Too much of my ADD medication - should I worry?
June 11, 2004 10:15 AM   Subscribe

Pharmacists, medical professionals: I take methylphenidate for ADD. A month ago my regular pharmacy was out so I went to a different one. The pill looked different but I'm used to generics varying in appearance. So I thougt nothing of it. Today I refilled the prescription and the pill looked so different that I got worried and looked it up. My perscribed dosage is 20mg 3 times daily. It seems that for the last month I'd been unknowingly taking 20mg extended release 3 times daily (occasionaly four when I had to work late). I honestly didn't notice a difference, but now I'm worried. This shit is dangerous and I don't like to mess around with my mind. What dangers are there to the increased syrum levels I'd been experiencing? Considering that that the ER plateaus at something like 10mg for about 8 hours, I could have had as much as 30mg active in my body for several hours a day for 30 days. This is scary. Note, no information given will be treated as advice. If you guys scare me I'll reconfirm with a doctor and persue an appropriate course of action. So please, be honest. Is this a problem, or no big deal?

for the curious. Somewhat amusing that ADD/ADHD was once called "Minimal Brain Dysfunction in Children." Also, I'd really like to not take this shit anymore. I've been on it for 8 years. The difference it makes in my life is noticable but has decreesed in the last four years. Without it I still have trouble functioning, but I worry that it is a crutch. For example, yesterday I did not have any yet was able to happily spend a couple hours rewriting a couple stylesheets, messing with php, and surfing. The first two are tedious and maticulous tasks requiring a great deal of focus. The reason I say it is a crutch is that I seem able to focus on things I enjoy, but things I don't enjoy I can't do without the meds. I'd like a non-stimulant work around for this problem.
posted by Grod to Health & Fitness (23 answers total)
It's scary/weird that this happened, but if you had no immediate adverse effects, I wouldn't worry about it at all. There are college kids taking way, way higher doses than that all that time just for kicks. Get the right dose, mention this situation to your doctor and the pharmacists. I'd say no big deal.
posted by TurkishGolds at 10:24 AM on June 11, 2004

The reason I say it is a crutch is that I seem able to focus on things I enjoy, but things I don't enjoy I can't do...

Shit, this describes me to a T. But I don't think I'm... hey, what's that?

I think you should chew your pharmacist's ass out and let your doctor know, but I wouldn't be panicking. If it did have effects, they're likely to go away now that you're back on the regular pill. I don't think it's likely to have changed your brain functions permanently. IANAD.
posted by five fresh fish at 10:30 AM on June 11, 2004

Response by poster: I'm not worried about fucking my brain over permanantly in a month, I'm more worried that the proper dose will now be less effective. My tolerance to any kind of medication develops rapidly and is very high. The first time I had a beer, I was tipsy, the second time it took four to get the same effect. I'm worried that the already diminished effect of the drug will now be wiped out completely. And that I've fucked my brain over.
posted by Grod at 10:36 AM on June 11, 2004

If you guys scare me I'll reconfirm with a doctor and persue an appropriate course of action.

I guess if we don't scare you, you'll forget about it. But your pharmacist filled your prescription incorrectly, and although you seem to be fine, you should report this. Medication side effects can come in many forms, from immediately obvious symptoms to the quieter beginnings of some other process that has a bad outcome. Even if you feel fine - and probably are - that doesn't mean your doc wouldn't want to do some kind of follow-up testing (like a blood test) to look for effects caused by this dosing error.

Please treat this as advice: You should call your doctor's office, ask to speak to the nurse, do whatever interview she (probably a she, after all) wants to do, possibly see your doctor in follow-up if the nurse recommends it, and give information about the pharmacy that filled the prescription incorrectly.

On preview: Every one of the questions you add in your followup comment should be addressed to your treating physician's office.
posted by caitlinb at 10:43 AM on June 11, 2004

I don't think that there are tolerances that develop from these particular psychoactive drugs. But, I'm not a doctor. I also think/know that it's not a crutch. I know it's a bummer to take the meds, but that label you joke about is absolutely correct. It is a minimal brain dysfunction. There is something physiologically/biochemically wrong in your brain when you have ADHD. The drug makes that system work correctly.

But yeah, tell your doctor (a phone call would probably be sufficient (and free!)) and tell the pharmacist/store chain/store manager depending and go on with life.

On preview: What everybody else said.
posted by ajpresto at 10:45 AM on June 11, 2004

It sounds like no harm was done, as one would expect. The main difference with the extended release tabs is that they take longer to be absorbed and last longer in the body, but since the total dose you were taking is unchanged (total of 60 mg/day in both cases) your body's total exposure is unchanged. The only difference should be that once your body reached equilibrium between absorption and excretion, the level of drug was more constant, with lower peaks after a dose and higher valleys before the next dose. I would mention it to the Dr. and pharmacist as above, but not worry about it. I think you are right to look into getting off the drug or at least decreasing your dose; mention this to your Dr. as well.
posted by TedW at 10:52 AM on June 11, 2004

The reason I say it is a crutch is that I seem able to focus on things I enjoy, but things I don't enjoy I can't do without the meds.

