ADHD Medications Guide, Part II

 

ADHD Medications Guide

Welcome to this ADHD Medications Guide Part II.   Part I of this ADHD Medications Guide focused on common questions and answers, provided by longtime ADHD specialist Ted Mandelkorn, MD, of Puget Sound Behavioral Health.

Here in Part II, Dr. Mandelkorn details the categories of medications along with dosing, pros, cons, and potential side effects.

I will continue to note updates to this information [in brackets.]

The more you know about your choices, the better you can choose a knowledgeable prescribing physician. Then you can pro-actively work with that physician for the best possible treatment outcome.

PART II: ADHD Medications Overview

We can break down ADHD medications into two general categories:

  1. Non-stimulant medications
  2. Stimulant medications

1. NON-STIMULANT MEDICATIONS:

  1. ATOMOXETINE, 24 HOURS (Strattera)

  2. CLONIDINE, TABLETS: 4-5HOURS, PATCH: 5-6 DAYS (Catapres)

  3. GUANFACINE LONG ACTING (Intuniv)

2. STIMULANT MEDICATIONS:

  1. METHYLPHENIDATE TABLETS, 2-4 HOURS (Ritalin)

  2. DEXTRO-METHYLPHENIDATE, 4-6 HOURS (Focalin)

  3. METHYLPHENIDATE SUSTAINED RELEASE, 6 HOURS (Ritalin SR20)

  4. METHYLPHENIDATE LONG ACTING, 8 HOURS (Ritalin LA)

  5. METHYLPHENIDATE CONTROLLED DISPENSE, 8 HOURS (Metadate CD)

  6. METHYLPHENIDATE EXTENDED RELEASE, 12 HOURS (Concerta)

  7. METHYLPHENIDATE TRANSDERMAL SYSTEM, 12 HOURS (Daytrana)

  8. QUILLIVANT LIQUID METHYLPHENIDATE [GINA UPDATE]
  9. DEXTROAMPHETAMINE TABLETS, 4 HOURS (Dexedrine, Dextrostat)

  10. DEXTROAMPHETAMINE SPANSULES 6 HOURS (Dexedrine)

  11. AMPHETAMINE SALTS TABLETS, 6 HOURS (Adderall tablets)

  12. AMPHETAMINE SALTS EXTENDED RELEASE, 12 HOURS (Adderall XR and generic)

  13. LISDEXAMFETAMINE, 12-14 HOURS (VYVANSE)

NOTE:

  • Medical treatment for ADHD should always cover the entire waking day, seven days a week.
  • There are few medical conditions that we do not elect to treat in the evenings, on weekends, or holidays.
  • No one chooses to turn down their brain chemistry during his or her wakeful hours.  Therefore, all medical treatment for ADHD should last for at least 12-16 hours daily.

1: Non-Stimulant Medications—Listing

GUANFACINE, Extended Release   (Intuniv)

This is a new formulation of an existing medication, guanfacine.

It is an alpha 2 agonist, which will have a 24-hour effect on ADHD symptoms and may be beneficial for individuals with ADHD, particularly those with significant mood, anger, oppositional symptoms.

Preliminary results show that it is clearly beneficial for some patients without the adverse side effects often seen with other ADHD medications.

Form: Pills.  1mg, 2mg, 3mg, 4mg.  Pills must be swallowed.

They must not be crushed, chewed or broken or they will lose the 24hr effect.

Dosage: It has a very slow rate of onset and will take 3-4 weeks to assess effectiveness.  The primary side effect is tiredness, lethargy, and it must be started slowly.  Suggest starting dose of 1 mg for one week, and raise by 1 mg each week to reach good therapeutic effect.  The effects do last 24 hours.

Side Effects: Lethargy, tiredness, dry mouth, constipation, dizziness, decreased blood pressure.

Pros: A non-stimulant medication that appears to have a good, positive effect on ADHD and oppositional symptoms that lasts 24hours with reduced side effect profile, compared to the traditional  treatments.

Cons: A new formulation with minimal time on the market to truly assess effectiveness. [This needs to be updated.]

ATOMOXETINE  24 hours   (Strattera)

Teleased by the FDA in December 2002.

It is a non-stimulant medication that is not abusable and can be written without Schedule II restrictions.  This is the first medication for ADHD that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night.

Unfortunately, since its introduction, it has not performed as well as expected.  It tends to often have side effect and does not deliver as robust a response as the stimulants.

Form: Capsules: 10mg, 18mg, 25mg, 40mg, 60mg.

Dosage: Weight-based dose:  first four days=0.5mg/kg;  target dose (day five and after)=1.2mg/kg.  To prevent nausea, take this medication with food.

Action: Very slow-acting and will take 3-4 weeks (or more) to reach therapeutic effect.  If the patient is already taking stimulant medications, suggest continuing them and adding Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.

[Gina Notes: Many people with ADHD and their physicians report them doing very well on a low dose of Strattera—25-40 mg—combined with a stimulant.]

Possible Side Effects: No long-term safety information is available. Primary side effects in children include daytime sleepiness, appetite changes, and mood or personality changes. If these occur, give the dose at night or lower the dose until they improve.  Then raise the dose, if possible.  Adults can experience more noted effects:  transitory dry mouth and dizziness, insomnia, sleepiness, and significant moodiness. Other effects in adults include possible bladder spasm, sexual dysfunction.  Occasionally a child or adult will get very agitated.  If this occurs, discontinue the medication.

Pros: 24-hour coverage.  Less effect on appetite than stimulants.

Cons: Many complaints about side effects, lack of efficacy compared to stimulants.  Has not been a very satisfactory treatment for many with ADHD.

