Yeardley Love Murder Defense

The Yeardley Love murder trial has started in Charlottesville, VA this week. I was invited by Fox TV (WBFF) in Baltimore to speak to the defense’s position that alcohol and adderall were the cause of death, not the head injury. My interview excerpts will likely be aired sometime over the next 2 weeks.

In reviewing the specific information on alcohol and adderall in this tragic murder, I share below public information (NBC29.com) on autopsy findings.

“Through testimony from Dr. William Gormley, the man who performed Love’s autopsy, we learned that she had a blood alcohol content of 0.14; nearly twice the legal limit if she had been driving. He also said there were no fractures to Love’s skull but her brain was riddled with contusions, and the alcohol in her system was not sufficient to cause death.” 

“Love also had a trace of a prescription amphetamine in her system (0.05ng/ml this I added from another source) consistent with the Adderall she took to help with her ADHD. Gormley testified that he did not believe the amphetamines were a contributing factor to her death.”

In regards to adderall, Yeardley was prescribed adderall under medical care. Adderall can be detected in blood up to 24 hours later so it is difficult to know when she had taken her dose of medication. Very likely it was taken much earlier in the day. The level is so low as to be relatively inconsequential in regards to clinical impact.

Two recently published studies reviewing the serious cardiovascular risks of stimulants in children, adolescents and adults found no association between stimulants and risk of myocardial infarction (heart attack), stroke, or sudden death. These two studies (NEJM, JAMA) represent the largest databases ever reviewed on stimulants and serious cardiovascular risks. There is additional study underway by the NIMH that is not yet published.

In my opinion, given that Yeardley was a seasoned athlete who would have had a pre-sports cardiogram and her heart was subjected to extreme athletic conditions without symptoms, the likelihood that alcohol and adderall provoked a cardiac arrthymia and sudden death is almost non-existent and wouldn’t rise to the level of consideration, especially in light of the more obvious cause of death determined by the medical examiner, “blunt force head trauma”.

We’ll await the presentation of additional facts in court and the jury’s conclusion.

So sad for all involved.

David W. Goodman, M.D.

ADHD Stimulant Shortage Video Maryland Public Television Jan 30, 2012

Watch my interview from Maryland Public Television live 15 minute interview by Jeff Salkin on Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm discussing the recent problematic shortage of ADHD stimulant medications. I offered explanations for the shortages and “work arounds” for patients. Let me know what you think.

David W. Goodman, M.D.

FDA, Pharmaceutical Companies, and Stimulant Shortages

 

Maryland Public Television has invited me to a live interview by Jeff Salkin on Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm to discuss the recent problematic shortage of ADHD stimulant medications. I will review the possible causes and make suggestions to “work around” the shortages for parents and patients.

As a preview to the show and for those who read my blogs, I have provided the FDA’s recent tables highlighting the manufacturers explanations for shortages. You will notice there are several companies making the medications so no one company can be held to blame. This is an industry issue entailing regulatory, manufacturing and economic factors.

Join us Monday night for my detailed explanations. Following the program, I will blog the detailed information I offered in the interview with further links.

http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

Amphetamine Mixed Salts, ER Capsules  (updated 10/31/2011)

Company/Products	Reason	Related Information
Shire Customer Service: 1-800-828-2088Adderall XR capsules 5 mg – 100 count (NDC 54092-0381-01); 10 mg – 100 count (NDC 54092-0383-01); 15 mg – 100 count (NDC 54092-0385-01); 20 mg – 100 count (NDC 54092-0387-01); 25 mg – 100 count (NDC 54092-0389-01); 30 mg – 100 count (NDC 54092-0391-01)	API supply issues and uneven product distribution patterns.	Product availability for all dosage strengths is adequate.
Teva Customer Service (888)838-28725 mg – 100 count (NDC 00555-0790-02); 10 mg – 100 count (NDC 00555-0787-02); 15 mg – 100 count (NDC 00555-0791-02); 20 mg – 100 count (NDC 00555-0788-02); 25 mg – 100 count (NDC 00555-0792-02); 30 mg – 100 count (NDC 00555-0789-02)	API supply issues	Teva continue to release product as it becomes available.
Global Customer Service: (215)558-430010 mg ,100 count (NDC 00115-1329-01); 15 mg, 100 count (NDC 00115-1330-01); 20 mg, 100 count (NDC 00115-1331-01); 25 mg, 100 count (NDC 00115-1332-01); 30 mg, 100 count (NDC 00115-1333-01)	Inadequate finished product supply to support current market demand	All finished product strengths are currently available on an allocated basis.

