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Comment by Rewrap3643 | Hacker News Reader

Psychs won't prescribe it because it's a wakefulness promoting agent, not a typical stimulant. There's insufficient evidence to prescribe it as a first-line treatment for ADHD. Insurance companies are also unlikely to pay for it in absence of a diagnosed sleep disorder.

Methylphenidate is the clinically correct alternative to amphetamines.

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So we should first-line treat people with addictive, known long-term harmful medicines rather than try things that have a known long-term safe profile simply because it's understood to be less likely to work?

That's just bonkers to me. I'll try every single safe potential treatment before resorting to higher evidenced unsafe treatment.

Also this "wakefulness" doesn't mean much. It's much like ADHD doesn't mean much - we're just describing symptoms. If we decided to describe the symptoms of taking modafinil as increasing concentration (which being more awake does) then it would be just as accurate.

There is no chemical being measured when we diagnose these medications and there is no chemical being measured when we clinically determine a successful treatment. It's all symptoms and entirely subjective. Which is exactly why we should tell people safe things work and allow the science of suggestion alongside medicine help treat people more safely.

If Modafinil is truly effective, then why is it not commonly used?

The fact that is less commonly used seems to point two potential reasons:

1. It's safety profile is actually not that much better the what is commonly used for ADHD.

2. Its efficacy is significantly worse than what is commonly used, and thus, there is no point in using it.

> There is no chemical being measured when we diagnose these medications and there is no chemical being measured when we clinically determine a successful treatment.

I'll give you that one. I have personally always been bothered by this too. I just cannot understand why so many psychs have to go through a rigorous and scientifically based education program only to discount much of it in practice.

> 1. It's safety profile is actually not that much better the what is commonly used for ADHD.

Modafinil is sold over the counter in many countries. Your claim does not reflect modern research findings. It's really not even close.

> 2. Its efficacy is significantly worse than what is commonly used, and thus, there is no point in using it.

efficacy for whom? ADHD isn't an infection that is treated with specific antibiotics. It's symptoms that arise in individuals with potentially drastically different root causes. For some people modafinil is effective for treating ADHD symptoms.

Speaking of other countries, Japan won't prescribe methylphenidate for ADHD - only issues prescriptions for sleep disorders. Most ADHD medications aren't even legal to bring into Japan, much less get prescriptions for them.

I think you'll find there isn't some global consensus on ADHD and medications and there's a good reason for that. ADHD treatment is barely science.

> Modafinil is sold over the counter in many countries. Your claim does not reflect modern research findings. It's really not even close.

What I was trying to say was that there are to potential reasons why Modifinil is not commonly used for ADHD. By potential reasons, I meant those two reasons might some of the reasons that could be an explanation, but that does not mean those two reasons are the definitive reasons nor the only reasons.

Now, I would agree from what I have read that Modifinil is probably safer than Amphetamine or MPH based medications in terms of addiction safety. Though all the reports of SJS and other issues do not seem like it's some perfectly safe medication either.

> efficacy for whom?

A large enough population size across multiple studies to deem it a safe and effective treatment -- like all other medications approved by some kind of governing regulatory agency. The approval of one medication does not disprove the efficacy of other medications.

> For some people modafinil is effective for treating ADHD symptoms.

Sure, the same can be said for caffeine, nicotine, plenty of other substances, exercise, etc.. I understand there is an individual aspect to all medication conditions. However, a medical system, at least none I have ever used, curtail all treatments to an individual. There seems to be more of an procedural approach to medical treatments in which the results are "good enough for most people."

> Speaking of other countries, Japan won't prescribe methylphenidate for ADHD - only issues prescriptions for sleep disorders. Most ADHD medications aren't even legal to bring into Japan, much less get prescriptions for them.

Are claiming that Japan based this decision on medical research and not [historical] social issues which plagued them? I would not cite Japan's drug laws, as well as plenty of other laws in their legal system, as the paragon for the world to follow either.

> I think you'll find there isn't some global consensus on ADHD and medications and there's a good reason for that.

I would imagine it's quite difficult to find global consensus on plenty of medical practices.

> ADHD treatment is barely science.

This we can agree on.

