2316: Myths & ADHD Medication with Dr. William Dodson
What do you know about your ADHD medications? We didn’t know much, so we brought in the expert, Dr. William Dodson, a Board-Certified adult psychiatrist and one of the first clinicians who specialized in adults with ADHD decades ago.
Because here’s the thing: we don’t deal much with ADHD meds. As a coach, Nikki refers folks to their physicians. And apart from being a patient himself, Pete’s experience dealing with medications is far from diverse. And yet, the field of questions we get from folks in our community relating to medications is vast. Today, we start the process of getting those questions answered.
Debunking Myths, Clarifying Understanding
As Dr. Dodson says, no one ultimately is going to care about your specific decision around medication other than you. But it’s important that you have the data you need to get your questions answered before you make that decision yourself. We can say this for sure: Dr. Dodson is a professional in the field with qualified experience in practice and a respected and verified source. We hope you find something you can take away from this discussion that helps you in your decision-making.
About William W. Dodson, M.D., LF-APA
Dr. Bill Dodson is a Board-Certified adult psychiatrist was one of the first clinicians who specialized in adults with ADHD 25 years ago. He has been on the faculties of Georgetown University and the University of Colorado Health Sciences Center. He was named a Life Fellow of the American Psychiatric Association in recognition of his clinical contributions to the field of ADHD (2012).
He was the recipient of the national Maxwell Schleifer Award for Distinguished Service to Persons with Disabilities (2006). He has written more than 120 articles and book chapters designed to help a lay audience better understand ADHD and its treatment.
Dr. Dodson is now semi-retired and devotes most of his professional time to working with homeless adolescents on the streets of Denver and writing a book about the optimal treatment of ADHD in both children and adults.
Episode Transcript
Brought to you by The ADHD Podcast Community on Patreon
Pete Wright: Hello everybody, and welcome to Taking Control, the ADHD podcast on TruStory FM. I'm Pete Write, and right over there is Nikki Kinzer.
Nikki Kinzer: Hello everyone, hello Pete Wright.
Pete Wright: Happy 501.
Nikki Kinzer: Happy what?
Pete Wright: 501.
Nikki Kinzer: What's 501?
Pete Wright: This is episode 501.
Nikki Kinzer: Oh. I had no idea what you were talking about. I'm like, "501?" Yes.
Pete Wright: We had our big party yesterday, where we recorded this.
Nikki Kinzer: And it's already forgotten. Yeah, I know.
Pete Wright: And it's already forgotten. You've got the 501 blues. What?
Nikki Kinzer: Yeah, I'm working on our 600th episode right now. All right, that all makes sense now.
Pete Wright: That all makes sense now, sure. It's all fine. We've got a conversation, this is, I think it's safe to say this has been, this conversation is long-awaited. Wouldn't you agree?
Nikki Kinzer: It is, because it's something that when we are asked about medication, our standard response is, "Go ask a doctor, ask an expert." We don't know, we're not the ones to ask. So it's so nice to be able to not only ask our questions that we have, but ask all of our listeners questions that they have, and have an expert who is so willing to talk about it so freely.
Pete Wright: And we've got quite a list of questions to go through. Now, who is that expert? Oh, dear. Nikki, it's Bill Dodson. It's Bill Dodson.
Nikki Kinzer: Yes it is.
Pete Wright: Did you-
Nikki Kinzer: It's Dr. Bill Dodson.
Pete Wright: I say that as if I was going to surprise you, but you already knew-
Nikki Kinzer: I already knew.
Pete Wright: ... that Dr. Bill Dodson is back. You may know Dr. Bill Dodson, because he's the guy who introduced all of us to the concept of RSD, rejection-
Nikki Kinzer: He's pretty famous in our-
Pete Wright: .... sensitive dysphoria.
Nikki Kinzer: Yeah, yeah.
Pete Wright: Yeah, he's a, what I like to call a luminary, a real thought leader.
Nikki Kinzer: He is.
Pete Wright: And he's just an all-around nice guy, and we sure love that he is willing to consider this a place, a platform for him to come and talk and share those insights, and to grace us with his expertise for all of your questions. So we hope we got them all. If you have more questions, please post them in show talk and we will keep a list for the next time Dr. Bill Dodson comes back to talk to us, but for today, what do you say? We should probably get started-
Nikki Kinzer: Absolutely.
Pete Wright: ... with Dr. Bill. Before we do that, head over to takecontroladhd.com, you can get to know us a little bit better. You can listen to the show right there on the website or subscribe to the mailing list on the homepage, and we'll send you an email each time a new episode is released. You can connect with us on Twitter or Facebook at Take Control ADHD, and if this show has ever touched you, if it's helped you make a change in your life with ADHD for the better, please consider supporting the show at patreon.com/theadhdpodcast.
Pete Wright: Patreon is, for us, listener-supported podcasting. You join, you support the show at a tier of your choice, you get some goodies in the backend, but you also know that you are supporting us continuing to make choices with our time and our sweat toward this show, toward building new resources for the show and building new resources for this community. Our Discord community is a great example, transcripts are a great example. Having transcripts, human-powered transcripts for every episode, that is a product of support from our patrons directly. So for everyone who is interested in investing in this show, patreon.com/theadhd podcast, it's an amazing, amazing community you will be joining. And for our purposes, it is the lifeblood of this show. Patreon.com/theadhdpodcast. And now, Dr. Bill Dodson.
