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General Medication Discussion This section is to be used for general medication discussion and other medications not broken out in their own respective forums.

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  #1  
Old 08-15-04, 12:12 PM
SB_UK SB_UK is offline
 
 

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Adults with ADD - Experiences on Stimulant Medication

Hi,

I'm from the UK, have ADD-Inattentive type and spend much of my 'forum posting life' on the message boards run by a British site.

I've learnt a great deal from this site.

In the UK, adult ADHD isn't formally recognized. Where Ritalin can be prescribed for adults if we're lucky -- Dexedrine is very difficult and Adderall is impossible to obtain. Wellbutrin isn't licensed in the UK for depression and Strattera, although licensed very recently, is virtually unheard of here.
We have very few British experts on ADD, only 2 centres within out public health system and 2 or 3 centres within the private sector. As you can imagine, the queues to be seen by a specialist in ADD are horrendously long. As a consequence of the lack of experience that the majority of our Psychiatrists have on ADD, nearly everybody that posts to our forum has been or is currently diagnosed as suffering from *depression* and *not* ADD.

The reason why I am posting the following request for information on a predominantly American forum, is because we don't have many long term (greater than 3 years) stimulant medication users within our British online ADD support community.

Regarding stimulant medication, I have tried Ritalin and Dexedrine - and found Dexedrine to work wonderfully (for the 3-4 months that I was on it), with Ritalin working, but much less well.

My question is simply, would you post the name of the stimulant medication that you're taking, time that you've been taking it, rating from 1 to 5 (relating to whether you wish you'd never started stimulant medication therapy, with 1 representing complete dissatisfaction, 5 complete satisfaction and 3 the advantages and disadvantages counterbalance one another) and comments regarding if tolerance (ie need to escalate dosage) or addiction occurred and when.

Many of the messages that I've read across many websites, seem to suggest that there's a honeymoon period that is experienced for the first couple of years on stimulant medication, and that this is bliss - but that once this period is over, that anything can happen........

The only 2 responses I've had from the UK so far have been.

From C
ritalin-5 years-5-No Tolerance/Addiction

From H
dexedrine-2 years-5-No Tolerance/Addiction

I should mention that the reason I've turned to you for help, is that there's a chance that I might soon be able to restart taking Dexedrine, but I'm ever so worried that I will only be buying myself a couple of years of improvement from ADD, and thereafter will be either back where I started (or even worse off).

Thanks in advance for your replies,

SB

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Old 08-15-04, 09:58 PM
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Quote:
Originally Posted by SB_UK
Many of the messages that I've read across many websites, seem to suggest that there's a honeymoon period that is experienced for the first couple of years on stimulant medication, and that this is bliss - but that once this period is over, that anything can happen.......
hi SB. i am not much help to you i'm afraid, because i have been on adderall less than one year. but i am very worried about what you posted about the "honeymoon period" and hope that is not what i am experiencing now... i have only been on adderall about 4 months and already the positive effects are greatly dimished and that is even with increases in dose. i started on 20mg/day and now am on 60mg/day (20mg 3x daily). i gernally seem to have a high tolerance for meds, judging by the high dosages i have been on of prozac (still on) and effexor (in the past), but this still seems like i should not have built tolerance so quickly. i am a 20 year old female about 90 pounds so it is especially odd, to me, that i have tolerance to this already

i am not even looking to get back the increase in energy that i initially had when i started taking the adderall (it didn't feel like physical energy, but rather mental stimulation? what i mean is, i didn't have a desire to exercise or run around but i had the mental energy to complete a task), i just want to be able to concentrate!! it is so frustrating, no matter how hard i try i seem to really only be focused a few hours a day. i will spend hours sitting at my desk but am not getting much done due to having to re-read everything so many times just to retain the smallest bit of information.

i am finding that tolerance with adderall, and possibly other stimulants (mostly i have been searching about adderall), is a real possibility, but that it doesn't happen to everyone. so you may not experience this at all. i have heard of people being on the same dosage for a few years and still receiving positive benefits.
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Old 08-16-04, 02:55 AM
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Hi Wasted,

Thanks for posting and yes - your post is of great interest to me.
I had thought that tolerance to stimulant medication took 1-2 years (taking into account the dosage adjustments that are often required), and your post has opened my eyes to the extremely alarming fact that benefits might only last 3-4 months.

I'm sorry that you've had this experience and I understand how very very disappointing arriving at this conclusion must have been for you.

I sometimes think that I'd prefer not to take stimulant medication, rather than suffer the extreme pain, at some point down the line, of the realisation that the drugs no longer work.

My 3-4 months on Dexedrine were the best 3-4 months of my life so far.

SB
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Old 08-17-04, 03:18 PM
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Addiction and tolerance is a function of simply increasing the dose. No? Addictive habits are common in ADHD types if the forums here are any indication. I know I've had my issues. Dex never appealed to me as a substance abuser for all the reasons that it works so well for me now.

The solutions to my coping better with ADHD do not ride solely on my medication. I rely very heavily on many other elements of good orderly conduct. I have had tremendous success in the past without meds but failed to appreciate what a big role my coach was playing in the mix and ended up hitting the ditch in a big way. So I know it can be done.

Having no expertise in the field besides my experience I still do not rely on my meds to maintain my growth and ability to adapt to my surroundings. I use them and appreciate their help but I am not willing to put all my eggs in one basket.

