At Florida Detox, our clinical research demonstrates that over 50 percent of our opioid dependent patients suffer from undiagnosed/untreated Attention Deficit Disorder ( ADD ) or Attention Deficit Hyperactivity Disorder ( ADHD ). Most of our cocaine dependent patients and many of our alcohol patients also suffer from ADD or ADHD. Many of these patients "feel more normal" when using Oxycontin, Vicodin, alcohol or cocaine. These drugs produce a temporary increase of dopamine, in the prefrontal cortex ( ADD area ) of the brain. This effectually allows the patient to self-medicate their genetic dopamine deficiency. Relapse rates are much lower, when ADD and ADHD are accurately diagnosed and adequately treated.

With the advent of neuroimaging, there is no longer a scientific dispute over the reality of the ADD and ADHD diagnoses.  Single photon emission computed tomography ( SPECT ) and positron emission tomography ( PET ) neuroimaging demonstrate altered brain blood flow distribution in ADD and ADHD.    Increased dopamine transporter reuptake has also been found in ADHD subjects. (increased dopamine reuptake decreases  dopamine availability to the next neuron, decreasing firing of brain dopamine circuits)  Recent research reveals decreased brain volume in both un-medicated and medicated ADHD patients. Decreased essential fatty acid levels have also been measured in ADHD patients These recent scientific observations help explain the beneficial effect of psychostimulant medication, targeted amino acid therapy and essential fatty acid supplementation in patients suffering from ADHD and ADD.

Percocet, Vicodin, and Oxycontin increase dopamine release from nerve A to nerve B, in the brain.  Opiate medications initially help the ADD patient feel more focused, when the overactive brain begins relaxing.  ADD patients also use alcohol to relax and allow sleep.  Patients describe a "freight train of thoughts"  traveling through their mind, while they attempt to fall asleep.  Cocaine is often used by ADD patients to normalize dopamine levels, in their prefrontal cortex.

Many corporate executives seeking treatment, at Florida Detox, were self medicating with both oxycontin and cocaine to manage their ADD.  ADD patients with high IQ are seldom diagnosed in school, since they perform well academically, despite poor focus.

The prefrontal cortex is the executive center of the brain.  Ordinarily, the prefrontal cortex filters extraneous stimuli protecting the rest of the cortex from distraction.  Other tasks performed by the prefrontal cortex include braking racing thoughts, controlling mood swings, decreasing verbal and physical impulsivity and prioritizing tasks.

When the prefrontal cortex in understimulated, secondary to inadequate dopamine levels, it can not perform it's job.  Patients fight continuous boredom, lack of focus, mood swings, and lack of task completion.  They often feel they can not turn down their brain, at night.  Many patients wake up, at  700 AM, but feel their brain does not wake up, till 1000 AM. They experience difficulty prioritizing the morning's tasks.

ALTERED BRAIN GLUCOSE DISTRIBUTION IN ADD and ADHD

SPECT and PET Brain neuroimaging scans reveal altered brain blood flow distribution and brain glucose utilization in ADD and ADHD patients.  Normally, when the brain concentrates, faster beta brain waves increase, in frontal brain lobes.  When brainwaves of ADD children and teenagers were measured, using electroencephalograms ( EEG ), faster beta waves did not increase. Instead, slower alpha waves increased, during concentration tasks, in children suffering from ADD.

Dopamine activity should increase in the prefrontal cortex, during concentration.

The brain's basal ganglia produce much of the brain dopamine supply. Studies reveal smaller basal ganglia volume in ADD brains. The basal ganglia contain dopamine circuits extending through the limbic region of the brain, to the prefrontal cortex.  If inadequate dopamine is produced, in the basal ganglia, the prefrontal cortex usually lacks sufficient dopamine to activate, when increased concentration is required.

