Problems with ADD: Stimulants1

Stimulants for ADD 1: The Titration Solution: it works if you work it.

“Titration” from the Wikipedia definition it is complicated. For us, for everyday usage, it's simple: adjust the dose correctly. Remember the last of my 3 R's? Right dosage is the most commonly missed activity, process, in 98% of second opinions, people who consult with our practice who just aren't “on the right meds.” Titration of dosage is a very big problem nationally.

Usually the meds are not the problem, dosage is.

Dosage issues sit right next to drug interaction issues as the most frequent problems across the country. The three main essentials in real estate: location, location, location. The three main essential for proper stimulant dosing are titration, titration, titration. Almost no one is asking this question, and our team often sees this oversight in the first 5-10 minutes of an initial interview. Why do we see it so easily? Because we all ask the same question repeatedly everyday with every person we see on stimulants.

“When did you take it, how long did it last.” As soon as they tell us they are taking stimulants we ask that same boring question every time. BTW – I will ask that same boring question everyday for the rest of my life. Why?

It is never boring to me. It's a key to the kingdom of self awareness. [Everyone I see becomes self aware one way or another. Some politicians would have a problem with me because I encourage self reflection, but then they likely won't be seeing me in the first place.]

In a sea of challenging psychiatric variables we ask this question at every med check, and train every single patient to think this way as well. Every new medical person that works with our team uses that same question with every patient, every visit because that answer helps us adjust the stimulant med. If patients are thinking about this view of the dosage, the adjustment of the dosage, they are on the team, not in a passive unpleasant demeaning role. In new medicine vertical management is very old news.

This titration question is only tongue-in-cheek boring. It's really fun to get it right and might as well help everyone to have an interesting time with the process.

A basic point: All stimulants last less than 24 hrs. If they last too long they cause side effects, if they last too short, the PM isn't covered and the family time is a wreck.

Another fun aspect of this process is our acronym: DOE. Nope, I don't mean female deer. I ask about Duration of Action and call it DOE for my chart. DOE is as close as we can get to metabolic science with stimulants. If we dial the Adderall in so that it lasts in the XR form from 7 AM – 5-6PM that DOE is… do the math: 5 hr in the AM until noon, and 5-6 hr in the PM = 10-11 hr duration [almost perfect with an objective of 10-12 hr.]. Focalin XR should run 10 -12 hr, Ritalin LA 8 hr, Metadate CD 8 hr. Concerta often 10 – 12 hr.

Before we close this note: Measuring dosage for anyone by weight is paleolithic. Weight titration is old news, an outdated practice. Weight is not an issue, rate of metabolism is. Next post on metabolism and burn rate: the Therapeutic Box.

Stay tuned.