36mg Concerta

Last Monday, I called my doctor and we discussed the med-free insomnia. He was a little perplexed. We agreed that I shouldn't start anything else until the problem resolved itself. He suggested I take 3mg of melatonin around 8pm, and I was to call him if it hadn't gotten better by the end of the week.

 I don't know whether it was the melatonin or not, but on Monday night it improved considerably, and on Tuesday night I slept like the proverbial log. It must have taken less than 5 minutes to fall asleep, and I remember nothing else before waking up in the morning. So, good news.

It turns out that neither the kind of insomnia I was experiencing nor the improvement after a week should be that much of a surprise. I looked up some research on amphetamine withdrawal, and very light, disrupted sleep is a nearly universal withdrawal symptom. One of the papers also found that most of their subjects recovered from the worst acute withdrawal symptoms after about one week.

Of course, the real question is: why would those symptoms start when I was still taking my meds? I see two possibilities:

1. I was going through withdrawal at night after my daily dose wore off. This might make more sense for my experience on 50mg Vyvanse than it does for 30mg Vyvanse.
2. When it started on the weekend it was withdrawal from the higher doses I was taking during the week when I supplemented during work hours with dexedrine.

A combination of these things is also possible. It may have been mostly #1 while on 50mg, and a combination of #1 and #2 while taking 30mg on the weekend. Of course, once I dropped the meds entirely it would have been just regular withdrawal.

There are many outstanding questions here. One of the most central for me is: Why am I so sensitive to amphetamines to experience withdrawal on such a low dose? My effective daily dose was only ~20mg Dexedrine. The subjects studied in the papers were taking 5-10 times that much. It is unlikely that I'll every really know the answer.

The question now is: Will I experience fewer problems on methylphenidate? The experiment we're running to find out is the only one possible: Try methylphenidate and see what happens. On Wednesday, sleep problems resolved, I started 18mg Concerta. Didn't really notice any effects, positive or negative. Maybe a little more awake without any need for caffeine, but that's it. No insomnia.

Today I went up to 36mg as instructed by my doctor when he gave me the prescription. Still not noticing much of anything, but I am feeling nicely awake and alert. So, that's good.

We'll see how work goes tomorrow. I'll call my doctor to consult. I imagine if I have no negative side effects he will put me up to 54mg on Wednesday. I'm fine with moving that quickly now; I think I'm better at assessing positive work effects now that I have more experience with the ups and downs of the meds. It may depend on how I feel today and tomorrow, though. Maybe if I feel like I'm getting some good help on 36mg I'll wait a little longer.

I looked up rough equivalences between Concerta and Ritalin, and Ritalin and Dexedrine. Concerta is equivalent to approximaetly 2/3 of the same daily dose of Ritalin (not all of the medication is released from the Concerta delivery vehicle). Ritalin, in turn, is equivalent to about 1/2 of the same daily dose of Dexedrine. Put that all together, and Concerta is approximately equivalent to 1/3 of the same daily dose of Dexedrine. So 36mg Concerta ~= 12mg Dexedrine.

Now, a given mass of Vyvanse is equivalent to a little over 1/3 of the same daily dose of Dexedrine:  30mg Vyvanse ~= 12mg Dexedrine. So it turns out that today's Concerta dose is about the same as my previous usual Vyvanse dose. Not surprising, then, if it is mostly making me feel more awake.

In any case, it is useful that Concerta turns out to be only a little less potent than Vyvanse mass-for-mass. It will make it easier to compare results vs. my Vyvanse experience.

Going up to 54mg Concerta will be the real test. That will be nearly exactly the Vyvanse dose at which I started to feel more jittery than focused, and at which I started to have sleep problems.

"...maybe amphetamine is just not your drug."

Prophetic words. Last weekend, just after posting about feeling like the Dexedrine wasn't working out very well, I started to have sleep problems. Same problem I had on 50mg Vyvanse: not too difficult to get to sleep initially, but then I wake up around 1:30am and barely get back to sleep at all after that. Really, really light, fitful sleep.

