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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.
I am your host, Jonathan Murphy,
psychiatric nurse practitioner
And this podcast is sponsored by
the Focus Path YouTube channel
You can go ahead and check that out
on YouTube at Focus Path Systems.
I'm just gonna jump right into it.
Today, I wanna talk about
ADHD medication again
before I get carried away with
various side tangents and rants.
I can see that the initial medication
videos that I posted were quite popular,
so now I got some more to discuss,
certainly You can always refer to my
book, The Process: An Adult's Guide
to ADHD Medication, now on Amazon,
if you do have any questions or just
want everything I have to say about
ADHD in one simple to find place,
Last time I talked a bit about how
the internet is different than my
office, and I encounter different
ideas and points of view The type of
things that you're only gonna find on
the internet, and this is a good one.
It's Vyvanse.
Vyvanse is a popular
extended-release ADHD medication
Which I've referred to as the
internet's favorite ADHD medication.
So today I'm gonna talk about what
Vyvanse is, how to think about it,
and how we got here in the first place
So as I've talked about in the past, as
long as we're excluding the non-stimulant
options and we're only talking about
ADHD stimulant medications, which is
going to account for the vast majority
of effective first-line ADHD medications,
we're talking about two separate
chemicals, amphetamine and methylphenidate
When these drugs were first discovered
there were obviously some benefits.
As time went on, there were clearly risks.
So the limitations are placed upon
the medication, and now we have
ADHD, which does a very good job of
identifying the subset of people who
will actually benefit from the medicine.
So remember that.
We're not talking about
performance enhancement.
We're talking about therapeutic
application of these medications for
a particular individual which just
so happens to make up a subset of
the population, a subset of humanity
Because yes, this phenomenon has been
documented before the medicine was around
And the medicine was discovered before
the appropriate application was found.
So two things can be true at once.
It wasn't until around the year
2000 we got the extended-release
formulations, which really allowed to
improve toleration, Because it allows
the body to absorb the medication in
a gentle way, and from there, it's
dialing in the individual amount of
stimulation for each adult with ADHD.
Just a reminder, I'm talking
about adults with ADHD
The kids from the '80s and '90s that grew
up, because the brain is done cooking.
It's just a different thing altogether.
In pediatrics, while I did treat
children and adolescents for some time
I'm not gonna speak on that population
because I feel they require completely
distinctive treatment approaches.
So I'm gonna talk about the one
I know best, which is adults.
So 95% of the time or more, you're
gonna land on an extended-release
stimulant medication as first line.
Most effective, the most safe
And the hopeful outcome
of all good, no bad
We're looking at the extended-release
stimulant medications,
methylphenidate and amphetamine.
The two most well-known brand names, we
know the names, Ritalin and Adderall.
The extended-release medications are
Ritalin long-acting and Adderall So
Long story made short, with the longer
version in my book, "The Process,"
finding the right ADHD medication
isn't difficult, it's deliberate.
You're applying a medication in a very
specific manner because the medication
is predictable, human beings less so.
Nonetheless, I find whether you start
with an Adderall XR or you start
with a Ritalin long-acting, which
are forms of either drug, the most
popular forms of methylphenidate or
amphetamine essentially People tend
to fall on one side or the other
Meaning some people do best
with amphetamine, some people
do best with methylphenidate.
Another way to look at these medicines,
they both do the same thing essentially.
There are minor differences in
pharmacology If we were talking
about receptor pharmacology and
psychopharmacology, we're using that
discipline as a frame of reference to help
us understand the clinical reality and
the medicinal benefits of ADHD medication.
So when we're talking about the
receptors and how the brain works and
all that, we're thinking dopamine.
Both medications activate dopamine.
We can think of that as providing
central nervous system stimulation to
the brain to a person that needs that,
so therefore the outcome is therapeutic.
Therefore, the stimulant category or
the designation, the pharmacologic
designation of stimulant is in name.
In effect, it's a therapy, and
the goal is not stimulated, it's
equilibrium, balance, or calm
We can think of those non-stimulants
as the lowest level of stimulation
Instead of pressing that dopamine button
directly, it's sort of indirectly.
There's a more subtle approach or reuptake
we can think of it as low levels of
stimulation to moderate and to high.
Methylphenidate is moderate, but
if you are getting dialed into a
methylphenidate and you really are
gonna respond best to an amphetamine,
maybe at a higher dose, it's not
uncommon for people to feel mentally
unusual or simply describing the
subjective experience of feeling,
I suppose, malaise, uncomfortable.
Not anxious per se, but
The best way I hear people put it into
words is, "I don't feel like myself."
But I like to use the
phrase zombification.
So because 50% of people are
gonna do best with either of
these medications, generally
what do people start with?
It's most common these days for people to
start with Adderall XR, which is the most
well-known ADHD medication right now, so
therefore it's prescribed the most often.
Just a quick aside, just because it's
prescribed more often doesn't mean
there's more prescriptions being handed
out or prescribed or whatever it is.
There's more Adderall than ever.
Maybe that's true.
I'm not sure.
I don't know the numbers, but my My
practice, I would say, goes through
periods of time where people are
looking for that ADHD diagnosis.
It spikes up and down.
It's always busy, but it's much better
that Adderall XR is preferred by insurance
companies now, because when I started,
you had to prescribe immediate release,
and I had to do that for years, and then
finally I said, "I can't do it anymore."
And luckily, insurance companies
started approving the extended releases.
So that's really, I think, the main
driver behind the perceived amount
of people on these medications.
