Episode 15. Non-stimulant Medications and their role



Stimulant medications are typically a mental health provider’s first choice of treatment for ADHD. But for some people, stimulants aren’t the best option and that’s where non-stimulant medications come in as another treatment option for people to explore. 

Join host Lindsay Guentzel for a conversation with Dr. Raafia Muhammad — the division chief of medicine and interim chief medical officer for ADHD Online — as they explore the different non-stimulant medication options and how they can play a role in treating and managing your ADHD symptoms. 

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Lindsay Guentzel (00:01):

You are listening to episode 15 of Refocused with Lindsay Guentzel, all about non-stimulant medications and their role in treating and managing ADHD. My name is Lindsay Guentzel and I’m your host of Refocused with Lindsay Guentzel. I mean, it makes total sense right? My name is in the title and a side note. If you ever think about starting a podcast or anything where you have to say the name a lot over and over again. Think long and hard about how often you want to have to say your own name before you put your name in the title of that thing. Just my two cents here after 15 episodes of the show. I’m a television and radio host, producer, writer and hobby collector living and working in the twin cities. That’s Minneapolis and St. Paul Minnesota and for the last few months I’ve been working with the team at ADHD Online to not only create this podcast. But to make sure we’re establishing a solid base of information to build up from and today’s conversation with Dr. Raafia Muhammad adds another layer to that database.

Lindsay Guentzel (01:33):

We’re talking about non-stimulant medications, not the first treatment option that comes to mind when you think about ADHD and I know there are a few reasons for that. Unfortunately, we know that the stigma surrounding the use of stimulant medications in treating ADHD has increased awareness and in some situations it’s not in a positive way. The recreational use of stimulant medication also needs to be considered when looking at how we and I wish you could see me gesturing around wildly right now. We as in society, as in the world, our neighbors, our colleagues, our families, how we start to form an opinion about the value of stimulant medications as a tool in treating ADHD. But there are also a lot of positive reasons why patients seeking a treatment plan for ADHD head right for the stimulant medications. The results tell us they work in diminishing some of our hyperactive symptoms, that interrupted behavior, the fidgeting and these realizations are happening now. But they’ve also been happening since the 1930s when amphetamines were introduced as a treatment method for reducing hyperactivity in boys.

Lindsay Guentzel (02:44):

But the use of non-stimulant medications in treating ADHD is increasing and for a lot of reasons. The biggest stimulant medication just isn’t for everyone and there are a lot of things to consider with your provider when deciding if you want to give one of them a try. The other reason is the options for non-stimulant medications are increasing and most of them aren’t ADHD specific. So they treat other conditions as well and here’s the part I didn’t know, non-stimulant medications can work with stimulant medications. It’s not necessarily a one or the other decision and that’s why again, having these conversations with your providers and talking about your life and what you want out of it, and what else you are willing to add to your treatment plan to your life in order to live the life you want, to be the person you’ve always wanted to be. It’s a really giant step forward when you’re able to communicate that to your provider so they can take all of that into consideration. So we’ve established the who, the what, the when, I mean this is happening now and the why.

Lindsay Guentzel (03:54):

But we’ve skipped the where and the where is a telemedicine healthcare company. So you guys stick with me, I promise I wasn’t aiming for this level of cheese. I just got myself here by looking for a way to introduce our sponsors, our partners without cutting in with a random commercial break. So as I said the where behind this podcast is all around us, it’s virtual or at least that’s how ADHD Online takes care of its patients virtually. But it is headquartered in Grand Rapids Michigan and as strange as this might sound, it feels exactly like a clinic. Except there are no patients physically inside the building, they’re being cared for and instead of the staff walking room to room and flipping those little flags outside the door up and down to signify where the patient is in their visits treatment plan. The patients are moving computer to computer inside the building and to a provider in the patient’s state and then back to the office and so on and so forth.

