Taking the A-Train, Part II (I Think)

This is a follow up post to Part I.  But I repeat some of that post here.  So maybe forget Part I.  But there is new stuff here so this is really Part 1.5. (Shut up and tell the story already!) If I “shut up,” though, I can’t technically tell the— (Really? This is how you talk to people?)

Okay then.

Aong the myriad changes to my life this summer, I began taking a new drug: Adderall.

After visiting a new ADHD specialist, I started on Adderall XR 20 once a day.  After a few days, the plan was to taper in Wellbutrin as well, after I described my depression as “severe” (with accompanying documentation)  The first day I took the Adderall, I felt relaxed and clear.  I took it in the morning and did my usual mental check.  How do I feel about finances?  Job? Mortality?  All topics returned positive thoughts.  It was a Saturday, and my wife and I had a good long talk about difficult topics: the finances, aging parents, our kids’ autism, our younger son’s cancer, etc.  I felt unburdened; I could send my thoughts anywhere without the automatic anxious responses. I could see my way to fixing many problems that have been ongoing, even those that I have always had trouble with since leaving home for college about a bazillion years ago (okay, it was 1989).  Those things being finances and getting things done in general.

But I cautioned myself.  Being on Adderall was a new project.  It was fun and untainted and full of possibility and lacking any failure suitcases.  After a second day of feeling good and getting some things done, I took a risk and had an antihistamine.  I have seasonal allergies, but I find that taking any kind of medicine for them gives me bad mood side effects (in that I seem to hate everyone and want to crawl under the bed) so I endure the allergies rather than experience those side effects.

English: Adderall

I slept well that night and started the Wellbutrin the next day. I felt confident about the anti-depressant because I had taken it years before and it had worked adequately. The idea of the new stimulant together with the antidepressant seemed like a potent combination to battle my sitting-around-ness.

However, something in that mix did not sit well with my brain.  My wife and I ended up in a big fight about nothing and I ended up taking a long walk around town to cool off. My wife called a friend over to stay with the kids and went looking for me in the car because I seemed too unpredictable.  I was sure it was the antihistamine and took another Wellbutrin the next day.

I didn’t have another tantrum, but I ended up with the same problem when I started Wellbutrin years ago: insomnia.  I wasn’t willing to wait it out this time, though, and felt like the depression had lifted with the Adderall anyway, so I chucked the Wellbutrin idea.

For the first two weeks, it felt like the positive change I was hoping for was just around the corner.  I saw clearly how to fix broken things in my life, and the steps were attainable.  There were so many of them, though, that I had made little actual progress.  That, and there is always the backdrop of my son’s cancer to consider.

I started to notice the first side effect of the Adderall: jaw tension. Adderall cuts me off from certain body signals. I can have a bad night’s sleep and still function okay and not have the crushing sense of fatigue that I’ve always felt. I am also less hungry.  Instead of stress affecting my whole being, stress seems only to affect my mouth.  My lips get tight and I have the urge to clamp my front teeth together.  From doing yoga and practicing mindfulness, I know I typically carry anxious tension in my body, but my normal jaw clenching is my back teeth.

tiny mouth

tiny mouth

On Adderall, when I start getting “tiny mouth,” I have to think to figure out what’s going on with my body.  Oh yeah, haven’t eaten in six hours. Or only got four hours of sleep last night.  The jaw tension also happens when the slope turns and the stimulant starts to wane. Normally hunger and fatigue would be right there without my having to think about them.

The Adderall effect feels different from the Ritalin.  On Ritalin, I’d upswing (which I hesitate to call a “high,” because that suggests a hopped-up feeling) for an hour or two.  I’d feel energized and calm and, on good days, have a sense of well being.  Then it would drop off and I’d feel like my baseline anxious mess of a self.  And then take the next pill.  I’d take as many as five a day and be up and down that roller coaster.

If you’re a coffee drinker, my Ritalin experience was like having that first good cup of coffee after you wake up and then within two hours going right back to just having got out of bed and everything sucks feeling. And doing that several times a day.

At the end of the day I’d feel exhausted from all the yo-yo feelings, and my depression would creep in there and make me feel hopeless.  God forbid I’d wake up in the middle of the night.  I would be so far away from Ritalin at that point that I would feel like I was dying. Some nights I was sure that I had completely stopped breathing in my sleep and only through some miracle had woken myself up and started breathing again.  Try going back to sleep with that thought in your head.

I had tried to remedy the roller coaster feeling with Concerta.  The timed release is supposed to give you a more steady feeling.  On straight Ritalin, I took 40 to 50 mg a day.  On Concerta I was up to 54 mg a day without the positive effect.  Also, with the Concerta, I had no options after it wore off. It was impossible to work in the evening.