You do know that this is a textbook ADD description right? I think one of the myths about ADD is that people with it can't focus on anything. The truth seems to be much more that they can't be MADE to focus on something they don't want to focus on, and they have hyperfocus at other times. Call your regular pharmacist first and get some advice. Then call your doctor. Medical care being what it is lately, it may be tough to engage either of them in a long conversation so focus on these two points 1) did pharmacist #2 screw something up? 2) [if so] what are the issues I may have to deal with as a result, if any [and report the guy] and then 3) can I get on some better meds or phase out of these? ADD meds have come a long way since Ritalin
posted by jessamyn at 10:56 AM on June 11, 2004 [1 favorite]

My job bores me to tears and I have a hard time focusing at work, but am fine otherwise.
Does that make me ADD?
Is there something I can take that'll help me breeze through work?
posted by j at 11:30 AM on June 11, 2004

I can say for a fact, that I know people with no built-up tolereance to a similar drug (d-amphetimine salts) open up a 50mg XR capsule and take it straight. They go from happy ecstasy to burnt out and aggressive but manage to get through finals. That's taking it every day for like 5 days. I would not be worried, but you should talk to your doctor.

One thing I noticed with friends that take it via prescription is they seem much more apathetic after taking it for time, and more irritable. They are also several times less creative.
posted by geoff. at 11:40 AM on June 11, 2004

DEFINITELY notify the person in charge of the pharmacy -- not the pharmacist himself, at first -- if there is incompetence, gross negligence, or just plain "oops" at work, somebody could literally be in a life/death situation as a result.

And of course you should contact your physician.

Oh, and j -- are you being serious, or just mocking?
posted by davidmsc at 11:54 AM on June 11, 2004

I would suggest at the very least having the pharmacy you submitted the original prescription to pull the script and see what it was actually written for.

When you transferred the prescription over to the other pharmacy, what they likely did was a "copy" -- that is, your store's pharmacist reads the prescription (from the computer records usually, not the original script, which is filed away after being entered into the computer and verified by the pharmacist) to the other store's pharmacist. As far as I understand it, this is how it's done at every pharmacy chain except Walgreen's, which has a centralized computer system (so all that needs to happen is the tech at the other store pulls up the prescription record and creates a refill for it).

Anyway, the prescription copy is likely where the error was introduced. Filling any prescription with any drug that isn't pharmacologically equivalent to the original prescription is a big no-no (and Extended-Release capsules change the drug release mechanism, so that obviously qualifies).

Sorry I don't have any particular advice, but I moonlight as a pharmacy tech at Walgreen's, so I hope this is a bit helpful. I would recommend consulting with a trusted pharmacist (perhaps the one at your regular pharmacy) as well as your doctor -- doctors are often completely ignorant about drugs, despite being the ones prescribing them.
posted by neckro23 at 3:40 PM on June 11, 2004

i'm canadian and i'm not sure if things like this exist elsewhere, but i've found one of the most useful medical services is a service that, here, is called health link. it's a service offered through my local health authority where you call a local number and are connected with a team of local registered nurses who can answer any health related question you may have in a confidential, honest, and open manner. it's designed to take pressure off of emergency rooms and prevent needless visits as well as to provide free health advice to keep populations healthier (in other words, to decrease acute and long-term health care costs)

they're absolutely fantastic when you have a quick question that you don't want to wait in line for an hour or so at a doctor's office. as well, they can tell you which doctors are taking patients, where to get different immunizations, hours of clinics, etc. they know everything!

check and see if something like this exists in your area - the nurses should be able to answer your questions and concerns regarding your medications and the pharmacy's error.
posted by lumiere at 3:43 PM on June 11, 2004

The extended release pills may be the reason that your "vacation day" (ie. day without pills) was still relatively normal. I know this was the case for me with SSRIs
posted by nprigoda at 3:51 PM on June 11, 2004

You do know that this is a textbook ADD description right?

If it is, I've got it, then. But I think it's a bit more than just that.
posted by five fresh fish at 3:58 PM on June 11, 2004

Response by poster: OK. I will try to notify the right people. I don't have insurance, so a doctors visit is out, but I'll be seeing my shrink next week. The pharmacy is a small independent and I don't want to cause them trouble if no harm was done. The presciption wasn't transfered, you can't do that with controlled substances and this one is classed as a narcotic and regulated. Thanks for all the input. And J, I've never used ADD as an excuse, even when it would've been one. I've just quietly failed at certain things. I try, but sometimes I can't focus to save my life, or money, or education. It kind of sucks, but I don't look for anyone to give me a break.
posted by Grod at 4:00 PM on June 11, 2004

I'm with TedW: I'd think that you would reach the same equilibrium on ER or non-ER pills, with the caveat that you'd have a moderate dip or a surge when you switched to/from the ER version. ( <-- not expert advice, just internet bs )
posted by hattifattener at 5:13 PM on June 11, 2004

FFF: The big deal is that it has to be disruptive to your life. You can be distractable, but if it doesn't mess with something important (say being distracted while driving to work and deciding to go to a ball game. every day.) then it's not a psychological disorder.

