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Emergency Medicine News:
doi: 10.1097/01.EEM.0000444861.46252.8a
Toxicology Rounds

Toxicology Rounds: ADHD Drug Toxicity Coming Soon to an ED Near You

Gussow, Leon MD

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Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital), an assistant professor of emergency medicine at Rush Medical College, and a consultant to the Illinois Poison Center. He is also the editor of his own blog, The Poison Review (http://www.thepoisonreview.com).

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It is amazing how frequently attention deficit hyperactivity disorder is diagnosed in school-age children in the United States. Alan Schwarz, in a superb series in The New York Times last year, laid out those statistics and reported on the marketing campaign intended to bring about a similar increase in adult ADHD diagnoses. These articles have significant implications for emergency practitioners and medical toxicologists.

The figures — based on data from the Centers for Disease Control and Prevention — are astounding. One in nine children is diagnosed with ADHD by age 18, and about 70 percent of those are prescribed medication (stimulants or other drugs) to treat the condition.

The prevalence of diagnosed ADHD is even higher in some subgroups. Approximately 20 percent of high school boys have received the diagnosis, and half of them are being treated with drugs.

This has been a bonanza for certain drug companies. Sales of ADHD medications have skyrocketed, more than doubling from $4 billion in 2007 to $9 billion in 2012. Some experts are becoming uncomfortable with these escalating statistics. Mr. Schwarz quotes William Graf, MD, a professor of pediatrics and neurology at Yale University, as saying, “These are astronomical numbers. I'm floored. Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.” (http://nyti.ms/1f9ZYgL.)

Clinical psychologist Keith Conners, PhD, a professor emeritus at Duke University who founded the ADHD program there, was even more alarmed, calling the explosion of ADHD diagnoses a “national disaster of dangerous proportions.” He went on: “The numbers make it look like an epidemic. Well, it's not. It's preposterous. ... This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.” (See FastLinks.)

This set of circumstances, which could justly be called the medicalization of adolescence, is certainly discomforting. And, in all likelihood, it is about to get worse.

The criteria for making the diagnosis of ADHD — used by clinicians in patient management and insurance companies for determining compensation — are established by the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook updated regularly by the American Psychiatric Association. DSM is, among other things, a work of enormous financial power and influence because it is used to determine not only how APA members will be paid but also the size of specific patient populations eligible for treatment with drugs. Political infighting over content in each iteration of DSM can be fierce.

The newest edition, DSM-V, came out in 2013, and it is instructive to compare the sections on ADHD with the previous edition. One discovers subtle changes introduced into the new version that, intentionally or not, will expand the number of children (and adults) who fit the diagnosis of ADHD and become candidates for pharmaceutical therapy.

Both DSM-IV and DSM-V agree that the prevalence of ADHD in children has historically been around five percent. Unfortunately, the new volume does not stop to ask why current prevalence rates in the United States are so much higher than the historical precedents or what the implications of this trend could be.

Criterion “B” in DSM-IV requires that “some hyperactive-impulsive or inattentive symptoms were present before age 7 years.” That same criterion in DSM-V reads: “Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.” (Emphasis added.) A new group of kids who first become fidgety or misplace their cell phones (both listed as behavior supporting the diagnosis) between 7 and 11 will now potentially be diagnosed with ADHD, and may be treated with medication. Addressing the diagnosis of adult ADHD, DSM-V has decreased the number of exhibited hyperactivity and impulsivity symptoms needed to qualify from six to five.

Some critics have charged that pharmaceutical companies are now promoting the concept that ADHD is a lifelong condition affecting adults as well. Mr. Schwarz in his New York Times piece, “The Selling of Attention Deficit Disorder,” refers to a 2011 Bloomberg TV interview in which Angus Russell, then chief executive at Shire, the company that makes Adderall-XR and Intuniv, noted that “the fastest-growing segment of the [ADHD] market now is the new adults who were never diagnosed.” (See FastLinks.)

Drug companies rolled out ad campaigns featuring celebrities such as Ty Pennington (host of ABC's “Extreme Makeover: Home Edition”) and Adam Levine (of the musical group Maroon 5 and NBC's “The Voice”) talking about their own experiences with ADHD and drug therapy. Some companies also posted easily accessible online quizzes that encouraged self-diagnosis. (Sample question: “How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?”) The Times administered one such test to more than 1100 adults in a nonscientific but telling telephone poll. The results indicated that nearly 50 percent possibly or probably had ADHD. On the other hand, they might just have been over-caffeinated.

The marketing push behind adult ADHD is quite reminiscent of the campaign to expand use of prescription opioids, and employs similar tools: patient-advocacy groups funded by pharmaceutical companies, promotional material offering highly selective research results, and “experts” who hype the benefits and minimize the risks of medication. The Times cites Ned Hallowell, MD, as a well-known psychiatrist in the field who “for years would reassure skeptical parents that Adderall and other stimulants were ‘safer than aspirin.’” (Reality check: Adderall is an amphetamine, and has a wide range of potential side effects including anorexia, insomnia, hallucinations, mood swings, and psychotic episodes.) The Times reached Dr. Hallowell for comment, and he confessed that he now regrets the analogy and wouldn't be using it again. (http://nyti.ms/1eVUhkc.)

All this has tremendous implications for emergency medicine and medical toxicology. Many medications — stimulants and non-stimulants — are used to treat ADHD in adults and children. (See table.) ADHD diagnosis-creep will likely increase the rate at which these drugs are prescribed, and that inevitably will boost the amount of drugs diverted to illicit markets. It is essential that clinicians be familiar with the pharmacology and toxicology of these agents, and that will be the subject of next month's column.

Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.

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Drugs Used to Treat ADHD

Stimulants

  • Adderall (amphetamine/dextroamphetamine)
  • Concerta (methylphenidate extended release)
  • Focalin (dexmethylphenidate)
  • Ritalin (methylphenidate)
  • Vyvanse (lisdexamfetamine)

Nonstimulants

  • Intuniv (guanfacine)
  • Kapvay (clonidine)
  • Strattera (atomoxetine)

Wolters Kluwer Health | Lippincott Williams & Wilkins

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