Prescribing Stimulants: Ethical Issues Mary Knutson, RN Advanced Concepts of Pharmacology February,...
-
Upload
bartholomew-hudson -
Category
Documents
-
view
222 -
download
1
Transcript of Prescribing Stimulants: Ethical Issues Mary Knutson, RN Advanced Concepts of Pharmacology February,...
Prescribing Prescribing Stimulants: Ethical Stimulants: Ethical IssuesIssuesMary Knutson, RNMary Knutson, RNAdvanced Concepts of PharmacologyAdvanced Concepts of PharmacologyFebruary, 2005February, 2005
Scope of the ProblemScope of the Problem
Ritalin use for children began in 1990’sRitalin use for children began in 1990’s Stimulant in the family of amphetaminesStimulant in the family of amphetamines Also known as Methylphenidate (MPH) Also known as Methylphenidate (MPH)
Use is rising dramatically for treatment of Use is rising dramatically for treatment of Attention Deficit Hyperactivity Disorder (ADHD)Attention Deficit Hyperactivity Disorder (ADHD)
American children consume 90% of all the American children consume 90% of all the Ritalin produced worldwideRitalin produced worldwide Estimated at 3-5 million children in U.S.Estimated at 3-5 million children in U.S.
Scientific ResearchScientific Research
““One of the most studied pediatric conditions”One of the most studied pediatric conditions” Many studies, but marginal resultsMany studies, but marginal results No proof of underlying neuropathyNo proof of underlying neuropathy No ADHD diagnostic testsNo ADHD diagnostic tests
““Hyperactive children are helped by Ritalin, at Hyperactive children are helped by Ritalin, at least in the short run.”least in the short run.” MPH increases dopamine and MPH increases dopamine and
norepinephrine levels norepinephrine levels Subdues children (exact action unknown)Subdues children (exact action unknown)
National Institute of National Institute of Mental Health, 1998Mental Health, 1998
““We don’t have an independent valid test for We don’t have an independent valid test for ADHD; further research is necessary to firmly ADHD; further research is necessary to firmly establish ADHD as a brain disorder.” establish ADHD as a brain disorder.”
““Existing studies come to conflicting Existing studies come to conflicting conclusions as to whether the use of conclusions as to whether the use of psychostimulants increases or decreases the psychostimulants increases or decreases the risk of abuse.” risk of abuse.”
““After years of clinical research and experience After years of clinical research and experience with ADHD, our knowledge about the cause or with ADHD, our knowledge about the cause or causes of ADHD remain largely speculative.”causes of ADHD remain largely speculative.”
Marketing of StimulantsMarketing of Stimulants
Millions of dollars have Millions of dollars have been spent by been spent by pharmaceutical pharmaceutical companies to promote companies to promote use of MPH, or similar use of MPH, or similar drugs drugs
Misleading StatementsMisleading Statements
““Compare the pills to eyeglasses. Explain the Compare the pills to eyeglasses. Explain the their medicine is simply a tool to help them their medicine is simply a tool to help them focus and pay attention.”focus and pay attention.”
““ADHD is like diabetes in that both are due to a ADHD is like diabetes in that both are due to a shortage of a chemical in the body.”shortage of a chemical in the body.”
““They are finding more and more evidence that They are finding more and more evidence that ADHD does not stem from the home ADHD does not stem from the home environment, but from biological causes.”environment, but from biological causes.”
