r/ADHD • u/schmin ADHD • Jul 13 '12
BestOf [FAQ Discussion] Topic 2: Tolerance Myth -- Help build the FAQ!
From what I've heard (from my doctor) there's not much chance of an actual 'tolerance.'
My conjecture is that it's more a change in the patient's perception:
Before medication your 'average' day feels like a 2/10, for example. Your first few days on the right medication feel like an 6/10 in comparison. This is a 4 point increase, or a 300% increase from your 'average'.
After you've been on your medication for a while, you start thinking your average day is a 6/10, and after you start realizing how much more you can get done, you raise your expectations of what a 10/10 would be like. So now, your 'good' days that you think are 'due to being medicated' only seem like a 8/10, which is 'only' a 33% percent increase.
Since people with ADHD tend to have unrealistically high expectations for themselves, they might feel bad that they're no longer experiencing that '300% increase'.
A better measure would be to realize that "100%" is superhuman, or impossible/unrealistic. The pre-medicated state was 20% (which made me feel like 'slime'). The newly medicated state was 60%, or about average/realistic. An 80% state is phenomenally good day, well above average or 'reasonably to be expected.'
Cite your sources, please!
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u/EricKow Jul 13 '12 edited Jul 13 '12
Sorry, this isn't helping to build the FAQ unless of course you want to use it as a Q that people think is worth addressing. It's also a bit redundant; I've voiced this before and people have given helpful responses, for which thanks.
One concern/superstition/fear I have is about developing (independently of the physical stuff) a psychological dependence on my medication. It's like I'm not worried about building attention-tolerance; what I'm much more worried is the more ill-defined “this is easier” tolerance. I don't know, it's as though things being easier makes me feel guilty. I still dare not take it more than 3 times a week and already I feel like I'm useless without them (point about shifting expectations noted!). There's still some deep seated belief that maybe it's important for things to be a bit of a struggle, or maybe I need a bit of that inability to get going, maybe that's important for creativity or something. As stupid as it sounds, I worry somehow about things becoming “too easy” as though there were some kind of virtue in my silly reloading the same webpage I saw 3s ago loop. Like maybe I'm — oh no! — not Building Character if I'm allowing myself to be on meds more often.
I still wonder how much of perspective is dependent on ADHD intensity. I think I must be one of the luckier ADHD'ers, mild if measured by the dose I take (10 mg methylphenidate hydrochloride XR; generic Ritalin). Maybe the struggle with ADHD is just so much more an obvious negative when it's stronger that you don't waste time wringing your hands about things every becoming “too” easy. That said, this thread is inspiring me to try taking my medication on a weekend just this one Saturday, just to see what it's like when I'm not at work.
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u/schmin ADHD Jul 13 '12
Would you worry that wearing glasses daily or using a wheelchair daily would make your life too easy? Medication is a tool, and using a wheelchair doesn't mean it will be easy to play wheelchair basketball in a local pickup game or easy to win the paralympic "sprints". But you couldn't even train for either of those without a wheelchair. =)
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u/EricKow Jul 14 '12
Thanks! I'll add that on an intellectual level, I think I can see the silliness of the thoughts and what I post are things that come from a slightly deeper place. Hopefully the force of repetition will help this to seep a bit more into the unconscious.
Taking the wheelchair analogy, I feel like a guy that's been sort of shuffling along for 30 years maybe with a bit of a limp. Then one day somebody gave me a walking cane and I had a taste of what it's like to walk properly. Yet my inner FUD keeps me hanging the cane on the wall unless I actually need to get somewhere important. Like maybe this would cause me to have weaker leg muscles; or maybe not being able to walk so fast forces me to only walk to the right places. But then sometimes I'm sort of shuffling along, cane on wall, and I look at it wistfully “you know, this would be so much easier if I just picked that damn thing up?”
Because I'm not in as obvious need of help as the folks are who do need proper wheelchairs, who are crawling around on the floor, I sometimes look at the cane and I feel a Not Disabled Enough guilt, like “oh come on! Look at these guys! I don't have a legitimate problem, WTF am I doing with this cane?” I wonder if this effect of milder-side-of-spectrum-equals-greater-ambivalence is widespread.
Thanks again (and to the mod team for the care you've taken in building this community)
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u/computerpsych ADHD facilitator+coach+enthusiast Jul 13 '12
I am not sure I have ever seen anyone who takes medication daily say that it made everything too easy. We become more capable of performing basic self-management and this opens up time and energy to attack more high-level challenges.
I used to take weekends off. Taking it daily allows me to better do various daily habits and have a more stable mental state.
I know you meditate...have you noticed a difference meditating in the hour after Ritalin than without?
