Adult ADD

A Guide to the Diagnosis and Treatment of Adult ADD

Stimulant Medications


Stimulants are the most commonly used medications to treat adult ADD. Hundreds of studies have shown their effectiveness for treating ADD. They are relatively safe for people who do not have a heart condition, drug abuse problems, or a history of seizures or psychosis. They include:

  • amphetamines dextroamphetamine (Dexedrine and others), mixed amphetamine salts (Adderall), lisdexamfetamine (Vyvanse).
  • methylphenidates (Ritalin, Concerta, Focalin, Methylin and others)

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Table of Contents

Click on any question below to see the answer.

General Information

Why are they called stimulants?
How do they work?

What mental functions can they help improve?

Why do medications called stimulants quiet down many people with ADD?

Treatment

What is the difference between the stimulants in the Adderall family and those in the Ritalin family?
Is there a difference between generic and brand-name stimulant medications?

How can people get their stimulant medication to work more quickly in the morning?

Is there a way to get stimulant medication to act more smoothly throughout the day?
Can food affect how well amphetamines work?

What other kinds of things can affect how well stimulants work?

Dosing

What is the best dose of stimulants?
How long do the effects of the stimulants last?

Side Effects

What are the common side effects of stimulants?
Can stimulants make a person irritable or depressed?

Can stimulants increase blood pressure?

What can be done to keep the stimulant medication from increasing the pulse rate?
Is there a way to keep stimulants from interfering with sleep?

What can help if I get heartburn from amphetamines?
What, if anything, can be done for dry mouth from stimulants?
What can I do if I sometimes get up-tight on stimulants when I am really stressed?

Special Populations and Other Concerns

Are stimulants addictive?
Can people become dependent on stimulants?

Are there long term effects of the stimulants on other psychiatric disorders?
Are there special considerations in treating women with stimulants?

Is it safe for women to take stimulants during pregnancy?

Can diabetics take stimulants
Is there a special health risk for athletes taking stimulants in hot weather?
Can people with bipolar disorder take stimulants?

Can stimulants be a cause of sudden unexplained death?

Have stimulants been successfully used to treat other disorders?
Is it safe to take stimulants and MAOIs (monoamine oxidase inhibitors at the same time?

Miscellaneous Issues

Does temperature and moisture affect the strength of amphetamines?
Can stimulants affect sperm?

How long after taking amphetamines are they detectable by tests?

Can a person test positive for methamphetamine or amphetamine even if they haven’t taken any?
Taking stimulants without a prescription

Is there a safe way to buy stimulants from an on-line pharmacy?

What is the relationship between coffee (caffeine), ADD, and stimulants?
Can stimulants help patients who don’t qualify for the diagnosis of ADD?

Do stimulants cause genetic damage?

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Stimulants

Why are they called stimulants?
The most obvious, immediate effect of the stimulants is to make most people more alert, to slightly increase their pulse, and, in general, to make them more active and productive. Before it was known that they had a therapeutic effect on ADD, they were labeled stimulants. The name can be confusing because many people with ADD find that stimulants calm them down and make them feel less anxious. The calming effect may be due to their feeling less anxious because they are much less likely to…

  • be forgetful
  • procrastinate
  • interrupt
  • be distracted

and therefore less likely to be criticized by others. They are also more likely to…

  • think more quickly
  • stay on the topic during conversations
  • think of things to say during conversations

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How do they work?
When people are excited, in danger, working against a deadline, physically active, or doing something they find very interesting, the adrenalin level in their body and in their brain goes up, and they become more alert and more focused. If they are really excited, the adrenalin may also cause their heart to start beating faster, and their mouth to get dry. They usually don’t have much of an appetite or want to sleep.

For some reason, the adrenalin-type of activity in the front part of the brain of a person with ADD is lower than normal. Because of this, in non-stressful situations they may not be able to get started on tasks, or stay focused, or get organized. The stimulant medications act by raising their level of adrenalin-like chemicals in their brain. When this happens, they become more alert, more focused, and better organized. They usually also have less of an appetite. People who already have a normal level of adrenalin in the brain usually get little or no benefit from stimulants.

The balance between the adrenalin-like effect of stimulants on the brain and on the body differs among people. If the stimulant effect is mainly on the brain, the medication has few physical side effects. But if it works more powerfully on the body, the person may experience a fast heart beat, a very dry mouth, an increase in blood pressure, and/or difficulty sleeping.

