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this is as much of a cocktail side effect issue as a stim issue, so i felt that this board was better than the stim board. Basically, I think ive hit a high enough tolerance on my adderall that it is trending from "helps mood and focus" to "required to get through the day without being a zombie". If I dont get 30-40 mgs right when i wake up the first half of the day is shot. Even then, i have to wait 90 minutes to take the rest of my meds so the stim kicks in. The worst part is, I am still mostly stuck at home, so its not even like there is anything to make me tired. I've been around the psych med train (and CB) long enough to know what the options are at this point. 1) increase dose 2)switch to methylphenidate 3) switch to nuvigil/provigil 4) try to switch amphetamine based meds and hope there isnt a huge cross-tolerance. The problem is none of those ideas are super attractive to me (and probably my pdoc) right now. And now i will do that annoying thing where people ask for advice but rule out most of the options, but its mostly cuz i am worried that i cant get things to improve. 

1) pdoc has seemed willing to bump to 70 or 80, but only for temporary situations like school issues etc, and since my status is not changing anytime soon, it would be very hard to find a spot to go back to 60, and if we didnt i feel like id just eventually hit tolerance at the higher dose eventually.

2) i had no luck with really high dose focalin, but i know that isnt the same as ritalin. However, I'm not sure that pdoc is gonna love making that cross-titration in the quarantine setting when my sleep is already a bit suspect. Pdoc and I have agreed to try and stick to IR formulations, at least to start becuase i had no success at all with XR adderall and because i need an immediate "punch" in the AM just to get out of bed.   

3) We've discussed this too, but pdoc and I dont think it will help much. I really need the stimulation of adderall, but while I don't have an ADHD Dx technically, it was suggested in my neurocog testing that I need something to help with executive function/focus. Also, my insurance is not a fan of either

4) Pdoc and I discussed adderall and IR dextroamphetamine when we picked the stim years ago. Would you think there would be lots of cross tolerance? @mikl_pls were you the dextroamphetamine fan (in the past?). Evekeo i dont know much about, and pdoc usually presents me with all his options so i'm guessing he doesn't like it or doesn't use it. Either way, he has been great with me about pushing limits and being creative, so when he doesn't want to use something i don't argue. Am I missing any options for IR amphetamine (no desoxyn, not even gonna go there)  sooooooo....

Anyone think one of those options sucks less? Am i missing an idea? Am I being unreasonable? All input welcome 

P.S. I should add that after I take a 20 mg dose 4ish hours after the 30/40mg dose, my body does catch up a bit... but having my highest energy right when I sit down to dinner isnt really useful, But i dont know how to alter the schedule, because taking more than 40 mg right away seems ridiculous 

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How often are you taking your stims? Every 4-6 hours is generally recommended for Adderall and other amphetamines, but you could go every 3 hours.

Yes, I'm (one of the) Dexedrine fans... lol. It provides me with more wakefulness promotion than Adderall every did. Dexedrine 60 mg seems stronger than Adderall XR 90 mg somehow... Or *seemed*. I think it may be the generic brand I'm on that sucks. As far as cross-tolerance goes, Adderall is 50% dextroamphetamine + 50% amphetamine, and Dexedrine is 100% dextroamphetamine, so I guess there could be some cross-tolerance.

Evekeo is 100% amphetamine (racemic), so it's 50% dextro- and 50% levoamphetamine. It doesn't suppress appetite as much as Adderall or especially Dexedrine (that stuff obliterates your appetite). Evekeo is the most peripherally-acting stimulant what with the most content of levoamphetamine.

Supposedly inattentive symptoms do better with more noradrenergic stims (Evekeo, Adderall), whereas combined and hyperactive type do better with dopaminergic ones (Adderall, Dexedrine). Even though I'm inattentive, I still prefer Dexedrine.

I personally think that if you were to get your pdoc to switch you to Dexedrine 60 mg (either IR tablets or Spansules), you'd be feeling a lot better.

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27 minutes ago, mikl_pls said:

How often are you taking your stims? Every 4-6 hours is generally recommended for Adderall and other amphetamines, but you could go every 3 hours.