The following SPECT brain scans  are used with permission from Daniel Amen, MD, who has viewed over 28,000 SPECT brain scans.  Many additional brain scans are viewable at his extremely informative website, amenclinics.com.  Dr. Amen has authored many excellent books, including Healing ADD: The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD

We highly recommend his website and books. AD/HD, combined type with both symptoms of inattention and hyperactivity-impulsivity. Brain SPECT imaging typically shows decreased activity in the basal ganglia and prefrontal cortex during a concentration task. This subtype of ADD typically responds best to psychostimulant medication

 In a study of 54 medication free children, diagnosed with ADHD, 65 percent displayed prefrontal lobe deactivation, during intellectual stress, compared to 5 percent of the non-ADHD comparison group. (p=.0001) (Statistically, a difference this large, in a study population, of this size could occur, once in 10,000 times, by chance.)   "Prefrontal lobe functions include attention span, concentration, judgment, activity level, critical thinking and impulse control."  Thirty four percent of the ADHD children did not display decreased prefrontal lobe activity with intellectual stress, however 63 percent, of those who did not suppress prefrontal lobe function, during concentration, displayed reduced prefrontal lobe activation, at rest.  When ADHD children who exhibited decreased prefrontal lobe activation, during intellectual stress (65 percent) are combined with the ADHD children, who exhibited reduced prefrontal lobe activity, at rest (22 percent), 87 percent of the medication free ADHD children exhibited decreased prefrontal lobe activity. Amen, DG, Paldi, JH, Thisted, R  Evaluating ADHD with Brain SPECT Imaging  J of Child and Adol Psychiatry 32:1080-1081, 19932. AD/HD, primarily inattentive subtype with symptoms of inattention and also chronic boredom, decreased motivation, internal preoccupation and low energy. Brain SPECT imaging typically shows decreased activity in the basal ganglia and dorsal lateral prefrontal cortex during a concentration task. This subtype of ADD also typically responds best to psychostimulant medication.

 3. Overfocused ADD, with symptoms of trouble shifting attention, cognitive inflexibility, difficulty with transitions, excessive worrying, and oppositional and argumentative behavior. There are often also symptoms of inattention and hyperactivity-impulsivity. Brain SPECT imaging typically shows increased activity in the anterior cingulate gyrus and decreased prefrontal cortex activity. This subtype typically responds best to medications that enhance both serotonin and dopamine availability in the brain, such as venlafaxine or a combination of an SSRI (such as fluoxetine or sertraline) and a psychostimulant.

 4. Temporal lobe ADD, with symptoms of inattention and/or hyperactivity-impulsivity and mood instability, aggression, mild paranoia, anxiety with little provocation, atypical headaches or abdominal pain, visual or auditory illusions, and learning problems (especially reading and auditory processing). Brain SPECT imaging typically shows decreased or increased activity in the temporal lobes with decreased prefrontal cortex activity. Aggression tends to be more common with left temporal lobe abnormalities. This subtype typically responds best to anticonvulsant medications (such as gabapentin, divalproate, or carbamazepine and a psychostimulant.

 INCREASED DOPAMINE TRANSPORTER REUPTAKE IN ADHD

In a study of six adult patients with ADHD, single photon emission computed tomography  ( SPECT ) imaging revealed a 70 percent increase in dopamine transporter density, compared to 30 healthy control subjects. The dopamine transporter essentially recycles dopamine, from the neurosynapse, to the afferent (upstream) neuron, reducing the effect of dopamine. Higher dopamine levels are associated with  motivation, drive, satisfaction, increased concentration and mental performance. Patients were excluded from the study, for the following: other evident psychiatric impairment, known drug or alcohol dependency, known drug allergy, or medication within past month, with dopamine altering medication. Dougherty DD, Bonab AA, Spencer TJ, Rauch SL, Madras BK, Fischman AJ.

Dopamine transporter density in patients with attention deficit hyperactivity disorder.
 

