View Full Version : Starting FocalinXR--how to ask doc to titrate faster?


airzonk81
07-31-16, 07:28 PM
Hi all...

So, after having my meds screwed with (I moved, and changed insurance after my Mom died two years ago) - I got heavy into illicit methamphetamine and heroin, in monthly binges. What a terrible mistake but I got help in December and am in sober living now and do a lot of recovery work.

Fortunately I have a psychiatrist now who's willing to start me on Focalin XR again. Yep, I'm also ADHD-PI. (Major depression, treatment-resistant, recurrent; ADHD-PI, GAD, PTSD)

I've been on Nardil for treatment-resistant depression for years - and yes, I've taken it safely with Focalin, Dexedrine ER, Concerta and Vyvanse before.

** Note: I never took Vyvanse like I was supposed to. I was already in abuse-mode the one time I did try it. The others I did.**

Here's the thing. I notice in hear people are very very frank about the "crash" from stimulants, but is it okay to frame it in those terms with your psychiatrist? Ya, I know, depends on the doc. Mine is being very cautious because I'm on a MAOI. (Please note, the MAOI-stimulant interaction thing is a myth. Never had a hypertensive crisis or serotonin toxicity or anything else like that. It's considered a heroic measure, but please don't quote the PDR to me telling me it's dangerous. Thanks.)

I'm keeping a med log. The first day I took 5mg XR several days ago, I felt a bit anxious and didn't take it for another several days, but I realized something. If I'm going to get to the optimal dose I *have* to titrate. I can't just not take it until the next visit and ask for a titration. So I took it this morning, and while the symptom relief (anhedonia, and all the classic ADHD symptoms) aren't as much relieved as when I used to take it, 15mg XR b.i.d., I can tell it's working and doing *something* and I don't have rebound anxiety so far. (If it wasn't working, I wouldn't have even been directed or focused enough to register for this forum.)

In fact, I gained enough assertiveness (I had been almost dead quiet for about a month) to send him a secure e-mail telling him I was uncomfortable with remaining on 5mg until my next appointment (October) - that's just too long.

So I guess the feedback I'm looking for is, when you know the planned titration is too slow, how have you effectively broken through prescriber resistance?

I know, I'm counting my blessings - that I had a substance use history and am in a sober living that goes with physician's orders (rare), that I have a psychiatrist willing to start me on Focalin XR at all given my screw up with illegals (awesome), and that it seems to be doing something - all blessings.

I really would like to get to a CHADD (or other ADHD support) meeting in San Diego County... probably a good idea. :) I do a lot of SMART recovery but even there, where they support legally-prescribed medication (unlike 12-step where it can be kind of off-limits to talk about) it's not the correct place to express my concerns.

Best,
az

Little Nut
08-01-16, 11:00 AM
--SNIPPAGE--

So I guess the feedback I'm looking for is, when you know the planned titration is too slow, how have you effectively broken through prescriber resistance?

--SNIPPAGE--

Personally I don't see how you can know that the 5mg/day is inadequate after just one day. Anywhoo, I think you have to demonstrate to your Doc w/ specific, current, actual results that your dosing/frequency is inadequate to treat your symptoms. For me it takes 2 weeks at a stable dosage/frequency for my body to adjust and reach somewhat equilibrium to a new med or a dosage/frequency change. (First you have to reach equilibrium levels in your system for the drug. While this is going on your body is going to make changes in how it tries to regulate your body chemistry due to the drugs effects. For me this is normally 2 weeks minimum.)So take 5mg/day for 2 weeks, keep your journal, list your symptoms and how well the focalin addressed each one and for how long the effects lasted during the day. So if most of your symptoms were treated but it only lasted ~4 hours each day, suggest you try 7.5 mg/dose twice a day (4 hours apart). After 2 weeks, rinse and repeat.

As an aside, you are suffering from anhedonia while taking Nardil? I would wonder if your AD meds need tweaking first. HTH, -LN

airzonk81
08-01-16, 05:00 PM
As an aside, you are suffering from anhedonia while taking Nardil? I would wonder if your AD meds need tweaking first. HTH, -LN

Heh. I appreciate the feedback (in total) - very helpful. If you don't mind me asking, did you find your titration at less-than-effective doses (or duration) kind of a pain?

