By Jean Fain
For more than 20 years, my binge-eating patients have wished for a magic wand. And for all that time I told them there is no wand — there are only strategies that require awareness and effort to get a handle on their eating.
Last week, when the FDA announced it had approved Vyvanse for the treatment of binge eating disorder (BED), I found myself at an uncharacteristic loss for words. With headlines touting a magical cure for this most common adult eating disorder, I feared there was nothing I could say to stop the stampede for this next, new drug.
The news, in and of itself, is hopeful. Vyvanse (lisdexamfetamine dimesylate) has been the subject of rigorous research, first for ADHD, and now for BED. In two good-sized studies with more than 700 adult participants diagnosed with moderate to severe binge eating, this central nervous system stimulant proved more effective at reducing binge days per week than placebo for three months.
What’s more, the FDA’s approval has proven a good opportunity for a drugmaker, U.S-based Shire, and leading eating disorder associations — the National Eating Disorder Association and Binge Eating Disorder Association — to coordinate a nationwide educational campaign. If even a fraction of the estimated 2.8 million Americans diagnosed with the disorder get help as a result of the campaign’s public service announcements and new website, there’s reason to be hopeful.
There’s also reason to be cautious. Consider some of the issues before you take tennis great and Shire spokesperson Monica Seles’ advice to "talk with your doctor." To help you do that, here are the pros and cons in my clinical experience and that of my colleagues.
But first, if you’re unclear on what constitutes binge eating disorder, here’s how the Binge Eating Disorder Association defines it:
“Routinely eating far more food than most adults would in a similar time period under similar circumstances.” Binge eaters typically feel out of control during a binge, and afterward, they’re consumed with guilt, self-disgust and embarrassment. Other hallmarks of the disorder: eating extremely fast, in secret, to the point of uncomfortable fullness, even when not hungry. Unlike other eating disorders, people with BED don’t try to “undo” excessive eating by throwing up, taking laxatives and other excessive actions.
OK, so here are a few points to consider...
•More Treatment Options
With the FDA’s first and only approved medication for BED, patients now have another way into treatment: their family doctor. Rather than seeking out a psychotherapist or a nutritionist, which many are reluctant to do, they might feel more comfortable asking their physician about a prescription and other treatment options for this lesser-known eating disorder, which was only recognized two years ago as a distinct disorder by the American Psychiatric Association.
•Fewer Binge Days
Vyvanse has been shown to markedly reduce, if not eliminate, binge episodes in two studies, both funded by Shire. According to last month’s JAMA Psychiatry study, participants who got a daily dose of 50-70 mg, reduced the frequency of binge days per week from about five to less than one over the course of 12 weeks. By comparison, those taking placebo continued to binge more than two days per week. What’s more, half the participants taking the 70 mg dose stopped binging after four weeks, compared to one fifth of those taking placebo.
•Possible Weight Loss
Because Vyvanse has yet to be studied as a weight loss aid, it’s approved only in the treatment of binge eaters, not the overweight or the obese. That said, study subjects who took Vyvanse lost about 10 pounds. The potential weight loss may come as welcome news to bingers taking an off-label prescription for an antidepressant or anti-seizure medication. A common side effect of most antidepressants is weight gain. While binge eaters are often thrilled with the weight loss that the anti-seizure drug Topomax can facilitate, they’re none too pleased by the mental impairment.
•Greater Risk of Abuse/Dependency
There’s a reason Vyvanse is a controlled substance with a black box warning. The potential for abuse and dependence is a real risk. Take it from psychiatrist Daniel Carlat, editor in chief of The Carlat Psychiatry Report, who expressed his reservations in a recent email exchange:
“I’m concerned that the FDA’s approval of Vyvanse for binge eating disorder is going to worsen our problems with stimulant abuse,” Carlat says.
“Vyvanse is a derivative of Dexedrine. We’ve seen epidemics of Dexedrine abuse in the past when it was used to help people diet. I predict that the FDA has just opened the gates to another similar epidemic – after all, binge eating disorder is a subjective diagnosis that could be potentially expanded to cover many millions of people.”
Whether or not Vyvanse is the answer to America’s obesity epidemic, it’s no antidote to the issues fueling the disorder. The best hope, according to nutritionist Marsha Hudnall, president of Green Mountain at Fox Run, a women’s weight-loss retreat in Vermont, is a comprehensive approach.
“A multi-pronged approach, one that addresses the many factors at the root of the disorder, offers the greatest hope of recovery,” Hudnall told me via email. “Among those factors is the need to move away from restrictive notions about food and eating, as well as unrealistic ideals about body size. Notions about "good" and "bad" foods, how we all "should" eat, and what we all "should" weigh have created an epidemic of eating problems that has culminated in eating disorders like BED.”
“Vyvanse,” Hudnall adds, “may decrease appetite and cause some to eat less, but eating less is not the same thing as eating well. When people begin to truly eat well, they often end up eating less naturally. They don’t have to restrict what they eat to avoid overeating.”
•Considerable Side Effects
Side effects are to be expected; 85% of the drug recipients experienced some kind of adverse reaction. The most common side effects are dry mouth, sleeplessness, increased heart rate, jittery feelings, constipation and anxiety. The most serious: heart complications (sudden death in people with heart problems or defects, stroke and heart attacks) and psychiatric problems (mania, hallucinations, delusional thinking).
Without a top-shelf insurance plan, the cost may be prohibitive. A month’s supply, according to online vendors, is $230.
After weighing the ups and downs of this medication, I’ll continue to tell clients I’ve got no magic wand. However, I will tell them them about the range of choices, from the new drug with a long list of side effects to mindfulness trainings, which have proven just as effective at reducing binge eating without the adverse reactions. I’ll support them in making their best choice. In the end, that’s all any therapist can do.
For more information, here are a few resources:
Binge Eating Disorder Association: 855-855-BEDA
National Eating Disorder Association: Helpline 800-931-2237
Multiservice Eating Disorder Association: 866-343-MEDA
Jean Fain, LICSW, MSW, is a Harvard Medical School-affiliated psychotherapist and the author of “The Self-Compassion Diet.”