This actually started on the Sunday, when I was only taking Vyvanse. Didn't think too much of it, though. Only one night, right? I start off on only 2.5 Dexedrine on Monday, though.

On Monday night, same thing. Hmmm...now I notice the trend. So on Tuesday I take just the Vyvanse. At this point I'm completely sure that the problem will go away. After all, I've never had a single issue on 30mg Vyvanse.

Same problem Tuesday night.

Now I'm worried. On Wednesday, I don't take anything, not even any caffeine. I expect to feel completely bagged, but I'm oddly OK. Call my doctor, tell him what's going on. We agree I should stop the amphetamine-based meds and try Concerta. "At least," I think, "I'll get a good night's sleep tonight."

Nope. Wednesday night is the same as the others.

On Thursday I again take nothing, though I have some tea to get me through the day since I'm now really tired. Can't tell if this is some amphetamine withdrawal or just the effects of not sleeping well for several nights in a row. Despite having picked up my new prescription, I decide to stay off all meds until I've had a good night's sleep. Concerta has a 12% reported occurrence of insomnia; how am I going to know if I'm affected if I have sleep issues before I take the first pill?

Thursday night I take 6mg melatonin. Never had to take it before since my previous sleep problems have gone away as soon as I reduced the meds. Friday I try 3 mg, and last night I tried 6 again.

I think last night I finally saw some improvement. I still woke up around 1:30am, but I had to pee and unlike the previous nights I felt pretty sleepy. Don't remember having a ton of trouble getting back to sleep. I did wake up a couple more times, but my memories of the night are of brief periods of wakefulness. I'll take 6mg melatonin again tonight and we'll see how things go.

One very interesting part of this experience has been doing my job through it. I have definitely had more trouble with alertness (not shocking given the lack of sleep), but I haven't had a ton of trouble getting things done. I feel much more relaxed. I don't know why, but it seems like over the last month the amphetamines stopped making me feel motivated and energetic, and started just making me jittery.

Hopefully my sleep will settle down and I can try the Concerta. Will post when I do.

30mg Vyvanse, again

Ugh. What a difference a few days makes. A few hours, actually, since things kind of fell apart on Sunday night, less than 12 hours after the last post.

I'd noticed a bit of irritability in the evenings on the Spansules during the week. I didn't take it too seriously, as short-term side effects are not unusual after changing doses or medications. I'd also noticed, with a little more alarm, some difficulty maintaining an erection around the same time. Again, I was willing to wait it out and see if there was really a long-term pattern.

Well, those things came together to make one big unacceptable problem on Sunday. Suffice it to say that my grumpy, anxious self made a nice wreck out of the end of the day. I had a horrible night, and I spent the morning lying in bed contemplating my own worthlessness until I couldn't delay getting up any longer.

Luckily, I did manage to get up and take my dose. An hour later, back in my right mind, I called my doctor and said I had to back off to 30mg of Vyvanse. That's the last problem-free dose I was on, and I have to get back to problem-free before I can seriously consider another experiment. I accept that this is a fundamentally experimental process, I really do. I just refuse to jump from problem to problem. I have to make sure I have a stable baseline of experience to compare with.

My doctor suggested that amphetamine may just not be my drug (his turn of phrase), and that we should consider trying methylphenidate (Ritalin) or atomoxetine (Strattera). I'm not ruling that out, but I don't think I should jump there from a crisis if I can avoid it.

In any case, it is clear that Spansules were definitely not my thing. Not only did I have negative side-effects, I didn't feel like I was getting the level of positive effects that I experienced on 30mg or 40mg of Vyvanse. This is surprising, since 20mg of Spansules is pharmacologically equivalent to 50mg of Vyvanse. I guess more amphetamine is not what I need.

So, back to 30mg Vyvanse for me. In addition to the 30mg of Vyvanse, though, I also have a bunch of 5mg dexamphetamine sulphate tablets. My deal with my doctor is that I'm going to try splitting those into 2.5mg halves and spreading 2 and then maybe 3 of them over my work day. My hope is that the smooth base of medication from the Vyvanse will prevent an evening "crash" without causing insomnia, and the tablets will let me play around with a bit of a higher dose during the day.

