Stimulants Complicated adderall question

[zombiesarepeaceful]

I take Adderall for my ADHD. I'm currently prescribed 15mg XR with two 7.5mg IR booster doses each day. I only take it as prescribed, I never take more or abuse it. I was originally diagnosed and medicated at the age of 17 and was taking 10mg IR twice a day then. It worked well, but at that point in my life I was also using dxm heavily which is also probably why I didn't gain an Adderall tolerance back then. But I also didn't take the Adderall every single day back then, only a few days a week. I was medicated from 17 to 21, then I moved and lost health insurance and had a hell of a time finding a doctor to continue prescribing the Adderall because of the stigma against the meds and the vast amount of doctors who refuse to treat or acknowledge ADHD, plus the income based clinics have a strict no controlled substance policy. So my ADHD went unmedicated for 9 years. For 9 years my mental health was a train wreck, and I struggled immensely. My anxiety and depression is far worse when my ADHD isn't being treated. When the ADHD is being treated, my depression and anxiety are almost non existent.

So last year in December 2020, I finally found a new doctor (who is amazing and also has ADHD so he understands the struggle) and got back on Adderall. I've been taking it pretty much daily since then because treating my ADHD has helped every aspect of my life and going unmedicated seriously impacts my day to day life. I started low, with 10mg XR. Then we added a 5mg IR booster dose twice a day. Gradually, that dose became less effective. So he raised it to 15mg XR with two 7.5mg booster doses. I've been at that dose for a few months now, and it has gradually become less and less effective. One big issue that I have is that the XR doesn't seem to last very long at all. It lasts maybe 4 hours if I'm lucky. Hence why I take two booster doses. I think the reason the XR isn't lasting very long is because the dose is being dumped instead of released slowly, because I take a PPI for GERD. The PPI is raising my stomach ph, and consequently the XR part of the Adderall XR is dissolving early instead of releasing later on. I read a study on it that actually proved that this happens with concomitant use of PPIs and Adderall XR. But I digress.

My dr tried switching me to Concerta, because the release mechanism of Concerta is less ph sensitive. That didn't work, because methylphenidate just doesn't work as well for my ADHD symptoms and also gives me anxiety. Adderall doesn't give me anxiety at all. So I switched back to Adderall XR 15mg with the 7.5mg booster doses. But my tolerance is still a huge issue and now that dose is no longer working at all for me, not even for a few hours a day.

Around the same time that I noticed the Adderall dose becoming totally ineffective, I also noticed that suddenly I was having cognitive issues and worsening ADHD symptoms. I've always had a shitty memory, but suddenly my memory is so bad that I forget what I'm doing while I'm doing it. A feature of my adhd brain has always been super fast thoughts constantly, except for when the Adderall makes my mind slow down so I have less thoughts at once and can think clearly. Normally when my meds aren't working I can still think super fast, but less clearly. Well now my thoughts aren't rapid at all...they're very slow and I have brain fog from hell. I'm having huge issues with word recall and I've never had that before. It's like thinking through sludge in my brain, all the time. This was somewhat sudden and like I said, only started around the same time that my current Adderall dose became totally ineffective. It's seriously affecting my performance at work, and it's scaring me. Because nothing I do is helping and I'm worried that people are noticing that I'm making careless mistakes because I can't focus on anything or think clearly enough.

I'm guessing that I might be experiencing dopamine downregulation, decreased dopamine receptor density, dopamine depletion, oxidative stress, something like that...

So I've taken a few days off of the Adderall here and there. I've also been trying supplements to upregulate dopamine receptors, reduce oxidative stress, increase cognitive function, etc. I've tried glutathione, emoxypine, l-tyrosine, 7,8-DHF, sabroxy, inositol, uridine, noopept...plus others that I'm probably forgetting right now. Not all at the same time of course. Inositol gave me heart palpitations, so I abandoned that one. I've tried magnesium (in glycinate form) because I know it's a big one as far as reducing tolerance, but magnesium also gave me heart palpitations so I was afraid to keep trying it or try another form of magnesium. I know dxm is supposed to be good for reducing amphetamine tolerance but dxm gives me pretty bad nausea even in standard doses for cough. Due to this, I haven't experimented with dxm to reduce amp tolerance more than a couple of times.

Is there anything that I'm missing as far as supplements to try to reduce tolerance and upregulate dopamine?

I know NMDA antagonists can reduce amphetamine tolerance. My doctor generally supports anything that I suggest to him as long as I can back it up with proven evidence of efficacy like published clinical studies. I've been thinking about suggesting memantine to reduce tolerance, but I'm worried about side effects.

I know that abstaining from Adderall for awhile would help, but Adderall has helped my all around mental health so much that I'm afraid to go off of it for longer than a few days. It's the only medication that has ever helped this much. Prior to getting back on Adderall my mental health was so bad that I had ended up in the psych ward again. After getting back on Adderall, my major depressive disorder and anxiety disorder became so much better than I barely notice them anymore, at least when my ADHD is properly controlled. If I stop taking Adderall for more than a couple days at a time, my depression starts creeping back in and it gets really bad.