Amphetamine Mixed Salts Immediate-Release Tablets (updated 1/12/2012)

Company/Products	Reason	Related Information
Sandoz Customer Service: 1-609-627-85005 mg tablets, 100 count (NDC 00185-0084-01)10 mg tablets, 100 count (NDC 00185-0111-01) 20 mg tablets, 100 count (NDC 00185-0401-01) 30 mg tablets, 100 count (NDC 00185-0404-01)	Increase in demand	Releasing product as it becomes available.
CorePharma 1-800-850-27195 mg tablets, 100 count (NDC 64720-0130-10)10 mg tablets, 100 count (NDC 64720-0132-10) 20 mg tablets, 100 count (NDC 64720-0135-10) 30 mg tablets, 100 count (NDC 64720-0136-10)	Increase in demand	CorePharma is releasing product as it becomes available.
Teva Customer Service: 1-888-838-28725 mg tablets, 100 count (NDC 00555-0971-02)7.5 mg tablets, 100 count (NDC 00555-0775-02) 10 mg tablets, 100 count (NDC 00555-0972-02) 12.5 mg tablets, 100 count (NDC 00555-0776-02) 15 mg tablets, 100 count (NDC 00555-0777-02) 20 mg tablets, 100 count (NDC 00555-0973-02) 30 mg tablets, 100 count (NDC 00555-0974-02) Adderall, 5 mg tablets, 100 count (NDC 00555-0762-02) 7.5 mg tablets, 100 count (NDC 00555-0763-02) 10 mg tablets, 100 count (NDC 00555-0764-02) 12.5 mg tablets, 100 count (NDC 00555-0765-02) 15 mg tablets, 100 count (NDC 00555-0766-02) 20 mg tablets, 100 count (NDC 00555-0767-02) 30 mg tablets, 100 count (NDC 00555-0768-02)	API supply issues	Teva continue to release product as it becomes available.

Dextroamphetamine Tablets (1/12/2012)

Company/Products	Reason	Related Information
Teva Pharmaceuticals 1-800-545-88005 mg tablets, 100 count (NDC 00555-0952-02) 10 mg tablets, 100 count (NDC 00555-0953-02)	Manufacturing delays	Teva has dextroamphetamine 5 mg and 10 mg, 100 count tablets, will be on intermittent back order through mid-2012. Product will be released as it becomes available.

Methylphenidate HCl (updated 1/12/2012)

