Stimulants! Myths & Managing the Shortage | MGH Clay Center

Stimulants! Myths, Misconceptions & Managing the Shortage, feat. Anthony Rostain, MD, MA – Shrinking It Down

Stimulants - In background is a messy table with quote I think parents with children with ADHD have a big job on their hands. They have to constantly be assessing, “What’s the environment and how is it influencing my child?” Anthony Rostain, MD, MA

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Posted in: Hot Topics, Multimedia, Podcast

Topics: ADHD

What role should prescription stimulants play in a child’s ADHD treatment plan?

Tune in below, or wherever you stream.

Today, Gene and Khadijah are joined by Tony Rostain, MD, MA, chair of Psychiatry and Behavioral Health at Cooper University Health Care, to discuss this and more. How do you talk to your child about stimulants? What side effects should you watch out for? How do you manage after-school rebound? If you’re a parent trying to navigate the stimulant shortage, Dr. Rostain has advice on that, too. PLUS, some cool info on the history of stimulants.

Check out our resource list and find the transcript, below.

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Episode Transcript

SPEAKERS: Gene Beresin, MD, MA; Khadijah Booth Watkins, MD, MPH; Anthony Rostain, MD, MA.

Jump To:

  • 03:17 What are stimulants and their history?
  • 06:22 Do kids with ADHD have to take medication? And if they do have to take medication, is it a lifelong kind of Is it a chronic treatment?
  • 11:13 How do you talk with your child about stimulant medication if they don’t want to take it?
  • 15:38 What are some of the side effects of stimulant medication that parents should be concerned about in their child?
  • 22:31 How can parents manage rebound in their child after stimulant medication wears off?
  • 26:31 What are some common myths and misconceptions about stimulants?
  • 29:42 Does stimulant medication cause addiction?
  • 33:30 What is causing the stimulant shortage in the United States?
  • 40:43 What can a parent do to navigate the stimulant shortage if their child is prescribed this medication?
  • 44:52 Gene takes Khadijah’s line!

 

Dr. Rostain  00:00

I think of ADHD as not just Adderall deficiency disorder which everybody comes in sort of thinking I my kid needs a stimulant. No, ADHD, in and of itself is a really important behavioral neuro behavioral disorder that needs much more treatment than just medication

[INTRO MUSIC]

Gene  00:28

Welcome back to shrinking it down mental health made simple. I’m Gene Beresin.

Khadijah  00:33

And I’m Khadijah Booth Watkins.

Gene  00:35

And we’re to Child and Adolescent psychiatrists at the Clay Center for young healthy minds at the Massachusetts General Hospital.

Khadijah  00:42

We are hoping to have a stimulating conversation with you today. We’re going to talk about… “Now, this is for Ritalin.” “Is that a tranquilizer?” “It’s a stimulant.”  “A stimulant, my god she’s higher than a kite now.” We’re going to talk about stimulants, myths, misconceptions and how to manage the shortage.

Gene  01:01

And to help us talk through this is a very special guest, I think one of my oldest friends. How far back do we go, Tony?

Dr. Rostain  01:10

It’s early 70s.

Gene  01:12

Yeah, really. It’s been amazing what a long strange trip. It’s been. So Tony Rostain, Dr. Rothstein currently serves as the chief and Chair of the Department of Psychiatry at Cooper University Health Center. He’s also professor emeritus of psychiatry and Pediatrics at the University of Pennsylvania, Perelman School of Medicine, my alma mater, where he co founded their adult ADHD treatment and research program. Tony has directed a program for ADHD through the lifespan. And I don’t think there’s anyone I know that has a better grasp of this complex disorder, often linked with other disorders, and the use misuse and myths about stimulants and other medications and also about the behavioral ways for treating ADHD. Because it’s not all about stimulants, as we’ll hear. And he’s one of the lead singers in our child psychiatry band, Pink Freud and the Transitional Objects, I might add, he’s also an amazing blues harp and harmonica, blues harp player. Cody, did you bring your microphone? Do you bring your harp?

Dr. Rostain  02:21

No, I didn’t bring my harp today. But um,

Khadijah  02:25

The harp didn’t fit in the bag?

Dr. Rostain  02:27

No, I should have brought it along. Well, I’m really glad to be here. Looking forward to this conversation. Really. Well, it’s really a hot topic, as they say.

Gene  02:36

Yeah. So, Tony, earlier this year, you did a fantastic job on NPR on point to discuss the ADHD drug shortage. And for those listening, please check out our media list and the link to the onpoint episode. The shortage is definitely still an issue for many families. So we definitely want to get to it. But we also want to bust some common myths and stimulant about stimulants, and about ADHD in general. But to make sure we’re on the same page, maybe we should start by just talking about stimulants, what kind of drugs they are, what they’re used for, and what they do to the brain. So Tony, how would you define a stimulant?

