Thursday, October 19, 2006

Rethinking ADHD: Pills may not be best solution

Rethinking ADHD: Pills may not be best solution


Spending on ADHD drugs in the U.S. soared from $759 million in 2000 to $3.1 billion in 2004, according to IMS Health, a pharmaceutical information and consulting firm.

In Canada, consumption of Ritalin quadrupled between 1990 and 1996 and the number of prescriptions written per year continues to rise. In fact, Ritalin, Concerta and Dexedrine are the third, fourth and sixth most frequently prescribed medications in pediatrics in Canada. Asthma puffers garner the top two spots and amoxicillin, an antibiotic, sits in the fifth position.

Currently, there are more than 350,000 Canadian children (and over four million Americans) between five and 19 receiving prescriptions for psychostimulant medication in one form or another to treat attention deficit disorder +/- hyperactivity. To justify such widespread use of these controlled medications (amphetamines), there should be strong evidence that these medicines truly benefit recipients, right?

Well, actually, no long-term studies have ever demonstrated these drugs to be effective in helping individuals adapt or adjust to the pressures and demands of school or society. Indeed, available studies provide little evidence that stimulants improve academic performance.

The medications do reduce the "core" features of ADHD – motor restlessness, distractibility and impulsiveness – but do these characteristics produce morbidity severe enough to justify such widespread prescribing considering their side-effect profile?

According to a May 2006 report by the U.S. Centers for Disease Control and Prevention, side effects and "problems" with widely prescribed attention deficit hyperactivity disorder (ADHD) drugs send 3,100 people to the ER every year – 80 per cent of them children.

"Problems" most often include overdosing or accidental use, and side effects can include chest pain, high blood pressure, rapid heart rate, stroke and sudden death. Between 1999 and 2003, 25 deaths linked to ADHD drugs were reported to the U.S. Food and Drug Administration (FDA), 19 involving children. The children affected were taking the medications in dosage and timing as prescribed. Some, but not all of them, had underlying cardiac abnormalities, family history of ventricular tachycardia (an abnormal heart rhythm), or other medical conditions.

In addition, 54 cases of other serious heart problems were reported, including strokes and heart attacks.

In late May 2006, Health Canada issued warnings of heart risks – including sudden death – on all drugs used to treat ADHD. "The effects are usually mild or moderate, but in some patients, this stimulation may – in rare cases – result in cardiac arrests, strokes or sudden death," the agency warned.

The U.S. FDA has also reported some serious psychiatric adverse events in children treated with stimulant medications. These included reports of psychosis or mania with hallucinations that emerged with the drug treatment. The symptoms resolved with discontinuation of the medication in many cases, and recurred with resumption in some.

Based on these reports, the Pediatric Advisory Committee to the FDA in the U.S. has recommended that a Medication Guide describing the potential psychiatric adverse events (as well as the cardiovascular risks) of stimulants be provided at the time the medications are dispensed.

As well, it is suggested that ADHD medications be discontinued in children who develop acute unexpected behavioural reactions, hallucinations, or increased aggression.

Less serious side effects are common. Anorexia or appetite disturbance is present in up to 80 per cent of those receiving stimulant medications, and significant weight loss is seen in 10 to 15 per cent. Sleep disturbances vary in frequency, but reportedly affect between three to 85 per cent, depending on the study and duration of medication use.

What happens to children if ADHD isn’t treated with medication? Well, some studies have shown significant drop-off in problematic features of ADHD as children moved to adolescence and then from adolescence to adulthood, whether or not medication was used.

Mannuzza et al showed, in follow-up of 103 hyperactive children, reduction in diagnosis of full or partial ADD with hyperactivity to 40 per cent during adolescence and eight to 11 per cent in adulthood.

Long-term studies do show many individuals with ADHD to experience problems with education, occupation and social outcome. But these findings are similar whether or not the ADHD subjects had been treated with psychostimulant medication.

While the major side effects of ADHD medications are rare, the utilization of these medications is not. Ultimately, parents need to be informed and knowledgeable about the risks and benefits that stimulant medications carry for their children. And as a society, we all have to ask ourselves if the use of these medications is justifiable or desirable in such numbers.

Perhaps it is time to rethink our current strategy of drug treatment and explore alternative interventions. A pill may offer quick short-term benefits, but there is a cost – and it is potentially very high.

John D. Grant, MD, FRCP(C) pediatrics, lives in Wolfville.


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