Hacker News Reader

Comment by graysnow86 | Hacker News Reader

> The treatment for ADD is one of two medications, methylphenidate or dexamphetamine. You can try other things in addition to these, but not instead of these, and you should try both - there really is just no substitute.

No, not quite - there's a variety of different ADHD medications and I'd argue there's more popular ones like Vyvanse (lisdexamfetamine). Non-stimulants like Strattera or Intuniv absolutely can and are prescribed on their own, which are really useful for people that respond poorly to stimulants.

Perhaps you meant to say there's two main classes of stimulants (amphetamines, methylphenidates) that are worth investigating and shouldn't be skipped over?

View on HN

Intuniv gets a bad reputation because the patient has to be titrated up to the final dose and it takes a long time to see the full effects. It's the opposite pattern of stimulants where the patient feels great (unnaturally so, due to stimulant euphoria at the start) and the effects wane over time.

The internet is really, really bad at pushing everyone toward ADHD diagnoses and then pushing them further toward stimulants. There's a darker part of some of the communities then pushes people to keep pressuring their doctors for higher and higher doses and also discourages people from trying therapy.

Outside of the internet I know several people who did the rounds with medications and ended up on the non-stimulant options and preferred them. This is an unthinkable conclusion if your primary source of information is Reddit, X, or TikTok ADHD influencers, but it's pretty common in the real world.

Stimulants have a habit of being enjoyable at first (meaning people like taking them, beyond their attention effects) and then the effects wane over the years, to the point that there are studies showing that the effects of stimulants taken long term in children are minimal to unmeasurable after several years. This is confusing to anyone who has been taking them for years and notices a difference on days when they don't take them, but that's explainable by the fact that it takes months (or longer) for the brain to adapt to not having them in the body. For some reason this same effect is not debated as much when you talk about people who drink 5 cups of coffee per day but then crash hard when they miss their coffee, but it gets protested and argued a lot when we talk about literal amphetamines.

Anyway, please don't listen too much to internet ADHD forums. They're just so, so bad these days with bad advice and poor psychology/therapy takes. You really need to engage with professionals with an open mind and not be single minded about acquiring and taking stimulants if you want to address this problem as a whole. The way the internet treats ADHD as a simple "low dopamine" state (which is wrong on many levels) and then points to stimulants as a "raise your dopamine" drug to neatly cancel it out sounds nice, but it's wrong on so many levels.

>Stimulants have a habit of being enjoyable at first ... and then the effects wane over the years

The standard approach to addressing this is thru the use of "drug holidays," regular short periods during which one doesn't take their medication with the intention of abating the growth of tolerance. I much prefer going this route since stimulants have proven to be such a solid solution. The other standard approach is, of course, upping dosage, which could be seen as only delaying the problem.

I don't disagree with anything you wrote, though. The internet is indeed a terrible place to get any advice on these topics.

Drug holidays can make a small impact, but tolerance is going to build to many of the effects no matter what you do.

The other problem with drug holidays is that some people start getting into cycles where they don’t take the drug and have lazy days where they justify not doing anything, then they wait for the drug to kick in on the return day to even try doing anything. The housework and personal life things pile up on the off days and then they try to speed around and do it all on the medication days, which is another pattern that isn’t sustainable forever.

Drug tolerance doesn’t build and then abate in a very asymmetric manner where someone could take it for 30 days and then have a couple days off and reverse it all. Some of the biochemical mechanisms of tolerance have persistence measured in months or years.

If you feel you're getting tolerance to amphetamines, the first thing to try is magnesium glycinate/threonate supplements, and then hydration and diet and sleep.

> Intuniv gets a bad reputation because the patient has to be titrated up to the final dose and it takes a long time to see the full effects.

I went up, but then backed down because even 2mg was seriously affecting my sleep quality. I'm feeling much better at 1mg.

nb I think if I wasn't employed than I'd be best off with just this, but employment is best with stimulants. Unfortunately stimulants have side effects.

Vyvanse is dexamphetamine. I suppose you can say “amphetamines” instead, I imagine the subtleties of the terminology differ quite a bit in different places.

Strattera can help (I mentioned bupropion, another SDNRI). Of course if you try stimulants and don’t respond well, it’s totally fine to just use e.g. Strattera. What I’m advocating against is e.g. “try Strattera first, if it seems to help, don’t bother with stimulants”. (Some places, cultures, or medical systems do have surprisingly strong biases against stimulants!)

To be specific, Vyvanse/Elvanse is lisdextroamphetamine.

But IMO it's not really that incorrect to say there are two main types of stimulants.

You rarely (at least never where I'm from) get instant release methylphenidate. Always some delay mechanism. Shorter - Ritalin, longer - Concerta.

And the lizine particle attached to dextroamphetamine acts as a such delayer, but isn't active by itself -- being only an amino acid. So it's still kind of amphetamine just as Concerta is methylphenidate.

Reply on news.ycombinator.com