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ADD/ADHD Medicines and Safety 

The Medical Perspective

Methylphenidate  Stimulants

ADD/ADHD Medicines and Safety 

The FDA has issued a warning about the risk of drug abuse with amphetamine stimulants. FDA safety advisors are also concerned about the possibility that all amphetamine and methylphenidate stimulants used for ADHD may increase the risk of heart and psychiatric problems.

The FDA has also issued a warning about a connection between antidepressants (including the non-stimulant Strattera) and an increased risk of suicide in adults aged 18-24, especially in the first one or two months of treatment.

While these risks may seem alarming, keep in mind that experts generally consider these medicines safe. Serious problems are rare. Still, you should discuss the risks and benefits of these drugs with your doctor.

Concerta

Concerta Side Effects and Warnings

Schedule II Substance

Brand Name: CONCERTA 

Generic Name: methylphenidate hydrochloride (HCI)

Category: CEREBRAL STIMULANTS

Concerta (methylphenidate) is an amphetamine-like prescription stimulant commonly used to treat Attention Deficit Hyperactivity Disorder (ADHD) in children and adults.

FDA “Black Box” Warning Label

The Food and Drug Administration (FDA) requires the following "black box" warning on all methylphenidate drugs, which means that medical studies indicate methylphenidate drugs carry a significant risk of serious, or even life-threatening, adverse effects.

WARNING

CONCERTA IS A FEDERALLY CONTROLLED SUBSTANCE (CII) BECAUSE IT CAN BE ABUSED OR LEAD TO DEPENDENCE. KEEP CONCERTA IN A SAFE PLACE TO PREVENT MISUSE AND ABUSE. SELLING OR GIVING AWAY CONCERTA MAY HARM OTHERS, AND IS AGAINST THE LAW.

TELL YOUR DOCTOR IF YOU OR YOUR CHILD HAVE (OR HAVE A FAMILY HISTORY OF) EVER ABUSED OR BEEN DEPENDENT ON ALCOHOL, PRESCRIPTION MEDICINES OR STREET DRUGS.

ABOVE: FDA black box warning label means that medical studies indicate the drug carries a significant risk of serious or even life-threatening adverse effects. The bold warning label appears on the manufacturer's wholesale packaging and is the strongest alert the FDA can require of drug-makers.

Used For

• Attention deficit disorder
• Narcolepsy

How Concerta Works

We don't know exactly why it produces the effects it does. Methylphenidate was first synthesized in 1944 in an (unsuccessful) attempt to create a stimulant that would not induce addiction or tolerance. Methylphenidate (Concerta) is very closely related to amphetamine: similar in chemical structure, metabolization and clinical effects. This close connection is the chief reason methylphenidate drug use raises concern among patients and others.

U.S. DEPT. OF JUSTICE: “Of particular concern is that ADHD literature prepared for public consumption does not address the potential or actual abuse of methylphenidate. Instead, methylphenidate is routinely portrayed as a benign, mild substance that is not associated with abuse or serious side effects. In reality, however, the scientific literature indicates thatmethylphenidate (Concerta) shares the same abuse potential as other

Schedule II stimulants

. Further, case reports document that methylphenidate abuse can lead to tolerance and severe psychological dependence.”

ABOVE: Drug Enforcement Administration, US Department of Justice. “Methylphenidate, A Background Paper,” NCJRS (National Criminal Justice Reference System) Abstract, NCJ 166349 (1995):www.ncjrs.gov/App/publications/abstract.aspx?ID=163349.

"Physiological effects of oral cocaine and methylphenidate were similar."

ABOVE: Rush, C.R., et al. "Behavioral pharmacological similarities between methylphenidate and cocaine in cocaine abusers," Exp. Clin. Psychopharmacol: Feb;9(1):59-73(2001): www.ncbi.nlm.nih.gov/pubmed/11519636.

Do Not Use If

You have high blood pressure or any form of heart disease, are very nervous or have severe insomnia, have a history of addiction to drugs or alcohol. Do not combine with monoamine oxidase inhibitors.

Common Side Effects

Addiction

Nervousness including agitation, anxiety and irritability

Trouble sleeping (insomnia)

Decreased appetite

Headache

Stomach ache

Nausea

Dizziness

Heart palpitations

Other Serious Side Effects Include

Slowing of growth (height and weight) in children

Seizures, mainly in patients with a history of seizures

Eyesight changes or blurred vision

Less Common Side Effects

High blood pressure

Rapid pulse rate (and other heart problems)

Tolerance (constant need to raise the dose)

Feelings of suspicion and paranoia

Visual hallucinations (seeing things that are not there)

Depression

Cocaine craving

Dermatoses (infected or diseased skin)

Urinary tract infection

Infection or viral infection

Elevated ALT enzyme levels in the blood (signaling liver damage)

Overdose Side Effects

Methylphenidate drugs have been extensively abused. Extreme psychological dependence and severe social disability have resulted. Abuse of methylphenidate drugs may cause a sudden heart attack even in those with no signs of heart disease. Symptoms of overdose that require immediate medical assistance include:

Restlessness

Tremor

Aggression

Hallucinations

Panic states

Hyperreflexia (overactive reflexes, which can include twitching or spasms)

Personality changes

Symptoms of depression

Seizures or abnormal EEGs

High blood pressure

Rapid heart beat

Swelling of hands/feet/ankles (for example, numbing of the fingertips)

Delusions

Sweating

Vomiting

Dehydration

Unexplained muscle pain

Lower abdominal pain

Rhabdomyolysis and kidney damage

Chronic abuse can manifest itself as psychosis, often indistinguishable from schizophrenia

What to Do About Side Effects

The last dose of the drug every day should be taken several hours before bedtime to prevent insomnia.