Pete Wright: Everybody, we are so excited to have our guest back on the show. You remember RSD? Do you, huh? We're sure you do, because you told us as much, and the guy who introduced that topic to us and to this community is here, Dr. William Dodson. He is an award-winning, board-certified psychiatrist and specialist in adult ADHD. He has been on the faculty at a number of different university medical schools and now he's retired, but working more than ever. Bill, welcome back to the ADHD podcast.
William Dodson: Good to be here.
Nikki Kinzer: Welcome.
Pete Wright: We're talking about drugs today.
Nikki Kinzer: Yes, medication.
Pete Wright: We are very excited to have this conversation, for many reasons, not the least of which that Nikki and I are wildly ill-equipped to answer some of the questions that-
Nikki Kinzer: Yes.
Pete Wright: ... we get from our community. And so we're very excited, we've actually collected questions from our listenership to share with you and get your insights on. But to start us off, why don't you talk a little bit about standards and practices and procedures for prescribing medication for somebody?
William Dodson: We have, in the world now, seven international standards of care. And this is one of the things they all agree on, is that medications are the treatment of choice, period. It's what you ought to try before you try anything else. Of course, in the real world, it's exactly the reverse. People have tried everything under the sun before they come to see me, because people are so very ambivalent about the medications. Most of this is based on ignorance, and here it's the physicians who are ignorant. They don't have the information to talk to the patients, allay their fears. These are some of the safest medications that ever came to the market, but you would never know it.
Nikki Kinzer: Right.
William Dodson: In Ed Hallowell's new book, he has a chapter, the chapter on medication, Medications: The Wonderful Drugs We Love to Fear. The attitude of the country, actually the world, is really kind of reversed, again. The belief is that it's the treatment of ADHD that's risky, not the disorder itself. And so people are always worried that, "What if this, what if that, what if this?" The choice of at least trying medications ought to be easy, because they're incredibly safe, they've been around for 80 years. I can tell you how safe they are, they're approved down to the age of three, so we can give them to little kids. They're approved for pregnant women, that tells you how safe they are. But you would never know that, because people come in and they're worried to death, and they go back and forth and back and forth. The average person, when they come into my office, has been thinking about trying medication for two years before they pick up the phone and call me.
Nikki Kinzer: What are they fearing?
William Dodson: A lot of times they don't know. They have a lot of beliefs that they're not quite conscious of. One almost universal belief is that this is a permanent decision. Trying medication, if you try medication, you can't go back. You're committed to medication forever. And I tell people, "Look, these are just trials. Try it, see what it has to offer you, get some real experience, then make a decision about whether medications are for you or not." Hell, most of my patients [inaudible 00:08:06], "This is not a permanent decision. We're not talking about putting a tattoo on your child's face." You can always change your mind.
William Dodson: The other thing I remind people of is that it's not one drug at one dose for everybody all the time. You're going to have to actively participate with your clinician to find the right medication for you as a unique individual, the right dose, the right timing of dose. Nobody buys off the rack, everybody has to have the medications tailored to them as a unique individual.
Nikki Kinzer: Do you find that you run into that a lot, where people'll be like, "Well, ADHD medication doesn't work for me, because I tried Adderall and it made me feel bad."
William Dodson: If somebody says that, I said, "Well, you need to, first of all, forgive the physicians of the United States." Because for a long time we didn't know what the hell we were doing, and we tended to overdose people. The Rule, capital T, capital R, The Rule is that if you have the right medication at the right dose, you should see dramatic improvement without side effects. So I tell people, "What you should expect from the stimulant [inaudible 00:09:28] is a reaction that I call the wow reaction. It should be life-changing, and if it's not life-changing, you shouldn't settle, you should go to the other stimulant medication."
Nikki Kinzer: Interesting.
William Dodson: So they should be dramatically effective, and essentially without side effects.
Pete Wright: That's, I think, a really important caveat, and once again, Bill, you've said something that introduced a concept to me that is a little bit mind-blowing, it's that third conceit that you should experience this without side effects, therefore if you are experiencing side effects, you haven't asked why enough.
William Dodson: Right. And you need to go down on the dose.
Pete Wright: Okay.
Nikki Kinzer: Oh, interesting.
William Dodson: The dose response curve, I've got it taped over on here, I can actually show it to you if you want, just draw an upside-down V. As you increase the dose, you see a nice linear improvement, each dose you're getting better and better and better, up to a point. We call it the sweet spot, and at that dose you're getting 100% of what medication has to offer and no side effects. Again, as you see the increase in medication, you get to the sweet spot, which is where a person with ADHD will have the same attention span and impulse control as anybody else. No better, no worse. But the playing field is level for the first time in your life.
Nikki Kinzer: Which is why you have that wow factor, then.
William Dodson: Right. On the left side of the curve, there should be no side effects. On the right side of the curve, you should pick up side effects, and they're of two types. Little kids get what's called the zombie syndrome. That's both the slang and the term that's used in the textbooks. And the kids just absolutely slows down, loses his facial expression. He's no longer disruptive, and the teacher's delighted, but he's also sitting brain-dead, he's not learning. He's just not disruptive any longer.
William Dodson: Adults tend to get the exact, it's called Starbucks syndrome. Imagine what you'd be like if you wandered out of Starbucks after four double espressos. You'd be revved up, your heart would be beating fast, you'd have a hand tremor. You'd have a headache, you wouldn't be able to sleep, all the things we associate with too much caffeine. So if you're having side effects, the dose is too high.
