The Problem

Attention Deficit Hyperactivity Disorder (ADHD), though commonly affecting children, also affects over 10 million adults in the US.

Adderall (amphetamine-dextroamphetamine) is one of the most widely prescribed medications prescribed to treat it. It helps some, but in many, its effect is much less than desired. Many continue to have difficulty focusing; many remain tense.

I am not a psychiatrist, and ADHD is not my specialty. However, my experience as a physician has taught me that there is an effective, well-tolerated, and inexpensive alternative to Adderall that is rarely prescribed! And few if any psychiatrists are even aware of it as an option worth considering. Given its beneficial effect, as well as the current shortage of available Adderall, I believe it’s an alternative you should look into.

Beta-Blockers

I specialize in the treatment of hypertension (high blood pressure). Among the many available drug classes used to treat hypertension are beta-blockers. 

Beta-blockers lower blood pressure by interfering with the secretion of an enzyme renin and by inhibiting the effect of circulating adrenaline. Adrenaline is a hormone whose secretion is stimulated by the sympathetic nervous system (SNS), the mediator of our fight-or-flight reflex.

Over many years of treating patients who were seeing me concerning their hypertension, I couldn’t help noticing that in some patients beta-blockers clearly had a calming effect.

It was likely a result of inhibition of the effects of circulating adrenaline.     

I also began to notice that when I prescribed a beta-blocker to treat hypertension in patients who had ADHD, many, perhaps half or more, reported that they felt calmer and were functioning better. And, on their own, some reduced the dose of, or even stopped, the Adderall they had been taking! In this regard, it seemed very relevant that, unlike Adderall, beta-blockers reduce rather than increase, the level of activation of the SNS, an effect that would seem desirable in treating ADHD. 

Unfortunately, the potential role of beta-blockers in treating ADHD has not been formally studied, and has not received attention. Since beta-blockers are largely off patent, are inexpensive, and have a huge market in treating patients with hypertension, coronary disease or arrhythmias, it is unlikely that the pharmaceutical industry would have any financial interest in examining their efficacy and safety in treating ADHD.

However, reassuringly, beta-blockers have been safely prescribed to tens of millions of patients. Unless you have asthma, or a very slow heart rate, a trial of a beta-blocker is extremely likely to be easy and safe. Your physician can alert you if there is any concern about trying one. 

Which beta-blocker should you try to manage ADHD?

There are many available beta-blockers. (see my blog on beta-blockers). The best-sellers are metoprolol (Toprol, Lopressor) and carvedilol (Coreg). My preference though is bisoprolol which provides a more consistent blood level, and, interestingly, has a calming effect even though, unlike metoprolol and carvedilol, it does not cross the blood-brain barrier!

The calming effect in patients with ADHD is likely from inhibiting the effect of the relentless secretion of adrenaline. 

I usually prescribe half of a 5 mg pill (2.5 mg), once daily. If no positive effect with regard to the ADHD is evident within a few days, I increase the dose to 5 mg. In some, particularly if the heart rate is still in the 70s or higher, I might try a 10 mg dose. 

I want to state clearly that beta-blockers are not FDA-approved for the treatment of ADHD. Also, it is unlikely that the pharmaceutical industry would undertake the financial burden of a large randomized, double-blinded trial to prove efficacy its safety. And it could be years before the results could be reported. 

Nevertheless, the reasonable safety of beta-blockers evident from decades of widespread use, and the inadequate response in so many to medications taken for ADHD, argue for consideration of a quick trial of a beta-blocker if you are not thriving on Adderall. 

Also important, it is very simple to give it a try. The benefit is evident within a few days. If it doesn’t help, or if there are side effects, it can be stopped. If it helps, it is easy and reasonable to then try to reduce, and maybe even stop, the Adderall, under the guidance of a psychiatrist. 

This treatment approach is truly a revolutionary idea in the management of ADHD.

The beauty of it is how simple it is to just try it. If you have ADHD, and are not satisfied with the effect of the Adderall you are taking, my experience teaches me that a brief trial of bisoprolol, under the supervision of your physician, is easy and worthwhile. Psychiatrists, in general, are not familiar with this approach, so it would be best to bring this summary to his/her attention.