English: Kirnu, a steel roller coaster in Linn...

The next option was to boost the Concerta, but I couldn’t understand why 54 mg of Ritalin inside the mechanism of Concerta did not work as well as 40 or even 30 mg of plain Ritalin.  My doctor was also concerned about my blood pressure which was testing at borderline high.  More Concerta could increase my blood pressure.

I now know that my family doctor was the wrong person to manage my ADHD meds.  The new doctor, the ADHD specialist, said several things about why my treatment wasn’t working.

  • First, some people respond more to the slope of the medicine rather than the level.  Concerta has a more gentle slope, so it’s not uncommon to need more of that than straight Ritalin to get the same effect. And plain Ritalin has a vicious down slope.
  • Second, if I was taking time release pills, I needed to have a “booster dose” of non-time-release stimulant on hand if I needed to work late.
  • Third, the way my family doctor measured my blood pressure was all wrong. I’d barely get into the office and after the nurse would ask me a stream of stress-inducing questions (when was your last physical [25 years ago] did you have your flu shot [no] why not [um . . .]). Then he or she would take my blood pressure while I sat uncomfortably on the edge of an exam table.

My new specialist waits until we’ve been talking awhile and lets me sit in a comfortable chair the whole time.  If I test high, he moves my arm to a more relaxed position, lets me breathe a couple times and then remeasures.

He said the other method virtually guarantees a wrong reading.  I bought a home blood pressure kit and thought it didn’t work because the readings were so different from in the family doctor’s office. (My other doctor was aware of this “lab coat syndrome,” but his solution was to get it monitored somewhere else on my own. To quote Bugs Bunny “He don’t know me very well, do he?”)

The upshot of all this was that I had plenty of room to go upwards on the Ritalin/Concerta route if I wanted to.  I was ready to be done with Ritalin, though, and he thought the slope of Adderall would work better for me anyway.

Adderall XR felt very good, but left me without much benefit after 4:00 p.m.  He told me to call if I needed a booster dose, so I did and left a message.

If you don’t know, ADHD stimulants are controlled substances because people abuse them.  My personal and unscientific opinion is that if Ritalin and Adderall were naturally occurring in coffee beans, they would be a regular part of our society, and if caffeine were only synthetic, it would be a controlled substance. I had plenty of friends who abused caffeine in school; No-Doz and Jolt were the study aids in my day.  Plenty of people are addicted to caffeine and use it daily as a “crutch.” Also I can’t make out why alcohol and tobacco are legal and marijuana is not. (Climbs down off soap box.)

Because stimulants are controlled, they are less convenient.  They can’t be called in, no refills are allowed, and there’s a limit to how many you can get at one time.  I have to physically take a paper prescription to the pharmacy and often have to show a driver’s license. I worried about how this might be a problem with my new specialist being an hour’s drive away.

I called and left a message and didn’t hear back and was feeling worried that maybe this was not the best place for me to be going after all.  I was thrilled to be proven wrong when a new prescription sheet arrived by mail within three days.  And it had a neon green sticky note attached with a reminder of my next appointment!  The significance of this cannot be overstated: not only are sticky notes important to my life, but neon colors are essential; pale yellow ones just don’t cut it.  This practice knows how to work with ADHD people.

Overall, the feeling of Adderall is more steady.  It is indeed a long slope and does not have that horrible drop off.  I do have the occasional what are you doing anxious thought at night, but without all that inconvenient existential dread.  I feel almost like a normal person sometimes.

On the downside, I am more blunt in my speech and say things that I intend to be funny that come out as mean.  I forget to eat sometimes and I eat less overall, but I can afford to miss a meal or two. (Dear Taco Bell: Fourthmeal?  I scoff at your paltry little number!)  I have to be careful not to take a booster dose too late or have too much caffeine or I have trouble sleeping. There is a slight decline in sexual response.  And the weird mouth tension thing.

But overall I felt much more positive and focused and less anxious and avoidant.  Until the end of my summer got messy.  But that’s for Part III.  Or maybe Part 2.25.  Can you do decimals in Roman numerals?

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11 thoughts on “Taking the A-Train, Part II (I Think)

  1. My daughter’s mom is addicted to caffeine (thanks to her parents giving her coffee when she was a kid, after they noticed she was crankier and more sluggish in the winter months) (Seasonal depression? Nah! She just needs some coffee to perk her up!). She has to take No-Doz right after she gets up in the morning, before she even drinks coffee, or she’s absolutely useless.

