ADHD & Medicines

by Ellen Moore

The episode accompanying this article will be published on Monday November 13th. However, the first two episodes of the Season 6 ADHD trilogy are live already. Click here to listen, click here to read more about ADHD & Women or click here to read more about ADHD & Sex.

Attention Deficit Hyperactivity Disorder, or in short ADHD, is a neurodevelopmental condition which impacts the growth and development of the brain and the nervous system. ADHD can affect one's competence in regards to attention, focus, concentration, memory, impulsivity, hyperactivity, organization, social skills, decision-making, planning, motivation, task-switching and learning from past mistakes.

Neurodivergence is a term used to refer to any and all conditions which impact the functioning of the brain. A diagnosis with ADHD, as well as Autism Spectrum Disorder, dyslexia, dyscalculia and a variety of other conditions make a person "qualify" as neurodivergent. People whose brains function the way a typical brain functions are called neurotypical people.

When it comes to ADHD, there are a variety of treatment strategies. Amongst adults, psychopharmacological treatment is considered the first line of choice. What this entails, you ask? Well, pills.

In order to fully understand what these pills are for, what they do to the brain and how it’s possible they achieve their desired effect, allow me to refresh your memory in regards to how ADHD causes the symptoms it does.

People with ADHD have dopamine - and to a lesser extent noradrenaline - deficiencies in their brain. These two chemicals are neurotransmitters, which play an essential role in filtering the stimuli that enter the brain. Lacking these neurotransmitters leads to the overstimulation, hyperactivity, impulsivity, impaired abilities regarding both focus and concentration and other symptoms associated with ADHD. Chemically interfering with these neurotransmitters people with ADHD lack, may therefore decrease symptoms and improve one’s overall quality of life. But what kinds of medicines are available to do this and how exactly do they impact these neurotransmitters?

Some of the most common medicines used to treat ADHD are:

  • Amphetamine;
  • Atomoxetine;
  • Dexmethylphenidate;
  • Lisdexamfetamine;
  • Methylphenidate;
  • And serdexmethylphenidate.

These meds can be categorized into two main subcategories: stimulants and non-stimulants. As stimulants are considered the first-line treatment option, let's first take a closer look at how exactly stimulants interfere with ADHD.

Stimulants
Admittedly, the term stimulant may be somewhat confusing considering how ADHD is strongly related to hyperactivity and thus stimulants may not be the first thing you think of when looking for a solution against hyperactivity. However, these stimulants stimulate only those areas of the brain which function poorly in people with ADHD.

Stimulants stimulate those brain cells which produce the neurotransmitters norepinephrine, as well as dopamine and its building block dopa. They thereby chemically supplement exactly those neurotransmitters people with ADHD are deficient in. Stimulant medication starts working within approximately 30 to 90 minutes after ingestion. There are two primary types of stimulants:

  • Short-acting stimulants
    • Work approximately 3-5 hours*
  • Long-acting stimulants
    • Work approximately 6-8 hours*

    *How long both short- and long-acting stimulants work is entirely dependent upon the metabolism of the person ingesting them, therefore these numbers are meant only as rough estimates to give you a general idea.

    In most cases, short-acting stimulants are supposed to be taken multiple times a day. People with ADHD may therefore prefer long-acting stimulants, for the simple reason they may otherwise forget to take their short-acting stimulants. No wonder, really, considering memory problems are inherent to ADHD. In result, this may lead to missed doses and fluctuating levels of stimulants, which in turn may cause unpleasant side effects like the infamous rebound.

    Rebound
    Even though all stimulants can have a so-called rebound-effect, it is short-acting stimulants which are notorious for having a more intense rebound effect than long-acting stimulants. ‘Stimulant medications enter the bloodstream quickly, then are filtered through the kidneys or liver and eliminated from the body fairly quickly. Stimulants work by gradually increasing dopamine and norepinephrine levels and activity in the brain.’ When the body has finished processing these stimulants, the levels thereof drop. This drop in stimulants is what causes the so-called rebound.

    Rebound symptoms can differ greatly, but are often described as fatigue and hyperactivity and may result in a bad mood, impatience and / or aggressive behavior. The effects are often similar to regular ADHD symptoms, but then a bit more extreme. Rebound effects last a maximum of approximately an hour.

    ‘Long-acting stimulants are designed to wear off gradually’ and although they may also result in a rebound effect, generally speaking it is short-acting stimulants which cause the greatest rebound. Although rebound effects are normal to a certain degree, extreme rebound effects can be a sign the stimulant dosage consumed was too high. Make sure to consult a medical professional if you suspect this may be the case for you or your child.