I have learnt what I can about tolerance and half lives of the meds I take and continue to try and avoid any tolerance and dependency issues. So far it's only been 8 or 9 months so long term I can't say much as to the results.

I will no doubt incorporate a drug holiday periodically to try and extend the usefulness of the Dexedrine that I'm taking.

Hope this helps. Thanks for understanding (if you do) about the live links.
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Old 08-17-04, 05:06 PM
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Many thanks for posting ItsChaotic.

The whole concept of drug vacations is fairly new to me, and it's only something that I've found out about from both American/Canadian support sites like this one and also from some scientific publications, including this one for instance:

http://ps.psychiatryonline.org/cgi/
content/full/53/1/102

[The URL seems to be corrupted on the board and so I've split it over 2 lines]

The authors of this paper in 'Psychiatric Services' seem to be giving 60mg ritalin/40mg Dex as a threshold which defines whether tolerance will occur. Their figures are quite striking - no tolerance below and a high % of tolerance above (arising in days to months). They also seem to suggest that a 1 month drug vacation can result in a complete reversal of apparent tolerance.

I should mention that I'm an ADDer 24-7 but a scientist [genetics/biochemistry/bioinformatics] 9-6 :-) and I really appreciate any advice on this subject. I don't know of any ADDers in the UK that take Dexedrine, or in fact of any ADDers in the World that have taken Dexedrine for over 3 years.

I have been told that Dexedrine is the preferred medicine (over ritalin) for treatment of ADD in Canada by our forum's ADD expert (from South Africa), and so figured that since there seemed to be quite a number of Canadians posting to this forum, that I stood the greatest chance of getting good advice from you.

PS No worries about the live link - I posted the URL of addforums.com on my British ADD support group forum, and just thought that it'd be nice, seeing as we're not competing, if I could post the URL of my British site on your forum.
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Old 08-18-04, 01:48 AM
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Quote:
Originally Posted by itschaotic
Addiction and tolerance is a function of simply increasing the dose. No? Addictive habits are common in ADHD types if the forums here are any indication.
I am not sure if this was meant for me, or SB_UK? But it seemed to relate to what I was saying, about having built up a tolerance (or so I am assuming). Anyway, if it was directed toward me, I know that increasing the dose would make it work better probably, but I am upset that I *need* an increase, already. I mean if my doc increases it again, I will most likely still build up a tolerance, and I don't want to be forever upp'ing the dosage (what is even a safe "max" amount?) because that doesn't sound healthy

And as for addiction, I do not think I am addicted to it, because when I skip a few days, I don't have any physical withdrawl, just the negative effects of no concentration etc. So that would mean I'm not addicted right? My only desire to continue to take it is that it is still helping a little bit with focus. But now I am reaching the point where I don't even want to take it because it's just depressing to take it and notice no difference whatsoever, I feel hopeless. So as a result I'm now taking approx. 20-40mg / day now, as opposed to my prescribed 60.

SB_UK : if Dexadrine was so helpful to you, why did you stop taking it? Are you not able to get it at all anymore? That's too bad if that is the case And you know, just because some people have the problem of needing increases in dosage often does not mean it would happen to you. It seems there are a lot of people that don't experience this at all. If you were on Dexadrine 3-4 maybe you could recall if you seemed to build any tolerance in that time?
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Old 08-18-04, 03:46 AM
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Hi Wasted,

Thanks for the message.

I have done soooo much research into ADD stimulant treatment, and there is only 1 question that I have and 1 effect that I fear.

The question and the fear are whether I'll become tolerant to the drug.

I am not so worried about addiction, because from what I've read and what you've posted, dropping the drug isn't that painful. Addiction only appears to occur when the drug is abused ie large and inappropriate doses taken in a short time, and regularly.

Your first message almost perfectly described my attitude to the drug. I don't want *anything* from the drug, apart from an increased ability to focus/concentrate. I daydream days and weeks away, and although I'm happy in my own private and safe little world, I am worried that I'm just frittering away life......

Anyhow, thanks for the questions and here are the answers.

Dexedrine was great for me, but my prescribing clinician was taken to court and he felt, that instead of fighting for his freedom to prescribe, he chose to take early retirement. The group that was hounding him are very well known and I believe their movement started in America. They appear to have a problem with psychiatric medicine.
However, yesterday I located another reputable clinician willing to prescribe the medication and so may start taking it again in a few days (10th Sept).

I hadn't built up a tolerance after 4 months to dexedrine, and I have one friend who hadn't built up a tolerance to dexedrine after 2 years......but from a handful of private messages sent out on this site, and from messages posted on other ADD sites -- there seems to be a majority of people that have witnessed the amazing, life-changing properties of the drug...only to lose them again, at some point down the line, be it weeks, months or a couple of years.

The only proviso I'd throw in though, is that there's usually a bias in the messages that one reads on these site. By that, what I mean is that it's more likely that ADDers will post if something is wrong (loss of effect, side-effects or no effect) with their medication, rather than if they're happy with their medication.

I really should stress, that just like you, I am a pretty responsible person, not smoking or drinking and bar the occasional use of my asthma inhaler - not taking any medication either.

I fear dexedrine but adore it at the same time. It has changed me from an individual living half a life to an individual leading a full and happy life. As I ponder whether I should go back onto the drug, the only worry I have, that *will* stop me from restarting the drug is.....but how long will the effects last?