    Thanks for the extensive write-up on Adderall (and Ritalin)! Because of my blood pressure (which is, like you, taken right after I get into the doctor’s office, usually when I’ve been rushing to not be late–because, of course, I have no sense of how long it will take to get ready and get there on time), my doctor won’t put me on either med, although since I started taking Lamictal for mood regulation, I feel like it’s less of an issue. (I’m still easily distracted, more abstract in thought, not great at finishing what I start, space off things I’m not really interested in doing, etc–but I’m generally less depressed or anxious about it.)

    • If you really needed a stimulant, though, you could treat BP or make sure that it actually is high. Every time I’ve had my BP checked the wrong way in the last 20 years, I’ve been told its high. My doc says doing the same things but not feeling bad about it could be accomplished with a lobotomy too. It depends on what your goals are.

  2. Hi there, This post has been really interesting(I’ve not read any of your others yet) because I’m prescribed Dexamphetamine here in the UK. Adderall is the long release version, as you said. My psychiatrist has been keen to move me over to a long release version especially as I have sleep issues and appetite suppression/weight loss as well (gradually over a period of time – has been nice as I’ve not NEEDED chocolate or caffeine) I also get the jaw tensing thing, and have always done so. I’ve found over the 9 months I’ve been on Dex it’s been decreasing though, or at least I’ve not needed as much of it recently as there’s a lot of new stuff going on (going back to uni, relocating to a different area of the country) and still get the jaw tensing thing, but not anywhere near as much as when I first started.

    With regards to your caffeine vs stimulants legality view, caffeine is not as dangerous as it doesn’t hit on dopamine pathways – which are used by the reward system in your brain, but also the information filtration system. Psychosis and schizophrenia are when your brain perceives more information to be more important than it really is, part of ADHD is when your brain isn’t able to differentiate properly between which bits of info are important or not (hence the distractability and the poor prioritisation-on-the-fly issues) because the dopamine pathway signals aren’t strong enough.

    The stims increase these signal strengths EVERYWHERE, which is fine in an ADHDer because ours are so poor in the first place we don’t get addicted to them anywhere near as easily. Caffeine in comparison does not cause paranoia. Cannabis does, tobacco doesn’t. However the question of whether to make any drugs or which drugs illegal is a different question. I’m just explaining why in my opinion why the decisions would have been made this way.

    • Thanks for the info. My doc said about the jaw tension thing that it will likely subside and that if it got really bad we could add a muscle relaxant. I read someone saying chewing gum and yoga help, and that does work too.

      My doc also said that caffeine is a poor ADHD stimulant because it doesn’t target the correct part of the brain. I have notes on that somewhere . . .

  3. I do best with concerta 72 in the morning and 54 in the afternoon totalling slightly above the max dose, but given my pulse remains at 80 in rest and my blood pressure 120/80 I’m handling it fine. Seriously, there is no medicine I tolerate better than concerta!

      • Ok, and to be honest, I needed an entire year to get concerta right, but I am glad my doc didn’t give up on it. This morning I was feeling fine off meds, now I’m feeling fine on them. I only tolerated paediatric doses of antidepressants, and get stoned from half a hay fever tablet. But I have no side effects from a total of 126mg of concerta a day.
        Ritalin makes me slow in the dose I need though.

      • Thanks for sharing the bit about it being a whole year. I wanted to leave Ritalin behind because of the horrible down feelings. Adderall interferes with my sleep sometimes, but Ritalin doesn’t, so who knows where this journey ends.

  4. Loved this post. I brought my daughter to an ADD specialist this summer and it was the best thing I ever did! She started on Adderall, but wow was she cranky — and it didn’t go away, so she switched to Concerta. She also takes Zoloft. The information given in the specialist’s office and the amount of time they spend actually listening to the patient and working to achieve correct dosage of correct medication is so much more effective than having the regular doctor treat the ADD. The only lingering effect of the Concerta is that she also is less hungry. She will eat next to nothing all day, but at least by dinner time in the evening she has some appetite back. Right now she isn’t taking an extra dose of a shorter term medicine to get through the afternoon and evening, but I’m thinking by the time she gets to high school it will probably be necessary just to get her through her homework.
    Now if I can find a way to stop carrying all this tension in MY jaw, I’d be in good shape!

    • Haven’t read about this as related to ADHD, but for my son’s chemotherapy I know there are lots of appetite stimulants if loss of appetite is ever a problem. Like I said, I could lose a few pounds. (It turns out anyway that I haven’t lost much weight. Doing yoga makes me stand up straighter and makes my spare tire less prevalent.)
      Thanks for the comment!

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