Text adapted from: "The adult patient with attention-deficit/ hyperactivity disorder," in Psychiatry in primary care by Umesh Jain (CAMH, 2019).
Principles of Medication Management
- Always ensure the patient is medically stable before medications are started because there are known risks that must be reviewed. Review the product monograph. All ADHD medications are known to have risk to the cardiovascular system—they all increase blood pressure and heart rate. It is not necessary to do a pre-treatment ECG. However, some patients are at a higher risk and should be referred for assessment before treatment if they have any of the following: history of unresolved structural cardiac problems, family history of known cardiac conduction problems, unexplained syncope.
- Start with a very low dose. Increase the dose and stop when the target symptoms are better (e.g. a typical target symptom may be the ability to sit down and pay bills and invoices every day, so the proper dose presents itself the moment this ability appears).
- Resist the urge to “see if a little more makes a difference.”
- Use long-acting medications over short-acting ones because they improve compliance and have better effects.
- For simplicity, try to use only one medication if multiple family members are on medication.
- Combining ADHD medications with antidepressants, mood stabilizers or other psychiatric medications is common. Review potential drug interactions.
- While long-acting medications are preferred, augmentation with short-acting psychostimulants could be used to account for variations in day-to-day attention loads. Non-stimulants (non-dopamine-based agonists) can be used with stimulants.
- Do pre- and post-reviews of medication efficacy and side-effects. You can use the medication form from the etoolkit that accompanies the Canadian ADHD Practice Guidelines.
- Monitor patients every two weeks until they are at their correct dose, and every three months thereafter.
Some patients only need medications in situations of high attentional load. However, the more common and ideal situation is that medication is used to promote functional behaviour patterns.
ADHD medications have a protective role in preventing the patient from self-medicating. Research has found that medication blocks reward pathways and prevents the binding of other energizing substances (Volkow, 2009).