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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Attention deficit hyperactivity disorder is a condition of impaired executive functioning. There are several types (Vulkow and Swanson 2013):
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 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.
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.
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.
After listening to this episode listeners will…
Dr. Simon reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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.
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THANK YOU for this episode! There is an appalling paucity of Psychiatrists in my area, and many have adopted a policy of not prescribing any controlled substances. I had been trying to educate myself about the topic so I could feel more confident treating ADHD in my primary care practice, but I frequently feel like an island as absolutely none of my colleagues will even touch this diagnosis. It was so very refreshing to hear this positive, non-judgmental, patient-centered approach. Dr. Simon you're a gem. The rest of you guys are ok (jk, ily). -Elyse, New Orleans (also fellow Morehouse graduate!)
Thank you for the great feedback! We were excited to cover this topic and are thrilled to have had such a positive repsonse to the episode. Happy New Year!