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What mental functions can they help with?
They can help with a number of mental functions:

  • they can help some people organize, prioritize, and see the big picture better
  • they give some people more energy, motivation, and perseverance
  • they may have an antidepressant effect – they can make a few people feel great, even high
  • they can give some people a much better sense of time and the future, enabling them to make, remember, and stick to long term goals
  • they can help people carry out conversations more easily because more ideas come to mind, the ideas are better organized, and the people don’t interrupt or lose track of what the other person is saying
  • they can help most people ignore unimportant distractions
  • they can help people act more calmly and less impulsively
  • they can reduce hyperactivity, the drive to be on the go all the time, and/or edginess

An individual with ADD may benefit from a few or many of these effects.

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Why do stimulant medications quiet down many people with ADD? If they stimulate, shouldn’t they make peope less calm?
Stimulants make some people anxious. But it makes some others with ADD less anxious. The increase in anxiety seems to be related to the direct effect of the medication since it starts at about the same time the medication starts working. The decease in anxiety may be more psychological. After being on the medication for a while, some people become much less fearful about being criticized for not getting things done on time or in a well organized way or for being spacey and distractible. Often those who feel calmer note that they can carry on conversations more easily as more thoughts comes to mind, and they are not so easily distracted. As their functioning improves, their fearful apprehension slowly dies down, and they begin to feel more calm, even peaceful.

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Treatment

What is the difference between the stimulants in the Adderall family and those in the Ritalin family?
(The amphetamines family of medications includes Adderall, Dexedrine, Vyvanse etc and the generic amphetamines while the methylphenidate family includes Ritalin, Concerta, Focalin, Methylin, etc and the generic methylphenidates).

The most important difference between them is whether they work or not for a particular patient. In my experience, at optimal doses of each, more people respond positively to amphetamines and they have a slightly stronge effect. But there are also many people who respond more positively to methylphenidate. Most people with ADD respond to either. Click here for a more detailed comparison of the effects of these medications.

A second difference is the length of action. amphetamines have a somewhat longer period of action than do methylphenidates, even if only the long acting versions are compared. Also, the higher the dose of amphetamines, the longer the action. This can often be an advantage, but for those for whom medication amphetamines with sleep, it can be a disadvantage.

However, some patients can’t sleep well even if they take an amphetamine early in the morning. In fact, some people find methylphenidate medications help them sleep better, both by relaxing them and by stopping their minds from thinking so much while they are trying to doze off. In addition, short acting methylphenidate medications tend to wear off abruptly. This can be helpful if stimulants are taken later in the day, and they start wearing off at bed time.

Some people take an amphetamine in the morning and afternoon and methylphenidate in the late afternoon or early evening. They find that methylphenidate’s shorter period of action is preferable towards the end of the day since it interferes with sleep less or not at all. Some patients find Ritalin type medications make them a bit more anxious and irritable than do Adderall type medications.

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What is the difference between brand-name and generic stimulants?
All of the short acting brand name stimulants as well as long-acting Adderall XR are available in generic form, but the long acting ones like Concerta and Vyvanse are not.  The short acting stimulants, not protected by patents, are considerably cheaper than the long  acting ones.Unfortunately, long acting generic Adderall XR costs about the same (or sometime more than) the brand name due to licensing arrangements by the manufacturers.  Although Dexedrine is available in a long acting form (a spansule, that is, a capsule with little beads of medication in it), the spansule doesn’t seem to work much longer than the short acting pill. By law, generic and brand name medications must contain the exact same active ingredients. However, at least in the short run, for psychological reasons, the effects of a well advertised and more expensive medication seems to be greater for the average person. That being said, the only brand name medication that I have fairly consistently heard works better than the generic is Dextrostat (vs. dextroamphetamine made by Barr). A number of patients of mine have reported that they get a different effect from two different generic versions of Adderall, one made by Barr and the other by Ion. This may have to do with differences in the “filler” used to bulk up the pills – the actual amount of medication in each pill is tiny, so filler is almost always needed to make it large enough to be easily handled. If you find one of the generic versions of Adderall works better for you than the other, try to get your pharmacy to stock it. If they don’t, get your medication at another pharmacy.

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How can people get their stimulant medication to work more quickly in the morning?
Sometimes people find that their medication doesn’t “kick in” early enough, and they are late for school or work. One solution is to put the morning dose of medication on the bedside table along with a glass of water. Put two alarm clocks there too. Set one for an hour before the usual wake-up time . Set the other one for the usual wake-up time. When the first alarm goes off, turn it off, take the medication, and go back to sleep. When the second alarm clock goes off, you should wake up more alert and ready for the day.

