HealthyGamerGG - ADHD And Dependence on Stimulants (Adderall & Vyvanse)

Episode Date: September 14, 2022

Dr. K talks about being afraid of dependence, external factors, stimulants, and more! Support this podcast at — https://redcircle.com/healthygamergg/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy Learn more about your ad choices. Visit megaphone.fm/adchoices

But in terms of whether you're going to become, quote, quote, dependent on a particular psychiatric medication, the first question is, is it doing what it's supposed to do? And do you want it to continue doing what it's supposed to do? My doctor just told me, I've become dependent on ADHD medication. What does that even mean? I got off the phone with my doctor just now to get my Adderall prescription refilled. During the call, he asked me, do you take it every day or as needed? So I told him, honestly, I take it every day because I feel I need it every day. My ADHD doesn't just vanish. But on the odd day that I forget to take it, I do just fine. It's when I forget for multiple days that it becomes an issue. And he said, it sounds to me like you've become dependent on stimulants. Okay? So I told him that I actually was planning on visiting a proper psychiatrist.

My prescription was given by a GP. And seeing about altering my prescription. Maybe a non-stimulant would work or a lower dosage. And he replied, no, stimulants work best for ADHD symptoms. So now I'm very confused as to what he's going on about, to be honest. I shouldn't take my medication if I don't need it because I'll become dependent on stimulants, but I also need to take stimulants because it helps me the most, therefore making me dependent. It's really confusing logic and I don't know how I feel about it.

He didn't really elaborate either. No concerns about my blood pressure or anything. He just said, hey, you're dependent, just letting you know your prescription is ready for you to pick up. It's just really confusing and I'm paranoid about my health as it stands. is really tough because especially if you've got ADHD, like anyone who's taking psychiatric medication usually has a concern that they're going to become dependent on it. I've seen this whether people have OCD, whether I have major depressive disorder, whether they have bipolar disorder, whether I have ADHD. People are afraid of becoming dependent on medication. And then sometimes

you'll have clinicians who will be like, oh yeah, you're dependent on this medication now. Like a doctor is telling you this. And that's kind of terrifying. Isn't dependency on medication like a bad thing? And then you're like not really sure. And sometimes you'll even ask your doctor like, hey, like, is there some way to get off the medication? And they'll say like, no, this is the most effective treatment. So I disagree with a lot of what this GP says. I'm pretty sure the evidence backs me up better than it backs the GP up. We'll talk about that for a second. But what I'd love to do is talk to you all today about what medication dependence means. Is it okay? Is it not okay? And how people wind up being dependent on medication. And is that scary? So the first thing to understand is

that the reason we prescribe medication is to sustainably help people, right? So I'm going to ask you all a question. Let's say I have a heart transplant. And as part of my heart transplant, I have to take immunosuppressive medication every single day. Why do I have to take immunosuppressive medication? So let's do a quick jaunt into physiology and transplant rejection. Not what y'all were expecting today, but let's explain this principle. So I have a body. My body has an immune system. My immune system learns what is me and what is not me. And then what the immune system does is starts to attack things that are not me, right? Pretty easy. Turns out that I got a bum ticker and I need a heart transplant. So what I'm going to do is I'm going to get a heart transplant. And in order for my

immune system to not destroy the transplanted heart because it comes from another person, I have to take immunosuppressive medication. Now this begs the question, am I now dependent on immunosuppressive medication. Like, sort of, right? I'm not, I mean, like, I guess I could stop taking it. So this is the key thing to understand. Medication is there to accomplish a particular goal. That's really the beginning and the end of it, right? We'll add a little bit of nuance in a second. But in terms of like whether you're going to become, quote, unquote, dependent on a particular psychiatric medication, the first question is, is it doing what it's supposed to do? And do you want it to continue doing what it's supposed to do? So when people take an antidepressant medication or

