Extended Release Stimulants for ADHD | Side Effects Ride Out or Bail?

The Ride Out or Bail framework for the first month on an extended-release ADHD stimulant. Jonathan Murphy, PMHNP-BC, reads from The Process and walks through the eight most common side effects, week by week, so patients and prescribers know when to hold the course and when to switch.

This episode covers:

Why the first four weeks are the assessment window and how to think about tolerable side effects inside "all good, no bad"

Dry mouth: ride out weeks one and two, bail at week four, and why prolonged dry mouth signals overstimulation

Why caffeine, cannabis, and nicotine muddy the read on any side effect and have to be pulled out to assess the medication alone

Low appetite versus appetite suppression, and why the ADHD-food-dopamine relationship changes on medication

Protein and calorie strategies for the first weeks and when persistent low appetite becomes a real problem

Mild insomnia and the first-place-to-look rule: take the medication as soon as you wake up, consistently

When mild insomnia after four weeks signals the wrong extended-release capsule or the wrong dose

Jitteriness as a mild overstimulation signal, and the caffeine-elimination step before considering a medication change

Euphoria in week one as honeymoon period versus euphoria at week four as a mania signal

Hypersexuality as a possible mood-irregularity signal versus a baseline personality feature

Headache: hydrate first, and why headaches are usually not caused by the medication itself

Irritability as a new-skill side effect versus true agitation

The automatic bailouts: persistent agitation, anxiety, and complete zombification, most commonly on methylphenidate

This is the fourteenth episode of Actually ADHD. 

The book The Process: An Adult's Guide to ADHD Medication is available on Amazon: https://www.amazon.com/dp/B0H2Z6PM4T

Focus Path | PMHNP-BC for the Ride Out or Bail video and the full clinical education catalog. https://www.youtube.com/@focuspathsystems

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.

My name is Jonathan Murphy,
psychiatric nurse practitioner.

Welcome back.

This podcast is brought to you by
the Focus Path YouTube channel.

You can check that out
at Focus Path Systems.

And today, I'm going to be reading
an excerpt from my book, The

Process: An Adult's Guide to ADHD
Medication, which is available right

now on Amazon and in the show notes.

What this part in the book
covers is side effects.

One of the most common set
of questions that I get.

So in order to make this as easily
understood as possible, I developed a

framework that I call ride out or bail.

And in my book, "The Process,"
there's actually a little chart in the

back, and it shows the side effect.

There's one, two, three, four,
five, six, seven, eight, eight

of the most common side effects.

And then I walk through what to do in
that first month, week one, weeks two

to four, and then weeks four plus.

Do you ride it out or do you bail?

Because

If these side effects are tolerable

It can still be you're all good, no bad.

We wanna look over the course
of weeks to determine the

effectiveness of the ADHD medication.

And just for context, we're talking
about ADHD extended-release stimulant

medications, and you can refer to
some of the other episodes where I

talk a bit about that, and of course,
the Focus Path YouTube channel.

But on the podcast, I also have the
optimization process as well as some other

medication episodes where I explain the
reasoning behind the first line of an

extended-release stimulant medication.

So week one, so we got the most
common side effect, dry mouth.

It's gonna get worse if
you have caffeine too.

So week one, you wanna ride it out.

Now, caveat here, dry mouth means
bacteria in your mouth, so you

need to do something about that.

They have mouth…

At the pharmacy, they have dry
mouth products, mouthwash, mints.

It can really help.

Week two, you're gonna ride it out.

But week four, if you still have dry
mouth, you're gonna wanna bail because

that's a long time to have dry mouth.

It could tell you something about
the dosage or the medication.

I would view prolonged dry mouth
as a sign of overstimulation.

So it could be that if you're on an
amphetamine extended-release medication,

you still have dry mouth after four
weeks, then you wanna switch medications.

But of course, you wanna think about the
medication without anything else, like

without having caffeine or cannabis,
for example, or nicotine in your system.

When you have any of those substances,
it's not the same thing anymore,

so you really wanna think about dry
mouth with just the medication by

itself, because any of these things,
with or without the medication, can

still give you dry mouth Moving on to
low appetite, it's a bigger concern.

And while it is true it can cause
appetite suppression, I think it's a

little bit more complicated than that
because the medication targets dopamine.

Food and pleasure, they're all linked.

People with ADHD seek
stimulation through food.

So the relationship
with food often changes.

And this can seem like appetite
suppression, but it's really

different person to person.

It's appetite suppression
if you really can't eat.