CLONIDINE  tablets 4-5 hours, patches 5-6 days   (Catapres)

Form: Patches applied to the back or shoulder.  Catapres TTS-1, TTS-2, TTS-3.  Tablets.  Clonidine tablets 0.1mg, 0.2mg, and 0.3mg.

Dosage: Very individual, usually .1-.3mg.

Action: Works quickly.  Tablets work within 1 hour, patches within 1 day.

Effects: Often will improve ADHD symptoms, particularly aggressive and hyperactive behaviors.  Not too helpful for focus and attention.  Decreases motor and vocal tics.  It can have a dramatic effect on oppositional defiant behavior and anger management.  Often used as one dose at night about 1½ hours before bedtime to assist with getting to sleep.

Possible Side Effects: The major side effect is tiredness, particularly if the dose is raised too quickly.  This disappears with time.  Dizziness, dry mouth.  Some will notice increased activity, irritability.

Pros: Excellent delivery system if the patch is used.  No pills required

Cons: Does not usually work as well as stimulants.  The patch can cause skin irritation in many individuals and may not be tolerated.  It can affect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.

2. Stimulant Medications: Safety and Common Side Effects

Some general comments can be made about stimulant medications as a class of medications:

  • The longer-acting medications have clear advantages over the short-acting medications, not only in duration of therapeutic effect throughout the day but also in the smoothness of the therapeutic effect.
  • It is very difficult for an individual with ADHD to remember to take multiple doses of medication during the day.
  • Multiple dosing increases the risk of missing doses, which results in the return of symptoms at inopportune times.  The afternoon dosing is frequently missed, causing significant difficulties.
  • Furthermore, each additional dose serves as an unnecessary reminder that treatment for this condition is needed and “something is wrong.”

The reason for medical treatment is to “normalize” the day.

My general rule is to always use 12-16 hour medications unless they are not effective or have intolerable side effects.  In such a case, the six- or eight-hour medications should be tried, because some individuals tolerate them better and find them more effective.  However, if the six or eight-hour medication is used, a second dose should be given to allow patients to have the therapeutic benefit for the full day.

Safety Profile

The stimulant medications are one of the most studied treatments in the history of medicine.  The medications have been used extensively in children and adults over the past 50 years, with no evidence to date of long term concerning side effects.  At this time there is no conclusive evidence that the use of stimulants causes any long term lasting effects on growth, although there may be some delay in height and weight gain in some individuals.

The short-acting stimulants are extremely abusable and are valued highly on the street.  It is best to always use the long-acting preparations, which are not abusable to avoid the temptation of misuse and abuse.

There have been recent concerns expressed by the FDA and the press with regard to the use of stimulant medications and the risk of sudden unexpected death.  This concern was a consequence of a study done in 1999-2003 in which they looked at a large number of individuals taking stimulants and felt that there may be a slight risk.

As reported in an excellent article in the New York Times Feb 14, 2006, the apparent calculated risk of sudden unexpected death in those using amphetamines was 0.35/million (1 in 3 million) prescriptions and the risk for those on stimulants was 0.18/million (1 in 5 million) prescriptions.  There is no real evidence that this is any different from that which occurs in the normal population.

These extraordinary events of unexpected death tended to occur in individuals with congenital cardiac defects.  For this reason, the FDA issued a BLACK BOX warning to all physicians that stimulants should be used very cautiously or not at all in individuals with congenital cardiac defects.

Common Side Effects

In general, the side effects with the short-acting stimulant medications are more pronounced and bothersome than with the long-acting medications.  Thus, long-acting meds are somewhat more tolerable for long-term treatment and are certainly a marked improvement for long-term therapeutic effect.

We can group potential side effects into three major categories:  1) Appetite suppression, 2) Sleep disturbance, 3) Mood changes

Appetite suppression:

Most patients taking stimulants will note decreased appetite during the effective hours of the medication.  This often means minimal lunch intake.  I suggest a small protein lunch such as milk, peanut butter crackers, beef or turkey jerky to get through the day.  A milkshake after school helps.

Many find their appetite returns late in the evening (around 8-9 pm) when their medication wears off, and they need to be allowed to eat at that time.

If weight gain is a continued concern, I often add cyproheptadine (Periactin) 4mg, ½ tablet at breakfast and dinner.  Periactin is an antihistamine similar to Benedryl, which enhances appetite and often results in 1-2lbs-weight gain per month.  Remember that good nutrition is helpful for all, and these individuals should emphasize protein intake in their diet.

Sleep disturbance:

Many ADHD individuals will have sleep difficulties before they begin their medical treatment.  At night, their brain continues its activity and starts thinking of the day.  Using stimulant medications may either improve or worsen this problem.

In those with no prior sleep difficulty, stimulants can create significant sleep issues.  ADHD individuals sometimes have no problem with sleeping through the night but often do have problems with starting the sleep.  A clear-cut bedtime routine helps (bath or shower and then read in bed). So does eliminating caffeine, computers, computer games, and television at least one hour before bedtime.

Interestingly, adding stimulant medication actually allows a percentage of patients to sleep better at night. This technique should be tried.  It only takes one night to see if a dose of a short-acting stimulant will enable sleep initiation.

Some patients, however, require more assistance.  Many patients will use a small dose of Clonidine tablets given one hour before bedtime to help with sleep initiation.  Clonidine is a mild sedative, not a sleeping pill, and it is nonaddictive.  Approximately 60-90 minutes after taking the medication, a brief sleepy phase will occur that lasts about 20 minutes.  If the patient is in bed and trying to go to sleep, it is very effective.  It will NOT make someone stop playing computer games and go to bed.

Mood Changes: Five Types

One of the biggest complaints about stimulants is that they can cause mood changes.  These come in a number of different forms.

1. Rollercoaster effect

Short-acting medications have continuous cycling of the blood level, either rising or falling throughout the day.  This can lead to significant mood changes, particularly at the end of the four-hour cycle when the medication is wearing off.  This problem with cycling can be greatly diminished by using eight-hour and twelve-hour medications.

