What are the recommendations for using Benzedrine (amphetamine) for conditions like Attention Deficit Hyperactivity Disorder (ADHD) or narcolepsy?

Benzedrine (Amphetamine) for ADHD and Narcolepsy: Clinical Recommendations

Amphetamines should be used with caution for ADHD and narcolepsy due to their high potential for abuse, and they are recommended as conditional treatment options rather than first-line therapy for most patients. 1

Indications and Efficacy

For Narcolepsy:

• Amphetamines (including Benzedrine/dextroamphetamine) are suggested as a conditional treatment option for narcolepsy in adults 1
• Dosing:
  • Starting dose: 5-10 mg daily
  • Usual effective dose range: 5-60 mg per day in divided doses
  • First dose on awakening; additional doses at 4-6 hour intervals 2
  • Avoid late evening doses due to insomnia 2

For ADHD:

• Not recommended for children under 3 years of age 2
• Pediatric dosing (FDA-approved):
  • Ages 3-5: Start with 2.5 mg daily, increase by 2.5 mg weekly until optimal response
  • Ages 6+: Start with 5 mg once or twice daily, increase by 5 mg weekly
  • Maximum daily dose rarely exceeds 40 mg 2
• Adult dosing follows similar principles but may require higher doses
• Low to very low quality evidence suggests amphetamines reduce ADHD symptom severity (SMD -0.90) 3

Safety Considerations

Contraindications and Warnings:

• Schedule II controlled substance with high abuse potential 1, 2
• Black box warning for dependence with prolonged administration 1
• May cause fetal harm based on animal data; human data insufficient 1, 2
• Not recommended during pregnancy unless benefits clearly outweigh risks 2
• Mothers taking amphetamines should refrain from nursing 2

Adverse Effects:

• Common: sweatiness, edginess, irritability, loss of appetite 1
• Cardiovascular: tachycardia, increased blood pressure 4
• Neurological: insomnia, headache, potential for stimulant-induced psychosis with long-term use 5
• Growth: may slow height and weight growth in children 5

Pregnancy Considerations:

• Possible increased risks for:
  • Preterm birth (aOR 1.3)
  • Poor neonatal adaptation
  • NICU admission (aOR 1.5)
  • Central nervous system disorders (aOR 1.9) 1
• A recent large study showed no increased risks for long-term neurodevelopmental outcomes, vision/hearing impairments, epilepsy, seizures, or growth impairment 1

Treatment Algorithm

1. First-line options for ADHD:

   • Children ages 4-5: Evidence-based parent training in behavior management (effect size 0.55) 6
   • Consider medication only if behavioral interventions fail

2. When considering amphetamines:

   • Start with lowest effective dose
   • Titrate gradually (weekly increments)
   • Monitor for efficacy and side effects every 3-4 weeks during titration 6
   • Once stabilized, follow-up every 3-6 months

3. Alternative options to consider:

   • Methylphenidate (conditional recommendation for narcolepsy) 1
   • Modafinil (strong recommendation for idiopathic hypersomnia) 1
   • Non-stimulants like atomoxetine (effect size ~0.7) 6

Monitoring Parameters

• Regular assessment of:
  • Appetite and weight
  • Sleep patterns
  • Blood pressure and heart rate
  • Growth parameters in children
  • Mood changes and potential for abuse 6

Important Clinical Pitfalls

1. Abuse potential: Amphetamines are the most commonly abused prescription medications; careful patient selection is essential 5

2. Dosing errors: Avoid late evening doses to prevent insomnia; consider splitting doses or changing administration timing to prevent rebound hyperactivity 6, 2

3. Comorbidity management: Stabilize mood disorders before initiating amphetamines in patients with bipolar disorder and ADHD 6

4. Drug interactions: Amphetamines may interact with antihistamines, antihypertensives, chlorpromazine, haloperidol, lithium, and several other medications 2

5. Long-term effects: Limited data on prolonged use in adults; monitoring for cardiovascular and psychological adverse events is warranted 5

Benzedrine (amphetamine) remains a therapeutic option for ADHD and narcolepsy, but its use requires careful consideration of risks versus benefits, appropriate patient selection, and ongoing monitoring for adverse effects and potential abuse.