Comment by chimeracoder | Hacker News Reader

Comment by chimeracoder | Hacker News Reader

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I posted this in a HN thread about therapeutic uses of nicotine a week ago, but it's even more relevant here:

> A friend of mine is a psychiatrist who specializes in treating ADHD. She told me about a conference she went to recently, where someone presented an interesting paper.

> Apparently, there was an amazing study done relatively recently (last five years), in which they demonstrated that, in mice, exposure to nicotine during pregnancy results in higher rates of ADHD in the grandchildren (passed down through the female offspring exposed to nicotine in utero, not the males).

As with any study conducted on animals and not humans, there's an asterisk next to it, but these findings would be monumentally significant for understanding ADHD.

Separately, I've never understood why Adderall isn't approved for use in Europe (or, futhermore, why Vyvanse should be approved, if Adderall isn't - Vyvanse is just a more concentrated version of the d-enantiomer, making it more effective[0] and reducing the side-effects).

On an unrelated note, it looks like the copy editing on the article was a bit off. Concerta is a long-acting drug, just like Vyvanse (the article makes it seem like it isn't). Also, I'm not sure what to make of the sentence "The U.S. still dwarfs Europe in sales of ADHD drugs, but the rest of the world has been catching up."

[0] It's actually less effective by weight than Adderall XR, but that's because the mechanism it uses for the extended release is very different.

EDIT: It's interesting watching all six of the comments on here (not counting losethos's) get upvoted and downvoted in roughly equal proportions. Clearly this is a controversial topic on here; I only wish the those upvoting/downvoting would join in the discussion.

> "Vyvanse is just a more concentrated version of the d-enantiomer"

Not at all; it's a prodrug that is converted into the d-enantiomer by your liver, at whatever your xenobiotic-metabolic speed is.

The major result of this has nothing to do with how safe a regular pill-dose of Vyvanse is vs. Adderall (or, equivalently, Strattera vs. Ritalin.) Instead, the effect is that you can't convert Vyvanse into an injectable or smokable form to make it absorb faster. There's no simple physical process you can put prodrugs through to turn them into something that will get you high; they need the full biological environment of your liver to be "unlocked", and it will only do so at a rate safe for you. (Or it'll create cytotoxins if you overload it, but this still won't get you high.)

And because of this, it's much safer statistically to prescribe it; with Adderall/Ritalin, there is a high chance that any voluntary self-diagnosed case will turn out to be a junkie/drug-seeker/drug-seller. With Vyvanse/Strattera, that potential for "malicious use" doesn't exist[1]. There are still all the same medical dangers, to be judged by doctors on an individual basis -- but there's a far lower worst-case downside in prescription.

(Further, prodrugs aren't addictive when taken at recommended dosages, since addiction is [likely] caused by your brain correlating spikes in its chemistry with recent memories, and prodrugs aren't "spiky" in the way their raw agonist or reuptake-inhibitor forms are.)

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[1] Well, it does, but only in the nootropic/"study drug" market; not on the street.

> There's no simple physical process you can put prodrugs through to turn them into something that will get you high;

The fact that Vyvanse is a prodrug is emphasized heavily in its marketing, but the anti-abuse potential is overstated, IMHO. Even some very cursory searching on Bluelight, et. al. will yield a dozen ways to either magnify or dampen the effects of Vyvanse using common foods, etc.

> with Adderall/Ritalin, there is a high chance that any voluntary self-diagnosed case will turn out to be a junkie/drug-seeker/drug-seller.

Well, we can't prescribe any psychiatric medication, addictive or not, to people who are "self-diagnosed".

> Well, we can't prescribe any psychiatric medication, addictive or not, to people who are "self-diagnosed".

I meant "self-diagnosed" as in "books an appointment with a therapist because they think they have X, whereupon the therapist tests them for X, and then sends them to a psychiatrist who tests them more carefully for X and, finding that they do have X, prescribes them medication for X."

Junkies can and do game this by looking up the tests online (which are, if you didn't know, just battery self-assessments of correlated behaviors.) But the only way to prevent this (besides coming up with objective measures for ADHD involving fMRI scans, like they've done for depression) would be to only prescribe neuroaffective medications to people whose lives take such a bad turn that they end up talking to a psychiatrist involuntarily (i.e. in a mental ward), thus preventing anyone who is self-aware-enough to notice that they have a problem from solving it.

How exactly is it supposed to work then? People don't recognize the symptoms of mental disorders in themselves or others. Sure, you can tell if someone is having an extreme psychotic episode, or an extreme depression. In less extreme cases outwardly "harmless" symptoms of depression or ADHD are wrecking people's lives.