anti-anxiety medication, for example, they're like, do I have to be on this the rest of my life. That's usually like one of the earliest questions they ask. The short answer is you don't have to be, and we'll get to that in a second. But this is where I'd say the purpose of medication, whether it's cholesterol medication, immunosuppressive medication, weight loss medication, or ADHD medication, or ADHD medication or depression medication. The goal is the same. It's to try to keep you healthy. Now, just like with many of those medications, if you do particular things as a patient, you will no longer need the medication to do that job for you. So let's say I have type 2 diabetes. which means that due to the number of adipocytes or fat cells that I have in my body,

this is an oversimplication, my body has become resistant to insulin. And so since it's resistant to insulin, I can take certain medications that will increase my insulin sensitivity. And what I can also do is adjust my diet, reduce the level of my adipocytes, right? Start to exercise and do other kinds of physiologic things that make it so that I no longer need the medication. So am I going to be dependent on this medication for the rest of my life? Well, that depends on my other behaviors and what else I do.

So let's talk a little bit about ADHD medication. So some people with ADHD require medication on a daily basis. Generally speaking, stimulant medication for most people that are prescribed for ADHD, I will actually recommend it on a daily basis. So the goal with people with ADHD is generally speaking, the ADHD kind of screws up their life, right? If I go to work every day and I need to pay attention every day, I don't want to be like missing some days and be like, okay,

other days. Like, if I show up three hours late to work once a month because I didn't take my ADHD medication every single day, like, I'm going to lose my job. So what I found is a, is a psychiatrist working with people with ADHD is, you can't afford to have ADHD 20% of the time. Like, you can't treat 80% of it. You're still going to get screwed if you, like, your 20% like, like, if your ADHD is like active 20% of the time. There are some cases where, for example, like, if people don't need it for work, what they'll do is they'll, like, not take their ADHD medication on the weekends or things like that. There are individual plans that you can kind of come up with.

But it's okay to take ADHD medication every single day. Does that build dependence? Before we go on, so people are asking about weekends. So, like, here's the thing. Sometimes you need your ADHD medication on the weekend as well. Why? Because you have to do all the crap that you don't get to do during the week on the weekend. Like, you got to do laundry.

You got to pick up groceries. You got to drop off packages to return to Amazon. You got to, you know, pick up birthday cards. You got to be on time to social events. So it's fine to use ADHD medication every single day. So does that mean you become dependent? Well, there's two issues to consider with ADHD medication. The first is that there may be a physiologic dependence.

So this is neither good nor bad. It's not a value judgment. It just means that if your body develops a physiologic tolerance and dependence on a particular chemical substance, that means if you don't take it, you're going to have withdrawal symptoms, and that could be bad. So we develop different kinds of symptoms with ADHD, I mean, different kinds of tolerance with ADHD medications. That's not necessarily a bad thing. It's just something that you need to be aware of, almost from a safety standpoint. So that's where like we can become dependent on caffeine.

Does that mean that morally we're bad people and we're addicts? Not necessarily. It just means that if you don't have caffeine, you may have a headache. That's it. It's just to understand the physiology. Now the second thing about dependence is, do I have to take this medication for the rest of my life? That's what basically people are asking when they're saying, am I dependent on this medication? And that's where that depends.

It depends. And then you may say, well, Dr. K, that's weird. Like, how can you say that depends? What does it depend on? Just like any other medical illness, or not any, but. many other medical illnesses. How long you need to be on medication, the dose of the medication, that all depends on what else you are willing to do as a patient. So let's go back to our diabetes example. If I start exercising every day, if I eat low glycemic index foods, if I start, you know,

doing other particular things like doing yoga or other practices that support type 2 diabetes and stuff like that, then I may not need to be on the medication for the rest of my life, right? So if I can like get to where I need to go without the medication, then I won't be dependent on the medication. I won't need it. So the question is, okay, what does that mean for ADHD? What's the equivalent of eating healthy and exercising for ADHD? First of all, eating healthy and exercising, both do help ADHD. We go into some of that stuff in the guide that we've got hopefully coming out in about a month on ADHD. So we'll go over a lot of different treatment options and stuff like that in more detail. The key thing to remember about ADHD, let's talk about science. Okay,