The best I've felt this whole time was when I was on 40mg of Vyvanse with a 5mg dexadrine tab at noon, but even on 40mg I remember feeling like I was sleeping a little too lightly and wasn't tired enough in the mornings. I think it is worth trying 30mg of Vyvanse as the base and seeing if I can't get back to the same level of positive effects by augmenting with the 5mg tabs.

I have to keep remembering that my goal is to get just enough help to be happy. I can't shoot for feeling awesomely focused all the time, or I'm likely to end up chasing that goal into riskier meds and doses than I'm really comfortable with. I'm getting a sense now, though, for how this process can take you in that direction. It is so tempting to just try a little more medication. Then when you get the negative symptoms, you get the offer to fix it with another medication, or a different medication. Going back to less seems like a step backwards, a concession, a defeat.

Well, I don't see it that way. Going back to a known good state is the only way to recover the stability necessary to make a good decision on your next steps. Maybe I'm just lucky that my unmedicated state was already not too shabby. If I was coming to meds with my life falling apart, I can see how it would be a much harder decision to back off in that direction again.

20mg Dexedrine Spansules...

Wow, the last couple of weeks have been a blur. 50mg Vyvanse worked fine without the 5mg Dexedrine, except for one thing: I couldn't sleep through the night. I could get to sleep well enough, but I would wake up several times during the night. Each time it would take a long time to get back to sleep.

Most telling of all, for me, was that I couldn't even manage to get a half-hour of sleep at the end of the night, around the time I usually get up. This is also the time I usually take my dose. I was too alert to sleep even 24 hours after taking the Vyvanse, even after barely sleeping that night. It was clear to me then that the Vyvanse must be sticking around in my system for way too long. In retrospect, this fit with my experience on Vyvanse from the very beginning. When I started on 30mg, exactly the same thing happened. I'd sleep for maybe 4 hours, and then pop out of bed effortlessly.

My doctor doesn't have any particular explanation for this. It is possible he thinks I'm just imagining the whole thing. I couldn't find much information on why it might be happening, other than some stuff about acidic diets speeding up the metabolism/elimination process, and basic or acid-neutralizing diets doing the opposite. My diet happens to not include many acidic items, so maybe that is it.

I got fed up with not sleeping on a Friday when I would not have an opportunity to talk to my doctor, so I just dropped down to a left-over 40mg Vyvanse for that day, and then went to 30mg for the weekend. No problems sleeping at all on the 30mg. Felt a little blurry around the edges dropping down to 30 that quickly, but nothing serious.

On Monday my doctor recommended trying Dexedrine Spansules as they are not supposed to last as long as Vyvanse. The mechanism for releasing the drug over time is also less complicated than Vyvanse, so it is less likely that something odd about my metabolism would cause it to last longer than usual. So far this has worked out well. I am not having difficulty sleeping, and I wake up in the morning feeling more like my usual non-medicated self; that is, I don't want to get out of bed.

I think I've been on the meds long enough to say that they are having a positive effect for sure. I think that the Spansules are not quite as potent as the Vyvanse was yet, so I may have to go up to 30mg. We'll see. My experience on Vyvanse indicates that I may have been receiving a higher, longer dose of medicine than most people would on the same intake, so it may take a larger-than-expected dose of Spansules to produce an equivalent positive effect.

40mg Vyvanse, Day 4

I had less trouble getting to sleep last night, though I did end up waking a few times. I'm working on a bit of an odd problem right now, though, and I was waking up because I was dreaming about it. This is not unusual for me when I work on something right before bed. I'm not going to blame the meds right now.

Otherwise, I feel good this morning. We'll see what the day brings.

40 mg Vyvanse, Day 3

No insomnia the first night on 40mg. Maybe a little irritable during the first day due to feeling somewhat frazzled. Second day was fine. A bit of trouble getting to sleep last night. Both the frazzled-ness and the sleep delay were well within my non-medicated experience. Third day, today, is good. Feeling energetic, but not too much so. Calm.

