11 The need for multiple daily dosing of immediate-release medications only further increases the risk of nonadherence in children, adolescents, and adults. Medication adherence is also a well-known problem in a chronic disorder like ADHD, with only about 20 percent of patients remaining on the same medication 15 months after first being prescribed that medication. However, clinicians should be mindful of the risks and benefits of this treatment approach in a high-risk population and should also bear in mind the labeling guidelines when working with this comorbidity.” In difficult cases like those patients with comorbid ADHD and SUD, long-acting ADHD medications are, in my opinion, almost always preferable to short-acting agents. Under certain conditions, psychostimulants may be a pharmacologic option in the treatment of patients with comorbid ADHD and. In a recent review article, Kollins 10concluded, “Patients with ADHD are at increased risk for SUD. Jasinski, et al., 9 in a human study, also showed that 50mg of lisdexamfetamine given intravenously to known stimulant abusers showed a lower c max and much longer t max as well as decreased drug likeability scores that were not significantly different than placebo when compared to 20mg immediate-release dexamphetamine. Lisdexamfetamine’s need for enzymatic cleavage may reduce the risks of intravenous and nasal abuse due to significantly decreased levels of the active compound seen in animal studies. Lisdexamfetatine is a pro-drug that requires enzymatic cleavage of lysine before dexamphetamine, to which it is attached, becomes biologically active. Importantly, the immediate-release formulation yielded significantly greater drug likeability ratings compared with the osmotic-release formulation. 7 These two formulations had almost similar average peak-drug concentrations and dopamine-transporter blockade, but the immediate-release formulation achieved these targets several hours earlier than did the osmotic-release formulation, suggesting a more rapid drug absorption and central drug activity with immediate-release MPH versus osmotic-release MPH. The subjective effects of oral immediate-release (40mg) and osmotic-release (e.g., osmotic-controlled release oral delivery system (90mg) MPH were studied in healthy volunteers. 6 Two studies compared short-acting and long-acting MPH formulations to examine this hypothesis. With extended-release stimulants, the slower rise and fall of MPH, amphetamine, and dexamphetamine levels in the brain may contribute to decreased drug abuse potential. Long-acting ADHD stimulant medications may also be less prone to contribute to the development of drug abuse or dependence. 3 Two other studies in adolescents and young adults reported that immediate-release MPH (Ritalin) was most frequently used (75% and 93%, respectively). 2 In a study of college students reporting nonmedical stimulant use, most (75%) indicated immediate-release mixed amphetamine salts (Adderall) was the stimulant used. These young adults, whose modal age was 19 to 28 years, reported lifetime nonmedical use of MPH and amphetamines of 12.3 (–0.4) for college students and 14.6 (–1.3) for young adults. In 2005, college students were interviewed 1 to 4 years beyond high school. Johnston, et al., 1 reported that lifetime nonmedical use of prescription MPH and amphetamines among secondary school students in 2007 was 6.5 (–1.0), 11.1 (–0.8), and 11.4 (–3.6) in 8th, 10th, and 12th grade students, respectively. The possibility of diversion or nonmedical use of stimulants is an issue clinicians should be aware of even though it is not a problem for the vast majority of patients. There is also less likelihood of diversion of long-acting agents because the giving and taking of medication is supervised at home during the morning dosing. The benefits of this once-daily dosing are that these children are not forced to go to a very busy school nurse or school office to receive their medications, nor are they singled out from their classmates in order to receive an additional dosage of immediate-release, short-acting ADHD medication. Children and adolescents given long-acting medications for ADHD generally are adequately treated for the entire day with once-daily morning dosing. The data presented in this article suggest that pediatricians are ahead of the curve compared to many psychiatrists and primary care providers in regard to utilizing the clinical advantages of long-acting medications for ADHD.
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