Some more questions on Ritalin

Sci got this comment to her Ritalin post the other day:

It sounds like you are suggesting that cocaine taken in the same form as Ritalin — as low-dose, slow release pills — would produce the same effects as the ADHD medication does. But, clearly, the FDA has seen fit to outlaw cocaine and place its seal of approval on doctor-prescribed Ritalin. Not that I think the FDA is infallible or anything, but did they really make the mistake of controlling one substance and permitting another that are essentially equivalents? Benzoylmethylecgonine and methylphenidate are clearly not the same chemical compounds, but if they act in synonymous ways on the brain, shouldn’t they be treated equally under the law?
And what about the all-touted maxim that patients who have not been prescribed Ritalin should not take it but those who have been shouldn’t miss a dose? Is there really such a neurological difference between those with ADHD and those who haven’t been diagnosed with it, or is it just a matter of how much rapport you establish with your psychiatrist? (I am not trying to patronize; I legitimately want to know!)
Similarly, are their patients for whom controlled doses of cocaine would yield medical benefits equal to or exceeding those of Ritalin? Or are there manifold side effects that discourage the use of cocaine as an ADHD/ concentration medication in spite of its similarities to Ritalin?
Personally, I’m skeptical of many of the diagnoses of ADHD that I see and of the politician-worthy campaigns that I hear that deny the efficacy of Ritalin for patients who have not been diagnosed with ADHD. It seems to me that for a disorder whose diagnosis is so imprecise and objective, it’s a convenient coincidence that most takers of Ritalin who have been diagnosed with ADHD (regardless of whether or not the diagnosis is accurate) show marked improvement in concentration…

As you can see, it’s long and has a lot of questions. And some of them are very good ones. But I knew that answering it within the comment thread was going to be long, and also I needed to use lots of links. So congrats, cerebration! You’re getting your very own post!!!
Here we go.

It sounds like you are suggesting that cocaine taken in the same form as Ritalin — as low-dose, slow release pills — would produce the same effects as the ADHD medication does. But, clearly, the FDA has seen fit to outlaw cocaine and place its seal of approval on doctor-prescribed Ritalin. Not that I think the FDA is infallible or anything, but did they really make the mistake of controlling one substance and permitting another that are essentially equivalents? Benzoylmethylecgonine and methylphenidate are clearly not the same chemical compounds, but if they act in synonymous ways on the brain, shouldn’t they be treated equally under the law?

Similarly, are their patients for whom controlled doses of cocaine would yield medical benefits equal to or exceeding those of Ritalin? Or are there manifold side effects that discourage the use of cocaine as an ADHD/ concentration medication in spite of its similarities to Ritalin?

Ok, first off, I don’t want to sound like I’m suggesting that cocaine if taken orally in and in the correct amounts would be therapeutic. This is partially because cocaine, as well know is addictive and illegal, but mostly I don’t want to suggest that because it’s wrong and probably wouldn’t work well.
Cocaine is in fact still useful medically, it’s a topical anesthetic (painkiller) and vasoconstrictor (tightens blood vessels to restrict flow and raise pressure) and works great for things like eye surgery, though it’s not used like that very often. Here’s the issue: cocaine has a REALLY short active period. It would be incredibly difficult to make a pill, even a REALLY slow release form, that would release cocaine in slow enough, steady enough amounts to produce focusing effects. Honestly, we’re far better off just using drugs with longer half lives, like Ritalin.
As far as the potential legality or illegality of this issue: Sci doesn’t like politics.
And I would like to point out that Ritalin and cocaine are not really equivalent, though they have a very similar mechanism of action (blocking the dopamine and norepinephrine transporters). The longer half-life is a HUGE difference, for one thing. For another, cocaine hits serotonin pretty heavily, while Ritalin does not. Additionally, some animals studies have shown that therapeutic doses of Ritalin preferentially affect norepinephrine in the prefrontal cortex (see Berridge, 2006), as opposed to dopamine in the mesolimbic dopamine system, which would create more of a high effect. It’s hard to compare this with cocaine, as low doses of cocaine haven’t really been looked at for this, but the activation of norepi over dopamine implies that the behavioral effects of low-dose cocaine and low-dose Ritalin will be different.
For those who need serotonin activity along with dopamine and norepinephrine, there’s Adderall, which is amphetamine, and has those actions (though the mechanism is different). I imagine some people with ADHD might be helped by low doses of cocaine, but again, I think it would be very hard to get the doses controlled enough, and the short action is always an issue.

And what about the all-touted maxim that patients who have not been prescribed Ritalin should not take it but those who have been shouldn’t miss a dose? Is there really such a neurological difference between those with ADHD and those who haven’t been diagnosed with it, or is it just a matter of how much rapport you establish with your psychiatrist? (I am not trying to patronize; I legitimately want to know!)

