Ritalin (methylphenidate) is an amphetamine-like prescription stimulant commonly used to treat Attention Deficit Hyperactivity Disorder (ADHD) in children and adults.
Many think Ritalin is safe, or mild, because so many children use it. However, the government classifies the psychoactive drug with cocaine and morphine because it's highly addictive.
FDA: “Black Box” Warning
The Food and Drug Administration (FDA) requires the following “black box” warning on all methylphenidate drugs, including Ritalin, which means that medical studies indicate Ritalin carries a significant risk of serious, or even life-threatening, adverse effects.
Attention deficit disorder
How Does Ritalin Work?
Ritalin works by initiating the acute stress response (“fight or flight” response). The central nervous system prepares the body for physical action by creating physiological changes as if it were stressed or under threat. These changes include:
The release of adrenalin, raises cortisol levels and other stress hormones
Increased heart rate and blood pressure
Redirected blood flow into the muscles and away from the brain
Methylphenidate (Ritalin) was first synthesized in 1944 in an (unsuccessful) attempt to create a stimulant that would not induce addiction or tolerance. Ritalin is very closely related to amphetamine— similar in chemical structure, metabolization and clinical effects. This close connection is the chief reason Ritalin use raises concern among patients and others.
Do Not Use If
You have high blood pressure or any form of heart disease, are very nervous or have severe insomnia, have a history of addiction to drugs or alcohol. Do not combine with monoamine oxidase inhibitors.
Ritalin has been extensively abused. Extreme psychological dependence and severe social disability have resulted. Abuse of Ritalin may cause a sudden heart attack—even in those with no signs of heart disease. Symptoms of overdose that require immediate medical assistance include:
Hyperreflexia (overactive reflexes, which can include twitching or spasms)
Symptoms of depression
Seizures or abnormal EEGs
High blood pressure
Rapid heart beat
Swelling of hands/feet/ankles (for example, numbing of the fingertips)
Unexplained muscle pain
Lower abdominal pain
Rhabdomyolysis and kidney damage
Chronic abuse can manifest itself as psychosis, often indistinguishable from schizophrenia
What to Do About Side Effects
The last dose of the drug every day should be taken several hours before bedtime to prevent insomnia.
Nervousness usually goes away and appetite often returns so that weight loss is rarely dangerous.
If high blood pressure, rapid pulse, paranoia, or tolerance becomes a problem, the drug is usually stopped.
Nothing can be done about the addiction except to remember not to stop taking any type of methylphenidate abruptly.
Dependence, Tolerance and Withdrawal
It is possible to build up a tolerance to methylphenidate, which means the person using the drug needs to take larger doses to achieve the same effect. Over time, the body might come to depend on methylphenidate drugs just to function normally. The person craves the drug and their psychological dependence makes them panic if access is denied, even temporarily.
Withdrawal symptoms can include tiredness, panic attacks, crankiness, extreme hunger, depression and nightmares. Some people experience a pattern of “binge crash” characterized by using continuously for several days without sleep, followed by a period of heavy sleeping.
If It Doesn't Work
The drug should be stopped gradually. Withdrawal symptoms are psychological and stopping suddenly can cause extreme fatigue and severe, even suicidal, depression in adult patients.
If It Does Work
“Also, in addition to increasing heart rate and blood pressure, causing insomnia and weight loss, and sometimes causing psychotic symptoms, the stimulant medications used for ADHD (methylphenidate and amphetamines) may cause heart disease if taken for a long time. The latter problem led to a debate within the FDA, well covered by newspapers, about whether to issue a special warning to doctors. In the end, the FDA decided not to do this, but the risk remains,” reports Jack M. Gorman, M.D., professor of psychiatry at Columbia University and deputy director of the New York State Psychiatric Institute. Ritalin “is a very powerful drug that undoubtedly works for ADHD, but there are alternatives with less abuse potential that should be tried first.”
What is the Difference Between Ritalin LA and Ritalin SR?
Ritalin LA releases two peak levels of methylphenidate per day:
first a rapid onset and
another release about four hours later.
Ritalin SR delivers methylphenidate into the blood more slowly and continuous over a 6-8 hour period.
