A Fix for Inconsistent, Ineffective ADHD Medication Use? New Collaboration Between Non-Prescribing and Prescribing Clinicians
Many patients with ADHD don’t adhere to their prescribed treatment regimens — usually because medications are ineffective, or side effects are intolerable. In a presentation at the 2018 annual meeting of APSARD, Thomas Brown, Ph.D., outlined one solution: greater provider collaboration to better educate patients and fine-tune medication based on detailed observations.
March 14, 2018
Most patients who are prescribed ADHD medication don’t fully understand how it works or what side effects might occur, said Thomas Brown, Ph.D., in a talk at the 2018 Annual Meeting of The American Professional Society of ADHD and Related Disorders (APSARD). The result? Lower than expected medication adherence and suboptimal treatment results. The solution? More collaboration between prescribing and non-prescribing ADHD clinicians — as well as more in-depth, realistic education on how ADHD medication works in the brain, he said.
Studies show that ADHD medication adherence is low for both children and adults. “A lot of people get prescriptions for medication for ADHD and don’t take them on any consistent basis,” Brown said. “Often they don’t get them refilled, or they don’t follow through” on the prescribed dosage schedule. One 2012 study on 46,000 children, for instance, found that patients who were prescribed short-acting ADHD medications took them an average of just 79 days in a calendar year.1 Another, focusing on 24,000 adults, found that short-acting medications had an adherence rate of just .52 — meaning they were taken little more than half the time.2
Research also shows that medication is effective for approximately 8 out of 10 people with ADHD, when it is dosed correctly and used as prescribed, Brown said. And since the dangers of untreated ADHD generally outweigh the risks of treatment, the question for clinicians to consider when grappling with low adherence rates is clear: “What are some of the things that are getting in the way” of patients taking their medication regularly?
ADHD Medications and Dosages Are Misunderstood
Several factors contribute to low adherence, Brown said, but incomplete or incorrect knowledge about the prescribed medication is a frequent, overarching cause. “In many cases, the patient (and the patient’s family) have an insufficient or totally unrealistic notion of how this medicine works and how it might help them,” he said. As a result, they’re often unprepared for unpleasant side effects, unable to tell when the medication kicks in, and/or uncertain when positive effects have worn away.
Many patients view ADHD as a simple “chemical imbalance in the brain,” Brown said, and may be under the impression that ADHD medication will be a quick fix. “But it’s much more complicated than that,” he said — and in order to improve long-term adherence rates, patients should be better educated on exactly how medication works, and what the most likely outcomes of its use will be.
ADHD medication works in the human brain by interacting with crucial neurotransmitters called dopamine and norepinephrine. Everyone has these neurotransmitters, but in the brains of people with ADHD, the neurons responsible for sending and receiving messages are deficient — either releasing neurotransmitters too slowly, or failing to clear out blockages that result in poor communication. “As a result, a lot of ‘control’ messages do not get connected,” Brown said.
ADHD medications can correct this problem by allowing neurotransmitters to sit on neurons for a fraction of a second longer, improving their ability to communicate. But complex neural networks and varying baseline scenarios make it impossible to tell from the outset which medication, dosage, or treatment schedule will work best for each individual. “There’s a lot that impacts how a medicine does or doesn’t work for a particular person,” Brown said — and age, weight, and symptom severity don’t seem to matter when it comes to determining an ideal dose.
What does matter, he said, is each patient’s sensitivity, speed of absorption, and any other drugs or chemicals interacting with their brain alongside the ADHD medication. If someone is a given a dose that’s too high for their particular brain chemistry, it will flood the neural networks, creating unpleasant side effects or a “zombie-like” state. Too small a dose, on the other hand, will provide insufficient symptom control or make it difficult to tell when a medication has kicked in. Either of these outcomes increases the likelihood that a patient will abandon a medication regimen, Brown said.
Benefits and Side Effects Are Not Tracked Closely Enough
In order for ADHD medication to work effectively with minimal side effects, Brown said, patients must understand typical medication outcomes, monitor their experience closely, and prepare to make regular adjustments as a result. But many prescribers — particularly primary care physicians, who may be limited to 15-minute office visits — don’t have the time to properly fine-tune medication for each patient’s unique needs.
Others simply don’t have the training. In some cases, Brown said, doctors report receiving as little as 20 minutes of coursework on ADHD medication during medical school — making it difficult for them to convey to patients what they should expect or what an effective dose should feel like.
Non-Prescribing Clinicians Must Play a Bigger Part in Medication Education & Monitoring
To bridge this education and expectations gap, Brown (a clinical psychologist) suggests that “adequately prepared” non-prescribing clinicians — that is, those who have been specifically trained on ADHD medication use — assist patients and prescribers by providing patients with in-depth information on how ADHD medication works in the brain, and what side effects or symptom management patients can expect. These non-prescribers — including psychologists, social workers, and therapists — often spend significantly more time with patients than prescribing doctors, he said, and are thus better prepared to give a more complete, accurate view of medication’s possible benefits and drawbacks.
“It’s really important, when we talk to our patients about it, not to oversell the medication,” he said. “Sometimes it really helps — and sometimes it makes side effect troubles, and sometimes it doesn’t do a damn thing.” Encouraging realistic expectations — as well as helping patients identify how long their medication is lasting, alerting them to the possibility of “rebound,” or collaborating on specific questions for the prescribing doctor — is a key way non-prescribers can improve their patients’ long-term treatment outcomes, he said.
Non-prescribers can write notes to prescribing doctors if necessary, he said, but their main role should be to “collaborate with prescribers in ways that will not infringe on them,” he said. “The person who is responsible for a prescription is the person who signs the prescription — none of the rest of us. But we can work together with prescribers and collaborate in ways” that will benefit the patient and improve their medication adherence.
By focusing their efforts on education and patient support, he concluded, “I think [non-prescribers] can make an important contribution in helping to educate patients about their medications.”
Brown’s presentation, entitled “Collaboration Between Prescribers and Other Clinicians In Managing ADHD,” was part of a symposium focusing on improving treatment outcomes for adults with ADHD. It took place on January 13, 2018, in Washington, D.C. Brown expands on these ideas further in his recent book, Outside the Box: Rethinking ADD/ADHD in Children and Adults — A Practical Guide.
1 Palli, Swetha R., et al. “Persistence of Stimulants in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder.” Journal of Child and Adolescent Psychopharmacology, vol. 22, no. 2, 2012, pp. 139–148., doi:10.1089/cap.2011.0028.
2 Christensen, Laura, et al. “Pharmacological Treatment Patterns Among Patients with Attention-Deficit/Hyperactivity Disorder: Retrospective Claims-Based Analysis of a Managed Care Population.” Current Medical Research and Opinion, vol. 26, no. 4, 23 Apr. 2010, pp. 977–989., doi:10.1185/03007991003673617.