Yes, I'm (one of the) Dexedrine fans... lol. It provides me with more wakefulness promotion than Adderall every did. Dexedrine 60 mg seems stronger than Adderall XR 90 mg somehow... Or *seemed*. I think it may be the generic brand I'm on that sucks. As far as cross-tolerance goes, Adderall is 50% dextroamphetamine + 50% amphetamine, and Dexedrine is 100% dextroamphetamine, so I guess there could be some cross-tolerance.

Evekeo is 100% amphetamine (racemic), so it's 50% dextro- and 50% levoamphetamine. It doesn't suppress appetite as much as Adderall or especially Dexedrine (that stuff obliterates your appetite). Evekeo is the most peripherally-acting stimulant what with the most content of levoamphetamine.

Supposedly inattentive symptoms do better with more noradrenergic stims (Evekeo, Adderall), whereas combined and hyperactive type do better with dopaminergic ones (Adderall, Dexedrine). Even though I'm inattentive, I still prefer Dexedrine.

I personally think that if you were to get your pdoc to switch you to Dexedrine 60 mg (either IR tablets or Spansules), you'd be feeling a lot better.

Thanks, Im trying for 4 hours... that was always how it was prescribed, but I often vary it depending on the day schedule. I am considering doing the old wake up and hour early and take the first dose and go back to sleep, in hopes that it will kick in. I am so biased toward "night owl" that the early as possible strategy is probably worth a try. Ive tried it in the past, with not really any remarkable results, but what the hell? Of course, I just talked to pdoc last week and forgot that im doing online pharmacy now, so there is currently a shitload of Adderall headed my way. My pdoc has always trusted me, but I am guessing he would prefer a dose bump trial before anything else to at least make use of some of the hundreds of pills. Which I guess makes sense, its a lot easier to mess with an abundance of pills already at my house than having to do a whole new trial. Especially because I sometimes have to rely on out of state pharmacies and the schedule 2 Rxs can be a bitch to deal with 

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Back in the days of normal schedules, he used to let me vary the dose depending on the day. Maybe i could talk to him about 30mg-20mg-10mg four hours apart (which is what I am technically supposed to do) and adding like a 20mg prn. 

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I don't take dexerdrine for ADHD bit it is my favorite stimulate. My doctor will only let me go up to 60mg. Only problem is I eventually build a tolerance and have to go on a drug holiday, which leaves me bedridden for weeks on end. I never know what to do. Sigh.

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21 hours ago, mikl_pls said:

How often are you taking your stims? Every 4-6 hours is generally recommended for Adderall and other amphetamines, but you could go every 3 hours.

Yes, I'm (one of the) Dexedrine fans... lol. It provides me with more wakefulness promotion than Adderall every did. Dexedrine 60 mg seems stronger than Adderall XR 90 mg somehow... Or *seemed*. I think it may be the generic brand I'm on that sucks. As far as cross-tolerance goes, Adderall is 50% dextroamphetamine + 50% amphetamine, and Dexedrine is 100% dextroamphetamine, so I guess there could be some cross-tolerance.

Evekeo is 100% amphetamine (racemic), so it's 50% dextro- and 50% levoamphetamine. It doesn't suppress appetite as much as Adderall or especially Dexedrine (that stuff obliterates your appetite). Evekeo is the most peripherally-acting stimulant what with the most content of levoamphetamine.

Supposedly inattentive symptoms do better with more noradrenergic stims (Evekeo, Adderall), whereas combined and hyperactive type do better with dopaminergic ones (Adderall, Dexedrine). Even though I'm inattentive, I still prefer Dexedrine.

I personally think that if you were to get your pdoc to switch you to Dexedrine 60 mg (either IR tablets or Spansules), you'd be feeling a lot better.

I also prefer dextroamphetamine, Dexadrine is 100% dextroamphetamine.

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Yeah like I said we talked about several years ago but I guess the adderall was a natural starting point, and it worked for years so there has been no need to discuss change. Like I said above, I am not sure that making a stand for dextroamphetamine is a wise choice when he just gave me a million adderall without at least seriously considering an adderall bump first. It is possible that he goes another route and tries to address my sleep better, with the logic of better sleep= less tired. Realistically nothing will hold sleep on long term though. Also, in the past August has been a breeding ground for mixed mania and I think he feels that the risk of pushing mania overwhelms the benefit of more energy... but that occasion may change as it goes toward winter SAD season (and if we ever get back to actually needing to leave the house) Also, clozaril is an absolute mania killer for me. But of course, it also can trigger the useless cycle of developing hypomania leads to more clozaril leads to more sedation leads to needing more stimulating meds and rinse and repeat 

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Depending on how long you need the stimulation to last, you could add a booster Adderall XR (10-12 hours) or Mydayis (16 hours) in the morning and take your IR tablets as usual.

