Generally, I only write about my ADHD when there's a news 'hook'. That's because I treat my ADHD with an amphetamine based medication called Vyvanse, made by Shire Pharmaceutical, that controls my symptoms to the point where the condition no longer dictates my life. Thus, I generally address the topic only when I hear something ridiculously ignorant or misleading in the media. Look back over my blogs, and you'll find a few choice examples.
Today, I'm making an exception to my rule because of a disturbing trend that seems to be emerging, the prescribing of Strattera as a first option. Please note, I commend Eli Lilly for bringing a new ADHD treatment to the market. That simply doesn't happen very often. In addition, it's worth pointing out that Strattera has a very good characteristic: it's not an amphetamine and so not a candidate for abuse. For those who have a history of "drug seeking behavior" this is a very important feature.
There's a down side as well. Strattera is relatively new. It can take up to six weeks to work. And then there are the potential side effects. According to Lilly, "Children and teenagers sometimes think about suicide, and many report trying to kill themselves. Results from STRATTERA clinical studies with over 2200 child or teenage ADHD patients suggest that some children and teenagers may have a higher chance of having suicidal thoughts or actions. Although no suicides occurred in these studies, 4 out of every 1000 patients developed suicidal thoughts." I'm not a child or a teen, but that scares the hell out of me. By the way, the same webpage also refers to a heightened chance of severe liver damage. Compare that to the increased blood pressure, weight loss, dry mouth and irritability that are the most common effects of amphetamines, and I felt good, as did my psychiatrist, about taking my chances with Vyvanse.
All of this would be less relevant if Strattera's effectiveness were better than other alternatives for most patients. Unfortunately, that evidence doesn't seem to exist. Common sense would therefore seem to suggest that while Strattera might be an important treatment option, it probably should not be the first one tried. And yet, I'm suddenly hearing all kinds of credible stories that this is precisely what's happening. In just the past week, I've heard of general practitioners diagnosing ADHD and insisting that their respective patients try Strattera as a first option. Maybe it's coincidence, but when I put it together with some other recent examples, it certainly sounds like a trend.
The question is why. Here's my best guest as to a combination of factors that may be contributing.
1. Amphetamines have a bad reputation.
Ritalin, Concerta, Adderall and Vyvanse are all amphetamines so they must be bad. And some people do abuse amphetamines, so they must be really bad. (By the same logic, beer is really evil.) Eli Lilly, I suspect, has done a very good job of reminding primary care physicians of this fact.
2. Doctors who abet drug seeking behavior get into serious trouble.
Brilliantly, Strattera is non-addictive which means that prescribing it will never put you in danger of supplying a junkie, like the late Michael Jackson or the very present Rush Limbaugh (a recovering substance abuser), by accident. And because amphetamines are a controlled substance, prescribing in this category comes with its professional scrutiny and risks for those in the medical profession.
3. ADHD should really be diagnosed and treated by experts.
Most primary care physicians are not ADHD experts; to get their patients to a specialist -- i.e., a psychiatrist -- requires a referral. If you're a doctor working in a managed health care plan, then you probably come under a lot of pressure not to make such referrals until you have exhausted all other treatments. For example, you might try prescribing a non-amphetamine option to a probable ADHD patient, even if the option carries some heavy duty health risks. (I doubt that most doctors make this sort of decision consciously, but they're under a hell of a lot of pressure.)
Add it all up and it feels to me like too many doctors who are not really qualified to diagnose ADHD are nevertheless pushing a treatment, to the exclusion of others, that may not be in the patient's best interest. I hope that's not the case, and I'd certainly like to hear from professionals who have a strong argument to the contrary.