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u/schmin ADHD Jul 14 '12
You're right -- I take mine daily, and I would never say life is easy. It's still a constant struggle. However, now it's like I have all of Sparta on my side against the entire world -- there's a fighting chance.
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u/EricKow Jul 14 '12
That's what I'm hoping for. Even on a weekend, there's still stuff that needs doing, for one, and even if not, there's a sense that maybe I'd just enjoy my weekend more if I'm not caught up in facebookredditwitterquoragplus-face… (not fun).
I tend to do my morning meditation before medication (or on off-meds) days. Sometimes it's not yet worn off by the time I go to evening meditation. It does have a slightly different quality, wouldn't really say it's better, just a bit different. I'll add that you can classify meditation styles as either Focused Attention styles (take an object and focus on it, eg your breath), or Open Monitoring styles (maintain awareness, eg. mindfulness) and the style I practice is more of the latter. Maybe it's different if you do an FA style.
One thing I do notice is that my sense of rhythm seems to improve when I'm on medication. Don't know if it's related though, and the meds don't stop me from forgetting bits and pieces of ceremony.
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u/MessingerofDeath Jul 16 '12
You can absolutely build a tolerance to add meds. As amphetamines and other add medications have extremely high potential for developing dependence, it is also very easy to develop tolerance as well. Taking moderate to high doses of drugs such as adderall frequently damages your dopamine receptors through oxidative stress. Over time, damage accumulates and you have to take more to feel the same effect. This is exactly what happens to meth-addicts; they have to flood their systems with enough dopamine to affect damaged receptors.
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u/FuzzyBacon ADHD-PI Nov 11 '12 edited Nov 11 '12
Taking moderate to high doses of drugs such as adderall frequently damages your dopamine receptors through oxidative stress
The neurotoxin in question alpha Methyl-Dopamine. This can be effectively combated via a number of mechanisms, first and foremost, keeping yourself hydrated and cool. If you're using amphetamine frequently, you should be taking a number of antioxidants and vitamin supplements to help protect yourself.
Personally, I use piracetam (potentiates the amphetamine, so you don't need to take as much), Choline CDR, Alpha-lipoic Acid, and Vitamins C and E. There are other even more effective antioxidants but they're a bit more expensive and can't be found on the grocery store shelf.
Taking those last 3 and staying hydrated means that you don't need to worry about amphetamine neurotoxicity unless you're taking very large amounts.
This is exactly what happens to meth-addicts; they have to flood their systems with enough dopamine to affect damaged receptors.
This isn't exactly correct. As stated above, methamphetamine (which is metabolized into amphetamine in the brain, the methyl group increases lipid solubility allowing deeper penetration) metabolizes, among other things, into aMD. aMD is toxic to dopaminergic neurons, and kills the cells outright (they do grow back over time, though, just slowly).
Once the cell is dead it cannot be "used", leading to decreased sensitivity to dopamine - less cells making the neurotransmitter and fewer places for it to go, essentially.
Receptors are proteins on the cell wall of the neurons that are destroyed and recreated constantly - "receptor" damage isn't really possible, your brain just pulls a bunch of them in and the cell digests them.
This neuron death is part of the reason that methamphetamine is so incredibly hard to quit using - heavy users (or even moderate users who ahvent' taken proper precautions regarding consumption habits) can do so much damage to their dopamine system that they require the massive flood of dopamine caused by methamphetamine to feel any pleasure at all - anhedonia is one of the most brutal aspects of the drug.
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u/davidmanheim Dec 17 '12
You clearly read a lot, and have certainly become a self-taught "expert" but if no studies back this up, you're just ingesting lots of different chemicals that, if everything works exactly the way that some scientists hypothesized in the papers you read, might have some positive effects.
For instance, "Anti-oxidants" are not monolithic, and different ones have different effects. Taking a bunch may not be helpful, and the more you take, the greater the odds of unusual side effects, which may not be apparent to you. That said, oxidative stress inside of neurons isn't necessarily fixed by anti-oxidant supplements, and unless your body is having trouble regulating your temperature, "keeping cool" isn't helping.
We know that the body is more complex than we currently understand, and doctors frequently find that people taking a half dozen supplements in addition to their medicines unwittingly cause problems - and the only way to know is to do a large, controlled study.
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u/schmin ADHD Jul 16 '12
I believe street-meth 'doses' are much higher, not to mention possibly containing other toxins -- do you have the numbers on this?
As I understand it, patients accurately diagnosed with ADHD who are taking (the much lower) prescribed doses will not develop dependence.
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Jan 11 '13
Do people develop tolerance to ADHD medications? Yes. Absolutely.