Lancet 1999 Dec 18-25;354(9196):2132-3

DECREASED BRAIN VOLUME IN UNMEDICATED AND MEDICATED CHILD AND ADOLESCENT ADHD PATIENTS

A study of 152 children and adolescents with ADHD and 139 age and sex matched controls, detected decreased brain volumes, in unmedicated and medicated ADHD subjects, compared to the control group.  The ADHD patients exhibited  total cerebral volumes 3.2 percent lower, (p = .004), and cerebellar volumes 3.5 percent lower (p = .001), compared to controls.  Previously unmedicated ADHD patients exhibited 5.8 percent lower, (p = .002) cerebral volumes and 6.2 percent lower (p < .001) cerebellar volumes. Compared to controls,  unmedicated ADHD children exhibited larger decreases in total white matter, 10.7 percent, (p < .001),than medicated children with ADHD, who exhibited 8.9 percent decreases (p < .001) in total white matter.Brain volumes were determined using automated  magnetic resonance imaging ( MRI ).  ADHD neuroimaging studies have been frequently criticized, with differences between ADHD subjects and controls attributed to effects of medication, since most ADHD studies have failed to include unmedicated ADHD subjects.  This study disputes these claims, since it found unmedicated ADHD subjects had significantly smaller white matter volume, compared to medicated ADHD subjects and controls.   Differences detected persisted after statistical correction for height, weight and handedness. F. Xavier Castellanos, MD; Patti P. Lee, MD; Wendy Sharp, MSW; Neal O. Jeffries, PhD; Deanna K. Greenstein, PhD; Liv S. Clasen, PhD; Jonathan D. Blumenthal, MA; Regina S. James, MD; Christen L. Ebens, BA; James M. Walter, MA; Alex Zijdenbos, PhD; Alan C. Evans, PhD; Jay N. Giedd, MD; Judith L. Rapoport, MD.  Developmental Trajectories of Brain Volume Abnormalities in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder JAMA. 2002;288:1740-1748(The entire JAMA article is available on the internet, in pdf format, at intramural.nimh.nih.gov/chp/adhd/castellanos.pdf ) 

ATTENTION DEFICIT DISORDER AND SUBSTANCE ABUSE

Adolescent substance abusers with ADHD were 2.5 times more likely to suffer alcohol relapse, than adolescent substance abusers without ADHD. This study was conducted in a drug treatment study of 220 adolescent substance abusers.  The higher risk for alcohol relapse persisted after statistical corrections for conduct disorder,  pre-treatment  alcohol use frequency and demographics were made.  Latimer WW; Ernst J; Hennessey J; Stinchfield RD; Winters KC. Relapse among adolescent drug abusers following treatment: The role of probable ADHD status. Journal of Child & Adolescent Substance Abuse 13(3): 1-16, 2004.In a study of 314  alcoholics of German descent, 21 percent were diagnosed with ADHD, with symptoms persisting in adulthood. Wodarz N, Lange K, Laufkotter R, Johann M. [ADHD and alcohol dependence: a common genetic predisposition?] Psychiatr Prax. 2004 Nov;31 Suppl 1:S111-3.

PSYCHOSTIMULANT MEDICATION  DECREASED SUBSTANCE ABUSE DISORDERS, IN MALE ADOLESCENTS

Unmedicated adolescent males with ADHD were 6.3 times (adjusted OR: 6.3 [1.8-21.6]) more likely to report substance abuse disorders than non ADHD control subjects in a study of 56 medicated ADHD subjects, 19 nonmedicated ADHD subjects and 137 non ADHD control subjects.  The prevalence of  substance abuse disorders  in medicated ADHD subjects was only 15 percent (adjusted OR: 0.15 [0.04-0.6]) of the rate of substance abuse, in non medicated ADHD subjects.  In other words, ADHD medication was associated with an 85 percent decrease in substance abuse disorders, in the 75 ADHD adolescent males.   Abused substances evaluated included alcohol, marijuana, hallucinogens, stimulants and tobacco.  Decreased substance abuse occurred, in the medicated ADHD group, compared to the non ADHD group, for each of the substances studied.   Joseph Biederman, MD, Timothy Wilens, MD, Eric Mick, ScDv, Thomas Spencer, MD, and Stephen V. Faraone, PhD.  Pharmacotherapy of Attention-deficit/Hyperactivity Disorder Reduces Risk for Substance Use Disorder PEDIATRICS Vol. 104 No. 2 August 1999, p. e20   (This article is available in PDF format, at pediatrics.aappublications.org/cgi/reprint/104/2/e20) Dr. Bankole Johnson, Chairman of Psychiatric Medicine, at University of Virgina, states "Dopamine is responsible for a lot of pleasureable experiences."  Eating triples dopamine levels. "Sex is 10 times the normal surge and cocaine is 100 times the normal surge. If you told someone to give up sex, it would be very hard, so you can imagine how hard it is to ask someone to give up cocaine."  Charlottesville Daily Progress, May 31, 2006Newer research  indicates enhancing glutamate levels decreases ADD symptoms.  Provigil (modafinal) has been primarily used for narcolepsy and shift work sleep disorders, but has proven effective for attention deficit and cocaine treatment.ADHD Psychostimulant Medications Are Safer Than Aspirin And Auto Travel Adderall, Ritalin and other psychostimulant medications, for ADHD, are safer than Aspirin, Acetaminophen and automobile travel. The annual risk of being struck by lightning is 33 times higher than the risk of a serious cardiac event, for adults, treated with psychostimulants.


