Podcast Summary: ADHD Experts Podcast – Ep. 575
"An Adult’s Guide to ADHD Treatment Considerations"
Date: September 16, 2025
Host: Annie Rogers, ADDitude
Guest Expert: Dr. John Cruz, Psychiatrist & ADHD Specialist
Episode Overview
This episode features Dr. John Cruz, a leading authority in adult ADHD treatment, who provides an in-depth, science-based guide to ADHD medication and treatment choices specifically for adults. Covering both stimulant and non-stimulant medications, side effects, dosing, safety in older adults, supplement evidence, and common myths, the episode balances rigorous science with practical guidance. Dr. Cruz also addresses audience questions on real-life medication dilemmas.
Key Discussion Points & Insights
1. The Multi-Faceted Nature of ADHD Treatment
[02:34]
- Medications are “never the complete answer” for ADHD; effective treatment is always multimodal (medication, environment, lifestyle, and therapy all matter).
- Sleep is the most pivotal lifestyle factor, even with optimal medication.
- Other vital non-medication factors: nutrition, exercise, exposure to nature, and mindfulness/relaxation.
- Cognitive Behavioral Therapy (CBT) is “proven effective” for many adults in learning executive function skills.
Quote:
"Even if you're on optimal medications... if you're not sleeping well, you're going to have executive function problems." — Dr. Cruz [03:24]
2. Understanding "Stimulants": Definitions & Efficacy
[05:13]
- The term "stimulant" is imprecise; in ADHD, it usually means “strong stimulants” (amphetamines, methylphenidate) that boost dopamine and norepinephrine release.
- Amphetamine-based meds (e.g., Adderall, Vyvanse) are most effective for adults; methylphenidate (Ritalin, Concerta) is closer in effect to non-stimulants than to amphetamines.
- Despite efficacy, findings “don’t mean they’re ideal for everyone."
Quote:
"Amphetamine is substantially better in terms of efficacy than methylphenidate, and methylphenidate actually is closer to the non-stimulants than to the strong stimulant amphetamine products." — Dr. Cruz [09:36]
3. Non-Prescription and Supplement Approaches
[12:19]
- Evidence is inconsistent or insufficient for most alternative/supplement treatments, though some (caffeine, magnesium, fish oil) have modest supporting data.
- Lion’s Mane mushroom: Promising early data; minimal or no clinical trials for ADHD yet.
- Ketamine clinics advertising ADHD benefits: “No evidence” beyond anecdotal case reports.
Quote:
"There's a lot of good basic science evidence [for Lion's Mane], but in terms of clinical data in ADHD, it's almost nonexistent." — Dr. Cruz [13:50]
4. Side Effects: Minor and Severe
Minor (but impactful):
[14:03]
- Dose-dependent side effects: anxiety, tremor, irritability, sleep disruption, appetite suppression, dry mouth, elevated heart rate/blood pressure—usually lessen with time or dose adjustment.
- Tolerance to side effects often develops, allowing continued benefit.
Serious/Life-Threatening:
[15:50]
- Cardiac: True fatal cardiac events are "extremely rare" (less than 1 in 100,000), most often in those with genetic predispositions (family/personal history of sudden cardiac death = reason for special screening).
- Most people don’t need EKGs unless strong cardiac history/worry is present.
Quote:
"Nobody wants this to happen... even the cardiology organizations don’t say [EKG screening] is clinically necessary as long as you take a thorough personal and family history." — Dr. Cruz [16:41]
5. Addiction, Misuse & ADHD
[22:59]
- True stimulant addiction rates are low (2-4%), though misuse as defined by not following prescribed directions is much higher (up to 60%).
- ADHD itself doubles the risk for substance use disorders; starting stimulant meds in childhood reduces this risk to general population levels.
- For people with SUD histories, Vyvanse can improve treatment retention and reduce relapse.
Quote:
"Having ADHD itself doubles the risk of developing a substance abuse disorder… but taking stimulant medications… lowers your risk to that of people in the general population." — Dr. Cruz [24:13]
6. Amphetamine-Induced Psychosis Risks
[29:28]
- Rare (about 1 in 500), but serious: delusional paranoia possibly lasting months or longer.
- Not limited to high doses or early use; can occur after years, and effects may be persistent.
- “If you’ve ever had even a single event [of psychosis], do not retry any amphetamine product.”
7. Stimulant Myths: Brain Damage
[34:21]
- Despite animal and street drug studies, no human research shows prescription stimulant use damages the brain. In fact, medicated brains “look more like people who never had ADHD.”
- Most worrisome animal studies used doses dramatically higher than safe human usage.
8. Optimal Dosing Strategies
[40:06]
- Adjust dose based on actual patient response—subjective improvement plus “anything you can quantify,” e.g., email productivity, ability to read.
- FDA dose guidelines are flexible: "Guidelines... are not meant to replace an individual clinician’s judgment."
- Rating scales help but should be combined with real-life functional measures and outside (collateral) observations.
