adhd treatment with amphetamines
DESCRIPTION
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.TRANSCRIPT
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Treatment?
Drug companies say that a pill is the cure, but pills don’t teach skills and may make
addicts ill!
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Why not use stimulants?
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Description
• 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.
HO
HO
NH2
OH
Norepinephrine(Noradrenaline)
NH2
Amphetamine
CH3
NHCH3
Methamphetamine
CH3
Methylphenidate(RitalinTM)
HN
O O
Me
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0100200300400500600700800900
10001100
0 1 2 3 4 5 hr
Time After Amphetamine
% o
f B
as
al
Re
lea
se
DADOPACHVA
Accumbens AMPHETAMINE
0
100
200
300
400
0 1 2 3 4 5 hrTime After Cocaine
% o
f B
as
al
Re
lea
se
DADOPACHVA
AccumbensCOCAINE
0
100
150
200
250
0 1 2 3 4 5hrTime After Morphine
% o
f B
as
al
Re
lea
se
Accumbens
0.51.02.510
Dose (mg/kg)
MORPHINE
0
100
150
200
250
0 1 2 3 hrTime After Nicotine
% o
f B
as
al
Re
lea
se
AccumbensCaudate
NICOTINE
Di Chiara and Imperato, PNAS, 1988
Effects of Drugs on Dopamine Release
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Would these responses
differ between controls
and addicted subjects?
Would these responses
differ between controls
and addicted subjects?
CA
PUTStriatumStriatum
VTA/SN
CGCG
PreFPreF
OFCOFCnucleusaccumbens
Would increasingDA enhance activity in the OFC?
Would increasingDA enhance activity in the OFC?
Compared the response to IV MP (methylphenidate given in 2 sequential doses of 0.5 and 0.25 mg/kg) in 15 controls and 21 cocaine abusers using FDG and PET to measure regional brain glucose metabolism
Compared the response to IV MP (methylphenidate given in 2 sequential doses of 0.5 and 0.25 mg/kg) in 15 controls and 21 cocaine abusers using FDG and PET to measure regional brain glucose metabolism
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00
22
44
66
88
1010
ControlsControls AbusersAbusers
baselinebaselineFirst MPFirst MPSecond MPSecond MP
Sel
f R
epor
t C
ravi
ng
Sel
f R
epor
t C
ravi
ng
(0-1
0)(0
-10)
00
22
44
66
88
1010
ControlsControls AbusersAbusers
Sel
f R
epor
t H
igh
Sel
f R
epor
t H
igh
(0-1
0)(0
-10)
Self Reports of Drug Effects After MP in Controls and in Cocaine Abusers
Self Reports of Drug Effects After MP in Controls and in Cocaine Abusers
P < 0.001P < 0.001 P<0.001P<0.001
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MP-induced Increases in Metabolism
OFC
1.001.00
1.051.05
1.101.10
1.151.15
1.201.20
1.251.25
1.301.30
ControlsControls AbusersAbusers
BaselineMP
Rec
tal G
yrus
/Bra
inR
ecta
l Gyr
us/B
rain
-4.0-4.0 -2.0-2.0 0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0-0.2-0.2
-0.1-0.1
0.00.0
0.10.1
0.20.2
0.30.3
CravingCraving
Rec
tal
Gyr
usR
ecta
l G
yrus
(MP
- P
lace
bo)
(MP
- P
lace
bo)
p < 0.005p < 0.005
Abusers > Controls p = 0.001
p < 0.01p < 0.01
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How Much of the Differences BetweenControls and Cocaine Abusers Reflect
their Past Experience with Drugs?
Effects of Expectation on the Brain Metabolic Responses
To iv MP in Cocaine Abusers
How Much of the Differences BetweenControls and Cocaine Abusers Reflect
their Past Experience with Drugs?
Effects of Expectation on the Brain Metabolic Responses
To iv MP in Cocaine Abusers
Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December
2003.
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Effects of Expectation on the Response to MP on Brain Glucose Metabolism and Behavior
Increases in Metabolism Were About 50% Larger When MP Was
Expected Than Unexpected
Increases in Metabolism Were About 50% Larger When MP Was
Expected Than Unexpected
“High” Was About 50% Greater When MP Was
Expected Than Unexpected
“High” Was About 50% Greater When MP Was
Expected Than Unexpected
0
2
4
6
8
10
Pl/
PL
PL
/MP
MP
/MP
MP
/PL
Feel
Dru
g
0
2
4
6
8
10
Pl/
PL
PL
/MP
MP
/MP
MP
/PL
Hig
h
0
2
4
6
8
10
Pl/
PL
PL
/MP
MP
/MP
MP
/PL
Like
Dru
g
0
2
4
6
8
10
Pl/
PL
PL
/MP
MP
/MP
MP
/PL
Rest
less
ness
00
551010
1515
2020
2525
3030
% C
han
ge%
Ch
ange
Une
xpec
ted
MP
Une
xpec
ted
MP
Expe
cted
MP
Expe
cted
MP
Expe
cted
MP
Got
Pla
cebo
Expe
cted
MP
Got
Pla
cebo
Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.
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Where the Rubber Meets the RoadData 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)
• Hx of stimulant abuse not exclusionary unless DOC
• Initial poor outcomes on Adderall led to switch to “safer” drugs (e.g. Concerta, Vyvanse)
• One psychiatrist did all med. adjustments
• Inclusion– No discussion on unit– 1 year enrollment in treatment– Leaving treatment meant no follow-up
from providers– 1+ prior CD treatments
• All had CBT manually/workbook driven and special groups with psychiatrist and psychiatric NP
• Behavioral problems resulted in one verbal warning, then behavioral contract, then discharge
• N=43
• Ages 18-55
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AGE DISTRIBUTION CONTROL VS STIMULANT
18-25 26-35 36-45 46-550
5
10
15
20
25
19
10 82
22
127
2
CONTROL STIMULANT
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RELAPSE AND LOST TO FOLLOW UP FOR STIMULANT TREATMENT OF ADHDBY QUARTER100%(43/43)
2
13
8
13
10
5
10
2
4
6
8
10
12
14
0-3 4-6 7-9 10-12
RELAPSE LOST TO FOLLOW UP
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Results and Conclusions of COPAC Study
• 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.
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The Benefits of Recovery
• Living in the solution
– 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.)