2. Rebound effect

Stimulants can often wear off very rapidly. Some individuals will experience a rebound—that is, a marked change in demeanor often characterized by irritability, loss of patience, and a worsening of the ADHD core symptoms.  Rebound can occur in the evening when the medication wears off and can also be evident in the morning on first arising.

The morning rebound may require an early dose of immediate-release methylphenidate (MPH) prior to the administration of the long-acting dose at breakfast.  The rebound effect is markedly reduced in frequency and severity in the long-acting stimulants.

3. Irritability and anxiety

All of the stimulants have the possibility of causing generalized irritability, and sometimes even anger, which is not tolerable over a long period of time.  They can cause anxiety and panic disorder and may aggravate existing anxiety.  Often, changing from one stimulant to another will reduce this side effect; it is worth trying different stimulants to identify the best one for each patient.

4. Overdose effect

When using the stimulants it is necessary to gradually raise the dose to find the most effective therapeutic level.  Sometimes in doing this, one gets an overdose effect.

The stimulants are incredibly safe. They have been studied for over 50 years. There is no evidence of any long term serious complications when used appropriately for ADHD.  However, if ADHD individuals take too high a dose, they will experience an overdose effect, which appears as a dulling of the personality:  They complain of being somewhat physically lethargic, subdued, dull, less conversational, less apt to laugh and be social.  By simply lowering the dose for one day, these symptoms will disappear.

5. Tic Formation

All of the stimulants have the possibility of temporarily causing a tic disorder or aggravating an existing one.  There is no evidence that the use of stimulant medications will cause permanent formation of a tic disorder or Tourette syndrome.

Children who already have tics (10% of children have mild tics at some point in childhood) and individuals with Tourette syndrome will find a number of different scenarios with the use of medication.  Approximately 1/3 will actually notice that the tics improve (lessen) with the use of stimulants, 1/3 will see no change at all, and 1/3 will find the tics worsen with use of stimulants.

If the stimulants are effective for ADHD symptoms but tics are worse, a medication to help control the tics is usually added to the treatment.

List of Stimulant Medications

Here is a list of the most common stimulant medications. New options have come onto the market since this writing but for the most part, they are not as well known or used.

METHYLPHENIDATE TABLETS  2-4 hours   (Ritalin IR)

Form: Short-acting tablets.  Methylphenidate (MPH) 5mg, 10mg, 20mg.

Dosage: Very individual.  Average 5-20mg tablets every 2-4 hours.

Action: Immediate release (IR) MPH starts to take effect in 15 minutes, which is extremely helpful for some individuals.  Some children need an early morning dose 20 minutes BEFORE arising in the am, followed by a long-acting medication at breakfast.  Often used as a booster for evening coverage.

Possible Side Effects: See above

Pros: Very easy to use for short periods of coverage, such as early morning and evening.

Cons: Must be administered frequently during the day (3-5 times/day).  Inconvenient to use at school and work.  Often causes rebound and rollercoaster effect.  Very abusable.

DEXTRO-METHYLPHENIDATE  4-6 hours   (Focalin)

8-12 hours (Focalin XR)

Focalin is an isomer product of methylphenidate.  Methylphenidate is composed of two mirror-image molecules, and it has been determined that the right-hand side of the molecule contains most of the therapeutic activity.  Therefore the left-hand side has been eliminated, giving a cleaner formulation of methylphenidate.

Form: Tablets:  2.5mg, 5mg, and 10mg. (Focalin)

Capsules: 5mg, 10mg, 20mg

Dosage: The same as methylphenidate, but divide the dose by half.

Action: The same as methylphenidate, but in some individuals up to 6 hours duration.

Possible Side Effects: Same as MPH but possibly to a slightly less degree.

Pros: A cleaned up version of MPH that may last a bit longer with slightly decreased side effects.

Cons: Same as MPH.  Very abusable.

METHYLPHENIDATE SUSTAINED RELEASE  6 hours   (Ritalin SR20)

Replaced by Ritalin LA.

METHYLPHENIDATE LONG ACTING  8 hours   (Ritalin LA)

Form: Capsules: 20mg, 30mg and 40mg.

Dosage: Very individual.  Average:20-40 mg daily or twice a day, every 8 hours.

Action: Same as methylphenidate, but eliminates the noontime dose.

Possible Side Effects: See above.

Pros: Eliminates midday dosing.  Works more smoothly than IR methylphenidate and is more effective than methylphenidate SR.

Cons: Only works for eight hours and therefore subjects the patient to losing focus and control in mid-afternoon.  This requires an afternoon booster.

METHYLPHENIDATE CONTROLLED DISPENSE  8 hours   (Metadate CD)

Form: Capsules: 20mg (10mg and 30mg to be available in 2003)

Dosage: Very individual.  Average: 2-3 capsules in the am.

Action: Same as methylphenidate.

Possible Side Effects: See above.

Pros: Works more smoothly than IR methylphenidate.  Sometimes is effective when Concerta and Ritalin LA are not effective.  Not abusable.

Cons: Works for only eight hours.  (See Ritalin LA)

METHYLPHENIDATE EXTENDED-RELEASE  12 hours   (Concerta)

[Gina Notes:  There are generic medications for Concerta. Two of them have been downgraded by the FDA as not being bioequivalent. But there remains an authorized generic.

It is the brand, marketed as a generic. It is worth learning about the differences and how to be a smart consumer. I detail everything you need to know here:  Consumer Q&A on Generic Concerta.]

Form: 12-hour long-acting tablet…uses a unique delivery system that delivers a constant therapeutic level of methylphenidate for twelve full hours.  Concerta 18mg, 27mg, 36mg, 54mg.

