DOSE:
150 mg
oral
Pharms - Bupropion
(pill / tablet)
20 mg
oral
Pharms - Dexmethylphenidate
(pill / tablet)
7.5 mg
oral
Amphetamines
(pill / tablet)
BODY WEIGHT:
160 lb
This is a pretty long review, with an explanation of my background and my experience being diagnosed with ADD as an adult. There's a lot of info so at the bottom I've condensed my impressions of the three drugs I've used (Welbutrin XL, Adderall, and Focalin XR) in case you don't feel like reading the details. (Mixed in throughout is some pharmacology you might find interesting.)
To start this off, a little about myself. I'm a 23 year old medical student, as well as a sculptor and musician. I've never had problems in school, never really acted out, and I'm at the top of my class. At first glance, I don't really fit the classic signs of ADD. Never even suspected I had it until a few months ago. Looking back though, it's a bit obvious.
Now, usually you'd expect someone with severe ADD to struggle in school. It's pretty damned hard to study when every five minutes you're staring off into space, caught in some daydream, or having some fact catch your eye, diving into Wikipedia to learn more about it, and forty minutes later learning all about the Demon Duck of Doom (a five foot tall carnivorous mallard that lived in Australia about fifteen million ago). Fascinating, but hardly relevant to learning calculus. Fortunately, I have an advantage.
Back in the fourth grade, as now, I was a very 'bouncy' person. In fact, if the diagnosis existed, I'd probably be called a unipolar manic. I was a nice kid, but a little distracting to my teacher, asking questions that frankly, an elementary school teacher can't be expected to know the answer to. So, this being the trend at the time, she convinced my parents to have me tested, part of which included giving me a WISC, the Weschler intelligence scale for children. Turned out my IQ is 155. That puts me in the 'Whoa' range. On top of that, while my memory isn't exactly photographic, it's close enough that if I see something once, I generally know it, at least well enough for a multiple choice test. Seeing that, my folks decided that I was just bored. Let's be honest - I was. So no diagnosis, but I had to do all of the G&T science projects that were optional for everyone else. Whoop-di-do.
Fast forward to college. Full ride scholarship, despite spending all of grades 5-12 reading books under my desk and daydreaming, never studying a day in my life. My grades weren't perfect, but I didn't have to do anything to get by. Half-way through, I became disillusioned with my major in engineering as it was boring as hell and unless you're the lead designer you'll likely wind up in a cubicle doing math. Shudder. I decided to go psych/premed. Suddenly, my wiki habits were actually useful - medicine is essentially trivia, and I am damned good at trivia. In two years, I finished the entire major, did all of the pre-med coursework, and got a 37 on the MCAT, again with very little work. Hello, Med School.
Like I said, Medicine is fascinating, really, really, fascinating. The human body is absurdly complex, and despite how doctors and scientists try to pretend to know everything, there's a lot that we don't. So, being so interested, I did well - really well. While other people were stressing over exams and struggling to adjust to the course load, I was giggling in manic glee during test week (which really didn't help everyone else with their stress ^_^) and honoring everything, despite never having to have studied in my life. With medicine, studying (like crazy) became necessary, but I could do so for hours, loved it.
Sadly, second year, one of my best friends, a classmate, died right in the middle of exams. There wasn't any warning, she just went in her sleep. For a while, it destroyed me. Massive depression. I don't mean the emotional component, that was there in spades, but was normal for grief. It was the vegetative symptoms that got to me. Suddenly, I couldn't wake up in the mornings. I didn't go to class, didn't study...couldn't really. Hard to force your mind into reading about how to perform an autopsy when you know that one of your best friends is lying on a slab. Six weeks went by, and I had to seek treatment, or it wouldn't matter how well I absorbed information - I would fail.
