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Vyvanse Adjustments: Start By Looking for the Exact Window
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- Measure in Detail
Watch For The Exact Therapeutic Window
This comment on Vyvanse is worth your time, and so commonly seen in the office. Vyvanse dropping in the PM is so forgiving that it's hard to measure exactly when it finishes. Measure the DOE anyway – always start with a detail grid – and download the pdf on the PS below.
Dear Dr. Parker.
Your articles and videos have helped so much in navigating the crazy pathway to treating ADD. I serve as my 52 year old brother’s ADD coach. He was just diagnosed two years ago, after a lifetime of failed jobs, frustration, alcohol abuse and all the other common experiences of others in his situation.
He was diagnosed with depression years ago and has been on Wellbutrin and Lexapro for years and continues to take both. He is also one of the nicest people in the world.
After reading about and realizing that he has classic symptoms of ADD, we found a psychiatrist with expertise who tried him on several stimulants, finally settling on Vyvanse. This made such a tremendous difference in his executive functioning, success at work and self esteem! The doctor started him on 30 mg and quickly switched to 70. At the time, the other doses were not yet available. He has been on 70 mg for a year and a half. The only negatives were that every once in a while, he would go through episodes of agitated, short-tempered, hyperfocused behavior – especially at work. These were very out of character for my mild-mannered brother and very short-lived. He would call me, incensed at how others at work weren’t doing their job, his boss was treating him like a peon, etc. His language and tone were very volatile and his perspective seemed irrational. Without exception, within 24 hours, he would be calm and rational and question why he had reacted with such ire.
These episodes happened sporadically, but increased this past February to the point that he was in jeopardy of losing his job. His boss, who is aware of my brother’s diagnosis and treatment (which includes behavior therapy) made it clear that he might have to let him go. At that point, it didn’t occur to his psychiatrist or me that this could be a toxic effect of the Vyvanse being above the top of the therapeutic window. The doctor suggested it was “shades” of bipolar [mood disorder is the too frequent conclusion] that are sometimes seen with ADD. He prescribed Abilify, 10 mg daily. The agitation ceased shortly after, but within 6 weeks, my brother became so sedated that he was sleeping 15 hours a day and half-asleep the other hours. When we realized this was a side effect of the Abilify, the doctor took him off. The withdrawal was awful and included tremors, anxiety and sleep disruption.
It has now been 3 1/2 weeks since we stopped the Abilify, and my brother continues to report “anxiety” which appears to be gaining in severity, as well as continued sleep disruption and some difficulty processing thoughts. Today, he described the feelings as “going 100 miles and hour”, “jumping out of my skin”, and “about to explode”. When he lays down to rest, he can’t stop his thoughts.
After reading many of your articles and watching your videos, I am beginning to believe that too much Vyvanse was the culprit all along. He was agitated; treated with a sedative (antipsychotic) that masked the agitation; and now that the sedative is gone, the agitation is returning because the Vyvanse remains the same. He does not seem outwardly angry just continually nervous and restless. The symptoms are not evident when he first wakes up and ease toward late afternoon and evening – which corresponds with when the Vyvanse is active in his system. [This is the frequent presentation at the top.]
Could you please give your opinion? I would like to ask the doctor to lower the Vyvanse dose to see if it would relieve the agitation. If you agree this is a wise course, how low would you start and how would you titrate upward? I have read people’s blogs that claim lowering from 70 to 60 relieved symptoms. Should the doctor start at 30 again, or maybe 50?
Any advice you can give would be a blessing. It has been a long course, with a lot of twists and turns. My brother, like so many others has shown tremendous courage and perseverance, and was just beginning to experience some success and peace, but the events of the past few months are eroding his confidence and he is feeling helpless, as am I.
Thank you so much,
Anne
_____________
REPLY NOTES:
This is such a classic situation, and so well written/reported in this comment that it deserves a full posting. To cut to the chase here – I often go down to 1/2 of the dose in a situation like this [knowing only these few variables, and not knowing about other key issues such as breakfast and transit time]. I’m on the conservative side, but don’t think you have to go all the way back to 30mg. My recommendation, because he is having so much trouble: just stop the med for a day or two and expect rebound. Then start back at about 40, and watch the DOE, – specific Duration Of Effectiveness timing will set the titration perfectly [most of the time!].
