CNS Stimulants (ADHD)

First-line. "Stimulants are the mainstay of treatment for ADHD. They are effective in about 70% of patients" (StatPearls). NIMH lists "Medication, usually stimulant medications" among the most common adult treatments, and "stimulant medications can be helpful for adults, as well as for children and adolescents, with ADHD." Methylphenidates and amphetamines (including lisdexamfetamine) come in immediate- and extended-release forms. Take in the morning: "avoid afternoon doses because of the potential for insomnia" (VYVANSE label). Extended-release tablets: "swallow CONCERTA whole with liquids, and not to split, crush, or chew" (label). Stimulant use for ADHD "is safe in epilepsy" (StatPearls).

Lisdexamfetamine for binge eating disorder — "the only medication with Food and Drug Administration approval for moderate-to-severe binge eating disorder in adults," and it "effectively decreases the frequency of binge eating episodes." StatPearls frames medication as first-line only "in patients who do not have access to psychotherapy, decline psychotherapy, or prefer medications."

The disorder-side role here is toxicity and its management, and the management is counter-intuitive twice over. Sedation is first-line, and four separate sources say so: "intravenous benzodiazepines are administered immediately for chemical sedation of severely agitated individuals" and "remain the first-line treatment to manage agitation and prevent seizures"; cardiovascular toxicity and agitation are "best treated first-line with benzodiazepines to decrease CNS sympathetic outflow"; "diazepam is an ideal choice if intravenous access is available; otherwise, intramuscular lorazepam or midazolam is appropriate"; and hyperadrenergic symptoms should be managed with benzodiazepines "titrated to effect and repeated as necessary." Titrating to effect means watching the airway while you do it, because the doses that settle a hyperadrenergic patient are not small. Sedation is efficient because it treats several problems at once — "hypertension related to amphetamine toxicity may abate with agitation treatment." On beta-blockers, teach the disagreement rather than the mnemonic. The amphetamine chapter says they "should not be used as SOLE antihypertensive therapies as their use may lead to unopposed alpha-adrenergic tone," preferring nitroglycerin and nicardipine. The methamphetamine chapter names labetalol or carvedilol — combined alpha-1 and beta antagonists — as adjuncts when agitation persists despite adequate benzodiazepines, with alpha-2 agonists dexmedetomidine or clonidine as alternatives. The defensible teaching: sedate first; never a beta-blocker as sole therapy; if one is used, a combined alpha-1/beta agent is the sourced choice. Two other agent notes: non-dihydropyridine calcium channel blockers (diltiazem, verapamil) reliably reduce hypertension but not tachycardia, and dihydropyridines such as nifedipine should be AVOIDED because reflex tachycardia may occur; and haloperidol for stimulant delirium "may cause harm" — it can lower the seizure threshold, cause extrapyramidal effects, increase heat production by altering thermoregulatory function, and prolong the QTc.

Potent pain control via µ-opioid receptor agonism. Watch for respiratory depression; reverse with naloxone.

Potentiate GABA for anxiety, seizures, and sedation. Additive CNS depression — deadly with opioids.

First-line antidepressants that raise synaptic serotonin. Delayed onset; watch for serotonin syndrome and early suicidality.

Stabilize neuronal firing to prevent seizures. Many are narrow-therapeutic-index — level monitoring and rash vigilance are essential.

A widely used fever/pain reliever with no anti-inflammatory or platelet effect — but hepatotoxic in overdose.

Dopamine-blocking drugs for psychosis. Watch EPS, NMS, metabolic effects — boxed warning in elderly dementia.