Prescribing Prescribing Stimulants: Ethical Stimulants: Ethical IssuesIssuesMary Knutson, RNMary Knutson, RNAdvanced Concepts of PharmacologyAdvanced Concepts of PharmacologyFebruary, 2005February, 2005

Scope of the ProblemScope of the Problem

Ritalin use for children began in 1990’sRitalin use for children began in 1990’s Stimulant in the family of amphetaminesStimulant in the family of amphetamines Also known as Methylphenidate (MPH) Also known as Methylphenidate (MPH)

Use is rising dramatically for treatment of Use is rising dramatically for treatment of Attention Deficit Hyperactivity Disorder (ADHD)Attention Deficit Hyperactivity Disorder (ADHD)

American children consume 90% of all the American children consume 90% of all the Ritalin produced worldwideRitalin produced worldwide Estimated at 3-5 million children in U.S.Estimated at 3-5 million children in U.S.

Scientific ResearchScientific Research

““One of the most studied pediatric conditions”One of the most studied pediatric conditions” Many studies, but marginal resultsMany studies, but marginal results No proof of underlying neuropathyNo proof of underlying neuropathy No ADHD diagnostic testsNo ADHD diagnostic tests

““Hyperactive children are helped by Ritalin, at Hyperactive children are helped by Ritalin, at least in the short run.”least in the short run.” MPH increases dopamine and MPH increases dopamine and

norepinephrine levels norepinephrine levels Subdues children (exact action unknown)Subdues children (exact action unknown)

National Institute of National Institute of Mental Health, 1998Mental Health, 1998

““We don’t have an independent valid test for We don’t have an independent valid test for ADHD; further research is necessary to firmly ADHD; further research is necessary to firmly establish ADHD as a brain disorder.” establish ADHD as a brain disorder.”

““Existing studies come to conflicting Existing studies come to conflicting conclusions as to whether the use of conclusions as to whether the use of psychostimulants increases or decreases the psychostimulants increases or decreases the risk of abuse.” risk of abuse.”

““After years of clinical research and experience After years of clinical research and experience with ADHD, our knowledge about the cause or with ADHD, our knowledge about the cause or causes of ADHD remain largely speculative.”causes of ADHD remain largely speculative.”

Marketing of StimulantsMarketing of Stimulants

Millions of dollars have Millions of dollars have been spent by been spent by pharmaceutical pharmaceutical companies to promote companies to promote use of MPH, or similar use of MPH, or similar drugs drugs

Misleading StatementsMisleading Statements

““Compare the pills to eyeglasses. Explain the Compare the pills to eyeglasses. Explain the their medicine is simply a tool to help them their medicine is simply a tool to help them focus and pay attention.”focus and pay attention.”

““ADHD is like diabetes in that both are due to a ADHD is like diabetes in that both are due to a shortage of a chemical in the body.”shortage of a chemical in the body.”

““They are finding more and more evidence that They are finding more and more evidence that ADHD does not stem from the home ADHD does not stem from the home environment, but from biological causes.”environment, but from biological causes.”

Side Effects of RitalinSide Effects of Ritalin

Side Effects of RitalinSide Effects of Ritalin

NervousnessNervousness Sleep Sleep

disturbancesdisturbances DizzinessDizziness DrowsinessDrowsiness Upset stomachUpset stomach VomitingVomiting Loss of appetiteLoss of appetite HeadacheHeadache

Call physician immediately:Call physician immediately: Seizures or convulsionsSeizures or convulsions Blurred visionBlurred vision AgitationAgitation Skin rashSkin rash Heart palpitations or Heart palpitations or

irregular heartbeatirregular heartbeat Fever or sore throatFever or sore throat Unusual bleeding/bruisingUnusual bleeding/bruising