Ritalin LA Dosage Conversion Table
Methylphenidate or Ritalin SR
10 mg methylphenidate twice-per-day
20 mg Ritalin LA once-per-day
20 mg Ritalin SR twice-per-day
20 mg Ritalin LA once-per-day
15 mg methylphenidate twice-per-day
30 mg Ritalin LA once-per-day
20 mg methylphenidate twice-per-day
40 mg Ritalin LA once-per-day
40 mg Ritalin SR twice-per-day
40 mg Ritalin LA once-per-day
30 mg methylphenidate twice-per-day
60 mg Ritalin LA once-per-day
60 mg Ritalin SR twice-per-day
60 mg Ritalin LA once-per-day
ABOVE: National Association of Chain Drug Stores, NACDS Chain Pharmacist Practice Memo (July 2002).
NY Times: Children's A.D.D. Drugs Don't Work Long-Term
The NY Times, in an op-ed article by L. Alan Sroufe, a professor emeritus of psychology at the University of Minnesota's Institute of Child Development, stated the following:
“Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects... Many parents who take their children off the drugs find that behavior worsens, which most likely confirms their belief that the drugs work. But the behavior worsens because the children's bodies have become adapted to the drug. Adults may have similar reactions if they suddenly cut back on coffee, or stop smoking.”
Parents might want to consider another approach.
ABOVE: L. Alan Sroufe, “Ritalin Gone Wrong: Children's A.D.D. Drugs Don't Work Long-Term,” New York Times, pg SR1, NY ed, 1/28/2012.
Harmful Reactions to ADHD Stimulant Drugs
Brain and Mind Reactions
Zombie-like (robotic) behavior with loss of emotional spontaneity
Drowsiness ‘dopey,’ reduced alertness
Abnormal movements, tics, Tourette’s
Nervous habits (picking at skin, pulling hair)
Mania, psychosis, hallucinations
Agitation, anxiety, nervousness
Irritability, Hostility, Aggression
Confusion, mental impairments (decreased cognition and learning)
Depression, emotional, sensitivity, easy crying, social withdrawal
Stimulant addiction and abuse
Abnormal heart beat
Hypersensitivity reaction with rash
Withdrawal and Rebound Reactions
Rebound worsening of ADHD-like symptoms
Over-activity and irritability
Endocrine and Metabolic Reactions
Pituitary dysfunction, including growth hormone and prolactin disruption, Growth suppression
ABOVE: Breggin, PR. Talking back to Ritalin, rev. ed. Cambridge, MA: Perseus Books Group, 2001: cited references include: Breggin, PR. “Psychostimulants in the treatment of children diagnosed with ADHD: Risks and mechanism of action.” Intl Journal of Risk and Safety in Medicine, 12, 3-35, 1999. Breggin, P. “Psychostimulants in the treatment of children diagnosed with ADHD: Part I: Acute risks and psychological effecs.” Ethical Human Sciences and Services, 1, 13-33, 1999. Arnold, L.E. and Jensen, P.S. Attention-deficit disorders, in H.I. Kaplan and Sadock, B. (Eds.). Comprehensive Textbook of Psychiatry, VI (table 38-5 p. 2306, table 38-7, p 2307), Baltimore: Williams & Wilkins, 1995. Drug Enforcement Administration (DEA), Methylphenidate (a background paper). Washington DC: Drug and Chemical Evaluation Section, Office of Diversion Control, DEA, U.S. Department of Justice, p. 23, 1995. Dulcan, M. “Treatment of children and adolescents,” in R. Hales, Yudofsky, S. and Talbot, J. (Eds.), The American Psychiatric Press textbook of psychiatry, (Second Edition) (table 35-6, p. 1217), Washington DC: American Psychiatric Press, 1994. Maxman, J.S. and Ward, N.G. Psychotropic drugs fast facts, second edition. New York: W.W. Norton (1995). Food and Drug Administration (1997).
Long-Term Effects of Ritalin—Changes in Brain Development
The same damage as in Alzheimer's.
Ongoing research shows early-life use of Ritalin (methylphenidate) has complex effects that endure later into life. A study published in Biological Psychiatry suggests that exposure of Ritalin in youth may later disrupt development of brain cells in the hippocampus, region of the brain critical to memory, spatial navigation, and behavioral inhibition and resulting in memory problems, disorientation and depression in adulthood.
Damage caused by Ritalin is the same as seen in Alzheimer's disease where the hippocampus is one of the first areas of the brain to suffer damage so memory problems and disorientation appear among the first symptoms.
ABOVE: Lagace, D.C., et al. Juvenile administration of methylphenidate attenuates adult hippocampal neurogenesis. Biol Psychiatry 60:1121-1130, 2006.