Dr. Rostain  03:17

Well, a stimulant is a compound that been really developed in order to change the way the brain works. The very first stimulant that was developed pharmacy pharmaceutically was amphetamine, which was synthesized in 1887, in Berlin, and it’s related to a plant called my one and it’s originally was sold as a decongestant in the United States. And finally, in 1935, there was noted that it was really effective in lessening the fatigue, that people with depression we’re feeling so it’s technically speaking, amphetamine was the very first pharmaceutical released for the treatment of what we call low energy depression, not melancholic, but just the kind of depression that makes people tired. And it was used during World War Two to help soldiers, you know, combat battle fatigue, both sides, by the way, in World War Two used it the allies and the Axis forces. And then it was used a lot in the 50s and 60s as a diet pill. But in the in the in the late 50s, and early 60s. It finally B was was studied again, it’s initially was found to be helpful to kids with hyperactivity in the 1930s but it really wasn’t widely released for treatment of children with hyperactivity until the 1960s. Similarly, the other class of medications we call stimulant are related to a compound called methyl methyl methylphenidate, and that was first synthesized in 1944, and introduced in the 60s, again to treat ADHD and hyperactivity in particular, in those days, it was called minimal brain dysfunction. Both of these medications, by the way, have been found to be useful in conditions other than Attention Deficit Hyperactivity Disorder, for example, they can augment the treatment of depression. They are also used for narcolepsy falling asleep a lot during the day and a host of other other conditions that I think, you know, listeners should know that even though we think of them primarily for the treatment of, of ADHD, that’s not that’s not their only use.

Gene  05:46

And the first one was dexedrine, right?

Dr. Rostain  05:49

dexedrine or, which is the right sided molecule of amphetamine. It’s dexedrine, is technically dextro-amphetamine. And that was yes, that was widely widely used in the 50s and 60s. The original one that was researched in the 1930s was Benzedrine, which is actually the left and the right compound of amphetamine. So it’s a it’s a mixture of the two but right, dexedrine or Dextroamphetamine is the was the one that was first introduced for treating mostly children with ADHD.

Khadijah  06:22

So do kids with ADHD have to take medication? What would I make? For instance, would therapy not be sufficient? are stimulants the only option if they if it is kind of determined to need medication? And if they do have to take medication? Is it a lifelong kind of Is it a chronic treatment? Will they be on it for life?

Dr. Rostain  06:41

Well, those, are those are exactly the questions I hear all the time from parents.

Khadijah  06:46

Every parent wants to know this.

Dr. Rostain  06:47

Every parent wants to know well, first of all, I think of ADHD as not just Adderall deficiency disorder, which everybody comes in sort of thinking I my kid needs a stimulant. No, ADHD, in and of itself is a very important behavioral neuro behavioral disorder that needs much more treatment than just medication. Right, the family and the child need to understand what the disorder is doing to their particular child, the behaviors are having trouble with its is it attention? Is it controlling impulses is it handling their moods? And certainly therapy is something we always start with, because we want to make sure that the child for example, is not given the Met the message that will you this is your pill to behave, you know that that kind of notion is not helpful one, what we’re trying to say essentially is ADHD, leads kids to have trouble controlling their impulses, trouble staying focused in school or after school, and, you know, makes life difficult for them. And we try our best to offer treatments like accommodations in school, tutoring, and other learning supports and parent training and how to raise a child who may not be listening all the time, or maybe, you know, doing things that they shouldn’t. That being said, we’ve learned over the years again, since the 1960s. I’ve actually mentioned earlier, it was first discovered to work for kids with hyperactivity in the 1930s. But it wasn’t really widely studied and used until the 1960s. So for the last 60 years, we have a pretty good understanding of the fact that children with ADHD do very well on these medications if they are properly prescribed. But stimulants are not the only medical treatment. And as far as I can tell lifestyle changes like giving kids a chance to exercise a lot, giving them choices in what they’re doing, giving them breaks so that they’re not getting bored, and minimizing overuse of, of screens and technology, all of these things as well as protecting sleep. All of these things are important, healthy behaviors we try to we try to introduce into into our approach.

Gene  09:04

And and one thing that you that you didn’t mention that I think a lot of that’s kind of a hot topic is executive functioning.