The following probabilities help place these risks in perspective

Annual risk per 100,000 persons or patients : Adults without high blood pressure, psychostimulant fatalities, 0.05/100,000

Adult psychostimulant fatalities, 0.125/100,000Psychostimulant fatalities per patient, (includes children),0.18/100,000

Psychostimulant adverse cardiac events, (includes children),0.56/100,000

Being struck by lightning,  4.2/100,000

Viagra fatalities per patient,  5.0/100,000

Auto travel fatality risk,     16/100,000 NSAID Deaths per arthritis patient,   38.3/100,000
(aspirin, Motrin, Advil, Feldene, Clinoril, Indocin, Daypro, Aleve, etc.)

Fatalities/acetaminophen(Tylenol) overdose,   360/100,000

Auto property damage collision,   10,000/100,000


Data and annual risk probabilities, for the preceding table and chart were derived from the following sources: Between 1999 and 2003, 25 people had died suddenly, and 54 suffered serious cardiac events such as a stroke, heart attack, hypertension or arrhythmia, while taking psychostimulant medications. www.healthyskepticism.org/library/ref.php

About 2.5 million children and teens take ADHD medications. Most of the drugs contain methylphenidate, found in Ritalin and Concerta and many generic ADHD medications. An estimated 1 million adults also use psychostimulant medications. (The National Institutes of Mental Health estimates 68 % of adolescents with ADHD continue to experience adult ADHD) www.healthyskepticism.org/library/ref.php

Using these numbers, the probability of a cardiac fatality was 0.18 in 100,000, annually, for patients using Ritalin, Concerta or Adderall, during the 4 year reporting period. This fatality rate is much lower than the fatality rate for Viagra, aspirin or automobile travel and less than the probability of being struck by lightning.

The Association of Reproductive Health Professionals cites a mortality rate of five per 100,000 for Viagra, the erectile dysfunction drug.

A 1998 article in the New England Journal of Medicine estimated that non steroidal anti-inflammatory medications cause 16,500 deaths annually in arthritis sufferers.

www.arthritis-depot.info/articles/arthritis-and-pain-relief-medications-cause-16500-deaths-per-year

The Arthritis Foundation estimated there were 43, 000,000 arthritis sufferers, in the United States, in 1998. www.arthritis.org/resources/gettingstarted/default.asp

These medications include aspirin, Motrin, Aleve, Naproxn, Feldene, Sulindac, Toradol and Indocin. Assuming every arthritis sufferer, in the United States, in 1998, used non steroidal anti-inflammatory medications, the annual fatality risk was 38.3 per 100,000.

Another common activity, with a higher fatality risk than psychostimulant medication is automobile travel. Although motor-vehicle accidents claimed 43,300 lives in 1996, the rate per 100,000 Americans has dropped significantly in the last two decades because of safer cars, safer roads, and efforts to curb drunk driving, says Alan Hoskin, manager of research and statistics at NSC. The 1996 rate of 16 automobile travel deaths annually per 100,000 population was down 18 percent from 1986, and down 41 percent from 1966 www.defendu.com/realrisk

The Toxic Exposure Surveillance System (TESS) for 2003 showed an increase in acetaminophen poisonings with 40,833 accidental overdoses leading to 147 fatalities. Acetaminophen produced 360 deaths/100,000 overdoses.

