Pain-relief scientists have never worked to develop a regimen that relieves pain for 8 or 12 hours a day, then stops. Why do ADHD treatment scientists think it’s okay to do that?
Drug companies say that their ADHD pills last all-day, and they hire research scientists to back up the claim. They should probably hire actual families to judge them first.
When pharmaceutical manufacturers advertise a 12-hour stimulant, check out what that means. (OK, I’ll do it. This is my day job, after all.) Their technical answer is that they started with a stimulant compound which–in its native form–works for a few hours. Chances are it was either Ritalin (methylphenidate) or Adderall (amphetamine). They then modified it to stay in the bloodstream longer.
Typically, they enclose little bits of fast-acting stimulant inside slow-release wrappers that either pulse or dribble out small bits of stimulant through the day. Then, they add a bit of fast-acting stimulant, just to get you up and out the door first thing in the morning. This assumes, that you wake up early and take the pill at least an hour before you do anything day-critical such as prioritize your task list or say something to your spouse.
When the research scientists are satisfied with their concoction, they send a big batch of their pills off to the clinical scientists
who test the pills’ effects in real people to measure how well the pills do what they are designed to do. 12-hour pills need to work for 12 hours or the 12-hour claim goes out the window.
Adderall XR and Concerta are common 12-hour stimulants. Their manufacturers AND the FDA have certified that claim, meaning that behavioral scientists observed statistically significant behavioral differences 12 hours after the pills were taken. That’s not saying the test subjects were behaving well, just that they were statistically less awful than the placebo group which was disassembling the research lab. Don’t judge the placebo group, though. You, too, might behave badly after 12 hours trapped in a lab full of behavioral scientists.
The FDA has final say over the claims a drug company can make about their medications. This introduces scientific oversight and a measure of consistency to the drug industry which is important. But let me take this opportunity to lodge a major complaint about the FDA:
The FDA doesn’t hire actual families to certify these claims.
Every day I ask people how long their 12-hour stimulant (or their child’s) is lasting, and I swear that “12 hours” is the answer I’m LEAST likely to hear. “Eight to nine hours” is the most common answer. “Ten or eleven” is a good solid response. “It lasts all day. I’m not certain when it wears off,” is the grand slam home run for a stimulant user. It happens, but not very often.
Eight or nine hours doesn’t even cover most people’s entire workday. For high-schoolers, it might cover all their classes and part of football practice, too, but not the homework hours. It definitely doesn’t cover all the social hours where there are temptations to resist or all the hours that kids drive cars. Is there is any phase of your life post-infancy during which 8-9 hours would be considered anywhere close to “all-day”?
Let’s post a hypothetical question. Pretend you have a daughter, and she’s going to her first high-school prom. Pretend the young man escorting her has ADHD and will be driving her along with another couple to the dinner, then the dance, then the after-party, then the beach, then the breakfast. Take into account what sleep deprivation and alcohol consumption do to driving safety. Consider that 90% of all accidents are caused by drivers 16-25 years old. Factor in the studies that found ADHD drivers have several times more auto accidents than other teenage drivers.
Now tell me what sort of ADHD treatment you would wish for your daughter’s companion. An 8- to 12-hour one?
Didn’t think so.
I agree wholeheartedly. It drives me crazy that my physician who prescribes my medicine says it will last 12 hours or sometimes even more she thinks. There is no way! Even with the fast acting ones….I feel I need it 3 times a day but she will only give me 2 and thinks that lasts long enough. I see a specialist but he can’t prescribe meds so my family medicine doctor prescribes them. I honestly feel she doesn’t know anything about ADD. I am considering changing physicians over this if I can find one. When I went on Adderall she asked how I was doing. I said it made me feel more alert and awake. She said two different times that it is not supposed to do that…..it will only help with focus and that’s all it’s supposed to do. That is not what the specialist told me…and why then do they use it to treat narcolepsy? I get so irritated but not sure what to do. I feel like I’m stuck.
Dr. Mason, I have yet to have a client with executive function differences, EFD, who says it is a problem 24/7. I have asked every one for the last 18-19 years and not one has any different experience than I. My paradigm shifted at 33,000 feet between my takeoff from the Phoenix ACO convention and the landing in Detroit. I finally accepted that I think as differently from most people as a visitor from a twin universe in the membrane or bubble next to ours. We look identical, but we are as different in our thinking process as cats are from dogs. I love you doctor, for your kindness and insights, which are true for your postulate, but it is limited.
However, if you want to know what it is really like to have a brain like ours you can’t unless you “have” a brain like ours. I did not know, no matter how hard I tried to understand, no matter how long I might hold my eyes shut, what it was like for my Lighthouse clients to be blind. Your question is drawn so tightly there is no room for discussion other than I wonder how much pain that “boy” (interesting choice when it will turn out about 50/50 in the end), was in and how could I help him “STOP TRYING HARDER” to think and act as if he had the same brain as these aliens in this universe.