It's kinda' like the idea of a blind man having his sight restored after 40 years in the darkness, and feeling all the joy of that event, only to find out, just a year or so down the line, that the operation has been a failure..............and that his blindness will return. The joy of the apparently successful operation would be dwarfed in magnitude by the extreme pain of the realisation that the experiment had failed. Why? The reason being that I am forced whilst 'in the fog' to live within my means, 'out of the fog' would come dreams and realizations of things that I could now realistically achieve; I'd rather not have these dreams, than have them and then suffer the pain of having to give them up as the drug effects waned.

Thanks for the encouragement. You mention that it seems that there are a lot of people that don't appear to experience a loss of efficacy whilst on the medication, please could I ask what you base this on?

Sorry to appear to be repeating myself :-) ... right now it's the one and only thing in life that matters to me. Sadly, I'm not kidding.

Thanks Wasted.

SB from the UK.

Last edited by SB_UK; 08-18-04 at 03:56 AM..
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Old 08-18-04, 11:53 AM
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Just from reading here, I'd estimate at least 3/4 of stimulant takers are able to continue long term & poop-out is not a big problem as with antidepressants where it's almost guaranteed, it's fairly uncommon with stimulants.

You can also choose to only take the meds when you really need them for particular circumstances... some people do that.

I think the real burning question you have is whether the ADD could be worse after a couple years on stimulants if they stop working. I've heard some anecdotal stories that make this sound possible... it seems probably more of a short term thing though, in the following hours/days of discontinuing where the person is in a mild withdrawal crash & feels worse than before the meds.

But really, if it works, then you should go ahead with it, even if it stops you will have enjoyed some period of improved productivity. I've not heard of people being totally crushed by having to stop, just disapointed but not worse off than before.

Unfortunately the stims don't work magic on me.
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Old 08-18-04, 01:42 PM
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Hi Paul,

The sorts of figures that you give, were in the same ball park region as I was expecting before going quite heavily into this subject.

I'm afraid that I've been unfaithful to any one ADD forum and have posted similar queries on 3 ADD sites.

So far yours is the most positive message that I have seen regarding the prognosis with stimulants. Unfortunately most people seem to burn out, or fearing burning out, resort to very occasional use of meds, to enforce their efficacy.

However, there's probably a bias in deriving conclusions from forums.

As a prospective Dexedrine user, I'm hoping to see a whole bunch more emails echoing your point. And if not...well the quote I quite like from a chap called Illini is ---'at least you have experienced normality even if its for just a brief time.'

Actually I think I paraphrased him...well anyways......

Cheers Paul,

SB
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Old 08-18-04, 11:39 PM
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Hey, SB:

Weíre Tom and Kay, and we have an ADD family.

Kay and I both take Adderall, and occasionally Ritalin. Next week Iím planning to try Strattera for a bit, to see if I can get a feel for how it works.

Strattera isnít really classified as either a stimulant or an anti-depressant, so it should be interesting to see whatís up with the effect.

Now, about your question:

Iíve been taking Ritalin for a while, starting in the sixties. Iíve been taking stimulants non-stop for over fifteen years now. Kay has been going for more than seven. We typically take 20 mg / 10 mg / 10 mg of Adderall, starting when we get up and spaced out over the day, four to six hours between.

We may add to that a 10 mg Ritalin, or substitute 10 mg Ritalin for any or all of the Adderall. Currently, Iím taking Ritalin 10 mg x 4, spaced about three hours apart.

Our son Bryan also takes both Ritalin and Adderall, but his schedule is task oriented. Heís a jazz saxophonist, and he plays the effect of the drugs off against what heís trying to do at any given moment.

For quite a few years, while he was in college, he didnít take any drugs at all when he intended to play. Now that heís a professional, there are times that the drug effect helps him with what heís trying to do creatively, and times that he lets them alone.

None of us has ever experienced the effect youíre calling tolerance. If I understand you correctly, youíre referring to the drug losing its effectiveness for its intended purpose. (That is a quite common use of the term in the ADD community.)

However, we have all experienced what we believe causes ADDers to feel that their drugs have become less effective. Only, itís not the drugs, itís us. Or rather, our changing lives.

To clear the murk from the discussion a bit, I should state that tolerance also has a formal clinical definition that is very specific. It refers to a measurable decrease in some effect of a drug during a time course of regular use, for a given dosage.

The formal use of the term is associated with physical effects, despite popular misconceptions about speed freaks and junkies. An addictís need to increase dosage to achieve the same perceived high is directly related to actual physical effects.

Similarly, addiction is also a formally defined term, referring to the behavior associated with the experience of a person that has established a state of physical dependence on a drug. And that, in turn, is usually associated with a physical tolerance.

Withdrawal is the third part of the formal picture of this stuff. Often, physical dependence is due to physical tolerance; the brain adapts to the effect of a drug, perhaps by increasing production of a neurotransmitter to counter a diminished sensitivity.

Continued use of the drug then becomes necessary just to maintain the normal activity levels of the neurotransmitter. When the drug is suddenly discontinued, there is a lag between the time that the inhibiting effect disappears and when the brain finally readjusts its compensating overproduction of the neurotransmitter.

Too much of a neurotransmitter can be a bad thing, and there are other scenarios that have a similar outcome. Getting more of the drug is the obvious answer, even though the brain has compensated for the original desired effect. The addictive behavior that results is a classical example of classical conditioning.

