ADHD, Adderall, and Modafinil

Hello doctors,

Seeing your response on the forums to a student asking about prescription stimulants piqued my curiosity, and I’m wondering what your thoughts are on: 1. medication for ADHD in adults, 2. Adderall for long-term use in adults, and 3. Modafinil in general (i.e. not necessarily in the context of ADHD, though obviously very interested in that as well)?

Thank you so much for what you do. You probably don’t know how much of a positive impact you have on those of us who don’t have access to medical professionals we can really trust. Oh, incidentally - any plans of SteadyMD in the Carolinas any time soon?

Can you make your questions any more specific?

“Thoughts on medications” is a bit too general.

If my question detracts from the OP’s question too much then I won’t be upset if this isn’t approved (or ignored) but I thought maybe you could comment on my case as an aid to answering the OP. I was diagnosed with ADHD at the age of 18 (28 now) through truly rigorous testing via the weschsler iii adult intelligence scale and was told I was the textbook case. Yet I found amphetamines absolutely mind blowingly addictive. God I loved the stuff. Indescribably euphoric for me. I would take 3x the max dosage throughout a day on occasion i.e. 90 mg of adderall or so. I was told that this absolutely wouldn’t happen if I was a true ADHD case so I felt lied to. The addiction really destroyed a couple of years of college for me (I was awake for 90 hours once). Is my situation common? Most of my ADHD friends I’ve met don’t seem to have this issue.

Sorry about that, let me try to be more specific:

Do you think that taking Adderall XR indefinitely is a good strategy for dealing with Primarily Inattentive type ADHD in an otherwise healthy adult, who has never been medicated for ADD prior?

Do you think that there are serious health risks (neurotoxicity, blood pressure changes, teeth problems) associated with taking stimulants (Adderall XR in particular) for ADHD, even with conservative doses?

Do you think that Modafinil is safe to use in the long-term?

Do you think that Modafinil is safe to use in the short-term, particularly for someone who is quitting Adderall XR?

Do you think Modafinil is in any way superior to, say, caffeine at “equivalent” doses, whatever they might be?

For context: I’ve been taking Adderall XR for ~ 3 years as an adult for ADHD-PI, and although I find it helpful, I hate the side effects and am very concerned about the long-term effects of taking it. My psychiatrist isn’t terribly helpful with this matter, and when I try to read the literature on this drug and adult ADHD I feel completely overwhelmed by what I am able to find.

Hope that’s better, please let me know if it isn’t, and thank you in advance :slight_smile:

  1. If the diagnosis has been made properly by a trained physician (which is less common than you’d think), using Adderall is a reasonable treatment strategy if it provides clinical benefit. Most people can come off the medicines at some point in their adult lives, however, rather than taking them indefinitely.

  2. Yes, there are always risks for adverse effects, though it’s impossible to predict how one person may respond from this standpoint compared to another. For example, the blood pressure changes are often dose-dependent, can be transient, and are thought to occur in anywhere from 10-35% of individuals. Do you define that as a “serious” effect? I don’t know.

“Neurotoxicity” is too vague of a term. And I’m not sure what teeth problem you’re describing, other than perhaps bruxism, which I wouldn’t consider “serious”.

  1. It is generally pretty well-tolerated. But, as with all medicines, it too has its share of potential adverse effects, some of which are rare, but potentially life threatening (like Stevens-Johnson syndrome).

  2. Modafinil is primarily a drug that promotes “wakefulness”, and is used for narcolepsy and shift-work sleep disorder. Use for ADHD is considered off-label, and I don’t prescribe it for this purpose.

  3. Superior for what? There is some comparative data between modafinil and caffeine for wakefulness, though I haven’t read it in detail. Not sure whether there’s data for other outcomes.

I can understand your concerns, and the world of adult ADHD is very complex and controversial.

Thank you Austin!

  1. I’m afraid that I’m very aware of how poorly the diagnosis can be made
  2. (a) At what point would you personally consider blood pressure changes serious?
  3. (b) Damage to dopamine transporters and receptors, which was shown in rats if memory serves, and which sounds scary, but I’m not even sure what it means/what the implications are.
  4. (c) Tooth decay/loss associated with the dry mouth that Adderall XR brings on, although I was also curious about the implications of the grinding.

3/4/5. I suppose what I really want to know is: do you consider Modafinil a good idea for someone who is dealing with the fatigue and memory/focus issues associated with stopping Adderall XR after years of near-constant use?

Thanks again!

@someguy what I am writing is not about meds, I like to stay in my lane… Austin is correct when he stated that it is less common than one may think that a physician be trained to diagnose ADHD (all types). The problem with being diagnosed ADHD in both adults and children is that there are so many other factors involved, such as did the physician rule out if the inattentiveness is actually caused by trauma, stress, anxiety, depression, lack of sleep …ect, that is why it is not always cut and dry and can be tricky to diagnose. Data I have seen indicates that meds help ADHD more than anything else, however, a behaviorist may be able to assist with some strategies for inattentiveness (such as organization, chunking, timers, movement breaks…ect) as well as ruling out any of the other disorders I mentioned all of which can be helped greatly by therapeutic intervention.

2(a) - when someone develops hypertension.

2(b) - Adderall certainly has dopaminergic effects, but I am not aware of this data. Probably a better question for a psychiatrist or psychopharmacologist than for me, to be honest.

2(c) - Same as above.

3/4/5 - I would consider that to be a clear off-label use, and would need to do a much more detailed/thorough evaluation to ensure there aren’t other reasons for your fatigue and memory/focus issues that we’d be “covering up” with Modafinil.

Thank you Austin!

So, if you could reasonably conclude that the lethargy and memory/focus issues were a consequence of withdrawal from the Adderall (and not e.g. sleep apnea, thyroid issues, general sleep hygiene, vast changes in emotional stress), would you think Modafinil would be a good/safe idea? Would extra coffee be a better idea, or even a good one?

If the symptoms were related to medication withdrawal, I would expect they’d eventually resolve rather than be permanent.

If coffee helps you get “over the hump” until this happens, that would be a better option than starting on a new medication.

Makes sense. Thank you, Austin!!

Actually, I have another question:

Do you put any stock in the idea that taking L-tyrosine, or any of the amino-acid precursors of serotonin and dopamine, can help in dealing with amphetamine medication withdrawal? And if so, how would you supplement them?

I’ve seen many people on various internet forums (so you know it must be a good idea) recommend taking L-Tyrosine (and/or L-dopa and/or 5-HTP, though I’m not sure of the connection as the latter appears to be the precursor for serotonin) for helping to “restore dopamine levels”, and came across a paper (Treatment of attention deficit hyperactivity disorder with monoamine amino acid precursors and organic cation transporter assay interpretation - PMC) suggesting that supplementation with 5-HTP and L-dopa may be a practical alternative to the prescription medications for ADHD in children, which seemed encouraging. But when I looked at the Examine.com articles (a site I’d seen you recommend in another post) for L-Tyrosine, 5-HTP and L-dopa, I realized I’m in over my head…

Thanks again sir :slight_smile:

Yeah, unfortunately this is veering pretty far outside of our area of expertise – like before, probably better questions for someone more trained in psychopharmacology than we are. I don’t think either of us have time to thoroughly digest the evidence on this for you. Sorry man!

Sorry, I realize these aren’t “fair” question to have asked you guys, it’s just, you know… there isn’t really anybody else, including the medical professionals I go to, whose opinions I trust and respect as much as yours :slight_smile:

I appreciate the help you’ve been able to give and the time you’ve taken!