No, I’m not kidding
I condensed the feeling I had thinking about that hypothetical boy into my linkedin post. The boy who knows everyone around him seems to be afraid of him or trying to control him in ways he finds uncomfortable…most of the time. Cut him some slack.
“My brain doesn’t have to perform the way others would like it to 24/7. So the only time I notice I think differently is when I am expected to behave or perform as if I did not. It dawned on me this week that I have been a victim of an invisible and insidious form of discrimination for a lifetime.
My friend Thom often tells about an experiment using two sets of dogs, a bell and shocks. The dogs who gained relief by jumping to the other side of the cage learned quickly to jump. But if both sides of the dog’s cages were electrified when the bell rang, the dogs eventually gave up and just laid down and took it. I’d bet that “boy” has felt like lying down and giving up trying more than once in his life. So sad…
This has been my son’s experience with Vyvanse. I was so excited when he started this long-acting medication, thinking it would last from when he takes the med at 7:30am to nearly when he goes to bed at 8:00pm. Not even close. It’s clear it is wearing off around 3:00 and it’s gone by 4:00 in the afternoon. It makes our time at home together more challenging than it would if the medication really lasted 12 hours.
That is unfortunate, Leslie. Treatments for ADHD need to help family life at least as much as they improve school life. I hope you can find a better medication for your family time.
Thank you, Dr. Mason.
Exactly. My daughter and I both take medication. I totally agree…..mine wears off around 3:00 to 3:30 but my family physician thinks it will last me just fine. I tell her it wears off too early but she doesn’t care. It makes me mad because I have so much to do after 3:30 and I feel she has no idea what it is like to have inattentive add and not accomplish anything because I am forgetting things or bouncing around from one thing to another working all the time but nothing to show for it. The meds help my daughter at school but wear off a little after she is home….so trying to get homework done is nearly impossible. She is inattentive and hyper so it’s hard to get her to stay in one place and has no patience for homework….takes forever and lots of stress trying to do it…..plus even her writing changes for the worse when meds wear off. I honestly think most people who don’t have adhd really don’t understand us that do have it. Even my dad says if she gets a spanking she will listen better….. that is so not true. It just gets frustrating. Sorry to rant.
My son and quite likely my daughter are ADHD with executive function issues and learning disabilities. He is also OCD and she is speech delayed. (Both Russian adoptees). My best friend is ADHD and OCD as well. She was able to help me understand what life is like on and off meds for her. We are looking at a stimulant for my son. Struggling with the possible side effects on growth as well as the addiction potential. He has sought out external relief through various means already including cutting and experimentation with certain drugs (some OTC). Vyvanse is not a covered med on our ins so the dr wrote for adderall xr. My husband doesn’t want to fill it, I do. As I read through this discussion my question is would it be better to go with straight up adderall 2-3 times a day to extend coverage? or perhaps 1 xr with a reg adderall to cover the extra hours? Or are 2 xr too much for some, good for others? My son works mowing after school and golf practice so I’m concerned about his focus like your example of the prom date driver in another post. He’s actually experiencing higher anxiety levels during golf than when working – he finds that relaxing! Can anyone help me understand? The dr will work with us on regimen, which is good. Thx!
These are all the right questions, Melissa! You are thinking very carefully through a minefield of issues. Please understand how general my answers to individual questions are, since I don’t know your son.
When stimulants are used for people with ADHD, addiction is almost never an issue. It is a much bigger problem when people without ADHD use it for energy.
I tell my patients that we do not “put people on medication.” We do trials of medication and continue them when they show good effect and low side effects. If the medications increase his anxiety, it doesn’t matter how many other things they help, you need to re-adjust.
Plain Adderall is one of the least ideal medications. Second and third doses need to be precisely timed, and people with ADHD are usually not good at that. Vyvanse is often the best choice, since it only rarely needs redosing for evening chores. If you have a chance to change to an insurance that covers it, you should consider that option. Adderall XR with an “evening extender” dose may be your best compromise right now.
I tend to start with Strattera when patients have anxiety or long days (or both as your son). Most of my Strattera patients take a small dose of Concerta or Adderall XR, as well, but rarely need “evening extender” doses.
It’s impossible to know how high or low the medication doses need to be. My patients take as low as 2.5 mg of Adderall per day and as high as 90 mg. As a rule, it’s best to march methodically through the doses (perhaps weekly) until you go too high, then back down to the most tolerable one.
It is also impossible to know whether Adderall XR or Concerta is a better choice for your son until you try them both. Some people get 8 hours of benefit from one and 14 hours from the other, even though the doctors call them 12-hour pills.
Finally, no one has any basis for saying whether the Adderall XR prescription is right for your son at this point. If he tries it, you can decide whether it’s right or not. If he doesn’t try it, you’ll never know.
My book, “Reaching For A New Potential” goes into more detail on medications, but no book can have enough details to guide you in all the fine-tuning needed to get medications right. Best of luck!