In our experience, all of the discussion about tolerance and addiction in these forums refers to something else, the feeling that the drug may lose its effectiveness. When a person has mentioned addiction, it has usually been associated with other (illegal) drugs and/or alcohol.

Also, the idea of a drug holiday has a very shaky origin. We strongly believe that it is related to the same kind of ill intent that is responsible for the rumors about horrible physical harm in children from long term forced Ritalin use, and comas induced by an innocent combination of Adderall and alcohol.

Our physician, when pressed for a reason, initially said he felt that a hiatus of a few weeks in the summer would give a child time to recover from any ill effects due to appetite suppression.

But a few weeks later he apologized and said heíd been completely out of line. I had asked if the kids he treated ever responded by gaining weight, and he had realized that, in fact, thatís what kids do. They tend to growth spurt at any time, but itís always most noticeable over a summer vacation.

When his patients werenít on meds, they didnít have any reason to come in unless they fell ill. So he had the same experience we all did growing up, when our friends came back from the summer break seemingly much larger than when school left out.

But the kids didnít jump on the growth charts at all; their progress was essentially normal, without any unusual spurts. And all the kids were in the same range as they were before they began their medication.

So he told us not to worry about Bryan, and definitely not to worry about ourselves. We let Bryan have as much responsibility for how he took his meds as he could handle. Our Doctors feel thatís a significant step for any ADDer trying to take control of their life, and Bry responded extremely well.

Now, a little bit about tolerance, as I believe you meant it in your post.

Kay and I have very specific ideas about how the drugs we take work, both in terms of the perceived experience and also the way they help a person with ADD.

We also have specific ideas about how the anti-depressants work, and what ADD and ADHD are, as well. We base that on over thirty years of formal research into human communication and some specific kinds of theories of mind.

With that background, the various effects that have been described as tolerance here in these forums make perfect sense. Kay and I both experience times when the drugs donít contribute in the same way to how weíre dealing with our ADD. Sometimes this can go on for quite a long time. But the drug hasnít changed; our lives have.

ADDers all have some period of adjustment to the idea of having/being AD/HD; how long and to what extent varies with each individual. After that period of adjustment (which can take years), there can be a letdown of sorts.

We begin to focus on the ordinary problems of modern living that may have been swept into the background while we were learning about ourselves. At the very least, the excitement of the discovery that there is a reason for the things we have experienced all of our lives fades. The same old normal difficulties remain; sometimes we can fall into a quite serious depression.

Our understanding of the (on the surface, somewhat contradictory) use of both stimulants and anti-depressants to treat the same symptoms doesnít require looking too deeply into the details of the biochemistry of their effect on the brain.

We just note that living with ADD has consequences, and sometimes those consequences can loom sharply enough to interfere in our daily routine just as AD/HD itself can. Which is more significant, the AD/HD related inability to focus and organize your life, or the depression related inability to care enough to try?

Outwardly, the effect can look and seem the same, even to us. But the drug of choice for helping us think in the unnatural patterns required by the world of Normals is a stimulant, whereas if depression freezes us in our tracks, anti-depressants are called for.

And just as life is change, the mix of direct AD/HD effects and the hit we take as a consequence of living with it changes over time. The drugs that seemed to help at one point may not do the job once we enter a different phase.

We have heard many stories here that we feel are related to exactly this phenomenon. Often, the natural thing to do is increase the dosage, leading to a sense that we have hit a plateau, or developed a tolerance.

Increasing the dose of a med that isnít appropriate for the new situation only delays the moment when we begin to deal with it correctly. And if the drugs have significant side effects, we may introduce a new set of problems as the dose increases, on top of whatís already there.

Fortunately, the reaction of ADDers to these situations seems to be fairly benign. Usually, we reach a breaking point, blow everything off, reset, and start all over. There arenít too many stories of falling into a downward spiral after weíve been diagnosed and treated successfully.

Of course, as you pointed out, our sample is hopelessly skewed. But now that youíre here, youíre a member of the club, too, so the stats should apply, meager as they are.

There is one other effect that Kay and I think we see on the stories that people have told here. We know from personal experience that there is a much larger set of issues associated with having/being AD/HD than what we are typically discussing.

To be clear, we believe that AD/HD is symptomatic of an ongoing speciation event. There is quite a bit of evidence to support that idea, and in general a fair amount of interest in the idea that a speciation event may currently be under way. But as far as I know, we are the first to associate it with AD/HD.

The nature of the change required to bring about such an event is far more unassuming than you might expect. We hypothesize that a small, slow shift in brain chemistry over the last five thousand years or so is responsible, with the magnitude currently of about the same order as the normal variation among individuals.

But emergent events of this sort are neither small nor slow, and the nature of the change in ourselves is anything but unassuming. Every ADDer sooner or later is faced with the fact that we have accumulated a body of knowledge about ourselves and our experiential context that sets us apart from the ordinary in very fundamental ways.

This realization can come gradually, or like a bolt from the blue. We suspect that this is strongly related to the fact that females have tended to be diagnosed late, in their 40ís or even early 50ís, often after seeking medical help for sudden radical changes in their lives.
In the not so distant past, this was usually attributed to menopause, leaving the woman feeling angry and ignored. But the trend seems to be reversing, and lately there has been a burst of males being diagnosed late, and many more females diagnosed in their teens, 20ís and 30ís.

Itís going to be interesting in a few years to go back and look at the statistics on the homeless over about a fifty year period.

