A Light Education on Stimulant Medication

Many people with Attention Deficit Hyperactivity Disorder (ADHD) are prescribed stimulant medication, yet few understand how these medications work. ADHD is a condition characterized by persistent difficulties with managing attention or focus, along with other executive functioning issues. Executive functions include “inhibition, resistance to distraction, self-awareness, working memory, emotional self-control, and even self-motivation.”1 These symptoms make it difficult to succeed in various environments: work, social life, or at home. Stimulants are just one tool to help someone manage their ADHD. It is important to disclaim that I am not a psychiatrist and this paper is an informal examination on the subject. That said, by providing anecdotes and describing the mechanisms of stimulant medication, I plan to inform adults with ADHD about their treatment options and potential ways to incorporate medication into their lives

There are two main groups of medication: stimulant and non-stimulant. Stimulants reduce symptoms in 70% of adults with ADHD.2 Additionally, they have been shown to “improve executive and non-executive memory [and] reaction time”.3 People also find that stimulant medication helps with motivation and energy. There are two big categories in these groups, amphetamine (Adderall) and methylphenidate (Ritalin). In these groups, there exist more unadulterated forms of these medications, dex-methamphetamine, and dextroamphetamine, respectively. There are additional stimulants that loosely fall into these categories, like lisdexamfetamine (Vyvanse) and levoamphetamine. These medications affect the brain in different ways, meaning that if one is not working, another may be more effective. 

There are different delivery methods. The choice of extended versus instant release is dependent on lifestyle. Extended release medications typically last 8-12 hours (except Vyvanse, which lasts 16 hours). These medications are useful for people who need to be medicated for longer and do not want the inconvenience of redosing during the day. There are various methods of extended-release. In Adderall ER, there are two kinds of drug beads inside of the capsule, one that dissolves instantaneously and one that dissolves hours later. In Concerta, a patented pump system releases different concentrations of methylphenidate to simulate the same effect of taking Ritalin three times a day. When extended-release medications wear off, sometimes people prefer to take a booster. That is a small dose of an instant-release pill that provides an extra 4-6 hours of coverage. Instant release pills enter the bloodstream quickly and last for a shorter amount of time, typically 3 to 6 hours. This is a suitable option for people who want more control over when they are medicated. For example, I know someone who eats lunch before their second dose because a common side effect of stimulants is a suppressed appetite. Outside of side effects, someone may prefer to only take their medication when studying and stay unmedicated for social events.

Although stimulants take effect instantly, there is a titration process to achieve the right dose.4 Psychiatrists or psychiatric nurses will increase the dose until the side effects outweigh the benefits of the medication. Common side effects include “loss of appetite, weight loss, sleep problems, crankiness,” and heart palpitations.2 The dose is usually increased during monthly appointments but can be done every four to seven days, depending on whether it is instant or extended-release.4 Side effects decrease with regular use; however, any extreme reactions (especially any involving the heart) are a good cause to discontinue the medication. The dosage and duration depend more on how someone metabolizes the medication, rather than their age or weight.

Stimulant medication is generally considered as “take as needed.” It is important to acknowledge why many people with ADHD prefer to be medicated daily. Productivity, emotion regulation, and focus are not solely required for professional productivity. A study among children with ADHD shows that those who take medication are more likely to complete their chores satisfactorily than unmedicated children.5 Medication can help one manage responsibilities, like chores. Adults with ADHD may favor constant medication to reduce the daily strain of completing homework, paying bills, making appointments, indulging in hobbies, and managing social events. However, some people take it daily, while others take breaks. As discussed earlier, people have different reasons for when they take their medication and how often. Once on a therapeutic dose, a person may decide they like to be unmedicated during weekends. Perhaps, they enjoy their creative hobbies more when unmedicated. Or they take breaks from medication on their off days but need medication on the weekends when they work. Some psychiatrists suggest their patients only take their medications on weekdays to mitigate tolerance.6 There have been mixed conclusions on the likelihood of tolerance and notably, many medicated people can stay on a single dose for years without issue.7 So, I believe the issue of tolerance is on an individual basis and should be worked out one-on-one with one’s psychiatrist.