Nikki Kinzer: So I have a question about this. My daughter is 16, and she was diagnosed with ADHD and we started her on Adderall. She said that it helped her focus, but she didn't feel like herself, so she didn't like to take it. And then-
William Dodson: Dose is too high.
Nikki Kinzer: It's too high, okay, so that's what you're saying here, all right.
William Dodson: Yeah. Again, the goal should be the best version of you.
Nikki Kinzer: Right.
William Dodson: You should feel exactly the same as you always did, your personality shouldn't be changed, but you should be performing at your very best all the time. And so if it changes you, if you start a sentence with, "I don't like," you either have the wrong molecule or the wrong dose. If you took 100 people just off the street with ADHD and you started them with amphetamine, the way your daughter was, Adderall, 70% of them are going to go, "Wow, where have you been all my life?"
William Dodson: That also means that 30% are going to try it and either not tolerate it or just not see much in the way of benefits. At that point, you try the other molecule, methylphenidate, and 70% of people will respond to methylphenidate. But it's a different 70%. So if you end up having to try both molecules, you end up with about 85% of people having a life-changing level of response. Now, that still leaves 15% of people, which is a lot of people. That's one in every seven who will try both medications and either not tolerate them, or just not see much in the way of benefits. Again, as with many things, there's absolutely nothing in the literature that would tell a clinician what to do for that 15%. It's absolutely silent. So I can tell you what clinicians do, but there's no backing for it. Well, you make sure that the diagnosis is correct, first of all. If it is, then you want to make sure that it's being absorbed.
William Dodson: If a person says, "I don't see anything, I don't see benefits or side effects," it could well be that it's not being absorbed. Neither one of these molecules will be absorbed into the body if you take it with citric acid or vitamin C, ascorbic acid. Both methylphenidate and amphetamine are strong bases, so if you wash it down with something that's acidic, it precipitates out, you may have swallowed your medication, but all you're going to get out of that dose is high octane.
Nikki Kinzer: Interesting.
William Dodson: So you need to separate taking the dose from fruit juices, sodas, and the big one is vitamins. A lot of people just for convenience sake will take their vitamins, or give the kid the gummy vitamins and stuff like that, at the same time they take their ADHD medication, and they end up sabotaging themselves.
Pete Wright: Yeah, yeah, I-
Nikki Kinzer: Oh, that's interesting.
Pete Wright: ... that was actually the first question in the chatroom today, which was, "Can you talk about the citric acid issue?" So how long should they wait after takin their meds before they have that glass of orange juice?
William Dodson: I tell my patients wait an hour.
Pete Wright: An hour, okay.
William Dodson: Or, better still, take your vitamins at night before you go to bed.
Pete Wright: Oh.
William Dodson: They're better absorbed at night anyway. You'll get more out of the vitamins if you take them at night.
Pete Wright: Of course you would not be taking your ADHD medications at night, before you go to bed.
William Dodson: Well, you'd be surprised. About 60% of my patients take a dose of stimulant at bedtime, because they sleep so much better.
Pete Wright: Fascinating.
William Dodson: If, for instance, you ask somebody about their sleep, "Tell me about your sleep." About 80% of people with ADHD will say, "Well, I don't even bother getting into bed until 2:00 or 3:00 in the morning, because I know if I do, I'll toss and turn and my thoughts will bounce from one concern and worry to another, I spend two hours every night trying to shut my brain and body off to fall asleep."
Pete Wright: I relate.
William Dodson: "Once I do fall asleep, I continue to toss and turn, kick the covers off, nobody can stay in the same bed with me." What you're seeing is that when the hyperactivity of ADHD dims down in adolescence, it doesn't go away. It shifts to the nighttime, and for some reason becomes tied to sunset. So you'll hear from people with ADHD, "When the sun goes down and it gets fully dark, everybody else is getting quiet and ready for bed, I get a burst of energy, and it's the best time of the day for me, and I know if I get into bed I'm not going to sleep anyway."
Nikki Kinzer: Yeah, that's what they do.
William Dodson: So most people with ADHD are night owls. So the cause of the insomnia is the hyperarousal of ADHD, so if you treat the ADHD, the person sleeps normally. [crosstalk 00:17:31]-
Nikki Kinzer: You can focus on sleep, that's interesting.
Pete Wright: Mm-hmm (affirmative).
William Dodson: Yeah, or just focus on nothing.
Nikki Kinzer: Yeah, right.
William Dodson: Now, that's a hard sell.
Nikki Kinzer: Right, I can imagine.
William Dodson: Somebody's already up for two hours, and here I am telling them, "I want you to take [crosstalk 00:17:44]-"
Pete Wright: A nice dose of stimulants, right, right.
William Dodson: ... "amphetamine, so you can sleep." I mean, they're usually polite because I'm the doctor, but you can tell by looking in their face, they think I'm crazy. So what we do is we really, really fine-tune the dose. And then on a day when they can, I ask them, while they're on their medication, to lie down after lunch and take a nap. Most people with ADHD'll say, "I've never napped in my life, that's a waste of time." I said, "Give it a try, on medication you can nap." And indeed, 99% of them, because they're sleep-deprived, nap just fine. Once they've proven to themselves in a no-risk trial nap that they sleep great, then they're much more likely to be willing to give it a try to see if it helps them with sleep, and it does virtually always.
Pete Wright: Wow.
Nikki Kinzer: That's so interesting.
