Washington Medical Marijuana

SUMMARY: Fifty-nine percent of voters approved Measure 692 on November 3, 1998. The law took effect on that day. It removes state-level criminal penalties on the use, possession and cultivation of marijuana by patients who possess "valid documentation" from their physician affirming that he or she suffers from a debilitating condition and that the "potential benefits of the medical use of marijuana would likely outweigh the health risks." Patients diagnosed with the following illnesses are afforded legal protection under this act: cachexia; cancer; HIV or AIDS; epilepsy; glaucoma; intractable pain (defined as pain unrelieved by standard treatment or medications); and multiple sclerosis. Other conditions are subject to approval by the

Washington Board of Health. Patients (or their primary caregivers) may legally possess or cultivate no more than a 60-day supply of marijuana. The law does not establish a state-run patient registry.

The medical use provisions in Washington do not include reciprocity provisions protecting visitors from other medical use states.

AMENDMENTS: Yes.

Senate Bill 6032, mandated the Department of Health to "adopt rules defining the quantity of marijuana that could reasonably be presumed to be a sixty-day supply for qualifying patients." In October 2008, the department finalized guidelines allowing patients to cultivate up to 15 cannabis plants and/or possess up to 24 ounces of usable marijuana. The new limits took effect on November 2, 2008.

Patients who possess larger quantities of cannabis than those approved by the Department will continue to receive legal protection under the law if they present evidence indicating that they require such amounts to adequately treat their qualifying medical condition.

Senate Bill 6032 also affirmed changes previously recommended by the state's Medical Quality Assurance

Commission to expand the state's list of qualifying conditions to include Crohn's disease, hepatitis c, and any "diseases, including anorexia, which results in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, and/or spasticity, when these symptoms are unrelieved by standard treatments or medications."

It also limits the ability of police to seize medicinal cannabis that is "determined ... [to be] possessed lawfully [by an authorized patients] under the ... law."

ADDITIONAL AMMENDMENTS: Yes.
Senate Bill 5798 allows additional health care professionals including naturopaths, physician’s assistants, osteopathic physicians, osteopathic physicians assistants, and advanced registered nurse practitioners to legally recommend marijuana therapy to their patients. The new law will take effect on June 10, 2010.

MEDICAL MARIJUANA STATUTES: Wash. Rev. Code §§ 69.51A - 69.51A.901 (2007).

CAREGIVERS: Yes. Designated provider is a person who has been designated in writing by a patient to serve as a designated provider. The caregiver must be 18 years of age or older. The designated provider is prohibited from consuming marijuana obtained for the personal, medical use of the patient for whom the individual is acting as designated provider. The designated provider may be the primary caregiver for only one patient at any one time. Wash. Rev. Code §§69.51A.010, 69.51A.040 (2007).

CONTACT INFORMATION: Fact sheets outlining Washington’s medical marijuana law are available from:

Washington State Department of Health101 Israel Road SE
Tumwater, WA 98501
(800) 525-0127

Attention: Glenda Moore

http://www.doh.wa.gov/

ACLU of Washington, Drug Reform Project(206) 624-2184

http://www.aclu-wa.org/detail.cfm?id=182

Attention-Deficit/Hyperactivity Disorder in Adults

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Attention-Deficit/Hyperactivity Disorder in Adults

Attention-deficit-hyperactivity-disorder-in-adults

• SECTION INDEX
  • Neurology
  • Preventive Medicine
  • Psychiatry & Psychology
• DISEASE MANAGEMENT PROJECT MAIN
  • Chapter Index
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• Published:
  August 1, 2010

George E. Tesar

• Summary
• References

     

Definition and etiology

Attention-deficit/hyperactivity disorder (ADHD) is the current diagnosis for what was previously labeled minimal brain damage, minimal brain dysfunction, hyperkinetic impulse disorder, and hyperactive child syndrome.¹ Contrary to popular belief, at least 60% of children with ADHD continue to exhibit features of the disorder during adulthood. ADHD in adults is associated with significant psychiatric morbidity and higher than average rates of divorce, unemployment, substance abuse, and motor vehicle accidents.² Poor adjustment and performance can have an erosive effect on self-esteem, leading to clinically significant anxiety or depression, or both, which are often the presenting features of adult ADHD in the primary care setting.
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Prevalence and risk factors

ADHD is a neurobiologic disorder with strong genetic determinants. Strict application of diagnostic criteria has been associated with a mean prevalence of 5% to 7% across studies of children and adolescents.³ Approximately 60% to 70% of affected children transition into adulthood with some or all of the signs and symptoms of the disorder.³
Family and genetic studies have shown ADHD to be the most heritable of psychiatric disorders.⁴ Results from the National Comorbidity Survey Replication estimated a 4.4% prevalence of current ADHD in the U.S. adult population.⁵ There was a high rate of psychiatric comorbidity in ADHD adults: 38% had a mood disorder, 47% had an anxiety disorder, 15% had a substance-use disorder, and nearly 20% had an impulse-control disorder. The odds of having both ADHD and another disorder were highest for drug dependence (odds ratio [OR], 7.9), dysthymia (OR, 7.5), and bipolar disorder (OR, 7.4).⁵