The potential abuse of the system does not mean it doesn't do more good than harm.

Of note: Adderall is by far not the only drug available for ADHD, and considering its addictive nature, should not be the first on you try.

It isn't addictive for everyone; a good thing for me insofar as having my supply stolen by people who are addicted or want to resell it causes me only financial rather than chemical distress.

What could be wrong with dosing children with amphetamines every day for years?

ADHD is not just a problem for children.

If you are not treating a child with severe or even moderate ADHD with Amphetamines, the risks are severe and not so rare at all.

Almost by guarantee the child will not achieve remotely as well as it could. Both in school and within social groups. Both of these failures will almost by guarantee lead to further problems down the road.

It has been shown that untreated ADHD multiplies the risk for other very real disorders, like bipolar disorder for example.

My mother was only just recently diagnosed with ADD (After having 2 out of her 5 children with the same ADD/ADHD diagnosis). This was AFTER dealing with depression and various diagnoses including bipolar. She is in therapy to not only manage her ADD, but also deal with all the issues as a result of a lifetime of unmanaged ADD. I have ADD, but was diagnosed young, I learned how to manage and only went on meds when I was mid 20's since my non medical management didn't work well outside a structured school setting (and barely did in highschool/college). My depression and anxiety are made worse if not caused by ADD and has affect social and work life (good and bad). While I agree that ADD/ADHD can be overdiagnosed and even possibly overmedicated, I agree that not having a diagnosis can cause a worse life than otherwise.

I disagree, and I'm confident sane history will eventually look back in horror at the idiots giving their kids amphetamines willy-nilly.

Perhaps some children need this. The vast majority receiving these drugs would benefit a lot more from realistic parenting and school situations than from a toxic, addictive stimulant pill.

Those enlightened future beings will have to discover some theoretical side effects which justify the obvious disadvantages of denying treatment and just haven't been seen yet despite of decades of experience with these drugs.

These side effects need to be severe, given the massive amount of consequences of untreated ADHD.

I don't even really believe that ADHD exists. I'm quite confident that I'm amphetamine addiction exists, however.

There is a very good MOOC on ADHD from coursera, the videos should still be up. I don't think anyone who has a low to medium understanding of the topic can claim that ADHD does not exist. The evidence for the existence is compelling and overwhelming.

A short non-exhaustive summary: visible symptoms, effects on specific cognitive tests, reversal of symptoms under treatment, significant changes in neuroanatomy and brain activity in MRI, differences in EEG spectra and severe consequences like lower Income, higher propensity for violence and addictive behavior plus a markedly worse social life.

The thing is that I'm more likely to believe its a combination of environmental toxins, food poisons such as artificial coloring and preservatives and incomplete parenting than something that could be treated effectively with more chemicals.

What do you suspect?

Nothing at all. Methamphetamine, which is not very different than the dextroamphetamine in Adderal, has proven to be a remarkably safe substance and in general, society benefits a great deal when people ingest methamphetamine. I'm sure schoolchildren being prescribed dextroamphetamine to take every single day for years is a very good idea as well.

Are you honestly comparing crystal meth from the street to something prescribed under the guidance of one's doctor? Your post strikes me more along the lines of hysterics than a rational foray into discussion.

For shits and giggles, let's compare apples to apples. Desoxyn (Methamphetamine HCl). There you get the scary M word, but one that's FDA-approved and prescribed--though, admittedly, not commonly--by doctors. Same chemical substance minus the crystallized form, impurities, and of course, the world of illicit meth.

Oddly enough, Abbott Pharmaceuticals isn't synthesizing Desoxyn in their backyard meth lab ala shake-and-bake and Walgreen's isn't hawking it from the saddle bag of their pharmacists' motorcycles. Same substance, different context.

If you want to argue against possible long-term effects of d-amphetamine on developing children, do so. You certainly won't be alone, though for all the hysterics and despite thousands of long-term studies on its effects, there's a rather glaring dearth of support for that position. But, hey, "methamphetamine!"

I am absolutely comparing dextroamphetamine to methamphetamine. It doesn't matter by whom it was synthesized.

They are very similar in pharmacology, so you'd be deluded to not compare the two. Same addictive properties, same deleterious effects on health, similar abuse potential.

And yet, different contexts lead to vastly different results. One is prescribed under a doctor's guidance at therapeutic doses and administered orally; the other is smoked, at [i]significantly[/i] higher dosages, to speed up absorption with much higher concentration levels accumulating directly in the brain.

