How to mitigate the Adderall crash (or "is this normal?")
March 14, 2017 11:51 PM   Subscribe

I was recently diagnosed with ADD (inattentive type), and have been taking 10mg of Adderall XR once a day (or twice, as needed, on the instructions of my prescribing psychiatrist) for about a month. The ebullient 'kick' of focus and wellbeing I'd felt in the initial week-or-so has dimmed, and by now Adderall's most noticeable effect is the all-consuming, irrational frustration, irritability, and anxiety of the comedown, which lasts for several hours. Is this something that'll wear off eventually, or that I can mitigate through dietary changes or (etc, etc). Or is Adderall just not the right drug for me? What have your strategies been, both with ADD medication in general and for mitigating the Adderall crash in particular?

The anger, frustration, and anxiety of my Adderall comedown is so significant--and so irrational--that it's becoming increasingly difficult to justify taking it even when I know I have important work to tackle, much less as a regular medication. I'm exhausted and brittle and utterly lacking in emotional fortitude of any sort, and pick foolish fights with my partner. If I have to be social, I feel like an awkward weirdo and don't know what to say--which to some degree is the case anyway, but pre-Adderall I was mostly able to be generous and forgiving with myself about it, and now it can provoke a totally unhelpful shame spiral.

I've written my prescribing psychiatrist to tell her all this, but though she seems like a lovely and receptive doctor, she's not someone I see regularly. (I'm also looking for a therapist right now, but don't currently have one.) Also, this is basically the first drug I've ever taken long-term, so I have no point of comparison or sense of how X or Y class of drug works with my body/brain chemistry. I'm interested in experimenting with Adderall routines and "tips and tricks" (and I'd love to hear what other folks' are) but I don't think I have much fortitude for these intense crashes, and while I like its effects otherwise, I'm not sure it's a magic bullet (particularly because I'm in my mid-thirties and have built a life around coping with ADD workarounds already).

At this point my work schedule sort of precludes a regular medication routine, which I think would make testing out strategies a bit easier: I spend mornings and early afternoons working on writing projects and associated professional commitments. (Or doing laundry, or lazing in bed a bit too late, or running miscellaneous errands, or... Essentially my time is my own, and while I usually have a lengthy to-do list, it's always longer than I can reasonably accomplish and I'm resigned to this.) My writing projects, for what it's worth, are avocational and largely unpaid, but they're something I can't afford to neglect, both for my own sense of self and because the professional development aspects require regular tending. My actual paid employment is three days a week from 3-10PM, plus a fourth day from 10-6PM. What this means is that I have ~3 really long days, and ~3-4 freeform days every week.

Some notes:
I wake up after 7-9hrs of sleep (depending on how late I got home the night before and how dark it is outside, since I need a lot of morning sunlight to feel human), usually around 9AM lately. I exercise lightly, largely in the form of a 6mi bicycle commute 2-4x/week. I'm not very good at eating regularly under the best of circumstances, but I'm doing my best to eat 'preemptively' now that Adderall masks my usual hunger signals, and I always eat breakfast and have a Clif bar in my bag for midday low bloodsugar woes. I'm usually good about staying hydrated. Also, I mostly haven't been taking the 2nd 10mg pill in the afternoons (see schedule weirdness, above), so I don't have a sense of what it feels like to do that regularly. I'm a woman in my mid-thirties, FWIW.

Some things I haven't tried yet:
Strangers on the internet recommend magnesium to ease the crash effects, and zinc, having a beer, and a bunch of random nootropics they seem to have researched on, like, the Alex Jones subreddit; I have mostly not tried any of these strategies but am open to them all. Strangers also recommend religiously taking Adderall 2x/day to establish emotional balance (rather than "as needed" as my psychiatrist suggested), or taking half an XR pill every 2-4hrs (rather than one every 4-8) to maintain a more even keel, and I haven't tried either, but may. They also recommend taking an afternoon Adderall IR to ease the comedown, or switching to Vyvanse [2017's holy grail, like Adderall was 2011's], and I'll pursue options like those if my psychiatrist suggests 'em and/or I realize that Adderall is 100% horrible with my body/brain chemistry.