Pathophysiology and natural history

A variety of neurochemical and neuroanatomic deficits have been associated with ADHD.^1,6,7 Studies employing structural neuroimaging point to an absence, in persons with ADHD, of the frontal lobe asymmetry seen in normal controls¹ ; in control subjects (no ADHD), the right frontal lobe tends to be larger than the left. Structural and functional neuroimaging studies have demonstrated decreased function and size of the prefrontal cortex, anterior cingulate, caudate nucleus, and cerebellar vermis in ADHD children, and most (but not all) studies demonstrate this deficit on the right.^6-8
Candidate gene selection is based on the hypothesis that deficient dopamine availability contributes to ADHD. Genes studied include those relevant to production of proteins involved in dopamine synthesis (dopa decarboxylase, the enzyme responsible for conversion of l-dopa to dopamine), inactivation (the dopamine and norepinephrine transporters), and degradation (catechol-O-methyltransferase) and in dopamine receptor activity (especially the dopamine D₄ receptor).⁷ No one gene or its protein derivatives has been found to have a consistent relation with ADHD, which suggests that like most psychiatric disorders, ADHD is the consequence of polygenetic influences.
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Signs and symptoms

The manifestations of ADHD in adults are generally less obvious than in children. Adults tend not to exhibit the impulsive, overactive behavior distinctive of many ADHD children and adolescents.^1,2 Common dysfunctional behavioral patterns in adults with ADHD include task avoidance, waiting until the last moment to complete a task, completing all but the most important tasks, and taking on new tasks before finishing others (Table 1).² Impatience, irritability, and explosiveness are common as well. Common comorbidities complicate the array of signs and symptoms that ADHD adults can present with. Abnormal mood, vocational and interpersonal problems, and substance abuse are often the problems that patients present with when the underlying primary diagnosis is ADHD.

Table 1: Common Dysfunctional Behavior Patterns in Adults with ADHD

Behavior	Description	Short-Term Gain and Long-Term Loss
Anticipatory avoidance	Magnifying the difficulty of a pending task and doubts about being able to complete it	Defers short-term stress but often creates a self-fulfilling prophecy because the task looms ahead and can seem overwhelming when facing a deadline
	Results in rationalizations to justify procrastination
Brinkmanship	Waiting until the last moment (e.g., the night before) to complete a task, often when facing an impending deadline	Deadline-associated stress can be focusing, but this tactic leaves little room for error and can yield a substantial result
Pseudoefficiency	Completing several low-priority, manageable tasks (e.g., checking e-mail) but avoiding high-priority tasks (e.g., a project for work)	Creates sense of productivity by reducing items on a to-do list but defers a more difficult project
Juggling	Taking on new, exciting projects and feeling busy without completing projects already started	It is easier to become motivated to start a novel project than to complete an ongoing one
		Pattern usually results in several incomplete projects

ADHD, attention-deficit/hyperactivity disorder.
Adapted with permission from Rostain AL, Ramsay JL: Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry 2006;5:13-27.

Diagnosis

Diagnostic criteria have been developed for children and adolescents (Box 1)⁹ but not specifically for adults. Despite having clinically significant ADHD, many adults do not fulfill the threshold of six or more criteria defined for children and adolescents. This points to the fundamental problem of employing a descriptive nosology to define clinical disorders. Future editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will struggle with this dilemma until the pathophysiologic mechanisms of specific psychiatric disorders such as ADHD are better understood.

Box 1: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
Diagnostic Criteria
Meets symptom criteria Some inattention or hyperactivity-impulse symptoms causing impairment are present before age 7 years Some impairment from symptoms present in two or more settings (e.g., home, school or work, social) Clear evidence of clinically significant impairment in social, academic, or occupational functioning
Symptom Criteria
At least six symptoms of inattention or at least six symptoms of hyperactivity or impulsivity have persisted for at least 6 months and occur often enough to be maladaptive and inconsistent with developmental level.
Inattention
Fails to pay close attention to details or makes careless mistakes in schoolwork, work, or other activities Has difficulty sustaining attention in tasks or play activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or work duties (not due to oppositional behavior or failure to understand) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks requiring mental effort (e.g., schoolwork, homework) Loses things necessary for tasks or activities (e.g., written instructions, school assignments, textbooks, pencils, tools, toys) Is easily distracted by extraneous stimuli Is forgetful in daily activities
Hyperactivity
Fidgets with hands or feet and squirms in seat Leaves seat in classroom or other situations where remaining seated is expected Runs about or climbs excessively in situations where these activities are considered inappropriate; in adolescents or adults, this feature may be limited to subjective feelings of restlessness Has difficulty in playing or engaging in leisure activities quietly Is on the go or acts as if driven by a motor Talks excessively
Impulsivity
Blurts out answers before questions are completed Has difficulty awaiting turn (impatient) Interrupts or intrudes on others (e.g., butts in on conversations, games)
Exclusion Criteria
Symptoms do not occur exclusively during course of a pervasive developmental disorder, schizophrenia, or psychotic disorder. Symptoms are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder).
Situational Notes
Symptoms might not be observable when the patient is in highly structured or novel settings, engages in interesting activity, receives one-on-one attention or supervision, or is in a situation with frequent rewards for appropriate behavior. Symptoms typically worsen in situations that are unstructured, minimally supervised, or boring or that require sustained attention or mental effort. In adolescents (or adults), symptoms include restlessness (rather than hyperactivity, as seen in children), impaired academic performance, low self esteem, poor peer relations, and erratic work record.

Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association, 2000.

Figure 1 is an algorithm for diagnosing ADHD in the adult patient. The core criteria for the diagnosis of adult ADHD is the evidence of the disorder during childhood, symptom persistence, and functional impairment.³ Determining whether the patient fulfilled these criteria depends almost exclusively on the patient's knowledge of his or her childhood behavior and school performance. Most adults with ADHD recall some evidence of problems related to either inattention or hyperactivity during childhood. Trouble sitting still, frequent fighting, temper outbursts, tendency to daydream, or suboptimal school performance is typical. Those with clinically significant ADHD who report successful school performance may have compensated with higher-than-average intellectual strengths, had an insufficiently challenging curriculum, or simply do not remember accurately. School performance records or collateral information from parents can be very helpful. Published questionnaires can be used to capture the necessary information and can assist with (but not confirm) the diagnosis (Box 2). Ultimately, however, the clinician must rely on the patient's veracity and accuracy of recall.

Box 2: Rating Scales Used in Diagnosing Attention-Deficit/Hyperactivity Disorder
Adult ADHD Self-Report Scale (AASRS) Symptom Checklist PDF available at http://www.med.nyu.edu/psych/assets/adhdscreen18.pdf (accessed March 20, 2009).
Barkley ADHD Behavior Checklist for Adults In Barkley RA (ed): Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 3rd ed. New York, Guilford Press, 2006.
Conners’ Adult ADHD Rating Scales (CAARS) Available for purchase from http://www4.parinc.com/Products/Product.aspx?ProductID=CAARS (accessed March 20, 2009).
Wender-Utah Rating Scale (WURS) Available at http://168.144.150.122/Wender%20Utah%20Rating%20Scale%20checklist.pdf (accessed March 20, 2009).

ADHD, attention-deficit/hyperactivity disorder.

There is no diagnostic laboratory test for ADHD. Neuropsychological testing can be used to determine whether or not a learning disability is present (e.g., dyslexia), but it cannot confirm the diagnosis of ADHD (by definition, not a learning disability). Although neuroimaging and genetic testing offer attractive diagnostic potential, they are not sufficiently specific or sensitive for routine clinical use.

Figure 1: Click to Enlarge

The difficulty of diagnosing ADHD in adults results largely from the nonspecificity of this behavior-symptom complex. Compounding the lack of specificity, many adults with long-standing undiagnosed and untreated ADHD develop secondary mood, anxiety, or substance-use disorders, alone or in combination, that become the focus of clinical attention and obscure detection of the more fundamental problem with attention. The National Comorbidity Survey Replication showed that many adults with ADHD are receiving treatment for other comorbid mental or substance-use disorders but not for ADHD.⁵

Differential diagnosis

Virtually any type of distress, regardless of the cause, can interfere with normal attention. Therefore, the feature that distinguishes ADHD from other causes of inattention is a lifelong pattern of the behavior-symptom complex. When this criterion is not met, other diagnoses must be considered (Table 2). Adults with ADHD are at greater risk for having or developing mood, anxiety, and substance-use disorders.⁵ Accurate diagnosis of these disorders and determining whether they are comorbid or secondary to ADHD have important implications for treatment selection and prognosis. Successful treatment of a comorbid disorder reduces symptom burden, but it does not affect the symptoms and behavior of ADHD. On the other hand, successful treatment of ADHD can result in improvement of secondary anxiety, depression, or substance abuse. Certain disorders that are commonly associated with or have features that can mimic ADHD are listed in Table 2.

