ADHD Medication Optimization for Adults

The Optimization Blueprint — the algorithm Jonathan Murphy, PMHNP-BC, uses to find the right medication and the right dose for adults with ADHD.

This episode is for two audiences simultaneously: clinicians refining their adult ADHD prescribing practice and patients trying to understand whether their current treatment is optimized.

This episode covers:

• The three medication categories: methylphenidate, amphetamine, and non-stimulant
• Why extended-release stimulants are first-line and why the "controlled substance" framing misleads prescribers
• The standard adult starting doses for the major medications
• The response and toleration framework for assessing the first prescription
• When to start with amphetamine versus methylphenidate based on presentation
• Why methylphenidate is often the better starting point despite being less culturally familiar
• What "optimized" actually means: all good, no bad, no side effects, works like a vitamin
• The risk of dysfunctional medication relationships and how they form
• Why providers who haven't developed comfort with adult ADHD prescribing should consider referring out rather than under-treating

This is the second episode in the sequence covering the optimization process from the book The Process: An Adult's Guide to ADHD Medication, available on Amazon: https://www.amazon.com/dp/B0H2Z6PM4T

Find the YouTube channel Focus Path | PMHNP-BC for the full clinical education catalog.

For educational purposes only. Not medical advice. Consult your own provider for clinical decisions.

What is Actually ADHD | Medication Strategies & Clinical Wisdom?

Adult ADHD from the board-certified PMHNP behind the YouTube channel Focus Path and the book The Process. Clinical perspective on medication, frameworks, and the conversations the internet hasn't been having.

This is Actually ADHD, sponsored by
the Focus Path YouTube channel, and

I am your host, Jonathan Murphy,
psychiatric nurse practitioner

today, we're talking
about ADHD medication.

The optimization blueprint is
the algorithm I use to find the

right medication and the right
dose for an adult with ADHD.

The sequence accounts for the realities
of insurance, individual variation, and

the fact that medication response is what
confirms the diagnosis in the first place.

The blueprint operates
on a few principles.

You gotta start with the
first-line treatment.

That's an extended-release
stimulant medication

You gotta begin at the standard
adult starting dose, assess at one

month, moving from less invasive
to more invasive options based

upon response and toleration.

So it looks like this.

There's the decision to prescribe
the medication in the first place.

So anyone that comes to me can say
anything, but this isn't necessarily

about rubber stamps, it's about medication
for that individual at that time.

There are a lot of factors that
could make someone not ready

to initiate ADHD treatment.

But the reality is most people that I
see on an outpatient basis are in a place

where they're able to start medication.

Usually, they've found me, they've
thought about it quite a lot by

that point to seek out the ADHD guy.

I get the motivated types, which is great

, But ultimately what medicine and the
timing and all of that is to the provider.

We have to sort of understand
that self-assessment is

only gonna take you so far.

The self-advocacy, and then there's
working with your provider and

Understanding that in order to collaborate
effectively and get your needs met,

you need to learn how to translate
what you're experiencing into language

that your provider can take in and
understand and will translate into

the medication outcomes that you want.

Because ultimately, at the end of the
day, the provider and the patient sh- have

the same goal, 'cause the medicine works
really, really well When it's prescribed

in this manner So let's just jump into it

You got three different categories.

You got your non-stimulant,
you got your methylphenidate,

and you got your amphetamine.

Amphetamine and methylphenidate are
the two stimulant medications for ADHD.

They're still first line.

They're still the most effective.

I've already talked about the history
of this, but that's your starting point.

In the non-stimulant, there's reasons
to start there, but most people won't.

The majority of people are gonna do best
with methylphenidate and amphetamine.

And here's the thing that
people get tripped up with.

They say controlled substance
But Controlled substance

means you control the supply.

So all of the things that lead
up to getting a prescription

is the controlled part But the
substance itself is therapeutic.

The controlled substance
doesn't have anything to do

with it not being therapeutic.

In fact, it is therapeutic.