Dr. Rostain  09:11

Oh, yes. Well, that’s that’s another way of thinking about ADHD. Being able to regulate yourself through space and time towards a distal goal. That’s not immediately rewarding. You know, how do you stay on track when you’re not getting on your board or when you’re not getting rewarded by what you’re doing? How do you make choices? How do you prioritize? How do you say no to things that aren’t really the most important things to do? How do you resist temptation? We could all use some help with this, by the way, given our current add inducing environment, but in kids with this predisposition. It’s really important to stick around and watch as they go and help them learn these executive functions because they don’t do they don’t learn it as easily. I kind of think of ADHD As partly a psychiatric disorder, but also a form of a learning disability, that it’s just takes longer to learn certain tasks, and it takes longer to master with ease, repetitive behaviors that may not be all that rewarding. So yes, executive functioning is a big thing. Now, Khadija, you asked, Did you need to be on it for your whole life, I never looked at it that way I think of ADHD is, let’s see how it helps with this treatment metod stimulant medication, let’s see if it helps your child. And at some point, perhaps they develop skills and coping mechanisms, so they don’t want or need to take the medication. I’ve got patients who stopped for a while and then come back years later saying, Well, you know, I was okay for a while. But now I’m realizing the challenges are too difficult. I need to, you know, I think I need to go back on a medication. And then let’s not forget that there are now non stimulant medications available. To a large degree, those non stimulants can offer alternatives for people who either don’t tolerate the stimulant medications, or who are at risk for some reason of taking them and or for individuals who don’t want to be on stimulants.

Gene  11:13

So in terms of not wanting to be on them, let’s just… How do you explain stimulants to your child? So let’s say you’re a parent, and you’ve decided, with your child’s doctor, that your child with ADHD could benefit from a prescribed stimulant meditate medication? How do you explain the purpose of the medication in a way that doesn’t affect their self esteem? Let’s say they don’t want to be on meds, let’s say that, that they hate the idea of taking medications? Or because it’s they have a hard time swallowing pills or because they’re worried about changing who they are changing their personality? How would How would you explain it to your kids? If you really think that it could help them, it could help them in a way that they could learn some of these executive functionings skills better, you know?

Dr. Rostain  12:07

Right. So first of all, it’s important to – like I use the analogy of eyeglasses, I wear glasses, lots of people wear glasses, if I could take my glasses off, it’s harder for me to read. So I wear my glasses because it makes it easier to read. What we generally say is these medications help kids focus better and learn better, and do things more easily that are hard for them. So it’s really meant to make life easier to make things more straightforward. And most kids, when you explain it that way, go Yeah, like I’m ready, because they’re tired of being you know, either, you know, reprimanded for not getting their homework done, or, you know, they don’t like feeling bored easily, they want to get involved in things and they can’t. The other thing I say not to sort of dealing with the self esteem is that a lot of kids already feel pretty, pretty upset with themselves. And so just explaining that ADHD is not their fault, that they have a difference in the way they process information. So your brain takes a little longer to process information, you notice things that other people don’t, you’re much more aware of, of lots of things that are going on all around. But when you want to focus in and zero in on something, it’s hard to screen everything out. So sometimes I use the analogy of like kind of helping you focus by putting something so that your eyes look at what you’re trying to look at rather than constantly looking what’s around you. So those are some analogies, I think to parents is worry about the potential harm to the child’s self esteem. I always say that this is not something we’re going to stay. We’re going to continue to prescribe if it isn’t visibly helping your child with the with the tasks in front of them. Like if it makes your kid feel bad. If your kid is really hating taking it, then maybe it’s time to wait for a while and and offer a different approach to the difficulties.

Gene  14:06

So, what’s interesting to me is that they may think that the meds lower their self esteem, but almost every kid that I’ve seen with ADHD has low self esteem, because they can’t do they can’t do what they’re supposed to do.

Dr. Rostain  14:22

Yeah, so, we talked about leveling the playing field with kids who play soccer, for example, I always like to say you’re playing soccer, but the field you’re you’re you’re going uphill and the other foot, the other team is running downhill. So you’ve got to this is going to level the field so that you’re not running so hard to get the same things done. And as far as what I hear a lot are parents and spheres, that somehow they’re going to harm their child’s health. They’re going to make it hard for the child to you know, ever learn these things without the medication. And what we always say is no know the purpose is to improve learning and to improve the child’s ability to get things done, they need to get done. And ultimately, like you say, to counteract the the feelings they have about the fact that they’re not meeting the expectations they have or others have. But I’m very, very cautious, by the way about don’t want to change your child’s personality. We don’t want you to make your child subdued, or overmedicated. That’s not the goal. The goal is to have them be their best selves. And if the medicine helps them get there, that’s great. And if it’s not, we’ll find something else.