I went to a psych doc, and he put me on Welbutrin XL. Made me feel fuzzy - only way I can describe it, a sort of emotional flatness that's both physical and mental - and gave me a bad case of dry mouth when I woke up, but it worked. Fast. Five days into the treatment (Welbutrin has a half-life of about 22 hours, and five half-lives is pretty much where meds reach steady state) the depression tapered down to a level I could deal with. It still sucked, but I could function again. But more importantly to this, a very interesting thing happened on day three.
Like I said, I was six weeks behind in an eight week block of school. I was screwed. Even at my best, my advantage isn't speed but that I can learn things in one read. My classmates, they go over the material three, four times, in the space it takes for me to do one read. They test themselves, use review books, everything. I just read it once, and my memory carries me through. I'll study for five hours, but only actually learn for an hour or so of that. The rest is distraction. On top of that, I've never been able to study in public. Even if there's only one other person in the room, completely quiet, I'm way too distracted - I'll end up reading the same page for two hours. So, day 3 of Welbutrin, I'm sitting in a cafe, starting to feel a little better from the anti-depressant effects, and I decide what the hell, I may as well look at the syllabus. In med school our syllabi aren't little one page schedules, but custom textbooks, everything we need to learn in a block. I don't expect to get anything done, but I'm desperate.
Seven hours later, I look up. I'm in a crowded coffee shop, full of distractions, and I haven't moved. In seven hours. And I'd just read, understood, and memorized 200 pages of pathology! In one day, I'd almost completely caught up in a class. Holy. Shit.
Even at my best, even in complete silence and ideal conditions, I'd never done anything like that. At most, I could have stayed still for five hours, maybe, and read 50, 60 pages. Again, maybe on a good day. Needless to say, I was amazed, and very curious. Over the next two weeks, I completely caught up in every class, and while I didn't honor every class, I made an even mix of honors and high pass (A's and B's). Considering I didn't go to more than a dozen lectures that block and I was still depressed, that was perfectly fine. Hell, that was incredible. Two weeks earlier, I was just hoping I'd score highly enough that I wouldn't have to take a year off.
So, thrilled and curious, I looked into Welbutrin. Turns out, while it's only considering a third line treatment, welbutrin is occasionally used for ADD. It's blocks the reuptake of norepinephrine (the neurotransmitter equivalent of adrenaline) and to a much lesser extent, dopamine. Not enough to make it addictive but enough that combined with the energy boost of norepinephrine, it helps with depression (and incidentally causes weight loss, increased sex drive in women, helps you stop smoking, and doesn't make you sleepy - the opposite, in fact). Very similar to amphetamines. Huh.
Anyway, winter break comes along, exams are over, so I go off the Welbutrin. I know, it worked wonders so why stop it? I just didn't feel like myself, emotionally, and the dry mouth was becoming problematic- not an issue during the day, but it would wake me up at night. Thankfully, the depression didn't come back, and emotionally, I was stable. When someone asked how I was doing, I could honestly say I'm doing just fine.
Unfortunately, I was distracted again. After that tragedy, my priorities had shifted. I still loved medicine, it was amazing, but other things were first on my mind. Before med school, I'd never had many friends. Various reasons, but the biggest one is that when you have an IQ higher than all but one person in a thousand, it's kind of hard to relate to people your own age. I'd debate philosophy with my parents friends when I was ten, but I couldn't care less about pokemon, football, or other peoples' prepubescent love interests. Along comes medical school, and I suddenly I'm surrounded by the most incredible people. Not just smart, but truly, incredibly decent human beings whom I could actually relate to. When our friend died (and she was one of the best of them) we came together. It's really the only thing that can come out of that kind of tragedy. It makes you realize how much the people in your life mean to you and come out and tell them. They were my family. Becoming a doctor was great, but I wanted to take advantage of every second I could spend with these people. Come two years, we'll all be going off to residencies around the country, and while we'll stay in touch, meetings will be few and far between.