We believe dealing with that epiphany is the last and biggest chapter of the story of our drugs and therapies losing effectiveness. Thereís not yet much written about this particular issue, but the undercurrent is there if you look for it.

Itís riddled with stories of failed marriages and relationships, repeated obsessive self-destructive behaviors, and drastically diminished expectations. But Kay and I have been through the experience of dealing with it directly, and we know itís possible to transcend the potential for disaster.

We were fortunate to already have a long committed course of study in several related areas, and specific experiences that offered us unimpeachable evidence that we werenít imagining the things that we were feeling.

I donít think thatís required, though; Kay often says we went through it the way we did so that others donít have to. I believe forums like this one are a part of that, and questions like yours are a sign that we are beginning to prevail.

I donít know the age stats on this group, or your age, but it doesnít really matter. The message is this: the experience youíre asking about can be best described as being due to a series of related periodic effects with different frequencies, maybe even varying frequencies.

Sometimes they sum constructively, and sometimes they interfere. We go up, and we go down, and the only thing you can do in our experience is expect it, donít blame the drugs or yourself, and be ready to adjust your strategies for dealing with it. And someday, when youíve done it for long enough, the whole thing might just blow up.

But we think you can handle it. We all can, with a little help from our friends.

And thatís it, really. I didnít cover as much as I thought we would, but more than Kay probably expected. Thereís a lot about AD/HD that should really capture your interest, given what you do during the day. If thereís anything specific that caught your attention, please feel free to ask about it.

Or feel free to pass it all off as the ranting of two harmless wingnuts, if that suits you. (big grins) Weíve been there.

Weíve got ADD, you knowÖ
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  #11  
Old 08-20-04, 02:50 AM
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Hi Stabile,
Just a quick post to say that I'm going through your post in detail, and will post again soon.
Lovely - so till soon,
Sumit.
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Old 08-20-04, 11:47 AM
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Hi Stabile - I really appreciate your contribution.

Iím going to try and go through many of your points, trying sometimes to paraphrase them (as a test of whether Iíve understood your points appropriately), and sometimes trying to offer alternative reasons for the observations youíve made. I also intersperse other bits and pieces of information, more that anything, for your comment.
Iíll try and give references where possible and where I donít, more likely than not, itís simply an opinion or conjecture.

*Tolerance/Addiction and Withdrawal*

Regarding tolerance, taking Wasted as an example (from this thread). He experienced the ability to read and take in more information, more effectively at least initially, whilst on stimulant medication.

If we use the process of reading the Herald Tribune as our example.
If, without the drug one can read only the first page, but with the drug one can read the Herald Tribune from cover to cover in 30 minutes, then would it be incorrect to say that Tolerance (proper clinical definition) to the drugís effects had been reached, if during a time course of 6 months, with a fixed dosage of Dexedrine, if oneís ability to read the paper gradually diminished from reading the entire paper in 30 minutes, back to reading just the front page in this time over the 6 month period.

You mention that the tolerance-like effects that are seen relate to changes within ourselves, rather than in the drugís effectiveness. Would that mean (taking the above example) that oneís inability to read the newspaper effectively with time on medication, is due to a reduced desire rather than a reduction in the effectiveness of oneís stimulant-induced ability to perform this task.

*Duration of Therapeutic effects* - Dosage dependent or independent Tolerance?

I apologise if through using words like tolerance, addiction (and withdrawal), if Iíve offended anyone on this site. The problem with these terms is that theyíre so intimately associated with drugs of abuse, that some might believe that Iím labelling stimulants (when used appropriately to treat ADD) as drugs being abused. This I certainly am not doing, however, from some of the literature that I have read, these medications when taken in large enough quantities over short enough periods of time can be abused, and it seems that they can then lead to tolerance-addiction-withdrawal behaviour. So, I guess my understanding was that thereís a barrier (probably individual specific) and expressed as medication taken per unit time (mg/hr) which separates real therapeutic benefit from addiction (and its unpleasant trappings).

OK Ė so can I suggest this as supporting evidence:
Itís a paper published in Psychiatric Services. Psychiatric services originates from the same stable as the American Journal of Psychiatry (http://www.psychiatryonline.org/).

The paper:
http://ps.psychiatryonline.org/cgi/c.../full/53/1/102
The authors seem to be giving daily administration of 60mg ritalin/40mg Dex as a threshold which defines whether tolerance will occur. Their figures are quite striking - no tolerance below and a high % of tolerance above (arising in days to months).
These authors claim that similar results have been shown in at least 1 other study.

*Medication Vacations*

The authors make the following observation (relating to medication vacations):
ďFor patients taking methylphenidate who became tolerant, we tried other drugs, starting with dextroamphetamine, and then we used the drug that produced the best response. If the substitute was less effective than methylphenidate, the latter would be tried again after a month. In many cases, tolerance disappeared after a month, and methylphenidate's original effectiveness was restored. The newfound effectiveness would often last the same amount of time as the original.Ē

I actually found this quite a heartening observation and took it to mean, that as long as medication is taken at low enough levels, and with large enough breaks, that lifetime efficacy of stimulant medication can be ensured. The authors do however say ĎIn most casesí and I have read of at least 2 examples of individuals that claim that they perceive that they have become immune to the therapeutic effects of a stimulant, even after retaking the medication following a vacation period of 5 years. I actually find this hard to believe though Ė although their brain physiology may have altered as a consequence of drug therapy, surely it would have reverted back to its Ďnormalí state following such a time without medication enforcing that change.
In your post, I took the impression that you were suggesting that drug vacations were principally aimed at combatting the growth retardation that has been suggested by some, is a consequence of growing children taking stimulant medication (whether through appetite suppression or otherwise). Did the concept of a drug vacation arise solely for this reason, or was it the combination of this and the reason the authors of ĎTreatment of ADHD When Tolerance to Methylphenidate Developsí provide above?