Our 80 year lifetime probability of being struck by lightning is 1 in 3,000. www.lightningsafety.noaa.gov/medical.htm

A 1 in 3,000 risk, in 80 years is a 4.2 per 100,000 annual risk of being struck by lightning and much higher than a 0.18 in 100,000 annual risk of a cardiac fatality, on psychostimulant medication. Our risk of being struck by lightning is much higher than the risk of a cardiac death, from psychostimulant medication!

How much sleep are you losing, worrying about being struck by lightning?

Florida Detox uses Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) diagnostic screens, which have been well validated by SPECT brain scans. We also confirm our Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder diagnosis with neurotransmitter testing for homovanillic acid, phenylethylamine and hydRoxy indole acetic acid.


Although Florida Detox believes Adderall medication is very safe when used properly, for Attention Deficit Disorders, we do recommend nutritional therapies including high dose EPA and DHA essential fatty acids, tyrosine, phenylalanine, micuna, S-Adenosyl Methionine, folate, and ferrous bisglycinate supplementation, based on test results. Thyroid hormone supplementation can reduce attention deficit disorder symptoms, when patients are hypothyroid. Deprenyl (Selegiline) medication can also enhance dopamine levels and reduce attention deficit disorder symptoms.

Food and food additive allergies and nutritional deficiencies also can cause or aggravate Attention Deficit Disorders. One of our Attention Deficit patients tested allergic to Yellow #5 food dye, in a serum immunoglobin test. Many of our patients with ADD/ADHD have low ferritin levels, especially if they suffer from restless leg syndrome. Increasing ferritin nutritionally can reduce Attention Deficit Disorders, if ferritin level is low. GENETIC EVIDENCEADHD occurred twice as often in full siblings, compared to half siblings in a study of ADHD children who were placed in foster care.  ).  Safer DJ. A familial factor in minimal brain dysfunction. Behav Genet. 1973;3(2):175-186.

ESSENTIAL FATTY ACIDS AND ADHD

Neurotransmitter receptors are located on cell membranes.  Receptor membrane permeability strongly influences neurotransmitter firing in the brain. Cell membranes contain layers of fatty acids called phospholipids.  Highly unsaturated fatty acids, including Decosahexanoeic Acid ( DHA ), and Eicosapentaenioc Acid ( EPA )  build membranes which flow nutrients and wastes  more easily.  Considerable research indicates higher intake of  the essential fatty acids Decosahexanoeic Acid ( DHA )  Eicosapentaenioc Acid ( EPA )  and Arachidonic Acid ( AA ) deceases symptoms of  Attention Deficit Disorders.Purdue University researchers studied 53 boys with ADHD and found significantly lower levels of  Arachidonic Acid ( AA ), Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid ( DHA ) in plasma lipids, compared to 43 boys, without ADHD.  Red blood cell  lipid  Arachidonic Acid ( AA ) and  Docosatetraenoic Acid  were also significantly lower, in the 53 boys with ADHD.  A subgroup of 21 boys with ADHD and more numerous symptoms of essential fatty acid deficiency, possessed considerably lower  Arachidonic Acid ( AA ) and Docosahexaenoic Acid ( DHA ), than 32 ADHD boys, with fewer essential fatty acid symptoms. LJ Stevens, SS Zentall, JL Deck, ML Abate, BA Watkins, SR Lipp and JR Burgess. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder.  American Journal of Clinical Nutrition, Vol 62, 761-768The Omega 3 essential fatty acids, Eicosapentaenoic Acid ( EPA ) and Docosahexaenoic Acid ( DHA ) appear especially helpful, in ADD or ADHD.  Frontal cortex dopamine levels  decreased 40 to 60 percent, in rats fed an Omega 3 fatty acid deficient diet. Dopamine release was 90 percent lower in the Omega 3 deficient rats.  Logan, Alan C.  Neurobehavioral aspects of omega-3 fatty acids: possible mechanisms and therapeutic value in major depression Alternative Medicine Review; 11/1/2003Many anecdotal case history reports of decreased attention deficit symptoms, after essential fatty supplementation, have been published on attention deficit bulletin boards and self help sites.

