When Adderall XR stops working for ADHD- what to do about it
I am a board-certified Child and Adolescent Psychiatrist. many of my patients come to me with ADHD, asking what to do when Adderall XR stops working. I will help you understand why, and what you can do.
First, though, here is what I do if I see a new patient with ADHD. If the patient or their family wants medication instead of nutritional or other treatment, I usually start with Ritalin™ (methylphenidate). For convenience, I’m going to call this drug Ritalin, even though it is sold as the generic form (methylphenidate). This is an older medication, has the fewest problems with it and works for about three quarters of my patients.
If the child takes a dose of Ritalin™ in the morning, a half hour before school starts, the drug starts working by the time they get to school, and lasts until about lunch. This means that the Ritalin™ is usually gone by about noon or 12:30. The child then needs to take another dose around lunchtime, and this second dose is effective until late afternoon.
Now most children do not want to see the school nurse at noon, so the drug companies have developed all kinds of different ways to make these ADHD medications last longer, through the entire school day. These are medications such as Concerta™, Adderall XR™ and Vyvanse™. In this blog piece, I am mainly talking about Adderall XR™ but the same explanations apply to Concerta™ and Vyvanse™.
When I see the children who have been on these extended types of medications, particularly Adderall XR™, this is what I typically hear: Their child was diagnosed with attention deficit hyperactivity disorder (ADHD). The medication Adderall XR™ was started, usually by a primary care provider rather than a child psychiatrist, without trying anything else, such as Ritalin™. At first the Adderall XR™ seemed to work fine. The child was able to concentrate at school and did better. But then the Adderall XR™ doesn’t seem to work as well or perhaps there are behavioral issues such as irritability or mood disturbances.
The parent then goes to visit the health care provider who prescribed the medication. The doctor increases the dose of the medication. Again the Adderall XR™ seems to work, but this time, after aan even shorter period of time, the medication stops working. The problems of inattention and difficulty with concentration seem to recur. The medication doesn’t really work. The doctor then increases the dose. However, now the child runs into major problems with decreased appetite and with sleep disturbances. The child doesn’t seem to want to eat or sleep. The parent becomes exhausted. The child may not even be doing as well as he or she did on the first and lower dose of Adderall XR™. So, instead of asking whether Adderall XR™ is the right medication, the doctor then adds other medications for sleep, such as Trazodone™ or Seroquel™. If there are behavioral issues, perhaps even Abilify™ is considered.
Now the child is on a cocktail of major drugs, and the parents do not know what to do.’ Then they are looking for a child psychiatrist, and that’s how I see them.
As I mentioned above, this is pretty typical in my practice. I am a child psychiatrist as well as a nutritionist and homeopathic physician. This is what I tell these parents.
What is Adderall XR?
Adderall is a diet drug from the 1970’s. Adderall is a mix of two types of drugs, amphetamine and dextroamphetamine. These drugs became popular because they made people feel as if they did not have an appetite and did not want to eat. The drugs used to be prescribed as diet drugs, but because they are so addictive, they are no longer prescribed.
Although the combination of drugs in Adderall cannot be prescribed for dieting, drug manufacturers realized that they could make money by using the same combination of drugs for ADHD. They also have engaged in a well-documented and very aggressive campaign to “Identify” not only all kids with ADHD, but also adults. The number of children and adults diagnosed with ADHD has skyrocketed.
Starting several years ago, the drug Adderall was created for ADHD from the same chemicals as the original diet drugs. The first formulation of Adderall was in what is called an “immediate release” drug. That is, the drug goes into your system right away. It works for some time, but then wears off and to keep the reaction going, the child needs to take another dose.
Back to the marketing issue. Drugs are protected from competition by patents, which allow a manufacturer to avoid competition during the first several years that the drug exists. A common tactic by drug manufacturers is to come out with a slightly different formulation of the drug as the patent is running out, so they can market the new version to patients. The drug company that makes Adderall made tons of money on Adderall, and once the patent expired, generic manufacturers could get in the market. The drug company needed something different. I will comment that Adderall is no different than most other drugs in this regard. When a drug company sees that a drug is going off patent, they promote a different version of the drug in a new form, that is on patent, and try to convince doctors to switch their patients.