Don't quote me on this, but I believe Adderall XR is 50% IR/50% ER, and Mydayis is 40% IR/40%  ER/20% "delayed IR" (an IR dose that doesn't kick in until 12 hours after you take it). It's to basically simulate an IR booster dose taken 12 hours after an Adderall XR is all.

Same could be done with Dexedrine. You could either use Vyvanse (bleh) or the Dexedrine Spansules ( :) ) for your ER stimulant along with your IR tablets.

Another possibility is adding an NRI, but not sure if that would agree with your mood too well. Strattera is one, but one of its metabolites is a delta-opioid partial agonist, which can not only be depressogenic but also psychotomimetic. I like the secondary amine TCAs, nortriptyline, desipramine, and protriptyline. Desipramine is probably the "cleanest" out of the three. Protriptyline is probably the most stimulating out of the three, although nortriptyline in high enough doses can rival protriptyline's stimulation.

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My doc wouldn’t put me within 15 miles of a TCA for a minute ... or probably almost any AD at this point. The XR + IR booster strategy we tried a while back, XR was just useless for me. I think it’s more the “punch” I need, and we’ve found that multiple “punches” (ir) just does a lot more for me... if that makes sense. I think part of this is because I do need a bit of  flexibility in timing based on when I  take other meds. (I won’t do the long dissertation here, but it’s not as simple as just take them at the same time everyday). I didn’t feel the XR help me stay awake. This is why if I do make a change down the road, it’d probably be to dextroamphetamine and it’d probably be ir (at least to start). It seems like dextro.... is easily the opinion poll winner on CB. Part of me wonders if any trial now would be that informative, since my work is all “on my own” scheduling and I don’t have classes until the fall. So I’m wondering if it’d be better to just get through the summer (possibly with 10-20 more ir if I can’t get this regulated) and then save the dextroamphetamine (in the future I might just say “Dexedrine” cuz it’s easier to type) for when I can get a read on a more consistent and demanding schedule. I appreciate the input, stims is the one area of psych meds where I don’t have much broad personal experience 

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23 hours ago, Iceberg said:

My doc wouldn’t put me within 15 miles of a TCA for a minute ... or probably almost any AD at this point.

Ooh, oh my... I assume because of the risk of mania?

23 hours ago, Iceberg said:

The XR + IR booster strategy we tried a while back, XR was just useless for me. I think it’s more the “punch” I need, and we’ve found that multiple “punches” (ir) just does a lot more for me... if that makes sense.

It makes perfect sense, I feel the same works better for me and my idiopathic hypersomnia.

23 hours ago, Iceberg said:

I didn’t feel the XR help me stay awake. This is why if I do make a change down the road, it’d probably be to dextroamphetamine and it’d probably be ir (at least to start). It seems like dextro.... is easily the opinion poll winner on CB. Part of me wonders if any trial now would be that informative, since my work is all “on my own” scheduling and I don’t have classes until the fall. So I’m wondering if it’d be better to just get through the summer (possibly with 10-20 more ir if I can’t get this regulated) and then save the dextroamphetamine (in the future I might just say “Dexedrine” cuz it’s easier to type) for when I can get a read on a more consistent and demanding schedule. I appreciate the input, stims is the one area of psych meds where I don’t have much broad personal experience 

XR's don't help me stay awake either, neither Adderall nor Dexedrine, but Dexedrine more than Adderall, if that makes sense.

Dextroamphetamine IR tablets, 10 mg 2 PO tid has been what I've been on for three years now (until recently my prescriber screwed it up after I tried switching to Zenzedi and not being able to find ANYONE who could fill Zenzedi 20 mg, I'm now on 30 mg/day instead, but it's something, and that whole weekend without it was just torturous hell. I'm so glad to have it in my system again I'm just happy with 30 mg.). Sometimes I would lump two doses together for 40 mg if I waited too long to take the 2nd dose or something like that. Probably not what you're supposed to do, but if I don't have all my D-AMP in my system, I turn into the living dead.