He may very well wind up at 60 mg, as only 10 mg can make a big difference, – but why not dial it in slowly and correctly, rather than leap over the necessary measurement/titration process to find the exact sweet spot?
My take with this limited info: it’s not the Vyvanse, you’re right, it’s the dose. Need to go more slowly in the first place. Easier on Monday morning looking at the game tapes!
Hope this helps-
cp
PS
Sorry for the silence, – writing and speaking have been busy. I just finished an extensive white paper/small ebook for the vADHD – Virtual ADHD Conference coming up in October – It's loaded there now for those attending the meetings – ebook Title: Predictable Solutions for the 10 Most Common Challenges with ADHD Medications.
And: This pdf Handout for my presentation at vADHD – Download this handout for your review
Hope you can make it!
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30 Comments
Hi Anne,
A note about Wellbutrin. I was 2 1/2 yrs on it before we realized I was highly allergic (or whatever) to it. My arms and elsewhere broke out in what I thought were pimples,etc. NOT SO! That and AGITATION were from the Wellbutrin. I am on Vyvanse now (looking to increase to 2x daily hopefully as it does’t have a strong active life). Am also on Venlafaxine HCL 75mg 2x daily which I take both at night. I also take Strattera (still) even with the Vyvanse which to me doesn’t do much for attention but ALL for normal energy. Wellbutrin made a nightmare of my life for 2 1/2 yrs. If your brother is still on it consider strongly replacing it with something else. I saw the agitation first hand with I thought recently, let’s try a few pills (leftovers) and see what they do. Crying jags, yelling, etc, etc. just in 3 days.you get somemore energy but it’s a bad energy. If you get this please email me to let me know you got mine.
THANKS, Joyce
If you have been on vyvanse for more than one year;
Taking a day or two off is the best advice Dr. Parker gives. I would add, try to take weekends off. Give your mind and body a rest from vyvanse.
Every day put your vyvanse dose into a 1 liter water bottle and drink it over a three hour period. The liver will process it more evenly and you get needed water. Putting vyvanse into a water bottle also gives you the flexibility of not taking all of it that day, saving it for the next day (it won’t spoil).
Use caffeine or nicotine only towards the end of the work day if you must, but never within 6 hours of taking vyvanse.
As a way of stepping on the brakes or slowing down for bed, don’t drink alcohol (not even a little) it will punish you.
When your off vyvanse on Saturday and Sunday do drink a little red wine with dinner.
Avoid sleeping pills but Melatonin is good.
When you get that vyvanse sleepiness, a 15 minute power nap can do wonders. Your brain just needs a few minutes to reset some synapses and clean out some toxins.
If you’re over 40 years old then keep an eye on your blood pressure with one of those wrist devices like Omron.
And for God sake get some exercise!
I’m 48 years old and have taken vyvanse for 5 years.
Tod,
More importantly: make sure that a toxic dose is never achieved in the first place!
See this playlist on Dosage: ADHD Meds Dosage: http://bit.ly/dosevids
See this posting coming out on 7-27-14 on Protein Breakfast: http://www.corepsych.com/2014/07/protein-breakfast-before-adhd-medications-4-videos/
Thanks,
cp
Dr Parker,
How do you feel about adding benzodiazepines for anxiety and panic attacks attributed to Vyvanse? My dr recently prescribed xanax prn for Anxiety that I have, especially when on a stimulant. Also, can a stimulant such as Vyvanse or Adderall cause a panic attack that is clinically dangerous? My dr says that it can’t and the xanax should help.
Jennifer,
I do agree w your doc on both statements, Xanax works and those panics most often are not clinically dangerous… But I reach a different conclusion. I prefer not to use BZ if I can help it anytime… even though with some situations it seems inevitable that I must. I’d prefer to work you up – and see what else could be accomplished through understanding possible IgG food allergies, trace elements, and so on.
cp
Hi.
