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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by juanantoniod on May 10, 2010, at 20:04:00
Hello everyone,
I am on three antidepressants (Wellbutrin 300mg, Lexapro 10mg, and Abilify 5mg), as well as other medications for various illnesses, which include Insulin Dependent Diabetes, HIV and Obstructive Sleep Apnea. Because of my daily fatigue, I must take stimulants to have enough energy and focus to get thru my day. I do not get high, buzzed, or racing from them.
The problem is that I have been taking Adderall 20mg (regular, immediate release) for several months now and have become tolerant to it. Today, for example, I took 2 (40mg total) to help me get up extra early for an appointment, and ended up falling asleep while on them.
My questions are:
1. Should I try and take a stronger, or XR version of the Adderall? I understand that the XR comes in 7.5mg, and is a mix of various forms of amphetamines. Would this somehow work differently or better, besides just being longer acting, than the plain Adderall?
Or
2. Should I try and take a different class of stimulant medication, such as Concerta, which has KIND OF worked for me in the past?
Or
3. What about combining the 2 classes of stimulants, the amphetamine and the Ritalin classes, for an additive effect? If so, what combo would you recommend?
For what its worth, the Provigil/Nuvigil class of stimulants does NOTHING for me. And, traditionally, I have preferred the amphetamine class over the Ritalin class because of the longer mechanism of action. I tried Vyvanse last month at the strongest mg; I even think I tried taking 2 at once, and it did absolutely nothing as well.
Any thoughts or input are greatly appreciated! Thanks for your help!
~Antonio
Posted by Phillipa on May 10, 2010, at 22:23:06
In reply to Need strongest stimulant suggestions, posted by juanantoniod on May 10, 2010, at 20:04:00
Due to your various medical conditions I would advise you to contact your physician. Sorry I'd like to offer more. Support is all I can offer. Phillipa
Posted by juanantoniod on May 10, 2010, at 22:34:52
In reply to Re: Need strongest stimulant suggestions » juanantoniod, posted by Phillipa on May 10, 2010, at 22:23:06
> Due to your various medical conditions I would advise you to contact your physician. Sorry I'd like to offer more. Support is all I can offer. Phillipa
Thanks for the response, Phillipa, but it is *precisely because of my conditions* that my physicians, in this case, my PDOC, depend on me to do the research and ask for what is best for *me*. Often, I know more than they do about certain things.
For example, did you know that Subutex, currently being used for "opiate 'dependence'" is approved in Europe for use in Treatment Resistant Depression? One of my doctors did not even know what Subutex was! Go figure...
Hopefully, someone will have some ideas for me.
Take good care,
~Antonio
Posted by Phillipa on May 10, 2010, at 23:42:39
In reply to Re: Need strongest stimulant suggestions » Phillipa, posted by juanantoniod on May 10, 2010, at 22:34:52
Oh I also hope someone chimes in with some great suggestions for you. Your doctor must value your research tremendously. That's wonderful to hear and welcome to babble so glad to meet you. Phillipa
Posted by hrguru on May 11, 2010, at 3:41:01
In reply to Re: Need strongest stimulant suggestions » Phillipa, posted by juanantoniod on May 10, 2010, at 22:34:52
Hi Antonio!
My mom is a Family Nurse Practitioner, who works with a Psychiatric Nurse Practitioner. I think that either one of these ladies might be able to give some helpful input regarding your questions. However, I can't ask them your questions without having your personal consent first. Please know that for confidentiality reasons, I would not give your name (of course). And although we are all anonymous here- I would not give the name of the website where I found your post.
I will wait for your consent, before moving forward. If you're okay with me asking for their advice, I will be happy to ask your questions. I'll then post their feedback. If you don't feel comfortable with me asking an outside source, I understand! Just let me know- I want to help any way that I can :)
HRGuru
Posted by juanantoniod on May 11, 2010, at 8:48:33
In reply to Re: Need strongest stimulant suggestions, posted by hrguru on May 11, 2010, at 3:41:01
> Hi Antonio!
>
> My mom is a Family Nurse Practitioner, who works with a Psychiatric Nurse Practitioner. I think that either one of these ladies might be able to give some helpful input regarding your questions. However, I can't ask them your questions without having your personal consent first. Please know that for confidentiality reasons, I would not give your name (of course). And although we are all anonymous here- I would not give the name of the website where I found your post.