The issue here is control over the problems that Ritalin can have. Ritalin IS a psychostimulant similar to the cocaine class of drugs. It WILL have effects in people who do not have ADHD. When taken improperly, it can give you a high, which can make you want to take it again. So rules are put in place trying to ensure that those who might be vulnerable to the addictive properties do not take it.
For those with ADHD, they often really don’t LIKE their meds (why is still a question people are trying to answer, or at least, Sci doesn’t know why). So they will skip unless you tell them not to miss a dose. Additionally, people with severe ADHD often have quality of life issues (low grades, difficult socializing, etc) that Ritalin can help with, and not taking your dose will obviously not give you the benefits.
There IS a neurological difference between people with severe ADHD and those without (studies point to changes in the dopamine system, particularly in reward-related areas, showing these kids may have decreased ability to wait for a long-term reward rather than a short one, though other studies have looked at changes in brain development in children as well, probably a combination of several factors), though there are cases of over- and under-diagnosis of the disorder. It’s a really subjective diagnosis, and for those seeking cognitive enhancement or just drugs, psychiatrists are human and can be fooled. Whether or not it’s good for you to attempt to fool your psychiatrist or diagnose yourself, well that’s not something Sci wants to talk about.
And yes, people who take Ritalin DO show improvements in concentration. It works, and it works well, for everyone. The question is whether those improvements should be confined to those who are seriously deficient in the ability to concentrate in the first place, or whether this is an opportunity and should be open to everyone. Sci doesn’t feel like dealing with that one right now. Have at in the comments if you like.
So that’s what I’ve got for you, cerebration! I hope it helped a little!

9 Responses

  1. I was diagnosed with ADHD as a teenager. It should have been obvious all along, but I got good grades and was well behaved (but overactive🙂. I HATED Ritalin, and regularly missed doses. It made me dopey, and I lost the creative edge that I had over my classmates. I could concentrate, but I was boring as hell.
    I took Ritalin and McLobemide (sp?) which helped with my main problem – impulse control. The biggest problem I had and still have with ADHD is that I couldn’t (and still struggle with) control what I said. You want socially awkward? Try saying everything that comes into your head, even if you know it’s stupid.
    The concentration boost was minor, and to be honest, I can focus better than anyone else I know when I’m solving an interesting problem. But the drugs helped me restrain my impulses long enough for behavioural modification to have an effect. I am now happily drug free. Unless you count the ones I take voluntarily…

  2. I also was diagnosed ADD (before the hyper was added I guess) and prescribed Ritalin. I also hated it and tried not to take it due to the loss of creativity and increase with serious boredom. I was able to concentrate better, but eventually was allowed by my doctors to stop taking it as my increased boredom led to increased class disruptions (because I could really focus on better ways to goof off… I think this speaks to my teachers at the time more than anything else).
    In any event, I always wondered – does Ritalin have any lasting effects similar to those of SSRIs? I realize they wouldn’t need the build up as much as SSRIs but is there any evidence that this is another reason that those on Ritalin shouldn’t miss a does?

  3. As a former elementary school principal, I am quite aware that attention difficulties are just the tip of the iceberg. ADHD children can’t filter out distractions, finish tasks on-time, use their memory optimally, etc. A pill doesn’t teach these skills.
    My wife and I opted to use cognitive training for our son, Alex. We used Play Attention (www.playattention.com) and ADHD Nanny (www.adhdnanny.com). We’ve been very successful with these approaches. We also changed our parenting skills with great success.
    It’s just important to know that medicine teaches nothing. Parents and teachers must actively participate to help change a child’s life.

  4. I remember decades ago I heard some “street wisdom” that heroin addicts couldn’t get any (significant) effect from amphetamines but cocaine had pretty much the same effect it has on everyone. Frankly, the idea of using a drug that “fakes” a neurotransmitter to the point of being taken up into the neurons where it can interfere with cellular internals scares the cr*p out of me. I’m glad nobody knew that was what it does back when I used it. (heh!)
    BTW Sci, the paper you cited is behind a paywall, but Google found me what looks like a good version (PDF) at http://ntp.neuroscience.wisc.edu/faculty/fac-art/berridge60p1111.pdf.
    I wonder how hard it would be to develop technology to slow-release cocaine (or something like Ritalin) in only the PFC (or whatever part of the brain was appropriate). That might help target the problems to be solved, while reducing side-effects. (Some of them, anyway.) An interesting technical challenge.
    One approach might be to run very fine tubes down the appropriate arteries, with an implanted dosage delivery system, and a larger tube for refills reaching to the surface. The surface interface might also have facilities to recharge the battery, as well as some fiber optics for programming. (Or would the dosages needed to get past the BBB be so high they’d fill the whole bloodstream. Perhaps the release could be somewhere behind the BBB?)
    It sounds a little futuristic, but something like that might have enough value to experimenters to pay for itself in a non-human-ready version until one suitable for humans could be developed. (I’d guess no more than three years between the first primitive version that could be used on rats (or cats or monkeys) and something the FDA (or whoever) could be expected to approve for humans.

