ADHD. They find stimulants and they feel better in the illicit market and I'm trying to get their ADHD managed to help them work on their recovery and then they feel better from an ADHD standpoint. Yeah, so, as always happens with this podcast, the hour just flies by. Well, you and I can talk forever. I would love to do this again. I have learned so much. So any last thoughts about managing ADHD in general or specifically in patients who use stimulants?

Speaker 2:

Well, first, I think it's less about treating ADHD or the specifics of how to treat ADHD, but more to bring home the fact that it's really important to treat ADHD. The risks of untreated ADHD are very well documented in the research and, particularly like pre-pubertal ADHD that goes untreated is a major risk factor for future substance use disorder, motor vehicle accidents, risky sexual behavior, academic failure, job failure, relationship failures Not to sound scary and so ominous, but this is. It is essentially right and it's very treatable. And so when we see our adult patients that have had untreated ADHD, they often come in with they're more complicated right. They come in with already a substance use disorder or depression or anxiety or all of the above together.

Speaker 2:

And as the treating provider, you're trying to figure out the layers of the onion and where you start, well said. And so you know you may have patients where you really can't treat the ADHD yet because you have to treat their. You know safety comes first. So if they're suicidal, you need to treat whatever's causing them to be suicidal, whether that's their anxiety or their depression, and recognize that you'll get to the ADHD when you get to it, but that you still really need to treat the ADHD.

Speaker 1:

I think for me, my perspective in the emergency department when I was my primary specialty it just really wasn't an issue. But yes, I agree with you 100%, it's a really important diagnosis to treat. As I say with all of my addiction patients, they use substances because they have an unmet need and they're just trying to figure out how to feel more functional, better, whatever it is. So I just want to say I have learned so much from you. This is how I learned, having not done a fellowship in addiction medicine. Any topics you think we should talk about in the future?

Speaker 2:

Oh man, I think it's a worthwhile conversation about the intersection between anxiety and addiction.

Speaker 1:

Oh, can't wait to do that one. That's all I do all day long, right on. Well, thank you so much for your time and we'll have to do this again. Thanks, casey, and that is the end of this episode. A few take-home points for me.

Speaker 1:

First, we probably need to consider the treatment of ADHD in people with addiction as a more urgent issue. Helping people to be able to focus and think makes the recovery work easier. Second, we also probably need to consider using stimulants to treat ADHD more in patients with addiction. Now, we obviously need to be careful, as stimulants can be addictive, but with proper supervision and monitoring, it can be done. I'm actually working for a protocol for how I'm going to do it and I will share it with all of you once I write it up and try it out. And third, the non-stimulant ADHD medications can be very effective and they are not addictive, so we can start them right away when treating someone with addiction. Thank you to Dr Mohat for being an awesome human and educating me and, with that, thank you so much for listening and thank you for what you do. And don't forget treating addiction saves lives. Thank you.