S-ADENOSYL METHIONINES-Adenosyl Methionine (SAMe) is the activated form of the amino acid methionine.  It is available, without a prescription, at  health food stores.  SAMe has activity at dopamine and norepinephrine receptors.  In a small 8 person open label trial, 75 percent of adult male ADHD subjects exhibited moderate to marked improvement, in ADHD symptoms. Patients who failed to improve, also failed to improve with methylphenidate (Ritalin).Shekim, W., Antun, F., Hanna,G., McCracken, J., Hess, E. S-adenosyl-L-methionine (SAM) in adults with ADHD, RS: preliminary results from an open trial. Psychopharmacol Bull . 1990;26(2):249-53 AMINO ACID SUPPLEMENTATIONThe naturally occurring amino acids l- tyrosine and l-phenylalanine are enzymatically transformed to dopamine.  Tyrosine or phenylalanine supplementation can reduce attention deficit symptoms.

At Florida Detox, Dr. Sponaugle considers us to be in a race to reduce or eliminate alcohol or drug withdrawal symptoms, before they trigger a relapse.  Since prescription medications usually work faster, we generally use them first.  Frequently, we can replace all or part of an Adderall dose with the naturally occurring amino acid, Tyrosine.  Since Tyrosine is naturally occurring, it is available at health food stores, and is relatively inexpensive.  It needs to be taken on an empty stomach, or at least separated an hour from other proteins or amino acids.  It is more effective taken sublingually, (under the tongue).  This is done by emptying a 500 milligram powder capsule, under the tongue and holding the powder, for about 2 minutes, before swallowing.  This allows the amino acid to be absorbed into the mucous membrane, directly into the bloodstream, and increases absorption of the tyrosine.  The 500 milligram powder capsule is available at almost any health food store.  General Nutrition Centers stock a 750 milligram tablet, which may be chewed, before holding under the tongue.  We have a patient who successfully replaced 20 milligrams Adderall, taken 3 times per day (TID), using this method, while he waited for his appointment with a local doctor,  willing to continue prescribing Adderall for him. Dosage used to replace Adderall or reduce or eliminate cocaine cravings is 1,500 to 6,000 milligrams per day, split into  at least two doses, per day. PLEASE DO NOT DISCONTINUE ADDERALL MEDICATION, ABRUPTLY, WITHOUT CONSULTING A PHYSICIAN.  In some patients, tyrosine may decrease in effectiveness, with time.  Decreased conversion of tyrosine to dopamine, occurs due to down regulation of tyrosine hydoxylase, by norepinephrine.  Recently, concentrated herbal extracts of a plant, called Mucuna Pruriens, which concentrates l dopa, have become available.  Since conversion of l dopa to dopamine, is not downregulated, by increased dopamine and norepinephrine levels, Mucuna supplementation could be continued indefinitely, without reduction in dopamine levels.  MUCUNA SUPPLEMENTATION SHOULD NOT BE DONE WITHOUT SUPERVISION, OR CONSULTATION, BY A PHYSICIAN.  Excess Dopamine production can cause low blood pressure, headache, tremors, eyelid tics, paranoia and hypomania or mania.  Tyrosine and Mucuna supplementation can potentially cause these symptoms. Tyrosine and Mucuna Pruriens both can alter blood pressure and should not be used without consultation with a physician.  The proceeding information is not considered to be a substitute for medical diagnosis, evaluation or treatment.We recently recommended Mucuna to a previous patient, to help raise his dopamine level. He is a 40 y/o male, with several years of opiate use for chronic pain issues. On several occasions, he related that he felt low energy, and has also said he would like to feel what he felt on the opiates without the dangerous addictive and withdrawal symptoms. He also had an issue with taking Adderall, for ADD, because he has high blood pressure. This patient reported that since he has started taking the Mucuna, he feels great. He says he feels like he has plenty of energy, and it has had no effect on his blood pressure.Florida Detox recommends targeted amino acid and essential fatty acid supplementation to all of our patients suffering from attention deficit disorders.   In view of clear and convincing scientific evidence, ignorance is no longer an excuse to deny effective treatment to attention deficit sufferers.