  5. #3 Memory is my main weakness. I have trouble with some maths, because my working memory is deficient relative to the rest of my cognitive skills. It’s really frustrating. Memory affects us in ways we don’t expect – visualisation is a notable one for me.
    Did you find anything to help your child with this? I might still be able to use it!

  6. Steve –
    There are some attention deficit links on the sidebar of my blog, including forums that have sections for adults with attention deficit problems. They are great resources for ideas that have worked for other people dealing with very similar problems.
    As far as memory – this is a tough one. It may sound silly – or at least feel silly, but finding a computer based memory game (you remember the game of matching the cards) would be a big help. It is one of the better exercises for developing better memory and there are free versions out there (or you can email me duwayne.brayton at gmail.com – though I may take a few days to respond). There are actually some really fancy programs that wouldn’t make you feel as silly, but I am not keen on spending the money and they basically do the same thing as the ones for kids. Mahjong is also really handy for exercising the memory, especially in terms of visualization – and again, you can find free versions.
    It helps to think of this like you would any other exercise regimen – you don’t start out weightlifting, by piling on the weight. Don’t feel weird about starting on easy settings and working your way up. Don’t move up until you can get through a set with the minimum turns possible. Allow yourself the validation of success and it is far more likely you will keep with it and actually do some good.
    And most importantly, keep in mind that as an adult, your mind isn’t nearly as elastic as the mind of middle children and pre-teens. You are trying to modify your cognitive function in a way and at a time of life that is exceedingly difficult. This is not something that will happen over night and far more than it is with a child, this really is a serious case of use it or lose it. If you don’t work hard to challenge your memory as it improves and gets to a place you are comfortable with, you will regress.
    And assuming you’re the Steve from #1, if one of the drugs you might happen to take voluntarily is cannabis – stop. Seriously, cannabis is not your friend – at least in regards to memory (I have a great deal of personal experience that suggests that cannabis was very much my friend in other regards – but memory – not so much).

  7. Hi DuWayne,
    Thanks for your answer. I’ll look into the memory tools you mentioned, particularly Mahjong. I play chess seriously, and have always wanted a reason to try it.
    As far as the drugs go, yes I am the one from the first post, but I only take cannabis very occassionally – a couple of puffs at a party every couple of years. Mostly, it’s caffeine, alcohol, nicotine and that kind of thing.
    Thanks once again for your advice – I did an MSc in perceptual psych, but I do remember some of my developmental stuff from 1999, so I know enough to believe what you say about elasticity.
    The main thing I have driving me is the knowledge that some things (as you say, memory is tricky) can change – I learned how to control what I said, something that shouldn’t be underestimated for difficulty or severity.
    Thanks,
    Steve

  8. Oh hell, trust me, I am well aware of the difficulties with impulse control – though mine tend to be more behavioral than verbal. I went through years of impulsive sexual activity, drug use, money management – all sorts of things. The worse thing about it, was making decisions without any real thought for the consequences. I mean I had ingrained habits, such as using condoms – not using particular drugs – not using needle drugs (without a great deal of consideration and controls – I did shoot heroin and coke, both just once). But the only controls were those that were completely automatic.
    Of course I am dealing with more than just attention deficit issues, so there are some different extremes at play.
    Memory is a very fascinating one for me lately. Being on Ritalin has made a massive difference, but it is interesting to see the sorts of things that it doesn’t impact. At the same time, I have been finding that the intensity of studying required for school is making differences that transcend being on Ritalin – they continue to function for me, whether I am on full doses or just taking a very low dose because I’m not in school.
    Mainly I just take it because it helps with my impulse control and ability to sit still. When I first started classes, I had serious problems with that – I actually had to get up and leave a few times, because I just couldn’t focus and would have quickly become a distraction.

  9. I’m wondering whether fish from rivers in Chicago, Dallas, Orlando, Phoenix, and Philadelphia no longer have issues with impulse control?
    http://blog.healia.com/00340/prescription-drugs-found-fish-across-us
    (Living and working and teaching within the Anacostia [read: Chesapeake Bay] watershed, this comment is not entirely tongue-in-cheek!)

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