Table 2: Differential Diagnosis of Attention-Deficit/Hyperactivity Disorder

Diagnosis	DSM IV-TR	Feature(s) Shared with ADHD
Mood Disorders
Major depression	296.2-3	Trouble concentrating; trouble initiating and completing tasks
Dysthymia	300.4	Trouble concentrating; trouble initiating and completing tasks
Depression NOS	311	Trouble concentrating; trouble initiating and completing tasks
Bipolar disorder	296.4-6	Distractability, hyperactive behavior
Cyclothymia		Distractability, hyperactive behavior
Anxiety Disorders
Generalized anxiety disorder	300.02	Inattention, distractability
Social anxiety disorder	300.23	Performance anxiety, task avoidance (especially tasks performed in front of others), unsatisfying social interaction
Obsessive-compulsive disorder	300.3	Repetitious activity
Anxiety disorder NOS	300.00	Inattention, distractability
Substance-Use Disorders
Nicotine dependence	305.10	Poor job performance and socialization
		Commonly comorbid with ADHD
Alcohol abuse or dependence	305.0/303.90	Poor job performance and socialization
		Commonly comorbid with ADHD
Cannabis abuse or dependence	305.20/304.30	Poor job performance and socialization
		Commonly comorbid with ADHD
Impulse-Control Disorders
Intermittent explosive disorder	312.34	Impulsivity, aggression
Impulse control disorder NOS	312.30	Impulsivity, trouble with task completion
Learning Disorders
Learning disorder NOS	315.9	History of poor school and job performance
Early onset dementia	290.10	Poor attention, forgetfulness
Mild MR	317	Trouble with learning, reading, attention
Personality Disorders
Borderline personality disorder	301.83	Impulsivity, aggression
Antisocial personality disorder	301.7	Impulsivity, aggression, history of poor school and job performance

ADHD, attention-deficit/hyperactivity disorder; DSM IV-TR, Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision; MR, mental retardation; NOS, not otherwise specified.

Figure 2: Click to Enlarge

Treatment

Figure 2 is a management algorithm. Optimal treatment of adult ADHD invariably requires pharmacotherapy. Adding life-skills coaching or cognitive-behavioral therapy, or both, in either individual or group settings can further improve outcome, but by themselves they are generally insufficient. Partners and family members can benefit from better understanding of the impact of ADHD on the patient's behavior and interpersonal style.²
Baseline measures of weight, heart rate, and blood pressure should be obtained before starting stimulant or nonstimulant medication. The patient with a history of cardiovascular abnormalities, in particular structural heart disease (e.g., idiopathic hypertrophic subaortic stenosis) should avoid stimulant medication in favor of a nonstimulant agent such as atomoxetine, bupropion, or modafanil. Treatment of such patients should involve close collaboration with an internist or cardiologist.

Medications

The standard of care for adults has evolved largely from studies in children, and the medications used in adults are the same as those used in children and adolescents with ADHD (Table 3).

Table 3: Medications for Attention-Deficit/Hyperactivity Disorder

Drug	Trade Name	Dosage Form (mg)	Dose* (mg)	Duration (h)	Frequency	Comments
CNS Stimulants
Dexmethylphenidate	Focalin	2.5, 5, 10	5-20	3-6	tid-qid	Dextroisomer of methylphenidate
						Start at 50% of current daily dose to convert from methylphenidate
	Focalin XR	2.5, 5, 10	10-20	8-10	qd-bid	Dextroisomer of methylphenidate
						Start at 50% of current daily dose to convert from methylphenidate
Dextroamphetamine	Dexedrine	5	10-30	3-6	bid-tid
	Dexedrine spansule	5, 10, 15	10-30	6-8	qd-bid	Dexedrine spansule
Methylphenidate	Concerta	18, 27, 36, 54	18-54	10-12	qd	The FDA-approved max dosage in children and adolescents is 54 mg qd, but doses of 108 mg qd have been used successfully in children and adults
	Metadate ER†	10, 20	20-60	6-8	qd-bid
	Metadate CD	10, 20, 30, 40, 50, 60		8-10	qd-bid
	Methylin	5, 10, 20	15-45	3-6	tid-qid
		5/5 mL, 10/5 mL solution
	Methylin ER†			6-8	qd-bid
	Ritalin	5, 10, 20	10-40	3-6	tid-qid
	Ritalin SR	20		6-8	qd-bid
	Ritalin LA	20, 30, 40		6-8	qd-bid	Lasts longer than SR
Mixed-amphetamine salts	Adderall	5, 7.5, 10, 12.5, 15, 20, 30		6-8	qd-bid
	Adderall XR	5, 10, 15, 20, 25, 30	20-60	8-10	qd-bid
	Vyvanse	30, 50, 70	30-100	12	qd-bid	Pro-drug
Selective Norepinephrine Reuptake Inhibitor
Atomoxetine	Strattera	10, 18, 25, 40, 60	40-100	24	qd-bid	Better than placebo, but not as effective as CNS stimulants in controlled trials for ADHD
Alternative Medications ‡
Bupropion	Wellbutrin	75, 100	150-450	24	tid
	Wellbutrin SR	100, 150, 200	150-450	24	bid
	Wellbutrin XL	150, 300	150-450	24	qd
Desipramine	Norpramin	10, 25, 50, 75, 100, 150	100-200	24	qd
Modafinil	Provigil	100, 200	100-400		qd

ADHD, attention-deficit/hyperactivity disorder; CNS, central nervous system; FDA, U.S. Food and Drug Administration.
^*The last dose is the FDA-approved maximum daily dosage in children.
^†There is no obvious difference between these two products in terms of dosage, duration, and efficacy.
^‡These agents may be effective in some instances of ADHD but have not been shown in controlled trials to be more effective than placebo. They are not approved by the FDA for treating ADHD.

