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Old 10-01-2010, 03:35 AM   #1
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Adderall timing/dose

Another long and involved post from the forum newb

I am taking a lot of Adderall. I feel great, mostly. For the first time in my life I can sit still without bouncing my leg madly up and down, sometimes causing the whole room seemingly to vibrate. I can talk on the phone while sitting down or standing still. My whole life I have paced madly while talking on the phone.

But I'm concerned about how much I'm taking, and the timing. After several weeks of titrating, I was prescribed 35 mg. Adderall XR to be taken at 6 am, and then 20 mg. Adderall to be taken at 3 pm.

I'm NOT sleeping. It's nearly 5.30 am, and I've been dozing on and off on the couch for the past 2-3 hours, but haven't been to bed. I'm supposed to take my Adderall XR in half an hour.

I don't think this is really due to the Adderall. I am unemployed, desperate for money and a future, hoping to find a job out of state and relocate, there is stress, a whole lot of stress. It is a daily struggle to stay positive and I often fail for a couple hours or a day or so at a time. I often don't want to go to bed simply because I don't want to face another jobless day. But, it bothers me to take a whole lot stimulants at the tail end of a sleepless night. It just seems excessive and wrong somehow.

I'm afraid I'l develop tolerance and then what? I'm already at nearly double the recommended dose for adults. I tried cutting back to 30 mgs and it was not sufficient, still felt the ADHD patterns, the nervousness and clutter and general inarticulateness, getting my thoughts and words tripped up with each other, etc. 35 is perfect, 40 feels good too, but I felt a bit jittery, like after having a second cup of coffee. So, 35 is good, but it's still nearly double the recommended dose!

When I was titrating up, I started having major mood crashes in the afternoon. Acute suicidal feelings and impulses, to the point where one weekend night, I took myself to an ER just to have them reassure me I could make it through the night and keep an eye on me. My doctor felt that losing the focus and general coping ability afforded by the Adderall right in the afternoon>evening transition, just when trying to wrap up the day, get dinner started, get the kids fed and taken care of, wrap up my work (I was self-employed, now I'm job-hunting full-time), etc., was causing me to feel out of control, and that combined with comorbid mood problems and the general down feeling of coming off a stimulant was snowballing into the deep depressions, and so he added in the afternoon/evening dose, 20 mgs of regular Adderall.

The regular Adderall is...not so good. For a week, I was just relying on the regular Adderall taken 3x daily, after my spouse was laid off and our insurance ran out, and that was horrible. I had terrible anger problems, was constantly either jittery or angry, and spent virtually all my energy trying (and sometimes failing) not to simply rage at my spouse, often with no provocation at all.

I was able to get assistance getting the Adderall XR, and it's working great, but the evening Adderall is still a challenge. Still prone to anger/rage, still sometimes jittery just shortly after taking it, etc. And frustratingly, not sleeping. Again, partly stress, and I'm really not sure what else. I don't know if it's the Adderall keeping me up, or the ADD! Often, I am able to nap in the late morning after taking the Adderall XR, but in the evening after the Adderall wears off, I feel ADD-ish again; nervous, thinking too fast, jumbly and cluttered and a little obsessive, and often resist going to bed because I'm focusing on some project or other, trying not to focus on the realities of unemployment/job hunting/etc.

Perhaps I'm just in my Adderall honeymoon, but I love this stuff, it has completely changed my life. I can't get over the bizarreness of the fact that I have had insomnia to varying degrees my entire life, but two hours after taking a large dose of stimulants, I can sleep peacefully, or that the only way for me to NOT pace the house madly when I'm thinking or talking is to take stimulants! How weird is that?

I'm still in shock that no one diagnosed this is in the past. And angry. So much lost potential.

But...I'm afraid the honeymoon of the awesome cure for everything has a catch to it. I've already encountered a whole lot of stigma. I'm a former cutter with obvious scarring and have been coping with serious mental illness for about a decade--I thought I knew all about stigma. Until Community Mental Health told me that they won't help me because Adderall is a controlled substance. And then the county health department told me the same thing.

And this tolerance issue...
That REALLY scares me. At 55 mgs Adderall total per day, everyday, I wonder how long this is sustainable. Eventually, I understand, I'll start building tolerance. Then what? 65, 70 mgs day? How many times the maximum dose do I take before either the DEA arrests me or my doctor or before I develop high blood pressure and such or before my doctor says "tough luck, you're done"?