Dosage: Dosage will vary as with all methylphenidate products.

Here are some approximations comparing Concerta dosage to Ritalin dosage:

  • 18mg = Ritalin  5mg three times a day
  • 27mg = Ritalin 7.5mg three times a day
  • 36mg = Ritalin 10mg three times a day
  • 54mg = Ritalin 15mg three times a day

Action: 12 hours of consistent therapy with no highs or lows throughout the day.  A few individuals will only get 8-9 hours of effective therapy and will need either a higher dose or a second dose.

Possible Side Effects: See above.

Pros: Unique delivery system avoids multiple dosing throughout the day.  No dosage at school.  No rebounding with missed doses.  Fewer side effects, fewer mood swings, better therapeutic response for many individuals.  No daytime dosing.  Less anxiety and worry.  Not abusable.

Cons: Does not work for all individuals who use methylphenidate.  If ineffective, should try Ritalin LA and/or Metadate CD.  May need a short-acting booster to cover the evening hours.

METHYLPHENIDATE TRANSDERMAL SYSTEM  12-15 HOUR (Daytrana)

No generic available

The medication in the patch is methylphenidate, and thus all of the above information regarding this medication applies.

The trans-dermal patch arrived on the market in July 2006 as a new and novel delivery system for methylphenidate. The patch has the medication within the adhesive layer and is thus very thin.  It works by diffusion. That is, it allows the medication to gradually diffuse through the skin into the bloodstream directly. That means it avoids the intestinal tract.

The Daytrana patch is designed to be worn for nine hours and then removed. It will last longer, however, if needed for evening activities.  After removal, it will gradually lose effectiveness over the next three hours, thus giving extended and controlled hours of therapy as the day dictate.

The unique attribute of the patch is that the patient has complete control of when to start the patch and when to discontinue the patch.  For the first time, the patient can regulate the treatment for part or all of the day.

[GINA UPDATES here with information on the patch causing inflammation or allergic reactions]

Some people will develop a reaction to the adhesive used in the patch. This is a common occurrence with all adhesive-patch medications, not just  Daytrana.

To cope with this, it is recommended to vary the physical spot on which the patch is applied.

If the irritation is mild, you can try something like this “calming” lotion after removing the patch:  Calmoseptine.

If the irritation is severe, talk with the prescribing physician about an alternate medication.

METHYLPHENIDATE LIQUID (QUILLIVANT XR)

[GINA UPDATES this list with a new entry, for Quillivant XR]

With the recent introduction of Quillivant XR, we now have a liquid, extended-release formulation designed to last 12 hours (as always, your mileage may vary, given your unique neurochemistry).

Basically, it comes as a powder that your pharmacist will mix for you into a liquid. You will receive:

  • 1 bottle (containing the liquid)
  • 1 oral dosing dispenser, and
  • 1 bottle adapter

To learn more about this new option, please read this post: A New “Ritalin”: Extended-Release Liquid Quillivant XR.

DEXTROAMPHETAMINE TABLETS  4 hours   (Dexedrine, Dextrostat)

Form: Short-acting tablets  5mg, 10mg.

Dosage: Very individual.  Average 1-3 tablets each dose every 4-5 hours.

Action: Rapid onset of action, approx. 20 min.  Lasts 4-5 hours.

Possible Side Effects: See above.

Pros: Excellent safety record.  Rapid-acting.  Some patients who do well on dextroamphetamine prefer the tablets to the spansules.  The rapid onset in tablet form is apparently more effective for these individuals.

Cons: Same as MPH.  Very abusable.

DEXTROAMPHETAMINE SPANSULES  6 hours   (Dexedrine)

Generic available

Form: Long-acting.  Dexedrine Spansules 5mg, 10mg, 15mg.

Dosage: Very individual.  The average is 5-20 mg.

Action: Very individual.  May take up to one hour to be effective.  Usually lasts 6-8 hours.  In some individuals, it may last all day.  In others, it may only last 4 hours.  Most will take twice a day, six-hour intervals

Possible Side Effects: See above

Pros: Excellent safety record.  Maybe the best drug for some individuals.  Long-acting, smooth course of action.  May avoid lunchtime dose at school.

Cons: Slow onset of action.  May require a short-acting medication at the start of the day.  Very abusable.

AMPHETAMINE SALTS TABLETS  6 hours   (Adderall)

Form: Long acting tablets: 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg.

Dosage: Very individual, usually between 5mg and 20mg, once or twice each day.

Action: Usually lasts 6 hours.  May be given once or twice a day depending on the length of therapeutic effect.  Duration of effect varies from person to person.

Possible Side Effects: See above.

Pros: Only needs to be given once or twice a day.  Often fewer side effects than the short-acting medications.

Cons: Can cause irritability in a small percentage of patients.  Very abusable.

[GINA NOTES: I’ve been warning for years about the many, serious potential problems with Adderall. Poor prescribing patterns risked—and still risk—de-legitimizing the ADHD diagnosis.

Please read my blog’s most popular post:  The Tragic Truth about Adderall, or Madderall.

There is some wisdom to considering Adderall only as a last resort—definitely NOT before trying other stimulants first. Unfortunately, many MDs seem to push Adderall. The reason remains mysterious. Who knows why?]

AMPHETAMINE SALTS EXTENDED RELEASE  12 hours   (Adderall XR)

Generic available April 1, 2009

Form: Uses a unique delivery system that delivers a constant therapeutic level of amphetamine salts for twelve full hours.  Capsules:  5mg, 10mg, 15mg, 20mg, 25mg, 30mg.

Dosage: Very individual.  Average 15-30mg daily.

Action: Long-acting 12-hour control of ADHD symptoms for coverage during most of the day.

Possible Side Effects: See above.

