Havent seen any mention of this yet but the reason for this is well known in the recreational drug community : amphetamine is a chiral molecule. The D isomer is more psychologically active. The L isomer creates more physical side effects. There is no regulation for the % of each isomer in the product. This means that one brand may be 70% L, 30% D, and a different brand could be the opposite.
I take this drug daily. The current supply crunch has meant I've had to take inferior versions of the product for nearly a year now. It fucking sucks. I need it to work but the side effects often mean little sleep, strange repetitive behaviour, absurd hypersexuality, etc.
Its a travesty, not in the best interest of the consumer. If you are on this medication you are treated like dog shit from the doctor to the insurance company to the pharmacy to the pill itself. All in the name of either preventi g addicts from getting it (who cares?) Or making more money for some massive company.
> There is no regulation for the % of each isomer in the product. This means that one brand may be 70% L, 30% D, and a different brand could be the opposite.
This is true for the unregulated illicit drug market, but it's most certainly not true for regulated drugs like Adderall.
The ratios of the different isomers in Adderall are well-defined and are part of the drug definition. There are also stimulant variants that are 100% d-amphetamine, which would obviously be in violation of their drug definition if manufacturers starting shipping racemic versions.
> Havent seen any mention of this yet but the reason for this is well known in the recreational drug community : amphetamine is a chiral molecule. The D isomer is more psychologically active. The L isomer creates more physical side effects.
This is over-simplifying the matter. The L-isomer has different effects and duration, but it's incorrect to suggest that it's all "side effects". Some patients do better on racemic mixtures with L-amphetamine. Some patients do better on pure D-amphetamine. It's not correct to suggest that one is pure side effects.
Yeah, naw. You can state the hypothetical way things are supposed to work in the best case -- and you can state so confidentially -- but that doesn't mean that reflects the real world at all.
Look through the FDA warning letters database for manufacturers of adderall (f.e. the "Auro" family of producers). You'll notice a lot of warnings have already been issued for quality control and adulteration issues (and continue to be issued yearly, ad infinitum).
Yeah, the 3rd world factory where these drugs are manufactured, for sure tested their product themselves and found it to be bio-equivalent and within the acceptable FDA variance of "how much of the active drug is actually in each pill, vs. what's stated on the specs."
And yeah, the FDA for sure trusts these factories which are thousands of miles away are always up-to-snuff -- even when they don't have an inspector around.
Your statements about the illicit market aren't true either (pro-tip: the legal and illegal market for the usual, non-exotic synthetic drugs comes from the same source; with minor exceptions in local markets).
And a final pro-tip: if you think the only reason brand drugs are expensive is branding/marketing/some other bullshit -- some of the cost is in proper quality control (they're incentivized to maintain high standards, so people keep coming back to ask for the brand-name -- instead of some nameless generic any fly-by-night shop can manufacture).
I have no doubt this is true after reading about the 8 years of shit quality heart medicine, metropolol, coming out of india, which so many older americans rely on and can cause heart damage if inconsistently taken. It's an outrage.
You are correct. After looking it up it seems I was misinformed about the enantiomers in generics thing.
As far as the effevts of l amph- eh. Yes. There is some amount of evidence the the L isomer produces symptom relief similar to d amph. Frankly ive never had the two seperated so I wouldnt know from experience, but I have read repeatedly over the years that L amph is associated with more norepinephrine effects than D, and norepinephrine agonists produce ohysical side effects such as vasoconstriction.
>This is true for the unregulated illicit drug market, but it's most certainly not true for regulated drugs like Adderall.
It's not even consistently true for the illicit drug market. You can just Google "amphetamine isomer separation tartrate" to get a bunch of information about it. The l-isomer of amphetamine is very weak, and sellers want return business.
There is no regulation for the % of each isomer in the product.
Do you have a source? The FDA label says it's 50% d,l-amphetamine (50/50) plus 50% d-amphetmaine, so you end up with a 3:1 ratio of dextroamphetamine to levoamphetamine.
Why would a manufacturer do more work to change the 50/50 mix? And why would it vary from batch to batch? The FDA has requirements on manufacturing that each lot is made to the same specifications.
The more reasonable explanation is that the binding agents changed, which may change the rate at which the drug dissolves and is absorbed.
This actually happened a while back with generic bupropion. Generic manufacturers made a 300 mg version, which had 300 mg of drug in it. However, the medicine was absorbed much more quickly leading to a rash of side effect complaints from patients. The FDA eventually recalled the drug.
"In that study, the results of which became available in August 2012, Budeprion XL 300 mg failed to demonstrate bioequivalence to Wellbutrin XL 300 mg."
Frankly, ive done all kinds of amphetamines, ingested them by every means except iv.
It is not a matter of the rate of absorption. The experience is qualitatively different. Perhaps I am wrong about the stereoisomer mixture - but amphetamine salts are NOT racemic in the first place - so some amount of seperation is happening- I am quite certain that the different brands do not contain the same proportions.
> Frankly, ive done all kinds of amphetamines, ingested them by every means except iv.
I hate to say it, but recreational amphetamine use and abuse via different ROAs is very likely the explanation for why amphetamine feels different for you now.
Abusing stimulants, especially through different routes of ingestion, will cause various forms of tolerance (as I'm sure you're well aware).
Amphetamines dont "feel different to me now" - different preperations of the same drug feel markedly different. Name brand adderall and sandoz generic feel the same as they always have. Actavis feels like I am geeked the fuck out. Honestly feels quite similar to the effect of eating the cotton out of benzedrex inhalers (please, no judgement, I was very interested in drug experimentation as a youth)
I did look into the stereoisomers of generics per your comment - you are correct, the fda does regulate the specific enantiomers present in a mediciation. So I am at a loss. I am certain Actavis specifically is chemically different. Perhaps there is an inactive ingredient that is modulating the effects? Or perhaps Actavis is just lying to the FDA.
I would love to find some 3rd party which does evaluations of chemical makeup for generics. Was unable to find such a thing, if you know of something like that, id be very interested.
I do believe not enough attention is paid to the "inactive" ingredients. We have had too many reports of things like finding vitamin tablets in the septic tank--they contained the right stuff but didn't dissolve like they were supposed to.
Man, this helps me understand so much of what I’m experiencing. I had to switch to cheap stuff about two months ago and I’ve been all over the place. Absolutely terrible sleep, too.
My understanding is much of the difference between name brand and generics is the excipients used, as they effect drug delivery. Not all generics will use the same and the name brands generally have patents on the ones they use. For psychoactive compounds this can make a considerable difference in how the drug functions for an individual.
YSK that lisdexaphetamine has come off patent this year, and is purely a dextroamphetamine prodrug. It might provide more consistent results compared to adderall even in a generic formulation.
Thank you so much. I had no Idea. I used to take vyvanse but my insurance no longer covers it. It was far superior to adderall so Ill see if my doc can get me back on it. Thanks!
Some of the rules around prescribed controlled substances seem to have no legitimate purpose in actually "preventing addicts from getting it" though.
Not US, Australia, but wouldn't be surprised if same rules apply there – suppose you are prescribed 50mg Vyvanse. You start to feel like 50mg is too much (the side effects are too bad), and you want to try 40mg instead. Can the pharmacist dispense you 40mg instead of 50mg? No. Because it is a controlled substance (or "Schedule 8" as it is called in Australia), the pharmacist can only legally dispense the exact thing you were prescribed – they'll tell you to go back to the prescriber and get a new prescription. If it wasn't a controlled substance, the pharmacist would have more flexibility; in the past, I've gotten pharmacists to dispense prescription drugs without a prescription because I hadn't got around to getting a new script – something they are legally allowed to do (at least here in Australia) for non-controlled substances. They can't do that again and again – it is important the prescriber is kept in the loop – but as a short-term once-off, it does no harm. But going back to the prescriber involves getting another appointment, taking the time out of one's day to attend it, paying for it, etc. In the end one might just decide to put up with the side effects–which is a clearly less than optimal health outcome. Or, one can be reduced to trying to cut the dosage one's self – open the capsule, dissolve the contents in a measured quantity of liquid, then measure out the liquid – which will seem like too much effort to bother with.
I can understand how someone who is prescribed 50mg asking for 60mg or 70mg could be a sign of a developing addiction, but asking for less than one is prescribed is the complete opposite of how an addicted person behaves. So why isn't it allowed? Because the rules only have a rather diffuse relationship with preventing addiction (or other health harms). I think, to a great extent, the rules have come to exist for their own sake, not for the sake of anyone's health.
Couldnt agree more.
Also, try telling your doc ypu cut open the pill and took less. Id say 3 out of 10 docs in the US will immediately terminate their primary care relationship with you and refuse you any further prescriptions. Might even put you on a "list" for being a drug seeker.
