Some of my friends on Twitter have been following the ADHD Myth series here. I asked for their favorite myths.
From Mobile, Alabama, ADHD specialist James Wiley, MD, responded with one he hears a lot in his practice.
Let’s call it Myth #6: That’s a Lot of Medicine For a Small Person!
He explains:
The dose of stimulant medication is not dependent on the size of the individual.
Sometimes little guys absorb the medication poorly and metabolize it quickly. So, they require higher doses than big guys that absorb well or metabolize more slowly.
I have 300-pound offensive linemen well-controlled on small doses and little gals on high doses! One size doesn’t fit all!
Hi Gina,
Your articles, guest comments, and your replies to them have been really helpful towards the navigation of my recent ADHD diagnosis 5 months ago at the age of 34. I especially resonate with the perfectionism article and this “that’s a whole lotta medication, bud” post!
My primary issue before the diagnosis had the ability and tendency to stay up 21-22 hours per night and have a 1-day recovery crash on the weekends. I hid this well for more than a decade since I never appeared tired during the day, but my colleagues and partner eventually caught on and realised that I was happily browsing the internet and replying to emails at 4 am in the mornings knowing that I had work at 7am. This led to the prompting to see a doc, a psychiatrist, and the next thing I knew, “take these meds”…
I was trialled on instant-release Dexedrine first, and the response was nothing short of a miracle. Surprisingly, the stimulants started to correct my insomnia, and I was finding myself sleeping 7-8 hours for once in >10 years.
However, the medications seemed to have lost potency real quick, but I always responded well to the titration bump-ups. We’re currently at 70mg with a 5mg Dex top-up, and this worked well for a few weeks (we’re a total of 5-6months in now), but similarly, it is losing its effectiveness, and this bothers me so much because I don’t want to be a whinger to the doc, psych, or pharmacist…
I don’t know how to explain well to my treating practitioners, but the medication, as odd as it sounds, feels like it is just on the cusps of helping, but instead, it’s doing this dragged-out riding underneath the therapeutic zone that creates this weird relaxed-sleepy sensation which is annoyingly distracting. This sensation lasts 6 hours, with the middle duration being the least annoying… like the feeling of needing to yawn, but not a strong enough stimulus to trigger it!
I was reading the genetics testing articles that you wrote, and I was hoping to ask you if my above situation sounds like a rapid metabolising situation. Is it possible for metabolism to break down the active form of 70mg Vyvanse faster than the medication being converted? What would be the best way around this if it were the case…
If it helps, a 5mg Dex IR in the mornings with the 70mg Vyvanse helps use really help take me out of the sleepy ride, but it feels like that’s lost its potency. I have the feeling taking 10mg would help, but that would be breaking doctor’s orders…
I would love to have your opinion and will appreciate any suggestions you might have that I could discuss with my doctor…
Thank you in advance, Gina. I’ll patiently wait for your reply! 🙂
Hi Zoe,
Thanks for letting me know you find my work helpful!
First, congratulations on the diagnosis.
Second, you aren’t being a “whinger.” You are trying to optimize your medication — exactly as you should be doing. Ideally, with the help of your prescriber. But that doesn’t always happen, for some good and not-so-good reasons.
It’s really best to be pro-active and do exactly as you are doing — e.g. noting specifically when it seems to be wearing off, making you sleepy, etc..
Third, I’m not surprised that taking a stimulant helped to regulate your sleep. It doesn’t always happen that way, especially with an amphetamine. So you lucked out there.
Fourth, the risk with amphetamines is expecting to “feel” it working. As opposed to having objective tests where you can gauge efficacy (e.g. trying to read a work report that would ordinarily be difficult, avoiding unnecessary Googling, etc.).
Also, the effect can be so powerful with amphetamines that the person doesn’t realize the importance of implementing external supports — using a calendar, paying attention to time, organizing tasks and priorities, etc.. So they just keep titrating up.
That “feeling it working” thing tends to fade. But it doesn’t mean the Rx isn’t working. Only you (the only one inside your body!) can tell the difference.
Finally fifth, I would not try to explain all this to your prescriber. Doctors aren’t any better than the rest of us at picking out salient details from a narrative string. 🙂
Instead present a note using clear, succinct bullet points, with minimal verbiage — or draw a picture. That is, a simple timeline showing:
1. Time take your first dose (would that be Vyvanse 70mg + 10 mg Dex IR?)
2. Time you feel it kick in (get specific as to how it is reducing symptoms)
3. Time it start to wear off (get specific….”weird relaxed-sleepy sensation”, more distractible, being on the verge of yawning)
Then do a quick comparison of the initial effect and what’s happening now:
Initially – …..
Now – ….
It might be that you need more sleep than you are already getting, even though it is an improvement over the past. That might be why the Rx is causing a sleepy feeling.
re: genetics…I would not go into the weeds of that yet. If the dose worked well for you before, I would look for other reasons. Such as above or other things such as a change in diet, alcohol or cannabis consumption, etc..