>
> I will wait for your consent, before moving forward. If you're okay with me asking for their advice, I will be happy to ask your questions. I'll then post their feedback. If you don't feel comfortable with me asking an outside source, I understand! Just let me know- I want to help any way that I can :)
>
> HRGuruHRGuru,
That is such a thoughtful request, and I am so thankful that you would do that for me. Thank you. I also appreciate your respect for discretion, but yes, you may share your information with your mother and her colleague.
I just did not want anyone here to think I was an addict trying to get high. I am just trying to find out the best way to maybe rotate or cycle through the stimulant medications (amphetamines and Ritalins) so that they can work optimally without building up tolerance. That is why I suggested either switching to a Ritalin based medication like Concerta, or combining an amphetamine with a Ritalin type to produce a synergistic effect.
Please do let me know what you find out. You are so kind. I am very grateful!
~Antonio
Posted by hrguru on May 11, 2010, at 13:04:24
In reply to Re: Need strongest stimulant suggestions » Phillipa, posted by juanantoniod on May 10, 2010, at 22:34:52
Subutex is being used for treatment-resistant depression in Europe?? This is a pretty potent drug. Although it acts as a partial "opiate blocker" (as you can tell, I'm not a scientist, nor a doctor), it still has a high potential for abuse, unless the patient is already taking strong opiates to begin with (i.e. oxycodone). I could only see it being used *safely* in extremely rare cases for treatment-resistant depression. Of course, this is only my opinion. But that is very interesting!!
Posted by juanantoniod on May 11, 2010, at 13:40:10
In reply to Re: Need strongest stimulant suggestions, posted by hrguru on May 11, 2010, at 13:04:24
> Subutex is being used for treatment-resistant depression in Europe?? This is a pretty potent drug. Although it acts as a partial "opiate blocker" (as you can tell, I'm not a scientist, nor a doctor), it still has a high potential for abuse, unless the patient is already taking strong opiates to begin with (i.e. oxycodone). I could only see it being used *safely* in extremely rare cases for treatment-resistant depression. Of course, this is only my opinion. But that is very interesting!!
In Europe, Subutex is used as a treatment for TRD, not as a first line tx. There have been several studies which showed its effectiveness in treating depression. After having the VNS implant, then taking opiates for chronic pain syndrome, it was good to be on it, because it actually improved my mood dramatically!
I guess Subutex _may_ have a high potential for abuse when injected, but I have not done that, so I would not know. I do know that, when taken orally, it is kind of hard to "abuse" because it tastes TERRIBLE! Also, there is no feeling of euphoria associated with it, just a feeling of being not depressed. Such a nice feeling after so many years of feeling awful!
I'm actually at my PDOCs now, I'm going to ask him to turn off my VNS because, not only did it NOT work for my depression, but now, even at the low dose, I am finding that it interferes with my speaking voice.
I decided to ask him about the Adderall XR, then also ask if I can get a script for the Adderall ir, just in case I the XR does not work. Alternatively, if he is pushing it, I will take Vyvanse instead at the highest dosage.
I did some research on the XR and Vyvanse, and the hard part for me is that the dosing for adults is much higher than what my insurance pays for monthly. (Adults would take 60 tabs, they pay for 30.)
Although I am here, and I have my "plan" set out, I will still listen to any input you can provide from your mother or her colleague. I very much welcome other opinios.
Best,
~Antonio
Posted by ed_uk2010 on May 11, 2010, at 14:25:27
In reply to Re: Need strongest stimulant suggestions » hrguru, posted by juanantoniod on May 11, 2010, at 13:40:10
Hi Antonio,
What is the cause of your fatigue? I know this is not necessarily an easy question to answer. Fatigue has so many causes. Sometimes, the cause is not known.
It sounds very much like any stimulant medication is likely to represent a 'dead end' for you. Stimulants may be effective for relieving fatigue in the short term but their long term efficacy is poor due to the development of tolerance. In addition, stimulants do nothing to remedy the underlying cause of the fatigue, whatever that may be. Increasing the dose or combining different stimulants can lead to toxicity eg. hypertension and occasionally psychosis.
My advice is to make a list of the likely causes of your fatigue, with the help of your doctor eg. disturbed sleep due to apnea etc. You can then try to work on each of the possible causes to see whether you can find a solution.
Take care
Posted by hrguru on May 11, 2010, at 14:33:27
In reply to Re: Need strongest stimulant suggestions » hrguru, posted by juanantoniod on May 11, 2010, at 8:48:33
Hi Antonio!