Lindsay Guentzel (04:59):

I’ve essentially said this without saying it so far, but ADHD online is a telemedicine healthcare company that specializes in diagnosing and treating ADHD through convenient and affordable assessments and personalized treatment plans, typically in just seven days. I wasn’t diagnosed through ADHD Online, in fact, I didn’t know the resources they provide were even an option for me when I started my own process, my own path towards a diagnosis. I am grateful my hyper focus and impulsivity pushed me to call my primary care provider’s office. But it still took four appointments over almost six weeks for me to finally receive my diagnosis and get a plan in place to start moving forward with this new information. ADHD Online is healthcare run by tech, not tech running healthcare and I think that’s an incredibly important distinction. It was started and is run by healthcare professionals who treat the whole person from diagnosis to treatment, to medication management and teletherapy. If you’ve been wondering if you have ADHD or perhaps you’re seeing behaviors in someone you care about that have you questioning a connection.

Lindsay Guentzel (06:08):

Head on over to adhdonline.com to find out more about their diagnostic process and how their team of healthcare professionals across the country can help you move forward in life with more answers and understanding. If you’ve been enjoying what you’ve been hearing on Refocused with Lindsay Guentzel please subscribe, rate, and review wherever you get your podcasts. Those quick action items help get this podcast into the ears of other people who might be looking for similar answers and to those of you who have taken the time to do that thank you so much. Whether you left a review online or you follow us on social media or you sent me an email telling me what you love about the show. It means so much to me so thank you for supporting the work we’re doing. I truly don’t know how to articulate what it means to me that you guys are enjoying this, so thank you.

Lindsay Guentzel (07:14):

Today’s episode dives into non-stimulant medications and the role they can play in treating ADHD and I should have taken it as a sign that this episode would be a challenge for me when Dr. Raafia Muhammad started our conversation with this.

Dr. Raafia Muhammad (07:29):

Non-stimulants are always so difficult to talk about because everyone is so different.

Lindsay Guentzel (07:33):

Dr. Muhammad is ADHD Online’s Division Chief of Medicine, as well as the Interim Chief Medical Officer and she spent her career focusing on preventative medicine and public health.

Dr. Raafia Muhammad (07:43):

Every patient is different there’s no right or wrong time to prescribe a non-stimulant. With stimulant medications because they’re the first line of treatment everyone kind goes to that first and then you have long acting short medications and everything. But with non-stimulants, because patients are so different, because symptoms are so different. Some patients may have more hyperactivity or even after being on a stimulant medication they may show a little bit more impulsivity. They may benefit from adding this non-stimulant treatment at that point. Some patients may because their schedules are so erratic and their sleep cycle and stuff they may benefit from it. So there really isn’t a specific criteria in a sense, and for kids sometimes non-stimulant is just a better route. You don’t want that to affect their sleep to affect their growth. There’s a lot of different factors that go into it. It’s hard to sort of have strict criteria for it.

Lindsay Guentzel (08:40):

Having done my own research on this topic for the podcast I can back up Dr. Muhammad’s sentiments in a very non doctor way.

Dr. Raafia Muhammad (08:50):

For non-stimulant medications I think there is a greater interest in this group of medications now. I think initially a lot of people felt like it’s more for kids and then for adults there’s the stimulant therapy. I’ve been noticing that a lot of my adults who either may have been on stimulants in the past and aren’t responding as well to that anymore, they benefit from switching over to a non-stimulant. As I mentioned earlier symptoms of ADHD, depression, anxiety, other mental health conditions really blend in together. So sometimes some patients may just respond well to treating those other conditions like depression and then with that once their mood stabilizes it also helps them focus and concentrate. A lot of the non-stimulant medications their mechanism of action. Since this builds up in your system about four to six weeks, it doesn’t have the same effects on sleep. It doesn’t have the same effects of insomnia as a stimulant would have. So a lot of my adults who work different shifts, nighttime, daytime shifts, just have a very chaotic work schedule. They also benefit from a non-stimulant because it fits into their schedule better.