William Dodson: Let's just say that I'm wrong. It's happened. For people who are taking amphetamine products, amphetamine products have an off switch, and it's the reverse of the absorption thing. If somebody takes 1000 milligrams of vitamin C, it will pull all of the amphetamine out of the body into the urine in about 20 minutes. So you just completely get rid of the dose of amphetamine with vitamin C. So if they try a dose of amphetamine at bedtime and they can't sleep, take 1000 milligrams of vitamin C, 20 minutes later they're back to themselves.
Nikki Kinzer: Yeah, interesting. So I do have a question-
Pete Wright: What a body hack. That's fantastic.
Nikki Kinzer: Yeah, right? I know.
Pete Wright: I'm learning so much.
William Dodson: Yeah. Well, then the real work begins, convincing your doctor to give you another dose per day.
Pete Wright: Yeah. Oh, that's tricky. Well, and that actually leads us to this big question, which is, in case there are any folks out there who don't know, or who haven't been asking the question, "Why isn't this one working for me?" Can you give us a brief on the differences between controlled medications, and amphetamines, and non-controlled medications? We've been talking about Adderall, Concerta, Strattera, [crosstalk 00:20:03]-
Nikki Kinzer: But it's the non-stimulant ones that I'm really interested in too, because that's what my daughter's doctor did, is she said, "Okay, well, we'll get you off of Adderall and we'll put you on Strattera." And I don't know if that's helping.
William Dodson: Let's just start with the whole notion of comparing these medications in terms of how well do they actually work. In medicine, we measure that with a statistical calculation called effect size. That is exactly what it says, it's more math than I can do, but it's a ratio, how well does this treatment work as compared to all the others we might've tried?
William Dodson: So just about everything in medicine falls in the range between .4 and one. One is really quite robust. The stimulants, if you try both molecules, you fine-tune it, you don't stop at the completely artificial maximums in the FDA, and you let the dose go up to where it's really optimized, you're going to get an effect size of about 1.7, 1.8, which is better than anything else in medicine. That's the scientific equivalent of, "Wow." Better than anything else in medicine. If you stop where the FDA stopped looking, and look at their maximums, you're going to get an effect size of about .95. Pretty good still.
William Dodson: If you try the second-line medications, which are the alpha agonists, and you find one that works for you, and that's about 60% of people, you're going to get a very good response there, about a 1.2. Again, much better than anything else in medicine. Strattera and Qelbree are non-stimulants, and so their effect size in children is much better than it is in adults. The child studies are coming in at about .6, .7, I think there's one at .7 for kids. But for adults it's down at about .44, which for adults means barely detectable, but consistently detectable in about half of people. So the non-stimulants do not work well for adults. Why, nobody knows. But again, it's the difference between a .7, which is, again, a better score than our antidepressants and stuff like that, so it's still pretty good, a 1.2, or 1.8. So that's sort of the mathematical backing of first line, second line, and alternative medications. So I think, I just don't have that many people on the non-stimulants because I can work around them. Again, I-
Nikki Kinzer: Where does Wellbutrin fall? Because I've heard that come up in conversations before too.
William Dodson: Wellbutrin is the drug that a doctor who's scared of the stimulants uses. It doesn't work. There's one study that shows barely detectable benefit. The reason they're using Wellbutrin is that it's made out of amphetamine. That's what they start with, and they put a chloride ion on it, stuff like that. So they said, "Why not give it a try?" In order to be effective, you have to get the dose up to four or 500 milligrams, where the usual maximum dose is only 300. And you will get, in some people, a detectable level of benefit, but again, it's down about .4.
Nikki Kinzer: I see.
William Dodson: Barely detectable. So it's not a drug that you're going to write home about.
Nikki Kinzer: Right, right, yeah. Interesting.
William Dodson: When you get into those alternative medications, most of them are not worth the hassle.
Nikki Kinzer: You mentioned earlier that ADHD medication is safe for pregnant women. I didn't know that. I thought they tended to stay away from it.
William Dodson: Again, it's because-
Nikki Kinzer: Fear.
William Dodson: ... people feel fear, yeah. And the thing is, to your listeners, if you have a concern about these medications, somebody else has too, and it's been studied six or seven times. I mean, ADHD and the medications used to treat it have been controversial their entire existence, so the things that people are concerned about have been studied, with the stimulants in pregnant women, these were people who were not just misusing pharmaceutical-grade amphetamine or methylphenidate, they were also using methamphetamine, and they were polydrug abusers, and stuff like that. And just, there wasn't any problem they detected. There's no problem with getting pregnant, staying pregnant, there's no problem with the delivery, there weren't any birth defects, there weren't any postpartum difficulties. And everybody expected something awful to happen, crack babies and all this.
Nikki Kinzer: But didn't happen.
William Dodson: And it was kind of, eh, nothing happened. So it's a decision that the mom and dad make together. I can tell you the pattern in my own practice is that it was the first child, usually the woman goes off of medication at least for the first trimester. And then about half go back on. For the second pregnancy, where they have a hyperactive little kid running around the house, everybody-
Pete Wright: Everybody's on meds.
William Dodson: ... stays on medication.
Nikki Kinzer: Yeah. Like, "Literally need this."
William Dodson: They're practical, they stay on the medication all the time.
Nikki Kinzer: So I want to wrap back around the fear piece, not with pregnancy, but around addiction. Because I think that that's part of where we see the fear.
Pete Wright: So much baggage, so much baggage.
Nikki Kinzer: Well, there is, and I mean, I'm not going to call it out, but there is a documentary that is just so irritating, because they're talking about the addiction of ADHD meds, and I'm just curious, from your point of view, what's going on here? Can somebody with ADHD get addicted to stimulant drugs?