I did not get that impression of you at all when reading your post (that you were an addict). I think you sound like an honest person, just looking for answers :)
I may not be able to get back to you until Thursday- as the psychiatric nurse practitioner at my mom's clinic only works on Thursdays & Fridays. She is pretty good in the area of psychostimulants. I'm sure she will have a few suggestions for you.
I have a question for you- if you don't mind my asking. Do you know if psychostimulants (like Adderall) have been proven to build-up/improve a person's immune system (i.e. make a person less likely to catch a cold or sinus infection, etc.)? I haven't found anyone who has been able to answer this question. What has been your personal experience with psychostimulants? If you don't feel comfortable sharing, please disregard ;)
I will get back to you ASAP will that info, and have a wonderful day! :)
HRGuru
Posted by hrguru on May 11, 2010, at 16:14:40
In reply to Re: Need strongest stimulant suggestions » hrguru, posted by juanantoniod on May 11, 2010, at 13:40:10
Hi there,
I probably didn't state that very well (regarding Subutex). I should have explained that I am an ex-opiate addict (though I have completed recovery and have been opiate-free for almost a year and a half). My Pdoc uses Subutex for recovering addicts, so I am just not familiar with its use for TRD. Although I have known others who have taken Subutex, I have never taken it myself. But you have- so you know that it is effective for TRD, because it's worked for you. To be honest, I'm not the best person to give an opinion on this because I don't know what Subutex feels like in the system. However, I do believe there are certain cases (as in yours) where people fit the profile to be treated w/ Subutex for TRD. I would probably NOT fit the profile, even if I had TRD, as I (to be blunt) have had major issues with opiates (no other meds, just opiates for some reason). I would probably even have problems with a partial opiate-blocker like Subutex. So for some it works, some it doesn't. In any case, I am SO happy you've found something that works for you!! :)
I am almost thinking that my mom's Psych-NP colleague will likely suggest Vyvanse, but I can't be too sure. I will have to of course, tell her your medical conditions first.
I can tell you one thing that helps me though, to keep my Adderall (I take instant release) working effectively. I don't know if this advice will help or not, but if I feel myself building-up a tolerance, I will decrease the dosage (just a little) the next day (or for a couple of days), and then go back to the regular dose the day after that. You can play around with it the dose a little (my doc's words), as long as (of course) you're not increasing the max dose. Here's an example of what I might do: I am prescribed to take 20mg. twice per day. So one day I might take a morning dose of 20 mg. and an afternoon dose of 10mg. Or each dose might be 10mg. Sometimes I do this for up to a week, decreasing the dose on certain days. Then I go back to my regular dose, and I will notice its effectiveness again. This has kept me from taking more than I am prescribed to take, and has kept me from becoming tolerant- while maintaining the effectiveness of the med.
You and I take stimulants for different medical conditions and to achieve different effects, so I don't know if this is advice you can use, but it has helped me. Just thought I would mention it.
And I will get back to you with any info I can find :)
HRGuru
Posted by juanantoniod on May 11, 2010, at 20:31:24
In reply to Re: Need strongest stimulant suggestions » juanantoniod, posted by ed_uk2010 on May 11, 2010, at 14:25:27
Hi Ed_UK2010,
For more details on my conditions, I am going to elaborate for both you and HRGuru in the next post. But I did want to thank you for your input, and believe me, I am going in to this eyes wide open. The cautionary message is still welcome though, thanks!
~Antonio
Posted by juanantoniod on May 11, 2010, at 22:55:11
In reply to Re: Need strongest stimulant suggestions, posted by hrguru on May 11, 2010, at 16:14:40
HRGuru, and ED_UK2010, I started to post my "story" here to answer your questions. Then I realized how many personal details were in it. Is there any way I can send it to you directly? For example, does this site have a Private Message function, or is there a way you can send me your email address? I don't mind sharing with both of you, but I don't want all of it public, so please let me know what we can do. If you use FB or Twitter, you can find me using the same username on either and PM me there, I think. At least on FB, but I am new to Twitter!
Posted by ed_uk2010 on May 12, 2010, at 13:41:54
In reply to Re: Need strongest stimulant suggestions, posted by juanantoniod on May 11, 2010, at 22:55:11
>Is there any way I can send it to you directly? For example, does this site have a Private Message function...
You can send a 'babblemail' by clicking on where my posting name is highlighted in blue at the top of my posts. You also need to switch your babblemail on.
Posted by hrguru on May 13, 2010, at 14:33:53
In reply to Re: Need strongest stimulant suggestions, posted by juanantoniod on May 11, 2010, at 22:55:11
Antonio,
I have some information for you, and I hope it is at least somewhat helpful and/or what you were looking for :) The following is medical advice provided by a licensed psychiatric nurse practitioner. She can prescribe the same medications and perform the same functions/services as a licensed psychiatrist in the state of Louisiana.