One of my big questions about this whole medication process is: When will I know I'm taking enough? I'll know I'm taking too much when I get unmanageable negative side effects. That's clear. I don't want to figure out where too much is and just back off a bit, though. That's not taking enough, that's taking as much as possible. I want just enough to give me the help I need.

So back on Thursday when my doctor called to say it was time to go to 50mg, I asked him. Turns out that taking too much and backing off is pretty much the standard procedure. I told him I already thought the medication was helping me a bit. Wouldn't it be better to figure out how much it was helping before trying a higher dose?

My doctor's opinion is that I would know for sure if it was helping. I have to consider that seriously; what is the point of having a doctor who specializes in ADHD if I don't? My work experience is highly variable, though. I have some very good weeks, some very bad weeks, and plenty of weeks in between. Even with ADHD I'm a pretty competent and successful person, so even on the so-so weeks I would manage to get the critical stuff done (and on the bad weeks I'd manage to make plausible excuses). I can only measure how well I'm doing by how happy I am with what not only what I got done, but how I got it done.

Last week was pretty consistently good, which tells me that the meds are likely helping somewhat. It wasn't perfect, though; I did end up doing some unnecessary surfing and other self-distraction when things got frustrating. What didn't happen was that part where I get caught up in self-distraction for hours. So, I can't be sure. It could be that just knowing I'm on meds making it easier for me to pull myself back from the edge. In other words, placebo effect. I won't really know until I've been on a dose long enough to stop thinking about the meds and just settle back into my life.

I told my doctor all of this. I want to take just enough medication to give me the help I need to be happy. I don't want to end up taking much more than that just because I wasn't yet completely sure, or because a little bit more might make me feel even better. I'm OK with some residual struggle. Heck, I have to expect struggle. If I'm not struggling, then I'm not challenged enough. I want to feel challenged.

He clearly thought I was making too big a deal out of trying higher doses. From his point of view the meds are very safe. If you are going to bother taking them, why not take whatever amount provides the most help? I can see his point. Even though the meds do present some risks, why take on 30mg worth of risk for marginal benefit, when 40mg might provide much more benefit for little additional risk? Moreover, just was one can't figure out what the benefits of a given dose might be beforehand, given one's unique physiology, neither can one figure out what the problems will be.

The short-term problems caused by the meds, the ones you know about right away, are not my biggest concern, though. I'm worried about the long-term risks, with cardiovascular health at the top. Potential long-term neurological changes are just behind that, not because I'd be less concerned if they occurred but because there is not much evidence that they will.

It is reasonable to conclude that the risk of long-term adverse effects increases with the dose. The shape of the curve is not known, though. I'll have to look up what the typical dose/risk curve looks like for these kinds of medications. The bottom line is that taking more meds means more risk, so I only want to take more if I don't think my current dose is helping enough to be worth taking meds at all.

So, I came to a compromise with my doctor. I went to 40mg instead of 50, and I'm planning to stay at 40 for two weeks instead of one. My life is not falling apart; I'm in no great hurry. I understand that the only way to find out how I'd feel on a higher dose is to try, but I'm not interested in seeing how non-ADHD I could possibly be without causing unmanageable side-effects. I'm interested in finding out how little meds I need to feel happy with my life, and I can't figure that out without going a little more slowly.

30mg Vyvanse, Day 6

Slept well last two nights. The insomnia is gone, at least at 30mg. No negative side-effects at all now, that I can observe.

Positive effects? A little harder to say. That clear feeling of constant energy and zero inertia has definitely disappeared along with the insomnia. That's good - it was disconcerting and abnormal - but it makes it a little more difficult to discern whether anything is happening at all.

I think I'm having an easier time starting and continuing difficult tasks. There is still that feeling of dread when contemplating longer periods of hard work. I can't expect all of my bad habits to disappear in 6 days, though. I will likely only feel more positive facing tough challenges when I've pushed through a few of them successfully. My dread is only natural; these kinds of tasks have consistently ended with me being disappointed and angry with myself for how I have handled them. I have to recalibrate my dread-meter.