In other words, your argument is inherently simplistic and purposely misleading. Despite similarities in structure, the pharmacodynamics differences between therapeutic usage of Adderall and illicit meth are significant. When you gloss over the differences, you're radically undermining your position. My point with Desoxyn, which you completely ignored, rebuts your position even more clearly.

Most medications have the potential for hazardous effects higher up the dose-response curve. That potential, however, doesn't magically negate clinical effects lower on the curve. A little is good, a lot (or with acetaminophen for instance, a little more) can be deadly. That's nothing new. Just as with potential for side effects, you and your doctor work to manage it during treatment.

On another note, when you raise the specter of crystal meth usage, you aren't just isolating it to matters of pharmacology. Especially when you're talking about usage externalities and societal benefits: the external costs associated with manufacture and distribution all come along as mental baggage with the words "crystal meth." Your hysterics purposely ignore this in order to make the comparison seem more damning on a purely emotional level.

The reason I appeal to sets of things is because I find it completely ridiculous that children are routinely prescribed this dangerous stimulant drug for what I consider very flimsy reasons.

Most people don't really realize what Adderall is, and American society as a whole seems to assume that doctors and pharmaceutical companies know what they are doing and are trustworthy, despite many indications to the contrary.

The pharmacology of "illicit meth" is no different than the pharmacology of legal methamphetamine, other than some contamination. The pharmacology of dextroamphetamine is not so different either, mainly it comes on slightly more slowly and lasts less time.

The reason that crystal meth usage is so bad for society is because the drug is truly terrible for you. I am well aware of everything you said, and I disagree that "just a little bit of amphetamines" is helpful for kids to be receiving for ADD.

I'm confident that history will see me out on this. If you want to give your children speed, have fun.

Methamphetamine in fact IS prescribed by doctors to treat certain disorders. It's unfair to compare prescription methamphetamine to street meth since street meth is not only often very impure, but is typically taken in dosages 30x - 50x greater than a therapeutic dose.

This logic could also be used to argue that acetaminophen / ibuprofen should be Schedule I narcotics since taking a dose 30x - 50x larger than the therapeutic dose would almost certainly result in death.

Anyone who took a dosage 30-50 higher times the prescribed dosage of methamphetamine would quickly die. The impurities are irrelevant: the drug is toxic even at normal doses.

I disagree with your comparison of acetaminophen and amphetamines. It seems to be based on your deluded idea about dosage, but other than that, the drugs differ in some rather significant ways such as abuse potential, habituation, psychoactivity, and so forth.

A therapeutic dosage of methamphetamine (Desoxyn) is about 5mg - 15mg, whereas a recreational dosage can be as high as several hundred milligrams. Though certainly toxic at higher doses, research hasn't shown that the drug is toxic at therapeutic levels. Like the majority of drugs, doctors must balance its benefits with any potential side effects.

You can disagree with my comparison if you'd like, but the fact remains. Don't take my word for it - I encourage you to read some of the research out there surrounding therapeutic methamphetamine as well as the more common levo/detroamphetamine.

I'm sure all the pharmaceutical corporations would love to have me hooked on their methamphetamine, and the history of these companies and the way they have taken advantage of and poison of the American public should be well known by now.

Amphetamines are highly addictive. They require perpetually higher doses to maintain the same activity in the body, like most other highly addictive substances. I'm sure there are some legitimate therapeutic usages for these drugs (narcolepsy). However, I see them as massively over prescribed to people who do not actually require them.

I don't think it's reasonable to compare the effects of street methamphetamine (which is most likely not pure and the dose is not regulated) with the effects of therapeutical doses of dextroamphetamine prescribed by a doctor.

The impurities in methamphetamine are not what causes the problem: it's the toxicity and danger of the drug itself.

Is this sarcasm? Hard to tell since many people do take methamphetamine daily as prescribed by a doctor.

If you have narcolepsy, great. You need strong drugs. If you are a kid who fidgets, I don't think you need amphetamines.

What would you recommend?

First off, I recommend you ask a licensed professional that type of question.

My experience being switched from Adderall XR to Vyvanse a few years ago when it first came to market in the U.S. has been positive. Vyvanse seems less addictive (missing a week or two between prescriptions is not a big deal) or prone to side effects like insomnia.

This was my experience as well. After 6 months on adderall I had already shown signs of addiction (dosage was needing an increase in order to maintain its effectiveness). I have been on the same dosage of Vyvanse for 4 years now, without any problems.

I found Wellbutrin worked very well for me.

Obviously, I'm not your doctor.

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