I have a question about stimulants and my six-year old son.
He has been on many different ADHD medications since he was first diagnosed at four. I would like to preface this though with the fact that we have no ADHD in our family history but we do have a parent with bipolar.
He has been on everything from Tenex for a year to various stimulants. For a few months he was on nothing.
Currently he is on a half pill (splitting 20mg) of vyvanse and 250mg of depakote. The depakote seems to keep the extreme anxiety, fear and worry from vyvanse away. With all the other stimulants he experienced extreme anger, opposition and irritability. Vyvanse does not have that side effect at least. But then there is the inconsistency…
One morning he’ll wake up extremely silly, bouncing off the walls, unable to sit still. The next morning he’ll wake up quiet, withdrawn, self-focused (where he doesn’t even appear to hear you when you talk to him). One evening he’ll be extremely hyper, no control over his body, talkative on the comedown (which happens between 5-7PM) and the next night he’ll be calm, focused, quiet. On the mornings that he wakes up hyper when the vyvanse kicks in he has an aggitated focus.
When we had him on a whole 20mg of vyvanse he was almost too focused, he never wanted to play, he just wanted to draw all the time. He was also very withdrawn and did not engage in conversations with you.
He was on Adderall for several months before and experienced these highs and lows on it as well.
My question is, could stimulants be causing this or is it possible he has bipolar and the depakote just isn’t high enough or isn’t helping the bipolar if that is what he has.
Shouldn’t stimulants be consistent?
Thanks!
ADHD Son,
Many possible reasons for this presentation, from comorbid diagnosis with depression [http://youtu.be/fu0mN68rkEs] to significant IgG allergies, both can look like mood disorder and both can be present at the same time. Many more questions arise, even as simple as Transit Time. SEARCH IgG here, Transit Time [http://bit.ly/ttnew] here, and look at this video series [http://bit.ly/medtutor], something in all that information might ring a bell. It could be looking like bipolar, but could very likely arise from an easily measurable biomedical imbalance.
cp
Dear Dr Parker.. I was wondering if you have heard of any cases such as mine. I recently got diagnosed with moderate sleep apnea and possible narcolepsy with a positive blood test. I currently take 150mg Effexor and 60 mg Vyvanse twice a day. I also take 800mg motrin as needed for muscle pain. My doctor quickly moved me up to the 60mg Vyvanse twice daily because at lower doeses I don’t feel anything. Its gotten to the point where I end up taking both doses at the same time. Still nothing… tired as anything… taking naps. What do you think could be happening to me as to why stimulants don’t seem to work. I’ve been on 400mg Provigil and 250 Nuvigil before and fell asleep on both those meds also. My doctor seems to be at a loss for words. He’s never seem anything like it before. I’ve been told that I should be clinging to the ceiling because I’m on so much uppers. I’ve even taken 200mg of provigl when I took 120 mg of Vyvanse… and nothing! What could be the problem here? I’m in the process of getting a mouth peice to help with my sleep apnea and then possibly a cpap if the mouth peice doesn’t work. But I’m just so tired of being tired all the time. Could the Effexor or Motrin be doing anything to make the stimulants not work?? Any help would be greatly appreciated. Thanks.
LB,
Your complaints do absolutely require a more comprehensive workup, and without a more careful set of questions I strongly recommend adrenal/hormone review and a full metabolic workup. Your underlying metabolic problems are clearly not only *not psychological* and not simply downline from the sleep apnea, but are likely, in fact, contributing to the sleep apnea.
No, highly unlikely that the Effexor or Motrin is the primary problem, but remotely could be contributory for some fluke reason based upon the other neurotransmitter disarray.
