Expert: First-Line ADHD Treatment Access for Adults, Children Remains Challenging

Pharmacy Times interviewed Michael Feld, MD, a specialist in neurology, psychiatry, and child and adolescent psychiatry on ADHD treatment in adults. Feld describes the obstacles that come with adults seeking out a diagnosis or finding the right medication to treat ADHD. Despite difficulties in receiving diagnoses, receiving medications, and facing stigma, Feld notes that adults with ADHD are more cognizant in seeking a diagnosis and medication for their children who present symptoms of ADHD.

Pharmacy Times: What is the Outcomes Insights survey assessing current ADHD treatment challenges, and what the results of the survey show?

Michael Feld: So, a survey was done with a bunch of health care professionals throughout the country—different types of health care professionals—and the intent of this survey was to find out issues with adult, adolescent, and childhood ADHD. But how these providers looked at areas with diagnosis, areas with treatment, in addition to that, [they] looked at what they thought about the impact of ADHD [was] on people's lives, whether adults or younger patients. In addition—which always gets addressed—is what are the positives and shortcomings of treatment right now in what is available to treat ADHD. And so, I think that was what the intent was, to try and get a feel from all these health care professionals throughout the country.

Pharmacy Times: What are some of the challenges that adult patients have faced when receiving a diagnosis as adults?

Feld: There's a lot of challenges…a lot of the adults that I see in my practice, maybe were told they had ADHD or treated for it as a kid, so a lot of them may have had not the most positive experiences in their treatment, particularly when they were on stimulants, 15, 20, 30 years ago, some of the stimulants back then might have had issues with tolerability and other reasons that would make [patients] not want to take these meds and then hold on to that feeling as an adult that they had a bad experience with meds. We now know—hopefully, the point of this interview is to show—the pharmaceutical industry is doing a great job in developing new biotechnology and new delivery systems so that we have the same chemicals, but it's a different world of being on meds right now.

The other issue is there's a lot of stigma associated with ADHD, and a lot of stigma associated with adult ADHD—probably more than kids ADHD—maybe because it wasn't thought that adults had ADHD for so many years. But I think a lot of adults deal with almost like an embarrassment or [there is no] comfort level when sharing this or being open to treatment.In addition to that, I think a lot of adults face concerns with, “What will happen if I get treated?” and the concerns with[if] they will respond, will there be [adverse effects (AEs)], will they be put on these meds for life without a great understanding of it.

"The other issue is there's a lot of stigma associated with ADHD, and a lot of stigma associated with adult ADHD—probably more than kids ADHD—maybe because it wasn't thought that adults had ADHD for so many years." Image Credit: © ClareM - stock.adobe.com

And then finally, a lot of adults are diagnosed with what we call comorbidities first. ADHD is what we call a highly comorbid disorder. When you have one mental health disorder, there's a higher risk of other ones, so, the average adult that truly is diagnosed properly with ADHD, 50% of these adults have a diagnosable anxiety disorder. And if you include unipolar and bipolar mood disorders, you're looking close to 50%, too. So, a lot of adults actually come to getting diagnosed with ADHD after they've been diagnosed with something else, and that not only confuses the diagnosis and the treatment of ADHD, but puts a different burden—especially if they've already been on other meds for other disorders.

Pharmacy Times: Some providers can have reluctancy with treating adults with ADHD for the ADHD rather than for their comorbid disorders. What is your perspective on this?

Feld: So, I'm a child and adolescent psychiatrist, but that means we're trained as an adult psychiatrist first, so I treat all ages. I think when you look at more general psychiatrists and people that haven't been as active in treating kids and adolescents with ADHD, you see that kind of hesitancy. There's a better comfort level, not only in the diagnosis but even in how to diagnose and how to look for it, there's a greater comfort level in treating the comorbidities. There's also concerns obviously, with the use of stimulants which we consider first-line treatment. There's not always a great awareness with providers about the newer generations of stimulants and the overall safety concerns with [them] and there's a lot of adults who also have a high comorbidity of addiction and substance abuse. So, there's often concerns about using stimulants and [whether] someone who might be vulnerable to that or might have already experienced that.

Pharmacy Times: What are some of the challenges that adult patients with ADHD face after receiving a diagnosis as children vs. after receiving a diagnosis as an adult?

Feld:Sometimes there are less challenges because adults are more open to [receiving a diagnosis] when they know that they had [ADHD] as a child. Almost every adult that has ADHD had symptoms as a child that might not have interfered or might have been compensated for, but some of the adults that were in treatment as a child…they were put on medications that probably had more AEs than some of the current meds and more issues with length of action, how you feel coming off it, and consistent day-to-day response. So, they just had a bad taste in their stomach about being forced to be put on meds—let's say by their parents or by the school—and then [there were] things they didn't like about the meds. So, I think the largest challenge is educating and it's due for us as the providers to make these adults feel more comfortable and realize that things are really different than they were 10, 15, or 20 years ago. One of the nice advantages is that ADHD is a highly genetic disorder, so, a lot of the adults I treat that maybe even had ADHD as a kid, they are more comfortable getting treatment for their kids. Once they see their own children who have ADHD being put on the medications that we're using now, then often they might be open to the idea of readdressing their ADHD.

Pharmacy Times: What are some of the difficulties patients with ADHD face in finding a medication that works for them?

