Week of 10.23.17

It’s interesting that ADHD patients have a higher potential for abuse, especially with opiates. The way I see it, however, is that everyone has a potential for abuse. Use becomes addiction when the use poorly affects health, relationships, work, school, and standing with the law; however, as the article pointed out, most addicts of opiates are highly functional people with prescription drugs, therefore, it is hard to recognize addicts because they may not present as the typical homeless person shooting up heroin in an alley. Of course biology plays a big part, but so does circumstance and timing. Take a highly functional adult with no biological predisposition with a recent leg surgery and an opiate prescription. If put in the right circumstances of financial distress, relationship turmoil, etc., he has just an equal chance of abusing that bottle of painkillers as any other person. One of the biggest issues, then, lie in the physician’s role in enabling these high functioning addicts and abusers; however, another issue is that pain is subjective. It is often difficult to assess whether a patient’s pain truly exists, and if it warrants a narcotic. It gets even trickier when patients come in requesting something “stronger” and complaining that they have tried icing, elevating, resting, Motrin, and Tylenol, putting the physician in a tight corner of little remaining management options. Problem is, many physicians give in, whether it’s to pacify the patient, get good reviews, or get the patient off their back. Physician’s need to start developing a stronger stance in how they deal with such patients and situations. At my past family medicine rotation, my preceptor told us off the bat that she does not condone doctor shopping and that she will shut down the idea and fire any patient that tries to abuse the system and get unnecessary narcotics from her, and she stuck to it. During my 6 weeks at the clinic, I witnessed her fire 4 patients for opioid abuse and attempting to get unwarranted prescriptions. Her methods might seem extreme, and I’m not saying that a physician should always resort to that method, but sometimes that’s what it takes. Physicians need to re-evaluate whether they are prescribing unnecessary drugs or prescribing narcotics too liberally. After my wisdom teeth removal of only two molars, I was given an in- office bottle of Vicodin along with a prescription for two refills. This is just one example of many daily situations of how physicians are making abuse too easy in a society struggling with an opiate addiction.

ADHD has become one of those conditions where people debunk its premise. It's unfortunate that the small percentage of the people who actually struggle with this get stigmatized due to the abuse of its treatment. Those who go undiagnosed unfortunately turn to sources that help take the edge off and it's unfortunate that it leads to a possibility of dependence. We all know what ADHD is perceived to be in childhood: predominant in boys, very disruptive, blurts at answers, very hyperactive, etc. It gets diagnosed, and patients get treated it accordingly. What is unfortunate is those who get diagnosed as adults. While that article stated that ADHD leads to a higher percentage of addiction, it's most likely due to those who went undiagnosed until adulthood and had to resort to drugs just to feel normal. I think if the stigma around this condition lessens, and there's more acceptance and less shame about seeking help at the appropriate time, these increased risks of addiction and pain could lessen since the coping methods would be avoided while getting treatment. As for medical students and residents, the field of medicine is getting more and more competitive, and it's the daunting and stressful nature of this career that make students turn to use these treatments, understandably since they're putting so much into this career. However, doing so comes with many risks and consequences that certainly need to be considered before seeking this type of "one-up" to stand out. Addiction signs also need more awareness, as anything (drugs, gambling, food, etc.) can be addicting. I think if people are conscientious of addiction being a possibility and its signs, moderation of use (as in using as needed vs. using it all the time) increases.

Article: ADHD and Addiction

Psycho-stimulants are chemically and pharmacologically similar to drugs of abuse such as cocaine and amphetamines, hence the correlation of ADHD and addiction to drugs of abuse. These drugs also have some euphorigenic effects. Lab studies in both humans and animals have shown the potential of abuse for methylphenidate, althought there is little evidence to support the concern in individuals with ADHD prescribed the drug. While psycho-stimulants may find illicit use in the pursuit of euphoria, they are also used as performance enhancement agents as a result of their ability to improve concentration and focus. The non medical use of psycho stimulants is however low, about 2% in American adults, the vast majority of whom do not have a legitimate prescription. There has however been an increase in the number of prescription stimulants used in the USA for patients without a diagnosis of ADHD.