Central nervous system (CNS) stimulants such as dextroamphetamine, methyphenidate, and dexmethylphenidate are the drugs of choice for ADHD in both children and adults. Their therapeutic effect is associated with enhancement of central dopaminergic and noradrenergic activity.¹ CNS stimulant compounds augment synaptic catecholamine concentrations by triggering presynaptic release of dopamine (and to a lesser extent norepinephrine) and also by blocking their reuptake.⁷ Drugs that influence both dopaminergic and noradrenergic function (e.g., dextroamphetamine, methylphenidate, dexmethylphenidate) are stimulants, and those that have less or no impact on dopamine and more on norepinephrine are nonstimulants, such as atomoxetine (Strattera). Other nonstimulant agents whose mechanism of action in ADHD is not fully understood include bupropion and imipramine.

Dose

The dosage of medication must be individualized by increasing gradually to maximal benefit while avoiding side effects. These principles hold for both stimulant and nonstimulant drugs. Clinical experience suggests a fine line between too little and too much medication.

Onset of Effect

Stimulant drugs have a rapid onset of effect. Clinical effects are felt within 15 to 30 minutes of oral administration, and peak blood levels are achieved within approximately 2 hours. It can take a week or more, however, to achieve full therapeutic effect. Assessing the patient's response to medication must account for exposure to circumstances that affect attention (e.g., comorbid disorders, environmental stress) and how effectively the patient monitors his or her response to medication. The nonstimulants work more gradually and can take days to weeks to achieve a full therapeutic effect.
The stimulants come in immediate-release and sustained-release forms (see Table 3). Immediate-release forms last anywhere from 2 to 6 hours, necessitating 2 to 4 doses daily. Sustained-release forms last 8 to 12 hours, permitting once- or twice-daily dosing.

Side Effects

Stimulant side effects are typically dose related and include nausea, headache, jitteriness, tics, high blood pressure, and high heart rate. They also have potential for abuse. Patients with baseline tachyarrhythmia, hypertension, or structural heart disease are at high risk for stimulant-induced aggravation of these abnormalities. The nonstimulant atomoxetine can cause increases in heart rate and blood pressure, but it is far less likely to do so than stimulants are. Its most common side effects include dry mouth, nausea, and sexual difficulties. Nonstimulants have no abuse potential.
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Prevention and screening

It is reasonable to expect that timely and effective treatment should reduce the risk of psychosocial morbidity associated with ADHD. A small but growing body of evidence suggests that patients with ADHD who are treated for it have less substance abuse, better work and academic performance, and better outcomes in general than those who are not treated.¹⁰
If the extensive psychosocial morbidity of ADHD can be prevented, then it stands to reason that it should be identified and treated as early as possible. In fact, many adults go through life without recognizing they have ADHD. This, as well as the complex comorbidities (e.g., depression, anxiety, substance abuse) that often trigger a request for help, make it difficult to detect ADHD.
Three validated patient self-report instruments are available to screen for ADHD in adults; alternatively, they can be used to substantiate a physician's clinical impression. The World Health Organization (WHO) Adult Self-Report Screener (ASRS) for Adult Attention Deficit Disorder (ADD) includes six questions rated on a scale from 0 to 4 (0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4 = very often). The maximum score is 24; the higher the score, the more likely that ADHD is present. The Wender Utah Rating Scale (WURS) was originally used as a research instrument and validated as a screener subsequently. A score of 46 or more obtained from adding the ratings on items 3-7, 9-12, 15-17, 20, 21, 24-29, 40, 41, 51, 56, and 59 is highly predictive of a diagnosis of ADHD. The Conner Adult ADHD Rating Scales (CAARS) elicit self reports and observer ratings. Further information about these scales and their acquisition is available in Box 2.

Special populations

Geriatric Patients

There is no age limit for the diagnosis of ADHD. Geriatric-age patients with a diagnosis of ADHD can benefit considerably from appropriate treatment. Older patients are more likely, however, to have coexisting cardiovascular abnormalities that warrant careful monitoring during treatment with stimulant medication.

Potential Substance Abusers

The challenge for the prescribing physician is to keep stimulant medications out of the hands of persons prone to drug or alcohol addiction. The risk of stimulant-induced substance abuse in uncomplicated adult ADHD is minimal. This risk liability is further reduced by the use of long-acting agents (see Table 3). Effective treatment of ADHD should reduce the risk of substance abuse, especially when substance abuse is secondary to ADHD. For persons with ADHD and comorbid substance abuse or dependence, the treatment of choice includes a nonstimulant agent such as atomoxetine, buproprion, or imipramine. A blanket policy of refusal to prescribe CNS stimulants to patients with a history of drug abuse, however, is ill advised. In all cases, substance abuse must be stabilized first, and ADHD treatment can be initiated as soon as the substance abuse is stabilized.