Lindsay Guentzel (10:03):

And because we want to be as thorough as humanly possible. We’ve also added an amazing blog from healthcare writer Sarah Roush, which has a more detailed description for each of the medicines, what they’re used for and any known side effects that have been reported. Sarah did an incredible job breaking down all of the important information and it’s a great resource to go through. If you’re on a non-stimulant or you’ve been looking at them or you just want to learn more about non-stimulants and the ADHD connection to expand your own options for the future. That’s available by heading to adhdonline.com and finding the blog tab at the top of the page. But back to my conversation with Dr. Muhammad. I thought it would be beneficial to revisit stimulant medications and take a look at them in comparison to their non-stimulant counterparts. Before we dive into more of the specifics about non-stimulants and their roles in treating ADHD.

Dr. Raafia Muhammad (11:03):

Stimulant medications are often the first line treatment for ADHD, whereas non-stimulant medications are often seen as second or third choice or more of an adjuvant therapy. So they may be used in conjunction with stimulant medications, they work quite fast in a sense that they don’t build up in your system. So if you don’t take it one day you don’t have benefits that day. Whereas in non-stimulant medications you have to take them consistently because they take about four to six weeks to build up in your system and that’s when they show their full effect. So for that reason the non-stimulants have to be tapered off, you can’t abruptly stop taking it. The risk of abuse for stimulants medication is high, whereas non-stimulant medications it’s little to no risk of abuse. The non-stimulant medications they are not controlled substances. So if someone is traveling or they ended moving a lot they can be prescribed across state lines. Whereas stimulant medications are controlled and there’s more strict DEA and federal laws around that.

Lindsay Guentzel (12:09):

According to Dr. Muhammad non-stimulant medications fall into three different categories. Remember how we said this topic wasn’t as straightforward as others have been? To start there are the non-stimulant medications that are ADHD specific that were developed to work on certain neurotransmitters. Then there’s the antidepressants and finally the blood pressure medications. So to get started I asked Dr. Muhammad to focus on the ADHD specific medications.

Dr. Raafia Muhammad (12:40):

In this category the common ones are Strattera and Qelbree. Strattera was the first non-stimulant to be approved and this is a norepinephrine reuptake inhibitor. So this means it’s working on that chemical messenger and by increasing norepinephrine in the brain it helps decrease the hyperactivity, the impulsivity, the inattentiveness.

Lindsay Guentzel (13:08):

Strattera received FDA approval in 2002 for use in treating ADHD and as Dr. Muhammad mentioned it focuses on norepinephrine. A chemical messenger in the brain that affects memory, sleep cycle, mood, attention, arousal and alertness. The second medication that falls into this category is Qelbree, and it is also a SNRI, a serotonin norepinephrine re-uptake inhibitor. Like Strattera, it also works to increase the amount of norepinephrine in your brain and according to Dr. Muhammad it can also help with anxiety and depression in addition to treating ADHD symptoms. Qelbree first received FDA approval for treating ADHD in children in April 2021 and then for adults in May 2022. So it is a very new treatment option to consider when building your plan with your provider. Moving on to the second group of non-stimulant medications, it’s the antidepressants and one of the most common antidepressants prescribed for treating ADHD is Wellbutrin. Wellbutrin is a norepinephrine dopamine re-uptake inhibitor or NDRI and it works to increase both dopamine and norepinephrine levels in the brain. Giving off both the mood disorder benefits and the attention benefits.

Lindsay Guentzel (14:33):

Wellbutrin is often prescribed to treat depression and seasonal effective disorder and Dr. Muhammad said sometimes it’s even prescribed to help people stop smoking.

Dr. Raafia Muhammad (14:42):

When you have ADHD the symptoms of ADHD, depression, anxiety, they can all blend in together and at times the depressive symptoms can affect the mood. Therefore, also affecting some of the focus and the concentration. Wellbutrin works on dopamine reuptake, there’s also some components of norepinephrine as well. So it’s sort of balancing out those neurotransmitters. So Wellbutrin is a really good option for patients who may have some mood disorders as well as trouble focusing and concentrating.

Lindsay Guentzel (15:13):

Finally, the third group of medications that fall into the non-stimulant category when we are talking about treating ADHD symptoms are blood pressure medications.