Side Effects of RitalinSide Effects of Ritalin
Side Effects of RitalinSide Effects of Ritalin
NervousnessNervousness Sleep Sleep
disturbancesdisturbances DizzinessDizziness DrowsinessDrowsiness Upset stomachUpset stomach VomitingVomiting Loss of appetiteLoss of appetite HeadacheHeadache
Call physician immediately:Call physician immediately: Seizures or convulsionsSeizures or convulsions Blurred visionBlurred vision AgitationAgitation Skin rashSkin rash Heart palpitations or Heart palpitations or
irregular heartbeatirregular heartbeat Fever or sore throatFever or sore throat Unusual bleeding/bruisingUnusual bleeding/bruising
Drug InteractionsDrug Interactions
MAO Inhibitors (Nardil, Parnate)MAO Inhibitors (Nardil, Parnate) Anticoagulants (Coumadin)Anticoagulants (Coumadin) Meds for depression (Elavil, Tofranil, Meds for depression (Elavil, Tofranil,
Norpramin, IsmelinNorpramin, Ismelin Meds for epilepsy (Dilantin, Meds for epilepsy (Dilantin,
phenobarbitol, Mysoline)phenobarbitol, Mysoline) VitaminsVitamins
Nursing ImplicationsNursing Implications
Ask about history of: Ask about history of: Severe anxiety, tension, mental illnessSevere anxiety, tension, mental illness Glaucoma, seizures, HTNGlaucoma, seizures, HTN Motor tics/spasms, Tourette’s syndromeMotor tics/spasms, Tourette’s syndrome
Monitor growth, mood, aggressiveness, Monitor growth, mood, aggressiveness, mental status, ability to sleep, CV status mental status, ability to sleep, CV status
Check with Dr. if pregnancy is suspectedCheck with Dr. if pregnancy is suspected
Teaching NeededTeaching Needed
Decrease caffeine Decrease caffeine intakeintake
Take MPH at least 6 Take MPH at least 6 hours before bedtimehours before bedtime
Give gum, hard candy Give gum, hard candy or sips of water for dry or sips of water for dry mouthmouth
Avoid OTC medications Avoid OTC medications and alcohol because of and alcohol because of interaction riskinteraction risk
Taper off MPH Taper off MPH gradually over several gradually over several weeksweeks
Prescriber may Prescriber may suggest “drug suggest “drug holidays” to assess holidays” to assess progressprogress
Do not drive or operate Do not drive or operate machinery until effects machinery until effects of drug are determinedof drug are determined
Response of ParentsResponse of Parents
Parents rave about success of the Parents rave about success of the drugdrug ““My child was a monster without it.”My child was a monster without it.” ““Our family life was in turmoil until Our family life was in turmoil until
Ritalin.”Ritalin.” A pill is easier and cheaper than A pill is easier and cheaper than
family counseling and/or private family counseling and/or private tutorstutors
Response of PhysiciansResponse of Physicians
Physicians who do not believe in Physicians who do not believe in Ritalin are going “against the grain”Ritalin are going “against the grain” Issues of managed care may Issues of managed care may
interfere with alternative interfere with alternative treatmentstreatments
Parents insist on the Parents insist on the “performance enhancing pill”“performance enhancing pill”
Community IssuesCommunity Issues
Pressure from school districts to have children Pressure from school districts to have children evaluated for ADHDevaluated for ADHD Parents do not want their child labeled with Parents do not want their child labeled with
diseasedisease But, children on MPH are easier to controlBut, children on MPH are easier to control
Medical evaluation depends primarily on Medical evaluation depends primarily on reports by teachers and parents reports by teachers and parents
Response By OpponentsResponse By Opponents
Serious side effects, including growth Serious side effects, including growth retardation and “zombie-like” appearanceretardation and “zombie-like” appearance
Class action lawsuits by parents have cited Class action lawsuits by parents have cited fraud, collusion by manufacturersfraud, collusion by manufacturers
Forty years of lab animal research found MPH Forty years of lab animal research found MPH toxic, addictive, and dangeroustoxic, addictive, and dangerous
There are psychological and social therapies There are psychological and social therapies for children that don’t involve drugging with for children that don’t involve drugging with amphetaminesamphetamines
Possible TherapiesPossible Therapies
PsychotherapyPsychotherapy Behavioral therapyBehavioral therapy Behavior Behavior
modificationmodification CounselingCounseling Family therapyFamily therapy
Issues of Performance Issues of Performance Enhancing DrugsEnhancing Drugs
ADHD may merely be the upper end of ADHD may merely be the upper end of biological variability, not faulty genesbiological variability, not faulty genes
Pro-Ritalin advocates consider gene Pro-Ritalin advocates consider gene manipulation in the wombmanipulation in the womb
College students may use Ritalin to give them College students may use Ritalin to give them extra focusextra focus
Some parents chose to give MPH to well-Some parents chose to give MPH to well-behaved but underperforming childrenbehaved but underperforming children
Some “experts” suggest that the answer to our Some “experts” suggest that the answer to our country’s sociological problems is giving MPHcountry’s sociological problems is giving MPH
QuestionQuestion
If there was widespread cognitive enhancing If there was widespread cognitive enhancing drug use by adults as well as children, what drug use by adults as well as children, what impact would it have impact would it have On human society?On human society? On our society’s values?On our society’s values? On social justice and equality?On social justice and equality?
