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    Thursday, February 09, 2006

    Cause Me to Tremble: "I want to cause people's hands to tremble a little bit before they write that prescription," - Dr. Steven Nissen, cardiologist and member of an FDA safety commission on his and his co-members' decision to recommend the FDA require ADD drugs to carry warnings that they're heart-risky.

    My hand already trembles a bit when it's asked to write those types of prescriptions. So much so that I rarely write them. They're too often turned to as an easy fix for problems that run much deeper than chemistry. And not only do I have doubts about their cardiac safety, I've got my doubts about the neurological safety. What kind of an effect do they have on a developing mind? I don't think we know. I usually insist that my patients see a specialist in child behavior before they start something like this, but, alas, I've found that they all end up on the drugs anyways - even when there are strong indications that their school and behavior problems stem more from family dysfunction than a miswired brain. It's just the easy thing to do. Like prescribing an antibiotic for a cold.

    Even more alarming, in the past couple of months I've had several adults ask me if they need to be treated for ADD. These are middle-aged people who have managed to hold jobs, pay mortgages, and raise families, and suddenly they think they have ADD. The sudden influx of queries left me wondering if Oprah had done a segment. It is certainly a very heavily promoted disease. The promotion of which is partially financed by the drug makers.

    So, I share the concerns of the FDA's safety committee. But, the numbers don't appear to be on their side when it comes to death and disability from ADD drugs:

    The votes came after F.D.A. medical officers described reports of 25 sudden deaths among people taking stimulants — the deaths were mostly children — and a preliminary analysis of millions of health records that suggested stimulants might increase the risks of strokes and serious arrhythmias in children and adults. The reports of sudden deaths never exceeded one in a million for any stimulant drug, although the F.D.A. usually receives reports of only a fraction of drug problems.

    As a comparison, the estimated incidence of sudden cardiac death in young healthy people not on stimulants ranges from 1 in 750,000 to 1 in 200,000.

    There's no doubt that stimulants for behavior problems are overused, but we should also expect our FDA safety panel experts to rely less on anecdote and theory and more on the evidence when it comes to issuing warnings, should we not?

    posted by Sydney on 2/09/2006 11:00:00 PM 6 comments


    I can't say I entirely agree with the notion that most medical treatment of ADD is unnecessary. We have no problem loading people down with 3, 4, even 5 blood pressure medications. This physical/spiritual division that says it is ok to treat for physical disorders but not for mental is not proven in medicine. Many neurologists feel emotional and behavioral problems do have a physiological basis. If they do, they should be treated as such.

    I have seen ADD treatment make a big difference in people's lives. I agree we need to take care, but how is that different from any other medical treatment?

    The catch is that Ritalin et al are Schedule II meds. But doctors are not worthy of the profession if they hesitate to write a medication because it is scheduled. If the medication is indicated, based on the evidence, it should be written.

    ADD kids often come from dysfunctional households. If we had the ability to fix the dysfunction, that would be one thing, but usually, we don't. Given these practical limitions, if the medication helps, it should be given.

    Of course, it goes without saying that controlled medications should never be given if they are abused, but none of the stimulants used to treat ADD have the track record for abuse that opiates and benzodiazapines do.

    Could stimulants affect a child's brain? Certainly, but again, risks have to be balanced against benefits. No different from any other medication.

    By Anonymous mchebert, at 5:09 PM  

    Treating ADD is like treating chronic pain. You get the gut feeling that prescribing narcotics is a cop-out, but for the right patient it can make all of the difference in the world. The problem is picking the right patients. Unfortunately a good number of the wrong patients get medication they should not be getting.

    I treat only children and teenagers with solid criteria for ADD. Parents and teenagers must sign contracts similar to the popular pain contracts. I insist on follow-up appointments twice a year, and I only prescribe by written prescription. I do not treat adults who diagnose themselves in middle age after reading a magazine article.

    If you ask me, the problem is with the so called specialists in ADD who prescribe medication for everyone that walks into their office.

    By Anonymous Anonymous, at 11:22 PM  

    I do not care much for a member of a government commission who admits to wanting people "to tremble" at his decision.

    Dr. Nissen sounds like a person who wants to get some attention rather than serve the medical needs of the American consumer.

    By Anonymous Timothy Bolton, at 3:42 AM  

    puh-leeeze! Quit with the apologist stance on ADHD drugs already! Admit that -- at BEST -- diagnosing ADHD in most children is like spinning a roulette wheel. There is NO scientific justification for the VAST MAJORITY of these prescriptions being written! Just admit that you are GUESSING that children are afflicted with so-called ADHD. I would respect you a heckuva lot more if you did.

    Don't hide behind the science...when it's not there!

    By Blogger kevinmiller, at 5:55 PM  

    If ADD is a physical condition manifesting itself in childhood, it may well be genetic in origin. I wouldn't be at all surprised to learn that parents with ADD tend to have children with the same condition, and that assortative mating would make the disease more prevalent generation by generation unless the offspring die of their condition before they get old enough to reproduce, e.g. a child who tends to run out into the street without looking both ways.
    If Dr. Nissen wants prescribers to "tremble" when they do their jobs, I then suspect he is yet another bureaucrat on a power trip. (Maybe he overstated himself for publicity's sake.)
    If you really want to pick nits, there is no scientific justification for a great deal of generally accepted medical practice. Physicians regularly find themselves acting without sufficient knowledge, and refusing to act is an act in itself.

    By Blogger Tresho, at 9:45 AM  

    Thank you for not being overly judgemental in your entry. Other blogs have labeled parents in an extremely negative way, but not all behavior issues are "normal, acting out" or the result of a dysfunctional family life. Sometimes the dysfunctional family life is a result of the behavior issues. I wish there were a blood test to help doctors diagnose ADHD and disorders with similar symptoms, but there isn't one. That doesn't mean it isn't a problem/disorder/whatever you want to call it . . . I don't know if it's ADHD, Asperger Syndrome, or the host of other disorders with the same symptoms, but in my son's case, it is definitely real. BTW, it doesn't help when teachers and other parents blatantly ignore my request not to give him food items containing artificial flavors/colors . . . People need to be more supportive and less judgemental.

    By Anonymous Difficult Patient, at 10:57 PM  

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