what does the evidence-based data suggest? So first thing that evidence-based data suggests is that medication and psychotherapy are equally effective, roughly, in terms of effect size. What does that mean? That means that if I have 100 people with ADHD, and I put 50 of them into psychotherapy, and 50 of them into medication, or give them medication, the symptom reduction that they get in terms of ADHD is the same, okay? You actually don't need a pill. You can just go to therapy and you will get roughly the same effect size. Now, people may ask, like, how do you get therapy for ADHD. It gets complicated. There's also a bunch of info on this in the guide, but basically a lot of the psychotherapy for ADHD is developing structures and systems to account for

your ADHD, essentially putting up guard rails so that your ADHD does not negatively impact your life. It is literally teaching people things like how to organize, how to prioritize, how to set alarms, how to set reminders. We go into a lot of detail about how to develop a good organizational system in the guide. But it teaches people these kinds of of skills. And so just like any other psychiatric illness, there are certain skills you can learn that will mitigate or prevent the illness from harming you. So a simple example of that is anxiety and meditation. So if I have an anxiety disorder and I'm feeling very anxious and I learn to meditate, that can reduce the symptoms of anxiety and reduce my quote unquote dependence on anxiety

medication. ADHD is no different. We can learn particular skills. That's what psychotherapy teaches us. Now here's where the data gets interesting. So when you take people who have have been given psychotherapy and people who have been given ADHD medication. Effect size is roughly the same. Difference is duration of benefit after ending treatment. Here's where the dependence comes in. So when I take ADHD medication, if I stop the ADHD medication, I'm more likely to go back to square one. Whereas the cool thing about psychotherapy is if I do psychotherapy for, let's say, 20 weeks, and I'm done seeing my psychotherapist, I will still get the benefit of that therapy for a year, two years, maybe even three years, or even somewhat, quote, quote, permanently.

Depends on the person. But what we know is that the benefits of ADHD medication even last after you've done taking the medication. So people will still get positive benefits for six months, nine months after stopping medication. So their symptoms don't return back to normal right away, necessarily, over long, you know, large populations and longitudinal studies. So the duration of psychotherapy far outweighs the duration of medication, which is an important consideration.

So when people ask me, am I going to be on medication for the rest of my life, it's like, well, that depends on whether you develop an organizational system that will protect you from your ADHD. And if you can learn how to organize, if you can learn how to prioritize, if you learn all these things, chances are you don't need medication. So the GP said, stimulant medication works the best. So there's something really tricky about stimulant medication, which is not necessarily that it works the best. So there are head-to-head studies that show that non-stimulent medications and stimulant medications basically work the same in terms of the effect size. The big difference between stimulant and non-stimulant medication is, first of all, stimulants work faster than non-stimulants. So there's a medication called buproprione, for example, that is just about as effective as stimulants.

The difference is that buproprione takes like a month to really kick in, whereas stimulants, you'll feel the benefit within 24, 48, or 72 hours. So stimulants are better in terms of acting fast, but they don't necessarily work. They don't reduce your ADHD symptoms more than non-stimulant medications, on the whole. The second thing about stimulants that makes them feel like they work the best, and I'm not surprised to hear that from a GP, is that patients think they work the best. So there's a very simple principle in our brain that the more rapid the reinforcement, the more behavioral reinforcement we see. Sorry, the more rapid the benefit, the more behavioral reinforcement we see.

So for example, like stimulants work instantly. So what happens from a patient perspective is patients will tell you stimulants work the best for me, nothing else works. And why do they say that? it's because they notice the benefit immediately. Whereas non-stimulate medication takes days or weeks to really kick in, so people don't notice it. But if you actually do studies where I take 100 people on stimulant medication,

100 people on non-stimulant medication, and I measure objectively how bad their ADHD is, let's say three months after they started medication, what I'm going to find is they're both equally effective. But the subjective experience of the two patients is going to be very, very different. The subjective experience is going to be any day I miss my medication, with a stimulant, people notice it right away. So there isn't a difference in efficacy.