Wang L., et al. Changes in hippocampal volume and shape across time distinguish dementia of the Alzheimer type from healthy aging. NeuroImage vol. 19, 2003. Zhao Z. et al. Hippocampus shape analysis and late-life depression. Plos One 3(3): e1837, 2003.
What are the differences between the various methylphenidate drugs?
(lisdexamfetamine) [extended release]
†Not sold in U.S.
What is the most important information I should know about RITALIN-SR?
The following have been reported with use of RITALIN-SR and other stimulant medicines.
1. Heart-related problems:
sudden death in patients who have heart problems or heart defects
stroke and heart attack in adults
increased blood pressure and heart rate
Tell your doctor if you or your child have any heart problems, heart defects, high
blood pressure, or a family history of these problems.
Your doctor should check you or your child carefully for heart problems before
Your doctor should check you or your child's blood pressure and heart rate
regularly during treatment with RITALIN-SR.
Call your doctor right away if you or your child has any signs of heart
problems such as chest pain, shortness of breath, or fainting while
2. Mental (Psychiatric) problems:
new or worse behavior and thought problems
new or worse bipolar illness
new or worse aggressive behavior or hostility
Children and Teenagers
new psychotic symptoms (such as hearing voices, believing things that
are not true, are suspicious) or new manic symptoms
Tell your doctor about any mental problems you or your child have, or about a
family history of suicide, bipolar illness, or depression.
Call your doctor right away if you or your child have any new or
worsening mental symptoms or problems while taking RITALIN-SR, especially seeing or hearing things that are not real, believing things that
are not real, or are suspicious.
National Institute of Mental Health. Medications. Bethesda, MD: National Institute of Mental Health,
National Institutes of Health, US Department of Health and Human Services; NIH Publication No. 02-3929, 2007 ed.
Johns Hopkins Medicine, Health Alerts, "Heart Attack: Symptoms and Remedies": johnshopkinshealthalerts .com (2008).
Sadock, B.J., et al. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (Synopsis of Psychiatry), 10th ed. Philadelphia, PA; Lippincott Williams & Wilkins, 2007.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC, 2000, as cited above.
Gorman, Jack M. The Essential Guide to Psychiatric Drugs—Rev. and updated, 4th ed. New York, NY: St. Martin's Press, 2007.
Cohen, J.S. Over Dose: The Case Against the Drug Companies: Prescription Drugs, Side Effects, and Your Health. New York: Penguin Putnam Inc., 2001.
Graedon, J. The People's Pharmacy. New York: Avon Books and St. Martin's Press, Inc., 1976.
Drummond, E.H. The Complete Guide to Psychiatric Drugs: Straight Talk for Best Results, Rev. and expanded. New Jersey: John Wiley & Sons Inc., 2006.
Reichenberg-Ullman, J., et al. Ritalin Free Kids; California: Prima Health, Prima Publishing (1996).
Diller, L.H. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill; Bantam Doubleday Dell Pub. Group, Inc. (1998).
Health Canada, Canadian Adverse Reaction Newsletter, Vol. 16, No. 3, Jul 2006: hc-sc.gc .ca/dhp-mps/medeff/ bulletin/ carn-bcei_v16n3-eng.php#a3.
National Association of Chain Drug Stores, NACDS Chain Pharmacist Practice Memo (July 2002): nacdsfoundation .org.
Lagace, D.C., et al. Juvenile administration of methylphenidate attenuates adult hippocampal neurogenesis. Biol Psychiatry 60:1121-1130, 2006.
Wang L., et al. Changes in hippocampal volume and shape across time distinguish dementia of the Alzheimer type from healthy aging. NeuroImage vol. 19, 2003.
Zhao Z. et al. Hippocampus shape analysis and late-life depression. Plos One 3(3): e1837. doi:10.1371/journal.pone.0001837 (2003).
Breggin, PR. The Ritalin Fact Book; Perseus Books Group, 2002.
Abreu BE, et al. Influence of amphetamine sulfate on cerebral metabolism and blood flow in man. J Pharm Sci, 1949;38:186–188.
Lombard J, et al. The Brain Wellness Plan; Kensington Pub. Corp., 1998.
Mazza M, et al. Primary cerebral blood flow deficiency and Alzheimer's disease: shadows and lights. Journal of Alzheimer's Disease 2011;23(3):375-89.
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