William Dodson: Is it possible? Yes, it's possible. Is it likely? Highly unlikely. And people already know this. If you talk to somebody, just a civilian out there, and you say, "What do you know about the ADHD stimulants?" You're going to get the same history. That people don't stick with them, half of people don't feel the [inaudible 00:27:48] prescription. If the dose is slightly too high, people hate how they feel. They don't get high, it's not pleasant. Your daughter complained about, "I don't like how this makes me feel." So there's no real reason to abuse these medications. They don't feel good. They're expensive, they're hard to get. If you contrast that with drugs of abuse, they're exactly the opposite. People take them because they feel good, they like how they feel on them. Those drugs become very compelling, and they want to take more, they increase their dose, they get tolerance and they raise their dose. Tolerance doesn't develop with ADHD medications.
Nikki Kinzer: I was going to ask you about that, we need to ... Okay, keep going, but we need to expand on that, yeah.
William Dodson: And so what you get is the person goes, "Well yeah, I mean, the drugs for ADHD and the drugs that people abuse are exactly the opposite." Where do we get this notion? Because people didn't make any distinction at all between amphetamine and methamphetamine. For the first 40 years these medications were on the market, they were over-the-counter medications. You could walk into any pharmacy and buy them off the shelf. They were used to treat asthma. Then after World War II, every nation, every army had huge stockpiles of amphetamine and methylphenidate that they gave to soldiers to stay awake, they got dumped onto the market, and there were some problems in Sweden of mixing amphetamine with poor-grade heroin. There was never a single case of somebody who abused just amphetamine or just methylphenidate. Not a one.
William Dodson: So the response in the United States was, "Let's take these over-the-counter medications and put them in schedule IV," which is the least restrictive category. And there they sat for 20 years. Then came the early 1970s, and the nation suddenly discovered drug abuse. Cocaine, marijuana, it became a national scourge. And in response, the DEA said, "We're going to ban methamphetamine, and we're going to ban anything that might be made into methamphetamine." So that's how amphetamine and methylphenidate got into schedule II.
William Dodson: Trouble is, they never slowed down to ask a chemist, "Can you make methamphetamine out of amphetamine?" And the answer is you can't. You make methamphetamine out of sudafed, which they left on the shelves for another 20 years. We measure progress for the DEA in terms of 20 year increments. But that's when you may have noticed if you wanted sudafed, you had to go and ask the pharmacist for it.
William Dodson: So basically these medications just got wrapped up in an overreaction because of other drug abuse. People will say, "Well, everybody in college uses Adderall to study with." Well, when you actually look at it, and yes, they've looked at it, 20 times, what you find is that, if you average them all together, "everybody" turns out to be somewhere between six and 8% of people.
Pete Wright: That's not as many as everybody, let me check my math.
Nikki Kinzer: Isn't that interesting? No.
Pete Wright: No, that's not as many as everybody.
William Dodson: Yeah. They used them, because they have some magical beliefs that it's going to help them with some sort of performance enhancement for tests, which of course, they have absolutely no ability to do, unless you have ADHD. But what we know is that people who misuse and abuse these medications regularly fit a very narrow demographic. They are white, male, fraternity members who were already alcoholic when they got to college, and they use the stimulants so they can stay awake and drink more. It's exceedingly rare to have women, blacks, Hispanics, or Asians misuse these medications. It's a white male phenomenon.
Pete Wright: Again? It's another one.
Nikki Kinzer: Interesting.
William Dodson: And it's almost entirely an immediate release delivery system phenomenon. People don't, I mean, if they're out there [inaudible 00:32:57] these medications, they don't want something that's very gradual, like the time-release stuff, they want the immediate release. So most docs, if they have a college student or high school student come in and they're insistent upon immediate release medication, we go, "I don't think so."
Nikki Kinzer: Yeah. Red flag, yeah.
William Dodson: Red flag. Red flag, red flag.
Nikki Kinzer: So why do doctors ... Because this still happens. I had somebody, in fact we got in this conversation earlier this week in a coaching group that I have, and I told them I was going to ask this specific question to you. One person's doctor said, "Take at least one day off of your ADHD medication so you don't build up a tolerance." That was said this week. What is that about?
William Dodson: I don't know. It's wrong. People will get tolerant to any side effects in a matter of a day or two. Feeling jittery, loss of appetite, that sort of thing. They'll get tolerant to the side effects, but not to the benefits. So there's a line in all the standards of care that say, "These medications don't develop tolerance." People will create a tolerance, if you will, by their magical beliefs. Again, there are a lot of people that believe that more is always better, and so they'll just keep on increasing the dose. The body will adjust to it, they won't feel jittery and buzz, so they'll increase the dosage again, and they'll be kind of revved up, but their body-
Pete Wright: Because they believe if they're not feeling the jitteriness, then it must not be doing anything.
William Dodson: Exactly. And so what they do is they push themselves over the side of the curve, and it no longer works anymore, just because the dose is too high. Again, people's false beliefs create the problem. Less is more.
Nikki Kinzer: Less is more. And it's interesting, because I remember this conversation happening in Discord, too, where somebody said, "Well, I was recommended to take the weekends off of the medication and just use it for work," and then somebody else popped up and said, "But why is home stuff not as important as work, and don't you want to be at your highest at home, at your best self at home, too?" And I thought that was an interesting point, and I'm glad you're bringing this up, because it's okay to take ADHD medication every day.