More specific testing will get you further along, don’t despair. I do think that the Triad by Metametrix would be quite useful, but don’t like to guess without knowing more about your specifics.
cp
cp
Hello,
I am a male college student who was only recently diagnosed with ADHD—about three months ago. I have watched your videos and read many of your blog posts and found them to be very informative. I was amazed when you explained your ‘Avoidance’ type ADHD. I am almost exactly like sub-type three and four. When going out, my anxiety would increase very much and seemed directly related to how many variables I expected—the more I had to think about at once, the more anxious I would get. I am a stickler for routine. About the only part that didn’t quite fit is that I am not (always) against talking about it (like Clint in Gran Torino), in fact I think all of this is very interesting—though the Clint-ish behaviors do arise when I am stressed.
The more I learn about ADHD, the more my life makes sense. I realize now that this condition has plagued me my whole life—and severely. I have a feeling that if I had caught on sooner, I might have graduated elementary and high school with honors rather than flunking out and having to go to night school in the end to get my diploma. I think the reason no one caught on is that I was constantly moved around every year or two, so I always had new teachers. I am 33 now, working on my bachelor’s in IT. When I was young, through elementary and high school I was very hyperactive, but I am not so much anymore; though I still have a very hard time maintaining focus—especially when structure is reduced and variables increase. I don’t think the hyper-activity went away really, it just went inward.
I think that maturity plays a very big role in the manifestation of many of the ADHD symptoms in my case—when I was young, I simply didn’t care. So when school work bored me (I would literally fall asleep in front of my homework, no matter how hard I tried not to), I would jump up and go run around seeking stimulation… I needed to be constantly stimulated to avoid feeling ‘sleepy’ for lack of a better term. It was like my brain would shut down. That is one reason I found your work so interesting. Now, being older and more mature, I know certain behaviors are not appropriate, so I suppress them—they turn inward. I might not be running around physically, but I am mentally.
I have been receiving treatment for anxiety and slight depression for almost a year before this in the form of Lexapro at 20mg. I am beginning to think that these may have been symptoms of ADHD rather than GAD and depression. The Lexapro did help some though. For instance, I used be very hermit-like. I simply did not want to go out anywhere I wasn’t familiar with. When going out to restaurants or say grocery shopping with my wife, out came the Clint-behavior. I became short-tempered—not mean, just very ‘no-nonsense’ and ‘do it my way period’. In fact, I would even go out of my way to explain to my wife the reasons for this behavior: because I have ‘everything planned out’ and I don’t need any extra things to think about that just complicate everything—that I don’t mean to be mean. I was always in a rush to do whatever needed doing. I would never ‘stop and smell the roses’. I just wanted to get home where I could relax and not be constantly crunching variables in my head. This was before I saw your videos or read your blogs, which is why I think you are correct and really on to something here. I have read the DSM-IV and countless other sources and gone over the common indicators for ADHD etc, but they didn’t fit quite as well as your descriptions do. Anyway, like I said, the Lexapro seems to help some with that. I tend to be calmer when going out and not in so much of a rush, but I definitely took a hit in my focal ability, that is, my ability to think logically and remained focused. It wasn’t all together unpleasant though, and didn’t seem too debilitating, unless someone asked me to do math in my head or something, so I didn’t complain.
But lately with schoolwork becoming more and more complicated and less forgiving, I was beginning to feel that lack of focus. So I did some looking around about these symptoms, which eventually led me to ADHD. It had never occurred to me that this might be a problem because I was very capable with certain things growing up. I excelled in art, reading, even general comprehension of complex ideas… that were interesting. I was so good at these things, that attention deficit didn’t seem at all applicable. The problem was, most things were utterly boring (certainly most everything practical, like school work, jobs etc.). Then I read about hyperfocus and suddenly my life started making a lot more sense. That was a few months ago, when the ADHD stimulant medications began.
I began my ADHD treatment with Concerta at 18mg, which did very little to help, in fact I really didn’t notice it. I took the Concerta at 6:00 AM, got on my homework and other things that needed doing, then at around noon I’d take the Lexapro, since it made me sort of sleepy and lackadaisical (I tried taking the Lexapro at night for this reason for about a week and had horrible nightmares). I also take Protonix 40mg for GERD (maybe stress related?) at this time, just for convenience sake. Then at around 8:30 PM, I take 100 mg OTC diphenhydramine along with 50mg trazodone to aid getting to and staying asleep.