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Is there a way to get stimulant medication to act more smoothly throughout the day?
If a person takes multiple doses each day, there may be times when one dose wears off before the next one kicks in. In that case it is sometimes useful to take the second dose about a half hour sooner, even though the first dose is still working. By the time the first dose starts wearing off, the second one will start taking effect, and the overall effect will be smoother.

Vyvanse seems to be the smoothest acting of the long acting stimulants and, for many people, lasts 12 hours.

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Can food affect how well amphetamines work?
There are two ways food or drink can affect drug metabolism: one is by affecting how much drug is absorbed from the gut, and the other is by affecting how quickly a person eliminates the drug via their kidneys.

In the case of the amphetamines, acid (and fatty) food decreases the absorption of the medication from the gut, reducing the medication’s effect. Also, acid food generally makes for more acid urine, which increases the speed at which the medication is eliminated in the urine, once again reducing the medication’s effect. The reverse happens when people take antacids like Tums, whic make their urine alkaline.

It might be assumed that any acid food, like orange juice, would reduce amphetamine levels by both of these mechanisms. But that turns out not to be true. For example, orange juice is acidic due to its high citric acid content, but after being metabolized nutritionists say that it causes urine to become more alkaline. (This doesn’t make sense to me. If you, the reader are a nutritionist or biochemist and it makes sense to you, please send me an email explaining this paradox.) So the effects of orange juice on amphetamine blood levels are mixed (less absorption and more excretion), and I don’t know what effect predominates.

Cranberry juice, pomegrante juice, and vitamin C all acidify the urine. It is possible that people who have trouble sleeping after taking amphetamines may be able to more quickly excrete it before bedtime by drinking a couple of glasses of cranberry juice or a Vitamin C pill at dinner time.

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What other kinds of things besides food can affect how well stimulants work?
The most common factor that affects how well stimulants work is how rested a person is.  Getting a poor night’s sleep or chronic insomnia or sleep apnea can all make ADD worse. Chronic fatigue or illness can also have this effect.

Depression and anxiety can make the symptoms worse as well.  Hyperthyroid and hypothyroid conditions, if untreated, can affect ADD symptoms.  Increases in life stress or increased demands on mental functioning can both make symptoms appear worse but can also make them worse.

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Dosing

What is the best dose of stimulants?
There is no way to predict best dose of ADD medication for any individual. Trial and error are required. Adults, who weigh more than children, generally need higher doses, especially if they want the medication to work for more than a six hour school day. The maximum dose of stimulants for adults proposed by some ADD specialists is

  • amphetamines: 3/8 mg per pound of body weight (60 mg per day for a 160 pound person).  However, I have found that some patients, particularly but not only those who weight over 180 pounds may need over 200 mg/day to get an optimal benefit.
  • methylphenidates: 1/2 mg per pound of body weight (80 mg for a 160 pound person).  As above, some people may need higher doses.

I have not been able to find any published documentation of the problems caused by off-label doses, that is, ones higher than those approved by the FDA. In fact, a study of the doses taken by patient in the practices of the editors of AdultADD.Info found that 15% of patients required higher doses to achieve optimal results. (Click here to read the results of the study. However, it would be unwise for a patient to take such doses unless they are under the supervision of a doctor since, for some individuals, such doses may be contraindicated.

Regardless of how much a person weighs, the general rule for prescribing a stimulant is to start low (5 mg or 10 mg taken once or twice a day) and build up each dose slowly, increasing it by 5 mg to 10 mg every three to five days or so until a good effect is achieved or the patient gets unacceptably unpleasant side effects (like moderately severe jitters, uncomfortably fast heart beat, or sleeplessness). Mild side effects usually wear off in a day or two. If there is a positive response to a dose of the medication, the patient should continue on that dose for three to five days and then try a slightly higher dose to see if even more benefit can be obtained. If the higher dose gives no further improvement or causes distressing side effects, then the patient should return to the previously beneficial dose.

If there are unpleasant side effects and no beneficial effects, obviously the medication should be discontinued. However, if there are both good effects and side effects, it may be worthwhile continuing the medication for a few days to see if the side effects wear off.

The effect of each dose of the short acting stimulants usually lasts from three to five hours, with higher doses of amphetamines (but not methylphenidates) lasting a bit longer than lower doses. Longer acting forms of most ADD medications are now available. These generally work for between 7 and 8 hours except for Vyvanse, which usually lasts 9 to 12 hours.

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How long do the effects of the stimulants last?
The stimulants have a number of effects each of which lasts for a different length of time. The effects on cognitive functions such as distractibility, focus, concentration, and organization seem to last for about four hours for the short acting stimulants and about eight hours for the long acting stimulants. Vyvanse lasts a few hours longer.

