Episode 020: A Conversation about ADHD Medications - Part II
Big Ol’ Disclaimer: We are not doctors or prescribers, but two therapists who have a lot of experience working with folx on/off, loving/hating, trying/not trying all types of medications and accommodations for ADHD. Please seek medical advice for all your medication questions! Continuation of disclaimers galore: we are not giving medical advice, just our opinions.
The importance of having a therapist or someone who can help you monitor medications if you are on them. Isabelle describes what it’s like to be off of her ADHD medications while she’s been pregnant/breastfeeding children the last couple of years (stimulant medications, see below, are often not recommended during pregnancy/breastfeeding, though other forms of meds are safe for pregnancy/breastfeeding—another reason why it’s so important to have empowered conversations with your doctors, prescribers, and therapists!) It’s hard when part of your accommodations is medication and that leg of your scaffold is not available. Non-medical or pharmaceutical interventions for ADHD are effective and include: diet, working out, getting adequate sleep, mindfulness activities (not all the time) but a practice during the day can help with frustration tolerance, fidget toys, finding ways to get the energy out, finding more existential interventions to get yourself excited about things instead of anxious or angry about things. David using the idea of guessing the color of the tie of the annoying dinner companions he was previously angry about having to go to—switching an annoying task to an exciting one (those meddling mendelson’s with their zebra zingers!) David also mentions there are some ideas around microdosing with mushrooms, cannibis, ketamine, etc. and he’s never seen them work, not that they don’t, but that he doesn’t even know how to begin talking about them working and is not comfortable talking about it as an expert (if you are one, email us at somethingshinypodcast@gmail.com! We’d love to have you on the show to talk more!). Also those microdosing interventions would clearly not work (and be illegal!) with kids. There are really different kinds of ADHD medications, including antidepressants like Wellbutrin (buproprion), which works on inhibiting the uptake (or increasing the quantity of) dopamine, serotonin, and norepinephrine in the brain (which works with the neurotransmitters affected by the brain difference that is ADHD). While a number of other medications can be prescribed for ADHD, David and Isabelle drill down into specifics about the stimulant meds most often prescribed for it: Ritalin and Adderall. Each of these meds have a line of meds that come from them (each med is more related to one or the other). Ritalin is more of a stimulant while Adderall is a stimulant with a mild anti-anxiety component to it. People will have sometimes have side effects to Adderall that makes them feel like there are ants running under their skin or a cold sensation, it’s typically a reaction to the anti-anxiety part of the med; those folks can take the Ritalin or Wellbutrin route sometimes. David shares the story of how he was lucky and Ritalin worked for him; however, his curiosity and studies wanted him to try a newer class of meds like Focalin. He noticed 3 weeks later that it was working; he noticed it was working because he picked up a piece of paper on the floor to throw it away—on the first try! Yet three weeks later he couldn’t remember his partner’s face when she wasn’t in the room and having intense intrusive thoughts of feeling awful and very depressed. He didn’t realize it was the medication right away, but his partner helped him connect the dots and it felt better as soon as he got off of the meds. Even though he tried a different med in the Ritalin family and it should’ve worked for him but it didn’t. David honors how if he was a kid, they would talk about how his behavior was improving, and how he was performing better on tasks, but he might not be able to vocalize his depressive thoughts and changes in recall—so important to not make someone take medication. If medication works, people with ADHD will take it (because it works). They often don’t want to take it when it doesn’t work. People can sometimes feel that people feel really zombie-like, or off, or not like a person—but then you see all these neurotypical-world gold stars for performance but they miss that there’s a person underneath it who is experiencing it working or not working, too. It can take so much patience and tenacity to find a good fit. David and Isabelle reveal that they also specialize in working with trauma, and even specific to survivors with ADHD, it can impact what type of ADHD medication they can tolerate. Medications that come in and out of the body really quickly (like short-release stimulants) can lead to rage-filled or anxiety-filled moments when it stops and starts, because. Imagine a triangle with a lopsided or long triangle, like a duckbill—there are medications like a Vyvanz that has a much slower ramp off which tends to be more effective for trauma survivors. If you have ADHD and you’re thinking about medication, try one. ADHD medications can be done in extended release (8-10 hours) or in short-release form (4-8 hours), that’s roughly how long you’re going to notice the effects. This means you know really quickly whether the med you are trying works for you, typically within an hour. If you’re trying a new med, ask your prescriber to avoid the XR or extended release version of the medication, because you don’t need a 10-12 hour experience to know if it helps (or is awful). Isabelle thinks of a metaphor or being on a rollercoaster which you know will end, versus the feeling when the rollercoaster operator walks away while you’re on it. This all gets to be a complicated question around kids: do you medicate to help preserve self-esteem or do you not medicate to preserve self-esteem? Whatever the kid needs to preserve self-esteem becomes a good gauge for all this. It’s really helpful for your child to be in therapy with someone who understands ADHD. A lot of kids won’t want to take medication because no one else is taking medication, because they’re normalized with their peers, but they also might want to take it for certain reasons; it helps to have a safe place to report how the medication feels because parents aren’t trained to hear what it’s like when a side effect of a medication is rearing its ugly head, for example, and professionals like therapists and psychiatrists and doctors, are trained to do. David errs on the side of going