Company/Products	Reason	Related Information
Sandoz Customer Service: 1-609-627-85005 mg (100s – NDC 00781-8840-01 & 00781-5748-01; 1000s – NDC 00781-8840-10), 10 mg (100s – NDC 00781-5749-01 & 00781-8841-01; 1000s – NDC 00781-1749-10), 20 mg (100s – NDC 00781-8842-01 & 00781-5753-01; 1000s – NDC 00781-1753-10)20 mg (100s – NDC 00781-8843-01 & 00781-5754-01)	Capacity constraints and receiving API orders.	Expect sporadic backorders for the next couple of months.
Mallinckrodt Customer Service: (800) 325-88885 mg (100s – NDC 00406-1121-01; 1000s – NDC 00406-1121-10), 10 mg (100s – NDC 00406-1122-01; 1000s – NDC 00406-1122-10), 20 mg (100s – NDC 00406-1124-01; 1000s – NDC 00406-1124-10) Methylin ER, 10 mg (100s – NDC 00406-1423-01) and 20 mg (100s – NDC 00406-1451-01)	Continued recovery as a result of previously unavailable raw material	All strengths of methylphenidate IR and ER tablets will be increasingly available as supply recovery continues, with most contracted orders being met.
UCB Customer Service: 1-800-477-78775 mg (100s – NDC 53014-0531-07), 10 mg (100s – NDC 53014-0530-07), and 20 mg (100s – NDC 53014-0532-07)Metadate ER Tablets, 20 mg (100s – NDC 53014-0594-07) Metadate CD, 10 mg (100s – NDC 53014-0579-07), 20 mg (100s – NDC 53014-0580-07), 30 mg (100s – NDC 53014-0581-07), 40 mg (100s – NDC 53014-0582-07), 50 mg (100s – NDC 53014-0583-07), and 60 mg (100s – NDC 53014-0584-07)	Increased demand	UCB is currently out of stock of our 5 mg IR, 10 mg IR and 20 mg IR and our 20 mg ER products.  UCB expects resupply by February.
Watson Customer Service: (973) 355-83005 mg (100s – NDC 00591-5882-01), 10 mg (100s – NDC 00591-5883-01), and 20 mg (100s – NDC 00591-5884-01)	n/a	Watson has all 3 strengths available for contracted customers only.
Noven Customer Service: 866.663.2539  Daytrana (Methylphenidate Transdermal System) 10 mg (30s – NDC 68968-5552-3) 15 mg (30s – NDC 68968-5553-3) 20 mg (30s – NDC 68968-5554-3) 30 mg (30s – NDC 68968-5555-3)	Not applicable	Currently all product is available

ADHD Drug Shortage on Maryland Public TV Jan 30 7:30pm

With the increasing shortage of ADHD stimulant medications, Maryland Public Television invited me to a live interview by Jeff Salkin on Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm. I had been invited on his show a few years ago about adults with ADHD.

I will discuss the possible explanations for these shortages in addition to the large picture of drug shortages across all medication categories. As is frequently the case, there is no one cause. I hope to lay out the explanations. More importantly, I’ll offer suggestions to work around these shortages for you and your family members.

Join us this Monday night. I want to thank my patients who have offered their stories about the impact of the shortages.

David W. Goodman, M.D.

ADHD Stimulant Shortage on Maryland Public Television Jan 30, 2012 7:30 pm

Because of my recognized expertise in ADHD, I’m honored to have been invited to speak as a featured quest on Maryland Public Television’s program, Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm.

I will be addressing the stimulant shortage over the past several months-possible causes, the routes of manufacturing medications, the distribution of medications across the country, the sporadic availability of these medications, suggestions to physicians and patients on how to avoid shortages or alternative medications when shortages occur.

This problem now plagues those patients and family who use these medications in order to function at their highest level. The absence of medication may severely compromise ones ability to perform consistently thus increasing anxiety.

Join us and listen to my commentary and suggestions.

David W. Goodman, M.D.

Why is my ADHD bothering me now?

ADHD (or ADD without the H) is a disorder whose symptoms start in childhood. Two of three of these children will continue to have symptoms to an impairing degree beyond age 18 . Of the adults with ADHD who are diagnosed in adulthood, only 25% were ever diagnosed as a child (Kessler et al 2007). One reason for the under-identification of children with ADHD is that only those children who are disruptive come to the attention of teachers and parents. Non-disruptive children with ADHD may not get diagnosed until later in life. So the question is, what would cause them to seek an evaluation later in life. “If you lived with it all this time, it can’t be that bad.” Right? Well, not exactly.

In our recent publication on ADHD throughout the Lifespan (Journal of Clinical Psychiatry February 2012), we discuss the developmental phases of life that prompt the question “Why is my ADHD bothering me now?” When reading this article, please note the authorship of internationally recognized experts in the field that include Drs. Atilla Turgay (Canada), Phillip Asherson (United Kingdom), myself and Russell Barkley (United States).