    Side-effects & effectiveness of stimulants
    Side-effects of stimulants vary, but may include decreased appetite, nausea, headaches, stomach pain and sleep disruptions. Stimulants have been proven to be incredibly effective in the short-term. Their safety profile suffices, however, insufficient research has been conducted looking into the long term effects of using stimulant medication. ‘Current evidence indicates that stimulants show efficacy and safety in studies lasting up to 24 months.’ Nevertheless, no conclusive evidence has been found to indicate that their use is harmful in the long-term, so long as they’re prescribed and used under careful therapeutic supervision.

    Stimulant medication has been demonstrated to improve the ADHD symptoms of approximately 70% of adults and 70-80% of children with ADHD.

    Non-stimulants
    However, that leaves us with the remaining 10-30% of people with ADHD who don’t respond to or tolerate treatment with stimulants. Luckily there are also non-stimulant medicines that can chemically assist individuals with ADHD. Generally speaking, non-stimulant medicines are only prescribed to patients who do not want to take stimulants or to those for whom the use of stimulants doesn’t provide sufficient improvement in regards to their ADHD symptoms.

    The primary non-stimulant medicines used to treat individuals with ADHD can be classified into four categories:

    • Selective Norepinephrine Reuptake Inhibitors - also known as SNRI’s

    Atomoxetine is a Selective Norepinephrine Reuptake Inhibitor (SNRI) which is used in the treatment of ADHD, because it increases both norepinephrine and dopamine concentrations in the prefrontal cortex. 

    • Norepinephrine and Dopamine Reuptake Inhibitors - also known as NDRI’s

    Both the stimulant methylphenidate, as well as the non-stimulant bupropion, are Norepinephrine and Dopamine Reuptake Inhibitors (NDRI) which are used in the treatment of ADHD. As their name suggests, they block the action of both norepinephrine and dopamine transporters, increasing dopamine levels in the prefrontal cortex as a result.

    • Tricyclic antidepressants - also known as TCA’s

    Amitriptyline is a Tricyclic antidepressant (TCA) used in the treatment of ADHD. Amitriptyline is primarily used as an antidepressant and is used to treat ADHD only in rare cases. Tricyclic antidepressants ‘increase noradrenergic or serotonergic neurotransmission by blocking the norepinephrine or serotonin transporter (NET or SERT) at presynaptic terminals.’

    • Alpha 2 Adrenergic Agonists

    Both guanfacine and clonidine are Alpha 2 Adrenergic Agonists (α2-agonists) which are used in the treatment for ADHD, as they mimic the effects of norepinephrine in the prefrontal cortex - supplementing exactly those neurotransmitters people with ADHD are deficient in.

    Side-effects of non-stimulants
    Side-effects of non-stimulants vary as well, but may include decreased appetite and stomach pain - just like with stimulants, but can also be fatigue and nausea. Although side-effects of any and all types of ADHD related medicines can be troublesome, many of them are temporary and will decrease or disappear altogether once your body has been able to adjust to the presence of the chemical compound in question.

    Most medication, used in the treatment of individuals with ADHD, have an effect on both blood pressure and heart rate. Thus, the use of these medicines should always be monitored regularly.

    So of all these options, what to use?

    Medication order of preference
    Luckily, you’re not expected to make that choice yourself. Psychopharmacological treatment for adults with ADHD takes place conforming to the medication order of preference which, although slightly different across various geographical locations, boils down to the following order:

    1. Methylphenidate or dexamphetamine;
    2. Atomoxetine;
    3. Bupropion.

    Medication for children
    In the treatment of adults with ADHD, medication is the first line of choice. Contrary to adults, in the treatment of children with ADHD using medication is not the first line of choice. Alternative methods like psycho education for both the parents and the child, parental advice and behavioral therapy for the child are preferred. Medicines are prescribed to children only when these alternative methods have afforded insufficient improvement, in regards to their ADHD symptoms.

    When prescribing medicines to children, the first line of choice - just like with adults - is methylphenidate. The second choice is generally atomoxetine, followed by dexamphetamine. Guanfacine is only administered to a child when stimulating substances aren’t suitable or when other medicines are either ineffective or poorly tolerated.

    Off-label
    ADHD medication can be, and often is, prescribed to individuals off-label. This means the drug in question is prescribed in a situation that doesn’t adhere to the guidelines created by the organization responsible for approving drugs.

    In the United States it is the FDA - short for Food and Drug Administration - which bears responsibility for drug approval. A common misconception is that the FDA - or organizations like it - also regulate drug prescriptions, however, it is doctors who bear responsibility for what it is they prescribe.

    So-called off-label prescriptions are used when the benefits of prescribing certain medicines outweigh the possible risk thereof. Off-label prescriptions are both legal and commonplace. In fact, they are far more common than you might think. Research found that in cancer treatment 33% of prescriptions were off-label. A study looking into off-label prescriptions for people with HIV found that 81% ‘of patients received at least one drug off-label.’