The truth is, these medications have
been prescribed for quite some time
and have been in medicine cabinets
and even on drugstore shelves way
back in your granddaddy's age.
So it's a perception
problem for most people.
We're not gonna change the
way the world looks at it.
I'm asking you to figure
out how to best understand
this concept if you're faced with a family
member or yourself with ADHD symptoms,
if you feel that you have ADHD, or
maybe you're a clinician, or maybe you
clearly don't have ADHD, but you need to
wrap your head around how other people
are dealing with a, a different set
of starting points, shall we say
So Adderall XR gets
prescribed most of the time.
And here's the thing, if you have ADHD,
any of the medications I described
before are highly likely to actually
help because the ADHD medications are
the only dopaminergic medications.
You're getting to dopamine.
There's a gate that's closed,
and ADHD unlocks that gate,
and it's dopamine medicines.
So that's the other thing.
For the people that are anti-ADHD,
I think there's also something to be
said for a prescriber toolkit, ' cause
when I went to school, we learned
about antipsychotics, and obviously
those medications are helpful that
people aren't institutionalized,
very important pharmacology.
However, working in an inpatient
hospital, seeing, the movement
disorders, these things are no joke.
And on the outpatient basis,
I've thankfully been able
to say, "Risk-benefit?
No, let's put them over here."
And when I bring them in, it goes
well 'cause the patients need them
But it's always a balance because whether
you choose to prescribe something or
not, choose to move forward or not,
there's still a decision involved,
a risk-benefit on either side.
Applying the intervention or not,
and that's ADHD across the lifespan
And that's how I know it's real
So back to the point the ADHD
medication is gonna work.
And oftentimes when it does, people are
thrilled about it, especially adults.
They're like, "Oh, I'll
take anything along with it.
I'm getting my work done, so what if I'm
grinding my teeth and I'm tweaking out?
This is great."
And I really caution everyone, and that's
why I really ram home all good, no bad.
Especially, too, with the tablets
that were associated with a spike
and crash side effects every time.
You're gonna get more side effects
from caffeine by and large.
The goal for a stimulant for
ADHD is to have no side effects,
but that's in the long term
But ultimately, for my patients on the
autism spectrum, I'd say by and large
methylphenidate responders, maybe those
that are more prone to ruminative anxiety,
more likely to do good on methylphenidate
or respond optimally to methylphenidate.
So it simply looks like this.
People are on Adderall XR, they're
tweaking out, but they're getting
their work done, and they go on
Reddit and they hear about Vyvanse.
"You gotta try Vyvanse.
It's the best ADHD medication.
Vyvanse, oh my God, it's the best."
So there's this really big
response, and someone reads
that, and then they go, "Okay.
I'm tweaking out.
Let me try some Vyvanse."
So they try Vyvanse, which is still
an amphetamine, lisdexamphetamine.
Lisdexamphetamine is a prodrug.
It converts in your bloodstream
from lisdexamphetamine to
dextroamphetamine.
Okay, let's pause for a minute.
So, going back to the amphetamine
piece, it's still the same drug,
but there are two kinds of it when
we're thinking about Adderall.
There's levo and dextro, or D and L.
And that D, dextro, is for
your brain, and the L, levo, is
more peripheral nervous system.
Think of it as your get up and go.
Well, not everyone
needs the get up and go.
Nonetheless, they make and
manufacture dextroamphetamine,
or Dexedrine, single amphetamine.
That's way older than Adderall.
It's the OG.
So what's lisdexamphetamine?
It's a prodrug, converts to
dextroamphetamine, so a sort of
smoother perceived onset toleration.
For the folks that are not doing great
on Adderall XR, it's a smoother ride.
So they get a smoother ride.
They're doing better.
They're still a bit tweaky,
but they go to Reddit and
they're like, "Yes, this is it."
No.
Hold on, because the
goal is all good, no bad.
If you're really tweaking or really
uncomfortable or overstimulated highly,
if you're saying things like, "Okay, can
I just take the medication sometimes?
'Cause I need to focus, but, like, I,
like, can't stop focusing," or, " You
know, I focus really good, but it's,
like, intense and then I crash,"
it's just signs of overstimulation.
. So you want to go to a methylphenidate.
There's so many people that
are on Vyvanse I described.
And Vyvanse is still a good medication
because someone could try Adderall
XR and then move to Vyvanse.
However, these folks are experiencing
minor side effects, mostly doing
good, maybe just some minor
restlessness from the levoamphetamine.
So Dexedrine Spansules is an
extended-release capsule form.
If you can't afford Vyvanse, That
is essentially my hot take on
Vyvanse, which I made a video about
Maybe four to six months ago
on my YouTube channel, and it
garnered a lot of excitement.
And I use the clickbait.
Vyvanse is overhyped, but it is overhyped.
Still a good medication.
If you're taking the medication,
it could be your all good, no bad.
25% of people with ADHD, Vyvanse is
probably gonna be the all good, no bad, if
we're talking about the main medications.
There's exceptions, but the big
four, XR, Vyvanse, extended-release
methylphenidate, Ritalin or Concerta
Count that as one, and then Focalin.
So Vyvanse isn't the best one,
' cause there can't be a best one.
There's no such thing as
the best ADHD medication.
There's only the right ADHD
medication for your brain.
The diagnosis gets you to a
medication, but it doesn't
dial in the individual therapy.
So that's what it's like when
you're actually treating ADHD.
So I thought I'd leave you there.
Thanks again for listening.
My name is Jonathan Murphy,
psychiatric nurse practitioner.
You can check out Survival Modality
Season 2 on the YouTube channel.
I'll talk to you later