Stimulant Problems: Roller Coaster Ride

The problem with stimulants is not that they don’t work or that they have side effects, but that they don’t work consistently.

The jagged lines reflect the concentration of methylphenidate in the bloodstream from 3 doses of Ritalin. The smooth line is from an equivalent dose of Concerta.

The jagged lines reflect the concentration of methylphenidate in the bloodstream from 3 doses of Ritalin. The smooth line is from an equivalent dose of Concerta.

I’ve spoken to dozens of adults with ADHD who went off childhood stimulant medications as soon as they could hassle their parents into quitting the stuff. “I was on Ritalin as a kid, but the ups and downs drove me crazy. I can’t go on those again.” The graph on the left shows the rapid shifts in blood levels that a child on Ritalin (methylphenidate) endures every day.

When the choices are limited to a) medication ups and downs with side effects or b) consistent under-performance without them, it’s hard to blame a child for hating side effects. Children have yet to learn how cruel the adult world is to under-performers.

Extended-Release Stimulants

The concentration of methylphenidate in the bloodstream when the Daytrana patch is worn.

The concentration of methylphenidate in the bloodstream when the Daytrana patch is worn.

Extended-release stimulants such as Concerta, Adderall XR, Metadate CD, Ritalin LA, Focalin XR and Quillivant XR represent a major improvement. To be clear, though, they were designed to eliminate repeat doses of medications, not to reduce the ups and downs.  Fortunately, they often smooth things out a little too.

Vyvanse and Daytrana have very smooth concentration curves with no rapid shifts during the day. They probably represent the state-of-the-art in consistent, all-day effectiveness for stimulants and can be a godsend for people sensitive to stimulant level fluctuations.

Getting Going Then Stopping. Every Day.

The problem with even the smoothest stimulant is the need to get it into a person’s system in the morning, then out in the evening to allow sleep. In general, the smoother and longer-lasting a stimulant is, the longer it takes to start working in the morning.  Vyvanse takes 3 hours to reach its best effect. It’s departure at the end of the day tends to be subtle.

Adderall pills are much quicker with full effect in 90 minutes, but their offset is often so rapid that people sometimes refer to it as a “crash”. The term is a colorful bit of hyperbole that refers to a notable loss of mental energy and efficiency. It is not remotely like a “meth crash” which has been described as “a deteriorated state, starved, dehydrated and utterly exhausted physically, mentally and emotionally.”

The main point here is that stimulants have a significant fluctuation “up” every morning, a large one “down” every evening and sometimes have smaller ups and downs in between. Personally, I like roller coasters once a year, but not every day.

The Nonstimulant Alternative

Nonstimulants don’t have the ups and downs in their effectiveness that stimulants do. People who use nonstimulant treatments for ADHD don’t have to order their to-do list around peaks and valleys in their executive function. However, nonstimulants tend to take a month or two to reach their full effect which makes them unpopular at that critical moment when you have to decide what medicine to try.

Pretend that your child with ADHD has six weeks to pull up some failing grades, and her teacher is begging you to do something that will decrease disruption in the classroom.  Pretend further that you are frazzled from an expensive hour in your physician’s office trying to discuss ADHD treatments while your child was climbing into cupboards and dumping out boxes of tongue depressors.  “So do you want to try the medication that will work in a month or two, or the one that will work by 8 am tomorrow?”

Now pretend that it’s six months later, the crisis is past and it’s a regular day at your house. Do you want your child on the medication that wears off every evening around suppertime or the one that works all the time?

 

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

Posted in ADD, ADHD, medications, non-stimulant, stimulants
15 comments on “Stimulant Problems: Roller Coaster Ride
  1. Phillipa Munari (I) says:

    thank you sooo much. We are awaiting diagnoses and this info is very helpful and I don’t even think my teen could handle the every day roller coaster. thanks for giving me info that can help me when and if the conversation arises about medication.

    Phillipa Munari

    ________________________________

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    • Best of luck, Phillipa, in your sons search for diagnosis and treatment. Some people respond well and don’t feel like they are on a roller coaster. But if your teen needs a consistent treatment, it’s very appropriate to ask a physician to start with a non-stimulant ADHD medication.