Dr. Raafia Muhammad (15:24):

There’s two medications that kind of fall in this category. One is Intuniv and one is Kapvay. These medications are FDA approved to treat ADHD, the more impulsive factor in kids six to 17 years of age.

Lindsay Guentzel (15:38):

Age Intuniv is an extended release medication that’s normally used to treat high blood pressure, but it’s been approved by the FDA to treat ADHD in kids as Dr. Muhammad mentioned. It works by decreasing adrenaline levels and can improve ADHD symptoms like sensitivity, social aggression and hyper arousal. Kapvay, the other blood pressure medication approved by the FDA for treating ADHD in children. It boosts norepinephrine levels in the brain which can improve ADHD symptoms like hyperactivity, impulsivity and inattention. Dr. Muhammad said both Intuniv and Kapvay can be prescribed by themselves or along with a stimulant and doctors often prescribe these medications for adults as well.

Dr. Raafia Muhammad (16:24):

Again, the end goal of these medications is to help with the hyperactivity, the more impulsive symptoms. A lot of times we end up using this in conjunction with stimulant medications to help sort of balance the symptoms.

Lindsay Guentzel (16:38):

All of these medications come with their own side effects and while we have them listed on the blog, again you can find Sarah Roush’s article on non-stimulant medications by going to adhdonline.com and heading to the blog tab at the top of the page. It is so important to talk through all of your options with your providers.

Dr. Raafia Muhammad (16:59):

When patients come over to me I like to give them all the options, their stimulants and the non-stimulant options. For patients who specifically come in wanting only non-stimulants, those patients may have had a bad reaction to stimulants in the past. They may have a medical condition that makes a stimulant medication unsafe. So the patients that come in asking for what are the treatment options in the non-stimulant category. They’ve sort of done their research and they come in kind of knowing what they want.

Lindsay Guentzel (17:35):

As we’ve talked about many, many times before and I’ll keep reminding you how we treat our ADHD and manage our symptoms, well it’s likely those treatment plans will change as our lives change and as we grow and adapt. So keeping an open dialogue with our providers is incredibly important because our options are always changing. Even in this episode we’ve talked about new medications that have recently received FDA approval for treating ADHD. The best way to find out about those new options is by having open honest conversations with the providers who are prescribing our medication and so I was curious. As a provider with ADHD Online I wanted to know what and also I guess who Dr. Muhammad is looking for when considering whether a non-stimulant medication could be a beneficial addition to a patient’s treatment plan.

Dr. Raafia Muhammad (18:36):

There are a few things that sort of stand out when patients come in where I would consider a non-stimulant. One, if patient has a history of medical conditions, thyroid abnormalities or some cardiac issues where I would be concerned that a stimulant may aggravate those conditions. So in those instances I would recommend a non-stimulant. If a patient is traveling a lot and just kind of going across state lines a lot and just may not be able to get their medication in a timely manner since controlled substances have certain state and federal laws around it. So for those patients, I may recommend a non-stimulant medication because at least they are getting their medication in a more continued manner.

Lindsay Guentzel (19:20):

As Dr. Muhammad mentioned, in order for stimulant medications to work you have to take them every single day. But in order for the non-stimulant medications to start to work you have to take them every single day consistently for a stretch of time in order for the medication to build up within your body and for the benefits of the medication to start to work. So I was curious how Dr. Muhammad prepares her patients for that. I mean, it’s not an immediate fix, it’s not even something you can start to feel immediately and it takes some time. So what should people be looking for?

Dr. Raafia Muhammad (20:02):

It’s important for my patients to understand that now that you’ve identified that you have ADHD this is why certain things are difficult or harder to manage. Whether you are on a stimulant or non-stimulant these are not magic pills, it’s not going to make everything better. The idea of these medications you are trying to build better habits so that path will take time. With stimulant medications they’re shorter acting in a sense, once you take it goes up, it comes down, it’s out your system so that’s how those work. With non-stimulants they’re building up over time. You may have to taper, start on a low dose and then go to intermediate and kind of have that regimen but it takes about four to six weeks. I also tell my patients that with non-stimulants it may take that time so be patient with how the medication’s working. But more importantly take it every day but just focus on building those better habits.