The shortest acting effect of stimulants is on appetite. This usually lasts only a few hours. (If you don’t want to lose weight, it’s best to take the medication after you eat.) Alerting effects, which interfere with sleep last longer than the cognitive effects so many people find they can’t get to sleep long after the cognitive effects have worn off. The effects on muscle tension, causing jaw tension, may last twenty four hours or longer. Sometimes the effect on sleep builds up slowly and doesn’t become a problem until the person has been taking the medication for a few days.Some people have found that it helps to take periodic breaks from the medication to overcome this problem.

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Some people have trouble sleeping after taking an amphetamine (Adderall) earlier in the day. What can they do about this?
Since more amphetamines is excreted in more acid urine, some people have found it helpful to take a Vitamin C pill or cranberry or pomegranate juice (which makes the urine acid) at dinner time. Keep in mind that not all acid foods or drinks make the urine acid. For example, orange and lemon juice do not.

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Do people in general take more or less stimulant medication than is prescribed for them?
A recent study showed that eighty percent of people with ADD don’t take their medication as often as prescribed. Those who are seen once or twice a year only fill about a third of the prescriptions for ADD medication they are given. Those who are seen every month fill 70% of their prescriptions.

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Side Effects

What are the common side effects of stimulants?
Side effects that are common at first but tend to go away in most people include:

  • nervousness
  • loss of appetite
  • stomach ache
  • headache
  • difficulty getting to sleep

Side effects that tend to remain include

  • dry mouth
  • nervousness
  • mild difficulty urinating
  • feeling of tenseness sometimes most marked in the jaw muscles
  • cold fingers or toes

Unusual or rare side effects that suggest the medication should be stopped are

  • suspiciousness
  • paranoia
  • unusual heart rhythms
  • very fast heart beat
  • consistently elevated blood pressure
  • more than mild difficulty urinating (men)
  • panicky feelings (if mild, these may be controlled by anti-anxiety medication)
  • manic behavior (overly elevated mood, excitability, poor judgment, sleeplessness, strange behavior)

For more extensive information about side effects, click here.

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Can stimulants make a person irritable or depressed?
Sometimes, if the dose of stimulants is too high for a person, the stimulants can make the person irritable or depressed. In my experience, irritability occurs somewhat more often with the methylphenidate stimulants (Ritalin, Concerta, Focalin) than it does with the amphetamine stimulants (Adderall, Vyvanse, Dexedrine).

More often, the irritability occurs when a long acting medication is wearing off, often in the late afternoon or in the early evening. One way of dealing with that is to take a dose of short acting medication in the mid or late afternoon so the medication will wear off around bed-time. I have not seen this problem with Vyvanse, which seems to wear off more smoothly.

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Can stimulants increase blood pressure?
Between 5% and 10% of people taking stimulants experience a small increase in their blood pressure. This can also happen to people taking buproprion (Wellbutrin). For most people this is not detrimental to their health. However, if a person’s pressure is already elevated or if the elevation caused by the stimulants brings the pressure into the “caution” or “high risk” zone, the person should certainly contact their doctor, who will probably reduce the dose of stimulants, or stop them, or add an antihypertensive medication to their medication program. It should be borne in mind that blood pressure is remarkably variable in many people and that mild or moderate temporary increases in pressure are common. Blood pressure should be taken after a person has had a time to relax for few minutes. There are some people whose blood pressure goes down when they take stimulants. This occurs most frequently in people who are overweight and who lose weight on stimulants because the medication reduces their appetite.

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My stimulant medication is working well except it makes my heart beat faster than usual. What can I do about it?
It is best to let your doctor know about this. This effect usually goes away after a week or so on stimulants. If it continues, your doctor may want to consider using a beta-blocker, which can slow down the heart and reduce the blood pressure. It is better to take one like Atenolol that does not cross the blood-brain barrier, as it is less likely to cause depression than some other types of beta blockers. Be sure to discuss with your doctor whether there are any limitations in physical activity you may need to put in place while taking a beta-blocker.

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Heartburn from amphetamines
What can a person do to get rid of heartburn from amphetamines? Some people have found it helpful to grind up the pill and take it with some milk. Consult your doctor about other possible causes of the heartburn to be sure it is being caused by the amphetamine.

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What, if anything, can be done for dry mouth from stimulants?
I have one patient who found that Focalin XR in the morning greatly reduced his dry mouth while taking Concerta.   Another found that he had very dry mouth with Adderall/Mixed amphetamine salts that disappeared a few weeks after he switched to dexedrine.