I think you had question #1 answered, since you have a prescription for AdderallXR. But let me know if you still need info on this :)
2. If Concerta worked better for you in the past than other types of psychostimulants (i.e. Adderall, Vyvanse), then that is what she would probably recommend (or another drug in the same class, like Ritalin). But- she has not treated you personally, so it's difficult to say for sure. In her experience, one type of psychostimulant tends to work best for a person; and, this varies from person to person.
3. It's extremely dangerous to combine two classes of psychostimulants together, such as amphetamine salts (i.e. Adderall) and methylphenadate (i.e. Concerta). These medications should never be taken together. An alternative combination would be to take two medications which both have a stimulant-type "effect" together, such as Adderall and Wellbutrin.
I hope this is somewhat helpful :)
I was wondering- are the ampakine drugs legalized in the UK? Such as piracetam and aniracetam? If so, has your doc tried you on either of these? I've *heard* these have a stimulating effect, but they aren't legal in the U.S. so I'm not sure.
Posted by juanantoniod on May 13, 2010, at 16:22:35
In reply to Re: Need strongest stimulant suggestions, posted by hrguru on May 13, 2010, at 14:33:53
HRGuru,
Thanks for getting me that most helpful information! It is good to know about NOT combining different classes of stims. I have been on the Vyvanse for about 3 days now, and it seems to wane after about 8 hours, so I would like something to boost it for another 4-6, like Adderall ir. It also interferes with my sleep architecture, so I am not getting good sleep. (Having weird dreams, talking in my sleep, etc.) I am going to email the PDOC I just saw to see what he says and if I can get a "booster" prescription. Is there something that could be taken for this, besides the Adderall ir?
ED_UK2010 suggested I email him privately thru babblemail, so I am going to do that. I will try and send you the same message with a little bit more on my history and thoughts on your questions.
FWIW, last night, out of curiosity, I did a Google search on my username, and these posts on psychobabble were the 3rd and 4th listings. I don't feel I have said anything private, that I wouldn't share with people, but it just reminds me how public the Internet is...
Bye for now!
~Antonio
Posted by kingcolon on May 17, 2010, at 13:39:29
In reply to Re: Need strongest stimulant suggestions » hrguru, posted by juanantoniod on May 13, 2010, at 16:22:35
I am using buprenorphine (Subutex) for TRD, but I also had a history of opiate abuse many years ago. I believe many opiate addicts self-medicate depression with opioids. Buprenorphine provides the unique benefit of an antidepressant effect without the abuse potential of opiates. I experience no euphoria whatsoever and use small doses, eg, 2 mg daily. This is the only med that has helped me and I'm now continuously euthymic for over 2 years. I suffer from fatigue for a number of reasons, among which may be that I'm taking some meds that can cause this (buprenorphine, Lyrica (for anxiety), Zoloft) but I also have always had a lethargic type of depression and it is known that some people remit from their depressions psychically, but still have residual fatigue or apathy. Recently, I have tried several stimulants. Provigil and Nuvigil weren't very helpful. Ritalin made me irritable and anxious. Adderall made me tired!! But now, finally, I'm on dextroamphetamine, 10 mg twice a day, and have experienced significant relief of the fatigue as well as some mood improvements. I've done a lot of research on tolerance to stimulants. There is evidence that NMDA inhibitors such as memantine, dextromethorphan (as in cough syrup), and magnesium reduce tolerance to opioids as well as stimulants. There is a lot of info on this site about these agents if you search for reducing tolerance to stimulants. I myself am using memantine, 20 mg daily as "prophylaxis" against development of tolerance, as I have a history of high tolerance to both opiates and stimulants from years ago. Interestingly, I seem to have a high tolerance for Adderall, but not for dextroamphetamine sulfate as a single agent. So far, the 20 mg daily of dex seems to be continuing to work and I'm very happy with the improvement in my fatigue. I hope it continues. In any event, I'm never going to take any more than 40 mg of dextroamphetamine a day as I think the higher you push the dose, the worse the side effects (like anxiety)and the more likely risk of dependency, and I don't intend to revisit my past indiscretions. Also, I am finding that dex seems to last longer than methylphenidate and I've not needed extended release as yet. If Adderall doesn't work out for you, you should consider trying plain dextroamphetamine.
This is the end of the thread.
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