At the very least they will be pissed. (Most docs are megalomaniacs that cannot fathom a patient being as intellectually capable or informed as them, or having agency over their own bodies, but im off on a tangent now)
Other regulations that hurt legit patients more than "drug seekers" : you cannot transfer a script between pharmacies, so if the pharmacy is out, you have to have your doc cancel the script and send to a diff pharmacy, a process which can take several days at worst. Some pharmacys say they are not legally allowed to disclose their stock over the phone, so you may need to repeat this process many times.
If you are in a different state, pharmacys will not fill your script from your home state, so good luck traveling anywhere if your script ends during your travels. And some docs/pharmacies will let you fill early to avoid this problem, but they may label you a drug seeker and put you on a list.
> Most docs are megalomaniacs that cannot fathom a patient being as intellectually capable or informed as them, or having agency over their own bodies, but im off on a tangent now
I don’t know what most American doctors are like. But my mother, brother, late grandfather, uncle, aunt, and two of my cousins are all doctors. (My uncle used to work in the US, but an Australian doctor working in the US probably isn’t very representative of the average American doctor.) I often mention this (without as much detail), in part because I suspect it makes them treat me better. Plus I’m unafraid of medical jargon, which probably helps too
A lot of my personal complaints are about the system and its rules, not the people who work in it, the vast majority of whom have absolutely zero input into what the rules are
My mom gets pneumonia fairly frequently and gets very severe cases of it. She is an absolute tank who could be on deaths door and would look normal.
She currently is extremely ill with pneumonia. She went to her doctor last week and told them she was coming down with it, and explained to them that everytime she gets pneumonia she has to have X Y and Z medications in order to treat it. The doctor refused to prescribe them, gave her a much much weaker antibiotic and no steroids, and sent her home instead. She came back two days later after not feeling better and they sent her home again. She finally came back a 3rd time and waz given meds X and Y but not Z. Still not better, she went a 4th time and was given X and Y again without Z. She has fought tooth and nail to be properly treated and has STILL not been given the meds that she knows will help her. She is currently on hour 35 of sleep in 48 hours and is still sick as a dog.
This is just routine for american docs in my experience. Perhaps I live in a medical care desert, but this is just not even remotely unusual.
Doctors ignore your cincerns, fail to address them, and then when you play thr squeeky wheel in order to get some grease, act like you are a burden on their ability to care for other patients.
Ive just had very poor experiences with doctors. They always seem to think they know more than me, but never really even listen to what I have to say.
For example I went to a derm once because I had a spot which looked like cancer for nearly a year. I went in, explained and asked for a biospy. He refused to even look at it, gave me a script for doxycycline to treat me acne (which I did not even mention) and sent me home telling me to come back if the spot was atill there in 8 months. When I came back and he looked at the spot he admonished me for not coming in sooner to have it biopsied.
This is just one example in a long line of medicial professionals refusing to listen carefully to what I have to say. They always think they know better
Do you come across as not very respectable looking or sounding? Or do you come across as aggressive?
My experiences really don't match yours at all. From working as a tech a couple years back I know 1000% that every pharmacist I worked with made judgment calls on whether or not to help people out.
If you had a sketchy vibe, you weren't helped out. If you were a regular and amicable enough to be liked we'd figure out something we could do for you if it was legally possible. You can see how this falls apart when you're traveling or going to a non-usual pharmacy because of how subjective it all is.
(Ex: for Texas if it was actually illegal to say CII stock over the phone it wouldn't be "some pharmacies", it would be "all". I don't know of anyone that would fill a CII early, too much professional risk.
I've also only met a single pharmacist that would do 90 day CIIs despite that being legal if written exactly for that. Pharmacists are generally very risk adverse.)
My experiences as a patient don't match yours either, at worst I went to a clinic that had on-site drug tests very infrequently. Never had any issues with doctors or PAs telling them how I actually took the meds, but I also wasn't dumb in the way I went about telling them.
I also never ran through primary care physicians for any of this. The fact that you said 3/10 of them would terminate the relationship just makes me wonder how much personal experience you have with that exact situation. It just feels extremely sketchy.
Also I would just like to say that I find it absolutely disgusting that "do you look respectable" is some kind of proxy for the quality of medical care someone deserves, or the level of suspicion or ire a person deserves.
No, I do not look sketchy or aggressive. I am literally just a normal looking dude. Rather healthy, rather well kempt. Now what the fuck should that have to do with my medical care?
I sure am glad I can afford nice clothes, glad I was raised to speak proper english, and glad I have adequate dental care, cause it sounds you are suggesting pharmacists will not work with you if you are an "undersireable". I think that is pretty fucking gross. If you gave 50 junkies their drugs but it meant you didnt hassle even 1 legit patient Id call it a win. What bizarre moral high grounds peoppe take.
Also I was at no point complaining about pharmacists - theyve always been super helpful to me, as much as they legally could anyway. I was complaining about the law itself, and complaining about primary care physicians.
And you are correct I should have said "some states" instead of "some pharmacies" - it was, in fact, in Texas where this happened to me and you are correct, The first pharmacy I called told me that no texas pharmacy could legally fill the script from an out of state doctor.
From a pharmacy POV that doesn't address your problems with Healthcare in general:
Everyone gets a baseline minimum level of care, but there are varying levels of "working with" when problems arise when you have a fixed amount of time you can get everything done in.
If you don't have time, you have to use SOME other heuristic to determine priority. (Mainly speaking to how much leg work the patient wants the pharmacy to put in, vs themselves)
From other Healthcare POV:
There's a reason why so many people burn out. The people that make a career out of it without getting jaded are actually incredible.
>If you gave 50 junkies their drugs but it meant you didnt hassle even 1 legit patient Id call it a win.
But the other moral hazard comes into place when you're the one okaying questionable prescriptions that could result in someone's death.
Insulin syringes was another case where junkies would lie to your face about what they were using them for. I worked with a pharmacist that wouldn't sell them to people that didn't have a reasonable way of proving that they needed them for legitimate purposes. Why? A junkie ODed outside his pharmacy after buying them.
How many junkies would you have to kill before changing your own personal policy? If you don't care about killing people, it's extremely easy to just say you'll sell them to everyone.
>I was complaining about the law itself, and complaining about primary care physicians.
My point was some of the blame should be on the pharmacists or techs when they aren't telling you the full truth. (And it felt like they weren't when I read your post)
The out of state script is a good example of what I'm talking about.
If it was a CII paper script they couldn't legally fill it.
But they could have also told you that an out of state doctor could eScribe in a CII if they really cared to do so.[1] And if it wasn't a CII but still scheduled they might have been legally able to fill it anyways based on the criteria in the link I posted.
I've gotten hassled for even out of city CII scripts, and it's the same play where they create just enough friction to make it easier for you to go somewhere else.
I understand the perspective of not wanting to give out material that may result in a drug overdose/death. I get it on an emotional level, but it just doesn't really make sense to me. For example, what is safer for a junky - to recieve prescription grade norco, or to sniff a pile of heroin that came from god knows where cut with god knows what? so in the case of a pharmacy sweating people about the legitimacy of their need for a norco, my way of thinking is just give the damn things out. If its a junky, so what, they just got a cleaner safer high. And if its legit, then you have just helped someone who you would have otherwise burdened with the inability to get their drugs.
Ive never had a doc terminate the relationship but I did have one threaten to do so after I told him that I tried my cousins adderall in an attempt to self diagnose my adhd.
100% my fault there, ill admit, that is not appropriate.
That some doc later prescribed me 2mg ativan and told me to "keep taking it till you feel it" which is how I ended up passing out in missouri and waking up in florida 48 hours later.
That same doctor gave me mometesone and after nearly 2 years of using it told me "oh by the way forgot to tell you : dont use that for more than 2 weeks consecutively because it can be life threatening"
My experience with healthcare professionals is consistantly that they do an awful job of listening and seem to think they can tell you more about how you feel than you can.
I am unusually educated about pharmacology and I think some doctors are suspicious of that. Fair enough I guess.
US here. Once had a pharmacist not fill a script for Vyvanse because my doctor's instructions were "take half tablet daily as needed". These were chewables with perforation marks on them, but apparently it didn't explicitly say on the Vyvanse instructions that you could split them or not.
In the US, when purchasing Vyvanse with cash (most insurance won't cover it), the price is dictated by number of pills, NOT by the dosage of those pills. So, it is half the cost to get 15 pills that you take a half of daily versus a standard 30 day supply.
I think the 30 day supply was somewhere in the realm of $400 by the way.
Vyvanse patent expired last month, so hopefully a generic product comes out soon!