In short, I like Adderall's effects on my life and focus in the first couple hours, but feel like the benefits are outweighed by its misery-inducing comedown. (Plus I'm surprised at how short the lifespan of XR seems to be.) I'm interested in developing a better medication routine, but feel sorta confounded about how to do so given my irregular schedule and aforementioned misery-inducing side effects, which are becoming a powerful deterrent to taking the meds regularly in the first place. What to do?
posted by anonymous to Health & Fitness (12 answers total) 8 users marked this as a favorite
I've been taking AD(H)D meds for over 20 years (holy crap), and I've been on Vyvanse ("Elvanse" now that I'm in Europe) for maybe 10. Some context: I never took Adderall, and it's been so long since I took my previous meds that I can't compare how Vyvanse compares to them re: crashing. It's great that you're talking to your psychiatrist and mention how "as needed" might not be working great for you. I have also always taken Zoloft (sertraline) along with my AD(H)D meds to manage my anxiety. This was not necessarily just to balance out the crash anxiety you describe—I was also exhibiting OCD-ish behaviors as a kid—but maybe adding an SSRI could be helpful. I certainly recognize that when I run out of sertraline, I'm much more irritable. Obviously ask your medical professional. But what I really want to suggest isn't pharmaceutical.

In grad school (on Vyvanse) I started noticing that I would be really irritable when I came home, and it was negatively affecting my relationship with my wife. I would often be at the office until 5 or 6 pm working on something—often something frustrating—and I would continue thinking about it to some extent on my commute home and basically through dinner.

What I worked out was that I needed better separation of "work time" and "home time."

The way I accomplished this was to set aside 15 minutes or so when I got home where I would just screw around online. My ever-loving wife, la Doña Diego, agreed to give me space for those 15 minutes; she recognized that my need for this "me time" did not mean I loved her any less. I would intentionally close all the windows I had open that were research-related (if I hadn't done it before leaving work, which was better) and just browse Twitter and blogs or look at memes or whatever. I also typically had a beer during this time. The beer especially was the signal to my brain saying, "You're okay to stop thinking about work." This would really chill me out and I'd be good after those 15 minutes.

So my suggestion to you is to figure out a way to tell your brain, "Enough." When you're done with work, do something that is decidedly not-work. It's interesting/funny to me that a beer was suggested for you as well, but maybe that wouldn't work on days you're done at 10 pm. Intense cardio after work was also good for me, but again your schedule makes that tricky. Maybe try something like a dumb little video game, or meditation (so many good threads here on how to get started). Social media may not be a good idea, since that actually tends to stress people out. Just figure out something to demarcate "work time" from "home time."

Relatedly, I feel like your non-"paid work" days could use a little more structure. If you work from home (you didn't say that, but I'm inferring), you're always at the office, so you really need to draw a bright line between working and not working. And even if you don't work from home, the lack of a set schedule can make it hard for your brain to shift smoothly into a lower gear once you're done for the day.

It's great that you've already developed some coping strategies and that you're willing to continue to experiment. Best of luck!
posted by dondiego87 at 1:33 AM on March 15

I work with a lot of young adults who begin trialling ADHD meds, and one of my kids also went on Ritalin, these are my observations and I am not an expert.

An afternoon/evening crash of sorts can be typical, but yours sounds extreme and really unpleasant. When my kid took Ritalin he had mild headaches and crankiness for about 2 weeks and then it stopped and he felt fine.

If you've had these side effects for more than 2 weeks and they're not getting better, I would ask to switch to something else and see how it goes because bodies are weird and people can suffer on one medication and be okay on another.

The thing about this type of medication is it'll either work well immediately or it won't; you don't need to build to a therapeutic dose which takes several weeks.

I would ask to switch.
posted by yes I said yes I will Yes at 2:23 AM on March 15 [2 favorites]

I have recently heard about testing for drug compatibility for ADHD while researching it for my family. Genesight is the one I hear mentioned most frequently from people who have had it done.
posted by candyland at 7:10 AM on March 15

The crash is typical, it sounds atypically bad for you though. I think b-vitamins help me feel less depleted, but maybe that's just me.