It's just we have to be careful for
the risk of misuse and abuse because

stimulants have an ability to, to
elicit performance enhancement.

But ADHD is the vetting process,
and really we're determining the

difference between a performance
enhancement and, , a chronic issue for

which this medicine will be helpful.

And

The amount of people that slip
through the cracks, let's say

The process of following up with a
provider, all the stuff that is set

up the way it is, is enough to, from
the provider standpoint, develop

confidence in their assessment skills
and understand that we don't get to

control the way the world's set up, but
we have one job to do, which is assess

the patient and treat the symptoms.

And the medication, people become fearful
of prescribing because of the biases.

There's a million and one reasons why.

But in terms of safety and effectiveness,
ADHD medication is first line.

It's safe in the right context.

I tell that to my patients.

They're like, "I'm nervous," and you hear
these stories and so on and so forth.

And I'm like, "Yes, that's true, but
this medication is for you, prescribed

by me at this dosage in this context."

You know what I'm saying?

So you've just taken the risk,
and you've reduced it to a

very, very, very small level.

And then the benefit, well, that
skyrockets the potential benefit.

It's an odds game, right?

If you want to reduce it to
that analogy, like a sort of

betting analogy, yeah, you are.

Anytime you're working with probability,
you're saying risk versus benefit.

So these choices you make yourself, you
weigh the risk and you weigh the benefit.

So the provider needs to feel
good about the recommendation

they're giving, there it is.

So I would ask any provider
to make up their mind.

If you're not comfortable prescribing
ADHD medication, you can simply say,

"I haven't developed the expertise with
that," and you would be best served

somewhere else and write a referral.

also understand that you could potentially
end someone's effective treatment.

with my book, "The Process: An
Adult's Guide to ADHD Medication" on

Amazon, people are going to learn,
and hopefully providers will learn

that argument of ADHD doesn't make
sense, stimulants are only bad.

The data doesn't line up,
and it's a position that

hopefully we can weed that out

But I think philosophically there's a wide
range of opinions, and that's acceptable,

but I also think that the people that
benefit from the medication should be able

to access the medication So here we are So
we're looking at response and toleration.

Those are the first two things
after the first prescription.

After the first prescription, the
response is the degree of symptom control.

This is the amount of stimulation.

So again, we're thinking about the
ADHD brain, applying stimulation

to elicit a therapeutic response.

Medication is going to provide that
stimulation with the medication.

We're doing it with the limitations that
we have, and we wanna do it behaviorally

one time a day because it just wake
it up and take it like a vitamin.

Those changes are not noticeable.

Hopefully, you just feel like yourself,
and that's the goal, to feel like yourself

toleration.

This is the degree of
side effects experienced.

This will play a large factor into what
the next medication option will be.

I'll get into that on another episode.

I'll dive deep into side effects,
but for now, this is just an overview

So you start with either an
extended-release methylphenidate

or an extended-release
amphetamine most of the time.

So that is gonna be Ritalin
long-acting or Concerta.

Those are both methylphenidates.

And then there's Adderall XR
or Vyvanse, , those are both

amphetamine-based medications

so I'll break it down like this

I see a patient and it's straightforward
with ADHD and there's no comorbid

anxiety, no autism spectrum disorder,
no sensitivity to stimulants, and

they present with a mixture of
mostly inattentive symptoms and maybe

fluctuations and bursts of hyperfocus.

I'm gonna start with Adderall XR
20 milligrams because that's the

adult starting dose for Adderall
and I'm choosing Adderall which is

a very effective ADHD medication.

It's a combination of two
amphetamines, dextroamphetamine and

levoamphetamine on the bottle you
might see mixed amphetamine salts.

This combination targets the peripheral
and the central nervous system.

However, it's not the right
medication for everybody.

But when you're looking at an
amphetamine It's a good starting point.

But what about the methylphenidate?

I start methylphenidate for
patients that seem a little anxious,

sensitivity to caffeine, autism
spectrum disorder, or even preference.