Compounding adds cost and turnaround time. Not all pharmacies do it. Rules saying all repeats have to be filled by the same pharmacy can prevent compounding if that pharmacy doesn’t do it
But there is no rational reason why a pharmacist shouldn’t be legally allowed to dispense a patient with a prescription for a controlled substance with a lower dose than prescribed. Prohibitions on them doing so are just pointless bureaucracy which have nothing to do with preventing addiction. They achieve nothing except harming patients
If a drug is available and there is addicts of said drug, the addicts don't suddenly stop being addicts just because the drug is not available, they'll just move on to a different drug. The problem is that addicts are not being treated, not that a specific drug is available or not.
We all have addictions. For some it is substances, other relationships, power, sex, gambling, food, etc. What if yours suddenly became really difficult to manage within the societal-framework-du-jour? Just don't start doing it?
I think it's trivializing the concept to say "we all have addictions," since by definition an addiction is meant to be a significant impediment to living a normal life. And I'm not sure how you're answering the concern here. Like yeah, a lot of people get addicted to gambling -- that's a compelling argument against legalizing gambling.
My point was more an attempt to point at an empathetic response as a possibility. "don't start abusing the drug in the first place", to me, felt like a way to dismiss the reality that it can be really easy to fall into addiction, because most of us are broken in our own peculiar ways and have our own vulnerabilities. What if someone else's response to one's own brokenness was "just don't do that"? It doesn't really help much, because the reasons for it are valid, and the need itself needs to be seen.
My own comment was a knee-jerk reactive comment in reply to what I felt in your post, which may or may not have been a real thing.
Idk. My hunch is that we are all addicted to something, and if you don't see what it is yet, then either you or society (or both) must not have much of a problem with that particular addiction, and that can always change.
> Addiction is a neuropsychological disorder characterized by a persistent and intense urge to engage in certain behaviors, one of which is the usage of a drug, despite substantial harm and other negative consequences.
In fact, the article goes on to specifically refute the argument you are making:
> The term addiction is frequently misused when referring to other compulsive behaviors or disorders, particularly dependence, in news media. An important distinction between drug addiction and dependence is that drug dependence is a disorder in which cessation of drug use results in an unpleasant state of withdrawal, which can lead to further drug use. Addiction is the compulsive use of a substance or performance of a behavior that is independent of withdrawal. Addiction can occur in the absence of dependence, and dependence can occur in the absence of addiction, although the two can occur together.
Not sure what you are saying here exactly, but ive heard far more stories of someone ruining their life because they turned to black market subsitutes for drugs they were previously able to obtain legally than stories of people who just decided to quit when it was no longer available.
I believe most people here would not argue against the right to autonomy. Furthermore, if the government itself was against it, people who attempt suicide would be charged as criminals. The issue when it comes to substance use is that people under the influence will potentially cause harm to others. Substance abuse is often a symptom of other problems, particularly with mental health, and instead of simply loosening restrictions on meds it's better to direct individuals through the healthcare system for proper diagnosis, treatment and monitoring.
Most of your comments just read like you are frustrated and need to vent, which is fine, but remember your audience on this forum is strongly deliberative.
I'm not - I think its wrong and cynical to gatekeep someones usage of a drug : whos to say what is theraputic and what is degenerate junky usage?
You know what is cynical? Putting up barrier after barrier that makes it hard for ANYONE to obtain a medication that can genuinely help people because we dissapprove of how some people use the drug on their own bodies.
Criminalizing the possession if a drug doesnt do jack shit to help people who are addicted - it just drives them into sketchy situations to obtain it and throws them in jail if theyre caught. And to top it all off it makes it incredibly difficult to obtain it even if you play by the rules.
I did not intend to be glib or offensive. But I do not apologize for my assertion that humans ought to have sovereignty over their own bodies. It is not the job of the governmemt to concern itself with what the citizenry does to their own bodies.
I'm not lacking empathy. I think it is more harmful than helpful to deny addicts the drug they are addicted to than to provide them legal means to obtain it.
Especiallu in the case of something like amphetamine, which does not directly cause bodily harm (an argument could be made that things like heroin and alcohol, which can and do directly kill, should be withheld)
When you prevent an addict from obtaining via legal means, all you are doing is forcing them to find illegal means, which may involve interacting with dangerous individuals or outright theft.
I do not believe my comment about allowing people to destroy themselves displays a lack of empathy - I dont think a family member or friend should not intervene if someone is engaging in self destructive behaviour.
But I do think it is immoral for the government to prevent someone from destreying themselves. It is not the mamdate of the government to prevent self harm.
I think addiction is not an issue in a vacuum. It is caused by underlying issues. We need to learn to accept addicts as they are. You cannot help someone when their needs are not met. To an addict, the drug is a need. That need must be met before deeper issues can be addressed. It is a fallacy (and dare I say a lack of compassion) to push addicts to the fringe of society by denying them legal means to carry on with their addiction.
Alcohol actually is relevant--and note what happened when we were stupid and tried banning it.
Opiates used at a sustained level are actually not that harmful--the danger comes from those who are deliberately seeking the extremes (things like crushing the time-release pills and snorting them) and from the lack of quality control of the illegal marketplace. We don't see the chronic pain patients keeling over left and right from ODs--except when we try to deny them the relief and drive them to the illegal market or to suicide. If the cause of their pain doesn't otherwise mess them up they can often lead reasonably normal lives.
We also have a problem with confusing habituation with addiction. A patient who needs controlled substances will likely habituate and be in a bad way if they're denied but that doesn't mean they are addicts--you can seek the relief the drugs bring without seeking the drugs themselves. If the underlying problem is resolved you taper them off and it's not an issue. Part of the opioid crisis was the doctors being deceived into thinking the tapering wasn't needed. The CDC has finally realized that cutting them too quickly is medically bad--but the system is still geared to persecute drug seekers and catches too many innocents in the loop. Woe to the patient that loses the doc that has been handling the drugs! (And it's not always because they were going to a pill mill. Doctors are human, they retire, they get sick, they die. And the DEA likes to pressure pain management docs into retirement.)
The thing is the primary harm comes not from the drugs but from the illegal market and from the controls that are put in place. This is especially true of the drugs that are both therapeutic and recreational.
My next door neighbor (who has since moved away, but I see his kids around the neighborhood still) is a very successful salesman and takes 120mg of Adderall “to get out of bed in the morning”. Which I thought was crazy considering I take 15-30mg in a day, but he didn’t seem like a bad guy or to have any ill effects from it (aside from assumably spending a good chunk of change a month buying Adderall off friends/dealers).
I think there’s way worse things to be addicted to than Adderall and feel like this guy is a “worst case scenario” but he’s still a productive contributing member of society.
Believe it or not you can be prescribed that much adderall. It takes a doc that is willing to go there, but I knew someone with a 200mg daily prescription.
I suppose he could have been gaming the system somehow by going to multiple places but I thought it was all from the same doc
I was previously consistantly using a generic that I tolerated well. In the last year I have had several months (maybe 6) where I was only able to obtain generics produced by actavis or amneal. These 2 absolutely suck compared to sandoz, teva (which I think may be exactly the same) or shire.
The side effects are overwhelming
Kind of bizarre that the author won’t entertain the most obvious explanation given the documented problems with many generic drugs [1]. I guess the difference in this case is that the patients can tell right away.
the generic concerta all have a KNOWN issue with manufacturing. The slow release mechanism is mechanic, not chemical, and only ONE generic is manufactured the right way.
It's literally a plastic capsule with microscopic holes drilled in it. A sponge on one end absorbs moisture and swells at a fixed rate, slowly pushing the methylphenidate out the other side.
Two of our kids are on Concerta and can confirm that the first time we got generics it was very fucking obviously working quite differently (in our case, it manifested like them barely working at all). Took us a little bit to put two and two together, but sure enough, the change was just as we switched (well, got switched) to generics.
Be great if the FDA would ensure that a generic is actually the same damn thing.
Slightly off topic, I found out generic of my birth control pill is not mono-cycle, meaning not every pill in the pack has the same dosage, it fucked me up for months.
It's not documented anywhere
> The brand one slow releases very evenly while the generic just slams me with the calm, focused joy followed by a significant emotional low for hours.
Prolonged-release of an orally drug taken in pill form is a "special feature", it's the difference between regular Adderall and Adderall XR.
There are patented techniques involved to make it work like that, generica manufacturers probably don't have access to those/leave it out to save manufacturing costs.
You can try taking the generica in smaller dosages, to compensate for their lack of prolonged-release, as the symptoms you describe sound like you are overdosing by taking too much in too short of a time.
Concerta doesn't need such manual dosage management, as it also has prolonged-release just like Adderall XR.
Generic substitutes for extended release medicines are extended release also. The problem is the extended release mechanisms are judged equivalent when they are not.
How often do you casually dispense medical advice to strangers? Especially without qualifying yourself as a SME expert (or non-expert), or at the very least providing reference sources or other supporting documentation?