In the case of Adderall, the manufacturer brought out the long release version of Adderall called Adderall XR™. They marketed this drug to doctors with the promise that the drug is easier to take, because the patient only needs to take it once a day.
I normally refuse to see drug company representatives, because I fear that they may influence my prescribing choices. In this case they were very aggressive and I consented to see them. I remember seeing the Adderall XR™representative about the time the Adderall patent was about to expire. She asked me if I had switched all my patients to Adderall XR™ as if I was supposed to help the company keep making money. I looked at her incredulously. I never saw her again.
There is one more problem with Adderall XR™ . Adderall as I said was originally a diet drug from the 1970’s. Adderall contains both dextroamphetamine and amphetamine. The air force uses dextroamphetamine for their pilots. Dextroamphetamine works well for concentration. Amphetamine does not work well for concentration. Amphetamine causes major side effects such as appetite suppression, difficulty with sleep and in the worst case hallucinations. I don’t think children with problems should be taking amphetamine. I try hard to avoid using Adderall at all for this reason
But back to the question.
Why does Adderall XR™ stop working?
There are only a few stimulant chemicals which help children pay attention better. In my experience, the reason immediate release Ritalin works is because the whole dose enters the blood at the same time. Then the blood level goes up to a peak level which is effective. Eventually, the Ritalin blood level falls and another dose must be taken. With longer acting drugs such as Concerta or Adderall XR™ , the blood level goes up slowly. There is never an early peak as there is with the immediate release form. Then because there is no peak level, the doctor has to raise the dose to make the levels higher. Then the overall dose becomes higher than it would be if the immediate release versions were used. Then the level of side effects goes up.
Look at the normal doses to see what I mean. A normal dose of Ritalin is 10 mg. twice a day, total 20 mg. A normal dose of the immediate release Adderall is 5 mg twice a day, total 10 mg.
The extended release Ritalin, called Concerta ™, usually goes up to 54 mg. per day, which is more than twice the amount of Ritalin. The extended release Adderall XR ™ is 30 or 40 mg per day, more than three times the dose of the immediate release Adderall. Kids are on these very high doses because they see less effectiveness of the drug from the extended release versions. The side effects that I see are much greater for Concerta at 54 mg or Adderall XR™ at 30 or 40 mg.
OK, so this might mean that the child just accumulates Adderal XR™ in their system. The question is why does it stop working? Shouldn’t the drug just last longer?
Go back to the immediate release versions. If given in the morning and at noon, the drugs are out of the child’s system by 5 PM. Then the brain has a chance to relax and reset itself. With Adderall XR™ , the medication lasts and lasts. If the dose is high enough, it is still present at night and the child cannot sleep. The brain never gets a chance to relax and reset itself. Instead the brain seems to be fighting the Adderall XR™ continually. The constituents of the medication, dextroamphetamine and amphetamine, are foreign chemicals in the brain. The brain seems to oppose them in some way, although I cannot say how for sure. Eventually the body wins and the Adderall XR™ stops working or the dose has to be increased. Other drugs may be added. The parents say that their child is “used” to the medicine, and they are correct. Unfortunately, nobody talks about this. The drug just keeps increasing.
In my experience over 20 years as a psychiatrist, I rarely have heard parents talk about Ritalin stopping working when used in the immediate release form. However, parents talking about Adderal XR™ and Concerta stopping working is extremely common.
What can you do if Adderall XR has stopped working for my child’s ADHD?
My main suggestion to the parents who want to stay with medication is to get their child off of the long acting drugs if the drugs have stopped working, and go back to the immediate release versions, such as Ritalin in the morning and at noon. Often, this change works.
For the parents who would like to try a different approach, there are alternatives to drugs, using a combination of an anti-yeast diet and treatment, and homeopathy. I discuss this thoroughly on my website. Click here.
I also devote a page to why this works with ADHD if you click here.
In my experience, I have had kids come to me for help with ADHD, and instead of taking drugs they made simple changes in their diet. They were able to function without any medications at all. The very first thing to do is to eliminate all foods with malt, which I explain elsewhere. To see what malt is, click here.
Often parents see a change within a week, and some kids may be able to avoid ADHD drugs altogether.