Khadijah  15:38

I think that’s a great segue to another question I have because often parents are afraid they’re concerned about being making the safest choice for their child. And I do often reframe the idea of self esteem and really point out to them how damaging struggling with ADHD can be to their self esteem and how this can help us I think that’s a great point. And also, they’re also worried about how can this affect my child negatively? So what are some of the side effects they should be concerned about? And be on the lookout for Yes, also should be on the lookout for to understand and to know that this is helping, because like you said, we want to be a help and not a hindrance.

Dr. Rostain  16:17

Right, right. Well, thank you for pointing that out. Number one, we try the lowest dose that’s effective, right? Because when you give too much stimulant, that’s not good either. I have a chart on my wall that shows what I call the inverted U, when you don’t have enough of the of the of the neurotransmitters in your brain available to you to concentrate or to get things done, then you’re inattentive, and you’re distracted, and you’re inefficient in what you’re trying to do. When you have too much of the of those of those transmitters, you’re stressed out, you’re you’re over, you’re either over focused or you’re too sedated. That’s not what we want, we want an optimal amount of, of transmitters to get you focusing and be flexible in what you’re trying to do. And that’s where we try and say that, we try and start with one dose, but we’re going to, we’re going to try different doses to see what works best. There’s no one dose fits all or one size fits all to this, you have to individualize. As far as side effects, the most common ones, we talked about what to do with, for example, suppressing appetite, that’s a big deal. You don’t want your child not to eat. So you have to really be cautious about how the child’s weight is how their height is, you don’t want to in the early days, when when the stimulants were first introduced, they were given at higher doses than we give them now. And so it turned out that, you know, pediatricians in particular, and child psychiatrists noticed that there was an effect on growth. So that’s something we pay a lot of attention to eating properly, growing, growing in a healthy trajectory. And if the child’s losing too much weight, we have to make adjustments. A second problem is interfering with sleep. Now this is fascinating because a lot of kids with ADHD don’t sleep well. So you have to ask about how the child’s sleeping, and if they’re sleeping well is this disrupting their sleep. But the opposite may be true. As well, they might actually sleep better as a result of having having a little medication helped them to settle back down and, and, and have more active productive days so that they’re not overstimulated in the evening. Another side effect we talked about earlier was change in personality, which we really don’t want to see. And in some children who are sensitive, they may not like that, they may not like the way the medicine makes them feel. Occasionally children will feel like it’s hurting their stomach. And it’s, it’s actually painful to take it because their stomach is hurting them. We definitely make changes and adjustments in the medication then, if it causes movements that child children don’t want to have, like tics, we have to be very careful that we don’t have those tics become innate disabling these are like squinting and grimacing and, and moving or making vocal utterances. We definitely have to look for that and any other unusual behaviors or thinking processes. If the child starts to talk, like, you know, some like they’re, they’re not themselves, we immediate I immediately have the parents call me because that’s a really unwanted side effect. Now, the last one I want to mention, because it’s been in the news lately, is people wonder about the long term effects of stimulants. And it turns out that with a review recently of of large datasets coming out of Scandinavia, it turns out that long term use of stimulant medication can cause a slight increase in both blood pressure and heart rate. Now it’s not. There’s no evidence that that’s causing any harm, because they measured that as well. So there was no, there were no bad cardiac effects. But there was a rise in hypertension, depending on how long the person had been on it. And whether there was a family history or other problem with hypertension. So that’s one caution I now bring forward which is making sure that if there is a family history of hypertension, that we watch very closely and monitor over time, whether there’s any change in the child’s blood pressure, to be sure that they’re not going to have long term effects.

Khadijah  20:42

I saw that study as well. And I know we have talked, going back and forth about the cardiovascular effects over over quite some time, so that it’s important for us to make sure,,

Dr. Rostain  20:50

Yes, you know, and it’s glad, I’m glad you do, because we’ve all been thinking about it, you know, there was about 20 or 15 years ago, 20 years ago, there was some concern about extended release, mixed amphetamine salts, causing cardiac deaths or cardiac arrhythmias. So the early concern was around arrhythmias, meaning rhythm disturbances, that could be very, very, could even be fatal for those that had structural heart diff differences. But but larger studies in subsequent years found no ill effects. So this is the first study and it’s a really important study for everybody to look at, does show that there is this small number of people who there there’s a larger incidence of the of the risk for hypertension, it doesn’t mean you’re gonna get hypertension, it just means that the risk goes up, especially if you’ve got other factors that work. The other. If you look closely at the data from that study, you’ll see that the people with ADHD had higher rates of obesity by a major factor, which may be for me anyway was a bit of a, a question, which is how much did the obesity that there was in that group that was being treated for ADHD contribute to their higher blood pressures? But anyway, as long as we’re watching for these things early, I always tell people, hey, if the side effects are a problem, we just stop. That’s the other nice thing about stimulants, you can just stop them on a dime. And, you know, maybe you experience a little bit of low energy and moodiness for a couple of days, but you don’t have withdrawal.