I hope this helps. You might be interested in my online course, on Physical strategies (sleep, Rx, and exercise/nutrition):
https://ginapera.adhdsuccesstraining.com/course-2-physical-strategies
best,
Gina
Diagnosed with ADHD at 17, and was lucky to get a perscription for Vyvanse a week later. Slowly bringing my dose up, neither I nor my family and friend’s noticed any difference until I reached the dose of 60mg. It worked amazing, until my sleeping disorder started interfering and we had to up my perscription to 70mg. At every doctor appointment since than (not including my perscribing doctor) I have faced at least one comment being made about how high my dose is. “Is this a typo?” “Can you confirm your vyvanse dosage, I don’t think we have the correct one in here.” “Thats a high dose, have you considered lowering that?” “I honestly didn’t know they went that high.” And I even had to switch pharmacies as my previous one claimed they didn’t even keep the amount needed for a month supply of my dose on their property and they couldn’t fill it for me.
I’m 5’3″ , 123lbs, and we are now adding a 10mg tablet of adderall for me to take in the afternoon as my doctor isn’t allowed to go higher based on information from manufacturer of vyvanse themself.
HI Alivia,
Seems you might be a rapid metabolizer. Your doc’s never heard of that, I suppose……
But have you tried a SECOND dose, after the first wears off? Many (most?) MDs don’t think of this.
Also, many believe you can increase the dosage to make it last longer. Nope.
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I’ve been on medicine for my ADD/ADHD since I was 5 now 33 I’m 4’11” and 105lbs I take 40mg of instant release Adderall a day. So size does not matter!
So true, Lil Lady! 🙂
When my child was thirteen or so, she took medication around the clock or could not sleep. Her smart psychiatrist understood the problem, and said more than once her liver must be made of strong stuff, because the dosage she had to take in order for it to do the job in her brain was more than he or any pharmacist said they had ever seen a child take.
And, she was most certainly not over medicated. We got to that point a time or two, and backed off. It was completely apparent, with a great slowing of cognition, which resolved as the medication was metabolized. She might have weighed 95 pounds and took something like 240 mgs of Vyvanse in a 24 hour period. So what.
Hi Betsy,
Wow, that must have been a trick to get approved by insurance.
BTW, I thought of you last night, at a talk by William Walsh, PhD, author of Nutrient Power.
I’ll post the videotaping when it comes online.
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Those were the days when her Kaiser pediatrician and Kaiser neurologist put their heads together and decided they would sign off on whatever our paid-out-of-pocket child psychiatrist wrote.
Until the day someone in the echelons of Kaiser must have audited random charts, and the pediatrician was livid, throwing accusations at her/us for abusing meds, etc. etc. It was a most ugly and unforgivable scene. We never went back. It was such a breach of trust and, to me, a clue that he hadn’t been paying attention all along, and that he didn’t trust US. Not a relationship to try to rescue when you’re living a beleaguered life already.
No regular insurance company will pay for that, and for all I know, Kaiser wouldn’t either, nowadays.
Probably the pediatrician just wanted to stay employed.
Here in the Bay Area, KP made ADHD a “low priority” for adults.
It’s gotten better in recent years, thank goodness, but only with specific Mds.
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That SF “low priority” for adults with ADHD thing at Kaiser served my brother ill. In spite of having two siblings both with ADD and in the field professionally, he has been woefully un-helped.
Hi Betsy,
If he’s still in the Bay Area, please tell me about our meeting. We try to keep tabs on the better ADHD care providers in KP, and we also buoy up folks with resolve to eke out treatment from a balking system. 😉
https://groups.yahoo.com/neo/groups/SiliconValleyCHADD/info
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I have explained this to many skeptics, including some with the letters, “MD” after their names. Discouraging.
Our first doc told Dr. Math/The Vulcan that he had, “The most severe case of ADHD he’d ever seen,” and that he “had no idea how [Dr. Math] was able to get a PhD.” Seriously.
Dr. Math takes a lower dose of MPH than I do. 😛
My doctor said that to me. It’s an odd thing to say. Was he in Orange County?
HI Carrie,
MDs everywhere say it, being unclear on the concept of these medications. 🙂
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There’s another thing that definitely DOES NOT affect how much medication is requied–the ‘severity’ of the ADHD. The previously mentioned 300# offensive lineman (seriously, this is big dude) is also one of the most hyperactive guys that I’ve treated. He is on very low doses.
My collegues are well meaning but we were never trained to take care of ADHD. Those of us who know these things have learned from a precious few mentors and the School of Hard Knocks–which is brutal (but often effective) teacher! We have to change that! Focus-MD and I are committed to making that change and I appreciated Gina and her passion for evidence based medicine. She is a great advocate!
Hi James,
Thanks for the addition. Great point.
My husband and I wrote a 7-part series on pharmacodynamics in order to explain some of these concepts.
https://adhdrollercoaster.org/tools-and-strategies/post-7-gene-testing-to-inform-adhd-drug-therapy/
Thanks for the kind words. Doing my best. As I know you are, too, and I’m appreciative!
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