Each developmental phase of life takes on more responsibility. For example, moving from middle school to high school means the academic demands and workload increases. As you move from high school to college, you need to be able to organize yourself to get to classes, do assignments on time, schedule time for study, sleep, play, and classtime. If you go onto first job, you need to be punctual, respond appropriately to supervisors, and complete work on time. When you get married, you need to negotiate household responsibilties and complete tasks timely and consistently to be a team player in your marriage. And then you go on to have children which adds additional layers of tasks and responsibilities requiring increasing levels of organization and efficiency. How about a job promotion with more tasks and the oversight of others. So, each developmental phase of adult life has its set of tasks and responsibilities and your ability to adapt and compensate becomes more difficult. At some point, your daily performance suffers whether at work or home.  At this point, either you or someone close (employer, family, friend) to you will bring it to your attention. Sometime this is done kindly, sometimes it is the result of an argument because you haven’t followed through as expected by others.

Our publication was written for physicians and psychiatrists so that they would understand why an adult with ADHD who had never gotten treatment might come to their office for an evaluation. We hope that this publication will disuade physicians from discounting an adult’s compliant of daily function and look for ADHD when indicated.

If you are not a physician, I think the article is still quite readable for most people and may provoke some thoughts and discussions amongst those effected by ADHD.

Thank you for your time and interest in reading my postings.

David W. Goodman, M.D.

Medical Crossfire- 4 videos by experts on adult ADD

Education about ADHD in adults is critical for everyone. In addition to my work in the public sector and assistance to public media (newspaper, magazines, and TV), I’m also involved in teaching physicians how to best identify their patients who have ADHD/ADD. My friend, Anthony Rostain, MD at the University of Pennsylvania and I did a 4 part video series (Medical Crossfire) explaining diagnosis, co-existing psychiatric conditions and treatments, both medication and therapies for adult ADD.

You are invited to view each of the segments here. You will need to register first. Don’t worry if you are not a physician. You will be able to understand the discussion. When you register: under “Profession” click on No Profession; under “Specialty” click on Non-clinical; under degree, well, you choose what’s appropriate.

These segments represent the opinions of internationally recognized experts speaking about the state of the art for this disorder. You will be very well informed after viewing each segment.

As I have said before, let science be the designated driver in the highway of opinions. Thank you again for your interest in my writings. I will be adding these video segments to my website in the near future.

USA Today Oct 25 quote from Dr. Goodman

With the recent release of the American Academy of Pediatrics diagnostic and treatment guidelines highlighting attention on preschool children and adolescents, USA Today newspaper is running a story in the Life section of today’s (October 25, 2011) paper. The author, Kim Painter, contacted me for background material and a teenager who has been recently diagnosed and treated. She has quoted me as an expert source and you can read the article here.

I am pleased to be of assistance to the media who heightens public awareness of the disorder, it’s negative impact on adolescents and the need for evaluation. For those people diagnosed and treated effectively, there is one repeated remark I often hear, “If I had only known this years ago, how would life have been different.”

As a heads up, look for an upcoming article on ADHD and women in Women’s Health Magazine within the next two months on this topic. Yes, I helped them too.

To those of you who periodically read my articles, thank you for your interest. I’ll try to post information you may not find elsewhere.

“Why do you ask me the same questions?”

Yesterday a patient, clearly annoyed, asked me  “Why do you ask me the same dumb questions each time I see you? How’s your mood been? How’s your sleep and appetite? Any side effects from the medicine? Did the side effects you mentioned last time go away? Is the medicine still serving its purpose?”

Yes, I plead guilty. I do ask these questions frequently. But the patient is annoyed. Shouldn’t I stop? Well…no, and here’s why.

The answers to the questions are important and may have changed since I last saw the person. The stability of the answers or any changes is necessary to consider when changing treatment. Maybe I’ll increase or decrease the dose. Maybe I’ll add or subtract a medication.  Maybe there are life circumstances that need to be addressed and no change in medication is needed. You are probably nodding your head saying, “Ok, I understand that.”

So why is my patient annoyed? Perhaps he or she would like to spend the time more productively discussing a recent situation at work or home. I understand that.

I also see their annoyance as a good thing. What? You see, the person is annoyed because they are so accustomed to the questions that they can ask and answer them themselves. “So why waste time in the session with what I can do at home.” That’s what I want, assess yourself. My repetitive questions have been incorporated by the person into their own mind and they have learned to assess themselves the way I do. That’s a good outcome. I want my patients to be able to assess their symptoms on a day-to-day basis. I want them to note the side effects that I might have to address if they don’t subside. I want them to ask themselves “Is the medication helping me with what I want help with?”