Khadijah  22:31

So maybe not a side effect. But what about this idea of rebound? And so a lot of parents are concerned about that. And some even complain, I think there was a parent who wrote into a magazine, who wrote that they’re really happy about the fact that the effect of the medication during the school day, but in the evening, the wine downs are horrible, and it feels like it’s very hard for the family to engage in activities in the evening, because and so what about that.

Dr. Rostain  22:55

Yeah, that’s a really important observation. So rebound means that when the medication wears off, the brain goes back to being an ADHD brain rather than a treated ADHD, brain untreated ADHD. And therefore Yes, you’ll see a an excessive amount of activity, difficulty controlling behavior, a lot of impulsivity, a lot of moodiness. So we say a couple of things. First of all, if you know what time that’s occurring, you try to spend time in that in that time period, not with high demand situations, that’s a time to let the child on wind, you know, do something fun, you don’t want to be doing homework. And you don’t want to be asking kids to sit down at the table, when they’re really at that moment, less able to control themselves. If it’s severe, we sometimes add a dose of medication later in the day, at a lower amount, so that the evening goes better. Or we might try a non stimulant medication, which I won’t go into which ones but you can try something that will reduce the hype, the rebound and excessive hyperactivity in the evenings. So there’s any number of ways to address it. But that’s a really good question. How do you handle it at home, most of all, be aware of it and give a child time to because once that period of rebound goes away, that’s about an hour or two at the most, then the child is their usual self. And you won’t see that they may be a little hyper but they won’t be as bad as they were when they were first. Withdrawing so to speak are rebounding from the medicine.

Khadijah  24:40

So it’s kind of like making sure that we’re aware and proactive in managing the environment.

Dr. Rostain  24:44

Exactly manage the – I think that’s the key. You know, I think parents with children with ADHD have a big job on their hands because they have to constantly be assessing what’s the environment and how is it influencing my child? We like to say that children with ADHD are more more environmentally sensitive than their same age peers. So if there’s a noise, they’ll be more distracted. If there’s a lot of commotion, they might not be able to stay oriented or focused on what they’re doing. And that’s why it’s important to keep things mellow, chill out, you know, use it as a time to just maybe play a video game at that point, you know, let them have that game for that period of time. But make sure there’s a limit to it as well.

Khadijah  25:27

So you never give me a chance to talk. But I just have two more questions. And so parents will often ask, you know, what about the generic? Should I insist on the brand? And then do they have to take it every day? Should we only take it during school?

Dr. Rostain  25:39

Again, no fixed rules. In most cases, the generics are working, okay, although there are some longer acting generic preparations that have been found not to be as effective. So that’s something to discuss with your prescriber. The prescribing clinician needs to sort of explain the different that stimulants come in different long acting, short acting, extra long acting, not released till the next day acting. So that’s something that has to be individualized, I would say that whether a child should be on it every day, I recommend that they do take it on weekends, because I don’t think ADHD is just a school related problem, you know, but some parents and some kids prefer to not take it, you know, on the weekend. So, again, individual decisions, worthwhile discussions.

Gene  26:31

So, let’s get to myths, misconceptions about stimulants. So let’s bust some common myths, misconceptions.<DRUM ROLL> So let me state a few prescription medications lead to addiction and substance abuse. That’s one, another one. <DRUM ROLL> Stimulant medications would make anyone perform better? Anyone run faster, jump higher and be smarter. And the third one is, <DRUM ROLL> ADHD meds anesthetize children. So do you hear any other misconceptions or we don’t have that much time? But But are those the big ones that you’ve heard, Tony?