If you are uncomfortable with the idea of taking stimulants, have a comorbidity that would interact negatively with them (anxiety, a history of substance abuse, or bipolar disorder), or have reacted poorly to stimulants in the past (no benefit or adverse effects), there are non-stimulant options. While stimulants are first and second-line treatment options, non-stimulants perform better than placebo.3 Non-stimulants include Atomoxetine (Strattera), Bupropion (Wellbutrin), Modafinil (Provigil), and others. These medications range in their original purpose and type. Non-stimulant medication takes months to titrate up to a stable dose. They tend to be less effective at treating symptoms than stimulants, however, they offer 24-hour coverage.4 Non-stimulant medication is taken daily for maintenance, rather than as needed. Common side effects include “fatigue, upset stomach, dry mouth, … trouble sleeping, nausea, constipation, dry mouth, sweating, and changes in sex drive,” but also depend on the medication.2 It is also important to note drug interactions, especially with alcohol, because the drug will continually be in your system, even if you skip a dose. 

Medication can be a valuable tool in managing ADHD, especially when used in conjunction with therapy. Cognitive behavior therapy (CBT) is remarkably helpful in managing ADHD symptoms; one study suggests that patients can glean more benefits from CBT when also on medication.8 They focused their CBT skills around “organization and planning, reducing distractibility, adaptive thinking, dealing with procrastination, [and] building helpful relationships.”8 Therapy and medication are helpful individually, but their benefits are maximized when used together. 

While there are a variety of treatments for ADHD, not everyone is receiving adequate care. Hopefully, learning about different medications will allow one to weigh their options and advocate for themselves.

1. Barkley, Russell A. “The Important Role of Executive Functioning and Self-Regulation in ADHD.” Https://www.russellbarkley.org/, Russell A. Barkley, Ph.D., LLC., 2011, https://www.russellbarkley.org/factsheets/ADHD_EF_and_SR.pdf. 

2. WebMD Editorial Contributors. (2023.) “ADHD Medications: Compare ADHD Drug Treatments & Side Effects.” Reviewed by Smitha Bhandari. WebMD. https://www.webmd.com/add-adhd/adhd-medication-chart. 

3. Hai, T., Duffy, H. A., Lemay, J. A., & Lemay, J. F. (2022). Impact of stimulant medication on behaviour and executive functions in children with attention-deficit/hyperactivity disorder. World journal of clinical pediatrics, 11(1), 48–60. https://doi.org/10.5409/wjcp.v11.i1.48

4. Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatric disease and treatment, 4(2), 389–403. https://doi.org/10.2147/ndt.s6985

5. Park, Rapoport, E., Soled, D., & Adesman, A. (2022). Impact of Medication on Performance of Household Chores by Children with ADHD. Journal of Attention Disorders, 26(1), 119–124. https://doi.org/10.1177/1087054720969980

6. Watson, L. R., Felson, S., & Fraser, M. (Eds.). (2023). Medicines to treat ADHD in children: San Diego Hospital, Healthcare. Health Library. https://myhealth.ucsd.edu/Library/News/Headlines/56,4014 

7. Handelman, K., & Sumiya, F. (2022). Tolerance to Stimulant Medication for Attention Deficit  Hyperactivity Disorder: Literature Review and Case Report. Brain Sciences, 12(8), 959. https://doi.org/10.3390/brainsci12080959

8. Pan, Huang, F., Zhao, M.-J., Wang, Y.-F., Wang, Y.-F., & Qian, Q.-J. (2019). A comparison of efficacy between cognitive behavioral therapy (CBT) and CBT combined with medication in adults with attention-deficit/hyperactivity disorder (ADHD). Psychiatry Research, 279, 23–33. https://doi.org/10.1016/j.psychres.2019.06.040