8 ADHD Medication Fallacies That Persist: Optimal Adderall Dosage, Risks and Interactions, Side Effects & More
Optimal dosage is pegged to weight. Afternoon stimulants disrupt sleep. Adderall causes high blood pressure. And other falsehoods about ADHD medication that may put your treatment plan at risk.
Adderall dosing – and all ADHD medication dosing, for that matter – is opaque and variable. Is there an optimal Adderall dosage for adults? Should your stimulant dosage change over time? What are the signs of an ineffective dose? With so many questions and misconceptions – even within the medical community – it’s critical for patients to research dosing for Adderall and other ADHD medications before using them to treat attention deficit hyperactivity disorder (ADHD or ADD).
Take Janet, a 37-year-old marketing manager, and her first experience with Adderall – “I was glued to the sofa, unable to move for two days,” she said. “I looked and felt like a zombie. It scared me off ADHD medication.”
Janet later learned, after attending a local adult ADHD support group, that it takes weeks for most people to tolerate the Adderall dosage her doctor had prescribed — and that many people were taking half that amount. “I should have educated myself first, instead of trusting the physician,” Janet says.
Janet’s experience is becoming less common, though adults with ADHD do still encounter professionals with questionable prescription practices. The bottom line? Be a smart health-care consumer, and take note of these red flag statements (and medically reviewed rebuttals) surrounding Adderall and other popular ADHD medications.
1. “My adult ADHD patients do best on Adderall (or this other stimulant medication).”
Adderall is among the most commonly prescribed ADHD medications. It’s also a stimulant – considered first-line treatment for ADHD. But these factors don’t mean that physicians can “play favorites” with it or with stimulants as a class. Those who do don’t have an empirical basis for doing so and are gambling with your chances of success.
Simply put, there is no way to predict how a patient will respond to Adderall or any stimulant, whether a methylphenidate (MPH) or amphetamine (AMP), until they try it.
Physician and ADHD specialist Patricia Quinn, M.D., suggests trying both classes of stimulants (MPH and AMP) before deciding that stimulants won’t work for you and moving on to a nonstimulant medication or another ADHD treatment: “You might even try several meds within the same class before switching to another stimulant class,” she said. For example, Ritalin LA and Concerta are both long-acting methylphenidates. Due to their different delivery mechanisms, however, each brings different results — and potential side effects.
2. “This is an average dose for adults with ADHD.”
Just as a professional cannot predict which medication will work best, they also cannot predict an optimal dosage – there is no “average” or optimal dosage of Adderall — or any other ADHD medication.
The ideal dosage of Adderall or another ADHD medications is identified using a method called titration: carefully increasing the dosage over time, until noticeable benefits are achieved and side effects are kept to a minimum. The approach should always be “Start Low, Titrate Slow.” In general, stimulant medications should be administered at the dosage that is both lowest (to keep side effects at bay and avoid overdosing) and most effective to the individual patient, and should also be adjusted according to changing needs.1
Adderall is available in several formulations and doses. Immediate-release tablets can be taken several times a day, or during specific activities, depending on patient need. Adderall XR is a one-daily, timed-release stimulant. How a patient responds to a prescribed dose depends on many factors, including:
- Your history of taking stimulant medications. Those who have taken stimulants in the past might be less response-sensitive than people who have not.
- Genetic differences — some people metabolize the medication more quickly than others.
- Co-existing conditions — anxiety or a mood disorder, for example, and their current treatments.
3. “For an adult of your height and weight, we start with this dosage.”
ADHD medication dosing is not related to an adult’s height or weight. The Adderall dosage of another adult your age, weight, and/or height is irrelevant. Clinicians, however, typically start adults at a low dose (usually 5 mg), and then adjust as needed.
4.“You can’t take Adderall if you have hypertension.”
Adderall is linked to increased blood pressure and heart rate,1 so adults with ADHD should have a thorough physical, including screening for heart problems, before starting Adderall or any new medication.
Hypertension alone does not preclude a patient from taking ADHD medication: “I would say that it is never a contraindication,” says Margaret Weiss, M.D., Ph.D., an ADHD clinician based in Vancouver, British Columbia. “You treat the hypertension first. And, in fact, there are medications for ADHD that lower blood pressure.” These include generic guanfacine and its longer-acting brand-name formulation, Intuniv, which can lower both systolic and diastolic blood pressure. These medications are often used as an alternative to, or in conjunction with, stimulants.
5.“Sure, continue consuming caffeine, if you like.”