I've taken a couple "days off," when I had absolutely nothing to get done, had clothes laid out the night before, didn't have to spend time alone with my kids, etc., and they were ok-ish, but the more used I get to feeling ok/functional, the harder it is to handle even a day feeling the way I used to feel all the time.

I'm also wondering about switching the schedule and doing the instant release in the morning and the XR in the evening. The instant release is a slightly larger dose, just because of the available formulations and because it has been working, but maybe taking the more brutal up/down higher dose in the morning would improve the chances of coming off it more gradually in the evening, and not being up all night? It seems like when people do a long acting + a short acting med, the short acting one is in the evening, but I have not seen any information as to why this is a the case. I understand for children it's desirable to avoid taking a med at school, but that is obviously not an issue for me.

Of course, there are other possibilities. For ten years, on and off, I've been treated for depression, varying from severe depression with catatonic features to more moderate months long episodes of depression to mere dysthymia. I always have generalized anxiety disorder. In the past, I was treated with SSRIs, Benzos and other anxiolytics, and during the most severe episodes, with atypical antipsychotics. None of these ever did much good at all, other than to drug me into even more of a stupor and make me feel even less capable/competent and less of a generally worthwhile person.

My doctor--who is pretty well-respected in treating ADD--explained that it appears that because of the co-morbidity and my lack of significant response to SSRIs, my problems are more closely related to insufficient dopamine than to serotonin at all. The Adderall affects dopamine, and he stated it could improve my mood as well as my attention. It absolutely has. My life is, at the moment, by nearly any measure, pretty stressful and kind of depressing, and yet all in all, my mood is ok most of the time. I struggle with staying positive, but for me, depression has always been a very physical thing--flattened affect, difficulty moving, sleeping, eating, talking, etc., and aside from the sleeping/eating issues related to Adderall, I am not having those other problems at all, and I can pull out of a negative or depressed mood by using positive self-talk and other such tricks.

Nonetheless, he has mentioned trying Wellbutrin, which may be more efficacious for my particular imbalance than the SSRIs. I wonder if I should address that asap, before really building a tolerance to the Adderall, or if I should not even worry about it. On the massive doses of Adderall, I'm ok, but I weary of the ups and downs. Seems like getting on an antidepressant that could perhaps give me a measure of improvement around the clock would be very nice.

I certainly do not like feeling like an addict, thinking in terms of ups and downs related to drugs. Since encountering the institutionally sanctioned disapproval of Adderall use on the basis of it's status as a controlled substance, I am kind of nervous about it.

Is it ordinary to be taking quite so much Adderall? It is clearly working for me, but I would feel better about it if I knew that it's not unusual to be taking 35 mgs XR and then 20 mg instant release every day.

Especially as I'm hoping to move out of state. Am I going to have trouble finding a doctor willing to consider continuing my current treatment? Ought I prioritize adding a trial of Wellbutrin and seeing if that enables me to reduce the Adderall at all? I don't even really, btw, know if my dr meant that adding Wellbutrin could mean decreasing the Adderall. He may intend to simply add Wellbutrin to my current dosage of Adderall.

I'd hate to move to a new place, start a new job, and while learning a new job and settling in to a new place, run out of meds and not be able to find a doctor willing to follow my current treatment plan! My current dr stated that he could continue to provide refills for a few months until I could get in with someone else, but I would really like to know whether my dosage is unorthodox or not.

I appreciate any thoughts. Figuring out this ADHD thing is quite the adventure, especially considering that none of the half dozen therapists and psychiatrists I've worked with over the past decade were even able to spot it. It's rather cheering to go from having treatment-resistant chronic/recurrent severe depression with anxiety, so severe at times that I've investigated experimental nerve stimulation surgery options, to having one of the most treatable mental illnesses there is, so common among little boys that it's barely even considered a mental illness by many.

But, it's still the same crippling problem. It's now treatable. The treatment seems to be working, but I need to think of the future, and how to make one. If I somehow manage to find a job--my mental health history makes that a challenge, but I am working with some vocational rehab programs to try to salvage some sort of career--the real test will come when I'll have a big project to do, a tight deadline, and uncertainties about how to do it. That's what sunk me the last time, and lost me a chance at a fellowship, or much support from faculty in finding a job. I need to find the right meds for coping with work, but right now I'm coping with the stress of no work. Frustrating.