Nervousness usually goes away and appetite often returns so that weight loss is rarely dangerous.

If high blood pressure, rapid pulse, paranoia, or tolerance becomes a problem, the drug is usually stopped.

Nothing can be done about the addiction except to remember not to stop taking any version of methylphenidate abruptly.

Concerta is a Schedule II Substance, which means it has a "high potential for abuse" that "may lead to severe psychological or physical dependence," and the federal government sets limits on the amount of that may be manufactured each year.

ABOVE: 21 USC Sec. 812 01/22/02. Drug Enforcement Administration, US Department of Justice. www.dea.gov/pubs/csa/812.htm.

Dependence, Tolerance and Withdrawal

It is possible to build up a tolerance to Concerta, which means the person using the drug needs to take larger doses to achieve the same effect. Over time, the body might come to depend on methylphenidate drugs just to function normally. The person craves the drug and their psychological dependence makes them panic if access is denied, even temporarily.

Withdrawal symptoms can include tiredness, panic attacks, crankiness, extreme hunger, depression and nightmares. Some people experience a pattern of "binge crash" characterized by using continuously for several days without sleep, followed by a period of heavy sleeping.

If It Doesn't Work

The drug should be stopped gradually. Withdrawal symptoms are psychological and stopping suddenly can cause extreme fatigue and severe, even suicidal, depression in adult patients.

Abrupt cessation of stimulant drugs such as Concerta can cause extreme fatigue and severe, even suicidal, depression in adult patients.

ABOVE: The Essential Guide to Psychiatric Drugs—Rev. and updated (2007).

If It Does Work

"Also, in addition to increasing heart rate and blood pressure, causing insomnia and weight loss, and sometimes causing psychotic symptoms, the stimulant medications used for ADHD (methylphenidate and amphetamines) may cause heart disease if taken for a long time. The latter problem led to a debate within the FDA, well covered by newspapers, about whether to issue a special warning to doctors. In the end, the FDA decided not to do this, but the risk remains," reports Jack M. Gorman, M.D., professor of psychiatry at Columbia University and deputy director of the New York State Psychiatric Institute.

The Question of Whether Concerta Impairs Creativity

Methylphenidate (Concerta) may have subtle impacts on cognitive and intellectual processes. Both parents and researchers have noticed that children taking methylphenidate sometimes answer questions in ways that seem overly compliant or narrow, suggesting the drug might restrict creative thinking. One study found hyperactive children taking methylphenidate offered less varied answers to open-ended questions.

How much do "neuro-enhancing" drugs really help?

And there's the question of what we mean by "smarter."

The psycho-stimulants help students bear down on their work, but with odd effects. One college student says he spends "too much time researching a paper rather than actually writing it--a problem, I assure you, that is common to all intellectually curious students on stimulants." Another student looked back at papers he'd written while on Adderall and found them verbose, "I'd produce two pages on something that could be said in a couple of sentences."

Could Enhancing One Kind of Thinking Exact a Toll on Others?

All these questions need proper scientific answers, but for now much of the discussion is taking place furtively, among an increasing number of Americans who are performing daily experiments on their own brains (or their children's brains).

"It's Not the Real You. It's a Fake Person"

Not all children with ADD feel better on methylphenidate drugs. One teenager said: "It's not the real you. It's a fake person." Another, after being on methylphenidate drugs for seven years, begged his parents not to make him take it, but one of his teachers would not allow him into her classroom unless he had a note signed by the school nurse that he had received methylphenidate at school that day. The boys complained of dizziness, stomach upset, inability to sleep, a buzzed feeling, and appetite-loss because of methylphenidate.

Emergency room visits by children ages 10-14 involving methylphenidate intoxication or overdoses have now reached the same level as those for cocaine--indicating escalating abuse of the addictive drug.

ABOVE: Diller, L.H. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill; Bantam Doubleday Dell Pub. Group, Inc. (1998); citing Feussner, G. "Actual Abuse Issues," Conference Report: Stimulant Use in the Treatment of ADHD, Drug Enforcement Administration, US Department of Justice, Washington DC, Dec. 1996.

A review of 20-years of scientific literature on using stimulant medications, including methylphenidate, to treat children with ADD and ADHD found a consensus: there is no documented long-term benefit (academic achievement or pro-social behavior) in using psychoactive drugs.

ABOVE: Swanson, J.M., et al. "Effect of stimulant medication on children with attention deficit disorder: a review of reviews," Exceptional Children, 60:154-62, 1993.

Concerta Withdrawal Suspected Association with Sexual Dysfunction

HEALTH CANADA (2006): A 16-year-old boy taking extended-release methylphenidate, with no history of sexual dysfunction, experienced priapism (a painful, persistent and abnormal erection unaccompanied by sexual desire or excitation) that would last up to 24 hours whenever he forgot to take his medication. He had been taking 54 mg of the drug daily for about one year for attention deficit hyperactivity disorder (ADHD) and was not taking any other medications. The priapism would resolve after he took his medication. Treatment with extended-release methylphenidate was continued because the product worked well in controlling his ADHD. The patient did not appear to have any sexual dysfunction when he remembered to take his medication. Priapism is not labeled in the Canadian product monograph.

A case of priapism associated with withdrawal from sustained-release methylphenidate has been reported in the literature. 

The Alternative Perspective Your Solution

If you are currently taking prescription medication for your symptoms and are interested in building more health and perhaps getting off your medication by addressing the cause of your health concern, please call the office and let us discuss your options.  I will work with your medical doctor to restore your health and reduce or eliminate the need for medication.