So my focus was shot, class made me fall asleep with my eyes open, and like I said, I can't study with anyone else. For one reason, I learn best if I talk to myself when I study, which can be distracting to other people. Highly recommend it though. If you hear yourself saying what you learn, and make connections as you go, your memory becomes way better. I put in the time anyway, but again, I was falling behind.
Finally, I mentioned to a friend of mine how I wished that the Welbutrin hadn't had the side effects, and, somewhat jokingly, how I wondered if I had ADD. Turns out, she actually was ADD, and she had assumed that I was, too. So she gave a few mixed amphetamine salts (generic Adderall), told me to take half of a 15 mg on an empty stomach, and see how it affected me. Yes, I know that that's of questionable legality, but I knew the risks, side effects, etc. and it wasn't recreational use. I was hesitant but I tried one a few days later. At first, I was ineffectively studying at Panera with my best friend, J, not really feeling it. Then I started to feel good.
I don't mean high - I didn't really feel drugged, but I just felt better, in general. The aches that I get in my knees disappeared (or maybe I just stopped caring about them?) and I felt alert, like myself again. The energy that I used to get during my first year of med school, when everything was new, fascinating, mine - it was back. I became a bit more eloquent. Sometimes I have trouble converting my thoughts to words. I'm thinking so much faster than I speak, and end up stumbling - that disappeared. I was still thinking quickly, and had a bit of logorrhea - speaking quickly, continuously. At first glance, I know - that sounds like anyone on speed or coke - but it wasn't grandiose mania, just clarity and connected statements. After it kicked in, I stayed there with J for about three hours, until it started to wear off, conversed for a lot of the time, and yet still managed to go through another 50 pages of pathology, not loosing track when we got off topic. A few days later, she quizzed me on what I'd read. I wasn't on the Adderall, hadn't tried it again since that day, and I not only remembered everything I'd read (a worry of mine was that I might have just thought it was getting in, or that the knowledge would be associated with my being medicated) but I knew it well enough that with one trigger word from her, I could teach it. I had one and half more tabs, so I decided to experiment. At this point I was pretty sure that I had ADD, but wanted to make sure. I tried taking it (again, very low dose - 7.5 mg) in different situations - alone versus in public, studying one day without, the next with, and seeing how much I processed. Night and day.
Still, I wasn't quite ready see a physician about it, and I've always had a general distaste for medication. I don't like feeling off, and I have a very rapid metabolism for most things that I've tried, everything from Advil to Adderall, to alcohol. For me the Adderall lasted for about three hours, whereas normal is from four to six. Fast metabolism runs down my father's side of the family - it takes us a little over half as long to sober up as the average person, and I've never had a hangover in my life, even when I really deserved it. I wanted to be sure before paying to see another psych (med student = broke).
I started researching deep on adult ADD, far beyond the little they teach us in med school. There's so much to learn that they settle for making you a sort of jack of all trades - it's more about providing a solid framework for future in depth learning in the specialty you choose than about making us true experts - that takes time. Pretty quickly, my suspicion of ADD turns to certainty. You always have to be careful when you study medicine or psychology - so much of what we term disorders are simply exaggerations of the norm. OCD is great, in moderation, and relatives of patients with bipolar disorder tend towards greatly increased creativity. It's easy to think you have a condition when you're constantly being exposed to every possible thing that can go wrong. You have to be sure. Sure, there was the inability to focus, the constant daydreaming, the hyperactivity, everything I already knew - but also my constant procrastination (if I have a paper, I always wait until the last possible moment to where I'm forced to do nothing but write to have a hope of finishing it), being late to virtually every class, answering questions before they finish being asked, speaking without thought or tact (for instance, multiple occasions of correcting professors - Not a bad thing, misinformed med students could wind up killing patients, but I really could go about it more tactfully) and appearing arrogant without meaning to.