In any case, apologies for the long and rambly message. It's now 6:30 am, and I can take my adderall and sleep for a few hours, start in on the next new day of trying to figure all this out. This is not easy, and I appreciate any words of wisdom.

 
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Old 10-01-2010, 05:23 AM   #2
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Re: Adderall timing/dose

Okay, need to go to work soon, so I can't address everything, but here's why XR stimulants aren't normally given late in the day.

Some ADD-ers, especially the "super-speedy" ones like you, actually do sleep better after (moderate doses of) stimulants. Others, like me, don't. For those people, it's better to have the drug out of the bloodstream at night. For you, maybe you need it at night!

Heck, if I take Adderall at noon, I'm up until four in the morning. I've run in to the same problem with asthma meds, because I'm just really sensitive to stimulants.

 
Old 10-01-2010, 09:47 AM   #3
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Re: Adderall timing/dose

I remember my first post here, I also remember apologizing for it, because reading it was like running a marathon! Several things came to mind while reading your post, I'll address them as I remember them, which means they'll be in no particular order.
  • 55mg of Adderall is not double the recommended dose. For treatment of ADHD in adults, 40mg per day is considered the upper end, though 60mg is recommended for narcolepsy. I have seen people here report being prescribed 100mg or more of Adderall per day, so honestly, 55mg isn't really all that much. I am currently on 40mg of Adderall, plus 450mg of Wellbutrin daily (which is a monstrous dose), and I haven't had the police knocking on the door yet. My 40mg Adderall is all extended release (instant release isn't legal in Canada), and is prescribed to be taken all at once in the morning, though I often break it into two doses to extend the period of efficacy (my point being that 35mg at a time isn't an unreasonable dose).

  • It's possible that your sleep disorder is a major cause of all your problems (that's not to say the only cause). I would see if you can get a referral to a sleep clinic to address the sleep disorder. You may well find that once you're consistently getting proper sleep (which the majority of us ADHDers don't) that your mental health issues diminish significantly.
    If you can't get a referral, or if financial considerations make it impossible, make sure you're getting plenty of exercise, do your best to focus on natural foods, and try to maintain a consistent schedule seven days a week. These things may help you control your sleep disorder, and thus alleviate your symptoms.
  • Many of the side effects you mention, the jitters, the anger, the short temper, tend to be associated more strongly with Adderall than with many of the other ADHD stimulant medications. I would recommend talking to your doctor about giving either a dextroamphetamine only (such as Vyvanse or Dexedrine), or a methylphenidate (Concerta, Focalin, Daytrana, Ritalin) option a try. If you're concerned that he'll view you as a drug seeker, keep the conversation on Vyvanse or Concerta, as both of these meds are considered to have a lower abuse risk than Adderall; if your doctor is indeed an ADHD expert, he likely knows that subtle changes in medication can yield major results. Unfortunately, neither of those are available in generic versions yet, so Ritalin might be your best bet if cost is an issue.
    This option may or may not work for you, as Adderall's weakness (increased incidence of side effects) seems also to be its strength, as many people find it works the best of all the ADHD medications.
  • Tolerance is very likely to occur, though it doesn't happen to everyone. I tend to be rather obsessive about the possibility of tolerance myself, and often convince myself that I've developed tolerance every time I have a bad day. Unfortunately, it's one of those things we can't predict, and can't control, so all we can do is take the meds and deal with issues as they arise. Obsessing over tolerance can cause so much anxiety on its own that it makes the meds less effective, a sad irony, to be sure. Do your best to let your fears of tolerance go, they're going to do more harm than good.

  • I tend to recommend against days off. Although common wisdom seems to contradict me in this case, I have found that I need several days of Adderall to get the full effect, and a day off leaves me with less overall effect for days afterward. My shrink agrees with me on this, keep the meds consistent to keep the effects consistent.