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What can I do if I sometimes get very up-tight and jittery on stimulants when I am really stressed?

Some people report that it has helped if their doctor prescribed Inderal (propanolol) for brief periods of time under these circumstances.  It is a medication in the beta-blocker family that is used for high blood pressure, performance anxiety, and many other conditions.  It can have side effects and medication interactions so it should only be taken under a doctor’s supervision.

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Special Populations and Other Concerns

Are stimulants addictive?
There are two kinds of stimulants: addictive ones and generally non-addictive ones. Sometimes, people lump them together, leading to fear that all stimulants are addictive. Addictive stimulants are chrystal methamphetamine, which is quite addictive and destructive to the brain, and cocaine. Addiction to stimulants can also be seen when legal stimulants like dextroamphetamine are taken by vein or by snorting. The usually non-addictive stimulants are those used to treat ADD, namely dextroamphetamine and methylphenidate. The reason they are rarely addictive is because the pleasure most people get from taking them is fairly mild or non-existent. In addition, distressing withdrawal symptoms when patients stop taking them are uncommon. Most people just have a tired feeling for a day or two. Nevertheless, many people with ADD get such great benefit from stimulants that they feel very badly when they stop functioning normally after they’ve stopped taking them. This is not a sign of addiction but a sign the medications have helped with their symptoms. Stimulants posed a widespread and serious addiction problem when they were widely used for weight loss and could be obtained without a prescription. Since prescription controls were put into place about fifty years ago, addiction has become a minor problem for the vast majority of people who take them under a doctor’s supervision.

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Can people become dependent on stimulants? People are considered dependent if they experience three or more of the following:

  • have withdrawal symptoms and/or use the substance (or other substances) to eliminate withdrawal symptoms
  • take the substance in larger amounts or use it over a longer period of time than originally planned
  • have a constant desire to quit or cut down their use of a substance
  • spend a considerable amount of time trying to get the substance, use the substance, or come down from its effects
  • give up activities that used to be important to them
  • continue to use the substance even though they know that it has caused (or making worse) physical and/or psychological problems

It is uncommon for people who take stimulants under a doctor’s supervision to become dependent. Just because most people being treated for ADD take stimulants every day does not mean they are pathologically dependency. Stimulants do not cure ADD; just like insulin for diabetes, the medication needs to be taken on an ongoing way to be effective. Taking a stimulant in order to function effectively is not a sign of addiction or dependency. Most people who benefit from stimulants take them as long as they are helpful. If people with ADD wish to be productive even when they get older, they may decide to continue them into old age, assuming they have no medical problems that make this unwise.

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Are there long term effects of stimulants on the development of psychiatric disorders?
There are some concerns about possible long term effects of stimulants. Investigators in Boston evaluated 112 boys with ADHD and followed them for 10 years. About three quarters of them had been treated with stimulants. Stimulants were started on stimulants at an average age of nine and used them for an average of six years. During a ten-year follow-up, those who used stimulants were significantly less likely to receive a diagnosis of major depression, conduct disorder, or oppositional defiant disorder than those who did not use stimulants. They were also significantly less likely to repeat a grade. And there was no difference in the rate of bipolar disorder diagnoses.

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Are there special considerations in treating women with stimulants?
Low estrogen levels can increase the severity of ADD symptoms. Clinicians must be careful evaluating the effects of stimulants on women who may have such levels. For example, at the outset of treatment, premenstrual symptoms may be misperceived as side effects of the stimulant, with result that the use of the stimulant may be rejected unnecessarily. Or the effects of the stimulant may not be as pronounced premenstrually as they are later in the patient’s cycle. Once successful treatment with a stimulant has been established, its effects my seem to wane during a woman’s premenstrual days. Other low estrogen states occur during the post-partum period, peri-menopause, and post-menopause. Sometimes the use of a SSRI medication (Prozac, Zoloft, Celexa or their generics) during the premenstrual phase overcomes this problem, and sometimes increasing the dose of the stimulant for a few days helps. Only the treating clinician and the patient can decide how best to deal with this situation.

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Is it safe for women to take stimulants during pregnancy?
Unfortunately, there is not enough scientific evidence to answer this question with certainty. However, because treating a pregnant mother’s ADD can be very important, a decision must often be made using the limited information that is available. To make this decision we rely on information from a number of sources including testing done on pregnant animals and information collected from pregnant women using either non-prescribed or prescribed stimulants.