WRT the Nardil, I am actually taking Focalin XR for two reasons - one, as an augmentation agent for Nardil (there's a lot of support for this, see, for example, http://onlinedigeditions.com/publication/?i=109397&p=8 ) and second but no less important, to treat my ADHD symptoms (untreated ADHD psychologically makes the depression works.)

I've been on Nardil since 2007 and have taken Nardil and Focalin XR before (15mg, b.i.d. - back then, doc started with no titration and I had no complaints. Wish I had better coping skills when Mom had died and not bolted for another state and started abusing drugs, but oh well.)

It's weird. Nardil as monotherapy goes through periods where it simply doesn't work. I don't mess with the dosage as I'm already at the max. A lot of augmentation agents are off the table (I am not interested in antipsychotics. Period.), and others have failed.

I was assertive in communicating with the doctor, who's away on conference, and his nurse, who will work with me in his absence.

Being patient with this is difficult - 4-5 hours of very, very small relief followed by just being tired kinda sucks. :)

Thanks so much,
az

Little Nut
08-01-16, 07:34 PM
No not at all. I knew it was basically the cost of doing business for this. It had to be done that way to keep my Doc and I on the same page, build trust, and it is only short term. Also, after filling in journal for a month or more, it was helpful to get the Doc's buyin to ideas I had on how to proceed. Point out real world evidence supporting my point of view. Of course if it contradicted my point of view, I would change my point of view.

I know that sometimes Psychostimulants are used to augment MAOI's. My understanding is that it can be "touchy". I know TCA"S are sometimes used as an augment as well.

Have you ever tried Parnate instead of Nardil? It might work better for the anhedonia. Regards, -LN

airzonk81
08-02-16, 12:43 AM
No not at all. I knew it was basically the cost of doing business for this. It had to be done that way to keep my Doc and I on the same page, build trust, and it is only short term. Also, after filling in journal for a month or more, it was helpful to get the Doc's buyin to ideas I had on how to proceed. Point out real world evidence supporting my point of view. Of course if it contradicted my point of view, I would change my point of view.

I know that sometimes Psychostimulants are used to augment MAOI's. My understanding is that it can be "touchy". I know TCA"S are sometimes used as an augment as well.

Have you ever tried Parnate instead of Nardil? It might work better for the anhedonia. Regards, -LN

Thanks - you *really* know what you're talking about. I absolutely have tried Parnate, and I switched to Nardil after it pooped out. At the time, I had a psychiatrist who was okay with doing a switch within a day, but I am not sure that's the case this time. I needed 120mg/day which is well above the PDR max. Something to reconsider, anyway.

I'm a little scared of TCAs - the one time I tried nortriptyline, it made me VERY quick to anger and very anxious. (I had the same reaction to Wellbutrin, FWIW - except with added sex drive - not a great combination!)

Yep, acceptance is key. I'm actually doing better as the days go on. Eating an ADHD-friendly diet (lots of protein, lots of fluids), which is really just a good diet anyway, and substantially reducing caffeine, has been helpful.

Thanks for responding. I'm looking forward to posting my progress here.

-az

airzonk81
08-02-16, 09:57 AM
Yesterday (08/2/16) .. 5mg again, took around 730am.

By 1-2 I was "done" for the day. Very little but noticable reduction in anhedonia and increase in goal-directed activity.

Headache despite hydration, didn't really "feel" the second release (I hear this a lot). Emotional blahs, which have persisted into the morning.

So, for anyone who started small, did you experience this as well? My doctor's out of the office until 08/08, but I do have the option of seeing someone in the practice if I insist.

I delay, not because there isn't need (in my view) but because this is a CII substance and I don't want it to seem like med-seeking with my substance abuse history. (Can anyone relate - where you know you'll do better on a higher or more frequent dose, but are afraid to be blunt because you don't want to look bad?)

This is tough. At this point, I am slightly more functional for 4-5 hours than I was pre-Focalin XR and less functional the rest of the time.

-az