I have always had a problem getting to sleep have been taking diphenhydramine for years at 50mg (like it says on the bottle). My general doc told me this was fine, that I could take it any time I needed it. When I began the Lexapro, the diphenydramine stopped working. I told the psychiatrist about this he gave me a script for 100mg trazodone. Unfortunately the trazodone did nothing to help me get to sleep (though it did help me to stay asleep), in fact the diphenhydramine worked better. The p-doc told me that he was reluctant to prescribe anything like Lunesta or Ambien because it was habit forming, and suggested upping the dose of diphenhydramine to 100mg. Well, I did and it worked to get me to sleep, though I would wake up several times throughout the night. Through trial and error I found that adding half a pill (50mg) of trazadone, I could sleep throughout the night—taking the whole 100mg added no benefit, so I took only 50.
So that was my cocktail for a month. By the way, I don’t drink or smoke, take illicit drugs, or abuse prescription drugs—though I experimented when I was younger with pot, LSD, and speed (18-20) and really crashed and burned. Luckily I never got in trouble with the law or anything. After that I began to binge drink on the weekends. That lasted for about 5 years and resulted in a DUI—no one was hurt, I just crashed into a dirt hill going slowly. After that I stopped everything all together and never looked back. I was lucky in that I never had a hard time quitting any of these things. I just decided to stop and did, simple as that. My life turned around after that and I began college and planning ahead.
Anyway, I tried Concerta 18mg for a month and it didn’t help. So my p-doc bumped me up to 36mg. I noticed this one and it helped some, but I would give it around a 50% in effectiveness, and it cut out early in the afternoon too. So, a month later, the doc increased my dose to 54mg. I had high hopes for this as I figured it would do the trick considering the 36mg was working, it just wasn’t quite strong enough. Unfortunately, the 54mg dose of Concerta put me to sleep all day! I was very out of it, and had a hard time keeping my eyes open—especially during sedentary activities like school work. I was baffled by this and quite disappointed.
So I did some research and found that many had good results with Vyvanse and suggested it to my p-doc. He prescribed it at 30mg to start. This was 6 days ago. I am due to see my p-doc again on Nov. 16th, so about a month from when I began the Vyvanse.
I am not quite sure what to make of Vyvanse. It does seem to help with me, but the problem is it does not ‘kick in’ until around say 10:30 AM to noon, after taking it every day at 6:00 am. Then it lasts until around 7:30 PM. And in the morning –when it isn’t working– I get so sleepy I need to take a nap sometimes! I will generally lay back in my recliner and fall asleep for about 45 min to an hour, usually between 8:30 AM and 10:00AM. The experience is not unpleasant or anything, it is peaceful I guess—it would be great if this pill did this at night… maybe then I could lay of the sleep aids. But that this happens in the morning is very inconvenient because that is when I gear up for the whole day—start my homework, plan the day’s activities etc. When it finally kicks in I notice it slightly… it is very subtle, but I do notice the increase in focus. I am not motivated at all though, in fact quite the opposite, and between the hours of 10:00 am and about 1:00 PM, I notice a drop in my mood… almost bordering on very mild depression.
I have had no problems with eating, except that I tend to need less food. I eat nutrigrain bar in the morning, a modest lunch (I used to eat a lot!), and a relatively small dinner. I try to stick with chicken and I avoid (and have for a long time) hamburger especially because it seems to stay in my gut for days.
I am concerned with a few things. I have read quite a bit about many people’s reactions to Vyvanse and sleepiness in the morning does not seem to be very common at all. Apparently many people require an IR booster in the afternoon sometimes, but I have yet to find anyone needing one in the morning… Is this something that can be fixed with an increased dose? It seems that an increase in dose usually makes the DOE last longer, but at the end of the day. Would it work the other way ‘round? Or so you think I ought to ask for an IR booster in the morning?