Drug InteractionsDrug Interactions

MAO Inhibitors (Nardil, Parnate)MAO Inhibitors (Nardil, Parnate) Anticoagulants (Coumadin)Anticoagulants (Coumadin) Meds for depression (Elavil, Tofranil, Meds for depression (Elavil, Tofranil,

Norpramin, IsmelinNorpramin, Ismelin Meds for epilepsy (Dilantin, Meds for epilepsy (Dilantin,

phenobarbitol, Mysoline)phenobarbitol, Mysoline) VitaminsVitamins

Nursing ImplicationsNursing Implications

Ask about history of: Ask about history of: Severe anxiety, tension, mental illnessSevere anxiety, tension, mental illness Glaucoma, seizures, HTNGlaucoma, seizures, HTN Motor tics/spasms, Tourette’s syndromeMotor tics/spasms, Tourette’s syndrome

Monitor growth, mood, aggressiveness, Monitor growth, mood, aggressiveness, mental status, ability to sleep, CV status mental status, ability to sleep, CV status

Check with Dr. if pregnancy is suspectedCheck with Dr. if pregnancy is suspected

Teaching NeededTeaching Needed

Decrease caffeine Decrease caffeine intakeintake

Take MPH at least 6 Take MPH at least 6 hours before bedtimehours before bedtime

Give gum, hard candy Give gum, hard candy or sips of water for dry or sips of water for dry mouthmouth

Avoid OTC medications Avoid OTC medications and alcohol because of and alcohol because of interaction riskinteraction risk

Taper off MPH Taper off MPH gradually over several gradually over several weeksweeks

Prescriber may Prescriber may suggest “drug suggest “drug holidays” to assess holidays” to assess progressprogress

Do not drive or operate Do not drive or operate machinery until effects machinery until effects of drug are determinedof drug are determined

Response of ParentsResponse of Parents

Parents rave about success of the Parents rave about success of the drugdrug ““My child was a monster without it.”My child was a monster without it.” ““Our family life was in turmoil until Our family life was in turmoil until

Ritalin.”Ritalin.” A pill is easier and cheaper than A pill is easier and cheaper than

family counseling and/or private family counseling and/or private tutorstutors

Response of PhysiciansResponse of Physicians

Physicians who do not believe in Physicians who do not believe in Ritalin are going “against the grain”Ritalin are going “against the grain” Issues of managed care may Issues of managed care may

interfere with alternative interfere with alternative treatmentstreatments

Parents insist on the Parents insist on the “performance enhancing pill”“performance enhancing pill”

Community IssuesCommunity Issues

Pressure from school districts to have children Pressure from school districts to have children evaluated for ADHDevaluated for ADHD Parents do not want their child labeled with Parents do not want their child labeled with

diseasedisease But, children on MPH are easier to controlBut, children on MPH are easier to control

Medical evaluation depends primarily on Medical evaluation depends primarily on reports by teachers and parents reports by teachers and parents

Response By OpponentsResponse By Opponents

Serious side effects, including growth Serious side effects, including growth retardation and “zombie-like” appearanceretardation and “zombie-like” appearance

Class action lawsuits by parents have cited Class action lawsuits by parents have cited fraud, collusion by manufacturersfraud, collusion by manufacturers

Forty years of lab animal research found MPH Forty years of lab animal research found MPH toxic, addictive, and dangeroustoxic, addictive, and dangerous

There are psychological and social therapies There are psychological and social therapies for children that don’t involve drugging with for children that don’t involve drugging with amphetaminesamphetamines

Possible TherapiesPossible Therapies

PsychotherapyPsychotherapy Behavioral therapyBehavioral therapy Behavior Behavior

modificationmodification CounselingCounseling Family therapyFamily therapy

Issues of Performance Issues of Performance Enhancing DrugsEnhancing Drugs

ADHD may merely be the upper end of ADHD may merely be the upper end of biological variability, not faulty genesbiological variability, not faulty genes

Pro-Ritalin advocates consider gene Pro-Ritalin advocates consider gene manipulation in the wombmanipulation in the womb