Dr. Raafia Muhammad (20:56):

The therapy also plays really intimately with both treatment options, because the idea is that even when you’re on the medication you want to be able to learn how to build better habits, create a better foundation.

Lindsay Guentzel (21:09):

Like stimulant medications there are a lot of things, rules, guidelines, restrictions that people should consider when deciding to add a non-stimulant medication into their treatment plan.

Dr. Raafia Muhammad (21:21):

Take it every day at the same time, based on a routine you’ve probably built up for yourself. So if you take it in the morning with breakfast that’s fine to do. But if you’re taking other medications at that time too that may interact, then you may want to space out the doses a little bit. So the idea is that as you’re building a better habit, routine and consistency is important. So whatever works in your schedule, whatever allows you to take it every day and to be consistent with it and then of course just make sure it doesn’t interact with other medications. Sometimes for some patients if they’re on a stimulant medication as well and then also non-stimulant. I may have them take the stimulant in the daytime and then non-stimulant right at bedtime so that way both of those medications don’t interact.

Lindsay Guentzel (22:05):

Over and over again throughout our conversation Dr. Muhammad stressed how everything we’ve talked about regarding these medications. Finding out if they’ll even work for you, it’s all incredibly personal and she did say when non-stimulants work they work beautifully. But there’s more gray area with non-stimulant medications unlike stimulants which are very it is or it isn’t.

Dr. Raafia Muhammad (22:33):

Because ADHD presents so differently for everyone, it is a dynamic condition. It is very important to have a relationship with your provider, with your therapist, kind of talk about these things. Kind of tell them like, “Hey, I don’t know today it’s just not working as well. This past month I’ve had more bad days than good days.” Because it’s not that the medication may not be working. Because the medication, the first one in the bottle and the last one in the bottle is the same pill or the same capsule. It just could be that the external factors could be adding to that. So maybe days are really busy, you’re trying to meet a lot of deadlines. So let’s see what we can do to kind of address these new challenges. So it’s very important to be honest and be open and have this open line of communication with your provider. For my patients I often say sometimes if you don’t know how it’s working maybe just put a smiley face or a sad face every week to see, do I have any more sad days, more happy days?

Dr. Raafia Muhammad (23:35):

That way then you can start targeting as to why was Monday so sad for me, what happened? And then let’s see if we can sort of dissect how you’re feeling. Because the overwhelming feeling of I just don’t feel good and I’m on a medication and I still don’t feel good. That feeling could just be very taxing. So it is very important to have that open communication with your provider.

Lindsay Guentzel (23:58):

It’s important to remember that this podcast and the information we covered does not count as medical advice, although Dr. Muhammad is a doctor she’s just not your doctor. This is a starting point for you and your provider, a way to walk into your next appointment more informed and hopefully more comfortable asking questions and advocating for yourself, your health and your wellbeing. Thank you so much for joining us for episode 15 of Refocused with Lindsay Guentzel. If you want to send us a note you can email me directly at [email protected] and you can find us on Twitter and Instagram @LindsayGuentzel and @refocusedpod. Refocused with Lindsay Guentzel is a collaboration between me Lindsay Guentzel and ADHD Online. A telemedicine healthcare leader offering affordable and accessible ADHD assessments, medication management and teletherapy. You can find out more by visiting adhdonline.com. The show’s music was created by Lewis [inaudible 00:25:08], a songwriter and composer based out of Perth Australia. Who was diagnosed with ADHD in 2020 at the age of 39. A huge thank you to Dr. Raafia Muhammad the Division Chief of Medicine and Interim Chief Medical Officer for ADHD Online.

Lindsay Guentzel (25:26):

As well as healthcare writer Sarah Roush for her in-depth coverage on non-stimulant medications that you can read over on adhdonline.com. Remember to subscribe, rate and review wherever you’re listening now and join us next week for another episode of Refocused with Lindsay Guentzel.

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