In Part 1, we explored the essential key facts of ADD/ADHD and the unfounded fears surrounding medication treatment. Today, we dig deeper into physician application of medication and why more, not less, medication, may be best for your situation.
State-of-the-art care may require more, not less, medication
State of the art care for Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ ADHD) frequently requires doses/dosage regimens of stimulant medications that are at variance with FDA approved manufacturer’s guidelines (i.e., off-label).
Lack of training and experience about ADD/ADHD and its pervasive nature, limited experience with the medications used to treat it, and a misunderstanding/ misinterpretation of the intent of the FDA approved guidelines promotes fear of off-label use of stimulant medications in patients and many professionals.
As a result, many patients who could greatly benefit from proper treatment receive sub-therapeutic dosage regimens or no treatment at all.
The medical literature provides ample support for the safe use of off-label doses/dosage regimens of stimulants in children and adults with ADD/ADHD when tailored to a patient’s individual needs. A national survey of family physicians, pediatricians, developmental pediatricians, and child/adult psychiatrists has shown that greater than 45% have prescribed stimulant mediations for ADD/ADHD off-label.
Technically speaking: Digging into the medical literature supporting off-label regimens
In general, the medical literature demonstrates that for most patients there is a linear dose-response curve with regards to stimulant medications. This means the higher the dose the greater the response. Other patients show no response at lower doses but require substantially more robust doses before they show any positive benefits.
These differences in medication responsiveness appear to reflect genetically-based individual differences in factors that affect how an individual metabolizes these drugs. We now have genetic testing that can facilitate a better understanding of why certain patients appear to be outliers when it comes to medication effectiveness and adverse effects.
Therefore, in the presence of continued dysfunction in an ADD/ADHD individual, medication can legitimately be increased to the point that all day clinical efficacy is achieved or side effects become intolerable or unmanageable.
In our experience, this later issue is oftentimes very complicated. Clearly, the ADD/ADHD field could benefit from much more research into the use of medication and dosage levels in particular.
We feel that the major limitation of current medical literature is the significant heterogeneity of the ADD/ADHD population in terms of the degree of their problem and profile of underlying attentional weaknesses and executive dysfunctions along with the presence of individual differences in temperament and/or co-morbid conditions that have not been accounted for in study designs.
A National Survey of Physicians Concurs
We have conducted a national survey of physicians regarding their prescribing practices with regards to ADD/ADHD. We obtained randomized samples (including geographic area) of membership lists from the American Academy of Family Practitioners (AAFP), the American Academy of Pediatrics (AAP), the American Psychiatric Association (APA), the Society of Developmental and Behavioral Pediatrics (SDBP), and the American Academy of Child and Adolescent Psychiatry (AACAP). Each physician was asked to complete a detailed questionnaire designed by a research psychologist with a strong background in marketing surveys.
Results indicate that approximately 45% of all physicians responding had used stimulants in treating ADD/ ADHD at dosages greater than the FDA approved manufacturer’s marketing guidelines. Furthermore, as training and experience with ADD/ADHD increases, the percentage of physicians using higher doses increases (see tables on page 13 of ADD/ADHD Basics 301).
Our interpretation would be that as physicians get more training and more experience with ADD/ADHD, they come to recognize that it is frequently necessary to exceed FDA approved manufacturer’s marketing guidelines for stimulants in order to properly manage their patients in all life spheres throughout the working day.
Medication in Context of Multi-Modal Treatment
By using a systematic protocol that involves a comprehensive multidisciplinary assessment to first establish a valid ADD/ADHD diagnosis and identify related co-morbidities, objective in-office medication trial testing, and ongoing supportive counseling, we have safely incorporated off-label dosing regimens of stimulant mediations when needed to help our ADD/ADHD patients function effectively in all life spheres.