Psychiatry - August 2008 - (Page 26)

[trend watch] during the morning dosing. The possibility of diversion or nonmedical use of stimulants is an issue clinicians should be aware of even though it is not a problem for the vast majority of patients. Johnston, et al.,1 reported that lifetime nonmedical use of prescription MPH and amphetamines among secondary school students in 2007 was 6.5 (–1.0), 11.1 (–0.8) , and 11.4 (–3.6) in 8th, 10th , and 12th grade students, respectively. In 2005, college students were interviewed 1 to 4 years beyond high school. These young adults, whose modal age was 19 to 28 years, reported lifetime nonmedical use of MPH and amphetamines of 12.3 (–0.4) for college students and 14.6 (–1.3) for young adults.2 In a study of college students reporting nonmedical stimulant use, most (75%) indicated immediate-release mixed amphetamine salts (Adderall) was the stimulant used.3 Two other studies in adolescents and young adults reported that immediate-release MPH (Ritalin) was most frequently used (75% and 93%, respectively).4,5 Long-acting ADHD stimulant medications may also be less prone to contribute to the development of drug abuse or dependence. With extendedrelease stimulants, the slower rise and fall of MPH, amphetamine, and dexamphetamine levels in the brain may contribute to decreased drug abuse potential.6 Two studies compared short-acting and long-acting MPH formulations to examine this hypothesis. The subjective effects of oral immediate-release (40mg) and osmotic-release (e.g., osmoticcontrolled release oral delivery system [OROS®]) (90mg) MPH were studied in healthy volunteers.7 These two formulations had almost similar average peak-drug concentrations and dopamine-transporter blockade, but the immediate-release formulation achieved these targets several hours earlier than did the osmotic-release 26 Psychiatry 2008 [ A U G U S T ] formulation, suggesting a more rapid drug absorption and central drug activity with immediate-release MPH versus osmotic-release MPH. Importantly, the immediate-release formulation yielded significantly greater drug likeability ratings compared with the osmotic-release formulation.8 Lisdexamfetatine is a pro-drug that requires enzymatic cleavage of lysine before dexamphetamine, to which it is attached, becomes biologically active. Lisdexamfetamine’s need for enzymatic cleavage may reduce the risks of intravenous and nasal abuse due to significantly decreased levels of the active compound seen in animal studies. Jasinski, et al.,9 in a human study, also showed that 50mg of lisdexamfetamine given intravenously to known stimulant abusers showed a lower cmax and much longer tmax as well as decreased drug likeability scores that were not significantly different than placebo when compared to 20mg immediate-release dexamphetamine. In a recent review article, Kollins10 concluded, “Patients with ADHD are at increased risk for SUD [substance use disorder]. Under certain conditions, psychostimulants may be a pharmacologic option in the treatment of patients with comorbid ADHD and [SUDs]. However, clinicians should be mindful of the risks and benefits of this treatment approach in a high-risk population and should also bear in mind the labeling guidelines when working with this comorbidity.” In difficult cases like those patients with comorbid ADHD and SUD, long-acting ADHD medications are, in my opinion, almost always preferable to shortacting agents. Medication adherence is also a wellknown problem in a chronic disorder like ADHD, with only about 20 percent of patients remaining on the same medication 15 months after first being prescribed that medication.11 The need for multiple daily dosing of immediate- release medications only further increases the risk of nonadherence in children, adolescents, and adults. As there is a significant likelihood that one of the parents of a child with ADHD will also have ADHD (often undiagnosed), or another psychiatric disorder, there is potentially a significant risk that the parent will forget to give the additional immediate-release doses of medication to the child every 4 to 6 hours. In adults, the reported prescribing pattern data suggest that some psychiatrists and primary care providers have as yet failed to fully take advantage of long-acting ADHD medications. It is important to consider that often a day in the life of late adolescents and adults is full of activities and responsibilities. Work and/or educational daytime hours blur with parental/social activities in the evening. With long-acting medications, many patients report that their mental focus remains clearer for them throughout the full day and sometimes into the early evening due to minimizing the negative impacts of the peak-trough effects often seen with twice or thrice daily dosing of immediate-release ADHD medications. Hyperactive symptoms when present are better controlled in many cases with long-acting ADHD medications for the same reason. Long-acting agents vary in duration with atomoxetine, a nonstimulant norepinephrine reuptake inhibitor, providing 24-hour coverage after chronic dosing in those patients that respond. Long-acting stimulants vary in duration and peak effect, though the longest-acting marketed compounds work in some studies for up to 12 hours in the cases of lisdexamfetamine in adults, mixed amphetamine salts extended-release preparations, MPH extended-release preparations, or dexmethylphenidate extended-release preparations.12 Clinicians and patients also have to take into account the possible negative

Table of Contents Feed for the Digital Edition of Psychiatry - August 2008

Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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