Pros: Very effective.  Same as Adderall with longer duration of action.  Cannot be abused.

Cons: May need a booster to cover the evening hours.

LISDEXAMFETAMINE  12-14 hours (Vyvanse)

No generic available

Form: A Pro-drug, which renders this delivery system minimally abusable.  A new and novel delivery system that delivers dextro-amphetamine smoothly over a 12-14  hour period.

Dosage: Capsules:  30mg, 50mg, 70mg

Action: The same as Dextroamphetamine

Side Effects: Same as Dextroamphetamine

Pros: Only long-acting Dextroamphetamine on the market; unlikely to be abused.

Cons: Same as stimulants

 

I welcome your comments on this post; no registration required.

If you enjoyed this post, please subscribe to be notified of new posts.

—Gina Pera

Medical Disclaimer:

Although the author and the publisher did our best to provide sound and useful information in this article,  we cannot and do not promise beneficial results to anyone who may use that information; nor does the author or the publisher accept liability to anyone who may use the information. Because we cannot respond to individual needs and circumstances, anyone who has a known or suspected medical condition, or is taking medication of any kind, or has health concerns, should consult a qualified health care provider before following any of the suggestions in this article.

 

26 thoughts on “ADHD Medications Guide, Part II”

    1. Hi Maggie, your comment wasn’t deleted. It was waiting approval.

      I have to approve messages or deal with sneaky spammers selling drugs online.

      g

  1. Hi Gina,

    I appreciate your breakdown of all of the medication options available and your continued work in the world of ADHD.

    I was diagnosed at 33 after struggling academically and professionally since I was in the 6th grade. I started on generic Adderall IR 10mg. That worked really well for me and I began to finally see my potential in my career. I became pregnant about 8 months into treating so I had to discontinue the Adderall. After maternity leave, I went back on Adderall IR however, it no longer worked. I have tried different generics and none have any effect besides increased heart rate. The brand name is effective, however, insurance will not cover brand name unless I have an allergic reaction to generics. I am perplexed as to why a generic made by the same manufacturer as the brand, same manufacturer I took previously, and even at a higher dosage than pre-pregnancy no longer has any therapeutic effect.

    There seems to be an odd consensus among prescribers and pharmacists that there is no possible difference in generic vs brand. Even though we have seen cases of drugs found not to be the bioequivalent of the brand after years on the market (Concerta, Wellbutrin). We seem to be blindly trusting “Big Pharma” and the FDA without question. I am by no means anti-Pharma or a conspirator, but I do believe in accountability and having the ability to advocate for the consumers rather than just take the word of those profiting from our illnesses. I have also worked in substance abuse counseling so I do also realize the other side of the issue regarding abuse of these drugs.

    I get the sense that no one is really hearing me or attempting to figure it out. I have talked to two of my providers, pharmacists and even the manufacturer. The doctors just give me more of the same or a different drug just to get on to the next patient.

    I myself have extensively researched and compared the ingredient differences, read through studies and read many peer reviewed research based publications with no real explanation on this matter.

    Do you know of any reasons why the generics are no longer effective for me after having no stimulants for over 14 months?

    I have also tried extended release Amphetamine based medications (Vyvanse, Mydayis, Adderall XR) but I still struggle with distractions and becoming too focused with anything other than what I need to be focused on.

    I would sincerely appreciate any input Or suggestions you may have!

    Thank you!

    1. Hi Maggie,

      For more information on generics, you might want to read through my series of post on Concerta generics (authorized and “true”):

      https://adhdrollercoaster.org/adhd-medications/authorized-generic-concerta-update-6-1-19/

      I’ve been educating on this a long time. When it comes to psychiatric medications, it’s very risky to use generics. At least in the beginning.

      That’s because you cannot determine that, if a medication doesn’t work, it’s due to the generic. Maybe the brand would work for you, but the generic would not.

      So you might end up eliminating stimulants based on them being inferior generics.

      For your information, the FDA was in the process of revising guidelines for generics of medications with complex delivery systems (eg, most of the modern stimulant choices). Then there was an election, and the new FDA chief came in, scoffed at FDA scientists’ concerns, and pushed through scores of generics. Before going back to the Heritage Foundation.

      Agencies can be politicized, in other words, so it’s on us to choose who we want to trust with those decisions.

      You ask why none of the Adderall generics worked well for you after you resumed following pregnancy.

      There are many potential reasons for that. The two that seem most obvious to me:

      1. Your body, hormones, and demands on your brain are not the same. Much has changed, including now parenting a young child.

      2. Generics change with the wind.

      From what I see, you never tried methylphenidate-class stimulants. Ritalin. Concerta. Etc.

      You should have been given a trial of both classes. Because one is likely to work better than the other — and you cannot determine prior to trying.

      But also, what are you doing in the way of external supports? Are you using a calendar? Do you have routines? Are you getting enough sleep? Are you consuming caffeine/nicotine?

      All of these things can affect perceived medication efficacy.

      Moreover, the amphetamines are more likely to result in what you describe: over-focus. Also called “tunnel vision.”

      I encourage you to look into methylphenidate-based options. Start low. Increase slowly.

      I hope this helps. Good luck!
      g

    2. Thank you Gina,

      I actually tried the brand name Adderall at 20mg to confirm that it works. I then got the generic 20mg made by the same manufacturer as the brand (TEVA) and it has no effect. This was within the last 6 weeks. They did have a recall in June of this year already. I read your posts about Concerta and I sincerely hope the Adderall generics are looked into as so many people have issues with their effectiveness.

      I have attempted to report my concerns to the FDA but the MedWatch site requests the lot number which the pharmacy doesn’t track and could not tell me 4 days after filling my prescription which is also concerning.

      Nevertheless, I will talk with my doctor more about the methylphenidate medications.