*Depression and ADD*

In the UK, most cases of ADD are diagnosed as depression. Stimulant medication is particularly interesting, because in addition to its properties on attention, focus, concentration, short term memory and motivation -- it also seems to be a quite powerful anti-depressant also.

http://amphetamines.com/dexedrine.html

So the above is an advert from SKF (now GlaxoSmithKline) in, I think 1961 (you can see the date in the advert), when Dexedrine was sold as an anti-depressant, in particular of efficacy in cases of depression with concomitant low motivation.

According to the British National Formulary, Dexedrine/Ritalin must not be used in treating depression nowadays.

Interestingly, I've come across info in the Journal of Clinical Psychiatry:
http://amphetamines.com/dextroamphetamine/
and
http://www.healthoptions.com/dexedrine.html
[Although the material in the healthoptions.com URL seems to tally with other sources, it does appear as though the authors of this page are using it to sell a non-simulant-based medication to ADDers.]

which suggests that Dexedrine can be used as an anti-depressant -- however only in depression which cannot be cured with standard medications and psychotherapy (SSRIs/MAOIs/TCAs) and also in terminal diseases eg to alleviate depression in cancer/HIV etc.....but many of these sites have the following warning..."Prescription of Stimulants should not be taken lightly, as prolonged use can result in addiction."

I actually find it quite interesting that some suggest that Wellbutrin (licensed in the States but not the UK as an anti-depressant) is an effective ADD (non-stimulant) therapy, because it works through dopamine reuptake inhibition ie on the same neurotransmitter that Dex and Ritalin operate on. I think that itís one of a kind with respect to its mode of action, ie dissimilar to Seroxat, Prozac and many others which all appear to exert their effects through Serotonin Reuptake Inhibition.

From:
http://www.rcpsych.ac.uk/publication...drugs5Chap.pdf

it's interesting to see how buproprion, like the stimulants, seems to target dopamine (DRI). I've also seen some info describing the chemical structure of buproprion as being close to the structure of (one of) the stimulants, and also have noticed that the side effects of buproprion are close to those of the stimulants too. I think I mentioned in an earlier post on addforums.com (on smoking, asthma and stimulants), that a couple of days following starting Dex, I gave up smoking/nicotine replacement after 17 years of trying - and so find it interesting for this reason, that buproprion is also used to help individuals give up smoking (Zyban). Furthermore, it's also interesting that the stimulants and buproprion are useful in treating depression.

http://www.healthyplace.com/medications/bupropion.htm
[same proviso as above]

seems to suggest mild amphetamine like activity is seen following administration of buproprion.

Also http://www.dr-bob.org/tips/split/Bup...-for-ADHD.html in which the majority of individuals seem satisfied with buproprion and the scientific study:
American Journal of Psychiatry, 1990 Aug,1018-20.............................
........authors treated 19 adults with attention-deficit hyperactivity disorder with an open trial of bupropion. These patients had received maintenance stimulant medication or monoamine oxidase inhibitors for an average of 3.7 years. **Fourteen** of the patients experienced moderate to marked benefit from bupropion; **ten** of these patients chose to continue bupropion rather than their former medication.

Dex and Ritalin also apparently affect the norepinephrine neurotransmitter and similarly, I think Strattera works via norepinephrine reuptake inhibition and is also a non-stimulant ADD medication (as you say).

I wonder if anybody has actually tried both Strattera and Wellbutrin simultaneously, and compared the therapeutic effects of this combination therapy versus a classical stimulant?

My understanding then of how amphetamine-based medications alleviate ADD symptoms, is primarily through increasing local levels of dopamine at interneuronal connections in specific parts of the brain. Secondary and synergistic effects are seen through affects upon localized central norepinephrine levels. Stimulant medication mediates its effects by increasing the release of the neurotransmitter or decreasing (and hence potentiating the effects of the neurotransmitter) the removal of the neurotransmitter (via inhibiting the reuptake process) from the synapse.

My own personal experience suggests that depression can arise if the following pathway is allowed to complete.
ADD problems with focus -> Anxiety ->Panic ->Depression.
Removal of the stimulus halts the flow, however a chronic stimulus can push the ADDer into depression, from which anti-depressants alongside a removal of the stimulus are the only escape routes.

*Positive benefits of stimulant medication on ADDers and the specific locations within the brain within which dopamine levels are being affected*

http://www.columbia.edu/~jh299/DA.html

Dopamine Anatomy

If you were to start from the bridge of your nose, and move backwards into the brain, you would find the two neighboring sites where most brain dopamine neurons originate, the substantia nigra (SN) and the ventral tegmental area (VTA).The dopamine neurons originating in the VTA send their axons to the prefrontal cortex (an area implicated in *attention and working memory*) and to the nucleus accumbens (associated with *motivational* functions).
The dopamine neurons in the SN project to the striatum (associated with motor function).