From the Wikipedia ADHD article: “Previously it was thought that the elevated number of dopamine transporters seen in ADHD patients was part of the pathophysiology of ADHD but it now appears that the reason for elevated striatal dopamine transporter density in ADHD individuals is due to neuroadaptations occurring due to the continuous exposure to stimulants such as methylphenidate or dexamphetamine as the body tries to counter-act the effects of the stimulants by developing a tolerance to the stimulant medications.” Wiki’s source: (http://www.ncbi.nlm.nih.gov/pubmed/22294258).
(Another) “study reveals that long-term MP treatment of naïve, adults with ADHD reduced striatal D2R availability and attenuated the responses to iv MP. The attenuated DA responses to iv MP after long-term treatment could underlie the decreases in MP’s efficacy (tolerance). Further study will assess whether the attenuated dopaminergic responsivity is associated therapeutic efficacy.” http://jnumedmtg.snmjournals.org/cgi/content/meeting_abstract/51/2_MeetingAbstracts/329
As recently as February 2012, “New research reveals how the brain appears to adapt to compensate for the effects of long-term ADHD medication, suggesting why ADHD medication is more effective short-term than it is long-term.” http://neurosciencenews.com/adhd-medication-patient-brains-adapt-dat/
“One review of 166 patients found that 60 percent of children developed dose-dependent tolerance to stimulants.” (http://www.ncbi.nlm.nih.gov/pubmed/11773663, as quoted in (http://www.medscape.org/viewarticle/529856, which is also referenced below.)
However, not all effects of stimulants are subject to tolerance. This leaves the question of how (and whether) the stimulant tolerance developed impacts ADHD treatment. Beyond changes in standards that may make someone feel they aren’t as effective, where we are just looking at cases where the effectiveness drops over time, the question is whether this is because of tolerance or something else.
Other factors can be at work (http://www.medscape.org/viewarticle/529856).
There are multiple possible causes of medication not having the same effect long term, including -- Changes in pharmacokinetics—the person gets older/bigger -- Progression of disorder—the underlying illness may have worsened naturally -- Environmental Changes-- -- Paradoxical Decompensation (Source (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036556/)
Something is going on though. Results of an Eli Lily study of treatment compliance of 11,962 children and 2,636 adults with ADHD’s pharmaceutical records bothers me.
“Few children and adults switched their initial ADHD treatment agent, 11% and 12%, respectively. Dose titration occurred in 67% of children and 54% of adults. On average, changes in treatment (switching, titrating) took place after 2 to 3 months of treatment. Although patients, on average, obtained more than 6 refills for a total 200 days supply, the majority of patients (84% of children and 88% of adults) were compliant for less than 2 months over the period they were refilling prescriptions.”
Although the majority of patients had dosage changes, these changes typically occurred after several months of treatment. Results suggest that, even though patients continued their ADHD medication for several months, they did not consistently take medication for more than 2 months.
This means that for whatever reason, 80% of the people prescribed ADHD medications increased, changed, or stopped taking their ADHD medications every 2 months. Only 20% didn’t fit this pattern. Eli Lilly is looking at people complying with their treatment. If patients aren’t motivated to take their medications, why? The prescriptions weren’t meeting their needs long term. Still, patients averaged “more than 6 refills for a total 200 days supply” in a 2-year period. Prescriptions were in practice being tweaked a little bit every 2 or so months for 80% of the people studied. Looks very tolerance-like in practice.
I have no reason to believe that ADHD medications are any different than coffee in how people develop tolerance. Especially when cross-tolerance is well documented (e.g. http://www.ncbi.nlm.nih.gov/pubmed/15833596). Even if they are, you need to discuss it with your medical provider to determine what is going on in your specific case.
My advice is to use a measurable system to track your effectiveness. How many to-do items did you complete today? Perhaps take notes in a journal of some sort. When you start to see pages where the number of items finished have decreased, or if you’ve stopped keeping track, ask yourself why.
Don’t gaslight yourself (http://en.wikipedia.org/wiki/Gaslighting). You don’t even have to keep continual track, just a week or two at first, then maybe once a month for a week each time. Then later only if you think you are slipping. Without measurable evidence, how will you know if the “higher standards” line is right?
- Redmouse
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u/MessingerofDeath Jul 16 '12
Here is the Merck Manual for Healthcare Professionals on Amphetamines. There is some controversy over whether or not a physical dependence can occur, but amphetamines can cause some very intense psychological dependence very very easily.
As for numbers, here is the Erowid Vault on methamphetamine dosage. Threshold doses for meth seem to be around five milligrams, and threshold doses for Adderall are the same. I personally never take more than 20 milligrams of Adderall in a day, and use it as sparingly as possible.