Many adults with ADHD rely heavily on coffee or caffeinated sodas. Yet caffeine may exacerbate the effect of Adderall and other stimulant medications, creating anxiety and heart palpitations. “Some people can tolerate stimulants and still have some caffeine,” Weiss says. “For others, caffeine interferes by creating or exacerbating side effects, making it impossible to increase the stimulant to therapeutic doses.”
You may not be able to determine what’s causing these side effects — the stimulant or the caffeine — unless you gradually wean yourself off caffeine before starting stimulants. (Try to break the habit in advance, though, to avoid mistaking a headache due to caffeine deprivation for a medication side effect.)
6. “You should see a huge improvement in ADHD symptoms right away.”
The potential positive effects of Adderall, other stimulants, or medical treatment for ADHD shouldn’t be oversold. Knowing that stimulants are first-line psychopharmacological treatments for ADHD doesn’t mean we can predict how any medication or dosage will affect a particular individual. “It’s true that some symptoms may improve dramatically in days, or even in hours,” Weiss says. “But it is important to wait to judge the full effect of the medication, because it can take some time for all the data to accrue.”
Judging a medication’s effectiveness requires more than a physician asking, “How are you doing?” It requires at least two steps:
- Taking careful inventory of the challenges you face (writing them down, one by one), before you started medication
- Regularly reviewing each challenge as treatment progresses, in order to track improvement (or not), worsening symptoms, or new side effects.
During this titration phase, experts recommend talking with your physician weekly and using an ADHD medication tracking log like this. In-office visits should take place every three to four weeks to review side effects, physical health, patient and family well-being, and other therapies when indicated.
Many experts and patients report that too few physicians closely monitor medications used in adults. “It’s critically important to do, but the utter paucity of clinicians doing it is shocking,” says Stephen Hinshaw, Ph.D., an ADHD researcher and professor of psychology at the University of California, Berkeley. “You can’t notice small improvements or side effects without a monitoring sheet.”
Weiss recommends using rating scales that measure a broad range of symptoms and functioning; in other words, a metric for tracking how you’re doing in life. The Weiss Functional Impairment rating scale is a good place to start. Having a tangible method for observing change makes the target concrete and keeps it in focus.
As you face challenging situations in your life, you can gauge how your responses differ from those in the past. “It can also take time to notice the differences in how people are reacting to you, or to evaluate changes in how efficient or how much better you’ve become at your job,” Weiss says.
Weiss offers these guidelines:
- Symptoms tend to improve within hours after taking stimulant medications, but it can take a few days to fully appreciate these changes.
- Nonstimulants take approximately five days to go into effect after dosage changes, and it often takes six to eight weeks to realize the full benefits of medications like atomoxetine.
- Functioning improves within months.
- Developmental changes happen over years. For example, the individual who never had a friend can now make and keep them. An adult who could not keep a job can now hold onto one for a year.
7. “If the stimulant disrupts your sleep, we will have to switch you to a nonstimulant.”
The causes of sleep problems among adults with ADHD are multi-faceted, and may not be fully understood by the treating physician. Increasingly, research on the ADHD brain is pointing to neurophysiological differences in circadian rhythm, the inner biological clock that tells us when to go to sleep. But there are other ADHD-related obstacles to sleep, such as being unable to “put the brakes on” a busy brain.
In evaluating the adverse effects of any ADHD medication on sleep, it’s important to pay attention to timing. Perhaps sleep problems are caused by the rebound from the medication’s wearing off. In that case, you should try taking the medication earlier in the day or taking a nap midday while the full dose is in effect. A no-risk trial nap can help to demonstrate that the medication is not causing the sleep disturbance, but rather the ADHD itself, and lack of medication in the rebound period. Some people with ADHD sleep better on a stimulant; such medications stop “brain noise” and increase focus on going to sleep and staying asleep.
8. “If you think that Adderall (or another stimulant) has stopped working, we should try something else.”
Before ruling out Adderall or any other ADHD stimulant, consider that the medication may have stopped working for any of several neurobiological reasons. After that, take a step back and try to remember what life was like before you started taking the stimulant. Is it better? Worse?
Adults who are diagnosed with ADHD later in life typically develop the habit of paying attention only to the exciting or new. After a few weeks of experiencing the “novelty” of improved symptoms, it’s easy to forget how far you’ve come. This is another reason for keeping written records of baseline symptoms and of the progress you’ve made. It’s the only way to know if the med is doing its job.
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