Dr. Rostain  27:11

Well, I also hear that people fake their ADHD to get medication. So they’ll, you know, you know, the typical one is college students who want to get you know, something to help them as a study aid. The truth is that even though it doesn’t make you smarter, there’s no question that a stimulant can keep you going longer, right? I mean, that’s part of what was discovered about it, that made it quite an important option. And during periods of excessive, you know, stress, right? Why did soldiers are and it continued, by the way to give air, air, air force pilots stimulus when they’re flying long missions. So A, it does keep you going longer, especially with boring things be there is another myth that sort of people can fake it, in order to get drugs, that’s a very small number of people, you would have to be suspicious if if there if there is no real evidence for the child or the adults, history of stimulants. So we have to verify a lot when especially when we’re diagnosing college students or adults. But when it comes to kids, I mean, I think the other myth from the kids standpoint is this pill is making me behave better. And I think that’s a really unfortunate belief. I just think that that’s, we have to say that this, this medication is helping you make good choices, you’re the one making the choices, not the pill, you’re the one deciding you’re going to do your homework, or you’re going to help with the chores or you’re going to practice your instrument or whatever you’re doing to have fun. Not the pill, the pill just gives you the ability to make better decisions. And one other myth by the way, from from the standpoint of how the child may also feel about it is that that it’s it’s something they don’t want other people to know, because other people are going to think they’re, you know, cheating, especially, you know, who really worried about this or high school kids. They think that, you know, their their friends, if they know about it are going to look at them go Yeah, yeah, you don’t really have this. So I think fear of embarrassment is another another. I don’t know if that’s a myth or just a common a common experience of what others view as an unfair advantage that people may be getting.

Gene  29:42

And what about addiction?

Dr. Rostain  29:43

Oh, we know that addiction is on everybody’s mind. But the evidence is quite the contrary. If at the very least, there’s no difference and better in some studies that shows that there’s less less less likelihood of getting addicted why? Because what addiction we think of especially and people with ADHD comes from untreated ADHD. It’s a form of self medication. So they’ll try cocaine, they’ll try methamphetamine, dangerous stimulants, those are, those are non medical stimulants that are widely used, that are dangerous, mostly because of the way that they’re ingested. But we know that methamphetamine and cocaine can have profound effects on the nervous system and are also classified as stimulants, although they’re not medical stimulants there, which I call recreational stimulants. I’m sorry.

Khadijah  30:33

I think another myth that is really concerning is that you hear often, unfortunately, that ADHD is not real. And if the child would just study harder, they wouldn’t be so lazy. And I think that that meant, you know, first of all, is is not true. But it really adds to the stigma and the shame and embarrassment around treatment. And it adds to the lowering of the self esteem for those kids who are struggling.

Dr. Rostain  30:59

Yes, yes. Well, look, it’s not just true in the United States, globally, there’s a lot of stigma, about having ADHD, and a lot of MIS misunderstanding. And the the sort of the, what you just mentioned, was the thought that if the child just tries harder, or if the parents parented better, the child would be better behaved or better able to get things done. And it’s all a bunch of baloney. You know, I talked to medical students now, whose parents, still they think ADHD is a myth. And it’s, it’s hard to argue with people who are convinced of something like that, I tend to say is, I hope they can be informed about the fact that we know that anywhere up to 8% of children, and almost 5% of adults in the United States meet the criteria for ADHD. And in terms of adults, they have a lot of other problems on top of the ADHD, there’s a lot of real higher rates of bipolar disorder of sub, you know, untreated ADHD is definitely linked to higher rates of substance use depression, trouble with jobs, automobile accidents. So when I put it in the public health context, what I think is that ADHD is probably one of the most treatable disorders of children that lasts throughout the whole lifespan, that if you treat it early, you can prevent terrible public health outcomes. Better Health will come from treating it and fewer automobile accidents and greater success in life. But no, you’re right. It’s a it’s a big, big fear people have and I always say that oftentimes, it’s not the parents, it might be somebody else in the in the family system, you know, that’s giving them that message. I just think we still have a lot of work to do. I have seen a D. stigmatization going on little by little, the social media is helping with people meeting other people with ADHD and learning about it. But when a parent says, Look, I am ready to accept the diagnosis, but I don’t want to start a medication. I always say, okay, we can hold off if that’s what you prefer to do. I don’t want to impose something that people aren’t ready to take on.

Gene  33:16

So now, what about the shortage?

Dr. Rostain  33:19

That’s been the worst scenario of all, because it’s already stigmatized, and then parents cannot find the medications they need for their kids.

Gene  33:30

How you understand – I mean, I’m not I’m not in the pharma industry, but I it’s fairly easy to make, right? It’s fairly easy to produce. I mean, this is not a complicated, modern, you know, situation. So how do you account for the fact that every year for the last four or five years, there’s been a shortage pharmacies just don’t have it. And then parents have to go look around, look around, look around, and find and find, and sometimes they have to buy brand name, because the generics aren’t around. So that’s right. So what’s what’s the what’s at the bottom of this problem?