      Thank you so much for your time!

    3. Sorry I missed that — lots of details to wade through.

      It doesn’t matter if the same manufacturer makes the brand and the generic. That is totally unrelated.

      It’s the overall problem with psychiatric medication generics. Dosing typically works best within a small window.

      The variability of generics means that can be a giant picture window — far out of the effective dosing range. Moreover, it varies generic to generic — and can often vary within the same generic.

      Generic medication for some other conditions work well and are cost-effective. But when precise dosing is required, generics are a roll of the dice.

      The pill bottle typically has the lot number.

      More about that here:

      https://adhdrollercoaster.org/adhd-news-and-research/consumer-qa-on-concerta-and-generics/

  2. I am so perplexed! I was taking Vyvanse for three years (started at 30 mg then went up to and finished at 60 mg). I maintained 60 mg for about 9 months. I did really well on Vyvanse! I was so pleased with how well it worked! An interesting turn of events occurred just recently. In March, I began looking for a new doctor, and I was without a prescribing doctor, as well as a Vyvanse prescription, from March until May; so, I had a two month break from the Vyvanse, which I did not want to do but had no choice. I just started seeing a new doctor last month, and she prescribed 60 mg of Vyvanse daily. I thought I was going to “jump right back in,” feel great, have the medication work really well for me, and have it be just as effective as it was before; however, the exact opposite has happened! I did not expect this at all, but I now receive no effects from the Vyvanse. It truly does not work at all. I’ve been so surprised and also frustrated. I shared this with my new doctor, and she said she’d never heard of this happening before. Would you be able to answer for me if you’ve heard of this happening to people? I have no idea what happened. Any help/guidance/information would be greatly appreciated! And to note, nothing has changed with my diet, lifestyle, stress levels, or anything else that could maybe contribute to the medication no longer working. Thank you so very much for your time!

    1. Hi Brynn,

      That does sound perplexing!

      When people say the medication is “effective” or “not effective,” I have to ask….effective at WHAT. 🙂

      In other words, how did it “work really well” and how is it not now “working really well”?

      Are you measuring by the same criteria (work flow, life stressors, diet, caffeine consumption, sleep, etc.)?

      One thing….going from 0 to 60 can be rather abrupt. If it were me, I might have started lower and increased slowly.

      And, of course, March is when we saw the full potential impact of COVID-19. That has created much disruption for millions of people.

      Are you sure it is brand Vyvanse? There’s not yet a generic for Vyvanse but it would still be good to check that it is brand.

      Those are my best shots to get you thinking…

      I hope this helps.
      g

  3. In this article, both Concerta and Adderrall XR are marked as preferrd *** medications. Based on the other articles, Adderrall should be the last resort or option. Would you be able to clarify? Is it preferred because it’s XR and not short acting?

    1. Hi Becky,

      Great question. I should have updated to exclude those ***. I just did so. Thank you!

      The idea of “preferred” is a bit questionable at this point (years after this article was written).

      What’s preferred is the stimulant that works for the individual, after a careful and methodical selection process. As described in my book.

      http://amzn.to/2ixxpRI

    2. “The idea of “preferred” is a bit questionable at this point (years after this article was written).”

      Gina, with all due respect, if you feel that the idea of a preferred medication is no longer valid; why not either remove these articles or at the least provide a disclaimer at the beginning of Part 1?

      After spending the time to read not only both articles but all the comments as well, I was disappointed to find as the very last comment that the author no longer feels the provided information is pertinent.

    3. Hi Sherry,

      The information stands.

      Only one minor detail changed, and it was dated as well as highly subjective.

      Cheers,
      g

    1. Hi Alana,

      I’ve heard zero reports about using Amantadine to treat ADHD.

      From my perspective, it would be a stretch. But anything’s possible.

      Given how badly most cases of ADHD are treated (MDs not following protocol, not treating co-existing conditions, etc.), I’d be reluctant to go that far afield before trying the evidence-based medications.

      But you can read for yourself, this meta-analysis of the limited studies on Amantadine and ADHD as well as autism.

      Conclusion
      The search for medications with alternate mode of actions led to the glutamate neurotransmitter and the NMDA receptor as pharmacological targets, with amantadine being studied for use in child and adolescent psychiatry. This review found that amantadine is fairly safe in children when used properly and offers a broad range of clinical utility with positive therapeutic effects in various conditions, although its use in such conditions is strictly off label. In order to draw valid conclusions regarding its true efficacy in any of the conditions mentioned, and to advocate for its broader use, further well-controlled studies are needed.

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565716/

  4. Pingback: ADHD Medications Guide, Part I - ADHD Roller Coaster with Gina Pera

  5. I disagree with some things.. I used to have 5 hour rebounds with long acting meds and I am hyper so I would start arguments with everyone. Also, I have taken the short acting form of Dexedrine since I was 5 and it was the smoothest. I need it because that gap when it wears off is my opportunity to eat. I am a smaller medium built Bavarian descent type of guy and my dose was higher as a kid and I had that zombie effect from it. Vyvanse and even the Dexedrine spansules feel nothing like the ones I take. I have no health problems at all and I take 20 mg 4 times a day for 16 hours of coverage. I personally think this is the most helpful for me and held up the long run and I used to drink and party as a teen (some psychiatrists think one joint is a drug problem) and not once did I want to take more. They make me more mature and quieter and I can sit still and think before I do things.

    With that said, I went to high school with a kid that used to sell his dexedrine to 3 students at school and all three of them were a complete wreck after awhile. One looked like he had AIDS, one of the women was psychotic and the other would talk non stop.

