Ritalin for ADHD: Is It a Safe Long-Term Solution?
The drug Ritalin is currently one of the Food And Drug Administration’s (FDA) approved treatments for attention deficit hyperactivity disorder (ADHD). The active ingredient in Ritalin is methylphenidate, which is also the active ingredient in Concerta, the extended-release version of methylphenidate.
Methylphenidate is classified as a controlled substance by the United States Drug Enforcement Administration (DEA). It is currently classified in the Schedule II category, indicating that methylphenidate has medicinal uses, but is also a significant potential drug of abuse. Other drugs in the Schedule II classification include cocaine, methamphetamine, and many of the opiate drugs, such as morphine, fentanyl, hydrocodone (in Vicodin) and oxycodone (in OxyContin). Controlled substances are only legally available with a prescription from a physician.
Methylphenidate is a central nervous system stimulant, meaning that it speeds up the actions of the neurons in the brain and spinal cord. Its initial approval and marketing were associated with its stimulant effects as it was believed to be safer than caffeine. It was targeted at housewives and older adults to increase their energy levels.
Eventually, the drug was found to be effective in the treatment of disorders like ADHD and was approved by the FDA based on research studies that demonstrated its effectiveness for addressing these conditions. It is no longer marketed to the general public as a stimulant, but it is used in the treatment of other conditions due to its stimulant effects, such as to treat lethargy associated with a neurocognitive disorder.
The Use of Methylphenidate in Children
The use of methylphenidate in all adolescents (with or without a diagnosis of ADHD) peaked in the early 2000s with about 4 percent of all students in grades 8, 10, and 12 reporting use of the drug. Its use then declined with slightly less than 1 percent of students in these grades reporting use of the drug. The Centers for Disease Control and Prevention (CDC) reports that a little over 10 percent of children in the United States receive a diagnosis of ADHD, which is inconsistent with the prevalence rates stated for the disorder by the American Psychiatric Association; APA lists an approximate 5 percent prevalence rate.
There has been ongoing controversy regarding the overdiagnosis of ADHD in children. The recent changes to the diagnostic criteria for the disorder by APA that allow for a diagnosis of ADHD in adults has also spurred some controversy.
Medication is the most common form of treatment for ADHD, and stimulant medication remains a common treatment alternative for both children and adults. The CDC states that overall about two-thirds of children diagnosed with ADHD receive stimulant medication as part of their treatment.
There is other important information to consider regarding the diagnosis of ADHD, according to the APA.
- Males are between two and three times more likely to get a diagnosis of ADHD than females.
- The mean age at which ADHD is diagnosed is 7.
- The symptoms of the disorder will most often begin to occur between the ages of 3 and 6.
- The diagnostic criteria from the DSM-5, the latest version of the APA’s diagnostic manual, allow for ADHD to be formally diagnosed in adults who are over 18 years old. This practice was frowned upon according to the diagnostic criteria from previous versions (although diagnosing ADHD in adults was still performed).
Abuse and Medicinal Use of Ritalin
It is important to understand that there are different ramifications that occur with the medicinal use of a drug compared to the abuse of the same drug. Abusers of drugs will often experience far more significant and intense side effects, issues with physical dependence, and dysfunction in their lives compared to individuals who use the drug for medical reasons under the supervision of a physician. For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports that few of the individuals who are diagnosed with ADHD and receive medication for the disorder misuse the medication.
APA reports that the prevalence rates for stimulant use disorders that are not related to cocaine abuse in adolescents is around two-tenths of 1 percent. Other research suggests that the abuse of medications designed to treat ADHD is most often not engaged in by individuals who were prescribed the drug for medicinal reasons, but instead, most often occurs in individuals who obtain the drug through illicit means, such as buying it on the street, getting it from a friend who has a prescription for it, or stealing it. Thus, developing a stimulant use disorder as a result of being prescribed Ritalin for the treatment of ADHD is not a major issue in most cases.
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What Does Ritalin (Methylphenidate) Do?
Central nervous system stimulants often affect the availability of the neurotransmitters dopamine and norepinephrine directly and also lower the production and release of inhibitory neurotransmitters like gamma-aminobutyric acid (GABA) in the brain and spinal cord. This accounts for their effects.
Research on the effects of methylphenidate indicate that use of the drug results in increased levels of dopamine in the brain by blocking the reuptake of the neurotransmitter once it has been released. This leaves more dopamine available in the central nervous system and results in its stimulating/medicinal effects. It has long been believed that individuals with ADHD actually have fewer of these excitatory neurotransmitters available in their central nervous systems. This lack of available excitatory neurotransmitters results in difficulty with concentration and in the person engaging in behaviors designed to compensate for this natural lack of stimulating substances (e.g., presenting with hyperactive and impulsive type behaviors).