I agree with advice about evening out your dose, either by taking 2x or taking an IR later in the day. Though, most importantly, I'd suggest taking less mg a day, however you take them. (For reference, I'm a 225# dude and I take 15mg XR once a day -- I have taken tons more over the years, but higher doses really exacerbate the up and down swings.)

Also the advice above about having a cooldown transition period is great. Much of my Adderall irritation comes from my brain shifting gears too quickly. If I give myself a little time to chill out, it becomes a lot easier to 'switch modes'.
posted by so fucking future at 9:34 AM on March 15

I've taken generic Adderall (regular/not XR) for ~15 years, 2-4 time/day (as needed), and from the beginning at a dosage that would have most people twice my size climbing walls. It doesn't affect my appetite or sleep pattern. I don't "crash" nor do experience that kick that you feel for a couple of hours after you take it. I know it's wearing off when I can't focus on the task at hand because my thoughts are racing re other things. For me, the only downside is that it seems to exacerbate my tendency to hyperfocus, so I need to be mindful of that. Iirc, it took maybe 3-4 months to work out the kinks re how much to take and when to take it.

Based on my experience, I'm guessing that a lower dose, taken more frequently, might be better for you.

Fortunately for me, when I started taking Adderall my psychiatrist was also my therapist and I saw her weekly for 50 minutes. So, she actually knew what was going on with me/my life. I know that that's unusual these days, i.e., that most psychiatrist basically just write prescriptions (a practice that my old school doctor found appalling). If you can't find a psychiatrist who also does therapy, look for a therapist who has a close working relationship with a psychiatrist and knowledge (i.e., beyond what is required, e.g., not a recently graduated MSW) of meds.
posted by she's not there at 10:05 AM on March 15

1/2: A few things beyond asking for other drugs and transition period:

1) You didn't say whether or not you're on generic or brand name. Every time I've tried generic, despite assurances they're the same, I've had much of the same experience you're describing. (I'm scientist, so I had my husband administer a "blind trial" to see if I was having some bias, hahaha! But I correctly picked which one he had given me every time, it was so obvious.) For me, XR lasts about 8 hours with a "soft" comedown; the generic about 4-5 with a really obvious crash. I'm not sure why, as the active ingredient is the same (but apparently can vary in percentage), but I've read that the release mechanism may be different or the inactive ingredients may affect people differently. My insurance will cover the brand name *if* my doctor insists on brand name only as medically necessary, FYI, but YMMV.

2) This is just a throw-out-there, but seeing as you're a woman in your mid-30s, have you had your thyroid checked recently? Due to the side affects of the adderall, it could be masking some thyroid symptoms that as a result become more obvious once it wears off in a way it might not have before when you might have been used to it as a 24 hours thing, especially if it's a high functioning thyroid, which includes irritability.

3) Along those lines, how's your diet? Are you eating regularly/getting enough calories, and are you getting all your minerals and vitamins? Personally, still, I have to force myself to eat as part of a schedule, because if I don't then I'm extremely "hangry" (hunger angry) when I start coming down. (Rather than eat a big lunch or what have you, it's easier for me to eat small snacks throughout the day.) I also take a multi-vitamin.

4) If this is a recent diagnosis, you also have to be kind to yourself! Figuring out why "you're the way you are" is really huge, and it may take some time to adjust. You may experience all kinds of feelings about it, some of them good, some bad. You're going to be looking at your life in the past, present, and future with new eyes. It may be good to talk to your doc about what you're feeling, because some of it may not be due to the medication. (Personally, I went through a period when, after seeing Adderall me and then the comedown, I'd spend the evening all depressed and frustrated that I couldn't be "normal" all the time. What was really happening was that I felt that way all the time, but the meds helped with the impulsiveness/control aspect of it so it wasn't as obvious during the day.)