    My major fear is that I am going to have to argue with a doctor when he claims that this drug is the “crack” of the ADHD medicines. I have legit use for this. And this form of this particular drug has to be ordered days in advance and I remember the prior auth crap over 60 XR pills with my insurance so walking out with 240 pills makes me have a complex. I also like the dose flexibility. My social aspect of life is damaged the most because of my hyperactivity so I take smaller doses when I need to socialize or give presentations or clean because the full 20 mg is almost zombie level.

    I have found that my symptoms vary in severity. Sometimes 5 mg in the AM is great and other times the 80 mg/daily dose barely touches it. Healthy eating and exercise is part of my program too.

    1. HI again, Mat,

      Yes, Dexedrine is rarely used these days. Still, for a minority of people, it will be the best Rx for them.

      I’d say try to present the information in as organized and cogent a way possible. Write it down. (Many physicians like simple, bullet-pointed information. Easy to scan and get to the important points.)

      You could say that you have tried other Rx, and that Dexedrine still works best for you. You could point to what you are accomplishing, thanks to the medication (work, etc.).

      I would also go in armed with some studies or articles that explain Dex will be the best Rx for some people. The idea is to calmly have the courage of your convictions — and the documentation.

      Finally I would encourage you to look into Vyvanse, if you can. It is actually Dexedrine in a novel delivery system. It might work even better for you than the Dex, without the “zombie” effect, etc.

      Good luck!
      g

  6. Thank you for your comments.

    My main point in writing my comment was to say that although Jane probably wasn’t too well informed, she did have a valid point, and frankly, addressing the point WITHOUT the derogatory tone of “henny penny alarmist” and “simple-minded propaganda” might do more to educate her in this field. I’m sure Jane was just trying to learn more about ADD treatments, so why use a tone that will probably make her more hostile toward this topic than she already is?

    1. Well, Sarah, what can I say? I’ve been advocating for better ADHD awareness for 10 years now, much of it online, and I’ve learned a few things.

      One is that people with that type of starting point seldom are interested in more information; they are interested in fear-mongering. Moreover, they often have an agenda that is well-known.

      So while you are “sure Jane was just trying to learn more,” I am pretty sure that was not the intention at all. To each her own. 😉

      But even so, I think the responses from MaskedADDer and me are more than sufficient.

      g

  7. Gina,

    Part of being an “educated consumer” is always reading disclosure statements for any study you are reviewing.

    OF COURSE questions should be raised about who is funding any research – and before you tell me that I “know nothing about research in medical science and I believe simple-minded propaganda,” as you told Jane, know that I say this as someone with a year’s worth of psychology research experience, and a Master’s degree. (My Master’s is not in psychology, but I have completed 38 credit hours in post-baccalaureate psychology studies, and I am applying to research-oriented PhD programs in clinical psych.)

    Are you aware that experimenter bias is a large issue, particularly in psychology experiments, but also in scientific research as a whole? Despite all our claims of the objectivity of the scientific method, the fact remains that researchers too often end up proving what they want to prove. And as for all that drug company funding – do you really think that any drug company will keep funding research done by professors who are finding their products to be largely ineffective?

    Funding is a HUGE issue in academia these days, and the extent to which a topic, disorder, etc is even researched in the first place often depends on whether it is popular enough to get grant money.

    Now, I’m not saying that this means that all research is invalid, or that we should get all our ADD medications (and other medications, too) and throw them out the window.

    I am saying, however, that knowing who funded a study is a valuable piece of information. While I won’t completely discard the results of a medication study that was funded by pharmaceutical companies, I will take them with a grain of salt, and examine their methods very carefully. I will also always trust favorable results a bit less than I would trust them if they were coming from a truly independent source.

    There is good reason to do so, as there have been a number of times in the past when pharmaceutical companies repressed or minimized results of a study that turned out to be unfavorable to their cause.

    So like you suggested, let’s all be “educated consumers,” and not take any research we read about for granted without looking over the actual study and analyzing not only the methods used, but also the funding and other possible sources of experimenter bias!

    1. Hi Sarah,

      Thanks for your comments. I wholly agree. I started noting the trend with industry funding academia back in the 1980s, when I worked at a business newspaper.

      As I hope you can see, however, your points are more nuanced than Jane’s. And while it would be great if all consumers of these medications could take the time or have the training to parse these studies, it’s just not possible. We have to go on the preponderance of evidence, which includes the points made above by the Masked ADDer and me, and also on first-hand reports.

      In my case, I’ve met and communicated with not only dozens of these researchers but also thousands of people affected by ADHD now. To me, the real problem is at the clinical level, where prescribing physicians either fail to properly diagnose or fail to properly choose and titrate these medications. We can rail against “Big Pharma” all we want but until these physicians are better trained and can properly integrate other information when treating these patients (sleep disorders, food sensitivities, nutritional deficiencies), it is barking up the wrong tree, in my estimation.

      Thanks for visiting and commenting.
      g

  8. The Masked ADDer

    Jane’s attitude toward Dr. Wilens is easy to understand given:

    1. the ethical lapses of some in the medical profession (yes, such do exist)

    2. a lack of understanding of what it means to be a researcher

    3. perhaps a lack of judgment on her part (fed by factors 1 and 2)

    Factor 2: After consulting NIH’s grant reporting tool (http://projectreporter.nih.gov), I find that Dr. Wilens currently has >$800K of research funding. How much funding is he getting from pharma? If the amount is a small fraction of what he is getting from NIH, no need to get too excited. It boils down to this: what is the relative contribution from pharma, and is it enough to POSSIBLY influence his impartiality? In his case, I very much doubt it. Why? Because he has a lot to loose if his peers were to conclude that he is an operative for pharma. In short, he would lose his ability to get funding and to get published, such that his career would be over. And what a career he’s had so far: I count 178 publications at PubMed since joining Mass. General. Clearly, he has a lot to lose by engaging in dubious scientific practices. Therefore, v. unlikely.