Patients with Cardiovascular Disease

CNS stimulant medications are relatively contraindicated in patients with hypertension, cardiac arrhythmia, tachycardia, coronary artery disease, and structural heart disease (e.g., idiopathic hypertrophic subaortic stenosis). Nonpharmacologic therapies or nonstimulant medications should be tried first in such patients. If these are ineffective, however, and the fully informed patient desires a trial of stimulant medication, it should be prescribed with careful monitoring in conjunction with the supervision of a cardiologist or internist to minimize the risk of adverse outcome.

Epileptic Patients

CNS stimulants do not cause a clinically significant reduction in seizure threshold and therefore can be used safely in patients with epilepsy.

Pregnant Women

All CNS stimulant drugs are listed as class C and should therefore be avoided if possible during pregnancy.

Summary

• Adult attention-deficit/hyperactivity disorder (ADHD) is a familial disorder with first manifestations before age 7 years.
• At least 60% of children with ADHD continue to exhibit clinically significant features of the disorder as adults.
• ADHD is among the most heritable of psychiatric disorders.
• Undiagnosed or untreated ADHD is associated with significant morbidity, including higher-than-expected rates of maladaptive behavior, family problems including divorce, problematic employment, substance abuse, motor vehicle accidents, and secondary mood and anxiety disorders.
• The primary treatment for adult ADHD is a methylphenidate- or amphetamine-based compound supplemented when necessary with structured, skills-based cognitive-behavioral therapy.

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References

1. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York: Guilford Press, 1998, pp 3-55.
2. Rostain AL, Ramsay JL. Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry. 2006, 5: 13-27.
3. McGough JJ, Barkley RA. Diagnostic controversies in adult attention deficit hyperactivity disorder. Am J Psychiatry. 2004, 161: 1948-1956.
4. Hudziak JJ, Derks EM, Althoff RR, et al: The genetic and environmental contributions to attention deficit hyperactivity disorder as measured by the Conners' Rating Scales—Revised. Am J Psychiatry. 2005, 162: 1614-1620.
5. Kessler RC, Adler L, Barkley R, et al: The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. Am J Psychiatry. 2006, 163: 716-723.
6. Vaidya CJ, Bunge SA, Dudukovic NM, et al: Altered neural substrates of cognitive control in childhood ADHD: Evidence from functional magnetic resonance imaging. Am J Psychiatry. 2005, 162: 1605-1613.
7. Pliszka SR. Neuroscience for the Mental Health Clinician. New York: Guilford Press, 2003, pp 147-150.
8. Biederman J, Safren SA, Seidman LJ, et al: ADHD: Applying practice guidelines to improve patient outcome and executive function. J Clin Psychiatry. 2006, 67: 2014-2025.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association, 2000.
10. Lamberg L. ADHD often undiagnosed in adults. Appropriate treatment may benefit work family social life. JAMA. 2003, 290: 1565-1597.

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Suggested Readings

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 2000.
• Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York: Guilford Press, 1998, pp 3-55.
• Biederman J, Safren SA, Seidman LJ, et al: ADHD: Applying practice guidelines to improve patient outcome and executive function. J Clin Psychiatry. 2006, 67: 2014-2025.
• Hudziak JJ, Derks EM, Althoff RR, et al: The genetic and environmental contributions to attention deficit hyperactivity disorder as measured by the Conners' Rating Scales-Revised. Am J Psychiatry. 2005, 162: 1614-1620.
• Kessler RC, Adler L, Barkley R, et al: The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. Am J Psychiatry. 2006, 163: 716-723.
• Lamberg L. ADHD often undiagnosed in adults. Appropriate treatment may benefit work family social life. JAMA. 2003, 290: 1565-1597.
• McGough JJ, Barkley RA. Diagnostic controversies in adult attention deficit hyperactivity disorder. Am J Psychiatry. 2004, 161: 1948-1956.
• Pliszka SR. Neuroscience for the Mental Health Clinician. New York: Guilford Press, 2003, pp 147-150.
• Rostain AL, Ramsay JL. Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry. 2006, 5: 13-27.
• Vaidya CJ, Bunge SA, Dudukovic NM, et al: Altered neural substrates of cognitive control in childhood ADHD: Evidence from functional magnetic resonance imaging. Am J Psychiatry. 2005, 162: 1605-1613.

 

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Receipe for Rick Simpson Oil

http://cannabisni.com/medicinal-cannabis-news/1194-how-to-make-hemp-oil-by-rick-simpson

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How to make hemp oil by Rick Simpson

on 02 December 2009. Posted in Medicinal Cannabis News & Information

48

For those of you who have watched the documentary "Run from the Cure", this should answer any questions about producing your own hemp oil.



Caution: Oils that drug dealers sell can have many contaminants and often little or no THC. From my experience, most hemp oil available on the street should be avoided for medicinal use. Make your own oil or have someone you trust produce the oil to assure a very pure, high quality oil is produced.