College students may use Ritalin to give them College students may use Ritalin to give them extra focusextra focus

Some parents chose to give MPH to well-Some parents chose to give MPH to well-behaved but underperforming childrenbehaved but underperforming children

Some “experts” suggest that the answer to our Some “experts” suggest that the answer to our country’s sociological problems is giving MPHcountry’s sociological problems is giving MPH

QuestionQuestion

If there was widespread cognitive enhancing If there was widespread cognitive enhancing drug use by adults as well as children, what drug use by adults as well as children, what impact would it have impact would it have On human society?On human society? On our society’s values?On our society’s values? On social justice and equality?On social justice and equality?

How would it impact education, employment, or How would it impact education, employment, or other opportunities for children and adults?other opportunities for children and adults?

QuotesQuotes

““Treatment can mean the difference between a Treatment can mean the difference between a kid ending up at Berkeley or ending up in kid ending up at Berkeley or ending up in prison. This is a disorder where we can really prison. This is a disorder where we can really make a difference.”make a difference.”

Dr. James Swanson, an ADHD expertDr. James Swanson, an ADHD expert

Pharmacology can participate, very modestly, in Pharmacology can participate, very modestly, in one of the major efforts of humanity, which is to go one of the major efforts of humanity, which is to go beyond the Platonic question, “Who are we”?beyond the Platonic question, “Who are we”?

Dr. C. Dr. C. Giurgea, French visionary (1972)Giurgea, French visionary (1972)

Ethical ConflictsEthical Conflicts

MPH has potential MPH has potential for addictionfor addiction

May produce toxic May produce toxic state involving state involving psychosispsychosis

Has powerful (and Has powerful (and possibly possibly irreversible) CNS irreversible) CNS effectseffects

Worldwide, Worldwide, governments restrict governments restrict availability of availability of amphetamines to amphetamines to adultsadultsBut nurses are to give But nurses are to give MPH to children and MPH to children and teens in schools and teens in schools and other settingsother settings

Problem SolvingProblem Solving

Nurses need decide how they stand on this Nurses need decide how they stand on this ethical issueethical issue

Be aware of developments and optionsBe aware of developments and options Educate familiesEducate families Children may do better with smaller class Children may do better with smaller class

sizes, or more art, music, and physical sizes, or more art, music, and physical education education

Our country needs to take the first step- Our country needs to take the first step- admit we have a drug problemadmit we have a drug problem

ReferencesReferences

Baldwin, S. (2000). Speed kills: Amphetamines, children and Baldwin, S. (2000). Speed kills: Amphetamines, children and nurses. nurses. Nursing Ethics, Nursing Ethics, 7(6), 535-537.7(6), 535-537.

Butcher, J. (2003). Cognitive enhancement raises ethical Butcher, J. (2003). Cognitive enhancement raises ethical concerns. concerns. LancetLancet, 362(9378), 132-133., 362(9378), 132-133.

Leo, J. (2000). Attention Deficit Disorder. Leo, J. (2000). Attention Deficit Disorder. SkepticSkeptic, (8)1, 63-69., (8)1, 63-69. Skidmore, L. (2003). Mosby’s drug guide for nurses (5Skidmore, L. (2003). Mosby’s drug guide for nurses (5 thth ed.). St. ed.). St.

Louis: Mosby. Louis: Mosby. Rose, S.P. (2002). ‘Smart drugs’: Do they work? Are they ethical? Rose, S.P. (2002). ‘Smart drugs’: Do they work? Are they ethical?

Will they be legal? Will they be legal? Nature Reviews: Neuroscience,Nature Reviews: Neuroscience, 3, 976-979. 3, 976-979. National Institute of Health. (2005). Methylphenidate, Retreived National Institute of Health. (2005). Methylphenidate, Retreived

February 12, 2005 from February 12, 2005 from http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682188.http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682188.htmlhtml