    So why does such a researcher risk being accused of being a pharma cronie by accepting their research funding? Only because research dollars are always limiting, particularly these days. So one takes the “bad” (pharma’s justifiably poor reputation) with the good (researching important health questions). You have to salute him (I certainly do) for exposing himself in this way. He could just as easily have decided to curtail his research by not accepting pharma research money, in which case we all would have lost the benefits of his investigations.

    Addressing factor 3, does anyone really think that becoming a biomedical researcher and keeping a career going is the road to wealth? I don’t know the size of pharma dollars he has obtained, and whether they involved salary support for him, but whatever the amounts, they are highly unlikely to be sufficient for justifying the MANY years of intense work required to become a distinguished researcher. So let’s all exercise some informed judgment before casting nasty aspersions, shall we?

  9. are you aware that the excellent reference book regarding meds you linked is written by a pharma shill?

    look at this review I copy pasted:

    I want every person contemplating the purchase of this book to use the “search inside” tool, and click on the copyright page.
    On that page you will see a box that says “Full Disclosure.” PLEASE, please read it.

    Dr. Wilens receives grant support from five different drug companies. In addition, he is a paid presenter for three different drug companies, and a consultant for six different drug companies. While the information contained in this book is exhaustive, as a parent of two children with a multitude of medical and psychological issues, I find it difficult to trust his opinions and “straight talk” when I know that he is making tens of thousands of dollars a year from these drug companies.

    Gina, do you truly think that a book written by a guy is a paid minion of big pharma is going to be unbiased and complete?

    The companies that pay out to this guy include Abott Labs, Eli Lilly, Merck and so on. You don’t see that as an issue?

    1. HI Jane,

      I appreciate your sentiments. I really do. It goes against the grain of any sensible person to think about giving psychotropic medications to children — except when that sensible person investigates the facts and learns that sometimes judicious use of these medications can vastly improve that child’s life.

      Beyond that, I cannot let accusations such as you make stand. You use strong language.

      “Pharma shill” and “paid Big Pharma minion” are recklessly derogatory terms bandied about on the Internet by “anti-psychiatry” adherents. These terms are typically used in ignorance about what it takes to be a psychiatric researcher and by people who typically have no conception of the human brain’s complexity — or vulnerability. Often, these terms are used by people trying to sell something — their miracle cure, DVD, series of religious-cult classes, or the fact that they don’t have a psychiatric disorder (it’s everyone else in the world who has a problem).

      Dr. Wilens certainly requires no defense — exactly the opposite — and I don’t fancy myself the best person to explain why. But I will try, since this is my blog and you asked me.

      Do you honestly believe that a researcher of Dr. Wilens’ calibre studied rigorously and doggedly for years, mastering highly scientific knowledge and methods, just to be a “pharma shill”? If money were the goal, it would have been so much easier to work in sales….or on Wall Street.

      The fact that many Americans know nothing about the demands of a career in medical science only adds to their willingness to believe simple-minded propaganda. It’s unclear to me why you would take the word of an anonymous person writing an Amazon review over a highly respected expert.

      Anyway, what do you think scientists do with these grants? Sit around the pool, smoking cigars? They work extremely hard and typically spend the funds on equipment, other researchers’ salaries, and the myriad demands of scientific research. Scientific inquiry is loaded with pitfalls; you can spend years investigating a hypothesis — years of tedious, tedious repetition of experiments — only to have it end in failure. And if these researchers do make a handsome salary, well, why not? Don’t they deserve it? They are producing tangible benefits to society — and trained long and hard to do so — unlike the financial sector, which produced only financial weapons of mass destruction.

      The first maxim of scientific inquiry is this: Association is not causation. In other words, simply because a phenomenon is linked to a certain factor it doesn’t mean the phenomenon is caused by that factor. A simple example: When bars used to allow cigarette smoking, many people drinking in bars smoked cigarettes. Could we say that being in a bar caused people to smoke cigarettes? No. It could be that people who smoke cigarettes are also likely to hang out and drink in bars.

      In scientific researchers’ case, receiving funding from pharmaceutical companies does not mean they are “in the pocket” of these companies. Scientists have their reputations to protect, and that’s why “peer review” of research is important. Without the respect of their peers, researchers don’t get published and they don’t get grants.

      Wilens’ peer-reviewed articles number more than 200, and are published in prestigious journals such as the American Journal of Psychiatry, Archives of General Psychiatry, and Pediatrics. Dr. Wilens has also published more than 60 book chapters, and 300 abstracts and presentations for national and international scientific meetings. Do you understand the effort behind these accomplishments? More importantly, why don’t you talk to some of the people who have benefited from the work of such researchers and ask them about their improved quality of life. (You won’t always hear from them on the Internet, because they are out doing more productive things.)

      Dr. Wilens is a Distinguished Fellow of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, serves as a scientific reviewer for 22 journals, and is active in a number of other local and national professional societies. Dr. Wilens is named consistently among “The Best of Boston” in Child/Adult Psychiatry and “The Best Doctors in America.”

      By comparison, this anonymous reviewer on Amazon who calls herself “bedrestmom” does….what exactly? My hunch: She never read the book. (Check the rest of her reviews; not much of a reader.) She seems to be just another “anti-pharma shill” from a certain anti-psychiatry cult. They’re omnipresent online, and their patterns are very familiar.

      Are there occasional “bad actors” among medical researchers — those whose egos and perhaps greed bias their focus? Of course. Why should this field be the only one where humans are flawless saints? But, given the peer-review process, their reputations do tend to catch up with them. This is especially true when they are also clinicians who treat patients.

      Are the marketing arms of “Big Pharma” often shameless in their pursuit of market share? Of course. But that’s precisely why we need educated consumers, not henny-penny alarmists.

      Gina

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