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stimulant medication

Dr. David W. Goodman invited to speak at the Neuroscience Education Institute in Las Vegas, April 2020

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A faculty speaker for the Neuroscience Education Institute (NEI) for many years, I have been invited to present several talks on adult ADHD and the complexity of medications. There are currently 28 different ADHD stimulant preparations (my last count). While there are only 4 different chemical compounds (methylphenidate, d-methylphenidate, amphetamine, d-amphetamine), the technologies delivering medication have exploded. With so many options, individual selection for each patient is possible. Good news for patients. Confusion for prescribers.

One of my presentations will focus on how to think through the medication options. How do you decide on the chemical compound? How do you select the delivery system? What medications interactions are concerning and what are not? Will side effects change if the deliver system is changed, even though the medication compound is the same?

Patients can help prescribers understand their experience with the medication by describing:

  1. What positive cognitive effect do you notice with the medicine? What time do you take it and when do you notice it’s cognitive effect wearing off.
  2. What side effects do you notice and when do they occur relative to taking the medication? Do the side effects occur 1-2 hours after taking medicine or do the side effects occur when it is wearing off? What side effects are subsiding and which ones are persisting?
  3. Can you afford the medicine? There are large price difference between medications. Without understanding the range of options (remember: 28 different stimulant preparations), you may not know there is a more affordable option.
  4. Can you swallow the medicine? There are several different forms: tablet, liquid, chewable, patch. All these forms have long-acting delivery systems so once daily dose is still possible.

The biggest challenge for prescribers now is the obstacle of insurance prior authorization and approval. This is an increasing frustration for patients and prescribers who work hard to find the right medication only to have insurance companies “decide” what medication is “appropriate” for you, the patient. Work with you prescriber to negotiate this obstacle course. Every time a patient changes insurance policy, these issues raise their head. Even if you have been stable on medication, the new insurance policy may deny future coverage. Oh, boy. Now that’s scary.

Believe it or not, I intended to describe my upcoming talks in April but got distracted by what I believe are important issues for patients to understand. It is the doctor in me to come back to the patient treatment and benefit.

Thank you for your valuable time. David W. Goodman, M.D.

Addendum: Because of COVID-19, this Neuroscience Education Institute conference was postponed and has been scheduled for Colorado Springs, Colorado November 5-8, 2020.

Latest generic Concerta may not work as well as others

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Recently, a new generic of Concerta, manufactured by Mallinckrodt, has come to market and patients may be getting this substitute for their prescription. I have  two patients who, having been on the previous generic manufactured by Watson, now say this new generic is clearly not working as well. One of my patients took the pills back to the local pharmacist who is reported to have said “I have several people who have come back complaining ‘It’s not working.’”.

Background: Brand Concerta pill contains a mechanism called “OROS” to deliver the methylphenidate over several hours at an increasing dose over time. The benefit of this specific delivery was established in sophisticated research. The Mallinckrodt generic does not and can not use this technology because of patents. This is not to say that an equivalently effective medication can’t be developed without OROS. It just appears that the Mallinckrodt formulation may not be equally effective to the Watson formulation in some patients.

I bring this to clinicians’ and peoples’ attention for two clinical reasons:

1. If you have been on other preparations of Concerta and now find the medication is not working well for you. Check the manufacturer with your pharmacist. He/she will want to know.

2. If you are prescribed Concerta for the first time, receive a generic, and you find it doesn’t work well, even at higher doses, check the manufacturer. Don’t rule out Concerta as an effective medication because of this experience. See if you can specifically request the Watson formulation from the pharmacist.

Hope this is helpful. I’ll be watchful and interested to see how this develops. Please leave comments for me. Thanks.