The Headlines Celebrated a New ADHD Drug. I Read the Label Instead.
Simtriyo may help some Hunters thrive, but the deeper breakthrough is understanding that Hunter minds were never defective in the first place.
Back when I first came up with my Hunter/Farmer hypothesis and wrote my first books about it in the 1990s, there were only a few drugs available to help out Hunters stuck in Farmer schools or workplaces. It was basically Ritalin and Dexedrine.
Thirty-plus years later the selection is wider, and last Friday it got bigger again.
The FDA approved a drug called centanafadine, which Otsuka will sell under the name Simtriyo, for adults and for kids six and older who weigh at least twenty kilos. What’s fascinating about this new drug is that it’s not a stimulant like most of the other ADHD pharmaceuticals.
The stimulants we’re familiar with — going back to Dr. Bradley’s Miracle Math Pills (Benzedrine) in the 1930s — work by jacking up levels of the brain chemicals norepinephrine and dopamine. Simtriyo picks up those two and adds in serotonin, all three at once, which makes it the first “triple reuptake inhibitor” ever cleared for ADHD.
As you know, I’ve never argued against medication for ADHD, although my critics love to wave my Hunter/Farmer theory around and claim I have. I’ve seen stimulants give people back their careers, their marriages, and in more than a few cases even the overall quality of their lives.
When my son was handed his diagnosis as a boy, the label nearly flattened him. What gave him back his life wasn’t a pill; it was him, Louise, and me figuring out what his brain was actually built to do.
That said, medication was a tool for him for a while, and tools — a hallmark of humanity — are good things to have. In this case, this new drug, I find the serotonin aspect of it the most fascinating.
Growing up as a Hunter in a Farmer’s world can cause psychic wounds and psychological trauma that can lead to everything from irritability to rejection sensitivity to full-on PTSD.
Because many of our most effective (and most controversial) antidepressants (the SSRI or “selective serotonin reuptake inhibitors”) work by increasing serotonin levels in the brain, some clinicians theorize that this new drug may help with that aspect of Hunter-ness along with the other two neurotransmitters that the stimulant drugs effect.
That said, the adult trials suggest this may not quite be a blockbuster when compared to the older drugs for people who actually need pharmaceuticals to function in this Farmer’s world.
In two pivotal studies, the numbers ran from about 0.24 to 0.40 against placebo, which, in plain English, tells us the real effect iss noticeably smaller than what similar studies report for stimulants.
The single most comprehensive evaluation of ADHD treatments ever assembled, an umbrella review pulling from more than two hundred meta-analyses, still puts stimulants at the top of the list for both kids and adults.
The Simtriyo trials ran just six weeks and their findings of improved executive function came from a post hoc analysis, a backward-looking review. The full results haven’t even been presented at a scientific meeting yet, so, for the moment, this should be thought of as a promising new option, not a pharmacological revolution.
And then there’s a word buried in the label that should get a lot more attention than it has in the literature, particularly that written for patients and potential patients.
Half the coverage on Friday described Simtriyo as a nonstimulant, but its manufacturer’s (Otsuka) own prescribing information calls it a “central nervous system stimulant.” It also carries a warning, like most stimulants, about the potential for abuse and misuse. And it won’t actually be available until the DEA schedules it, which is expected later this year.
So, the headlines say one thing but the label says the opposite; this deserves some explanation, but I’m not finding it in articles written for the general public. And because it’s labeled as an abuse-potential-stimulant, odds are it’ll end up having some of the same supply and reluctant-to-prescribe problems as the other stimulants do.
It’s also important to remember that no medication can make you into a Farmer. What it can do, when it works, is quiet the external noise enough that you can point your attention where you decided to point it instead of where the last interesting thing (Squirrel!!!) dragged it.
It’ll be a while before we start getting reports back from people using this new drug, particularly long-term results, so keep track of this.
If you’re a Hunter considering a new option, Simtriyo may end up being a good one, especially for those who’ve had a rough time with traditional stimulants or who’re carrying anxiety alongside everything else.
But the pharmacology was never the part we should have been debating. For decades, we were, instead, getting the story wrong, the one where they tried to tell us that a Hunter’s brain is simply a Farmer’s brain with the wiring damaged.
If this helped you think about it differently, forward it to the Hunter in your life who’s already texted you about Friday’s news, and subscribe here so we can keep reading the fine print together.
The label always tells us more than the headlines do.