#374 ADHD with Dr. Kevin Simon

January 2, 2023 | By Paul Williams

Video

Don’t get distracted, pay attention to the details, and manage ADHD in your patients!

Dr. Kevin Simon, @DrKMSimon (Boston Children’s Hospital) shows us how to stay focused and diagnose and manage attention deficit hyperactivity disorder (ADHD)  in your patients.  Learn how to make the right diagnosis, choose an appropriate medication, and modify therapy. 

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Credits

• Written and Produced by: Paul Williams, MD, FACP
• Show Notes: Paul Williams, MD, FACP
• Infographic and Cover Art: Paul Williams, MD, FACP
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Reviewer: Fatima Syed, MD
• Showrunner: Matthew Watto MD, FACP; Paul Williams MD, FACP
• Technical Production: PodPaste
• Guest: Kevin Simon, MD

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CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Case from Kashlak; Definitions and diagnosis of ADHD
• Stimulant medications for ADHD
• Non-stimulant medications for ADHD
• Mitigating diversion of medications for ADHD
• Managing ADHD in patients with substance use disorder
• Lightning round and picks of the week
• Outro

ADHD Pearls

1. ADHD is a childhood illness that can persist into adulthood.  However, it may go unrecognized until it is made more obvious by increased cognitive demands.
2. ADHD is a disease of executive function, and is characterized by inattention, hyperactivity and impulsivity, or both.
3. Stimulants are first line medications for ADHD.  Dr. Simon favors methylphenidate, and long acting formulations are preferred in general.
4. Non-stimulant medications for ADHD include atomoxetine, guanfacine, clonidine, and viloxazine.  Viloxazine has been shown to improve concentration, similar to stimulant therapy.
5. Comorbid substance use disorder is not a contraindication for stimulant treatment for ADHD.  Appropriate treatment for ADHD can actually improve retention in care.

ADHD Show Notes

ADHD – definitions and diagnosis

Attention deficit hyperactivity disorder is a condition of impaired executive functioning.  There are several types (Vulkow and Swanson 2013):

• Inattention type: Difficulty in attending to details, sustaining attention in mundane tasks, struggling to follow through in directions, a tendency to avoid things that require mental stamina
• Hyperactive and impulsive type: Typically subsides in adulthood; characterized by being fidgety and restless; feeling as if they are driven by a motor; may interrupt or be impatient in conversations
• Combined type: Combines elements of both inattentive and hyperactive type

Ancillary questions can help identify these features in various domains of life.  Patients living with ADHD may be able to compensate to a point, and then the diagnosis may declare itself in settings that require higher cognitive demands (e.g., graduate school, medical school).

The symptoms are usually present in childhood, but ADHD may go unrecognized until adulthood.  In order for this to be true ADHD, the symptoms must manifest themselves in multiple environments (Thapar and Cooper 2016)

Patients should be evaluated for anxiety, depression, substance use disorders, and insufficient sleep if a diagnosis of ADHD is being considered (Volkow and Swanson 2013).

Neuropsychological testing will test multiple domains and can be helpful, but is not required, and can be challenging from an accessibility and insurance coverage standpoint.

Structured interview tools like the DIVA 2.0 can be helpful in making the diagnosis, but do take a significant amount of time (Ramos-Quiroga et al. 2019).

Medications for ADHD

Medications for ADHD fall into 2 major categories – stimulant-based and non-stimulant based.

Stimulants are first-line treatment for ADHD (Medical Letter 2020).  Dr. Simon favors methylphenidates as his initial treatment of choice.  Most patients recognize the trade name Ritalin, but Dr. Simon favors the long-acting formulations of methylphenidate.  This can be either methylphenidate extended release or dexmethylphenidate, and the choice will largely be determined by insurance coverage.

Mixed-salt amphetamines – Adderall is the brand name most recognized by patients, but multiple formulations.

Regardless of which is chosen, Dr. Simon advises using a long-acting formulation, starting at a lower dose and up-titrating slowly.  You should also check blood pressure and heart rate prior to the initiation of the stimulant medications (which you are hopefully doing anyway!).

Dr. Simon may provide a short-acting “booster” dose for patients who may need additional focus at a known period of time.

Non-stimulant medications for ADHD include atomoxetine, guanfacine, clonidine, and viloxazine.  

• Viloxazine has a similar mechanism of action as bupropion, which itself is a second- or third-line medication for ADHD.  It has also been shown to improve concentration, similar to the stimulant medications (Nasser et al. 2022).
• Non-stimulant medications may be used for patients with co-morbid substance use disorder, or for patients who do not tolerate multiple trials of stimulant medications.
• Guanfacine extended-release and clonidine extended-release do have evidence for managing symptoms of inattention (Newcorn, Krone, and Dittmann 2022).

Drug holidays are okay for things like the weekend and on vacation, but this should be taken within the context of symptom severity.

There is not a lot of guidance on duration of therapy, and this too should be considered on a case by case basis.

Managing ADHD in patients with substance use disorder

Substance use disorder is not a contraindication for stimulant treatment for ADHD, but these patients may require close follow up.  Additionally, it is important to ensure that their substance use disorder is well-managed.

It is important to recognize that management of ADHD in patients with substance use disorder can help patients remain engaged in their care (Kast, Rao, and Wilens 2021).  These patients may benefit from co-management with a mental health specialist.

Mitigating diversion

The evidence for urine drug testing in patients who are being treated for ADHD is not compelling.  It can be used to guide conversations in patients who use drugs  to ensure safety.

Use of a Prescription Drug Monitoring Program is invaluable in ensuring proper use of medications.

The use of long-acting medications also helps protect against diversion, as these medications do not lend themselves well to recreational use.

Links

1. Thanks for the Feedback – Douglas Stone and Sheila Heen
2. Think Again – Adam Grant

Learning objectives

After listening to this episode listeners will…  

1. Recognize the potential presentation of ADHD in adults, and understand how it may differ than when seen in children.
2. Utilize appropriate screening tools and interview instruments to make the diagnosis of ADHD.
3. Develop a treatment framework for the medication management of ADHD.
4. Implement strategies to mitigate potential diversion of prescribed psychostimulants.
5. Develop treatment strategies for the management of ADHD in adult patients with substance use disorder

Disclosures

Dr. Simon reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Simon K, and Watto MF. “### ADHD with Dr. Kevin Simon”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list December 26, 2022.