Also, I noticed that you mentioned that Paxil and Prozac should not be used with the AMP class of stimulants because they clog up the 2D6 pipelines. Unless I misunderstand the Handbook of Psychiatric Drugs (which is possible, I am no doctor!), Lexapro seems to do this somewhat too: “Cytochrome P450: Modest inhibition of the hepatic enzyme CYP2D6… This interaction is unlikely to be clinically significant”. Do you think I should worry about this? Any advice would very appreciated.
Thank you for reading my story. I am a new fan of your work, and have subscribed to your channel and blogs. I look forward to watching more videos and reading more about your ideas. Thank you for making them available to people like me.
Sincerely,
CDH
CDH –
Excellent homework! Thanks for your comments – these important remarks parallel what I see in my office so often and will provide excellent structure for others:
1. I have had only min probs with Lex on the 2D6 issue. I have regularly heard from pharmacists who call and tell me the same about Effexor but most of my comorbid ADHD folks are on either of these or Pristiq – all are quite clean on 2D6.
2. Sounds like you do need the antidepressant with the Vyvanse, and you’re quite right, I don’t think that’s a Vyvanse thing per se but the dopamine/serotonin balance described in detail at the end of this Anxiety, ADHD Stimulants with Antidepressants piece. The drop in the PM with the mood is the tell-tale on that one.
3. I would crank the Vyvanse dose if your doc is OK with it, doesn’t sound like you are having the mysterious AMP prob associated with overdose – top of the Therapeutic Window see the Top of the Window link at EzineArticles.com
4. With either Lex and Vyvanse, and Vyvanse at 40 in the AM my best guess is that the variables you describe would iron out.
5. With the complicated sleep issue and when the stim meds have quizzical outcomes, the next best bet is specific neurotransmitter measurement, paid for by most insurance companies.
Thanks again for your thoughtful and well written comments, very instructive, and will prove most helpful,
cp
Your words are very appreciated 🙂
I enjoyed your article: Anxiety, ADHD Stimulants with Antidepressants and it explained quite a bit actually. That bit about the top of the window for the MPH type stimulants made perfect sense. That must have been what happened to me with the Concerta when the dose was raised. The 36mg was effective, but I felt that ‘stoned’ feeling at 54mg. I wonder if that negative side effect wear over time. I thought the 36mg was effective, just not quite strong enough. It is too bad the beneficial effect didn’t scale with the increase in dose.
I will ask my doctor about increasing the dose of Vyvanse to 40mg when I go in next.
I have one more question. Is it normal to feel a touch anxious in the evening when taking Vyvanse? Say around 4:00 or 5:00 PM after taking it at 6:00 AM? Would the increased dose remedy this in your opinion? The anxiety is not severe at all, but just a bit uncomfortable. I have xanax on hand if needed, but I don’t like to take them unless absolutely necessary because they tend to build a tolerance and they are too valuable a tool to lose. I would prefer to just avoid the anxiousness at the end of the day all together. I think this could be achieved if the Vyvanse lasted until I took the sleep aids, as they tend to relax me anyway.
Once again, thank you very much for your time; I know it must be very valuable so I really do appreciate your replies ^^;
CDH
CDH,
Drops in the PM, as this likely is, result from the variation between good neurotransmitter levels and markedly diminished levels. This phenomenon if not intolerable is likely do to dose inadequacy, as with Vyvanse you can go for, as an adult, 14hr DOE.
Troublesome ongoing issues could be fixed by targeted amino acid precursors – if you know the specific one that is a bit low by testing, you can target the precursor specifically thus obviating the drop. Simple, and doable if needed.
cp
Thank you once again! Your explanation of the dopamine/serotonin ratios from before made a lot of sense as to why I was getting tired early on. I am pleased to say that I am no longer feeling sleepy in the morning. I am still on the 30mg dose of Vyvanse because I wont see my doc again until the middle of November, but the neurotransmitter levels must have equalized or something, because the Vyvanse seems to be producing the more ‘typical’ effects now: more focus in the morning, and throughout the day, until around 2 ish, when it starts to wear, then the slight twinge of anxiety around 4-5 PM, which will abate at about 9 PM– a half hour after taking the sleep aids. I have also begun to eat more protein in the morning (as suggested in your writing). I think this might have really helped with this too, as feel generally better throughout the day in the last few of days since I started this.
