Greg is a college age student who is at the physician’s office asking for Dexedrine for his Attention Deficit Hyperactivity Disorder (ADHD). The purpose of this discussion is to answer the questions as it relates to this case.

What symptoms of ADHD does your patient present with?

Greg states he is experiencing poor concentration, difficulty focusing, is forgetting things, he feels hyper, he can’t sit still, and he feels “out of control.” He also states his grades are suffering as he is getting B’s and C’s and needs to get A’s. Greg states he has been on medication since he was 5 or 6 years old, and that the Dexedrine made all of his symptoms disappear. He denies having any side effects from taking the medication such as a decrease in appetite or any sleep disturbances.

What are other possible causes of his symptoms?

There are other possible comorbid psychiatric conditions that could be causing Greg’s symptoms. Greg may have a substance abuse issue, possibly alcohol, drugs, or a stimulant issue. Greg could have overlapping symptoms of anxiety or a mood disorder such as bipolar disorder (Stahl, 2013).

What further information, if any, would you like about this case?

I would like a lot more information on Greg from a subjective standpoint. I would like to know his medical history, surgical history, and if there is any trauma in his background. I would like to know if Greg takes any other medications including over-the-counter or herbal preparations. I would also like to get a family and childhood history on Greg including a social, developmental, and psychiatric history. I would like to know if any behavioral therapy interventions have been attempted and if they were successful. I would examine any history of substance use or abuse.

I would like to know if Greg works and if he does, how he functions at work. I would like a copy of Greg’s grades from college currently and any past semesters to see his grades, and if there are any changes from one year ago when he was taking Dexedrine versus being off of the Dexedrine. I would like to know about Greg’s ability to perform daily tasks such as getting food, paying bills, and taking care of basic day to day tasks.

I would like to obtain Greg’s last physical examination and labs from his primary physician to be sure there are no underlying medical concerns that may account for any of his symptoms. I would ask for a release to speak with his primary physician. Greg was very reluctant to obtain the information from his mom regarding who his past prescriber of Dexedrine was. If it was only a year ago that he stopped taking this medication, I find this very hard to believe. I am very suspicious that Greg has a stimulant use problem.

With the assumption that the patient does have ADHD, what medication would you prescribe (list name and dose)? Why?

If I could not elicit any further history or records for Greg, based on what I know I would prescribe atomoxetine (Strattera) starting at 40 mg orally daily in the morning for 3 days, and then increase to 80 mg in the morning (Putzanian & Carlat, 2020; Stahl et al., 2020). Brent et al. (2020) recommends medication as first-line treatment over cognitive behavioral therapy for adults. For adults, first-line treatment is recommended to be initiated with amphetamines over methylphenidate, or a non-stimulant medication (Brent et al., 2020). For patients with suspected substance use or stimulant use disorder atomoxetine is recommended as it carries no abuse potential (Putzantian & Carlat, 2020). Due to the fact that I suspect stimulant use disorder in Greg, I would choose atomoxetine.

Atomoxetine boosts norepinephrine and dopamine in the prefrontal cortex (Stahl et al., 2020). It can take 6 to 8 weeks to work, and full therapeutic effect can take up to 12 weeks (Stahl et al., 2020). If the medication works for Greg, he should see a reduction in his distractibility, and hyperactivity, as well as an increase in his ability to focus on his school work (Stahl et al., 2020).

Greg should be educated on the potential for a decrease in appetite, which is unlikely since he states he had no decrease in appetite with a stimulant medication previously. Behavioral therapy such as CBT can be initiated as research does warrant the positive effects (Brent et al., 2020). It is important to treat ADHD in adults as not treating the symptoms can lead to problems with quality of life, relationship issues, employment concerns, an increase in substance abuse, higher rates of depression and anxiety, and suicide (Geffen & Forster, 2018).

Greg will also need accommodations for school such as an individual education plan (IEP) which may include more time for assignments, work broken into smaller sections and testing accommodations. If the medication does work, I will also recommend complementary therapies such as mindfulness-based activities, and yoga to help increase focus and calm Greg.

List any relevant safety information and screening (labs, etc) related to your medication choice.

Before starting atomoxetine baseline LFTs must be obtained and repeated if there are any concerns for liver disease (Putzanian & Carlat, 2020). While taking atomoxetine, MAOIs should not be taken, and because it is metabolized by the CYP2D6 enzyme it should be taken cautiously with inhibitors fluoxetine, paroxetine, and quinidine because they can increase serum levels of atomoxetine (Putzanian & Carlat, 2020).

References

 

Brent, D., Bukstein, O., & Solanto, M. V. (2020). Treatment of attention hyperactivity disorder in adults. Retrieved February 27, 2021 from https://www.uptodate.com/contents/treatment-of-attention-deficit-hyperactivity-disorder-in-adults

Geffen, J., & Forster, K. (2018). Treatment of adult ADHD: a clinical perspective. Therapeutic advances in psychopharmacology, 8(1), 25–32. https://doi.org/10.1177/2045125317734977

Puzantian, T., & Carlat, D. J. (2020). Medication fact book for psychiatric practice. Carlat Publishing (5th ed.).

Stahl, S. M., Grady, M. M., & Muntner, N. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide. Cambridge University Press (6th ed.).

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.

 

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