Finding the right ADHD drug at the right percentage may take some time. I know the thrill of the first few weeks is amazing, but that doesn't mean it was the right drug for you. Your doc should be closely monitoring this, and willing to work with you to figure out what's best for you. As the years progress you'll still need to monitor it - weight gain/loss, getting use to the meds, work/lifestyle changes - all of these may require some adjusting or new tactics.
posted by barchan at 10:54 AM on March 15

2/2 To answer your question about routines, etc.:

Medication is just one part of ADHD management. I think of my management as a stool with 4 legs (bear me out): medication, exercise/diet, routine/habits, and strategy. (These could vary for you, depending on how your ADHD presents.) I can knock one of those legs away and still have a stool that works okay. While it's best if I have all of them working, if I don't exercise for a few days, it'll be okay if the other 3 legs are working. (And importantly, this creates the mindset that my Adderall is just one part of a whole, not the "magic bullet".)

1) Exercise and eating properly is really important for me. My ability to focus is so much better on days I exercise regardless of the meds. YMMV but sugars and different carbs will affect my ADHD. I think the jury is out on if/why/how diet affects ADHD clinically, but I know that sugar realllllly affects mine. (hey have you checked how much sugar's in your clif bar?) That chocolate croissant at the coffee shop may be super tempting, but is it worth the struggle I'll have later? Usually not.

2) Routine routine routine. Habit habit habit. I work from home, but it doesn't matter - Tuesday is laundry day no matter what, for example. So many routines, so many habits. It's little things: I eat the same breakfast almost day (eating a lot of the same meals is a coping mechanism for grocery shopping, so I don't stand in the aisle completely overwhelmed with choices and distractions and forgetfulness). I take a walk around the block so that I feel like I'm "going" to work. I answer e-mails only at certain times. The first thing I do after I finish breakfast is check my personal to-do list for the day and the times I've scheduled to have completed them by. The first thing I do at work is create and check my to-do list. Etc., etc. Boring and takes time to establish, but incredibly freeing at the same time.

Since exercise helps and I naturally work better in the morning, I exercise early, work for awhile, and take my pill at 9 on weekdays. My meds last about 8 hours with a soft comedown of 1-2 hours. So if I have something going on in the evening, I have a 5 mg IR Adderall for things like social events and 10 mg for work. (This took years to dial in, btw.) I do have exceptions, but I've outlined them out in a spreadsheet - like working nights and sleeping during the day. The spreadsheet allows me to switch to a new "routine" without it being "willy-nilly". It's still a routine, just a different practice.

3) Strategy kind of includes routines, but it's more about what pre-diagnosis were coping mechanisms. At your age you've probably developed a lot of coping mechanisms; that's fantastic and you should be proud of yourself! But you may find that some of the coping mechanisms may need to change, can be improved, or dropped all together. It's a good time to evaluate. My strategy also includes self-care; it includes recognizing things like how my anxiety about something is a hold-over from the days when even an email when I was struggling could send me over the edge; it includes being easy on myself, acknowledging the support of others, asking for help, etc. It's all the little things, like carrying a note card in my pocket as a to-do list. It's meditation. It's looking at my life and saying, how am I doing?

A diagnosis and medication is going to change how your approach these things. If you can and are able to find a good therapist for ADHD, one who recognizes the value of having a strategy for ADHD management, I highly recommend it. It doesn't need to be lifelong or anything - in fact, a few sessions may be all you need. A good one can help you develop/establish routines/habits/mechanisms and ease the feeling of being overwhelmed. A primary part of strategy is support! You don't need to fix all the things at once - one at a time, my friend.

