Full Transcript for Why Listen to Me? ADHD Medication History & Philosophy

that ADHD extends into adulthood, 00:04:09.937 --> 00:04:11.797 because those kids grew up. 00:04:12.137 --> 00:04:12.487 Okay. 00:04:12.787 --> 00:04:15.197 The pharmacology has also evolved significantly. 00:04:15.247 --> 00:04:17.027 Immediate-release tablets, all right? 00:04:17.327 --> 00:04:22.477 Those tablets, they were the standard in the '40s through the '90s. 00:04:22.477 --> 00:04:25.007 1990s, the introduction of extended-release formulations 00:04:25.007 --> 00:04:26.367 in the early 2000s. 00:04:26.767 --> 00:04:29.697 Concerta in 2000, Adderall XR in 2001. 00:04:29.997 --> 00:04:34.297 Vyvanse in 2007 changed the clinical picture entirely. 00:04:34.707 --> 00:04:37.527 Patients could now take a single morning dose and have stable 00:04:37.527 --> 00:04:41.107 medication coverage through the whole day without the spike and crash 00:04:41.107 --> 00:04:42.927 cycle of immediate-release tablets. 00:04:43.227 --> 00:04:47.187 And this is what makes the optimization process possible. 00:04:47.467 --> 00:04:51.057 This is the whole principle behind my medication philosophy. 00:04:51.407 --> 00:04:55.627 And the adult ADHD treatment field is in many ways newer than the patients in it. 00:04:55.927 --> 00:04:58.407 The framework for treating adults specifically has matured over the 00:04:58.407 --> 00:04:59.967 last twenty to twenty-five years. 00:05:00.397 --> 00:05:03.477 Many were diagnosed late after years of struggling without a clinical 00:05:03.477 --> 00:05:05.337 lens to manage their symptoms. 00:05:05.797 --> 00:05:08.257 What hasn't changed is the underlying clinical reality. 00:05:08.677 --> 00:05:12.227 Patients with ADHD respond to dopaminergic stimulation and 00:05:12.227 --> 00:05:14.707 medication that can change their lives 00:05:14.857 --> 00:05:18.657 with ADHD, the conversation of is ADHD real? 00:05:19.147 --> 00:05:20.887 Well, okay, so we just went over that. 00:05:21.117 --> 00:05:25.567 It's real because it's a diagnosis, a diagnostic label. 00:05:25.727 --> 00:05:27.087 So it's real on that basis. 00:05:27.087 --> 00:05:28.037 It's in the DSM. 00:05:28.237 --> 00:05:29.257 is it legitimate? 00:05:29.557 --> 00:05:32.007 So this is what Russell Barkley showed. 00:05:32.307 --> 00:05:38.077 This pattern of behavior is observed back to the 18th century. 00:05:38.377 --> 00:05:41.607 And then the stimulant medication Pops up and it was prescribed 00:05:41.607 --> 00:05:44.387 for all these reasons, you know, like we just heard the history. 00:05:44.687 --> 00:05:47.017 And this is another thing Russell Barkley is credited for. 00:05:47.017 --> 00:05:51.967 We can see the benefits of the stimulant medication for a certain group of people. 00:05:52.267 --> 00:05:53.587 It's not the majority, though. 00:05:53.887 --> 00:05:59.317 And as someone that actually has ADHD, when I went to start working prescribing 00:05:59.317 --> 00:06:03.957 this medication, I had taken the immediate-release tablets I started being 00:06:03.957 --> 00:06:07.977 prescribed when I was in high school, and it was an on and off sort of thing. 00:06:08.267 --> 00:06:09.197 But I always… 00:06:09.387 --> 00:06:12.757 Obviously, it's helping if I'm continuing to take them, but I 00:06:12.757 --> 00:06:17.817 wasn't given good advice, and I didn't understand how the medication 00:06:17.827 --> 00:06:19.907 should be applied, taking too much. 00:06:20.057 --> 00:06:21.687 Taking medication as needed. 00:06:22.147 --> 00:06:25.507 You know, take some when you need to focus, you know, that kind of logic. 00:06:25.937 --> 00:06:29.817 And it made me feel like the meds are the problem. 00:06:30.017 --> 00:06:36.217 So when I went to the West Coast to start my first job, the ADHD 00:06:36.217 --> 00:06:39.647 clinic, I was going in with like a anti-medication sort of mindset. 00:06:40.087 --> 00:06:42.147 Medication was like not good for me. 00:06:42.377 --> 00:06:45.237 I need to go and help people get off this med. 00:06:45.237 --> 00:06:45.797 I don't know. 00:06:46.097 --> 00:06:49.637 I at least knew I felt comfortable prescribing medication that I, 00:06:49.667 --> 00:06:51.487 like, knew more about, I suppose. 