If people aren't sure, I tend to start
people on methylphenidate 'cause it's

the less talked about medication.

Everyone talks about Vyvanse and
Adderall, but when someone gets on

Vyvanse or Adderall, they can end up
being on it for a long time, enduring

side effects that they do not have to.

And that's the number one thing,
is the goal of this optimization.

You know your dose is optimized when
it's all good, no bad, no side effects.

You know, just, uh, take the
medication, works like a vitamin.

So if that isn't your experience,
I would talk to your provider about

it because the hard part is getting
the medication to work at all.

If the medication isn't therapeutic, so
just the scenario I described before,

methylphenidate or amphetamine, it doesn't
mean they need to nail it right out the

gate, and we're not trying to do that.

An assessment of initial response.

But, you know, in the event of
overstimulation, then you go to the

non-stimulant, um, medications, and
that should account for people that

can't tolerate stimulants but do
genuinely meet the criteria for ADHD.

When you go through all the ADHD
medications with a proper trial like I'm

describing, you're increasingly getting
closer and closer to ruling it out.

And there are comorbidities that are rare
that do rule out ADHD, and I think, uh,

it speaks to why it's necessary for the
providers that are comfortable or maybe

they're on the fence to just, continue to
build that experience because the biases

and the myths go away, and the confidence
that you hear me speaking with comes

from the fact that I've done it so much.

And you have to sort of get your
feet wet, and it's not the end of the

world if someone gets prescribed a
medication for ADHD, they get Adderall

or Vyvanse, and maybe you figure out that
wasn't the right medication for them.

That's okay because they're
talking to you, they're meeting

you in your appointment.

Um, it's not like this be-all,
end-all thing, and we should encourage

people to access the medication
in the most appropriate way.

And then I'll close with this last
bit, which is the sharing of medicine.

Obviously, it happens, and there's
nothing we can do about that.

But What we wanna make sure,
what I'm gonna make sure is this

patient's on board and meaning
like, okay, what happens, happens.

Seriously consider the people that
are around you when that's happening.

I think it's not a
healthy sort of behavior.

If that's occurring around you,
think about that environment.

But what it is doing, if this is like
your introduction to the medicine,

you're being introduced to the
medication in a very dysfunctional way.

So this is the biggest risk of
the medicine, is developing a

dysfunctional, meaning it's not
conducive to the most benefit.

So you wanna have, if you have ADHD,
the optimal or best relationship with

the medication that's going to increase
your function and make life better.

But because of the nature of ADHD,
impulsive, need everything now, and

because the extended-release capsules
are new, people have continued

to take an as-needed approach.

And because it is a performance
enhancer, people will always

take stimulants to party.

It's just a part of our culture, but we
have to cut out all this noise and think

about one individual person in life.

If you're the clinician, then you
need to think about your patient, and

if you're the patient, you need to
remember that this is a real thing.

Not everyone's brain works this way.

I don't know the exact percentage.

Let's say five percent of the
population, but it's still a minority,

and it's still not most people.

The only thing matters is being able
to direct your thoughts and action

into behavior, take expectations and
reality and finally line them up.

And that's what ADHD
treatment is gonna do.

When ADHD is truly an accurate
diagnosis, You're looking at an

improvement in quality of life,
and Russell Barkley has the data.

There's less car accidents, longer
lifespan, so on and so forth.

So we know the medicine's safe,
But the patient and the, , provider

have the same goals in mind.

, The goals are all good, no bad.

And if someone is developing an
unhealthy pattern of behavior,

there's bigger issues going on.

When you see the patients and
you understand the pattern

people's lives get better.

Show up defeated

And they leave as themselves,
and it never gets old.

Well, that's it for today.

Join me next time and I will break
down the medications in greater detail.

I'll go through all the different capsules
and explain the differences and how you

dial in the duration That's gonna be
on the next episode of Actually ADHD

Hosted by a nurse practitioner
that won't sell you short