Transcript Document

• Stimulants
• Methylphenidate (Ritalin,
Concerta, Daytrana)
• Dexmethylphenidate (Focalin)
• Amphetamine/dextroampheta
mine (Adderall)
• Dextroamphetamine
(Dexedrine)
• Lisdexamfetamine (Vyvanse)
• Modafinil,amodafinil
(Provigil/Nuvigil)
• Antidyskinetic/Antiviral
• Amantadine (Symmetrel)
• Alpha agonists
• Clonidine, Guanfacine (Kapvay,
Intuniv)
• Non-stimulants
• Atomoxetine (Strattera)
• Buproprion (Welbutrin)
• Tricyclics
• Imipramine, Desipramine,
Nortriptylene
• SSRIs/SNRIs
• Fluoxetine (Prozac)
• Venlafaxine (Effexor)
• Mood
Stabilizers/Antipsychotics
Me
O
O
OH
HO
NH2
NH2
CH3
H
N
NHCH3
CH3
HO
Norepinephrine
(Noradrenaline)
Amphetamine
Methamphetamine
Methylphenidate
(RitalinTM)
• Amphetamine is a stimulant that is primarily used to treat narcolepsy and
attention-deficit hyperactivity disorder. It is also used recreationally as a
club drug and as a performance enhancer.
• Prescription amphetamines are subject to diversion and are one of the
most frequently- abused drugs in high schools and colleges.
• A Schedule II drug is classified as one that has a high potential for abuse,
has a currently-accepted medical use under severe restrictions, and has a
high possibility of severe psychological and physiological dependence.
AMPHETAMINE
DA
DOPAC
HVA
200
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
COCAINE
DA
DOPAC
HVA
200
100
0
5 hr
NICOTINE
Accumbens
300
% of Basal Release
250
1
2
3
4
Time After Amphetamine
% of Basal Release
400
0
% of Basal Release
% of Basal Release
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
250
0
1
2
3
4
Time After Cocaine
Accumbens
5 hr
MORPHINE
Dose (mg/kg)
0.5
1.0
2.5
10
200
150
100
0
0
1
2
3
4
Time After Morphine
5hr
Di Chiara and Imperato, PNAS, 1988
CG
PreF
CA
Striatum
PUT
OFC
nucleus
accumbens
VTA/SN
(0-10)
1.30
1.25
1.20
1.15
1.10
1.05
1.00
(MP - Placebo)
0.3
0.2
0.1
0.0
-0.1
-0.2
-4.0 -2.0 0.0
2.0
4.0
6.0
8.0 10.0
Pl/PL
PL/MP
MP/MP
MP/PL
Pl/PL
PL/MP
MP/MP
MP/PL
Feel Drug
MP/PL
Restlessness
MP/PL
Pl/PL
0
MP/MP
5
10
8
6
4
2
0
10
8
6
4
2
0
10
8
6
4
2
0
Like Drug
10
MP/MP
15
PL/MP
0
PL/MP
20
Pl/PL
25
10
8
6
4
2
High
30
Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.
Data from Dr. Lloyd Gordon from the treatment of patients at COPAC
Information obtained from CAPTASA 2012 website
• Two interviewers had to agree with
diagnosis (MD, PhD, PNP)
•
All had CBT manually/workbook driven and
special groups with psychiatrist and
psychiatric NP
• Hx of stimulant abuse not exclusionary
unless DOC
•
Behavioral problems resulted in one verbal
warning, then behavioral contract, then
discharge
• Initial poor outcomes on Adderall led to
switch to “safer” drugs (e.g. Concerta,
Vyvanse)
•
N=43
•
Ages 18-55
• One psychiatrist did all med.
adjustments
• Inclusion
• No discussion on unit
• 1 year enrollment in treatment
• Leaving treatment meant no followup from providers
• 1+ prior CD treatments
CONTROL
STIMULANT
25
20
15
10
22
19
5
12
10
8
7
0
18-25
26-35
36-45
2
2
46-55
RELAPSE
14
12
10
8
6
4
2
0
LOST TO FOLLOW UP
13
10
8
5
3
2
0-3
1
4-6
7-9
1
10-12
• 100% (43/43) participants were relapsed and/or lost to follow-up.
• 31% of controls (12/39) relapsed and/or were lost to follow-up
• Only 25% of the stimulant group had abused stimulants in the past
• There were many more behavioral discharges in the stimulant vs. control
groups though the disease severity was equal. (Some of the control group
participants were given Welbutrin or Clonidine. Strattera was not available
at the time of the study.)
• Stimulants do not work in the 1st year of treatment.
• ADD is very difficult to diagnose
• There is no distinct profile on testing, most of what is used in adults is self-report, and even
sophisticated testing can be “fooled”
• Expectancy effects on self-report of symptoms and treatment (with stimulants) are large
• Because a person likes having more energy and can “get more done” on stimulants, it does
not mean they have ADD.
• Most experienced practitioners, if they are brutally honest, will probably admit that they are
almost never sure about the diagnosis.
• The best predictor of the likely diagnosis of ADD is the patient deciding they have it.
• The greatest disability that can be directly linked to the diagnosis is academic difficulty.
• ADD symptoms and personality traits are difficult to differentiate.
• People want a quick fix.
• Living in the solution
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One day at a time, easy does it, first things first, keep it simple
Acceptance
Utilize tools such as smart phones
Delegate
View the energy and creativity as wonderful gifts
Consider safe medications, but don’t expect to be “normal” (False
expectation of stimulants as cure.)