00:06:51.787 --> 00:06:58.957 But then it was like Seeing the different reactions and realizing, wow, like I-- 00:06:59.257 --> 00:07:03.547 several life stories explained in front of me, It's less about the medicine and 00:07:03.547 --> 00:07:09.037 more about like ADHD as a diagnosis and hearing your life story in a diagnosis, 00:07:09.107 --> 00:07:12.817 and then you reflect and, you know, I was like the kid that was 00:07:12.817 --> 00:07:14.457 d- you know, sleeping in class. 00:07:14.477 --> 00:07:16.897 You wake up, everyone's laughing, that type of thing. 00:07:16.897 --> 00:07:21.557 And, um, but the medication thankfully got me, saved my life. 00:07:21.597 --> 00:07:25.067 I don't know where I'd be today, and I was able to graduate high 00:07:25.067 --> 00:07:26.597 school and get it together. 00:07:26.897 --> 00:07:31.847 But, um, life didn't really improve until that moment because while this is 00:07:31.847 --> 00:07:35.967 happening, I'm-- never lived cleaner, more like a monk, working every single 00:07:35.977 --> 00:07:40.517 day and, um, oh, exercise, you know, all the things you're supposed to do, 00:07:40.877 --> 00:07:42.717 and I was pinching my leg, you know. 00:07:42.947 --> 00:07:46.337 So then I got a psychiatrist there, and he worked with me, and take the 00:07:46.337 --> 00:07:50.037 medication every day like it's a vitamin, and you find the right dose, and then 00:07:50.037 --> 00:07:51.657 all of a sudden everything got better. 00:07:51.837 --> 00:07:57.427 And so I know that like the this conversation about ADHD, it's as 00:07:57.427 --> 00:08:02.897 if everybody is gonna be better in life with a stimulant medication. 00:08:03.197 --> 00:08:04.507 That's just not the case. 00:08:04.677 --> 00:08:05.127 It's not. 00:08:05.147 --> 00:08:05.827

There's no way. 00:08:06.127 --> 00:08:10.857 Now, can people take stimulant medication to improve their performance? 00:08:11.077 --> 00:08:11.897 Sure. 00:08:12.397 --> 00:08:16.397 That's risky when you don't really need to because when you're bringing 00:08:16.407 --> 00:08:19.997 in a stimulant when you don't need to, then you'd be overstimulated, 00:08:19.997 --> 00:08:23.187 and ultimately it's like any other recreational substance, you know? 00:08:23.337 --> 00:08:26.967 It's ultimately, it's like ADHD medication, the benefit of it is 00:08:26.967 --> 00:08:29.977 should- people can be like, "Oh, okay," they can actually fall through their 00:08:29.977 --> 00:08:37.097 lives as opposed to disorientation or just, um, the sense of time. 00:08:37.417 --> 00:08:41.417 , I don't really remember much, but I do remember this one moment of 00:08:41.717 --> 00:08:44.987 taking the medication when I was like 16, 17 and being like, "Oh my 00:08:44.987 --> 00:08:46.987 God, what am I doing with my life?" 00:08:46.987 --> 00:08:50.687 But up until that moment, everything was just constantly in the moment. 00:08:50.727 --> 00:08:54.227 Like, I was just watching a movie that was playing. 00:08:54.527 --> 00:08:57.897 So in the beginning too, I was, um, nervous about, I knew people 00:08:57.897 --> 00:08:59.467 were wanting to get on meds. 00:08:59.467 --> 00:09:04.087 Cause they got evaluated before they got to me, so I was like you 00:09:04.087 --> 00:09:05.887 know, they were set up and excited. 00:09:05.917 --> 00:09:09.997 You know, this clinic you know, they had shady business practices, at first 00:09:09.997 --> 00:09:12.627 I was like, "Oh, they're already vetted, so I can just prescribe the med." 00:09:12.887 --> 00:09:15.517 But then quickly I was like, "Oh, well, what if I don't agree?" 00:09:15.797 --> 00:09:17.917 'Cause I was developing a better sense of the diagnosis. 00:09:17.917 --> 00:09:22.737 I was like, "I don't know," but like not sure, maybe they have ADHD, maybe they 00:09:22.747 --> 00:09:24.447 don't, but I like didn't trust my gut. 00:09:24.457 --> 00:09:27.147 And they came back and they were like, you know, tweaking it. 00:09:27.177 --> 00:09:29.417 They couldn't even take the med, you know. 00:09:29.637 --> 00:09:33.727 So the, when you're prescribing the medication clinically to adults, 00:09:33.727 --> 00:09:36.797 like I have all this experience, 20,000 hours prescribing experience 00:09:36.827 --> 00:09:40.827 prescribing these medications, it's like that's where the patterns come in. 00:09:40.827 --> 00:09:43.207 So it's almost diagnostic. 