Animal experiments have had mixed results. Some studies have demonstrated no harm to the offspring of rats and rabbits given even high doses of amphetamine during pregnancy. On the other hand, increased agitation and anatomical malformations have been observed in offspring in other animal experiments where the doses used were generally much higher than those prescribed for humans.

Studies of women who used non-prescription stimulants during pregnancy demonstrated a somewhat higher than normal rate of birth defects, prematurity, and low birth weight. This was particularly true if the fetuses were exposed early in pregnancy. However, there are a number of differences between these women and women taking prescribed stimulants. For instance, they tended to get poorer prenatal care and did not take stimulants in the same doses or in the same manner as women who were prescribed these medications as part of a medical regimen. Also they often abused other substances (for example alcohol, cigarettes, and/or heroin) making it difficult to know whether it was the stimulants or some other factor that led to the problems seen in their babies.

There are a few studies of women who were prescribed stimulant medication by doctors during their pregnancy. The rate of birth defects, low birth weight and prematurity in these studies was no different from normal. This is the strongest evidence we have that it may be safe for pregnant women to use these medications. However, the small numbers of women in these studies mean that we still must be cautious in drawing any firm conclusions.

Putting all of this together, it seems safe to say that amphetamines are not clearly dangerous to all fetuses and are probably safe for most, especially after the first trimester. Because the effects of untreated ADHD (higher stress, poor self care, more accidents) can in themselves be harmful to the fetus, in many situations it may be safer to remain on these medications during pregnancy than to stop them. However, if there is a birth defect, it will currently be impossible to tell if the amphetamines caused them.

Because there is so much we don’t know, the final decision to take stimulants during pregnancy likely involves weighing the risks and benefits in each individual case. One thing is clear however: stimulants are safer for the baby when the mother taking them is under a doctor’s supervision.

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Are there any special concerns regarding stimulant use by diabetics?
Stimulants can decrease the blood flow to the hands and feet, and this might make diabetic neuropathy worse. They may also increase the pulse rate and blood pressure in about 8% of people and, if you have cardiovascular problems, this might be a concern. If you have diabetes, you should ask your physician about taking stimulants.

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Is there a special health risk for athletes taking atimulants?
The most serious problem for athletes is for those doing high physical intensity sports in hot weather. The resultant dehydration, increase in body temperature, and heavy energy output can lead to an acute breakdown in muscle tissue called rhabdomyolysis (rhabdo=bundles of rods, myo=muscle, and lysis=breakdown). If this occurs, the muscle tissue gets into the blood stream and can be harmful to the kidneys.

Overdoses of stimulants alone have been found to cause rhabdomyolysis, but even normal stimulant doses combined with heavy exercise, heat, and dehydration and are much more likely to have serious consequences.

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Can people with bipolar disorder take stimulants?
It is known that most antidepressants can induce manic effects. Over the years, there has been a concern that stimulant medications, which have an anti-depressant effect, might also trigger manic symptoms.

There is a growing body of evidence suggesting that this may not be true. A recent study of 16 children with ADHD (mean age 10) who were receiving divalproex and/or lithium for bipolar disorder found that methylphenidate significantly reduced the severity of the ADHD symptoms and improved the patients’ overall condition without inducing mania.

Nevertheless, if manic symptoms appear in a patient taking stimulants, the medication should be stopped and the patients’ mood stabilized. Once that is achieved, there would be serious reservations about restarting it as mania can be a very destructive symptom.

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Can stimulants cause heart attacks and death?
Several years ago, both Health Canada and the US Food and Drug Agency reviewed the studies of sudden unexplained death (SUD) among ADHD patients taking stimulants and found no convincing connection between use of stimulants and elevated rates of SUD. Still, studies have found that almost half of the people taking stimulants who experienced sudden unexplained death had a pre-existing heart problem, often not previously recognized, or a family history of an unexplained death at an early age. To me that means that people who have heart problems or have a blood relative who died young for no apparent reason should be wary of taking stimulants, which are known to increase the heart rate and blood pressure and alter the heart rhythm in some people. If stimulants are strongly indicated, it would be prudent to get a consultation from a cardiologist before deciding to start them. If there is even a very slim chance of sudden cardiac death from stimulants, it may be reduced further by the doctor…

  • taking a careful medical history of the patient and his or her biological family especially with regard to heart problems, brain disorders, fainting, seizures, and SUD of a blood relative at an early age
  • doing a physical exam at baseline and, if physical problems arise later, during treatment
  • asking the patient to notify him or her if cardiac symptoms such as unexplained chest pain, fainting, and palpitations appear
  • if there is a family history of heart problems early in life, it would consider obtaining an EKG and a cardiac consultation

In many European countries, EKG screening for all student athletes participating in organized sports is mandatory. Studies in Japan have shown that EKG’s are more sensitive to cardiac abnormalities than are a medical history and physical exam, and universal screening of school children for cardiovascular disease has been mandatory there since 1973. For more detailed information on this topic, see the page on sudden unexplained death.