William Dodson: Absolutely. And, 24 hours a day. Because again, about 60% of my patients were taking medication so they could sleep normally. The problem here is that the stubborn clog in the pipe are the physicians. We've got plenty of good products out there that people can take, we've got plenty of people who need them. The problem is physicians are not trained. In my residency, ADHD was never mentioned once. Not once. And it's still that way. 93% of adult psychiatry residencies don't mention ADHD at all, even though 20% of the people who walk into psychiatrist's office are going to have ADHD. It's just intentionally neglected. When the American Academic of Pediatrics put out its guidelines two years ago, they said, "These are great guidelines, the problem is half of pediatricians have never been exposed to the topic of ADHD." They know nothing about it, and don't want to know.
William Dodson: So finding yourself a doctor who wants to know, who wants to be good at this is a lot of work. The best [inaudible 00:37:02] to do is go to your local CHADD meeting, or the NADDEA, talk to people who have been through this before. They can tell you who's good, who's not. That's the best way to find somebody. Virtually everybody out there had to be self-taught. ADHD does not have a textbook. So if a doctor said, "I want to get hot with ADHD," not textbook for them to go look at. So that's why most of the docs who do a lot of ADHD work are that way for one out of two reasons. Either they have ADHD themselves, or they've got a family member with ADHD who got terrible care, and so they decided to put in the 1000 hours it takes to teach yourself.
Nikki Kinzer: Well, it's interesting, because it's not even just the medication. My daughter would've been missed if it wasn't me knowing that we needed to keep at it. The primary doctor, "Oh, she doesn't have ADHD, she's fine." Teachers didn't think she had ADHD, "She's fine."
William Dodson: Well, again, the very first piece of research on females with ADHD was published in 2000.
Nikki Kinzer: Wow.
William Dodson: Just 20 years ago.
Nikki Kinzer: That's just 20 years ago.
William Dodson: Up until then, the orthodoxy was that it was strictly a male condition, that women did not get ADHD. Their experience of it is very different from men, because most women are not overtly hyperactive. They tend to be daydreamers, they don't disrupt the classroom. So you'll hear the slang of noisy ADHD and silent ADHD, and really they're talking about males and females. The girls sit in the back of a class, they don't disrupt, and culturally we just don't have the same expectations of females that we do of males. What's the line, the-
Nikki Kinzer: Definite bias.
William Dodson: ... subtle prejudice of low expectations?
Pete Wright: Right in the heart, okay. We've been talking a lot about symptoms, and I just want, we have one of our questions from the community specifically related to someone with a heart condition. Are there ADHD meds that work for a person with a mild heart condition? Stimulants like Adderall seem to be contraindicated. Your take.
William Dodson: The FDA, the people in the neuroscience division, are absolutely sure that these medications are cardiotoxic. The thing is, in 40 years, they just haven't been able to find any evidence whatsoever to support that belief. That doesn't stop them at all. So they've done three very large epidemiological studies, 7.2 million people. And what they found was taking stimulants did not raise your risk of cardiovascular disease one bit. Not at all.
Pete Wright: Wow.
William Dodson: They have a black box warning based on pretty old data, now, it's back in the '60s and '70s of 20 children who died while they were being prescribed stimulant medications. And as you can imagine, when a child dies, it gets autopsied, it gets looked at very closely. Not a single one of the children did the ADHD medication had any role whatsoever. In fact, half of the kids weren't taking the medications, which is also another problem. So that's still in there. Once something gets into the PDR, it never leaves. There are a number of-
Pete Wright: Well, yeah, I can imagine as soon as you start feeling the shakes, and you feel your heart beat fast, all of a sudden it doesn't take a very large leap to get from there and this rumor of studies where kids died to develop a belief system.
William Dodson: Yeah. And the thing is, we go, "Oh my gosh," when we hear the problems. We don't then go and say, "Okay, but following that, they looked at all this, studied it, and they found no connection." In fact, the thing called SUUD, sudden unexplained unexpected death, and it's, there's a background rate about three children per 100,000 will just die for no apparent reason each year. It's tragic, nobody knows why. In adults, it's about eight per 100,000. It runs in families. So this is the one where you hear Uncle Frank died of a heart attack when he was 30, that sort of thing. The slang for it is the U&D syndrome. Some people just up and die.
Pete Wright: Oh.
William Dodson: What they found was that taking stimulant medications for ADHD had a strongly protective effect, it lowered the rate of suddenly dying for no apparent reason. There are about 10 studies using these medications for children with congenital heart defects. As long as you fine-tune the medication, and the heart rate doesn't increase, the blood pressure doesn't increase, what all 10 studies showed, you can still use the first-line medications, and the kids do well. So again, it's just do a simple blood pressure and pulse rate. If you've gone past the sweet spot, the diastolic pressure, the second or lower number will suddenly pop up 10 to 15 points. It's the canary in the mineshaft. So that's the very first side effect. So with my patients, I got a blood pressure and pulse rate at every visit.
Nikki Kinzer: Right, right. So I'm curious, because we've had a lot of questions that have been tossed your way. I want to know from you, what do you think is important for our listeners to know about medication, what kinds of things have you experienced that you think is important they know?
William Dodson: The first thing they need to know is that after 70 years of research, all of the risks are associated with non-treatment, not with treatment. It's the fact that you have a 400% increase in automobile accidents, 400% increase in substance use disorders, tenfold increased in unplanned pregnancy, you just go on and on. An eightfold increase dropping out of school before getting a high school diploma. You find any malady of the human condition, and not treating ADHD will quadruple your risk of bad outcome. There's just no risk for taking the medications. So-
Nikki Kinzer: Gosh. Makes you think you should maybe at least consider trying if it's an issue, yeah.
