6.7 Stimulants

Stimulant medications are prescribed to treat children, adolescents, or adults diagnosed with attention deficit hyperactivity disorder (ADHD). Stimulants block the reuptake of norepinephrine and dopamine in the synapse and increase the overall level of these substances in the brain, but they have a paradoxical calming effect and improve the ability to focus and concentrate for individuals diagnosed with ADHD. Common stimulants used to treat ADHD include methylphenidate, amphetamine, dextroamphetamine, and lisdexamfetamine dimesylate. Stimulant medications are safe when prescribed with close supervision, but they are a Schedule II controlled substance because they have a high potential for misuse and dependence. Stimulants are available in short-, intermediate-, and long-acting formulations. See Table 6.7 for an overview of information about stimulants.

Table 6.7. Stimulants

Side Effects

Stimulants may cause minor side effects that resolve when dosage levels are lowered, or a different stimulant is prescribed. The most common side effects include the following^[1],[2]:

• Difficulty falling asleep or staying asleep
• Loss of appetite and weight loss
• Stomach pain
• Headache

Less common side effects include motor or verbal tics (sudden, repetitive movements or sounds) or personality changes (such as appearing “flat” or without emotion).^[3] Sudden death, stroke, and myocardial infarction have been reported in adults with CNS-stimulant treatment at recommended doses. Sudden death has been reported in pediatric clients with structural cardiac abnormalities and other serious heart problems taking CNS stimulants at recommended doses. If paradoxical worsening of symptoms or other adverse reactions occur, the provider should be contacted, and the dosage reduced or discontinued. Stimulants are contraindicated in clients using a monoamine oxidase inhibitor (MAOI) or using an MAOI within the preceding 14 days.^[4]

Black Box Warning

CNS stimulants, including methylphenidate and amphetamine-like substances, have a high potential for abuse and dependence. The risk of abuse by the client or their family members should be assessed prior to prescribing stimulants, and signs of abuse and dependence should be evaluated while the client is receiving therapy.^[5]

Client Education

There are several important client education topics to provide to clients and/or the parents of minor children^[6]:

• Medication information: Discussing the purpose, potential side effects, and the importance of adherence to prescribed treatments.
• Controlled Substance Status/High Potential for Abuse and Dependence: Stimulants are a controlled substance by the FDA that can be abused and lead to dependence. Stimulants should be stored in a safe (preferably locked) place to prevent misuse and should not be shared with anyone. Unused or expired stimulants should be disposed of based on state law and regulations or returned to a medicine take-back program if it is available in the community.
• Cardiovascular Risks: Stimulants can increase blood pressure and pulse rate. Potential serious cardiovascular risks include sudden death, cardiomyopathy, myocardial infarction, stroke, and hypertension. Instruct clients to contact a health care provider immediately if they develop symptoms, such as exertional chest pain, dizziness, or passing out.
• Suppression of Growth: Stimulants may cause slowing of growth in children and weight loss.
• Psychiatric Risks: Stimulants can cause psychosis or manic symptoms, even in clients who have no prior history of these symptoms.
• Priapism: Painful or prolonged penile erections can occur; seek immediate medical attention.
• Alcohol: Alcohol should be avoided.

Nurses should reinforce with the client and their family members that the reason for the prescribed medication for ADHD is to help with self-control and the ability to focus. Possible side effects should be reviewed, and clients and their family members should be reminded it may take one to three months to determine the best pharmacological treatment, dose, and frequency of medication administration. During this time, the child’s symptoms and adverse effects will be monitored weekly and the medication dose adjusted accordingly.^[7]