Dr. Rostain  34:09

Well, let’s first start with the pharmaceutical industry as a whole, not just with stimulants, but with all prescription medications. Once medication stopped being profitable for the companies that make them, there’s less of an incentive to make a lot of them. Okay. And you’ve seen shortly we’ve seen shortages in cancer medications. We’ve seen shortages and diabetes medications, all because of quote, the incentive for pharmaceutical companies to produce enough medication for because the more so there’s an advantage to these pharmaceutical companies to watch very carefully how much of their medication is on the market. And what you just said, driving people to take brand name rather than generics is definitely part of the story. Okay, so then you’ve got the companies may Making these generic stimulants in a sense, they want to increase their market share, but they can’t because there’s only so many tons of men of stimulant allowed to be produced. So this gets into the Drug Enforcement Agency, that in 1965, there was the beginnings of a discussion about, you know, the stimulants being classified in a different way. And in 1971, they were put on a schedule, DEA schedule, and they are highly regulated. And so one company cannot produce more than there were given the, the legitimate right to so what happens then is there’s a shortage in terms of the demand for stimulants has gone up, but the amount that is allowed to be produced every year by these laws has not gone up.

Gene  35:52

But is that is that is that for just the generics with the generic and the brands?

Dr. Rostain  35:56

It’s for all of them two together, they’re not letting more than a certain number of pills of either methylphenidate products or amphetamine product.

Gene  36:05

But Tony, what’s what’s in it for the DEA to to exert these controls? I mean, they’re not making the money.

Dr. Rostain  36:11

No, the DEA is afraid of stimulant abuse and misuse the stimulant stimulants represent to the DEA a potential liability, number one, from what they work, what happened to them through the opiate crisis, you know, the DEA said, Oh, it’s okay to have these, these other forms of opiates. And as we all know, unfortunately, sadly, horrendously. Hundreds of 1000s of people die every year, and have died over the years, not every year, but over the last decade, from these these pain relief in medication. So what happened was, the DEA became very concerned that they had not limited the access to opiates. And they turned around and looked at stimulants, they noticed that stimulant abuse and misuse was going on, especially of compounds like methamphetamine. So they now become very highly worried about that there’s actually going to be a next week, a major meeting in Washington DC, with the DEA, and the Institute of Medicine, and the FDA, talking about the supply safe supply of stimulant medication, it’s all going to be about this crisis, because the DEA was not trying to make it hard. They were trying to protect public health. And then Tony, but there’s one more group that we didn’t talk about, which are the Insurance insurance companies, because they want to limit access to because they’re concerned also that more and more prescriptions are being written. And so everybody’s on, was unprepared for this. They were unprepared for the growing recognition and treatment of ADHD, the growing rise in demand for the the medication, the strict restrictions on supply, and then the growing in attempts at controlling costs, but what I call a perfect storm.

Gene  38:15

But look, if it’s not life threatening, like opiates, or on fentanyl or and other, you know, for overdoses, if What if the risks of of death if are minimal? If the risks of morbidity or of danger to the self is minimal? Then what’s the worry about? Is it a gateway drug to other addictions? For some people? I mean, what what is the basis for limiting the numbers? I mean, why don’t they limit the number of GERD medications?

Dr. Rostain  38:48

Yeah, well, I always I always joke that if if this if medications for ADHD were not a controlled substance, none of us in our field would be given as we would have much less heart hardship and so with our patients, but because the best medication for ADHD happens to be something that was put on that list by the Nixon administration, and you know the you know, Attorney General John Michell they were out to stamp out any kind of what they perceive to be threats to me, obviously, they went after people smoking marijuana, they went after people for using opiates. And they went after people using stimulants stimulus was thrown in with all of those and the medical reasons for using medication were not what what led it to become a schedule two drug. So we are stuck with this with the history of the of the Drug Enforcement Agency. It’s not a threatening, it’s not a life threatening medication. But when you listen to the news, and you listen to the way the DEA approaches it, they make no distinction.

Gene  39:56

So when you think about it, statins like live Lipitor, and Prednisone. And some of the more and the antihypertensives that are the most common, are considerably much more dangerous overall, than stimulants.

Dr. Rostain  40:11

They are no question more dangerous, but they’re not regulated. They’re not put on this list of controlled substances. I think that we’ve we look, I said this on the onpoint. I think parents and patients with ADHD should protest that these medications are scheduled to to begin with, as you point out, they’re really much safer than people think they are. And we’re doing a disservice and we’re harming patients.

Khadijah  40:41

But in the meantime…

Dr. Rostain  40:43

<Laughing> Okay…

Khadijah  40:43

…what can parents do?

They cannot buy this medication at the pharmacy and their child is struggling at school struggling at home, should they switch to another stimulant? Should they request brand? I’ve had some kids say that and parents say that they’re rationing, like they’re only giving it on certain days.

Dr. Rostain  41:00

I know. Isn’t that awful?

Khadijah  41:02

That is awful. So what are they supposed to do? What should they do?