Good luck with your future course! It's an amazing thing, to get this far, and with good management your life can become so much better.
posted by barchan at 10:56 AM on March 15 [3 favorites]

After years of occasionally adjusting dosage this way and that, I've ended up with this medication routine for my ADD prescription (it's a non-XR tablet):

9am: 10mg (full tablet) (sometimes adjusted to 8am)
noon: 5mg
3pm: 10 mg
6pm: 5 mg

It sounds complicated, but I've been taking a variation of this for so long that it feels normal, and I have an app that reminds me. For whatever reason, other dose schedules have always left me hanging either in the morning or afternoons, and it's just not worth it. On vacations and weekends, sometimes I only take half tablets all day.
posted by redsparkler at 12:16 PM on March 15 [1 favorite]

I generally do alternating half-doses like redsparkler describes above, but with 10 mg less. In the morning, I take 5 mg; around 1 pm, I take 10 mg, and around 4 or 5 o'clock (my workday is 10:00-6:00 with lots of busy stuff afterward. I shifted my schedule a little later so that it works better with my natural sleep cycle) I take another 5 mg. One factor that might prevent a crash is that I typically have a very large lunch, and generally make sure lunch is my biggest meal of the day. That way, if I don't eat a proper dinner or a dinner at the right time, it doesn't ruin my blood sugar. And then at night, a glass of wine or some sleepytime tea is really helpful for winding down. But if I haven't gotten enough exercise that day, I will often need some melatonin or something to help me fall asleep, so. Perfection not achieved yet.
posted by witchen at 12:38 PM on March 15

I started taking meds for ADHD about 10 years ago, when I was about 50.

I have been taking sertraline(Zoloft) for over 20 years for Panic Disorder.

I was the classic adult woman with ADD. I lived in hyperfocus for 40 years. I was always really good in school and at work and completely disorganized everywhere else. Seriously, the hyperfocus was so bad that I often woke up with sore muscles because I never relaxed.

It took a while to get it all sorted out. I have taken regular, short acting adderall and the extended release Adderall, and concerta, when the adderall felt like it wasn't working. The adderall XR didn't feel like I was crashing nearly as much as the short acting. The concerta didn't have the crash effect, but it wasn't very long before it had no effect. When I started with adderall XR again, I also started taking Guanfacine. (There is now a fancy version called Intuniv) and that seems to even out the waves of the adderall XR as a new dose dissolves and releases. When I have a very long day, as in working and commuting 2+ hours each way, I take 2 Adderall XR 30 mg. One first thing in the morning (5:30 am) and a second one at 10 am roughly. I am not currently working, so I take one 30mg Adderall XR in the morning, and if I need to do something requiring additional focus I will take half a 30 mg short acting to bolster the XR.

I can tell when my body has used up the Adderall because I start having trouble putting coherent sentences together easily and without pause.

Since the Adderall XR is a capsule, I can't take a half dose of that. And it does make a difference which generic you get, especially with the short-acting.

I know this is a high dose, but believe me, I am not getting a rush. Sometimes I have to take a small dose of adderall in order to sleep, and some days, it's definitely less activating and more de-activating.

It is important to eat breakfast as close to waking as you can. That helps align your biological clock. Also, I suspect that, over time, as you adjust to not having the same level of ADD, you also adjust to the Adderall.
posted by Altomentis at 1:23 PM on March 15

i'm a 31 year old woman taking adderall extended release, 5 mg a day.

my psychiatrist asks me, whenever i see her, how i feel when i come down. she said that for some people it's like this: adderall finally helps your brain filter out the signal from the noise, and then when it wears off at the end of the day, suddenly all the noise comes back at you full blast, and this can make you feel overstimulated and cranky.

she said, for instance, some patients would have their comedown on the subway at rush hour--crowds, loud noises, etc. bad news. so she advised them to take their meds either a little earlier or a little later so that they'd be in a good situation for the comedown.

so in your case, maybe think about where you are/what you're doing when the meds are wearing off, and as others have said, try to create a cool-down period for yourself. minimal sensory inputs, chill vibes.

also, maybe space out your snacks a little differently. add MORE water, if possible.

but it definitely is something tweak-able that your psychiatrist will know how to handle when you speak with her next.
posted by iahtl at 8:46 PM on March 15

you could try the daytrana patch as it is very flexible wrt when you take it and how long you take it for.

i also have the issues mentioned above with the generic version of XR; the brand name is remarkably better.
posted by poffin boffin at 11:55 AM on March 16

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