I took this as evidence that medication was countering the problems of *attention*, *short term memory* and *motivation* (and hence both focus and concentration too), by specifically promoting excitation of neurones within these areas associated with these functions. Interestingly, dopamine is also associated with motor functions, and I believe Parkinsonís disease is associated with reduced dopamine levels (production), which expresses itself as involuntary motor activity.
I wonder whether any research has concentrated on whether thereís a shared molecular aetiology between ADD and Parkinsonís disease, and whether using stimulant medication might confer some protection against later developing Parkinsonís disease, ie through elevating synaptic dopamine levels.

*STABILE- ĎBut the drug hasnít changed; our lives have..í *

Would it be possible to expand on this point? I guess Iím having trouble understanding why you believe that ADDers perceive (incorrectly) that they have hit ĎToleranceí or how a change in life can appear to create the illusion that ĎToleranceí has been hit. Apologies if you tackled this question by way of answering the first section of this message.

*STABILE - To be clear, we believe that AD/HD is symptomatic of an ongoing speciation event.*

The way in which scientists appear to be attempting to understand ADD, and particularly the genetics of ADD, is through running through the human genome and attempting to find the specific Ďmutationsí that have arisen in certain genes to predispose the individual to the disease eg:

Adams J, Crosbie J, Wigg K, Ickowicz A, Pathare T, Roberts W, Malone M, Schachar R, Tannock R, Kennedy JL, Barr CL.
Glutamate receptor, ionotropic, N-methyl D-aspartate 2A (GRIN2A) gene as a positional candidate for attention-deficit/hyperactivity disorder in the 16p13 region.
Mol Psychiatry. 2004 May;9(5):494-9.

Loo SK, Fisher SE, Francks C, Ogdie MN, MacPhie IL, Yang M, McCracken JT, McGough JJ, Nelson SF, Monaco AP, Smalley SL.
Genome-wide scan of reading ability in affected sibling pairs with attention-deficit/hyperactivity disorder: unique and shared genetic effects.
Mol Psychiatry. 2004 May;9(5):485-93.

Instead of suggesting that evolution is driving us into a state in which ADD will become the norm, I think that the argument is that mutations (or changes) that occurred in key genes, conferred an advantage at some point in our evolution, but that those advantages are not of any use to us today. To use an example, asthma/allergies can be viewed a tendency to react inappropriately to inocuous allergens nowadays, but had we been in a parasite infested environment, the asthmatic of today would in fact have been the survivor of yesterday. The immune reaction that is seen to parasitic infections bears astonishing similarities to the pointless immune reactions that are elicited to dust mites and to grass pollen.
SoÖ.if instead we look at ADD in this light, we need to identify why genes conferring a risk of ADD have been selected for throughout evolution. Could it be that displaying Hyperactivity at an early age increased the likelihood of survival, Could it be that Inattentive type within females increased the likelihood of mating?
In effect, I am painting a picture in which certain changes within DNA, maximised the potential of that DNA to survive and propagate. Viruses like HIV have the capacity to mutate quickly, to avoid any restraints on their growth by Protease, Reverse Transcriptase etc.. inhibitory drugs Ė and this evolution occurs quickly, and is essential to allow the survival of their DNA and the propagation of their DNA.
However, in stark contrast to lower organisms, higher eukaryotes evolve much less quickly.
Is it possible that we should be searching for the reason for ADD, not in the future but in the past?
Have we been subject to sufficient selective pressure and over a sufficiently long time-frame to support the theory that we are evolving towards ADD, as opposed to evolving away from ADD?
This is only a counter-argument, and donít forget Iím an ADDer Ė Iím just an ADDer that likes to test theories ( :-) ).

OK-so where does my ad hoc theory fall down?
I find it quite difficult to understand how ADHD with hyperactivity and ADD-Inattentive type, with such seemingly different behaviours can be as tightly bound as they appear to be (ie within the same syndrome and with the same medications). Although Inattentive Type is more common in females, what is driving the appearance of Inattentive type in males (my type)?
From a poll on this site, it appears as though Inattentive type is the most common form of ADD in adults.

In actual fact, I prefer your theory for explaining Inattentive Type in males ( :-) ) Ė Why?
Because I think it is associated with a tendency towards philosophy and contemplation. I feel that our society is flawed in that we are taught from an early age that having an expensive house, car, holiday etcÖ ie capitalist ideals are our goals in life. Although these are associated with an increased likelihood of our DNA being propogated ie finding a mate, is it possible that a tendency towards philosphy could break this evolutionary imperative and actually herald the next stage in evolution ie towards the development of a better society.

Alternatively, I donít think thereís any dispute that the majority of ADD diagnoses occur in the United States. Is it possible that this is due to an increased awareness of the problem Ėor- an increased frequency of ADHD genes in American society (since individuals choosing to leave their native country and colonise America would have been more likely to exhibit aspects of ADD eg Ďthrill seekingí) Ėor- perhaps related to the unique cultural pressures that an American will feel whilst growing up.
Using a generalization, it appears to me as a non-USA resident, that Americans are subject to great pressure to succeed, in the terms I described above. Is it possible that the stress associated with growing up in this environment increases the likelihood of any underlying ADD mutant genes expressing their functionality? In formal genetics speak, that is, that stress increases the penetrance of ADD susceptibility genotypes. OK, so to rephrase that last bit, Is it possible that ADD is a disease that has arisen through the unnatural (at least through our evolution from lower organisms) stress that is placed on Americans (and now spreading to other Western countries) to achieve?
If life were simpler, would symptoms of ADD be seen? I will retire at some point in the next 10 years to France, and Iím sure that without the stresses and strains of succeeding in our current cultural climate, that ADD will cease to be a problem.