The use of stimulants appears to have a paradoxical effect on people with ADHD. Instead of making these individuals even more excitable and distractible, it improves their ability to concentrate and results in them not engaging in impulsive or hyperactive behaviors.
However, the use of any medication for any condition over the long-term will result in structural changes in the system. Central nervous system stimulant use is no exception to this. Thus, even though all of these medications have been demonstrated to be effective in treating the problems that occur in children who have ADHD, there will also be the potential for side effects and long-term effects. This is a principle that occurs with nearly any type of medication for nearly any type of medical condition.
The approval of medications for the treatment of psychiatric conditions relies on a sort of cost-benefit analysis where medications that effectively treat the condition, and are associated with fewer short-term and long-term side effects, are more likely to be utilized and approved. But there is no such thing as a “free ride” when one takes any type of medication or engages in any form of treatment. There are always associated effects.
The effects of the use of methylphenidate have been well documented in numerous research studies.
Overall effects can include:
- Increased levels of attention/concentration
- Increased levels of energy and activity in people who do not have ADHD; decreased levels of activity in people with ADHD
- Suppression of appetite
- Changes in blood pressure and heart rate
- Increased respiration
- Interference with the sleep cycle, particularly with REM sleep
All drugs have a side effect profile. The major side effects associated with the medicinal use of methylphenidate include decreased appetite, problems with one’s sleep cycle, headache, nausea, and chest pains. Very rare side effects, such as the appearance of tics, obsessive-compulsive behaviors, and even psychosis, can also occur. When very rare and unusual side effects like these occur in individuals who take Ritalin for ADHD, it will most often lead to discontinuation of the drug and attempts to find a suitable alternative to treating the person’s ADHD.
Surprisingly, up until very recently, there was little reliable research associated with the long-term medicinal use of methylphenidate. One of the most common associated effects of long-term use of Ritalin (methylphenidate) in younger individuals with ADHD was the observation of a decreased overall growth rate in these individuals. Physical development primarily occurs when an individual is asleep. Since the use of Ritalin will often result in a disrupted sleep cycle in some people, some individuals who experience more severely disrupted sleep may also experience issues with growth.
The classic solution to this problem has been to give children “drug holidays” when they are not in school (e.g., on long vacations or over the summer) to allow them to catch up on their growth cycle. This approach has generally been effective, and disrupted growth in children is no longer mentioned in recent research studies as a potential long-term effect of Ritalin.
Long-term use of Ritalin for ADHD has also resulted in:
- Improved functioning and control over the symptoms of ADHD
- Fewer issues with control, including a decrease in a co-occurring diagnosis of oppositional defiant disorder or a significant decrease in oppositional behaviors
- Increased performance in academics
- Increased social functioning
- Increased self-esteem
Recent research has also been able to shed light on some of the potential changes that occur in the central nervous system as a result of long-term treatment with Ritalin for ADHD. One of the changes in the brain as a result of long-term medication use is a change in the availability of the neurons that are affected by the medication. When a particular medication affects the availability of a neurotransmitter in the brain, the person’s system often adjusts to this change by either increasing the amount of neurons associated with certain neurotransmitters or decreasing the amount of neurons associated with utilizing certain neurotransmitters.
- Upregulation is a term used to describe the increase in neurons associated with a particular neurotransmitter that may occur when that neurotransmitter becomes less available than normal in the brain and spinal cord.
- Downregulation is a term used to describe a decrease in the number of neurons that use a specific neurotransmitter that may occur as a result of the increased availability of that neurotransmitter in the central nervous system.
- Upregulation may also occur in neurons that use a neurotransmitter that exerts opposite actions of the neurotransmitters that are increased by the medication. This is the body’s attempt at maintaining balance within the system.
- With continued use of the drug, the upregulation and downregulation of neurons in the brain can lead to significant long-term changes in neuropathways that can have numerous functional consequences.
Recent research studies have highlighted the effects of upregulation and downregulation that may occur with long-term use of Ritalin for ADHD. A research study published in the journal Frontiers in Systems: Neuroscience suggested that the long-term use of Ritalin for the treatment of ADHD may result in changes in the availability of neurons and neurotransmitters in the brain that decrease brain plasticity in these individuals as they get older. Brain plasticity refers to the brain’s ability to change as a result of experience. Brain plasticity is associated with numerous behaviors and functional consequences, including the ability to learn new information, learn from experience, plan ahead, switch between tasks, control emotions, and become flexible and change behavior accordingly. The article suggested that the changes that occur in the brain associated with long-term use of Ritalin may decrease an individual’s potential in these areas.