I was very interested in your suggestion about the amino acids precursors. I am going to read up on that myself and suggest this to my doctor when I see him next. I would love to be able to use a supplement or something to alleviate this problem rather than Alprazolam or some sort of booster. I feel better knowing that I might be able to get away without needing to resort to an IR booster yet. I would rather hold off on any of those for as long as possible, to save them for if/when I absolutely need them rather than beginning to build a tolerance and start the ‘constantly-up-the-dose’ cycle that seems to inevitably occur after beginning with the IRs. I don’t know, as I haven’t used any IRs, but from what I’ve read it seems like this cycle might be caused more often by the increased likability of the IRs rather than any real reduction of their effectiveness, which I’m not too worried about, but I’d rather hold off just the same.
Anyway, thank you again for your advice 🙂 You’ve given me much to think about and I very genuinely appreciate your help. I look forward to the release of your book and more of your videos and blogs.
CDH
CDH,
Thanks for your kind remarks, and just to let you know, we do remote consults on the neurotransmitter assessments detailed here at Neurotransmitter References. Really pleased your are doing better, often it takes just a few tweaks to turn the situation dramatically around.
cp
Thats very good to know… thanks
enjoyed reading this post, thanks, appreciated
adding xanax would help alot. i am on the same medication and xanax has helped alot
Tri[p-
While this comment looks a bit like spam, I am leaving it here because so many take Xanex for ADD – it’s simply amazing – especially in light of the recent science on the neurotransmitters. Cognitive anxiety is different than affective anxiety, and Xanex is primarily for ‘affective anxiety,’ – stimulants for the cognitive anxiety most frequently associated with ADHD.
There is an interesting common ground out there in the synapses of humankind that has to do with specific inhibitory neurotransmitter deficiencies, – and can be corrected most effectively by targeting specific deficiencies rather than just thinking about Xanex. Why not use targeted, measured amino acids, neurotransmitter precursors, as a first line, rather than addictive substances. That observation might sound ridiculous in the context of all i write about stimulants, but here is a brief explanation:
Cognitive and affective anxiety may indeed feel the same, but their origins are different from a neurotransmitter perspective. Evidence will direct the correct intervention strategy. Example: Think Bipolar as the tip of the iceberg, and Traumatic Brain Injury as the problem floating that symptom picture. Miss the TBI, and you miss the entire underlying issue – perhaps for a lifetime.
While I do agree that Xanex does help in some of these presentations, it is my firm opinion that we should use Xanex only as a last resort, and only for brief periods to stabilize at the outset. I have seen far too many spend their lives looking for more Xanex because of the tachyphylaxis [rapid accommodation to lower treatment doses] leaving a very high likelihood of addiction.
As a routine: correct intervention, yes, Xanex, a resounding no.
cp
k well i have recently started taking vyvanse and it was good the first day it helped me focus but i did not eat at all and i havent slept at all and today is day two yesterday i took 4 30mg pills and today i took only 2 and im in school right now but last period i just got so irratated and i cannot focus at all and im just confused it pisses me off how not one medicine can work for me with out having bad side effects. i dont see any way of me passing school and actually obtaining information with out something to help me focus but i cant take medicien to have it only be affective when it wants to be and then it occasionly makes me focusing problem worse where i cant take it and jsut dont knwo what to do
Zach,
Your frustrations are shared by many, so rest assured they can be corrected with precise measurement of targeted effects. Read these many posts here about DOE – duration. You are likely on too much medicine, as indicated by apparently starting at 120 mg – highly likely to cause significant problems. I strongly suggest you get back with your doc, start more slowly, read up on the specific I have outlined in great detail in these many posts and sign up for the ADHD book on the front page, and read that white paper: Predictable Solutions are quite likely – if you simply have a correct big picture on the details.
Sorry to mention homework, but if you don’t do your homework you won’t know what to tell your doc.