SoÖI guess Iím asking whether ADD has its roots in evolution, but is only becoming a problem because of the way that we collectively currently choose to drive our society forwards.

*Stabile-Every ADDer sooner or later is faced with the fact that we have accumulated a body of knowledge about ourselves and our experiential context that sets us apart from the ordinary in very fundamental ways.*

Part of the reason why I feel that the ADDer is better able to engage in contemplative thought, is that the ADDer is better at focussing inwards, rather than outwardly into society.
To the Non-Adder, questions relating to the point of life with such pointless vacuous goals as striving towards the perceived trappings of wealth, may never be asked. The Adder, however, whilst looking inwardly, may ask these questions Ė and may be better placed at identifying what he/she actually wants to achieve, rather than what he/she is told they should achieve.
There is a flip-side though, because abandoning oneís taught ideals is fine, as long as thereís something to replace them. Without something to replace them, there becomes no motivation for living.

*Stabile-We believe dealing with that epiphany is the last and biggest chapter of the story of our drugs and therapies losing effectiveness.*
Iím sorry, could you expand on this point?

==================================================
Can I end this message off with a personal comment.

I like taking stimulant medication (though Iíve only taken it for 4 months). I think I have a crude idea how stimulant medication works. I donít really know why ADD is such a problem now, or how it arose, but I am convinced that I have it.
Going back to my original message, (!!) all (!!) that I want ( :-) ) is some form of guarantee that if I take the medication in a certain way, that I will benefit, for as long as I am wedded to the medication, in the same way that I benefitted during these 4 months.
After reading your message I am heartened by the length of time for which you have taken the medication, and also by the observation of how you feel that the medication is as effective now, as it ever was. Unfortunately though, I cannot fully grasp the idea of how change in oneís life, can make it appear that the medication is losing its effectiveness.

Hopefully I will soon though :-)

Thanks Stabile,

This is kindaí funÖ.oh and be gentle to me in your reply, I have ADDÖyou know.

SB

Last edited by SB_UK; 08-20-04 at 12:02 PM..
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Old 08-21-04, 11:41 AM
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Hi stable or uk,
I posted before on the Adderall board,but some info caught my eye on this forum. To be brief, im having a problem with adderall tolerance. Im up to 30mg x daily. Im already immune to it, and 2x dialy is not cutting it. I was told or also read to take a stimulant holidy, but i know that (this happened before on 20mg) i laid in bed for 3 days and then some. Its just adderall makes me so motivated, non anxious, very concentrated and enjoy doing things, simple tasks, heck i can stay up all night and do paper work. Before adderall, i had a bad time doing anything, and kept dwelling on problems, using opiates, but adderall and a small dose of klonopin make me feel just right, not high but functionable. Also i see a bit of a mood boost where SSRI's dont do nothing. I was diagnosed with add 5 months ago , and believe i have type 2 which is lack of motivation, joy in doing things, just lazy and dont wanna do anything.

For the longest time i thought there was a problem with my seratonin system but afte trying numerious ssris, and other se drugs, i had no luck or very minor luck. But now i read about dopamine and others im starting to figure out i may have been on the wrong meds for a long time. Now i have 2 great meds and adderall is pooping out on me. Any suggestions since i do have like 2 weeks of ritalin 30mg la laying around. Im thinking about stopping adderall and taking the ritalin or could i take both as i believe one post above i read. I know i should run this by my doc, but if i need a break, i need a break or something new. I was thinking of taking 30mg of ritalin 2x daily which are Long acting, or possibly just taking 1 dos eof ritalin in the am, and then at night 1-2 doses of adderall. ANy comments
nm
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Old 08-21-04, 11:59 AM
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Hi Mind,

Unfortunately I am not taking stimulant medication at the moment, and previously only took it for a few months - and so I fear that I can't be of much use to you.

But hopefully some of the more experienced ADDers may be able to help.....

SB.
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Old 08-21-04, 03:57 PM
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Mind:

You definitely need to run it by your dr. We have approval to adjust our dosage and/or switch from one drug to another, as long as he knows what we're doing and we limit ourselves to a reasonable dosage.

But we do think you should try to qualify your subjective experience with these drugs, in the sense of developing models of how the drugs are helping, and what it is they help.

We know from personal experience that we are all capable of being directly aware of the effects of these drugs, as well as the internal mechanisms that cause us problems in the first place. Itís not something that we grow up learning about (and we may be taught itís not possible), but that never stopped an ADDer yet. (grinning, hereÖ)

The perspective of the actual biochemical activity is hopelessly confused, for many reasons.

One is that the systems in which the activity is observed aren't the functional systems that support the conscious mind and experiential states. The systems that are affected directly by the biochemistry are systems that emulate the operation of the brain.

The systems that support the conscious mind, in which we experience and interpret the problems and joys of everyday living, are formed and function within that emulation.

And there isn't any real chemistry in an emulation of brain neural function, so drawing conclusions about how drugs might work are useless, in our not so humble (but informed) opinion.

SB_UK, we're looking over your post (grin!), and we'll get back to you in a bit. Thanks. --Tom and Kay
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