How would it impact education, employment, or How would it impact education, employment, or other opportunities for children and adults?other opportunities for children and adults?
QuotesQuotes
““Treatment can mean the difference between a Treatment can mean the difference between a kid ending up at Berkeley or ending up in kid ending up at Berkeley or ending up in prison. This is a disorder where we can really prison. This is a disorder where we can really make a difference.”make a difference.”
Dr. James Swanson, an ADHD expertDr. James Swanson, an ADHD expert
Pharmacology can participate, very modestly, in Pharmacology can participate, very modestly, in one of the major efforts of humanity, which is to go one of the major efforts of humanity, which is to go beyond the Platonic question, “Who are we”?beyond the Platonic question, “Who are we”?
Dr. C. Dr. C. Giurgea, French visionary (1972)Giurgea, French visionary (1972)
Ethical ConflictsEthical Conflicts
MPH has potential MPH has potential for addictionfor addiction
May produce toxic May produce toxic state involving state involving psychosispsychosis
Has powerful (and Has powerful (and possibly possibly irreversible) CNS irreversible) CNS effectseffects
Worldwide, Worldwide, governments restrict governments restrict availability of availability of amphetamines to amphetamines to adultsadultsBut nurses are to give But nurses are to give MPH to children and MPH to children and teens in schools and teens in schools and other settingsother settings
Problem SolvingProblem Solving
Nurses need decide how they stand on this Nurses need decide how they stand on this ethical issueethical issue
Be aware of developments and optionsBe aware of developments and options Educate familiesEducate families Children may do better with smaller class Children may do better with smaller class
sizes, or more art, music, and physical sizes, or more art, music, and physical education education
Our country needs to take the first step- Our country needs to take the first step- admit we have a drug problemadmit we have a drug problem
ReferencesReferences
Baldwin, S. (2000). Speed kills: Amphetamines, children and Baldwin, S. (2000). Speed kills: Amphetamines, children and nurses. nurses. Nursing Ethics, Nursing Ethics, 7(6), 535-537.7(6), 535-537.
Butcher, J. (2003). Cognitive enhancement raises ethical Butcher, J. (2003). Cognitive enhancement raises ethical concerns. concerns. LancetLancet, 362(9378), 132-133., 362(9378), 132-133.
Leo, J. (2000). Attention Deficit Disorder. Leo, J. (2000). Attention Deficit Disorder. SkepticSkeptic, (8)1, 63-69., (8)1, 63-69. Skidmore, L. (2003). Mosby’s drug guide for nurses (5Skidmore, L. (2003). Mosby’s drug guide for nurses (5 thth ed.). St. ed.). St.
Louis: Mosby. Louis: Mosby. Rose, S.P. (2002). ‘Smart drugs’: Do they work? Are they ethical? Rose, S.P. (2002). ‘Smart drugs’: Do they work? Are they ethical?
Will they be legal? Will they be legal? Nature Reviews: Neuroscience,Nature Reviews: Neuroscience, 3, 976-979. 3, 976-979. National Institute of Health. (2005). Methylphenidate, Retreived National Institute of Health. (2005). Methylphenidate, Retreived
February 12, 2005 from February 12, 2005 from http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682188.http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682188.htmlhtml