Another recent study published in the journal Neuroimage: Clinical suggested that long-term use of Ritalin may affect levels of the inhibitory neurotransmitter GABA. The research looked at patients who had been treated with stimulants for ADHD before they were 16 years old, patients who began treatment with stimulants like Ritalin when they were adults, and people who had not been treated with Ritalin at all.
The use of Ritalin increases the availability of GABA in a brain area known as the medial prefrontal cortex, and this leads to a downregulation of these neurons over time. The study suggests that long-term use of Ritalin may affect cognitive problems with flexibility, emotional control, abstract thinking, and higher-level reasoning in individuals who began taking the drug while their brain was still developing.
They found evidence that only the people who had begun treatment with stimulants at an early age demonstrated significant changes in neurons associated with GABA.
The media and some sites have made claims about the potential ramifications associated with the findings of the two above studies that should be considered extreme. The researchers themselves in both of these studies report that the overall ramifications of their findings are still under review and that further research needs to be performed in order to understand the practicalities of their findings and the behavioral effects that their findings imply.
The available research on how long-term treatment with Ritalin affects the neuropathways associated with dopamine and other excitatory neurotransmitters has been mixed. It is unclear if there are any measurable effects at the current time other than the ones stated above (e.g., increased ability to concentrate, decreased hyperactivity, etc.). Long-term abuse of stimulants like Ritalin is associated with significant changes in the dopaminergic neurons in the brain, such that individuals often have problems with experiencing pleasure and with emotional control; however, there is a major difference between the abuse of a drug and its medicinal use.
As stated previously, abusers often experience far more extreme effects from long-term use of a drug than people who use controlled amounts of the drug for medical reasons. For instance, the development of psychosis as a result of Ritalin abuse is not uncommon, but it is extremely rare in individuals who use the drug for medicinal reasons. Finally, the recent research cited above has suggested that long-term use of Ritalin does not affect white matter in the brain, and findings of white matter abnormalities in patients on Ritalin may be due to other factors.
According to APA, all individuals with diagnosed psychiatric conditions that are either treated or untreated also tend to have higher rates of health issues than individuals without these diagnoses. These health issues can range from high blood pressure to more severe cardiac issues, an increased potential to develop cancer, and an increased potential to develop other illnesses or disorders. Because this appears to be an overall effect over most of the psychiatric diagnoses currently listed by APA, the use of Ritalin should not be considered to be a specific factor in this observation. However, the ramifications of having an untreated mental health disorder appear to be far more severe than the effects of the treatment (see below).
Is Long-Term Use of Ritalin Safe?
In general, most of the available evidence points to the conclusion that long-term medical use of Ritalin for the treatment of ADHD is safe; however, long-term use of any drug, including Ritalin, is not without its costs even if the drug is being used solely for medical reasons and in accordance with its prescribed dosages.
There is evidence that long-term use of Ritalin may result in changes in an individual’s brain that can limit their potential with flexibility in thinking and emotional control. However, there does not appear to be a large body of research that currently defines significant functional and cognitive problems that can be attributed to the long-term use of Ritalin in individuals who have ADHD. Instead, most of the research indicates that the benefits of long-term Ritalin treatment for ADHD are positive.
Research also indicates that individuals who were not treated for ADHD as children typically have lower levels of achievement as adults, higher rates of unemployment, higher rates of substance abuse, higher rates of legal issues and incarceration, higher rates of co-occurring psychiatric conditions, and higher mortality rates than individuals who were treated for ADHD as children and continued their treatment. Thus, the current cost-benefit analysis suggests that the overall benefits of medicinal treatment with Ritalin outweigh the overall costs. The research also indicates that the long-term abuse of stimulants like Ritalin can result in significant psychological and physiological problems, and the costs of abusing the drug indicate that abusers should seek treatment as soon as possible.
Nonetheless, it is appropriate to understand that treatment of ADHD should include both medical and behavioral components. Behavioral components to treatment include instructing individuals on how to control their impulses, improve their attention and concentration, and devise alternative ways to manage problems with hyperactivity. When behavioral management for ADHD is combined with medication, treatment outcomes are significantly improved over the use of either approach alone. In the long run, using consistent behavioral management approaches in the treatment of ADHD may result in less reliance on medication and therefore a decreased risk to experience the costs that are associated with long-term use of psychoactive medications.
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