    A 2009 study found that ‘approximately 96% of cardiovascular-renal, 86% of pain, 80% of gastrointestinal, and 67% of pulmonary and dermatologic medication prescriptions were off label.’ Experts have estimated that nearly all pediatric patients (80 to 90 percent) are prescribed drugs off-label.’

    When looking into statistics regarding the prescription of off-label drugs, in the treatment of individuals with ADHD, we find that ‘among children ages 3 to 5 years, 91.4% of prescriptions were off-label. After the age of 5 years, the percentage of off-label prescriptions dropped notably to 21%, reflecting the increase in availability of approved medications for the treatment of ADHD starting at age 6.’

    In Australia, Canada, Germany and the United States, as well as a variety of other countries, stimulant medication is registered for the treatment of adults with ADHD. In The Netherlands methylphenidate, dexamphetamine and atomoxetine are registered for the treatment of both children and adolescents with ADHD. Interestingly, however, for the treatment of adults with ADHD only atomoxetine is registered. As a result, those medicines which aren’t registered for the cause or demographic at hand, are prescribed off-label.

    Although different rules apply, in different jurisdictions, in the Netherlands doctors are obliged to inform their patients when they want to prescribe them medicines off-label. A patient needs to agree with such off-label treatment and their compliance must be documented in their medical record. This is called ‘informed consent’. 

    Did you know ADHD also impacts the way you experience sex? Click here to read the full article about it.

    Off-label - good or bad?
    Whether or not prescribing medicines off-label is an incredibly good idea, an absolutely miserable one or somewhere in between is up for debate. Opponents argue that such practices are risky and unethical, claiming it lacks scientific substantiation, increases the risk of unwanted side-effects and may thus lead to a surge in unwinnable lawsuits.

    Advocates for off-label prescriptions prefer highlighting the benefits, claiming off-label treatment is inevitable at times, considering doctors are required to offer patients personalized treatment. Moreover, emphasizing how off-label prescriptions may allow for otherwise prohibited, yet life-saving treatment.

    The benefits of using medication, as a way of treating ADHD, are evident. Yet it is both psychoeducation and behavioral interventions, like cognitive behavioral therapy (CBT), that play a pivotal role in generating progress of executive functioning and organizational skills in the long-term.

    Important to note is that starting medicinal treatment for ADHD should only be done under guidance of a healthcare professional, however, when it comes to medication there’s no one size fits all kind of solution. Figuring out which type of medication works best for you is a process which might take more time than you initially anticipated for. Especially in those cases it’s a matter of patience. Considering how exactly that is something that doesn’t come natural to many people with ADHD, that process may be frustrating at times.

    When I (@byellenmoore) first took the right dose of meds, I didn’t know what happened to me. I was more productive in a day than I had been in years. I was able to focus in a way I didn’t know was humanly possible. For me, these medicines allow me to use my ADHD to my advantage. They allow me to remain calm in situations which used to drive me absolutely nuts. They have given me the sense of peace for which I had been looking in the wrong places for years and years.

    Considering the many scientifically proven benefits medicines for ADHD can result in, my personal advice would be to try and see for yourself if medicines can help you with what it is you're looking for. However, regardless of what it is you choose to do, make sure to do it under supervision of a healthcare professional.

    Be safe and you do you.

    For a full list of ADHD symptoms & diagnostic criteria, click here :)

    Interested in hearing more? Check out the full episode of The Slut Show on your favorite podcast platform, by clicking here! Or head over to our Instagram @TheSlutShowWithEllenMoore for your daily dose of intersectional feminism. Want to send in questions for our mail-segment? Want to be on the show yourself? Know someone who should or want to request an episode about a particular subject? Don’t be a stranger. Our DM’s are always open ❤

    We hope to see you on our socials and for now, sluts out!

    Lots of love,

    Ellen Moore

    The slut show is about way more than sex. It is about breaking taboos, asking questions and fucking the patriarchy, by having real, raw, uncensored and heartfelt conversations about topics that matter. In a safe space we aim to make room for the voices of marginalized folks, creating a place to listen to the pain, sorrow, hopes and dreams of those who came before us. Found in & by intersectional feminism, we believe that everybody should have the same opportunities and get treated equally - regardless of the color of their skin, the size of their body, the gender they identify with or the people they choose to love. Let it be known that the feminism we know today rests upon the foundation black, indigenous, people of color & the queer community built for us. May the battles they fought and the struggles they overcame keep the raging fire in our hearts alive, to make sure that they - nor their legacy - will ever be forgotten.

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