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Column originally published Sep 26, 2023

There Is No Best Medicine For ADHD, Use Long-Acting Medications

Question: Our ten-year-old son was recently diagnosed with ADHD. His teachers started raising concerns almost on day one. He has to be the first in lineups; this led to many conflicts with his classmates. In class, he constantly interrupts the teacher, talks to friends, and makes jokes. However, when he was asked questions, he could give correct answers. Homework is a nightmare; if we can coax him with rewards, it would take so long that we often give up. He is a split image of my younger brother who struggled through school but somehow graduated high school. He was diagnosed with ADHD in middle school, and given Ritalin pills. This turned him into a zombie; my parents stopped them after a few days. He dropped out of college, and works as labourer, although he is so smart. He smokes weed all the time; he says this calms his brain. I don’t want our son to follow this path. Is there such a thing as a perfect ADHD medicine?


The short answer is no, unfortunately. We all wish that there is a magic pill that can cure ADHD. Your description of your son (and your brother) is typical of many hyperactive and impulsive boys, doing things without thinking. Many girls, and some boys, however, are daydreamers who have difficulty paying attention; they are much harder to recognize. Their hyperactivity is in the brain.

Attention deficit hyperactivity disorder (ADHD) is a genetic condition, passed on from parents to children. That is why you see similarities between your brother and your son. Unfortunately, your brother didn’t receive proper treatment and didn’t do as well in school, and now dependent on cannabis.

The most effective treatment for ADHD is stimulant medications: methylphenidate (Ritalin) and dextroamphetamine (Dexedrine); both of them were discovered over a century ago. There were only short-acting formulations available before; they were quickly absorbed and could reduce hyperactivity rapidly. As a result, parent thought the pills were turning their kids into zombies.

In the last two decades, scientists have engineered ways to slow down the absorption or delivery of these medications to the brain, making them work better and longer.

There are three formulations of Ritalin-based medicine: Biphentin, Concerta, and Foquest. Biphentin delivers more medicine in the morning than the other two, and works for 6 to 8 hours. The capsules can be opened and sprinkled on food, which is helpful when children cannot swallow pills. It is less effective later in the day for homework and after-school activities.

Both Concerta and Foquest have special mechanisms that make them work smoother and longer, up to 14 hours for Foquest. This is ideal for older children and adults. One word of caution: there is a generic version of Concerta which doesn’t work well; Health Canada should never have approved it. Pharmacies can get copay cards that can pay for the difference between generic and brand- name versions of Concerta. Your doctor has to write “no substitution” on the prescription.

Dexedrine has two long-acting formulations: Adderall XR and Vyvanse. Adderall XR works for about 8 hours. Unfortunately, it is more easy to be abused and is sold on the street. Vyvanse is produced by combining Dexedrine with lysine (an amino acid). There is an enzyme in our blood that removes lysine from Vyvanse and releases Dexedrine to the brain slowly. It is effective for up to 12 hours, and virtually impossible to be abused.

These medications can calm the brain of children and adults with ADHD, allow them to focus on things that they have to do. They can reduce distraction and impulsivity, improve motivation and organization. Some work longer than others. It is impossible to know which one is better until we try. Some laboratories claim that genetic tests can predict favourable response to certain ADHD medications, but they are not accurate.

All ADHD medications can reduce appetite at lunch. I suggest my patients to eat healthy food, eat what they can, and drink lots of water. Over time, side effects will decrease. Start medicine at a low dose and gradually increase over days to weeks, monitor for benefits and side effects. Almost always, we can find a medicine that works well for most of the day with very little side effect.

I hope this helps you to discuss treatment plan with your physician.