Treating ADHD in Prison: Focus on Alpha-2 Agonists (Clonidine and Guanfacine)

Attention deficit/hyperactivity disorder (ADHD) is prevalent in prison populations, but optimal treatment recommendations in prison are uncertain. Stimulants are problematic because of the potential for abuse. This article is a review of medication options for ADHD, focusing on the alpha 2 agonists clonidine and guanfacine, which, in their extended-release (ER) forms, are U.S. Food and Drug Administration (FDA) approved for the treatment of ADHD, although they are probably less efficacious, overall, than stimulants. Advantages of alpha 2 agonists in prison include: they are not controlled substances and have no known abuse potential; they may be particularly helpful for ADHD with associated aggression and other features of conduct disorder; they may reduce anxiety and symptoms of posttraumatic stress disorder; and they are somewhat sedating. The pharmacology of these agents and the presumed mechanism of action are discussed, including the fact that guanfacine more specifically affects alpha 2A receptors, which are postsynaptic in the frontal cortex. Other differences between clonidine and guanfacine and between the generic immediate-release (IR) forms and the ER forms are also discussed. The IR forms, while themselves not FDA approved for ADHD, may, with dosage adjustment, be reasonable alternatives (with considerable cost savings). Overall, given the FDA-accepted evidence of efficacy, the lack of abuse potential, and the favorable side effect profile, alpha agonists may be the treatment of choice for prison inmates with ADHD.