Edit: @djmips: Are you familiar with the differences between medical and non-medical advice? The potential repercussions of you following my potentially bad advice on programming are vastly different from the possible fallout from encouraging someone to mess with their medication dosing. The responsible thing to do is refrain, because some people are on a very specific regimen for good reasons. In a medical context, sharing one's own experience (and qualifying it as such) is often appreciated, however this is not how I would characterize the structure of the parent comment.
I hope this helps, I only wish the best for you and others.
> How often do you casually dispense medical advice to strangers?
Semi-regularly, as I work in palliative healthcare.
I'm just not sure why that would be relevant to "medical advice" like "If you experience too intense sympthoms, try lowering the dose" and explaining the differences between instant and prolonged-release drugs?
Some might consider that common sense, which shouldn't need to be pointed out.
But life is hectic and complicated, leading to a lot of overthinking, sometimes we just need a reminder of the simpler and straight forward solutions.
It’s the internet: let’s stop with all the fourth-degree second guessing of hypothetical dimwits which are extreme edge cases when they exist at all, but are mostly the figments of imagination. Most often, this comes across as very hollow and disingenuous virtue signaling.
Let’s set our expectations higher. The admonishing rhetorical questions are a waste of time to post and quite boring to read. You seem to be aware of the risks of strangers dispensing advice on the internet, despite stated qualifications (which may be imaginary or real). Assume most of humanity is aware of this as well.
The FDA allows generics to be sold within much looser tolerances than the brand product (variances allowed of +/- 20% of active ingredient per dose.) If you've ever noticed a "brand medically necessary" checkbox on a prescription a doctor has given you, that's what it is there for.
There's no way that the variance allowed is +/- 20%. That's insane.
Does that also imply that a 30mg Adderall could come out as either a 24mg or a 36mg? In reality that is likely easier for the manufacturer to detect than the individual weights of the active ingredients in a random mixture, but still.
They measure maximum blood concentration and other parameters. Not just how much of the primary ingredient. But the variance allowed for those parameters is 80% to 125%.
That sounds like your generic is not extended release but an immediate release version, which sound like different medications overall. Maybe split the dose in half and take the second half 4 hours later which is what they usually do when people are taking immediate release? Whoever your doctor is should understand this dynamic...
I've been on 4 different brands of generic Ritalin. I'm sure I can tell them apart by taking one.
1. Normal (the first one - don't remember the manufacturer - was extremely hard to break in half)
2. Actavis - strong, but slow to hit
3. KVK - strong and hits fast
4. Mallinkrodt - weak
For years Mallinkrodt was the only brand my drug store would get. Now they switched back to KVK and it's like night and day. I only have to do half as much.
i've worked in the biotech industry and have been to some generics manufacturing plants and they are "up to code" but also a whole hell of a lot jankier than the big name brands.
The brand name worked significantly better when I took seizure medication with fewer side effects. The differences between the brand name and generic medications were very pronounced.
I don't think it's still manufactured, and maybe it's unrelated to this current situation, but around 8-15 years ago, one of the manufacturers of generic Adderall XR did something that made it much less effective. It was obvious which ones were theirs, because they were the only company that put theirs in blue capsules.
Subjectively, it felt about half as effective as anyone else's. There were many, many forum discussions at the time from adults taking it as well as parents of kids who'd received it and noticed a big difference.
It was especially frustrating because of all the rigamarole one has to deal with to get the medication in the first place. To not have it work and also have to wait another month to get one that does is ridiculous.
I submitted a complaint to the FDA about it at the time. Never even got a form letter back. It's caused me to avoid generic drugs where possible ever since because if that can slip through, what else can?
I assumed at the time it was some difference in the capsule itself or the delayed-released mechanism, as opposed to the active ingredients being different.
You see this with a lot of psychotropic medications (and likely others).
It’s why when you fill a generic the label will specifically list the manufacturer. I’ve heard of at least a few instances with psych meds where people will either try to get a specific generic manufacturer or go back to name brand because of the significant impact due to variability you’re describing.
I would also say that ADHD meds are much more susceptible to this, because the psychological effect is just so noticeable. Taking Vyvanse by itself compared with taking it with a little snack it makes quite a difference in the absorption for me; when I take it with Psyllium husk, then...
EDIT: I guess I should expand on the effects of Psyllium. I mean the meds take longer to kick in
I am in a similar situation as you and trying to figure out the best way to take my medication. I never really thought about my psyllium husks having an effect, so I'm very curious what you've noticed
From what I read it doesn't seem like a good idea to take psyllium husk together with other medications. They seem to recommend one hour or two of interval between it and other meds. I don't know if it's just doctors being cautious, though.
I usually take Vyvanse just by itself at around 7AM just before walking to the gym, so I guess I associate the effect kicking in to my walking back home. On the days I ate something together with it, or specially with Psyllium, I notice a diminished effect
the stuff in here about 'minor differences in coating could make a difference but shouldn't' is surprisingly badly researched
both teva + shire manufacture a branded and a generic -- just ask them what the difference is between the two, right? and if they hang up you can write, 'both teva and shire refused to say if their generic works'
(from plasma concentration, the double-pulsed one looks as smooth as continuous delivery, but I'm guessing the brain + blood half lives are different)
but the bead material is probably FDA scrutinized, and any chemical difference between the branded + generic version is in theory public knowledge; shocking nyt didn't like, call a chem lab or something before hitting send on this one
the author speculating that someone is complaining about switching from an immediate release to an XR also feels bogus -- presumably I would say in my tiktok that it's a capsule instead of a tablet?
I suppose things might have changed in ~half a century, the FDA used to care about everything.
Back in the late '80s the VAX-11/750 that was part of the Siemens MRI scanners was shipped in the old blue trim color long after DEC had switched to the very chic "brown on tan" color scheme. The FDA approval for the scanner would not let them change the color of the paint because of some bleedover of medication regulation language into the equipment approval regulations.
There are whole classes of products designed to be eaten for various purported benefits but which are evidently neither sufficiently foodlike not sufficiently druglike to warrant FDA attention. Herbal supplements are apparently just edible magic.
“Inactive ingredient” is a term with similar provenance as “junk dna”, “oldest human tool-making”, and “oldest humans in North America”. These terms represent a state of current understanding more than absolute truth.
As somebody approaching 40 who has been on ADHD meds most of his adult life and for portions of his childhood:
It’s not that (generic) Adderall is different so much as there seems to have been an explosion of generic manufacturers all using wildly different amounts of the actual amphetamine salts and binding agents.
For me personally, the Mallinckrodt generic seems to use a different binding agent that causes bloating and occasional headaches.
The shortage has really demonstrated just how differently these generics are formulated.
Eg: I used to take Sandoz 20mg tablets that were about the size of two baby aspirins. At one point, a few months back, I was forced to modify my prescription so it could be filled as 10mg tablets.
My new 10mg bottle was filled with Teva manufactured pills that each were roughly the size of 2.5 of my old Sandoz 20mgs - despite being half the dosage. That’s a ton of filler.
The worst part about the shortage - beyond the anxious pharmacy hunt each month - is that my insurance pushed a new shortage policy that places a moratorium on modifying ADHD prescriptions. I literally am not allowed to try “creative” solutions like Dexedrine or even something like modafanil.
This is 100% happening, we need these pills tested in a lab. My bet is they are likely thinning it because the demand is too high. The DEA will not approve the new limits because of "The War on Drugs" is being revived.
I was switched to Teva at same dose this past month because of the shortage and it does not work at all. Its very frustrating, like getting your wheel chair and realizing it doesn't have wheels.
The Teva generic or the Teva brand name? They make both a generic and a brand-name. Everyone I've heard swears by the Teva non-generic as "the best" for just adderall.
I'm considering going back to smokeless tobacco because of this sitution. For 400 years, the majority of the population used tobacco/nicotine for increased concentration. Over the last 30 years, that rate has declined, while at the same time, ADHD diagnoses have increased. Studies have shown nicotine is effective in reducing ADHD symptoms, so it seems that society's elimination of nicotine has revealed that it was covering up ADHD for all those years.
Regarding generic equivalents - let me give a little history lesson:
For Methylphenidate based medications, Ritalin, Ritalin LA, and Concerta all have the same active ingredient. However patients were willing to pay extra for Concerta due to it having the OROS delivery system which delivers the medication over an unusually long period of time of 12 hours in a very steady way.