Feld:Well, 1 of the difficulties is finding healthcare providers that are comfortable treating [ADHD], are aware of how to treat it, and are open to being to being creative and following an algorithm if there's not great responses. So, I think 1 of the biggest issues is maybe even access to good health care and providers that are comfortable with ADHD. And then, there's also always an issue—potentially—with insurance and a provider’s comfort level for using stimulants as first-line treatment. So, I think with adults—depending on their experiences with friends, their own children, their own physicians, nurse practitioners, and other providers—is really how to you get them to enter that comfort zone to try some of the medications and treatments that we have available right now. Once you treat ADHD, when you get the right treatment, these meds are life changing. They help they help reduce the symptoms of ADHD and then people's functioning in multiple areas of their life often improved dramatically.

Pharmacy Times: Many patients with ADHD are prescribed non-addictive ADHD medications, however, these medications are not always as effective. Can you describe further some of the challenges facing both patients and health care professionals around this issue?

Feld:If you look at, let's say the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the American Family Physicians Academy, and you look throughout, it's well-documented that stimulants are first-line treatment, unless there's a reason not to use stimulants. But a lot of providers—particularly with adults—would rather start with nonstimulants. And there are different nonstimulants, but they are definitely second, third, and fourth-line treatments that don't often have the efficacy that stimulants would have. But because stimulants are often considered [Schedule II] medications with the risk of abuse, misuse, and diversion, so, a lot of providers in the country would rather start with a med that carries less of that risk and have less concerns, so they start a lot with nonstimulants. The issue with that is most nonstimulants take longer to work than stimulants—because stimulants work immediately when you find the right dose and the right medicine—and most nonstimulants have a buildup period like other psychiatric meds. So, what I've seen is an adult being put on a nonstimulant or trying a few nonstimulants and it's taking time, it's taking weeks, and it's taking months, it kind of turns them off to the idea of continuing their treatment and maybe trying a stimulant.

The other issue for the providers…most providers in this country really need to be open to learning about some of the newer medications that have come out because as I told you earlier, any medication, any stimulant, first-line treatment medication that has come out in the last several years, there's no new chemicals, it's the exact same chemicals that were developed around the 1940s. There's the class known as methylphenidate and a class known as amphetamine, and what happened in the pharmaceutical industry—and it's happening in a very positive way—as they're developing new biotechnology and new delivery systems for these chemicals, so the experience on these chemicals is better AEs, length of action, consistency. But there's less of a likability with a lot of these products for people who like substance abuse and like having mind alteration, and with some of these newer delivery systems, there's also less risk of abusing them directly by how you get the molecule delivered and how [it] enters and is distributed in your body.

Pharmacy Times: Where are we in addressing the ADHD drug shortage—is that still a challenge facing providers today?

Feld: It’s absolutely a challenge and it's hard to know and to see—and I'm not you know a national expert on this—but I can tell you clinically and from teaching around the country is that it's hard to imagine that some of these shortages are going to clear up because of what happened with the opioid lawsuit and what's happening with wholesalers in the DEA right now with [Schedule II] medicines. You can see that it's happening with almost every immediate release stimulant, whether it's d-methylphenidate, regular methylphenidate, mixed amphetamine salts, or dextroamphetamine, I'm seeing pharmacies not having it and not stacking it as quickly. And for sure, there is a shortage because there are some meds that have been discontinued by the pharmaceutical company, and then there are some generic meds that are actually some of the better biotechnologies that have been discontinued. And then 1 prominently known medication is in the midst of going generic, so that branded medicine is not easy to get and the generics are just hitting the market. So, a lot of it depends on how insurance handles the generics and how patients respond because there's multiple generic companies providing this new method, like the new generic equivalent of a medication that's out. So, for sure, there are consistent shortages.

I've had 3 patients this morning—at least—request having to change pharmacies because it wasn't in stock at their pharmacy, and they found it in stock at [another] which is 10 miles away in the city of Chicago. It's really annoying as a provider having to electronically prescribe, then stop, and then change and change pharmacies, so it's impacting patients but it's impacting providers, like our tolerance level.

Pharmacy Times: What are some key takeaways from this survey, and what can health care practitioners, such as pharmacists, do to be more aware of these challenges?

Feld: I think some of the cool key takeaways have to do with the adult age…health care providers recognize that a lot of adults come in because…a lot of it is due to something that's happening professionally for the vast majority of it. But those same health care professionals recognize that the ADHD was impacting other areas of their life, so [it’s] impacting finances, relationships, health, even driving, and just every area of life can be impacted, not just the reason why [they are] coming is what [they] need to change the most right now. And obviously, with the kids, the same thing. This isn't just a school-based disorder, there might be issues in school, but we're looking at multiple areas of kids’ and adolescents’ lives including social and mental, personal, athletic, and family, and [other] important areas of life.

So, I think the survey brought out everyone's awareness that we're really looking at different areas of life and that ADHD impacts more than 1 area, but the primary areas are what we expect jobs and school to drive people. But that's forcing us to look at multiple settings, which then makes you realize you have to treat ADHD—definitely in moderate or severe ADHD in adults and younger patients—you have to look at all hours of the day, we're not just looking at work from 8AM to 4PM or school, we're looking at helping their lives in the morning, during the day—no matter what they're doing—and even into the evening.

So, I think a lot of the [health care providers] expressed concern that it's very difficult, their average patients, the average adult, it took maybe an average of 3 med trials to find the right med that patients responded to and tolerated the best, and then there's obviously large concerns with weighing out the benefits versus the risks. We always look for efficacy versus AEs, so I think a lot of health care professionals—and I experienced this through what I do professionally—are really wanting to learn about the next generation of the biotechnology and delivery systems because all of these health care professionals in the survey noted that they wanted early onset, that they want a consistent ADHD response day in and day out, they wanted a good length of action, they wanted [AEs] to be more tolerable, and for sleep not to be impacted. So, we're really looking [this] growing awareness of what we need to look at and how we need to treat ADHD more aggressively, and probably more hours of the day.