How much to make and take?
One pound (500g) of bone-dry hemp buds will usually produce about 2 ounces (55 - 60 mL) of high-grade oil. This amount of oil will cure most serious cancers; the average person can ingest this amount in about three months. This oil is very potent so one must begin treatment with small doses. A drop of oil about half the size of a grain of rice, two to four times a day is a good beginning. After four or five days, start increasing your daily dosage very gradually. As time goes on the body builds a tolerance to the oil and more and more can be taken. In cases where people are in a great deal of pain, I recommend that their dosage be quickly increased until it kills the pain. High quality hemp oil will stop pain even when morphine is not effective. The oil can be applied to external injuries for pain relief in minutes.

Will I get high?
Following the dosage previously described, many people can take the full treatment and never get high. In regards to hemp, getting "high" is a joke, even if a person does take too much oil the effect wears off quickly and no harm is done. No one has ever died from the use of hemp medicine.

Will I become addicted?
Hemp oil does not cause your body to crave more. It is non-addictive, harmless and effective for practically any medical condition.

Is this the same as hemp seed oil?
No! This is hemp oil, made from the bud and small leaves of the hemp plant. It is the essential oil of the hemp plant. Health food store sells oil made from hemp seed that is often mislabeled as hemp oil. Although seed oil is very beneficial, it does not contain enough THC to have any effect on cancer and other serious illnesses.

Are hemp and marijuana the same?
The word marijuana is one of over four hundred slang terms used worldwide to describe the cannabis and/or hemp plant.

Are all hemp plants the same?
When buying or growing hemp, procure a strain that has the highest possible THC content. To energize someone suffering from depression, I recommend a good Sativa strain. For most other medical conditions, I strongly suggest that Indica strains be used. Indicas relax a person and provide them with more rest and sleep.

How do I use it?
High quality hemp oil can be vapourized, ingested or used topically. Add the oil to creams and salves for external use.

Where can I get information about making the oil?
The process in the video could only be described as crude at best, but the oil that is produced will cure cancer. In reality, this medicine should be produced in a controlled environment, using distilling equipment, etc. to reclaim the solvent and to purify the oil. Most people do not understand distilling and do not have access to the required equipment. This is the reason such a simple method is descried in the documentary, so if need be just about anyone can produce the oil. As in the video, again we stress that this process, if not done properly can be dangerous and we bear no responsibility if this educational information is misused.

Rick Simpsons process of making hemp oil

Starting material:
I generally work with a pound or more of good grade hemp starting material. You can use just one ounce. An ounce will usually produce 3 or 4 grams of oil. The amount of oil produced per ounce of hemp will vary from strain to strain, but it all has that wonderful healing power.

1 - Place the completely dry starting material in a plastic bucket.
2 - Dampen the material with the solvent you are using. Many solvents can be used. I like to use pure naphtha but it costs $500 for a 45-gallon drum. You can use 99% isopropyl alcohol, which you can find in your local drug stores. Alcohol absorbs more chlorophyll from the plant material than naphtha does. This gives oils made with alcohol a darker colour but does not diminish the potency of the oil to any noticeable degree. Ether, naphtha or butane and many other solvents can produce oils that are amber and transparent. Granted these clear oils do look better but dark oil can be just as potent. If the process is done properly, little or no solvent residue is left in the oil. I have been consuming oils produced using different solvents for eight years with no harmful effects. You will require about two gallons of solvent to strip the THC off one pound of dry starting material. 500 milliliters of solvent should be more than enough to strip the THC from one ounce of hemp starting material.
3 - Crush the plant material using a stick of clean untreated (chemical free) wood or some such device. Even though the starting material has been dampened with the solvent, you will find that the material can be readily crushed.
4 - Add solvent until the starting material is completely covered.
Use the stick to work the plant material. As you are doing this, the THC dissolves off the plant material into the solvent.
5 - Continue this process for about 3 minutes.
6 - Pour the solvent-oil mix off the plant material into another bucket. You have just stripped the plant material of about 80% of its THC.
7 - Second wash - again add solvent to the plant material and work it for another 3 minutes to get the other 20%.
8 - Pour this solvent-oil mix into the bucket containing the first mix that was poured off previously.
9 - Discard the twice-washed plant material.
10 - Pour the solvent-oil mix through a coffee filter into a clean container.
11- Boil the solvent off. I have found that a rice cooker will do this boil off very nicely. The one I have has two heat settings - high and low - and will hold over a half gallon (2.5 liters) of solvent-oil mix.
12- Add solvent-oil mix to the rice cooker until it is about ¾ full.

Make sure you are in a very well ventilated area and set up a fan to carry the solvent fumes away. The fumes are very flammable. Be sure to stay away from red-hot elements, sparks, cigarettes etc. that could ignite the fumes.