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Can stimulants affect sperm?
As of March 2008, from my search of the literature there does not appear to be any evidence that the stimulants adversely affect sperm. To be absolutely certain of avoiding any effect, the man could stop taking stimulants for three months before conception, the time it takes for sperm to develop. For personal advice and updated information about this issue, I would suggest you consult with your personal physician.

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Have stimulants been successfully used to treat other disorders?
It is important be have a doctor check the patient’s heart and take a thorough medical history before starting stimulants as people with certain conditions may be prone to serious, even fatal, reactions.

Stimulants have been found helpful for the following disorders:

  • gastric paresis (chronic painful slowing of the bowels)
  • bulimia (repeated gorging on food then vomiting it).   This disorder may  a bit more common among people with ADD.

They have also been used for alertness in some cases of:

  • mild to moderate dementia from Alzheimers
  • narcolepsy
  • excessive work-time sleepiness caused by shift work

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It is generally believed that it is risky to take stimulants and MAOIs at the same time because of danger the combination might cause high blood pressure.  However, a number of clinicians have used this combination for years with no problem.  I personally have no experience with the combination, but for more information, you might want to look at this link: Stimulants and MAOIs.  Remember, this is the Internet.

Does temperature and moisture affect the strength of amphetamines?
Exposing amphetamines to high or low temperature or high moisture for more than a few hours can reduce the medication’s effectiveness.

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How long after taking amphetamines are they detectable by tests?
Amphetamines can be detected in saliva for 3 days, in urine for 1 – 4 days, and in hair up to 90 days. However these numbers may vary with individual metabolism, diet, and exercise patterns and well as with frequency and length of use.

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Can a person test positive for methamphetamine or amphetamine even it they haven’t taken any?
The basic screening tests that are done by employers, the armed forces, and the legal system for amphetamines may give false positive results for amphetamines when a person has taken non-amphetamine drugs like ephedrine, pseudoephedrine (Sudafed), phentermine, fenfluramine, phenylpropanolamine (PPA), propranolol, phenmetrazine, Thorazine (chlorpromazine), mephentermine, MDMA (Ecstasy), methylphenidate (Ritalin, Focalin, Concerta), buproprion (Wellbutrin), Vicks nasal inhaler, tricyclic antidepressants, selegeline, and ranitidine.  In addition these basic screening tests can mistake therapeutic amphetamines such as Dexedrine, Dextrostat, Vyvanse, mixed amphetamine salts, and Adderall for illicit amphetamines such as methamphetamine.  Many tests are inaccurate 10% of the time.  It you believe you tested positive in error, have the test repeated.   If it still incorrectly registering positive, get a test using gas chromotography/mass spectrometry test for the specific drug you are falsely thought to be taking.  It is costly however ($120).

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Taking stimulants without a prescription
Question asked by a visitor to the site: ” I am 25 years old and have extreme difficulty concentrating and organizing my thoughts. I procrastinate and have anxiety and severe restless leg syndrome at night. In addition, at night it is difficult to get my mind to stop wandering so I can get to sleep at bedtime. I am currently studying law. With this condition it is very hard to focus on material that requires dedicated study. When I was younger I was diagnosed with ADD and was treated with Ritalin. I took this all the way through high school, but I stopped after graduation. I think I may now have adult ADD.

“I was concerned about the anxiety and told my doctor about it, and he prescribed Lexapro, which helped marginally with the anxiety but did not help the concentration problems. A friend with ADD gave me a capsule of his Ritalin. I took it at 5:00 pm, and it seemed to calm me down. It even alleviated the restless leg syndrome, which my wife was pleased about. If I inform my physician about this do you think he will agree that it is adult ADD. I am becoming increasingly concerned because of the effects it is having on my studies.”

Answer: It is not a good idea to take medication without a doctor’s supervision. There are people with certain medical and psychological problems who can have serious reactions certain ADD medications.

It is hard to be sure of what to make of your response to Ritalin. Some people have a good response to stimulants initially because of the placebo effect. But most who respond well to the medication with their first dose continue to do so. The fact that you were diagnosed with ADD and had responded well to Ritalin when you were younger makes it more likely your response was not just a placebo response.