00:09:43.507 --> 00:09:49.387 So I've gotten a really strong sense for this ADHD pattern. 00:09:49.687 --> 00:09:54.237 And it's neurodevelopmental, meaning it's, you're gonna be 00:09:54.237 --> 00:09:56.097 able to track it for adults. 00:09:56.107 --> 00:09:57.717 You have to go back in time. 00:09:58.187 --> 00:10:03.367 And what you don't need to do, which is hilarious, I see this type of stuff, 00:10:03.797 --> 00:10:06.247 patient testimonials of you gotta… 00:10:06.317 --> 00:10:10.527 Oh yeah, there would be these ridiculous practices that are just like CYA. 00:10:10.707 --> 00:10:14.487 If you understand ADHD, it just makes the most sense, but my previous employer 00:10:14.487 --> 00:10:19.697 did this where it's like, f- talk to a friend many people are against 00:10:19.697 --> 00:10:23.767 ADHD, so, like, why are you gonna have a family member that would be bias? 00:10:24.067 --> 00:10:25.137 And, um 00:10:25.437 --> 00:10:26.957 You know, it's not necessary. 00:10:26.997 --> 00:10:29.647 Like, I don't know, it actually obscures diagnosis more the 00:10:29.647 --> 00:10:30.657 more that I think about it. 00:10:31.037 --> 00:10:31.487 But 00:10:31.787 --> 00:10:37.757 What I, I look for is, You have, like, the symptoms of ADHD, and people, I think, 00:10:37.757 --> 00:10:42.037 focus too much on those because to go, "Doesn't everybody have this issue?" 00:10:42.037 --> 00:10:45.587 Yes, but there's a-- this is a chronic issue, and it's across the 00:10:45.587 --> 00:10:49.037 lifespan, and there's, like, a pattern, and you can track this pattern. 00:10:49.457 --> 00:10:53.607 And when internally there's not as much stimulation, so there's more 00:10:53.607 --> 00:10:55.577 reliance on external stimulation. 00:10:55.907 --> 00:10:58.537 So then across the lifespan, you have what you're born as, what 00:10:58.547 --> 00:11:00.307 the life situations around you. 00:11:00.687 --> 00:11:05.407 There's other things going on, but the presence you're seeing with the 00:11:05.407 --> 00:11:10.637 executive function, you're seeing a trajectory of adaptation forming 00:11:10.947 --> 00:11:13.477 in childhood into adolescence. 00:11:13.527 --> 00:11:17.807 I don't think that it's 100% necessary to have this be the defining 00:11:17.807 --> 00:11:20.167 characteristic, but there are clues there. 00:11:20.167 --> 00:11:23.477 There's always a clue there, and then you're getting into their 00:11:23.477 --> 00:11:26.977 early 20s, and then when you're an adult, you know, there's more of a 00:11:26.977 --> 00:11:30.077 consistent chronic, uh, back and forth. 00:11:30.187 --> 00:11:35.557 But That's if there's ADHD is the thing that you see first because ADHD 00:11:35.557 --> 00:11:39.777 is also, you know, and oftentimes the diagnosis cannot be treated 00:11:39.777 --> 00:11:41.447 until other things are treated. 00:11:41.447 --> 00:11:45.517 So in other words, you can't treat someone with bipolar if they're manic 00:11:45.647 --> 00:11:50.577 for ADHD, even someone that's really anxious or really super depressed ' cause 00:11:50.577 --> 00:11:54.877 the stimulant medication only works as well as the stage that it's set upon. 00:11:55.087 --> 00:11:59.427 So I think the real question people ask, like philosophically, like how do you feel 00:11:59.437 --> 00:12:06.107 philosophically about pharmacotherapy, using a medication to

help with your life? 00:12:06.587 --> 00:12:11.057 And it's an option, it's a treatment in the controlled setting. 00:12:11.057 --> 00:12:14.007 That's why the medication is not just illegal. 00:12:14.357 --> 00:12:16.327 It's because it helps in this one area. 00:12:16.347 --> 00:12:21.204 That's why the symptom criteria matters because we wanna make sure that we 00:12:21.204 --> 00:12:25.014 wanna, we're prescribing the right thing to the person for the right reason. 00:12:25.314 --> 00:12:28.854 But at the end of the day, that choice, people act like it's 00:12:28.854 --> 00:12:31.014 such a life or death situation. 00:12:31.014 --> 00:12:31.894 "Oh my God." 00:12:32.194 --> 00:12:37.314 Because there's a lot of concerning behavior out there culturally, 00:12:37.324 --> 00:12:38.714 the narrative about stimulants. 