I've considered asking my dr about dexmethylphenidate, to see if that might help my adhd symptoms more than regular methylphenidate, with less anxiety.
I tried Vyvanse and it caused severe nausea (which isn't an issue on any other stims) so that wasn't an option either.
At work I saw one person prescribed Adderall XR with dexmethylphenidate as a booster dose. I thought that was very interesting since I'd never seen that combo used before, and it made me wonder if that might be an option for me also.

Sorry if this is all jumbled together and confusing. The current state of my brain makes it difficult to put this together in a way that makes sense.


Side note: I'm a pharmacy technician so please get as nerdy as you want in your replies because I love pharmacology.

 

[BridgeInspector]

Damn that's quite a conundrum. I can relate to how much easier life is when my ADHD is medicated and how scary it is to think of not being able to have that. I also find that after a while, days without my meds tended to feel a lot slower than I'd remembered them being. I think the mixture of mild withdrawal and resurfacing ADHD symptoms just makes for a shitty combination.

As for the meds issue, I would try first experimenting with higher doses and maybe having your fully daily dose broken up into IR? Could also try dexamphetamine just to see if that works any differently for you. I don't know too much about NMDA antagonists and tolerance reduction but I've heard they work better as tolerance preventers. So you could take a break from the Adderall and then take an NMDA antagonist with your dose.

You could maybe ask your doctor about Atomoxetine? That appears to be an NMDA antagonist on top of other functions and is prescribed for ADHD. Alternatively, there's agmatine which I believe you can just buy as a supplement.

Hope this helps a little

 

[BridgeInspector]

Also how long did you take the vyvanse for? I'm curious because it appears that its release mechanism isn't affected by PPIs (https://www.eurekalert.org/news-releases/626222) I'm just wondering if maybe you had nausea as an initial side effect that might have subsided over time? I realise it was extreme enough to put you off of it but if your doctor is open minded perhaps you could get an anti nausea med for a week or two and see if your body adjusts? Idk if that would affect your GERD but it's something to consider I guess

 

[zombiesarepeaceful]

Damn that's quite a conundrum. I can relate to how much easier life is when my ADHD is medicated and how scary it is to think of not being able to have that. I also find that after a while, days without my meds tended to feel a lot slower than I'd remembered them being. I think the mixture of mild withdrawal and resurfacing ADHD symptoms just makes for a shitty combination.

As for the meds issue, I would try first experimenting with higher doses and maybe having your fully daily dose broken up into IR? Could also try dexamphetamine just to see if that works any differently for you. I don't know too much about NMDA antagonists and tolerance reduction but I've heard they work better as tolerance preventers. So you could take a break from the Adderall and then take an NMDA antagonist with your dose.

You could maybe ask your doctor about Atomoxetine? That appears to be an NMDA antagonist on top of other functions and is prescribed for ADHD. Alternatively, there's agmatine which I believe you can just buy as a supplement.

Hope this helps a little

Because of my job, I have difficulties with redosing throughout the day as needed. I'm a pharmacy technician so even if I keep my medication on me, I can't just reach into my pocket and take a pill...I do get a break of course but it's always so busy that I can't sneak off to the bathroom to redose, my only break is my lunch break. I do take my booster dose during lunch.

My dr has mentioned dexamphetamine as an alternative to try. I thought about asking him about dexmethylphenidate also, since in theory it should cause less anxiety than regular methylphenidate and that was an issue with methylphenidate, besides it not working as well.

I'm going to ask about atomoxetine as an add on at my next appointment. I'm hesitant to try it again because of side effects, plus when I was a teen they tried it and it didn't help. But it is a substrate for CYP2D6, the same as amphetamine, so it should in theory help the adderall to work for longer.

I take bp meds which is why I haven't tried agmatine yet, since it can also lower bp. I've considered adding a low dose of it cautiously to see how I do.

As far as the vyvanse, I only took it for a few days. I'm guessing that the lysine part of the vyvanse just didn't do well with my body and that's what caused the nausea. Apparently some people have a hard time processing lysine. I don't get nausea from any other stimulants. The nausea was too severe to deal with, and I do take nausea meds occasionally for my stomach problems but nausea meds sometimes don't work at all, so adding a nausea med for the vyvanse wouldn't really be an option.

 

[polyboss]

I personally concoct a potion of 42 mg ketamine /spray inside a "Snoot!" Nasal spray bottle. Take two sprays and magnesium with my Adderall and it works wonders. Very strong nmda antagonist. This is the same dosage as Spravato induction, it helps with depression and anxiety long term.

Used to take memantine for chronic migraines and oh boi does that help with tolerance! Large doses of that feel like a whole day dysphoric ketamine buzz I suppose. Low doses it allowed me to use tramadol every once in awhile and get zooted. You can find it non-prescribed btw, the side effects weren't bad for me, I didnt notice any on 5-10mg.

Interested in the whole PPI duration thing. I usually take 600 mg cimetidine (also supposed to help with tolerance) 30-40 min before, only ever noticed it helped tho. Did not notice reduction in how long the XR lasted.