Ultimately, we take medication not so much for health (long-term issue) but for quality of life (daily issue). Does the medication allow me to function to my satisfaction? Does the medication provide me with a comfortable state of mind?

Every time you swallow a pill, you consciously or unconsciously ask yourself “Do I really need this?” Well, if you ask yourself my “annoying questions”, you get the answer.

I want my patients to learn the symptoms of their illness, identify when symptoms are stable or not, judge the level of distress and/or impairment, and make treatment decisions accordingly. This ability gives them a sense of control over the illness rather than being a victim of it.  And they want to same.

How do people come to see me for an adult ADHD evaluation?

Adult ADHD is now one of the most discussed topics in psychiatry. Physicians discuss it because there are an increasing number of research publications in the past few years. The general public talks about it because there have been many articles in newspapers and magazines. Business people discuss it so as to identify employees whose productivity might be improved. Police talk about it because ADHD can lead to confrontations with the law: driving accidents, drug arrests, alcohol intoxication, and other risk-taking illegal activity. Attorneys discuss it in order to advocate for academic accommodations in school or for exams (SAT, ACT, GMAT, MCAT, GRE, etc).

The largest psychiatric survey of the general U.S. population estimates that 4.4% of adults meet criteria for adult ADHD; that’s approximately 9-10 million adults of whom only 10-20% have been treated in the past year.

So how might they come to see me for an evaluation? There are several routes.

1. Pediatricians: That’s right. Adult parents are referred by pediatricians. Why? When a child is diagnosed with ADHD, pediatricians turn to the parents and ask, “Who has similar symptoms?” Because ADHD is highly genetic (75-80% of the cause), pediatricians have been trained to ask the parents. The child’s behavioral treatment for ADHD isn’t going to be optimal unless the parent with ADHD is also treated. For example, having the child take medication for homework won’t work well if mother with ADHD is highly distracting and unable to provide consistent behavioral guidance at home. The treated child with ADHD is going to become frustrated if dad with ADHD forgets to pick his child up after school or runs late to his games. You can see why treating all family members in the household is best for an optimal outcome.
2. Primary Care Physicians: In the past 5 years there have been a large number of publications and CME programs providing an overview of adult ADHD. People are approaching their doctors with questions about ADHD and how to diagnostic the disorder. So, your physician may do an initial evaluation and may decide to treat if your symptoms are straightforward. However, if you have other co-existing psychiatric conditions, a referral to a psychiatrist is best in order to distinguish the conditions. This approach facilitates a thoughtful sequence of treatments to improve symptoms.
3. Family members: So often, one family member gets diagnosed and effectively treated. Then the family looks at other people and encourages an evaluation. I have treated three generations within a single family.
4. Friends: As people become aware of the behaviors common to adults with ADHD, close friends or co-workers may say something about careless oversights, tardiness, speaking over and interrupting others in conversation, inconsistent follow through on tasks, and forgetfulness. A noticeable pattern of “consistently inconsistent” becomes apparent to people around the ADHD adult. The person who approaches to discuss it is the one that cares but most people will simply stop interacting because the inconsistency is too frustrating.
5. Patients: Once when they are effectively treated and learn more about their symptoms, they see other people around them who exhibit similar symptoms. This commonly happens at work where ADHD impairments are evident as underperformance, chronic tardiness, and repetitive careless errors and oversights.
6. Employers: Human resource professionals are more aware of the negative impact of untreated ADHD in the workplace. Employees whose job performance declines or has been chronically problematic, are screened for mental issues that now may include ADHD.

With increasing awareness of the validity of ADHD in adults and understanding the symptoms, more people are being identified, diagnosed and treated for adult ADHD. Treatment represents the opportunity to reduce symptoms, improve daily performance, and promote self-confidence.

Pass this information on to someone who might benefit. Do so respectfully.

Thank you again for your interest.

David W. Goodman, MD