The Psychology Today article does a fairly decent job at giving a general overview of how ADHD and opioid addiction are linked, as it lists risk factors in ADHD patients such as impulsive behavior, stimulation-seeking behavior, and general frustration as reasons why these patients would be more likely to use and abuse opioids. It also brings up an interesting and important point regarding physicians overprescribing opioids – it can be tricky to balance trying to help patients with these drugs and making sure they don’t overdose, and I do agree that some doctors can overprescribe these drugs as it’s sort of a “quick fix” to the patient’s complains of pain. What this article lacks however are definitive facts and numbers on how many ADHD patients are actually addicted to opioids, which would have been beneficial.

The Vice article addresses the issue of ADHD in adulthood. As the article mentions, many people often think as ADHD as a childhood disease. I think a lot of people think of this as a disorder that is easily recognized and addressed in childhood and therefore no longer an issue in adulthood. However the article brings up a great point – what if the diagnosis is missed in childhood? How would this then present in adulthood? Whether or not undiagnosed Adult ADHD is actually linked to increased risk of substance use and abuse seems to still a matter of debate. I’m personally not completely convinced that there is a strong link – decreased attention span and hyperactivity does not necessarily mean a person will resort to substance use. I think the medical community can definitely benefit from more research into this possible connection.

Prior to reading the Salon article, I had never heard of MDMA being investigated as a possible treatment for PTSD. It’s a really fascinating topic of discussion that I think we should all take a closer look at. Most of the article however focuses on semantics, the fact that many sources that are reporting on this finding use the term “Ecstasy” instead of “MDMA,” which does not sit well with the general public, as Ecstasy is often perceived with a negative connotation. This in itself is a valid point – peoples’ bias may automatically cause them to dismiss a potentially beneficial treatment as negative just because of wording.

The Medscape article on medical students using cPEDs in order to enhance academic success doesn’t necessarily come to much of a surprise. Medical school is a highly competitive and demanding endeavor, and many will do whatever it takes to achieve success no matter the cost, including taking these drugs. What is surprising however, is the statistic that 75% of American medical students are taking stimulants, antidepressants, or other psychiatric medications. This number seems high, but if that is in fact the case, we may want to take a closer look into what potential harms this may lead to. These medical students will soon become doctors, and many of the habits they’ve developed during medical school may carry over into their medical careers, including the use of these various substances. Ultimately this may lead to potential harm to patients down the road.

MDMA as a treatment for a disorder like PTSD is something that most may disagree with and be unwilling to try due to the stigma behind the drug. In my opinion, if a drug whether it is good or bad is referred to by its street name rather than using medical terms would led to increased shock value when it is discussed. What people have to realize is that any drug if not taken the correct way can have adverse effects. For example cocaine use to be used for nasal surgeries due to its numbing properties but later began to be abused so now its looked at as a street drug. Therefore, any drug to include Tylenol can be dangerous if used the wrong way.
When reporters say Ecstasy instead of MDMA it misleads people to think that street drugs are a approved treatment for this disorder and may even lead to those affected to try other street drugs in its place. In my opinion it is perfectly fine to try different or unorthodox treatments for diseases as long as they are referred to by there correct name and not street name to try and mislead people or promote the wrong message. This article was a wonderful example of how things can be taken out of context and should be fully researched before passing judgement and making a decision.

MDMA and PTSD

It is reassuring to see that MDMA is being looked at for its possible therapeutic value in treating PTSD patients. It has always been disconcerting to see how drugs developed by drug companies, originally supported and pushed by doctors, end up becoming illegal, only to end up back in patients hands for now alternate purposes. Drugs previously lauded for their great potential to heal, have all research on them stopped. Drugs that could heal speedily become 'drugs that kill'. As the article states, amphetamine has been a drug of abuse since the 1930s, but is now the drug of choice for ADHD. Ketamine is known more popularly as a drug of abuse, but is now being used for depression treatment. Looking at MDMA for PTSD treatment shows that these drugs wev'e deemed 'bad drugs' still have the potential to help more than harm.