So, it's a matter of degree, as are most ailments. I have some killer headaches but I don't call them migranes because I can pop some asprin and they're gone. My wife calls hers migraines.

FYI, spellchecker is still broke. Don't laugh at "distractable."
posted by ajpresto at 6:32 PM on June 11, 2004

I don't think that there are tolerances that develop from these particular psychoactive drugs.

As someone who spent a stupid year at college like those kids TurkishGolds* described, taking way higher doses of ADHD drugs recreationally, I can with some authority say that you're wrong, aj. Tolerance develops from these particular psychoactive drugs, and fast. They aren't chemically addictive, but have a very high potential for psychological addiction (the crutch grod speaks of) because of how over time the effect of a given dose lessens. Methylphenidate can only be considered to not be addictive in the same way a much stronger stimulant like crystal meth is not technically addictive. Even those studies that claim to show methylphenidate doesn't cause chronic tolerance admit to the possibility developing if the body never has a chance to metabolize all of the drug before the next dosage. The controlled-release pills were designed so that one is taken in the morning, which releases a steady dose over the day. This was to correct a problem with methylphenidate--acute tolerance occurs, so that in the afternoon, a dose won't have the same effect as in the morning. It's conjectured that this acute tolerance would become chronic if doses were given throughout a whole 24 hours--anotherwords, pretty much what happens when you take 3x20 controlled release in a day. I don't agree with these studies. Even with a good 12 hours between doses of regular release, and only 20mg doses, in my experience, there's a damn good chance you'll get less effect over time. That seems to be what Grod has found ("The difference it makes in my life is noticable but has decreesed in the last four years.")

I am not a doctor, Grod, but this is going to have a pretty big effect the first month off of CRs. You're going to experience short, intense highs followed by longer lows before you take the next pill, I'd bet. And it might take awhile to feel as "on" as you were last month. 60mg CR a day is a lot, even from my experience as an ex-abuser of this drug. However, a little caffeine should be enough to pad you for a week or three until you get adjusted to the normal Ritalin/Concerta again. To be blunt, this is an addiction you're managing, albeit a neccessary one (I don't begrudge anyone who takes ADHD drugs because a psych recommended them *cough* j *cough*, but even if ADHD patients' brains function differently, it's still basically an amphetamine). Definitely tell your doctor, and the pharmacist deserves a good reprimand, but this isn't going to significantly affect your life besides a lethargic fortnight.

*TurkishGolds, nice nick. My favorite brand.
posted by jbrjake at 9:12 PM on June 11, 2004

Ask the pharmacist. As a former pre-pharm student who also interned, this is EXACTLY some of what pharmacists are trained for. More and more, they know more about what to prescribe and how it prescribe drugs at hospitals versus just being pill-pushers. At most hospitals now, a doctor's prescription must be confirmed not only by the floor pharmacist with whom the doctor interacrs with but also by the actual pharmacy itself that fills the prescription. If one pharmacist doesn't know, ask another. They are much more of a wealth than people think.
posted by jmd82 at 9:58 PM on June 11, 2004

davidmsc -- I was definitely not mocking. I know ADD is a really hard disease to live with. I had a co-worker who we thought was undiagnosed ADD -- it was a huge struggle for him to sit down and actually work.

I was being half-serious, half-silly. I *am* having an insanely hard time concentrating at work. I'm overloaded and overworked. In fact, I'm supposed to be working from home right now. The problem is probably situational, not chemical, but I really do wish there was a pill I could take to just make me push through all the work.
posted by j at 9:22 AM on June 12, 2004

Response by poster: j, bad news, there is no magic pill even for people with ADD. It helps, but its like turning a dimmer switch. My default focus might be lower than yours, but when I'm overwhelmed there's no drug that can make me push the work anymore than you can. All it does is bring me closer to par.
posted by Grod at 12:47 PM on June 12, 2004

My wife's a pharmacist. She says: "Don't worry about the extended release vs. the regular -- it's not unheard of for drugs to be prescribed this way on purpose -- but do get it fixed. And don't take a 4th when you're working late."
posted by Zed_Lopez at 5:49 PM on June 12, 2004

The pharmacy is a small independent and I don't want to cause them trouble if no harm was done.

Please do report it. True, it sounds like no harm was done to you, but if s/he messed up your scrip its very likely that s/he has messed up others as well. Speaking as someone who has been on the receiving end of a mis-filled scrip, please do report it. The life you save may not be your own.
posted by anastasiav at 9:47 PM on June 12, 2004

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