Dr. John Kruse: ADHD Medication Guide and Considerations
Ritalin, or methylphenidate, was one of the first medications developed for ADHD. Today, there are many slow-release versions and even a skin patch. While often grouped with stimulants, Dr. Kruse doesn't consider Ritalin a full stimulant.
Amphetamine-based products like Adderall and Vyvanse are stronger dopamine and norepinephrine reuptake blockers. They prevent these neurotransmitters from being reabsorbed, making more available longer. Amphetamines also force a bigger release from the vesicles when they're released at synapses.
Methylphenidate (Ritalin), by comparison, is a weaker vesicular manipulator. It's primarily a norepinephrine and dopamine reuptake inhibitor, similar to Wellbutrin. When looking at effectiveness data, amphetamine products are significantly more effective at reducing ADHD symptoms than methylphenidate and other medications.
The side effect that concerns Dr. Kruse most is amphetamine-induced psychosis. While uncommon (about 1 in 500 people), it's particularly concerning because unlike alcohol-induced delirium that resolves when you sober up, amphetamine-induced psychosis can continue for days, weeks, or months after stopping the medication. About 20% of those affected remain in a permanent psychotic state 20 years later.
In San Francisco, Dr. Kruse saw higher rates of amphetamine-induced psychosis (about 1 in 100) particularly among HIV-positive men and young white males who had previous psychotic episodes but concealed this history to get prescribed stimulants again.
When considering cardiovascular effects, most stimulant medications increase heart rate and blood pressure slightly. While there are extremely rare cases of sudden cardiac death with stimulant use (usually in people with undiagnosed heart conditions), the absolute risk remains very low.
For patients seeking ADHD treatment, Dr. Kruse typically explains that Adderall or Vyvanse will likely be most effective but also carries greater risks. He then listens to the patient's preferences and concerns before making recommendations. He absolutely avoids prescribing amphetamine-based stimulants to patients with personal or family history of psychosis.
Regarding cannabis, high-THC products may increase psychosis risk, while CBD might have antipsychotic effects. Nicotine can improve executive functions and focus while both arousing people and reducing anxiety simultaneously - an unusual combination.
Caffeine, while widely used, is a "lousy stimulant" compared to prescription medications when used at equivalent doses. It causes more anxiety, jitteriness, and cardiac side effects. The caffeine content in commercial products can vary significantly - a University of Florida study found a threefold difference in caffeine content in the same Starbucks drink purchased over three weeks.
Guanfacine is an alpha-2 agonist originally developed as a blood pressure medication. Unlike stimulants that work immediately, guanfacine takes weeks to show effects by strengthening synaptic connections in prefrontal circuitry. It's often sedating, so most people take it at night.
Modafinil (Provigil) and Armodafinil (Nuvigil) work on the orexin system - the natural waking system that promotes alertness without overstimulation. They help with executive functions of attention and concentration but generally fewer people find them as helpful as amphetamines.
For amphetamine medications, immediate-release versions work quickly and provide flexibility but can cause withdrawal symptoms when wearing off. Extended-release formulations like Vyvanse provide a smoother experience. Vyvanse was designed to be less attractive for abuse, as it requires an enzyme in red blood cells to convert it to active dextroamphetamine.