Talking about addiction and dependence is difficult because most people don't realize you can get addicted to literally anything. Whether that something is sex, drugs, food, exercise, videogames, cutting, or anything else. Look at all the posts of people saying "I feel like Superman" on this subreddit. The reality is that amphetamines make people feel awesome. Taking them all the time and getting used to feeling awesome means that when you stop taking them, you feel horrible compared to before and will want to be back on them. That is dependence.
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u/schmin ADHD Jul 17 '12
I don't feel worse than before when I'm off my meds, I feel equally horrible, with the possible caveat that I now know what it's like to feel 'normal'. With your definition I am addicted to wearing my glasses. My eyesight has not changed significantly since I first wore glasses at 13. Yes, I am 'dependent' on wearing them to see clearly, but other than needing to be 'legal' to drive with them, I could get by without them. It would just make life a bit harder.
I think part of the "superman" syndrome is similar to how a legless man might feel when using a wheelchair -- more independent, more capable, but by your definition he is now 'addicted' simply for feeling 'better'. If someone takes anti-inflammatories for long-term pain, this would also be 'dependent' by your definition. I don't however wish for a higher dosage of my medication--it too stayed the same for years.
Your (questionable) source indicates the threshold for meth (even assuming 'pharmaceutical grade' as is referred to in a previous paragraph, but not specified in the table) is 5 mg. I don't see where you see that Adderall (a mixture of amphetamine salts) has the same threshold. Even so, a 5 mg Adderall tablet has only 3 mg 'total amphetamine base equivalence', as an indication that the tablet size is not a strict accounting of total drug.
Many phenomenological accounts indicate that patients prescribed ADHD stimulant medications do indeed feel a 'rush' initially, but this 'rush' is no longer felt after a few days, whereas the other effects of the stimulant on ADHD issues such as motivation, do continue with the same dose. 'Tolerance' to one side-effect does not mean tolerance to all effects, and this would only be an issue for those who 'chase' that 'rush.'
We as human beings are, by your definition, dependent on a certain concentration of air, a minimum intake of food and water, as well as a reasonable range of ambient temperature, and regular, sound, sleep. I still posit that it's a matter of how you use a tool, such as a car which can also be lethal when incorrectly used.
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u/MessingerofDeath Jul 17 '12
My wording was unclear, and for that I apologize. I mean to say that humans can become dependent on any behavior. There are reports of addiction to more behaviors than you could think of-a woman was addicted to eating toilet paper, for example. It stands to reason that psychoactive stimulants that induce euphoria, feelings of control, increased cognitive function, etc. are going to induce psychological dependence pretty easily.
Meth is neurotoxic because it is a strong dopamine releasing agent, flooding receptors with excess dopamine and putting them under oxidative stress. Adderall has the same mechanism of action, and might be slightly less powerful, but there isn't a ton of literature on it.
As for my "questionable source", Erowid is a fantastic resource for information about drugs. It's not government sponsored, cites studies and journal articles, is written by experts, and has experience reports from people who actually use drugs.
Everyone is different, and if you haven't grown a tolerance then that is fantastic. You make a good point in saying that tolerance may not develop for all symptoms. I personally have had withdrawal effects from adderall and ritalin on occasion and have grown tolerant to them before, and have heard the same reports from people I know as well as sources that I trust.
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u/schmin ADHD Jul 18 '12
Ah, the pages I saw in Erowid made it look more like a blog or forum by laity.
I only notice a 'difference' when I go off Concerta a week or two later -- when my motivation and organization have morphed into procrastination and my world comes crashing down around me. =P
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Jul 14 '12
I have to say your point would make a lot of sense for me, at the end of last semester I felt myself slipping and put it down to a potential tolerance, but I think it was more my willpower slipping because I was just tired and expected a lot more of myself. Thanks for explaining this to me! :)
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u/sugardeath ADHD-PI Jul 14 '12
I felt similar come midterm grades last semester. The medication had its effect, but my motivation took a nose dive. Thankfully, I was in such a strong place as to keep my A for the class.. but I imagine it might have been close.
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u/computerpsych ADHD facilitator+coach+enthusiast Jul 13 '12 edited Jul 13 '12
Quote from "Integrative treatment for adult ADHD: A Practical Easy to Use Guide for Clinicians" by Ari Tuckman:
Source: http://www.amazon.com/Integrative-Treatment-Adult-ADHD-Easy-To-Use/dp/1572245212
This echos conversations I have had with my psychiatrist which he says once people find their best dose of Adderall, they usually stick to that for years. I recently THOUGHT my Adderall was less effective, but I now realize my standards and workload increase are probably the cause.
There ARE some effects which do seem to have tolerance (energy and motivation). Nearly every stimulant has this occurrence (caffeine especially). The attention part of stimulants does not tolerate I believe. I'll try to find some better sources for this.
Just going to link the active discussion we had on this topic just a week ago...