Therapeutic Effects of Adderall in ADHD

Adderall, also known as dextroamphetamine-AMP, is one of the most effective treatments for attention deficit hyperactivity disorder (ADHD) in the U.S (Lakhan & Kirchgessner, 2012 p662). Adult ADHD is one of the most prevalent psychiatric disorders with significant personal, social, and community impact. ADHD can considerably impair academic, social and occupational performance (Scrandis, 2018). Amphetamines have existed for close to 100 years with multiple therapeutic uses however, due to their high potential for abuse they must be prescribed and controlled (Heal et al, 2012).

History of Dextroamphetamine-AMP

Heal, Smith, Gosden, and Nutt report amphetamines have existed for quite some time. American chemist, Gordon Alles, created the amphetamine molecule while seeking a cost effective bronchodilator for the treatment of asthma in the 1920s ( Heal et al. 2013 p.1). After its initial indication to reverse the effects of anesthesia, it was also administered to improve narcolepsy and increase alertness in Allied soldiers during WWII. Amphetamines were established as an effective treatment for ADHD in the 1970’s ( Heal et al. 2013 p.1). Other therapeutic uses include narcolepsy, obesity and depression

Discussion of Research

Effects on Receptor Sites

Sinha et al. (2016) state dextroamphetamine and other stimulants increase the concentration of neurotransmitters, dopamine and norepinephrine, by promoting their release and by preventing their reuptake (Sinha, Lewis, Kumar, Yeruva & Curry, 2016). Lakhan and Kirchgessner admit, “the precise mechanisms… are not completely understood” (2012). However, Stahl (2011) reports, “Enhancement of dopamine and norepinephrine actions in certain brain regions (e.g., dorsolateral prefrontal cortex) may improve attention, concentration, executive function, and wakefulness (Stahl & Grady, 2011). The higher levels of dopamine and norepinephrine stimulate the central nervous resulting in accelerated brain function.

Desired Effects

According to the Cleveland Clinic, prescription stimulants can alleviate symptoms of ADHD such fidgeting, restlessness and poor focus (2018). Felicilda- Reynaldo (2015) agrees by stating, “intended effects are alertness, decreased fatigue, improved self-confidence, ability to concentrate, and increased initiative.”, (Felicilda-Reynaldo, 2015). Lakhan and Kirchgessner discuss prescription stimulants have been shown to boost productivity and improving classroom behavior with fewer disruptions (Lakhan and Kirchgessner, 2012).

Side Effects and Percentage of Incidence

Dextroamphetamine is classified as a schedule II drug by the U.S Drug Enforcement Administration, meaning that despite its therapeutic uses it carries a high risk of abuse and may be habit forming. Surges in dopamine trigger the brain reward system producing mood alterations and euphoria which decrease in intensity as tolerance develops requiring larger doses over time (Felicilda-Reynaldo, 2015). Common side effects seen greater than 5% more often than in patients in the placebo group include: headaches, dry mouth, trouble sleeping, reduced appetite, weight loss, emotional lability, nervousness, and rapid heartbeat.

Possible adverse effects are allergy, hyperreflexia, hallucinations, psychosis, delusions, paranoia, cardiovascular complications and sudden death (Deglin, Vallerand and Sanoski, 2014). A flat affect may be a sign of long term use or abuse (Felicilda-Reynaldo, 2015). Signs and symptoms of possible overdose or toxicity are restlessness, tremor, hyperreflexia, rapid respiration, confusion, assaultiveness, hallucinations, panic states, hyperpyrexia and rhabdomyolysis (Duramed Pharmaceuticals, 2007). Sinha et al. warn that stimulants increase the risk for cardiovascular events due to varying factors such as age, chronic illness, cardiovascular conditions, arrhythmias and hypertension (Sinha et al. 2016).

Management of Side Effects

Dextroamphetamine should be taken in the morning or early in the day to reduce sleep disturbance. Dosage should only be adjusted by physician, and be tapered gradually before discontinuing to avoid withdrawal symptoms. Periodic “breaks” may be scheduled by the provider to decrease medication tolerance. Patient teaching on side effects, and instructions for use, and adverse effects is necessary to reduce undesirable effects and promote medication compliance. Patient are instructed to notify their physician of any new prescriptions, over the counter drugs, and new or worsening symptoms (Deglin, Vallerand and Sanoski, 2014). Known or suspected dextroamphetamine overdoses may be managed by increased intravenous fluids and ammonium chloride to aid excretion, antihypertensive medications and possibly peritoneal or hemodialysis (Felicilda-Reynaldo, 2015).

Clinical Observations

Observation of therapeutic effects

Heal et al. state ADHD is produced by dysfunction of catecholamine regulation in the CNS. Neuroimaging in subjects with ADHD showed alterations and functional differences consistent with inadequate dopamine activity in multiple parts of the brain (Heal et al. 2012). According to Lakhan and Kirchgessner a recent study assessing the cognitive effects in adults with ADHD showed those treated with stimulants scored significantly better in intelligence than the non stimulant group (Lakhan and Kirchgessner, 2012).

Patient Reported Side Effects

This author interviewed and observed patient A.P, a thirty six year old caucasian male diagnosed with ADHD since childhood. A.P struggled with poor grades due to symptoms of restlessness, hyperactivity and difficulty concentrating prior to starting treatment. A.P reports past use of a few non stimulant medications with little to no improvement. A.P currently takes dextroamphetamine XR 10 mg PO once a day and denies adverse side effects. A.P stated, “ I don’t feel jittery or anxious with [Adderall], it just helps me focus and get on task. People seem to expect to you jumping off the walls on a prescription stimulant but for me it’s the opposite.”, (A.P interview, 2018). Throughout observation A.P appeared calm and comfortable without signs of restlessness, nervousness or impaired attention. The patient observation and clinical findings are consistent with the published research.

Conclusion

ADHD is a chronic psychiatric disorder characterized by inattention, impulsivity or hyperactivity. Scrandis wrote that pharmacologic therapy is the “first line” in treating adult ADHD (Scrandis, 2018). Adderall or dextroamphetamine has a high risk for abuse and a potential for life threatening complications and therefore requires strict regulation to prevent adverse outcomes (Felicilda-Reynaldo, 2015). Nurses promote patient safety by providing education regarding medication safety, common side effects and important changes to report to the physician.

References

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