  • Give Wellbutrin a try. I can honestly say, that after several years of unsuccessfully seeking the right treatment, that Wellbutrin changed my life. Wellbutrin is what I call an antidepressant style treatment for ADHD because along with other similar meds, it's a reuptake inhibitor, which means it increases the available levels of neurotransmitters in the brain by slowing the process by which they're broken down and reabsorbed in the body. In this way, it's similar to SSRIs, but rather than working on seratonin, it works on dopamine and norepinephrine instead. By this action, it can work in concert with your stimulant medication to further increase the available levels of the required neurotransmitters in your brain (it can also work as a standalone option, though probably with less effect than the combination).

  • The ironic effect of ADHD is that our outward hyperactivity is caused by hypoactivity in the brain. It's thought that this is the reason that stimulants work to calm us down. Because the messaging system in the brain is short on raw materials (specific neurotransmitters), many messages sent from the higher brain don't reach the lower brain (which is the part that has actual control over our actions), leaving the lower brain to make decisions on its own. The effect is that our lower brain, which is similar to that of lower animals, acts as it sees fit, which is why we tend to lack impulse control, and react poorly under stress.
    Because the brain's messaging system is short on couriers, many messages are lost. Your higher brain might be screaming "We need sleep!" but the message isn't getting through. Once the proper supply of neurotransmitters is restored, the message gets through, and we're able to calm down. Sadly, not sleeping exacerbates the issue, and the supply of messengers is further reduced, leading to further declines in delivered messages.
  • Would your doctor consider trying to intervene on your behalf with the relevant health authorities? Despite the fact that Adderall is a controlled substance, it's still a valid prescription for a valid illness. Your doctor, especially if he's a respected member of the medical community, may have more success cutting through the red tape than you do on your own. He may also assist with finding a new doctor if you move, and may help your case with a new doctor by providing a letter, or relevant documentation. Although he may be unwilling to get involved, you won't know if you don't ask.

As I final word, I will urge you to be patient. Finding the right medication or combination of medications at the proper dosages can be a long and frustrating process. You may find meds that work at first, but lose efficacy quickly, you may find meds that do nothing for you. You may, like me, find that it takes 2 years of trying to find the right option, but trust me, it's well worth the effort. 35 years of hell ended for me a matter of months ago, but my level of function and self control are at levels I've never experienced before. I finally can see a tiny dot of light at the end of my dark tunnel, my challenge now is to stay on the tracks and not derail before I reach it. It's a profound and wonderful feeling that I hope you can experience soon, but even if it takes time, stick with it, you won't regret it in the end.

 
Old 10-03-2010, 07:18 PM   #4
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Re: Adderall timing/dose

Heh.

Yeah.

I have noticed that lately, I have tended to write EXTREMELY long posts. It seems to always be late at night/early in the morning, when I'm off Adderall. It is somewhat difficult adjusting to having a med that has some major effects!

My previous experience has mostly involved meds that had no effect other than making me feel terrible with side effects.

Jane--I think I will try switching the doses. For one thing, I am more frequently at home at 10 am than at 3 pm, and the afternoons are still the most difficult time for me. The instant release Adderall just isn't very subtle!

Thunor--thanks for making it through my crazily long post.

It is good to know that my dosage is not all that high. I must have been confusing "recommended" dosage with maximum dosage.

Sleep issues are likely an issue. I can't get a referral at this time, but at some point in the (I hope not too distant future) when we have successfully relocated, that is an option I will explore. I have asthma that has interfered with sleep too, and I often have difficulty staying on the meds schedule.

I want to stay on Adderall rather than switching. It is just so effective that I would try just about every possible way to stay on it rather than switch to something else. Not very logical, but I am so delighted with my ability to get things done that in the past would have been just impossible. I will have to cross the tolerance bridge when I come to it, and I will try adding Wellbutrin asap.

I'm not in an acute depression right now, but I still think it could help, and something that is effective round-the-clock would be good. A lot of the anger, jitteriness, and sleeplessness are also situational--life is tough right now.

Exercise would probably help with those a lot, as well as with the sleep issues. I had a very good routine, but it ended due to economic pressures and I just haven't had the fortitude to reshape it to fit the circumstances.

But, thanks for all your comments. I'm still getting used to the awesomeness of being able to do just one thing at a time, and actually focus on it. I was taken aback when after all sorts of testing, my psychiatrist stated that he expects my IQ test results to increase about 10-15 points upon finding an effective med regimen. After experiencing it, I'm no longer surprised. I certainly feel a lot smarter.

 
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