William Dodson: So confront your fears, try the medication with somebody who knows what they're doing. And once you have real, personal information, then make your decision. But you can decide not to take medication, I don't care what decision you make, but at least make it on reality and facts.
William Dodson: Second thing is find a doc who will help you fine-tune the medication. Most people can tell the difference of three milligrams of medication high or low. So fine-tune-
Nikki Kinzer: Interesting.
William Dodson: ... fine-tune, fine-tune. Right molecule, right dose.
Pete Wright: How long would you expect the fine-tuning process to take to find that sweet spot for you?
William Dodson: Okay, again, because I did nothing but ADHD, I would considerably more [inaudible 00:45:40] than most people. But I would do two medication trials, one on amphetamine, one on methylphenidate, and have them back in two weeks. You can do a trial in a week with the stimulants, because they're immediately effective in an hour. What you see in one hour is everything they're going to do. All the benefits, all the side effects. So you can just, boom, boom, boom, just right on up.
William Dodson: With the alpha agonists, it takes about two weeks to do a single trial. Because, the long story why being, when you change the dose it takes about five days for you to see the benefits develop. With the non-stimulants, a trial takes about six to eight weeks, because those very gradually increase, sort of like the antidepressants, they take eight to 10 weeks to fully develop.
Nikki Kinzer: Right.
William Dodson: So it depends on which medication you're taking, how quickly it can be done. But you should not settle for anything less than, "Wow." I have never, in 42 years worth of practice, had somebody say, "Gee, I'm glad I waited that extra decade before starting medication." What you hear almost 100% is, "What would my life have been like if I had known about this when I was back in school? My life would've been so different." And you almost get a period of, after that first elation of, "Wow, I've finally figured out what's going on with my life," most people will go into a period of mourning, really. "What would my life have been like?" And then, especially with older people, you get another burst of energy, it's sort of, "Time's a-wasting, I've wasted all this time, I am not going to waste another moment," and they go off and have a very rich and active life. But they need to go through that period of mourning of, "Why didn't I try this years ago?"
Pete Wright: Another, I just want to make sure I catch the other sort of random questions that we've gotten here too, we've talked about, I have a feeling I know your answer on this, is there anything we should think about in terms of exercising, any risks with exercising while taking a stimulant?
William Dodson: If you drink coffee, if you drink colas, you're going to get the same amount of stimulation that you would get from your ADHD medication. People are somehow thinking in terms of a speed freak who comes in across the ceiling, no. When you go slightly past your sweet spot, you feel a little racy, like you've had one too many coffees. That's it.
Pete Wright: Okay, all right. Is it possible to be on a stimulant medication for a long period of time, let's say over 10 years, and find it's no longer working. Is that a thing?
William Dodson: It is exceedingly rare. In 42 years of practice, I had six cases like that. And it's usually, the person just wakes up one morning and their medication's not working. Not working at all, they can raise the dose, they can eat it like Chiclets out of a candy dish, and it's just not working. There are a couple of theories about why that happens. If you stop the medication for about two weeks and then restart, you're back, it's working again.
Pete Wright: Huh. So you just need to kick it.
William Dodson: Well, I'm not sure ... Yeah, we just took two weeks out of the air, not the magic [crosstalk 00:49:39]-
Nikki Kinzer: Yeah, right, could be anything, yeah.
William Dodson: But it will restart. And it's very rare to happen, it happens suddenly. The other place where it happens is women going through menopause. Estrogen is absolutely necessary for the ADHD stimulants to work well, and so you'll hear from women, women with ADHD will have premenstrual dysphoric disorder, which is the new term for PMS, much more severely, much more frequently than women who don't have ADHD. And they will find that the five days right before their menstrual flow, their ADHD stimulant doesn't work worth a hoot. They can raise the dose, they can try all sorts of stuff ...
Nikki Kinzer: Doesn't matter.
William Dodson: Doesn't change. As soon as they have the menstrual flow and estrogen gets produced again, it works again. And so what we've found is that you don't need physiologic levels of estrogen, which are three to 400, 125 to 150 nanograms per milliliter is enough for the stimulant medications to work perfectly well. So you see it in that five days before the menstrual flow, and in post-menopausal women. They'll come out and say, "My ADHD medication doesn't work. I can't sleep, my math ability has just gone to hell. I can't calculate the tip on a check." And so for those women, if you can find a doctor who'll do it, hormone replacement therapy works wonders. And again, you can do it at very low levels.
Nikki Kinzer: I'm glad you brought that up.
William Dodson: Those are the two places where you'll just sort of suddenly see it not work.
Pete Wright: Okay, okay. We've got a comment on long-acting versus short-acting, and it's actually come through twice. The first was with the pregnant or breastfeeding, and I think you answered that, but if you have any more comments related specifically to would short-acting stimulants be a better choice than long-acting while pregnant or breastfeeding? The other is, related to your comment earlier in the show on sleep, would you normally recommend a long-acting or short-acting stimulant for someone to take at night for sleep?
William Dodson: I always, doesn't matter what time of day it is, I always recommend extended release medications. If you can get them and the insurance company is the slightest bit cooperative, I'll always take extended release. Immediate release products are a false economy. And again, there've been dozens of studies on this. If somebody is taking immediate release medication, they'll get the first pill of the day in pretty regularly. But the chances of forgetting the pills for the rest of the day-
Nikki Kinzer: Oh, gosh.