What finally settled me was the sleep habits seen in ~70 percent of adults with ADD (shows up after puberty). What happens is, we, (especially me ^_^) end up having a shift in our circadian rhythm. Instead of the typical, sleep at night, wake at light, our schedule tends to shift. We end up being fatigued, distracted, throughout the day - irregardless of whether we had enough sleep the night before- and then when the sun goes down, instead of becoming tired, we can become more awake, more alert, staying bright eyed and bushy-tailed until 3, 4 AM. Then when we do try to sleep (especially if we try to be reasonable and go to sleep at eleven or midnight) we can't. We toss and turn, our minds race, we just can't turn it off. One theory is that at night there are fewer distractions, so it's easier for us to become focused, the other that we have a dysfunctional circadian rhythm. Our inner clocks aren't actually on a 24 hour cycle, so normally our brains reset the clock every night - that may not happen in ADD. Then when we finally manage to sleep, it's like we're dead. Waking us up is impossible, even with seven, eight hours of sleep. We snooze through multiple alarms. If someone wakes us up, we're so delirious that we can have entire conversations, pass out, and not even know that they happened. Mornings are hell.
That's me, to put it mildly. Without classes, I go to sleep an hour later every night until I'm passing out every morning at 4 am, and sleeping till two. If I'm in an interesting class, or there's an interesting professor, or I'm actively participating, I'm wide awake and aware- if not, I almost get whiplash from constantly nodding off, and then I pass out midway through the afternoon. Three separate alarms, and I still miss classes.
So finally, I went to a doc. It didn't take long to convince him - he just wanted to make sure I wasn't bipolar first! Thankfully, mania doesn't usually last for years at a time - I'm just bouncy.
He decides to prescribe me Focalin XR. Focalin is essentially Ritalin, the first, and most common anti-ADD med. Ritalin's been around for years - there's lots of evidence for it's use. He tends to prescribe Vyvanse, lysine-conjugated extended release dextroamphetamine - basically dexedrine XR, but it functions through similar pathways as welbutrin, which apparently makes it likely that I would get the same flattened affect if I used it chronically.
The thing about Ritalin, or methylphenidate, is that it while it works quite well to control ADD, it also has an unpleasant body high - I haven't used it, but others have told me that it feels 'dirty,' somehow. One of the reasons Adderall is so popular these days is that it has a more clean feeling, and a slightly longer effect than ritalin.
So in comes Focalin, or dexmethylphenidate. It turns out that traditional Ritalin is a racemic mixture- it contains equal parts D- and L-methylphenidate, identical chemical formulas and structure, but with the position of two molecules switched. Think your right hand and your left hand - identical, but mirror images of each other. Some smart chemist separated out the two isomers and found something interesting: dexmethylphenidate, the D-isomer of Ritalin, is the compound that provides all of the therapeutic benefits and serendipitously, the recreational part as well. Really, therapy or getting high, there's no difference, just higher dosage and different routes of administration. Using it for ADD still makes you feel good and energized, it just happens to correct the symptoms of the disease along the way. Funny thing is, one of the FDA approved therapies for ADD - still used, just not often - is straight methamphetamine. That's right: find the right physician and you can be prescribed the same thing meth-heads go crazy for, one of the most addictive drugs we've got. The thing is, used properly - and by this I mean don't snort it, shoot it, smoke it, or quintuple your dose - and you're not going to get addicted. The other isomer, L-methylphenidate, causes almost all of the bad side effects. On top of that, it competes for the same receptors that the D-isomer uses, making you have to use higher doses for the same effect.
Cut out the L-isomer, and you have Focalin. More potent, smoother, better. More expensive too, but you can't have everything. They add in some bead technology to make it extended release (nothing more than multiple doses in a single pill, with half of medicine coated so that it takes 4 hours to dissolve) and it ends up lasting 8 to 12 hours instead of 3-4. It only has effects above a threshold dose, so by adding the second dose on top of the first, the first dose lasts the usual 3-4, but the second takes more immediate effect, and lasts 5-6, depending on your metabolism.