13 - Plug the rice cooker in and set it on high heat.
14 - Continue adding solvent-oil mix as the level in the rice cooker decreases until it is all in the cooker.
15 - Add a few drops of water to the solvent-oil mix as the level comes down for the last time. The amount of water added depends on how much starting material you had in the beginning. If I am producing oil from a pound of good bud, I usually add about ten drops of water.
16 - When there is about one inch of solvent-oil-water mix left in the cooker, put on your oven mitts, pick the unit up and gently swirl the contents.
17 - Continue swirling until the solvent has been evaporated off. The few drops of water help release the solvent residue and protect the oil somewhat from too much heat. When the solvent has been boiled off, the cooker that I use automatically goes to low heat. This avoids any danger of overheating the oil. At no time should the temperature of the oil go over 290F degrees (140 C).
18 - Put on your oven mitts and remove the pot containing the oil from the rice cooker.
19 - Gently pour the oil into a small stainless steel container.
20 - Place this container in a dehydrator or put in on a gentle heating device such as a coffee warmer. It may take a few hours but the water and volatile turpines will be evaporated from the oil. When there is no longer any activity on the surface of the oil the medicine is ready for use.
21 - Pour the hot oil into a bottle; or as in the video suck it up into a plastic syringe. Putting the oil in a plastic syringe makes it very easy to dispense the medicine.
When the oil cools off it has the consistency of thick grease. Some strains will produce very thick oil and you may have trouble squeezing it out of the syringe. If this happens, place the syringe in warm water a few minutes prior to use.

To anyone starting to use hemp oil as a medication, here are some simple facts.
Hemp oil will lower blood pressure and if you are on blood pressure medication, you may find that this medication is no longer needed. The same is true for diabetics. I have seen hemp oil control blood sugar to the extent that insulin was no longer needed.

I am not a doctor and I do not have the right to tell people what they should do. Personally, I would not consider taking any cancer treatments currently in use by our medical system, I do not recommend that hemp oil be taken along with chemotherapy. What would be the sense of making your own cure and then allowing the medical system to give you massive doses of poison?

From my experience with hemp medicine, I have found that most pharmaceutical medications are no longer needed once a person starts using hemp oil. Hemp oil seems to mix well with most natural medications but I have had a few reports from people trying to take hemp oil and pharmaceuticals who experienced stomach pain etc. All problems ceased when they stopped taking the prescription drugs.

To anyone who is going to act on this information to help a loved one, I welcome you to the world of real medicine. Again, I caution you to be very careful when boiling the solvent off. The fumes are very flammable. Be sure to stay away from red-hot elements, sparks, cigarettes etc. that could ignite the fumes.

I wish you the best luck and health.
Warmest regards,
Rick Simpson.
Source www.phoenixtears.ca
Rick Simpson Interviewed by Jindrich Bayer
Rick Simpson Interviewed by James Martinez on Achieve Radio

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Medical Marijuana Improves Good Result in Multiple Sclerosis

by Administrator 21. October 2011 05:29

http://www.thcsupport.com/blog/post/Medical-Marijuana-Improves-Good-Result-in-Multiple-Sclerosis.aspx 

Medical Marijuana for Multiple Sclerosis

Medical marijuana for Multiple Sclerosis has confirmed to be a helpful medicine for people with this incapacitating disease. Around 350,000 people in the United States are expected to suffer from multiple sclerosis. It is a disease that affects the central nervous system, and at times can be critical.

Multiple Sclerosis is the most common disabling neurological disease of younger age groups. Usually, Multiple Sclerosis is more common in women and usually happens between the ages of 20 and 40 even though symptoms may vary depending on the person, spasticity is the most common problem that most Multiple Sclerosis patients have to face. This phenomenon causes many problems for patients, including spasm, pain and loss of functionality. It also gives causing difficulty when they are in care of nursing professionals.


Know all about Multiple Sclerosis in Detail

 

The use of medical marijuana in multiple sclerosis may help alleviate problems associated with spasticity, and also proved to help people improve tremor. Multiple Sclerosis is known as a disease that demolishes the defensive cover of courage fibers, identified as myelin, both in the spinal cord and brain. It has been shown in pharmacological studies of medical marijuana in Multiple Sclerosis disease has a positive collision on the momentum systems of the central nervous system, which helps decrease the symptoms of spasticity and tremor. Irritation and damage of myelin is thought to be caused by disorders of the protected system, and the use of medical marijuana in Multiple Sclerosis treatment has confirmed to decrease the autoimmune attack potentially having a positive effect on the protected system.

Possibly the most significant optimistic qualities reported by patients who used marijuana in Multiple Sclerosis is that many patients who were before confined to a wheelchair said that they could walk without assistance, when they increasing smoke medical marijuana. Many patients who have used this a lot of medical marijuana was also reported to improve sense of balance and positive impact on bladder control, vision, speech, tremors and muscle spasms.

Although no research has yet to be done, it seems that medical marijuana for Multiple Sclerosis may also be able to slow down the process of neurodegeneration. This leads to chronic disability in Multiple Sclerosis and other diseases, and is able to slow down this process can mean the health and lives of many people in the central nervous system diseases.

THE CNS & MMJ

RSD affeced side spead it through the entire body

 

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JANUARY 2012

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MARCH 22, 2012

 

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