When I see a new patient on my roster with a chief complaint of “focus difficulties,” “ADHD,” or “my therapist told me to talk to you about how I cannot remember anything,” I pause. Though prescribing ADHD medication may seem like the obvious next step, the reality is that these meds are complex and come with their own particular quirks and considerations.
ADHD medications typically fall into one of two categories: stimulant or non-stimulant. Both of these may be appropriate for patients to use — but with stimulants, we clinicians have additional concerns and responsibilities. How do we determine dosing? How do we caution against potential abuse of medications, or addiction? How do we handle ongoing shortages of these medications, or manage transfers?
Stimulant ADHD medications fall into two subgroups, the methylphenidates (such as Ritalin or Concerta), and the amphetamines (like Adderall and Vyvanse). Both of these subgroups are classified as Schedule II drugs on the DEA website, which ranks these substances based on their medical use and abuse or addictive potential. The Schedule II drugs are the highest level that we currently prescribe, with the resultant highest restrictions to their use. We as prescribers cannot simply write for these meds without serious consideration and oversight.
When a patient comes to me seeking stimulant ADHD medication, I always have a detailed conversation with them. I tell them that stimulants are one of the very few medications I prescribe that they will feel, a palpable response that they should not equate with efficacy. It’s a tough concept to grasp, like being told that the restaurant you love doesn’t actually smell like basil: it doesn’t match up with our senses, and seems dishonest. However, as I tell patients, side effects of medications don’t always have to be bad.
Commonly, patients complain of headaches, stomachaches, insomnia, agitation and irritability, and anxiety. With stimulants, however, I see a lot of those complaints cast to the side in comparison to what patients report as activation, energy, feeling “on edge,” and better focus. It can be hard for them to admit that they are having more trouble with sleep, for example, if they fear that I might advise reducing or eliminating a stimulant in favor of other alternatives.
We are wired for certain chemicals and hormones. Stimulants work in part on our dopamine channels, our “reward” channels. Why would any of us want less of that? We are born with the desire to seek comfort rather than pain, safety rather than risk, and love rather than disdain. Given the choice between an easier path, and the more trepidatious alternative, who can blame us for choosing the former? And yet, stimulants are not a silver bullet — they can have real side effects and downstream consequences, much as we may try to downplay them.
We are human, and fallible — both as clinicians and as patients. When something works for us, we wish to continue on that path, sometimes to the exclusion of other choices. As clinicians, if a patient reports that their symptoms are controlled, their lives are better, we are validated and encouraged. But there can always be too much of a good thing.
I liken this effect to “nose blindness,” or our body’s need to acclimatize such that we can continue to experience change and contrast as it presents itself. We enter a room where someone is burning a candle, for example. We smell it; it fills the room with scent. However, after a short while, we no longer feel the scent as strong, it seems to diminish, we “get used to it.” Does it, though? Has the smell lessened, or have we adjusted to it? The side effects of stimulants work in a similar fashion: their ability to keep us awake, to quell our appetite, or how strongly we feel them working will always diminish to some extent. Thus, those fading side effects may create the cycle that leads to abuse, or addiction: We seek more of those feelings, rather than the treatment of our symptoms.
There is no doubt that stimulant medications will need adjustments along the way to optimal dosing. Though my patients may wish to just grab the prescription and go, I find that explaining to them that these medications are simply tools that we can use to help treat the neurodevelopmental disorder that affects their focus often results in a more realistic expectation. We cannot rely solely on what our body is reporting to us as the measure of efficacy, or to determine the need for more medication. It is a more objective view of our symptoms and treatment options that will allow us to arrive at a balanced medication plan. With reasonable expectations, open communication, caution, and compassion, we are far more likely to arrive at a beneficial and safe treatment course.
How do you talk to your patients about ADHD meds? Share in the comments.
Chris van Eyck, DMSc, PA-C, MSHS is a psychiatric physician associate working in psychiatry in Northern Virginia. He was a 2023–2024 and 2024–2025 Doximity Op-Med Fellow.
Illustration by Diana Connolly