I think we mostly agree, but this is a particularly interesting point

> I would not cite Japan's drug laws, as well as plenty of other laws in their legal system, as the paragon for the world to follow either.

Japan is one of the (if not _the_) healthiest countries in the world. Further, US has one of the worst medical malpractice rates in the developed world.

Why would we _not_ cite Japans drug laws or any of their medical practices as a paragon for the world? Certainly we would in relation the US healthcare.

> Japan is one of the (if not _the_) healthiest countries in the world.

Sure, I could believe that. I have never been (always wanted to go). I am quite fond of some of the more romanticized elements of their culture, but I would not claim to know a lot about Japanese culture. So, I imagine my expectations would not intersect reality. However, I do love my pure bred Shiba Inu, so they can cultivate some great dogs. ;)

How much of Japan being the healthiest country can be directly attributed to their drug laws and healthcare system?

Sure, both might contribute, but I also wonder how things like having walkable cities, a sense of community/social homogeneity, dietary differences, genetic differences, etc. also play a factor.

I'm sure their healthcare and drugs laws do not make most individuals worse off. Is healthcare socialized in Japan or is it private? (I guess I could look this up). But I would imagine this could be a factor too.

How litigious are people in Japan compared to the rest of the world? I could be wrong, but I want to believe people in the US are probably more litigious than in Japan, but I have nothing to base that on other than unfounded stereotypes.

Alcohol is more dangerous than most commonly used drugs, but it's perfectly legal in Japan. So is tobacco. So, clearly what is deemed acceptable is arbitrary and based on cultural values and not public safety.

If Japan wasn't so tweaked in the 50s and 60s, then perhaps they might have a different outlook on substances?

While we are on this topic how does Japan view addiction? Is it viewed as a moral failing or a disease or something else?

Also, somewhat irrelevant, but do you want to know something ironic? Did you know a Japanese company, Takeda Pharmaceutical Company, is the proud owner of a significant amount of R&D and rights of the most popular stimulant medications? They merged with Shire in 2019, which is the company that R&D'd Adderall XR, Vyvanse, Mydaysis, Daytrana, etc..

They now pocket money off drugs they cannot even legally touch in the country they are headquartered in.

Your argument has several flaws. First, we prescribe drugs based on expected risk and reward. The likelihood of successful treatment absolutely matters. Otherwise, we'd require a trial of a homeopathic placebo for every mental health condition, before prescribing something that's clinically proven to work. Homeopathy is 100% safe, and 100% useless. But hey, sometimes the placebo effect works, right? That manic guy who thinks he can fly? Let's give him sugar pills for a year before lithium, just to be safe! Natural solutions and "alternative medicine" are always best, after all. The stuff that actually works is a last resort only! Just look at Steve Jobs, he's doing so well these days! His cancer was completely cured by his weird diet. /s

Second, you assume there's a significant difference between the risk of amphetamines at low doses and the alternatives -- usually off-label anti-depressants with a slew of nasty side effects. Do you really believe the science is unbiased when the DEA has been meddling in it for decades now? Come on now. These are the people that still insist cannabis is more dangerous than fentanyl. They're thugs, not scientists. Every 1960s housewife in America was microdosing speed in the form of diet pills, and it was mostly fine, until Nixon's alcoholic ass started a war on other drugs that broke everyone's brains. Then on the other end, you have Big Pharma corrupting FDA officials to make their newer, more dangerous, and less effective drugs look better than they really are.

More importantly, you assume there's no risk to delaying treatment. It's no big deal that someone loses a job and their health insurance because the "safer" drug you made them trial first did nothing or made things worse. It's probably already taken you months, if not years, to get the diagnosis and an appointment with a psychiatrist. The status quo probably isn't going great for you. Relationships, school, career, etc are suffering. Oh, not to mention the significantly increased risk of death of dying in a car crash when we're unmedicated. But sure, giving us some shitty placebo for three months, that's totally safer for everyone! Including you, right?

Can you people please stop peddling this anti-intellectual nonsense about a disorder you know absolutely fuck-all about, outside of stigmatizing pop culture memes? You're not a doctor. And get your damn vaccines too, while you're at it.

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