And that's a problem, of course.

You need to eat.

So you're going to want
to ride that out week one.

Got to have some protein shakes.

Think about it as brain fuel.

The medication's not going to
work if you don't have those

calories to fuel your focus.

Weeks two to four, watch closely.

You want to be careful here depending
on How well-nourished you are.

Are you already low body weight?

But week four, if it persists,
you definitely wanna change

because appetite suppression
after four weeks, that's a problem

Moving on to mild insomnia.

The key word is mild.

So, you always wanna make sure to take
the medication as soon as you wake up at

the beginning of the day consistently.

That's the first place to look.

It's the first place to start.

But riding it out week one,
that's perfectly normal.

Weeks two to four, you wanna look closely.

It should be better, but if it
continues week four, you wanna bail,

and it could just be bailing to a
different extended-release capsule.

Some of them have longer
durations than others.

But the goal is to find the right
medication at the right dose, and

that would mean that's not the right
dose because it's lasting too long

Number four, jitters, jitterbugs.

This is a sign someone's mildly
overstimulated, but they have ADHD,

so they benefit from the medicine.

So they're like, "I don't wanna stop.

This medication's good," but they're just
a little jittery So a lot of people live

with this, and I would just say if you
do live with this, you may not have to.

It could be that another medication
will treat your ADHD while not giving

you the jitterbugs, because the harder
thing to do is have a benefit at all.

So if you do have a benefit, that means
you're likely to experience a benefit

with another medication But week one, you
wanna eliminate caffeine That should get

rid of the jitterbugs if you have them.

Weeks two to four, reassess.

And again, week four plus,
you're gonna wanna change meds.

Here's the next side effect,
euphoria, where you feel high.

Well, week one, you wanna ask
yourself, do you really feel high,

or maybe you're just high on life?

If you're high on life,
that's the honeymoon period.

So enjoy it while it lasts.

But weeks two to four, you
probably wanna reassess.

You know, a lot of life benefits
come secondarily to ADHD medication.

But week four plus you feel high or
euphoric, you wanna check for signs

of mania, and I'd suggest bailing.

But that is a very
individualized recommendation.

It's very rare, I would say.

None of my patients nearly are
gonna have euphoria week four plus.

The reason I have this one in here
is just because people have it

right away in the beginning, and
usually that's not a good thing.

But if someone's depressed, they
can feel euphoric, in which case it

definitely is only gonna last a few days.

Something to think about.

The next one is hypersexuality.

Um, you know, getting a
little frisky, if you will.

, Again, that could be initial response, but
you wanna keep an eye on it 'cause that

can be a sign of mania or irregular mood.

And, um, if that's the case,
you might be more irritable.

Maybe the ADHD medication is helping,
but you probably wanna talk to your

provider about stabilizing your
mood or trying a different med.

Um, so I'd bail after week one on that.

But if that's just who you are, if
you're in freak mode and that's normal

for you, let your freak flag fly.

This is just a change from baseline.

Headache, the most common
side effect for any med.

Week one, hydrate.

That's gonna probably knock out
90% of the headaches is hydration.

But if you continue to have
headaches week two to four,

four plus, you wanna reassess.

Usually headaches are not a result
of ADHD medication, but rather it's a

ADHD medication, maybe an underlying
migraine issue, what have you.

Headaches are a bit elusive
and mysterious, but the rule

of thumb is to drink a lot of
water if you do have a headache.

And finally, we got irritability.

You wanna ride out week one.

Weeks two to four, reassess.

Four plus, bail.

Now, that's mild irritability
because you can have irritability

depending on who you are.

If your brain's online, you're
engaging with things when otherwise you

would've checked out is a new skill.

You can become irritated
or irritable perhaps.

Maybe you haven't eaten.

But agitation and anxiety, those
are automatic bailouts So if you're

super agitated every time you take
the medicine, you gotta bail out.

And the other automatic bailouts are what
I like to call complete zombification.

That's a bailout.

Sometimes people report that
with any of the ADHD meds, but

most commonly methylphenidate.

So that was a speed round, but I wanted
to give you some value in this podcast.

I can see we got some downloads here,
so I wanna give you people what you

need, what you want, in addition
to the ranting and raving that I do

plan on doing in subsequent episodes.

But for now, I just wanted to provide this
information, which you can get more of in

the show notes, the link to the YouTube
version of this, uh, framework, the Ride

Out or Bail video, as well as my book.

Once again, this is Jonathan
Murphy, Actually ADHD.

Talk to you later