What there is is a difference in sort of noticing or kind of like an awareness bias where you can really feel the difference of the medication. Whereas when you're on a slower acting medication, you don't quite feel it as much. So that's part of the reason why people say stimulants, quote unquote, work the best. I don't think they actually,

the data suggests that they don't work substantially better than non-stimulants. It's just the difference is a lot more noticeable and therefore is much more likely to reinforce the behavior. So a lot of people are genuinely concerned about am I going to be dependent on my ADHD medication? The answer is maybe, right? So what I tend to see as a clinician is that a lot of people will find it very convenient

to just take a medication every day because they don't have the time or the energy or wherewithal to learn organization, prioritization, whatever. Especially if we're talking about like people who are students, right? So sometimes like I'll get someone who's like a sophomore who's coming in during midterms. You know, you can teach me organization and plan. but in the two months it takes me to like figure out how to use a calendar effectively, like my midterms are going to be gone and I'll have failed them. So sometimes people will need medication because it's the easiest thing to do.

Now how dependent on it you become, not just from a physiologic perspective, but we're talking like long term. Do you need to take a medication for the rest of your life? The answer is that depends. It depends on the severity of your ADHD. It depends on what other kinds of things you're willing to try. So we also know, for example, that meditation strengthens frontal lobe function. and the goal is going to be over time to literally, like, reduce your mind's distractibility

through practices like meditation, the more of that kind of stuff you do, the less dependent you're going to become on your medication. And the last thing about people sort of saying stimulants work best, well, I think they work fastest, and they work most noticeably. But fastest and most noticeable does not technically mean best, but it oftentimes looks like best. Because think about it from the GP's perspective, when I give someone a non-stimulant medication, they come back in two weeks and they say the medication isn't working, I'm still having problems.

Then as a general practitioner, I switch them from a non-stimulant to a stimulant. They call me the next day and they're like, this medication has changed my life. And so then as a GP, I don't blame the GP for, you know, they can't stay experts in everything. You know, I don't blame them, but they'll sort of say like, oh, okay, so it seems like stimulants work better. And then what happens to the GP is the next time someone comes in with ADHD, I just start them on the stimulant. And then I don't ever hear from them again, except when it's time from refill. I ask them, how's the medication working? They say it's working great.

So these kinds of biases, not really the GP's fault in a sense, right? Because there's very natural ways why GPs will get to that conclusion. Last thing that I kind of want to say is that if your doctor uses terms with you that you don't understand or terrify you, like they say like, oh yeah, you're dependent on this, by the way. That may mean something different to them than it does to you. And if your doctor says things that scare you, ask them to explain themselves. Be like, what do you mean by that? What does that mean? What are the implications of being dependent on ADHD medicine? medication. Is this a bad thing? Like, what do I do about it? Second thing is, by all means,

get a second opinion. If a doctor's not talking to you enough, if they are not explaining things enough, then by all means, get a second opinion. Explain to them that you need more explanation. And also, by all means, go see a specialist. So someone's asking, how does one's life, why 2-915 is asking how does one's life change if they get diagnosed with ADHD? Chances are their life gets substantially better. So that's kind of a weird thing to say. Because remember getting diagnosed with ADHD or not getting diagnosed. Like, you have the ADHD, whether it's diagnosed or not. It's affecting you whether you have the ADHD or, I mean, whether you get to have the diagnosis or not. You've got ADHD either way. It's impairing your

function, whether you have a diagnosis or don't have a diagnosis. The only thing that the diagnosis, hopefully the main thing that the diagnosis does is gives you the opportunity to do something about it, engage in treatment. Now, what we do know is that living a life of untreated ADHD, leads to all kinds of problems. We've probably got a lecture that we're going to share with you all in about a week or two about this, about the ADHD iceberg. But for example, we know that something like 50 to 70% of people with ADHD, let me think about this statistic.

That sounds high even to me. I think I may be misquoting this. But if you look at the comorbidity of ADHD and depression, three to five percent of people with depression will grow up to later be diagnosed with ADHD. But of the people who have both, 50 to 70, percent of people with ADHD will be will also have depression later in life for that comorbid population. So what does that mean? Does that mean that if you've got ADHD, you have a 50% chance of getting depression? No, there's four people who have both. If you take

that subset of people who already have both, what you see is that there is a causal relationship, ADHD leading to depression. And it doesn't go the other way. It's not just correlated. One causes the other. And why is that? It's because growing up with ADHD, especially untreated ADHD, shapes your life to be depressed later. So I'll give you all a simple example of this. Very fascinating study that found that kids with ADHD are less likely to be invited to birthday parties than neurotypical kids.