Whether you should tell your physician or not about your recent experience with Ritalin depends on your assessment of the physician. Many doctors would disapprove of your taking stimulants without a prescription but still might find that you have ADD and be willing to treat you. But some might be critical of what you did and refuse to treat you, If your physician won’t treat you, I would think that you could find another who will.

To help a doctor evaluate your ADD, you might want to print out the questionnaire on my web site, complete it, and bring it with you to your appointment with him. It might also help if you brought your wife along, and she reported her impressions of your symptoms and how they affect your life and functioning. As you may know, ADD does persist into adult life in over half the people who had it during childhood.

With regard to your anxiety: it is not uncommon for people with ADD to feel anxious about their memory lapses and general level of mental functioning. While the stimulants can sometimes have a biological anti-anxiety effect, many people find that once the medication starts working and their thinking gets clearer and more focused, their anxiety disappears because they are less fearful of making embarrassing mistakes.

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Is there a safe way to buy stimulants from an on-line pharmacy?
The FDA recommends that, before buying a prescription drug over the Internet, patients check with the National Association of Boards of Pharmacy site to see if the online pharmacy possesses a valid pharmacy license and has met state practice standards. All approved pharmacies require a doctor’s prescription to be mailed to them. Upon receiving a stimulant prescription in the mail for the first time, they will probably call the doctor to confirm the prescription. Some of these pharmacies will fill prescriptions for stimulants only if the prescription is written by a doctor practicing in their state.

It is not wise to buy stimulant drugs from web sites that:

  • offer to prescribe a prescription drug after only a telephone interview
  • do not offer the opportunity to ask questions of a registered pharmacist
  • require that you link to another web site to purchase the drug
  • do not provide an U.S. phone number and address to contact for questions

There are a lot of pharmacies with names like “Trusted” or “Verified” or even “FDA-approved” that will offer to sell you stimulants online without a doctor’s visit and without a prescription. But you won’t be sure about what’s in the pills you are getting, whether you have some medical condition or treatment that might affect how the medication affects your brain and body, and whether there is some non-ADD condition you have that only looks like ADD.

Even if you don’t go on-line, there still may be ways to buy stimulants less expensively than you do now. If your health insurance plan provides drug coverage, you may be able to get three months of stimulants mailed to you at one time by the plan’s pharmacy at much less the cost of three one month supplies.

Even if your plan does not have “mail-in” benefits, you may be able to save some money by phoning the pharmacies in your area and comparing prices. I’ve done this and found that they vary from one store to another. I have discovered that some pharmacies charge less for Ritalin than others in an area, but charge more for Adderall than others and vice versa. I think you will find it worth while to phone around and check prices for the dose and amount of medication you want to purchase. Steel yourself as an unprofessional pharmacist may respond to your question as if you are a drug addict searching for a hit. In that case, just politely ask to speak to the manager to get the information you want or hang up.

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What is the relationship between coffee (caffeine), ADD, and stimulants?
I know of no controlled studies comparing the effects of stimulants and coffee on ADD, but in my experience, no patient with ADD who had previously used coffee to treat their ADD symptoms ever found coffee the more effective treatment.  The stimulants are clearly better for treating memory, focus, concentration, and distractibility.

In addition, since both coffee and stimulants can be energizing, taking both at the same time can lead to anxiety, jitteriness and difficulties with sleep. Each can also cause heart beat irregularities. When taken together, this side effect is more common. The combination is also more likely to lead to upset stomach or heartburn and can make it difficult to evaluate the effects and side effects of the stimulants accurately.

I generally suggest that patients stop drinking coffee and/or other caffeine drinks) before starting stimulants.  The only problem I have seen with this is that some people have caffeine withdrawal symptoms of tiredness and headache that may be misperceived as side effects of the stimulants.

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Can stimulants help patients who don’t qualify for the diagnosis of ADD?
Very many people have some symptoms of ADD, like forgetfulness or a tendency to put things off until the last minute, but their symptons are not numerous enough or severe enough to meet the standard criteria for the diagnosis. Very little research has been done on the effects of stimulants on such people. In clinical practice, however, some of them are treated with stimulants and experience significant benefit.

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Do stimulants cause genetic damage?
A study of white blood cells of 47 children taking either methylphenidate or mixed amphetamine salts for a period of three months showed no more chromosome damage than did the white blood cells of children not taking these medications. While somewhat reassuring, longer term studies, now under way, are warranted. (reported in the J Amer Acad Child Adolescent Psychiat December 2008)

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