00:12:38.714 --> 00:12:40.714 But that isn't this. 00:12:40.744 --> 00:12:44.994 I used all those other things to not be consistent with treatment, but my life, 00:12:45.024 --> 00:12:47.344 cut out all the noise, this helps me. 00:12:47.644 --> 00:12:49.884 And it's obvious and it's plain to see. 00:12:50.224 --> 00:12:52.794 And the great moment for many people with ADHD is they look at their 00:12:52.794 --> 00:12:56.474 significant other and it's always very telling, you know, when you give 00:12:56.474 --> 00:12:59.674 the ones in your life an opportunity, they'll be like, "You know what? 00:12:59.974 --> 00:13:01.004 That could be good for you. 00:13:01.304 --> 00:13:06.684 So Ultimately, we need to ask ourself before we can evaluate other people's 00:13:06.684 --> 00:13:10.754 choices, we need to look at ours because sometimes people have a 00:13:10.754 --> 00:13:16.024 bias that have ADHD, so that's makes the conversation messy and noisy. 00:13:16.494 --> 00:13:21.434 But ultimately, if you do have ADHD, then I would imagine your 00:13:21.444 --> 00:13:23.484 function, that's the thing. 00:13:23.744 --> 00:13:31.184 Functional decline meaning, like, a major problem is present that results in maybe 00:13:31.184 --> 00:13:35.774 issues at work, maybe issues with family, maybe emotional issues, social issues. 00:13:36.074 --> 00:13:40.624 A variety of different problems can result from the way we're carrying 00:13:40.624 --> 00:13:44.024 out our daily activities, and I think car accidents, leaving the oven on. 00:13:44.484 --> 00:13:48.704 There's a lot of low-key things that you know, a lot of divorces and 00:13:49.004 --> 00:13:53.874 people, uh, when they get their brain online are able to self-actualize 00:13:53.914 --> 00:13:55.094 and move their life forward. 00:13:55.144 --> 00:13:58.864 We're bringing in ADHD in the way it actually is. 00:13:58.924 --> 00:14:03.414 This is why I'm calling the podcast "Actually ADHD," is because it 00:14:03.424 --> 00:14:06.934 actually makes sense when you're looking at a psychiatric evaluation. 00:14:07.084 --> 00:14:09.114 Cause it's really an issue with the brain. 00:14:09.164 --> 00:14:10.554 You need executive function. 00:14:11.004 --> 00:14:13.114 You need that level of awareness to engage. 00:14:13.144 --> 00:14:18.914 And when you treat ADHD for someone that meets criteria for ADHD, it 00:14:18.914 --> 00:14:23.164 needs to be treated for the person to experience, like, holistic improvement. 00:14:23.254 --> 00:14:26.244 It can be the barrier, But it's not everybody. 00:14:26.544 --> 00:14:29.714 But, it's really important that the symptom criteria is clear, 00:14:30.204 --> 00:14:31.454 and I'm not gonna go over that. 00:14:31.454 --> 00:14:35.564 But next time I'm gonna get into the medicines and my process 00:14:35.564 --> 00:14:36.964 for this, the medication. 00:14:36.964 --> 00:14:40.434 So this is the part you know, you wanna perk up and listen to because I think 00:14:40.434 --> 00:14:44.154 a lot of providers unfortunately get this wrong, no fault of their own, 00:14:44.154 --> 00:14:46.104 people that are well-intentioned. 00:14:46.104 --> 00:14:49.054 At the end of the day, people need to get familiar prescribing the 00:14:49.054 --> 00:14:52.854 medication in order to, to see, so there's some people trying out there 00:14:52.854 --> 00:14:55.344 and other people that just have their biases, and the people with their 00:14:55.344 --> 00:14:58.534 biases have the worst practices, oddly. 00:14:59.024 --> 00:15:04.214 So if people just open their mind a bit more, that's such a weird irony there. 00:15:04.514 --> 00:15:07.504 It's like the people that are anti-ADHD, , can often have the 00:15:07.554 --> 00:15:09.834 worst prescribing practices. 00:15:09.874 --> 00:15:11.684 "Here's some immediate-release tablets. 00:15:11.684 --> 00:15:12.614 Take some when you need." 00:15:12.914 --> 00:15:13.314 You know? 00:15:13.614 --> 00:15:13.774 But 00:15:13.824 --> 00:15:17.744 That's it for today Thanks for joining me on Actually ADHD, brought 00:15:17.744 --> 00:15:21.824 to you by a psychiatric nurse practitioner that won't sell you short