However in the US, the FDA allows medications which deliver within 80% to 125% of the same medication to qualify as a generic. A bunch of generics for concerta which did NOT use the OROS delivery method but instead used cheaper inferior methods which did not deliver medication as steadily or for as long were released simply because they were within that 80% to 125% window. In fact these generics were more similar to Ritalin LA than they were Concerta, so essentially the FDA allowed essentially a different drug to be substituted for Concerta when the ENTIRE POINT of Concerta for many patients was that it gave a longer lasting steadier dosage than Ritalin LA. If a patient didn't need this advantage, they could just take Ritalin LA instead. This was used as a pretence to deny insurance coverage for Concerta because a generic existed and caused many insured patients to pay thousands of dollars out of pocket for the real deal which they never saw again. These generics were scams which hurt patients quality of life and the medical system was complicit in hurting patients while financially benefiting these fraudsters since only having to pay for fake medicine instead of real medicine saved them money. Nobody besides patients were punished.
The problems with Concerta generics happened around the same time as the problems with Wellbutrin generics, problems which the FDA ALSO denied for years before backpedalling. The whole "generics are the same as the brand name" dogma is not actually true for all medications, and it's ADHD patients historically who were one of the groups of patients who found this out for themselves.
So if people suspect there is a problem with their Adderall generics, I am VERY inclined to believe them, because we know that patients using similar drugs have shown extreme sensitivity to differences in generic equivalents in the past, and we know the FDA has approved "Generic equivalents" that were anything but repeatedly in the past.
If you are getting ADHD medications, you can request your doctor write "no substitutions" and a specific brand on your prescription. If you are having coverage denied for either the brand name or the generic medication of the brand name (the exact same medication but with a different name and lower price, rather than being an equivalent) you CAN often get your doctor to help you lobby your insurer to get a specific brand covered by claiming medical need.
>This means that, theoretically, obtaining a generic form of Adderall from a different manufacturer could alter how you feel while on the medication. However, the differences between generics are so small that an overwhelming majority of patients wouldn’t feel any change from their previous medication. “It’s not supposed to have drastic differences,” Dr. Dube said.
What an absolutely fucking ignorant assertion given the history of ADHD patients being noted for their sensitivity to small differences between brand name medications and generic equivalents. What data did he use to come to the conclusion the "overwhelming majority" wouldn't feel any change and is he talking about the ADHD patient population or the general patient population? If he means the former he's wrong, if he means the latter he's being obtuse and misleading.
> What data did he use to come to the conclusion the "overwhelming majority" wouldn't feel any change and is he talking about the ADHD patient population or the general patient population?
This was my thought as well. Im very sensitive to manufacturers and spent months bugging my pharmacist to tell me which "brand" they had in stock so I could pick the one with least side-effects. Even though they had a note in my file they would just give me whatever they felt like and told me there was no difference.
It took a different pharmacist who was also sensitive to understand my problem - to the point she chased me down this month after paying to tell me that it was a new manufacturer she hadn't seen filled for me and wanted to double check I wanted it before leaving the store. With the shortage I didnt care & was why she filled it before checking since it was all they had and would run out if she waited. And, it's not great, it's weaker which causes me to get tired (small doses put me to sleep), and starts to dissolve instantly so it will sometimes stick if I dont drink fast enough.
I think that is one of the biggest problems. If people think they should all work the same and then get worse side effects they think its a fake, but it's probably just a different manufacturer that they have no idea to even check.
For those that do, they dont seem to consider they are sensitive to the change. The best manufacturer for me is Camber, it's the only one that has no side-effects and "just works". The first few days I thought it was a sugar pill until I realized just how much I got done without even noticing. But do a quick search and people are outraged at getting switched to them and trying to get the FDA to revoke it.
> and it's ADHD patients historically who were one of the groups of patients who found this out for themselves.
I guess the things that work with immediate changes are going up be easier to spot. But even then you don't often know the expected result with (for example) pain killers. On the other hand, if ritalin wouldn't work as usual, it would be really obvious to me within a couple hours.
I have the same issues with my birth control. I thought I was becoming a conspiracy theorist, because it was entirely undocumented. But I know what I feel.
I took the same name brand pill since I was 13, then I moved to the US at 21, had to switch to bunch of generics, they never worked the same (I mean I didn't get pregnant) but I'd get terrible migraines and other side effects I never got from name brand
This is an incredibly insightful comment. It’s a bit insane that the scope of the drug does not include it’s delivery system. Timing is everything for psychiatric medicine but also I could easily see it being important for things like antibiotics or pain medication.
I know this is overly tangential, sorry.. there are xr mechanisms with varying degrees of linearity, molecular 'handednesses', and recently I wanted to try these eye drops to replace reading glasses and stumbled onto this fractional dosage relationship. The last defined a medication's application - that generics vs expensive effects depend on customized level of active components that can produce a completely different drug. The point being that the discount of bulk medication and fine tuning make for the expense and it is still a compromise.
The epiphany for me was those eye drops for reading would be so cheap if I could get it in bulk maximal strength and dilute to arrive at a specific concentration that changed a drug already used for completely unrelated (dry mouth or something) purposes at a slight difference in concentration apparently changes the fluid level in the eyes enough to compensate for age. I recalled all of the times a helpful pharmacist would change other types of prescriptions to avoid the expense of brand label fractional doses letting the patient substitute a common bulk variety and a pill cutter which becomes more difficult with fine granularity - this active ingredient/filler ratio for pills.
So I began to wonder what do they do when manufacturing processes produce more desirable chiralities - what happens to the remainder?
If there is some conspiracy it is probably related to manufacturing processes, bulk availability, and/or capacity for a pharmacy to behave like a custom apothecary, all of the liability that that would entail.. thus the expense of name brand pharmaceuticals?
I'm glad there's no obvious shortage in Canada, this stuff has a tendency to spill over from America. I finally I was to get prescribed and it definitely works for me. 20mg of Sandoz XR, it's like magic.
The shortage is entirely arbitrary, and only exists in the US.
We had a significant increase in ADHD diagnosis during the pandemic, because telehealth is much more approachable for people with untreated ADHD.
Despite that increase, the DEA refused to increase the arbitrary limit for how much Adderall can be manufactured in the US. So we have an entirely avoidable shortage on our hands.
> We had a significant increase in ADHD diagnosis during the pandemic, because telehealth is much more approachable for people with untreated ADHD.
And, in typical fashion, the DEA responds to the problem in nearly the worst way possible: they announced new regulations to stop telehealth providers from writing new prescriptions for ADHD meds. I suppose this keeps the shortage from getting worse, but that’s about it.
They aren’t new regulations, its the ending of the temporary suspension of the old regulations which was premised on the pandemic state of emergency, which has ended.
Its bad because the pre-existing rules were bad and should have been changed instead of merely suspended based on the pandemic.
You may have just gotten lucky. It seems like the situation in the US is highly location/pharmacy-specific. The other variables are type (IR/XR, generic/non, etc.) and unit dosage. The worst hit seem to be 10mg/20mg generic IR Adderall, because that is usually the most popular and cheapest option. Switching to XR or to a less-common unit size (like 25mg) may increase the odds of finding it somewhere.
It really is a super frustrating situation. Because of the tight controls on the drug, prescriptions are almost always sent electronically from provider to pharmacy, and any changes or transfers must go through the provider. Most providers aren't going to play whack-a-mole by continuing to transfer the script, and as the article implies, changing medication type (Ritalin/Adderall/Vyvanse) or IR/XR can have significant impact on the effectiveness and potential side-effects. Responsible providers aren't just going to flip/flop medications without at least a consultation.
>It seems like the situation in the US is highly location/pharmacy-specific.
Anecdotally, this definitely rings true. I recently moved from Dallas-Fort Worth to a VERY rural part of west Texas (population >2000). The only pharmacy within an hours drive, which is 30 minutes away in a town of ~20,000 has filled my prescription regularly. Back in DFW I know of three different people who have been unable to get their Adderall filled for months. And there's a pharmacy practically on every corner out there.
>Because of the tight controls on the drug, prescriptions are almost always sent electronically from provider to pharmacy, and any changes or transfers must go through the provider.
Very different from where I live in Canada. I just get a written script and can take it wherever I like. The pharmacy submits the info to the provincial drug tracking program to make sure it's all kosher and when it is I'm on my way.
If a pharmacy every refused to fill it I could just take the script elsewhere.
Some of these "differences" can be life-threatening.
I'm on 30mg of generic dextroamphetamine sulfate XR per day. It evaporates my ADHD entirely, makes me feel much more comfortable and relaxed, and makes it easier to regulate emotions and stress. As a bonus it also helps me feel my emotions more readily, which I consider amazing.
But last time, the brand of generic that my pharmacy gave me was Actavis (owned by, guess who, Teva) instead of the Mallinckrodt that I got the first time.
When it first kicked in, I was in the middle of relaxing in bed and my heart just suddenly went completely insane out of nowhere. My heart rate was around 130bpm and I could not sleep at all anymore, even with generous amounts of melatonin 4+ hours before bed. My blood pressure was 180 over 130 for two days straight.