- Body size/gender are “crude predictors”; focus on benefits/side effects.
9. Combining Medications and "Siesta Time"
[43:57]
- Combining long- and short-acting stimulants is “reasonable" for coverage or extending effect.
- Guanfacine often used to reduce blood pressure or “sympathetic arousal” when combined with stimulants.
- "Siesta time" in the afternoon is biological—try to work with it, not medicate through it.
Notable Q&A Moments
1. Stimulant Use in Older Adults (65+)
[46:06]
- No age limit "makes sense" for discontinuing stimulants; evaluate based on cardiac risk, not arbitrary cutoffs.
- Dr. Cruz has patients into their 80s/90s on stimulants with no issues besides occasional dosage reduction.
Quote:
"Almost any hard cap is denying the individuality of certain humans. I have patients in their 80s, even 90s, who continue their medications safely and with great benefit." — Dr. Cruz [46:06]
2. Stimulants for Adults with Hypertension
[48:34]
- Stimulants are not universally contraindicated with hypertension; check if blood pressure actually changes on/off meds.
- Blood pressure meds (including guanfacine) can be paired with stimulants for safety.
Quote:
"If your blood pressure two hours after taking your Vyvanse isn’t different… then it is not a part of what's contributing to this individual's hypertension and therefore safe to continue." — Dr. Cruz [49:09]
3. Long-Term Health Risks of Stimulants
[50:41]
- Cardiac risks are small but present (2% above baseline over 15 years).
- Far greater risk comes from untreated ADHD itself, which reduces average lifespan by 7-9 years (mainly due to suicide and accidents).
- One study may link ADHD meds to increased Parkinsonism, but unclear if medication or ADHD is the cause.
Quote:
"ADHD itself kills people... the data is pretty darn clear. On average, if you've had ADHD since childhood, you're likely to lose 7, 8, 9 years of life." — Dr. Cruz [51:09]
4. Med Tolerance & “Medication Vacations”
[53:55]
- Little evidence to support “medication vacations” for preventing tolerance.
- In Dr. Cruz’s practice, 80% stayed on same dose for years, with equal splits between needing more vs. less over time; most remain stable.
5. Brand vs. Generic Medication Differences
[56:48]
- Brand and generics are chemically equivalent but FDA allows 15-20% leeway in absorption/release, which can affect efficacy and side effects for sensitive individuals.
- Psychological factors may contribute, but real physiological differences can exist, especially with fast-acting drugs.
Quote:
"For stimulants... how quickly that dosage is changing from the previous minutes is a part of physiologic action of stimulants." — Dr. Cruz [58:22]
"The FDA themselves acknowledged... several of the generic versions were not biologically equivalent, even though they were chemically equivalent." — Dr. Cruz [59:48]
6. Supplements: Where to Learn More
[61:51]
- Dr. Cruz has YouTube videos on supplements (lion’s mane, fish oil, magnesium, ketamine) — more planned.
- Most supplements are low risk but lack robust clinical data for ADHD.
Memorable Quotes
-
On Treatment Philosophy:
“You're always treating or working with the brain that's interacting with a specific environment.” — Dr. Cruz [02:56] -
On Cardiac Risks & Screening:
"Any alarming family history of cardiac problems is a good reason to screen with an EKG. And even someone's just worry or concern is a good reason to screen with an EKG." — Dr. Cruz [18:52] -
On Brain Damage Concerns:
"People who took stimulants...have brains that look more like they never had ADHD than the people who avoided stimulant medication use." — Dr. Cruz [35:36]
Timestamps: Important Segments
- [02:34] Multi-modal ADHD treatment & role of sleep
- [05:13] What counts as a "stimulant"; amphetamine vs. methylphenidate
- [12:19] Supplements: caffeine, magnesium, lion’s mane, etc.
- [14:03] Common side effects—minor and dose-dependent
- [15:50] Serious cardiac risks: how rare?
- [22:59] Addiction, misuse, and SUD risks
- [29:28] Amphetamine-induced psychosis: rarity and seriousness
- [34:21] No evidence for brain damage from Rx stimulants
- [40:06] How to find your optimal dose
- [43:57] Combining medications; “siesta time”
- [46:06] Age limits for stimulants
- [48:34] Stimulants and hypertension
- [50:41] Long-term stimulant risks vs. risks of untreated ADHD
- [53:55] Tolerance, medication vacations, and dose stability
- [56:48] Brand vs generic meds — why differences matter
For More Information
- Slides & Webinar Recording: attitudemag.com – search for episode 573 or 575
- Dr. Cruz on YouTube: Dr. John Kruse YouTube Channel
- Supplements: See Dr. Cruz’s videos for deeper dives into specific non-medication options.
Summary Prepared For: Listeners seeking clear, actionable, and science-based ADHD treatment information, especially adults facing real-world medication decisions or seeking to understand the evidence behind supplement choices and medication safety concerns.