slow, having a lot of eyes on it; shame might make you want to keep this private, but it’s not about shame, it’s about making other people see it so the kids can feel better. Isabelle explains why she kept interrupting David and how her working memory was at capacity and she didn’t want to forget what she’s hearing or asking. David names that he steamrolled through Isabelle’s question and that wasn’t her interrupting him, that was on him. David was on a hyper focused rant, it was not interrupting, it was social conditioning that makes her feel like she did, and Isabelle loves David’s hyper focus and does not find it ranty, but rather part of the passion of removing the barriers to access to this information. Isabelle struggles to remember what she wanted to ask, and David prompts Isabelle to remember by retracing what they were talking about. Isabelle wonders: how can you tell the med is working? David recommends running an experiment on yourself: start a task, (like: read a book, or spend 30 minutes cleaning a garage), with no meds. The next day, do the same task and with the meds notice: how did it feel? Did it feel different? Was it easier to start/stop? Did you find a rhythm? Were you less angry/anxious? Did you make it longer before you got distracted. It’s your own experiment on yourself, to see if it’s helping with the tasks you want help with. And then the next important question: how is it making you feel? You are noticing the behaviors medication is helping with rather than thinking it needs to “fix” you as a person. It’s a noticing dirt in corners, sitting still disability, not a learning disability. If you’re observing a loved one on medication or not—how important to not equate the behavior with trying/not trying, caring/not caring, putting in effort, etc.—but rather noticing the task and how you do it and how you managed transitions and frustration tolerance. If the medication is working, it should make you less angry. Transitions could be difficult for any age person. Knowing what you need the medication for is the most important task. For example, David does not need it for work because he loves it and is interested in it, but needs it for grocery shopping. We all need to be stewards of our own experiences and there ain’t no shame in the medication game. For example, if you need the medication to be in the car for three hours to hug someone who smells weird, take the meds: what does David mean? He means everyone’s family trip they don’t want to take. We all have that family member or friend. And that medication may be running around the block, or shopping, or caffeine, or a puzzle.
What about pregnancy/breastfeeding and ADHD meds? An episode focused on this to come! In the meantime/additionally, check out this resource.
DAVID’S DEFINITIONS
Psychopharmacology: The study of medicine used to alter brain states and behavior.
Self-Stimulants (emotions you use to make your heart beat faster, arouse your nervous system, up your stimulation level): anger, excitement, anxiety or fear.
Non-medical interventions: Besides using emotions (see self-stimulants above) or medications (see below) for working with ADHD, also know that the following things have been shown to have big impacts:
diet
exercise/movement
getting enough sleep
fidget/sensory toys
existential interventions (changing something anxiety or anger-provoking to something excitement-provoking, or harnessing the self-stimulant idea above)
How do you know the med is working? Start a task, (like: read a book, or spend 30 minutes cleaning a garage), with no meds. The next day, do the same task and with the meds notice: how did it feel? Did it feel different? Was it easier to start/stop? Did you find a rhythm? Were you less angry/anxious? It’s your own experiment on yourself. When you have a gauge of if the med is working, you ask: how is it making you feel?
The medication should make you less angry. Notice transitions and your frustration tolerance.
What are some types of medications for ADHD?
Non-stimulant: small chemical restraints, like a heavy blanket. Slows you down by slowing down your blood pressure. Often more effective for folx experiencing more anxiety alongside their ADHD, because it works against the anxiety.
Eg. Strattera, Intuniv (Guanfacine), etc.
Stimulant: You don’t have to be angry to be interested, or nervous to be focused, you are just stimulated (your nervous system is stimulated with the medication).
Eg. Adderall, Ritalin, Concerta, Focalin, etc.
Adderall - stimulant with a hint of anti-anxiety (in how the molecule works in the brain)
Ritalin - pure stimulant
Focalin - extended release form of Ritalin, lasts longer
Stimulants: Short-release v. Extended Release (or XR)
Stimulant medications go in and out of the body relatively quickly. Some medications, like Adderall or Ritalin (or non-XR medication, XR meaning Extended Release) go in and out of the body within 4-8 hours (about how long you feel the intended effects, based on dosage and of course each person’s unique metabolism). Other meds that are XR or like Focalin, have a much slower release in the body or a slower drop-off and last longer (8-10 hours). There are pros and cons—a trauma survivor, for example, may notice their flight/fight/freeze response is activated by the quick kick-in and drop-off of a short-release med and do better with a longer release med. It totally depends! One advantage is that you will know often within the hour if an ADHD medication is working or not for you. If you’re trying a new med, ask your prescriber to avoid the XR or extended release version of the medication, because you don’t need a 10-12 hour experience to know if it works for you or not.
Antidepressant: Can be typical or atypical, and connect to changing the levels of certain neurotransmitters (mainly serotonin, as the class of drugs known as SSRI or selective serotonin reuptake inhibitors) in the brain. For example: Wellbutrin (atypical antidepressant, generic name bupropion) is off-label prescribed for ADHD, and works by inhibiting the uptake of (or increasing the quantity of) dopamine, serotonin, and norepinephrine in the brain. All of those neurotransmitters are affected by the brain difference that is ADHD.
e.g. Zoloft, Wellbutrin
REMINDER: We are not doctors or prescribers, but two therapists who have a lot of experience working with folx on/off, loving/hating, trying/not trying all types of medications and accommodations for ADHD. Please seek medical advice for all your medication questions!
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Cover Art by: Sol Vázquez
Technical Support by: Bobby Richards