Meme of the week: I forgot to take my highly addictive drugs

i forgot to take my addictive medication

This one is going to be a bit of a screed.  To all the good and empathetic doctors out there… you can sit this one out.

As the tweet above points out, it is extremely common for those of us with an adhd diagnosis to run up against resistance in being able to access the class of medications that are most effective for the most number of people. That class of medication is called psychostimulants or simply stimulants. Stimulants are a controlled substance in Canada, as they are in most countries.

pill

To start with, what are we talking about here? What are the names of these medications. Though doctors would have you think otherwise, understanding stimulant medications is completely straightforward. There are only molecules out which all the first line, adhd medications are made: amphetamines and methylphenidate. There are a variety of formulations of stimulant medications, but they all contain either amphetamine or methylphenidate. That’s it. Two drugs.

Amphetamine is likely familiar to most people, but methylphenidate less so. Methylphenidate is a drug typically referred to as Ritalin. These drugs are available as either fast acting—all the medication gets into your system immediately—or slow release—the medication is released into your system over 8-16 hours. These days, it is most common for people with adhd to be prescribed long acting formulations, because those only need to be taken once in the morning. Why is this important? Because—as the tweet above points out—memory is a site of difficulty for many people with adhd. Fast acting medications need to be taken three or even four times a day, and keeping track of three to four hour intervals for most people with adhd is no easy task.

But these drugs are highly addictive and dangerous aren’t they? Doctors warn us about the dangers of stimulant medications. Of course, all drugs, whether they’re for gastric reflux or inflammation or to treat adhd can be dangerous. In the US last year, 100 000 people were hospitalized for taking Advil. 

Stimulant medications, like any medication, can be dangerous when taken improperly. If you’re a neurotypical person and you’re taking these drugs recreationally, they can indeed be habit forming and potentially dangerous to your long term health. But I can say in all the years I’ve been doing this work, I have had one single client who has used their medication improperly, but that client started using these medications improperly prior to their diagnosis and now struggles to use them as prescribed. But, at least in part, this is the fault of the medical and school systems that denied them a proper diagnosis as a younger person and the fact that they resorted to illegally obtaining these medications and using them improperly was simply a way for this person to find some relief where available.

Let me repeat myself here: in the many thousands of hours of therapeutic time with clients, there has been one case of misuse of medication. One. But in that time I have heard the following measures doctors have taken to ensure that their clients are using their drugs as prescribed:

  • Demanding patients take urine tests, to demonstrate that they have the medication in their system, and thus are not selling their medication to others.
  • Require patients to bring their pill bottle in to appointments so they can count out the remaining pills to make sure that… they’re not selling them to others.
 

This sucks. It’s demeaning. I’m sorry that some people use these drugs improperly. And I’m sorry that the drug that I take to help me with the difficulties attendant to adhd can be used for studying and for shits and giggles. But here’s the thing (and I’m sorry for the yelling)… I DON’T GIVE A SHIT! This is not a problem that those of us with adhd need to solve for the rest of society. Please know that I am not diminishing the problem of addiction to these substances. Dependence on stimulants is a real and difficult problem to solve. 

reminder

The tweet above makes the joke about addiction vis a vis the proclivity of people with adhd to forget to take their medication. This is the truth: some people with adhd simply forget to take their medication. Further, people with adhd often forget to renew their prescriptions, because… you know… adhd. This happens all the time. And what happens when those who take these “highly addictive” substances forget to take their medication? Nothing… except having a day where they drag their ass around in the absence of their medication. Do they suffer withdrawal? Nope. Why not? Why doesn’t a person who takes one of these medications daily start craving the drug immediately? Because, for those of us with adhd, these medications increase the amount of certain neurotransmitters—dopamine and noradrenaline—up to the physiological levels of neurotypical people. And when we forget to take or forget to renew our prescriptions, we return to baseline.

Since I’m on a roll, let me add one other abomination that doctors regularly inflict on their patients: namely, getting bent out of shape if their client needs a higher dose of stimulant medication than they’re “comfortable with.” Let me give an example using the drug Vyvanse. Vyvanse is a long acting amphetamine preparation. It is one of the most common long acting medication along with Foquest (a methylphenidate preparation). In Canada, Vyvanse is recommended to be prescribed in doses from 20-70mg. Some people need more and some less. Size and gender do not matter. It is impossible to predict the dose for any individual before trying them.

Most commonly, people end up at 30 or 40mg. But some people simply need more. I recall a client from a few years ago who got their diagnosis and started on Vyvanse. As is standard, they started at 20mg, which was effective, but didn’t last long enough into the day. After a couple of weeks, they titrated their dose to 30mg and had a similar experience. But as this point, even though it is well recognized that it is appropriate to further increase a patient’s dose, the doctor balked. He said that he “wasn’t comfortable” prescribing more than 30mg of Vyvanse. Imagine such a thing happening with any other medication:

Patient: Hey doc. The insulin you prescribed me isn’t sufficiently managing my blood glucose levels. I think I need a higher dose. 

Doctor: I hear what you’re saying but I worry about extreme hypoglycemia, so no dice. Please learn to live with chronic high blood glucose, because it allows me to feel more comfortable.

Of course, this is a ridiculous scenario, because we all know that the dose of medication is related to its efficacy. The client I referenced above scuffled along on 30mg for some time before they let me know about their doctor’s unwillingness to be an actual doctor. The client found another doctor who was willing to offer them competent care, and they eventually ended up at a dose of 50mg, and has continued on that dose ever since to good results. Was that original doctor ever questioned or investigated for their abysmal care? Nope. Carry on… nothing to see here. Just another example of shitty care directed at a population that doesn’t garner much sympathy.

bully

It’s simply unimaginable that doctors would treat patients this way with any other condition than adhd. But because adhd is generally not taken very seriously by doctors or psychiatrists, this is an easy group of patients to bully. I know that is a harsh word in 2024, but after hearing so many stories about the shitty diminishing way that doctors talk to people with adhd, I think it is appropriate to call it as such.