William Dodson: ... runs somewhere around 90%.
Nikki Kinzer: Oh, easily.
Pete Wright: Yeah, easy.
Nikki Kinzer: I see it in my coaching clients all the time. Yeah, yeah.
William Dodson: Right. If the medication doesn't get in, it's, yeah, it's-
Nikki Kinzer: Out of sight, out of mind, yeah.
William Dodson: Yeah, why bother? So for my patients, it's extended release, extended release. It's convenient, it makes sure the medication gets in, they're smoother, both in onset and offset. You don't usually see the crash at the end the way you do with immediate release products. So there's just no comparison.
Pete Wright: That's amazing. I have a feeling that-
Nikki Kinzer: Wow, this is so informational.
Pete Wright: ... the people listening to the show are going to have the best night of sleep of their lives tonight. I can't [crosstalk 00:53:31]-
William Dodson: Try that no-risk trial nap after lunch, make sure that works.
Pete Wright: Yep, no-risk trial nap after lunch, I love it.
Nikki Kinzer: [crosstalk 00:53:36]-
William Dodson: I don't want to get emails tomorrow morning-
Nikki Kinzer: Emails coming your way.
Pete Wright: Hey, everybody, be more tired, leave him alone.
Nikki Kinzer: So at the beginning of the show, you were talking about extending your research with RSD, and you need some help doing that, right?
William Dodson: We're doing the first study to validate the existence that, yes, rejection-sensitivity disorder is a thing, it really does exist, and it's highly associated with ADHD. And so we need research subjects, both people who have ADHD and people who don't have ADHD for the control group. So if people would like to contribute 20 minutes of their lives to be subjects in this very first piece of research, just, you have to be over the age of 18, and your ADHD has to be clinician-diagnosed, you can't have done it on your own, type of thing, but a physician somewhere has to have made a diagnosis. Just send it to my email, and it's, get something to write this down. It's not hard, but I would forget it. It's billdodson, D-O-D-S-O-N, 19@gmail. Billdodson19@gmail, and then I send them on to somebody else, and they will give you a call and have you fill out the checklist and things like that.
Nikki Kinzer: And what are the criteria for people that don't have ADHD? Were you looking for those people too?
William Dodson: Anybody.
Nikki Kinzer: Anyone, okay.
Pete Wright: Just the criteria is don't have ADHD?
William Dodson: So long as they're over the age ... Yeah.
Nikki Kinzer: Well, I was going to say, I don't, so I can be one of those people that help you on the non-ADHD side.
Pete Wright: All right, that'll be in the show notes everybody, take a look out. Contribute to this study, if that conversation that we had introducing RSD to you meant anything to you and your relationship with ADHD, help the cause, join Bill in this research. Fantastic. Bill, as always, you're an amazing resource, thanks so much for your [crosstalk 00:56:02]-
Nikki Kinzer: Thank you so much.
Pete Wright: ... [inaudible 00:56:03] your weight here, it's been really, really great. Where would you, do you want people to go anywhere, to learn anything? You're retired, you take everything offline, you've got nothing to plug? What are you doing? What are you doing right now?
William Dodson: I'm doing two things. One of them is trying to write that book that doesn't exist. A book for both people who have ADHD and their clinicians that just walk people through, "This is how you get a good result with ADHD medications. This is why so many of the non-medication-based therapies fail," there's a good reason for that, and so that you can know which ones to put your time and money into, and which ones not to do that with. So I write very slowly. But it's almost done. And the other part of my time is I work with homeless adolescents in downtown Denver. About 80% of homeless people have ADHD.
Nikki Kinzer: Yeah, I could see that.
William Dodson: So again, ADHD is not a benign condition. A couple of months ago I had a colleague talk about the fact that he thought ADHD was an optional disorder, and it was optional whether you looked for it, and if you found it it was optional whether you treat it or not.
Nikki Kinzer: Oh boy.
William Dodson: And I refrained from choking him.
Nikki Kinzer: I was going to say, yeah, had to have taken some self-control not to ... Yeah.
William Dodson: But we did a little continuing medical education right there on the spot.
Nikki Kinzer: Oh, I'm sure, yeah.
William Dodson: But there are a lot of docs out there that are like that. MedScape did a study a couple of years ago, 46% of practicing physicians didn't think that ADHD existed.
Nikki Kinzer: It's crazy. It's crazy.
Pete Wright: That's a disappointing number.
Nikki Kinzer: It is, it is. And I tell people, when I talk to clients, and we've done this on the show, too. If something's not right, if it's not sitting with you right on that first visit or with your doctor, get a different one. Get a new one.
Pete Wright: [crosstalk 00:58:22]. Yeah, [crosstalk 00:58:22].
Nikki Kinzer: Yeah, yeah. Absolutely. Well, we appreciate you coming and we appreciate all the work and everything you've done in the ADHD community, and we just, I look forward to the book, and the research on RSD, and going to keep learning from everything else you've done in the past, too. So we really appreciate you, thank you so much.
William Dodson: Thank you very much.
Pete Wright: And we appreciate all of you downloading and listening to this show, thank you for your time and attention. Don't forget, if you have something to contribute to the conversation, head over to the show talk channel in the Discord server, that's where we'll be. You can join us right there by becoming a supporting member at the deluxe level. On behalf of Nikki Kinzer and Dr. Bill Dodson, I'm Pete Wright. We'll see you right here next week on Taking Control, the ADHD podcast.