I eventually realized what the problem was and switched back to Mallinckrodt. My heart rate was soon okay and I could relax and sleep again, but it took around 4–5 days for my blood pressure to return to safe levels, probably because of all the bodily load that those Actavis capsules caused.
At my doctor's appointment yesterday, I had my doctor explicitly forbid Actavis and then put "brand medically necessary" on my latest prescription three times, once in handwriting, requiring Mallinckrodt specifically. Hopefully I will not get the wrong meds again.
AFAICT, the main reason it was so dangerous is probably because I am taking 30mg daily. But either my ADHD is really that bad or I started off with a very high tolerance, because my tolerance was discovered from having to take 20mg of adderall IR for it to do anything at all. And that just so happened to be terrible badness, so I switched to pure dextroamphetamine which seems to work wonderfully.
But only this very specific capsule from this very specific brand. The others might literally cause me a heart attack.
I am on a similar script, and I think the half life on these pills is way longer than commonly advertised. The primary effects last 4-6 hours, sure, but the actual half life is more like 12 hours. I will absolutely not be sleeping within 4 hours of taking 15mg of dexamphetamine. Wikipedia also seems to confirm this (duration of effect vs. elimination half-life) [0].
The implication of that is that if you take the same amount every day you can build up a wall of toxicity. I recommend skipping your dose on the weekend, or cutting it significantly and only taking it in the morning. I find this helps me keep the effects feeling more even over time.
Also, maybe I should start drinking a glass of orange juice a few hours before bed to try to accelerate the excretion.
> I am on a similar script, and I think the half life on these pills is way longer than commonly advertised.
My capsules are advertised as 24-hour; they are specifically extended-release. For me that's a good thing; it keeps me functional until I need to take the next day's dose. Won't be able to take it on time if I can't get out of bed due to ADHD, after all.
They do require a bit more preparation to take, though (stuffing myself with as much food as possible).
> The implication of that is that if you take the same amount every day you can build up a wall of toxicity.
Not exactly a wall of toxicity—dextroamphetamine isn't toxic in the same ways meth is—but the medication from the previous day can indeed stay in the body for a while longer than advertised. From what I've been told, as long as you take doses significantly less frequently than the half-life, it eventually reaches an equilibrium and doesn't just build forever.
> I recommend skipping your dose on the weekend, or cutting it significantly and only taking it in the morning. I find this helps me keep the effects feeling more even over time.
I already take the entire day's dose in the morning, anyway. Usually 8am every day, but sometimes a few hours earlier.
I don't like to skip days because basically my entire issue with ADHD was spontaneously losing the ability to function. Stopping stimulants causes me to sleep 15 hours in a row. I wish I was joking; I basically go into hibernation for a day. I'd be sacrificing my weekend for no real benefit except getting high on Monday I guess.
> Also, maybe I should start drinking a glass of orange juice a few hours before bed to try to accelerate the excretion.
Citric acid only neutralizes the capsule itself, not the drug once it's in your body. If you need help sleeping just take around 5mg melatonin four hours before bed. After a week or so of this you should start to get tired and sleep naturally every night, even on stimulants, as long as you keep taking the melatonin.
Ths basically works by correcting your circadian rhythm.
I haven't needed this because I can sleep manually, as long as I'm not having a heart attack. But I should probably do it anyway because circadian rhythm is important for more things than just sleep.
Anecdotal, but the generic (Alvogen) I've received the past few times for the IR version has felt much stronger and has ultimately led to me adjusting to about half my prescribed dose.
I've taken the same dose produced by many different manufacturers for ~10 years and this is the first time I have noticed such a big difference. So far I haven't been able to find any other confounding factor that would account for the change in effect.
I wouldn't be surprised if they are doing this. It should be relatively easy to test, though. I know many people that'd volunteer do run NMR or mass spec.
Pretty much anyone with friends who study chemistry would do. The problem is, no matter what you do, it is going to be very challenging proving the chain of custody to hold them accountable.
Noticed this as well. Now I can’t find that generic in stock either.
As an alternative, I would like to know what THC / medical Marijuna product is the best alternative to out of stock Adderall. I will take my answer off air. Click
Are there any concerns that the reduction in prescription stimulant supply/quality will cause some individuals to substitute their prescription medication for illicit methamphetamine or cocaine?
Recreational stimulants medications don't substitute for ADHD medications. You can always find anecdotes from people who think they're going to use some street drug as a substitute for ADHD medication, but it always ends poorly.
Proper ADHD treatment requires stable dosing. It's impossible to dose street drugs accurately due to the varying quality and different "cuts". Even with precise measuring, a person could end up dosing twice as much from one batch to the next.
I browse recreational drug forums occasionally to see what people are doing these days. Even the recreational drug users on Reddit will readily admit that trying to use research chemicals or street drugs for therapeutic purposes is a dead end. It just results in abuse-style patterns as people chase the high and subsequently crash.
If people are really struggling, the real solution is to try methylphenidate or the various non-stimulant ADHD options. The non-stimulant options aren't as "fun" and can take a few weeks to kick in, but they beat the stimulants for a lot of people who have the foresight to try them and stick with it. They also seem to be much less prone to tolerance over time.
I'm literally trying to figure out how to do this safely right now.
I have a person I can get it from, it's decriminalized where I live, and there are abundant facilities for detailed testing so I can get a sense of what the purity is.
Just wondering about dose and how this could work. I'm ADHD and it's been impacting me a lot recently
I recently met someone who says they take Vyvanse for ADHD and they just can not shut up, and constantly butt in on conversations to tell everyone about themselves.
I didn't know this person before they started taking these meds, but I suspect these meds might be a contributing factor to that behavior. Could that be so?
That is the ADHD. Constantly changing the topic to talk about something that happened to you once which you were just reminded of because of a detail in the conversation. Too much sharing of personal details with people I maybe just met. Telling too much to someone in spite of knowing that I should have shut up.
It has taken me ages to be fully aware that I do it, and when I notice I try to stop myself from derailing the topic being discussed. If I feel that it is truly relevant I cross my fingers or something like that to add it at the end of the conversation, but usually after a few seconds it loses the urgency and I feel I can drop it, or even forgetting what I wanted to add at that point. It is absolutely a social problem and I know people see it as a flaw of character, but it is slowly getting better. Being gently reminded that I am doing it helps because sometimes you just don't notice.
Of course if your acquaintance is on a too high dose of Vyvanse or has been wrongly diagnosed it can cause a bad case of motormouth, as all stimulants do...
Adderall is a mixed salt, it's two stereoisomers, amphetamine and dextroamphetamine. One of them (I think it's the amphetamine) is "speedier" feeling and the other one (I think dex) is "cleaner".
Dextroamphetamine is also available as a purified salt itself, as dexedrine. And I think that's more of a "kids medicine" specifically because it's less "speedy".
I think there's nothing that guarantees any particular ratio comes in the product, and obviously generics have very mixed results on just how "bioequivalent" it really ends up being. I think the mixture is varying and people end up feeling like it's different because they're feeling the "speediness" change and that's the feeling they associate with being medicated with stimulants.
Amphetamines are another dopamine-releasing and gaba-ergenic family of drugs and my suspicion is that in the presence of an opioid antagonist like naltrexone probably patients would not be able to distinguish between the exact mixtures of the stereoisomers but without it they probably can tell which feels "speedier" and the perception is that is how much their symptoms being treated. The dopamine-releasing loop probably is a not-insignificant part of how it treats ADHD though, dopamine-seeking is a key aspect of ADHD (do you drink caffeine or eat sugar before you go to bed, or when you wake up in the middle of the night, and then fall right asleep? that's because your brain is getting dopamine satiation finally).
(Incidentally this all makes stims a very difficult combination for alcoholics and other GABA-loop drugs because the effects are synergistic and mask each other.)
Obviously a difference in coatings should make zero difference but half the time there are broader problems with bioavailability or just generics being inferior quality in general, not just adderall but in general. The FDA isn't doing a good job with this really, just IMO, and not just with adderall. The entire foundation of generics rests on "this is chemically equivalent and absorbed the same" and it's clearly not for a lot of people and the generic is almost always the one that comes off worse. The entire product needs to be the same, binder and coating and all, with the same level of quality and in the case of stereochemistry it needs to be the same mixture.
The bigger problem is just the shortages in general... my last 2 refills have both taken 7 days past the end of of the prescription, and this latest one I only managed to get 1/3 of my prescription filled (and they won't fill the rest of the prescription later if you pick it up, nor will they hold what they have while the rest of it comes in). Leftovers and reducing my dose (against the instructions of my doctor) will only carry you so far, I can't run 50% longer on a given prescription. The mood swings and stress and dopamine-balance/seeking problems that come with bouncing off it are rough too.