D-AMP is definitely the best I've taken hands down. And I've even tried Desoxyn, that stuff is crappy. Not nearly as stimulating as dextroamphetamine. I honestly believe dextromethamphetamine is weaker than dextroamphetamine, at least IME... I then became suicidally depressed and weepy on Desoxyn the second time around and gave it back to my pdoc to dispose of properly. The first time I was just in a constant haze, but that was also when I was on Luvox, which may as well have been dropping acid.

I've heard Adderall is better for giving you a motivational "kick in the butt" and can even make you feel listless if you're not doing anything, like you HAVE to be doing something all the time on it. It's been so long since I was on it I don't remember what it felt like. But I don't remember anything that major. I just remember the magic of switching from Adderall 40 mg to Dexedrine Spansule 15 mg (that was what my pdoc said was the equivalency and she stuyck with it) and how much more socially outgoing it made me. It did make me liable to being a little cranky at first but that passed within a week or two.

If you can, find a pharmacy that distributes Mallinckrodt generic (whether IR or ER). It is virtually unanimously agreed upon that it is the strongest, most potent generic out there. Amneal is the authorized generic of the ER spansules, so it's just like take brand-name. Sometimes you can request a brand, but usually you're just SOL as to what brand they have if it's not the one you want. Not even Mom and Pop pharmacies are that good about ordering because if your insurance won't pay for it you have to pay cash up front. (Boo!)

Evekeo (racemic amphetamine sulfate) is a bit of a mystery stimulant. I've tried it twice, both times at 20 mg/day because that was what the free voucher was for, and I didn't notice anything.

I have pretty extensive experience wth stimulants, as long as they're amphetamines... lol. They methylphenidates don't work for me at all, so I haven't taken them much. I just know Ritalin is placebo and Focalin XR is a panic attack pill. lol

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Yeah. TCAs way too risky for mania. I had serious problems with both celexa and Wellbutrin both at the lowest dose. Remeron was also problematic... and those are typically lower risk for issues so I think any TCA ever is out. I have also heard adderall is a more “kick in the butt” which I think is why I never tried D-Amp cuz the kick is what I need most 

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9 hours ago, Iceberg said:

Yeah. TCAs way too risky for mania. I had serious problems with both celexa and Wellbutrin both at the lowest dose. Remeron was also problematic... and those are typically lower risk for issues so I think any TCA ever is out. I have also heard adderall is a more “kick in the butt” which I think is why I never tried D-Amp cuz the kick is what I need most 

What about atomoxetine (Strattera)? Do you think it might do the same? I mean, it's not the greatest med ever, but if taken in augmentation with your stimulants, it may help with vigilance and wakefulness. (I believe norepinephrine is highly related to the "wakefulness center" of the brain or something like that? Don't quote me on that...) Then again, dopamine has a strong wakefulness promoting effect too... That being said, perhaps augmenting (instead of switching) to modafinil/armodafinil could possibly help. They're not primarily dopaminergic, if anything orexigenic and histaminergic, but armodafinil is a D2 partial agonist I believe. My pdoc said that 200 mg modafinil = 150 mg armodafinil if that info is of any use. Modafinil is typically dosed up to 400 mg/day, but can be dosed even higher (with yet another PA I'm sure) up to 600 mg I've seen, and while armodafinil is typically dosed only up to 250 mg/day (highest dose pill they make), I've seen some people dosed up as high as 500 mg/day of it (they had to fight their insurance company tooth and nail, but they finally got them to approve it and they say it's totally worth it). I personally wasn't a responder to modafinil (up to 400 mg/day), and 250 mg armodafinil barely really did anything much for me except boost mood and cause extensive weight loss on top of the tremendous weight loss I had from first starting Adderall earlier at that time.

I wonder if trimipramine (Surmontil) would throw you into mania? 🤔 Trimipramine is considered an "atypical tricyclic" because it has no monoamine reuptake inhibition to speak of. It works mainly as a 5-HT2A antagonist and a presynaptic D2 autoreceptor antagonist (releasing dopamine) (kinda like low doses of low-potency antipsychotics and some high-potency antipsychotics like flupenthixol, sulpiride, amisulpride, etc., none that are in the US, as well as low doses of buspirone). Trimipramine itself, in high doses, is sometimes used in schizophrenic patients because its antipsychotic properties are very close to those of clozapine. (But you're already on clozapine so...) Just wondering to myself aloud... lol.