So I'd already experienced Adderall. The doc was right - there was some affect blunting, but it let me focus. Here's what happened with the Focalin XR, 20 mg. To start with, when I tried the Adderall, it gave slight feeling of physical well being, a little mood blunting, and focus - lasting three hours. The Focalin was a very different, especially the first time. The onset, as with the Adderall, was essentially an hour after taking the dose. Unlike with Adderall, there isn't the physical euphoria - instead, there was an intense mental euphoria. I started feeling happy - really, really happy. For about two hours, I was dancing around my apartment, absolutely euphoric, listening to 2cellos and Aerosmith. Frankly, I was high as a kite. :) Since I had a pharmacology test in two days, this wasn't what I was looking for, but I'll admit, it was a hell of a lot of fun! I ended up talking a friend of mine's ear off for almost a half hour (she was very amused) and I found out that watching the iTunes visualizer while two insane Croatian cellists play the best cover of Muse's Resistance ever made is really, really sweet when I'm on focalin. My mind's ability to interpret three-dimensional structures went through the roof and it was like watching wormholes dance through a field of lightning. After two hours, the high faded and I felt kind of mellow for the rest of the night.
At that point I wasn't sure Focalin was going to work for me. Enjoyable, sure, but I needed to treat my ADD, not get high. I had gone through the trouble of being diagnosed, so I decided to give it another try the next day. Completely different! Again, it took about an hour to kick, in, and mentally I felt good - but this time it was clarity - I could focus! It cleared my head, made me feel awake and alert, I went through a good 70 pages of pharmacology. I still went off on tangents when I saw something interesting, or not well enough explained, but I could pull myself back on track without any effort. Best yet, it lasted for more than eight hours! Since then, same effect - mild mental euphoria, focus, energy and clarity. Overall, for ADD, this is a wonderful drug.
So, in Summary:
Welbutrin XL 150 mg: Intended for depression, its secondary effects led to me discovering my ADD. Norepinephrine/dopamine reuptake inhibitor. It's nice, because it can be taken as a once a day XL formulation, and works very quickly. Only 5 days, versus SSRIs that can take well over a month. Improved my sleep cycle, making it easier to wake up, vastly improved my focus, and treated my depression. AEs were bad dry mouth (progressive over course of treatment), mild blunting of affect, and some a fuzzy feeling in my eyes that went away after levels peaked.
Adderall 7.5 mg: Onset in an hour, provided improved focus, and gave a feeling of physical wellbeing. Effects lasted a bit over three hours. Did give me some blunting of affect, but it wasn't very problematic as I was taking it to study, and it's quickly cleared from your system. The short duration is both a pro and a con. I didn't have any of the withdrawal symptoms on the comedown, but I was on a low dose.
Focalin XR 20 mg: Onset in an hour. First dose was weird. I became extremely euphoric (borderline manic) and high for about two hours. It's effects are almost entirely mental, unlike the Adderall. Tons of energy, talking a mile a minute, dancing around while listening to music (the last I should mention is something that I occasionally do while completely sober ^_^). Subsequent doses were far more therapeutic, lasting 8+ hours, providing a minor mental euphoria rather than the blunting of Adderall, improved my focus, and was very beneficial to studying. No side effects noted. For ADD, I'd highly recommend it - don't be worried if the first dose makes you high instead (and if it does - enjoy).
I did notice that both the Adderall and Focalin gave me some appetite changes - I would describe it more as a feeling of satiety rather than as the aversion to food that I've been told some people have on stimulants. I felt less need to eat. My stomach still growls when I should be hungry but I can ignore it. The pain that usually accompanies hunger is gone.
Sorry for the length, hope it helps. Be safe, y'all- don't want to see you in my ER. :)
Exp Year: 2012ExpID: 95088 Gender: Male Age at time of experience: 23 Published: Jan 4, 2013Views: Not Supported [ View PDF (to print) ] [ View LaTeX (for geeks) ] [ Swap Dark/Light ]
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