Think about that for a second. So if I'm an ADHD kid, why does it mean I'm going to be less likely to be invited? It's because I don't pay attention. So all the other kids are talking about Pokemon cards and I start randomly talking about something that's completely unrelated. And the kids all look at me like I'm weird

because I'm highly distractible. I can't keep pace with the conversation. I also don't pay attention when they're talking to me, right? So over time, like, those kids aren't going to want to invite me to their birthday party. And then over time, if I stop getting invited to birthday parties, what does that mean for the development of my social skills? I don't get opportunities to, like, develop my social skills because I get invited less.

Can't level up if you don't zone into where the fighting is, right? Like, you can't get any XP if you're not invited to the game. And so over time, kids with ADHD experience more social isolation and loneliness. Rusty social skills, which in turn makes it harder for them to, get promoted at work because a lot of getting promoted at work has to do with social skills. And so what we tend to see with kids with ADHD, especially when it's undiagnosed and untreated, is that living a life of undiagnosed ADHD predisposes you to depression through features like underperforming in an academic sense.

So there's underachievement academically for kids with ADHD. There's lack of social opportunities, which leads to isolation and loneliness. There are all these different factors where you can almost, this is what we do, in the lecture that there's a whole lecture about this and Dr. Kay's guide to ADHD and doing stuff where you can map it out how growing up with ADHD leads to particular factors which later in life lead to depression.

Because what ADHD does is all of these factors over here are risk factors for depression later in life. So hopefully getting diagnosed changes your life for the better. Scalicious is saying, I often hear people say that ADHD and other diagnoses disorders

are being over diagnosed. Do you think that this is true? So I've said this before, I'll say it again. I think ADHD is both the most over diagnosed and at the same time the most underdiagnosed psychiatric illness. So you may ask a question, wait, how can something be over diagnosed and underdiagnosed? What I mean by that is I think that ADHD is oftentimes missed in people who have it. So this is why we're seeing a lot more

adult ADHD diagnosis. Why is that? It's because the diagnosis was missed when they were kids. Why was it missed when they were kids? Because the kids were super smart and built up compensatory mechanisms that allowed them to hide the ADHD. So when you see a smart kid with ADHD, oftentimes that kid won't get diagnosed. Because even though they can't pay attention, they can use brute force reasoning to figure out what is going on. So I'll give you all just a classic example. So kid isn't paying attention in math class.

My mind is wandering. I can't pay attention. Teacher says my name twice. And then suddenly I snap back to it. I can see the whole classroom is looking at me. Teacher is looking at me. And I can see that people are upset. Using my ADHD brain, which can quickly interpret information, I glance around the classroom.

I see teachers holding chalk. I see there are four problems on the chalkboard. Three of them have answers. I look at the fourth problem that doesn't have an answer. I calculate very quickly because I have a high IQ. I say the answer. Teacher looks at me with suspicion because they were sure I wasn't paying attention, but I came up with the answer.

They write the answer and then they move on. Kids with ADHD develop compensatory mechanisms. Leads to underdiagnosis of ADHD. At the same time, people over-diagnose ADHD. parents are frustrated with their kids. Kids don't listen. All they ever want to do is watch the iPad. Parents never train attention in their kids.

Anytime the kid is upset, anytime the kid is distracted, anytime my nanny doesn't show up, I'm guilty of this as well. Take the iPad. Turn on the screen. Shatters the kid's attentional span. Increases emotional dysregulation. Kid has problems at school because I never sit down and read with them at home. Parents are like, kid doesn't listen because I don't have healthy boundaries at home.

Kid gets diagnosed with ADHD. So it's both over-diagnosed and under-diagnosed. Sounds like me? Oh, yeah. You betcha.