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  2. Kristin says:

    I really appreciate your blog. I have two college age sons with forms of ADD. My oldest has ADHD and was diagnosed at a very young age. Ritalin, then Concerta, when it came out, was his best friend for years….worked great, until he outgrew the highest dosage allowed on Concerta in high school. Since then, he has tried a few others and settled on Adderall XR, which for him, seems to mimic Concerta the best with the fewest side effects. My younger son, manages his inattentive form of ADD with a low dose of Concerta and has never looked back. It works just right for him. Thanks for your insight as to how each medicine does its job. For someone who doesn’t take it herself, it makes it easier to understand.

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  3. Glen Hogard says:

    Orin posits: “Children have yet to learn how cruel the adult world is to under-performers.” Newsflash: They are even more cruel to adults who under-perform.
    “Under-perform” is a relative term, in the same way as ADHD/EFD is situational.

    When judging the effects of medication whether desired (benefits) or undesirable (side-effects), ask yourself where the problem lies. Is it in the brain of the “patient” or is the task or desired behavior, (i.e. Sit down and shut up!), a bad “fit” for the default-brain-wiring of the patient?
    It is no fun growing to middle age and not knowing the world you inhabit is actually not the same world as “they” inhabit. We are truly “Strangers In A Strange Land”. Aliens would get better treatment if they appear with similar differences in brain wiring: people would understand and cut us some slack if we had blue skin and huge eyes and they wouldn’t expect us to conform but more likely would celebrate our amazing differences.

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  4. Louis says:

    Thanks for your interesting post. To what nonstimulant medications do you refer? Thanks.

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    • Thanks for asking for this rather important clarification, Louis. Strattera is the only non-stimulant medication that is FDA-approved for treating ADHD in all age groups. Intuniv and Kapvay are approved for children. Wellbutrin, Elavil, Norpramin, Pamelor, Tofranil, Catapres, Duraclon, Nexiclon, Tenex are used “off-label”,

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  5. Leslie says:

    Dr. Mason, thank you for this invaluable information. I had never considered a non-stimulant for my son with ADHD.

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  6. Dr Mason, I came across your blog when looking for a physician in the Holland/Grand Rapids area for my college aged son. I’m a psychiatrist in Colorado, your website information is great, sounds like you are providing some valuable services. Don’t forget about the option of using stimulants temporarily while the non stimulant medication kicks in.

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    • Thanks, Dr. Anrooy. A couple early registration trials–one US and one European–showed decreased investigator-rated response to Strattera in stimulant-experienced cohorts vs. stimulant-naive, despite double blinds and placebo controls. I’ve shied away from temporary stimulant “coverage” in my own practice since then, partly because of this finding, partly because of the likability of stimulants, partly because there aren’t many situation where quick response is a clinical imperative. However, your practice does have an artistry to it it that my analytic method certainly lacks. All the best to you and your son!

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  7. chaddgr says:

    In your reply to Dr. Anrooy, did you mean that if someone had previously been on a stimulant, Strattera wasn’t as helpful, or were you saying that if they took a short acting stimulant, along with Strattera, that Strattera was thought to be less effective? And what does “likeability” imply? Something bad?

    It would be great if we could have the best of both worlds, though, because, without taking BOTH a short and long acting stimulant, by 9 a.m., I would get a call from my son’s school, (like when they thought the anarchy symbol was a gang symbol).

    After learning to drive, Strattera might have been a godsend, in allowing me to get some sleep instead of waiting up until he was home, safe and sound. When he finally did try Strattera, as an adult, it didn’t help, tho, at the highest recommended dose. He has always needed higher than “recommended” doses of stimulants, though, (meaning “not tested,” –not “contraindicated”), but he has never been one to beg.

    I had no idea it might take 3 hours for long acting stimulants to get onboard! Thanks for the graph and information about other meds.

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  8. Jeff Taylor says:

    this is a very helpful post, thank you. I’m a second year medical student repeating, ADHD has been very difficult to control. I’m trying to get my plasma concentrations stable throughout the day. Do you see daytrana as a viable option for adults?

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    • Jeff, Daytrana probably makes even more sense for adults than for children. Getting medication to last for the 16-18 hours of an adult day is not easy. Usually, it requires multiple dosings. Daytrana is the only stimulant that reliably lasts the whole day for all users. On paper, at least, it would be a great medication for you to try.

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Oren Mason MD
Oren Mason MD

Oren Mason MD

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

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