ADHD: Strategies for Developing a Further Dialogue - Episode 7
A discussion on the altered dosing of medicine for pediatrics with ADHD (attention deficit hyperactivity disorder) during the COVID-19 pandemic.
Tim Wilens, MD: One of the questions that does come up, and Harlan you may want to lead this one, is are people stopping their medication? Do you advise people to stop their medication because they’re not in school? Do they need their medication? Are you increasing their medication? What’s medicine management during this period?
Harlan R. Gephart, MD:It’s all secondhand because I don’t see patients anymore, but there’s a lot of variability out there. For years I’ve always preached don’t stop taking the medication on the weekends for example, or during the summer, because a lot of people think medications are just for school. That’s something we’ve been trying to get people to do for years. Now, what I hear is there’s a lot of difficulty….
Tim Wilens, MD: Difficulty getting the medication?
Harlan R. Gephart, MD: No, difficulty being consistent with taking the medication. There’s a lot of inconsistency. As you know, there was research that you did years ago that if you didn’t take medication on Saturday and Sunday, it took you to about Tuesday to get back up to blood level again where you were working OK. Monday is usually a very important day in school, so you weren’t adequately medicated Monday morning when the teacher was presenting a new math process or something. That’s just accentuated that. I think medications are not being used.
Tim Wilens, MD: The other component of that Harlan, about the medication, is that, I would agree in our area, variable. More people are using more of them, and I think one of the byproducts, because parents are seeing their kids and realizing how bad the deficits are, plus these kids are already being super-challenged by being on Zoom all day. Our adults without ADHD [attention-deficit/hyperactivity disorder] are challenged. Can you imagine kids with ADHD?
To top that off, we just recently had a symposium about drug shortages at the American Academy of Child & Adolescent Psychiatry meetings in 2020. One of things we were talking about is that there’s just-in-time invoicing, where people don’t have a lot of surplus of medicines available in the distribution lines right now. This is all being strained because of COVID-19 [coronavirus disease 2019], and pharmacies are being challenged with increased orders in some areas that they haven’t seen previously. So we’re dealing with quotas and distribution problems.
People are having more problems finding, in particular, stimulants…and the specific ones they may want, and they may have to go to 3 or 4 different pharmacies with every different prescription they get to find it, and that just makes it harder. That’s just another barrier to filling prescriptions. It seems like Ann, you’re seeing the same things in Las Vegas?
Ann Childress, MD: Yes, and we have the highest unemployment rate in the nation right now. I think we’re down to 12.5%, so a lot of people have lost their health insurance. The casinos really did a good job and they tried to carry them through most of the summer, but a lot of people have been laid off. That means they can’t afford the brand name medications that they were getting. I’m having to do things that I don’t like to do, and that’s switch people to immediate-release [formulation] that they can afford. That’s a problem. Probably the only good thing for COVID-19 with me is I bit the bullet and got up and running on e-prescribing. But then, if they have to go to 3 or 4 different pharmacies to get it, and pharmacies won’t tell you if they have it or not because they don’t want you to break in and steal it. Then I have to send it to this pharmacy, and then go back and send it to another pharmacy, and I don’t know if everybody else has had that problem. It takes up a lot of time just to try to get somebody their medicine.
Mark Wolraich, MD: I haven’t been as strict about taking it 7 days a week, and it’s from the perspective of knowing that on average, the kids stay on it about 3 years despite what you recommend. And you have to have buy-in from the parents and the children for the medications, and I’ll go with what they see as what’s working for them. There are kids who have fewer demands on the weekend, and the parents don’t like their appetite suppression, or they don’t like some things about them. So, I’ll go along with whatever I can get them to buy into to be on the medications.
Harlan R. Gephart, MD: One of the fallouts from COVID-19 that we might want to talk about, Tim, is increase in adolescent suicide attempts.
Tim Wilens, MD: Yes. You’re right that there are increases in drug use disorders, there are increases in depression, remembering that 20% to 30% of kids with ADHD have depression, so that’s a major risk in ADHD. What you said Harlan is correct, that we’re already stepping into an endemic of increased suicides in kids, and this is going to be amplified by COVID-19. Have we seen that yet? No, but it’s too myopic, it’s occurring, but your point is well taken.
-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.
-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.
-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.
-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.
-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.