Stimulating Herbs in Place of Amphetamines in Adult Attention-Deficit/Hyperactivity Disorder (ADHD)
Attention-deficit/hyperactivity disorder (ADHD) is an underdiagnosed, undertreated, and often comorbid condition in adults.1 While recognised as a common childhood behavioural disorder,2 ADHD persists through to adulthood in as many as two-thirds of patients3,4 despite a general lack of awareness.1 It majorly impacts an individual’s social life and wellbeing. It is strongly linked with substance use disorder,1 wherein self-medication may be a factor.5
ADHD can be viewed as a deficiency of stimulation.6 In normal neurotransmitter physiology, a ‘brain reward cascade’ occurs. Serotonin, enkephalin and gamma-aminobutyric acid (GABA) work in concert, resulting in the release of dopamine at the nucleus accumbens7 – a crucial part of the brain reward system.8 However, in the pathophysiology of ADHD, this process is dysfunctional. The dysregulation of these neurotransmitters is caused by genetic abnormalities such as a defect in the dopamine receptor D2 (DRD2) gene. This defect decreases the number of dopamine receptor sites in reward centres and reduces the amount of dopamine produced in this area. This underlying need to increase brain dopamine to produce feelings of pleasure helps explain why individuals with ADHD engage in high-risk activities (e.g., substance use).6
Conventional medications for ADHD are psychostimulants that increase dopamine and noradrenaline in the synaptic space. These promote the release of catecholamines from presynaptic nerve terminals and block their reuptake via competitive inhibition.9,10 Notably, released catecholamines also affect α- and β-adrenergic receptor sites,9,11 with α-adrenergic receptors playing an important role in blood pressure (BP) regulation.12,13
Statistics show that as many as nearly one in every four patients with substance use disorders meet the criteria for a diagnosis of comorbid ADHD.14 Self-medicating (unknowingly) is not uncommon for the undiagnosed adult. However, while doses of prescribed stimulants are predictable, illicit drugs such as methamphetamine are not. High doses of methamphetamine induce damaging neurotoxic effects by eliciting oxidative stress within dopamine terminals and surrounding compartments.15
Herbal therapies prescribed by naturopathic practitioners can address neuroinflammation, exerting neuroprotective effects16-19 to help correct underlying neurotransmitter imbalances, alleviate symptoms and improve quality of life. As such, the clinical aim in this case was to replace synthetic forms of stimulation with stimulating herbs that could concurrently offer neuroprotective benefits.
Patient History
An adult male presented with regular use of methamphetamine. He had been using the illicit drug for around 3 years and found it helped him to feel calmer and think more clearly. The patient was a successful finance broker with very high expectations of personal achievement. His sense of self-worth was tied to his ability to provide for his family. He would purchase his supply monthly and cycle 2 weeks on 2 weeks off. For the off period, he would tolerate the withdrawal symptoms.
He then tried taking the drug without a period of abstinence for 2 months when things began to fall apart. Around the same time, his wife discovered his drug use, moved out with their children and demanded a clean drug test for him to visit his kids.
He was referred to a psychiatrist through his marriage counsellor. The patient was eventually diagnosed with ADHD and prescribed dexamphetamine. However, as a clean urine drug test was part of his marriage, he wanted to stop use of dexamphetamine as this is indistinguishable from methamphetamine in the test.
Medications
Dexamphetamine
Initial Prescription
Liquid extract: 5-10 mL three times a day
Herb | Extract Ratio | Quantity |
Korean Ginseng | 1:2 | 30 mL |
Schisandra | 1:2 | 25 mL |
Ginkgo | 2:1 | 25 mL |
Rhodiola | 2:1 | 25 mL |
105 mL |
NB: 210 mL was provided for 1 week
Rationale: I consider all herbs to be stimulating. Ginkgo combined with American Ginseng (replaced with Korean Ginseng) can improve hyperactive-impulsiveness.20 Korean Red Ginseng can significantly improve inattention/hyperactivity scores.21 Ginseng phytochemicals are neuroprotective.17
1-week Follow-up
• The full amount of the liquid extract was used at a dose of 10 mL three times a day
• Felt he needed more from the herbs
• He felt tired for the first few days, experienced abdominal pain, but both resolved at the same time a few days
later
• Reports that he has been sleeping well
• Focused on getting better. Attending Narcotics Anonymous meetings four times weekly, deleting drug dealers’
numbers from his phone contacts and meditating for an hour each day
• Feeling optimistic
• BP: 158/70 mmHg
Prescription changes:
o Increased dose of the liquid extract to 15 mL three times a day
Follow-up
• Ran out of the mixture for three days and had not been sleeping well since
• He wanted to get something from the pharmacy to aid his sleep (e.g., herbal sedative) but I suggested against
this, believing that he needed stimulating during the day with the liquid extract rather than sedating at night
• Stress from an estranged wife who still was not trusting him to see his children
• Same prescription dispensed. Enough to last 10 days
Lost to follow-up.
Clinical Thoughts
Sometimes our best intentions and hopes don’t align with the client’s own expectations. Natural medicines work slowly and steadily, requiring perseverance on the patient’s behalf to get there. This case highlighted to me the importance of managing expectations, especially with substance use.
References
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