Don't get me wrong, Dexedrine has a "kick" all to itself, but it's just... "different" than Adderall's. I do wonder if I should go back to Adderall though because I have been so unmotivated to do anything. My room has become a maximal disaster zone. There's basically just a path (barely) from my door to one side of my bed and that's it, and I can't find anything. My keys have been missing for a week. No idea where they could be. Everywhere else, shin-deep in clutter and papers (probably mostly unpaid bills). Since my prescriber accidentally mistakenly wrote my Dexedrine prescription for 30 mg/day, I actually have noticed I have a lot more motivation to get stuff done (but I'm a lot more tired and want to take more naps). I kinda wonder if 60 mg was too much Dexedrine? And like I said, I also wonder if I should try going back to Adderall? 60 mg should suffice, but I may need 80 mg or higher to equate to the 60 mg I was used to in Dexedrine (although lower might be better). I've also considered giving Evekeo another spin but at a higher dose. It's not nearly as potent a CNS stimulant as Adderall or Dexedrine, more peripheral nervous system stimulant than anything, but I imagine the "kick in the butt" effect is pretty strong with Evekeo if it's 50% levoamphetamine. Next appointment I honestly may do Adderall and then Evekeo after that (sort of to transition from the ratios of D-:L-amphetamine more gradually) because I've been extremely curious about Evekeo.

I was also curious about trying oral selegiline for the L-methamphetamine/L-amphetamine metabolites that it confers along with the Dexedrine (that way I wouldn't have to make a switch). I do believe my reward center is just completely broken which is why I can't motivate myself to do anything (dopamine thing rather than noradrenergic thing I believe), but having selegiline on board would give the L-methamphetamine/L-amphetamine (which are basically selective norepinephrine releasing agents and hardly work on dopamine at all), plus the selegiline, which in the doses I'd be taking (5-10 mg PO) would be selective for MAO-B inhibition, so theoretically it should be safe to take with the rest of my cocktail.

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Yeah, the tricky bit is that I don’t think I’d ever find a pdoc comfortable with two stimulating agents on board at the same time. My first three pdocs didn’t even consider one. Especially because when certain symptoms come back the first consideration is lowering the stim. Nu/provigil would be an insurance fight on their own I can’t see ever getting it buy with already taking adderall at a higher end dose. I also have to be careful that the effect will wear off fast enough to not kill my sleep. He and I considered provigil a while back but decided I. Needed the stronger amphetamine. I think any type of antidepressant (or antidepressant-ish) is probably off the table, so if there were a change it would probably be thought of in the current state as best: up adderall, 2nd best - introduce d-amp or other amphetamine option. 3- try methylphenidate 4-do any sort of combo. He is more of a Max first, then augment type prescriber (although he’s also been pretty aggressive with me) so I can’t see an Add one without Maxing some sort of stim. The other concern is that adderall battles my depressive symptoms in some way so I don’t want to lose that but I bet other amphetamines could also do that to some degree 

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42 minutes ago, Iceberg said:

He and I considered provigil a while back but decided I. Needed the stronger amphetamine.

IME, Provigil did nothing, even up to 400 mg/day. Nuvigil barely did anything when it was brand-name, and did nothing when it went generic.

43 minutes ago, Iceberg said:

(or antidepressant-ish)

So that probably includes atomoxetine (Strattera) then lol

43 minutes ago, Iceberg said:

3- try methylphenidate

I can tell you from experience (my experience anyway) that if you start with amphetamines and are used to them, methylphenidate is far weaker. But don't rule it out, especially dexmethylphenidate. It's about as potent as dextroamphetamine, and with Focalin XR you can go up to 40 mg/day for some reason.

44 minutes ago, Iceberg said:

The other concern is that adderall battles my depressive symptoms in some way so I don’t want to lose that but I bet other amphetamines could also do that to some degree 

I can say from my experience Dexedrine definitely combatted my depression far more/better than any amphetamine I've tried has ever done. Evekeo was surprisingly good at bringing my "goofy, silly" side out of me, but I didn't really give Evekeo a fair trial.

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Haha unfortunately focalin failed me. However, I have heard many opinions like the one you just gave That methylphenidate isn’t as “robust”

It’s interesting though, cuz I always heard focailin was milder 

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