Do download my 22 pg White Paper on the Precise Solutions for these ADHD problems – it will be helpful: Link for Precise Solutions
cp
Dr. Parker,
I’m having a hard time figuring out my DOE. I am a third-year high school teacher, so a typical day for me consists of numerous cognitive activities. I was wondering if you had any tips for a quick assessment to measure effectiveness towards the last half of intended duration (often the time when it begins fading and becomes unnoticed). After a long day with students, I commute 40 minutes home and have a two-year old and a pregnant wife awaiting my arrival. Poor me, I know… But lately I’ve been popping another dose of meds on the way home because I feel like its the only way I’ll be productive through the evening. I appreciate any advice from you and the guests here on your blog. By the way, I am currently PRESCRIBED 70mg Vyvanse once-a-day and 20mg Adderall IR once-a-day (or as needed). I look forward to responses. Thanks.
James,
Just using the experience from my office here, I suspect you are running too short on your DOE. A recent study by Shire took the documented/verified DOE out to 14 hr in a simulated work environment with very boring tasks.
This is anecdotal, not speaking for Shire here, but strongly suggest that you talk to your doc about increasing the dose to 90 or, next click 100 mg based upon the time you appear to run out. Usually will increase your PM DOE by about 2 hr/10 mg increase. Sounds like you are out at about 4, and 90 mg should cover, without more scripts and co-pays.
What to look for depends on your initial eval and objectives, – but it sounds like you are simply loosing concentration such that you regress to avoidance due to the decreased ability to stay with the decreased structure and increasing variables in the home upon return – no fault! Said another way, look for the cognitive signs, not so much the somatic feelings, and you will better recognize that PM side of the Therapeutic Window.
Be well and please keep us posted,
cp
Could the Vyvanse taken along with the Wellbutrin be a problem?
John,
Wellbutrin can become a problem – have created it myself, and I do watch for it. Wellbutrin is a moderate inhibitor of 2D6 [see this on buproprion, pg4], and is often the case the most frequent problems are with larger doses, sometimes with 300mg, more common with 450mg.
This is Top of the Window is easily reversible, but more mysterious and difficult to assess due to the forgiving nature of the Vyvanse. I simply is not ‘in your face,’ but shows as irritability, moodiness with depression, sleep and appetite disturbance that didn’t appear previously, and often after the person has been on the combo for some time.
cp
Dear Dr. Parker,
I hope this man and his WONDERFUL sister have been able to take your advice quickly and resolve his problem. I take Vyvanse too, and because of your wonderful blog and lots of other things I’ve found online (the intense draw of the internet for ADDers isn’t all bad!) I was quickly able to see when I was taking too much Vyvanse. I am also blessed with several Dr.s who respect my opinion and don’t hesitate to change a dosage when I suggest it. I’m 45 with an 11 year old son with ADD, and I’m determined to get my life in order and especially save my son a lot of the pain I’ve had with undiagnosed ADD over so many years.
Jan-
My feelings exactly – it’s great to see the dialogue open up about new medications and using more precision with dosage. I’m looking forward to the new medication [Intuniv] coming out this fall for the angry and more difficult to treat ADHD folks – the combo could be quite interesting.
Thanks for your note, glad all is well with you-
cp
Dear Dr Parker I’m 28 and have been on multiple adhd medication I’m currently on 60mg vyvanse a day I take it a 8 am and by 2-3 pm its wearing off I’m pretty much in bed sleeping by 8 pm cause I just can’t stay awake I used to take 27mg concerta twice daily and it worked better than my dr wanted a trill on vyvanse so I agreed at first it worked great and the DOA was perfect would asking my Dr for 50 mg vyvanse in am following 20 vyvanse around 1pm be reasonable so when I get home I’m not just laying on the couch missing family time?
Nick,
Everyone, everybody, every metabolic person is different. I strongly recommend more careful measure rather than speculation about specific meds.
cp
Jan,
Thanks so much for your kind and supportive comments. It certainly feels better to be part of a community and not feel like you’re all alone. From now on, when we’re feeling lost and at the end of our rope, we’ll remember there are people like you and Dr. Parker out there.
All the best to you and your son,
Anne