My doctor's office is entirely unsympathetic and views their job as 24-48 hour turnarounds which is obviously completely insufficient for this kind of situation, no way it will be on the shelf in 48 hours. And if I push it then I come off drug-seeking (yes, voluntarily taking 1/3 of my prescription per month so I can get something at all, definitely drug-seeking). It sucks and I've become very disillusioned with my doctor over this, they just are not sympathetic at all.
Everything to do with C2s is just so tainted by the adversarial relationship between the DEA and doctors and that only emphasizes the sometimes-adversarial relationship between doctor and patient.
If this were lupus patients struggling to get their meds during the height of COVID mania, there would be no concern whatsoever about doing what was needed to get people their meds. There would be no concern about other generic providers just making more, either. But it being a C2 changes everything. It fucking sucks and it's disgusting this is how a health care system works.
Some clarification: the stereoisomers of amphetamine found in Adderall are levoamphetamine and dextroamphetamine, the former feels "speedier" because it mostly affects the body (heart rate, blood pressure, fight-or-flight response) whereas the latter mostly affects the brain (wakefulness, focus, etc.) Adderall exists because apparently a small amount of levoamphetamine has been shown to produce some effect on focus, but most of the heavy lifting is done by the right-handed isomer. In my opinion the risk of addiction is higher if there is a noticeable physical high.
Which is why I personally have decided to go with dextroamphetamine (in the long release form of lisdexamphetamine) which doesn't cause any body stimulation, and in fact lowers my blood pressure due to reduced anxiety, while producing no physical stimulation whatsoever. A cup of coffee feels "stronger" than lisdex.
In Britain Ritalin (methylphenidate) is usually first line treatment for children, while Elvanse (lisdexamfetamine) is preferred in adults. AFAIK Adderall is not prescribed here.
"Studies of Adderall and similar stimulants, such as methylphenidate (Ritalin), estimate that psychosis occurs in about 0.10 percent of users. However, new research with over 300,000 adolescents with ADHD showed that the rates of psychosis in adolescents in the amphetamine group was as high as 0.21 percent. "
> and this latest one I only managed to get 1/3 of my prescription filled (and they won't fill the rest of the prescription later if you pick it up, nor will they hold what they have while the rest of it comes in)
You can have your doctor send in a new prescription for the remaining amount. Whether your doctor will for you is another story.
The way it was explained to me is a prescription of say 90 count is -yours- for the month. You get to have 90 in a 30 day period. If a pharmacist can only fill 30 and you pick it up, the rest of that particular script is no longer valid (or something). But you are still good for 60 as long as your doctor will write a new script for that remaining amount.
source: same situation couple months ago or so and a great doctor and pharmacist who understands the situation. I received a 10 day supply and had a new prescription sent in that would not be able to be filled until after that 10 days and only for the remaining amount.
The isomers in adderall are dextroamphetamine and levoamphetamine. They are both “amphetamine”.
Last I checked it’s a racemic mixture, so it’ll be 50/50 levo/dextro.
Fun fact! Certain SKUs of Vicks inhalers use levomethamphetamine as a very effective decongestant. It’s literally methamphetamine! Just not the kind that can get you even remotely high.
In Australia we only have pure Dex. I'm not sure if I buy that they're a benefit in using 25% levoamphetamine vs the manufacturers just wanted a way to cut their product and get cheaper manufacturing...
It's mostly an accident of history. Adderall was originally marketed as a weight loss product (!) containing 4 different amphetamine salts, including methamphetamine (!!).
The FDA made them remove the meth in the 70s, and in the 90s the company that made it was acquired, and it was rebranded as an ADHD drug.
Or, maybe an increasing number of people have suffered from brain fog caused by long covid, and that would make them feel like their Adderall is not working?
Nope. Line up 4 different brands of amphetamine salts and try them on different days. You will find that some make you feel geeked and strung out. Some make you feel calm and focused.
This is an unhelpful and incorrect sentiment in the context of ADHD medication.
The cause has been linked primarily to genetics as ADHD in particular is caused by the brain not producing enough dopamine (or cleaning it up too quickly) to function well in our society. It is also not endemic of modern times as there is evidence that ADHD has been with the human race since it existed. Stimulant type drugs are some of the most effective drugs we have to treat the conditions they target, because it counteracts precisely the mechanism (dopamine production/retention) that is deficient in ADHD brains.
Diet has been strongly linked to mood, focus, and sleep. Consequently, the hormones Dopamine, Serotonin, Epinephrine, and Norepinephrine all have receptors in the brain as well as the gut and this should not be too surprising because consuming calories, vitamins, and water is fundamental to survival. In fact your gut has 100 million neurons in it, more than a dogs brain. While it’s not “thinking” in the way we know as consciousness, it does make decisions and pull levers to motivate you to do stuff. It should come as no surprise that dumping refined sugar into this system, something we did not evolve to process in its current form, will cause issues.
ADHD is a sort of misnomer, it doesn’t describe a deficit of attention but rather intention. It messes with the wiring of your prefrontal cortex to limit the effectiveness of executive functioning which handicaps your ability to make decisions based on importance (because everything seems just as important) and the brain makes it very unpleasant to start tasks that non stimulating (to the point of withholding dopamine and dumping cortisol into the bloodstream).
There is plenty of ADHD in Africa but you need to find it in the places where non-ADHD brains are rewarded. I suspect that as African nations become more metropolitan and the workforce demands shift to meeting the needs of a city, we will see even more ADHD diagnosis in this part of the world.
This thread is FASCINATING to read -- My brand of Adderall changed recently. I even more recently decided to try going off of it.
I miss it. Somewhere here wrote that it helped them be in touch with their emotions. I can give up the focus, I can give up the productivity, I can give up the impulse control. But losing the fast instinct to stick up for myself, ask for what I want, express my needs before they overwhelm me...
... it's a bummer to think that Adderall really was helping me and that it wasn't simply a matter of fixing my depression/perspective.
Don't be ignorant. There are many people living normal lives due to these medications whom would otherwise not be able to function. I do wonder though how did people deal with these problems in the past when neither ADHD or these drugs were recognized and available.
> I do wonder though how did people deal with these problems in the past when neither ADHD or these drugs were recognized and available.
For 400 years, the majority of the population used tobacco/nicotine for increased concentration. Over the last 30 years, that rate has declined, while at the same time, ADHD diagnoses have increased. Studies have shown nicotine is effective in reducing ADHD symptoms, so it seems that society's elimination of nicotine has revealed that it was covering up ADHD for all those years.
> I do wonder though how did people deal with these problems in the past
Children get beaten for not sitting quietly, men who can’t hold down a job become homeless and die on the streets, women become dependent housewives and get beaten for preparing dinner wrong… The past was not a great time to have mental health conditions :P (The present isn’t great either, but at least we’re no longer burning people at the stake for being socially awkward)
>I do wonder though how did people deal with these problems in the past when neither ADHD or these drugs were recognized and available.
I was diagnosed with ADHD as a child and again as an adult. I was medicated as a child and for part of my undergrad but intentionally haven't been medicated for more than fifteen years. I can give you my own personal picture of this situation.
My understanding of my own now-sober psychology is that I will avoid anything that I don't have to do or don't actually care about (where these are contextually defined). While unmedicated, I focus on the things that I actually want to focus on, but the extent to which I can consciously control what those things are is largely out of my control. In this state, my conscious mind plays the LLM to what my body and unconscious mind are doing, namely my mental narrative is simply justifying and predicting what the next actions will be rather than determining what those actions actually are.
When I was medicated, it was the exact opposite. My conscious mind was seemingly in control. Other inhibitory parts of my brain were turned off and I was able to consciously decide to do something, and then simply do it. In my personal experience though, the results of having "properly" functioning executive action were decidedly negative.
The sober me that is in my body and doesn't require self-talk to actively maintain is content to be an economically unproductive, no-status nobody, merely exploring the world and taking care of my needs and those of my loved ones. The medicated "me" was nothing but conscious ambition, made poor long-term decisions, and created novel stressors with high cognitive loads that required constant medication and self-talk to maintain.
I realized that I identified more with the sober me than the medicated me and accordingly stopped taking stimulants.
To draw on all this to answer your question, I think that in the absence of habitual stimulant use and being surrounded by the "achievements" of those that are habitual stimulant users, the majority of people wouldn't know of or have "these problems" but simply lead uneventful, low stress lives, following their very bodily-determined whims and fancies.