Dr. Rostain  41:06

Okay, first of all, they talked to the prescribing clinician and say the following. I’m having trouble finding the medication. What do you think we should do? There are a couple of options. One is start looking wider. If that doesn’t work, find out from the pharmacy when they’re expecting the shipment. Because when the shipment comes in, if we can time our prescription right, they might be able to get there in time to get the prescription filled. If that doesn’t work, I agree you have to try a different if they’re not saved, the medication you’ve been using isn’t available, try an alternative. Now should you use brand, if push comes to shove, I’ve actually spoken to a couple of pharmacy plans and insisted that until the generic was in that they should agree with paying for the brand. And a couple of parents had been very successful at harassing their insurer and getting an override to allow them to get the brand because of the shortage. So yeah, but but no rationing. So you don’t give your child the medication they need is, I mean is is is not a good idea. And I always like to say can you imagine if they said you have to ration your child’s insulin? I mean, come on. It’s just unconscionable. I’m sorry?

Khadijah  42:25

I said parents should not be putting parents in that situation.

Dr. Rostain  42:27

Exactly. We are putting parents in untenable situation. So I’m, I’m both enraged, but I’m also I’m really, I’m really trying to empower parents to challenge the pharmacy plans.

Khadijah  42:41

Gene told me to zip it. So I’m gonna be quiet have nothing else to say.

Gene  42:44

<Laughs> No, no, no, no. You’re in charge of the closing today.

Khadijah  42:48

Oh, I am?

Gene  42:48

You’re in your charge wrapping it up.

Khadijah  42:50

Oh, okay.

Dr. Rostain  42:52

I think it’s, I’d be happy to come back whenever you say so we can, you know, continue the conversation. I think that what’s really important to say in closing is that neurodiversity is a really important concept that more and more people are grasping, and that people who have brains that are somewhat different gets penalized, stigmatized and marginalized. And I think that this is a good example of how the treatment for people with a very common and very debilitating disorder are looked at like a we don’t believe you have it. And B, if you do have it, we’re not going to make it easy for you to get the treatment, we’re going to make it harder. And we didn’t even get into the problem of finding good therapists and people who can work with the family or work with the teachers. You know, there’s so much need out there. And it you know, I always like to say ADHD is not about Ritalin or about Adderall. It’s about helping people grow up and become productive human beings in a world that’s increasingly information. You know, information heavy.

Gene  43:57

I was gonna say, we should have a part two.

Khadijah  44:00

I think we need to have a part two and three. But we are so thankful for you joining us today this has been and I’m gonna say my little corny plan again, a stimulating conversation. And and we’re gonna wrap up, but is there anything you’re looking forward to in the next week or so?

Dr. Rostain  44:13

Yes, I personally am. Well, I was looking forward to this. This was actually a highlight for me. But I am gonna go see the Nutcracker Suite this weekend, which is one of my favorite ballets.

Khadijah  44:21

Oh, that’s awesome.

Gene  44:23

That is great. So thank you, Tony. And thanks, everybody. For listening. We’ll be sure to subscribe – So be sure to subscribe and consider leaving us a review and we’ll see you back on the third Thursday of next month. I’m Gene Beresin.

Khadijah  44:41

And I’m Khadijah Booth Watkins, I’ll see you next time.

[OUTRO MUSIC]

Gene  44:52

Today’s episode is about stimulants.

Khadijah  44:56

Wait, I was supposed to say we’re gonna have a stimulating conversation.

Gene  44:59

Okay. Go ahead.

Khadijah  45:00

And we’re going to talk about myths, and we’re going to talk about misconceptions, and managing the shortage.

Gene  45:06

Okay so you go, you go.

Khadijah  45:07

You took away, you took away my, my info.

Dr. Rostain  45:08

Start from the beginning. Start from the top.

Gene  45:09

Okay, I’ll start from the beginning.

Dr. Rostain  45:12

I saw the script and I thought Khadijah had a really great line there.

 

Music by Gene Beresin

Episode research by Spenser Egnatz

Episode produced by Sara Rattigan

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Gene Beresin

Gene Beresin, Executive Director

Gene Beresin, MD, MA is executive director of The MGH Clay Center for Young Healthy Minds, and a staff child and adolescent psychiatrist at Massachusetts General Hospital. He is also...

To learn more about Gene, or to contact him directly, please see Our Team.

Khadijah Booth Watkins

Khadijah Booth Watkins, Associate Director

Khadijah Booth Watkins, MD, MPH, is associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital (MGH), and the Associate Director of the Child and...

To learn more about Khadijah, or to contact her directly, please see Our Team.