Sure, there'd be fewer Paul Erdőses ("You've showed me I'm not an addict. But I didn't get any work done. I'd get up in the morning and stare at a blank piece of paper. I'd have no ideas, just like an ordinary person. You've set mathematics back a month.") churning out theorems, but equally, there'd be fewer Hitlers (See: Blitzed: Drugs in Nazi Germany), SBFs ("I think they are things that, on the margins, helped me focus a little bit. I wish I had been a lot more focused over the last year."), or Caroline Ellisons ("[N]othing like regular amphetamine use to make you appreciate how dumb a lot of normal, non-medicated human experience is").
I got a diagnosis. But I figured, I’ve done reasonably well for these 32 years so far, I have a great career, a fantastic partner and am doing fun challenging work. Why change anything, so I skipped the medication.
Maybe that will need to change in the future, but it’s fine for me for now.
This comment touched on a lot of the wrestling that I’ve been doing for the past couple of years with my relationships to productivity, intentionality, and fulfillment. It’s a really useful perspective and validated some of my feelings. Thanks for writing it.
Thank you for this. I think most people are like this, me included, when we don't have a project that actively interests and excites us.
This whole ADHD thing might be just true bullshit. Some people just chose to do the absolute minimum to survive/provide for their families at times AND also do A LOT some other times when the situation is, well, different.
I don't need gray hair, RSI, headaches, coffe, glasses etcetera to climb the ladder or drive the latest car. But to each their own.
Also, sorry to those that actually can not function and might feel put down by my comment.
It's always said by people who don't have to deal with it. If I had to wear a cast, or had a huge gash in my head, people would understand. But they can't see it, and they function fine, so it must be made up.
Coming from a culture where psychiatric medications are not normalized (because people simply couldn't afford them, if pharmacies even carried them), it is pretty disturbing how many people take some kind of pill. You can't help but feel as though so many people shouldn't have anything wrong with them such that they need pills -- i.e., mental illness should not exist at such high rates lol.
(And, as subtext, should be feared and stigmatized.)
This is a dangerous take, and I would recommend you do the reading to upgrade that feeling to a thought, with all the relevant context.
The idea that someone should be a certain way, and that they shouldn't need a pill, is making some heavy assumptions about what's needed to exist in the world. This is something that's changing rapidly - one can no longer make a comfortable living doing many jobs, and most of those are the kinds of things you could do if focused thinking isn't in your wheel house.
Speaking as someone who thought that way for a long time, and has a severe executive functioning disorder, I can tell you it was wrong minded. I spent over a decade trying to just "push through" because I felt "I should be enough without it" and I didn't want to be dependent on a medication. I flunked out of high school and then college, went through a series of careers that always flopped, and watched my relationships fail because I couldn't keep a job or a schedule.
At some point, I became fed up with my situation and started seeking help. After admitting that I might need this help, things got immediately better in my head, and then in my life. I taught myself to code and I now work in tech, which is the story of career I had given up any hope of ever achieving. I no longer struggle to make ends meet and I have a stable and fulfilling life, which wasn't going to happen unmedicated. I know this because I tried.
If this isn't you, then great. But please recognize that by putting up barriers to others getting this stuff, we've almost certainly forced people like me into lives that are measurably worse and less productive for society than they could otherwise live.
Seems reasonable that a large percentage have suboptimal neurological issues that can be helped by a drug for the same reason so many have suboptimal vision: it doesn’t stop you from reproducing often enough to be selected out.
I don’t disagree with you. But… we can tell when eyes are messed up by verifiable flaws in the mechanisms, we can literally look in and see the issue. Not exactly so for brain meds.
I agree that the biology is more complex and these conditions are less black and white but I’ve seen people helped by meds as dramatically as eyeglasses.
It can be truly stark with ADD. I’ve seen people have miraculous improvements to their lives from ADD drugs.
> I’ve seen people helped by meds as dramatically as eyeglasses.
With ADHD I was unable to get out of bed properly, unable to shower more frequently than every 6 months, unable to perform any other basic hygiene, unable to do any of the hundreds of hobbies I've enjoyed over the years but spontaneously lost the ability to actually do, unable to do any of my chores until weeks after they got really bad, etc.
I'd let things like toothache or fucking organ failure go unnoticed for weeks while I was too lazy to tell anyone because I was hoping it would just go away. Ended up needing a root canal because I waited too long, and an IV to stop my pancreas from failing (!!) because I waited a week before telling anyone about the very obvious pain in my side.
I had to drop out of school because I literally couldn't leave the house after some winter break. Just out of nowhere, my brain was like "nah, no more school". I proceeded to lose three jobs because either I became so unable to do them that I had to quit, or I loved the job far too much to quit, so I got fired when I tried for weeks and failed to overcome my brain just completely refusing to function at all.
I was so depressed that I would sleep for 12 hours every time and I sometimes wouldn't even be able to stay up that long before falling asleep again. There was no 24 hour schedule. I could not stay up long enough to make it through a 24 hour day even if I slept for over half of it. I slept because I was so bored, I was so unmotivated, so starved and unable to do anything that I would just be trapped in bed wishing I could get up but unable to think of any possible reason why that would ever even help. It's the classic depressive mantra of "what is even the point" except the mantra came first and the depression followed.
It's even worse than just glasses. You could be completely blind and still not be as dysfunctional as my case of ADHD. I wasn't in control of my own body or my own brain. I felt so isolated and dysphoric that I developed a fucking dissociative disorder because I was unable to identify with my own body. It's baaad, it's baaaaad, it's really really bad. Even people who know what ADHD is just don't believe my case of it because it's so bad.
But some dextroamphetamine just... fixed it. Literally. It's just gone. No more dysphoria. No more struggling to get out of bed. No more struggling to take showers, or wash my stuff, or do chores, or eat food, or do any hobby I want. No more depression, no more intrusive thoughts, no more excessive sleep, no more inability to fulfill promises or jobs or obligations or expectations or desires... the difference is so great that I could cry. I could cry because of how good my life is now. I could cry because of how long it took me to realize that I had ADHD and it could be treated. I could cry because of everything I lost in order to get to this point. Or I could cry because the only reason I found out is because of a single kind Redditor who just so happened to change my entire life... could cry because of how nobody else ever noticed...
To be fair, nowhere did they say pills shouldn't exist... just that not everyone in the entire world should be taking a big pile of them. Reminds me of that episode of Rick and Morty where nobody eats food anymore, they just have something like 30 pills shoveled into their mouth.
But... something about saying that feels wrong to me. Sure, I feel like doctors should not be offering pills to people who do not need them, especially stupid overprescribed shit like antidepressants, especially SSRIs. But some people need pills... some people really, really need pills...
Adderall is a mix of four amphetamine salts, of which dex is one. My impression is people went to dex because it was available as a cheap generic before Adderall's patent expired. But you can get generic Adderall now because the patent expired (cue: Vyvanse), so there isn't much of a cost reason to go on dex.
I was getting increasingly confused so I just looked up the history.
Adderall was invented to renew the approval of a weight loss drug which contained two salts each of methamphetamine and amphetamine. They replaced the methsalts with 2 more amphetamine salts, for some reason. That's why the 4 salts. Adderall was introduced in 1997, which suprised me. I always assumed adderall was first because surely it would be easier to synthesize than enantiomerically pure d-amph.
But apparently Dexedrine has been around as a treatment for narcolepsy and attention problems since 1937.
So it's not so much that the world moved on to dex, more that the US moved on to adderall for historical reasons having to do with pharmaceutical patents, approval and marketing. And the rest of the world were just fine staying with dex, which makes perfect sense to me.
> I always assumed adderall was first because surely it would be easier to synthesize than enantiomerically pure d-amph.
I am not a chemist/pharmacist, but I am under the impression that amphetamine synthesis is neither complicated nor recent. I am under this impression because a) References to different amphetamines are common place as early as the 40s and b) The United States has a rich criminal history of amateur methamphetamine production.
Random Trivia: the 80s band ”Dexys Midnight Runners" were named for the recreational use of Dexedrine which was apparently common in the UKs Northern Soul community.
My impression was that dextroamphetamine also worked better in many patients than drugs that combine it with levoamphetamine such as Adderall. Even when Vyvanse was under patent and expensive, it was preferred by many for this reason (Vyvanse is converted into dextroamphetamine in the body). Levoamphetamine primarily acts on the norepinephrine system, while Dextroamphetamine acts primarily on dopamine, being 3-4 times as strong as Levoamphetamine in that sense (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670101/). As a result, many patients find levoamphetamine to cause much more physical side effects like racing heart, jitteriness, etc. and be less effective at promoting mental focus than Dextroamphetamine.
Adderall is still 75% Dextroamphetamine, but I haven't seen much literature on why it would be preferred over drugs like Vyvanse that include no Levoamphetamine.
I know this. But it also contains levoamphetamine.
But as far as I know there's no clinically proven benefit(happy to be proven wrong) to including levoamph, and it can cause more side effects. Which is why in most countries these days adderall is not really prescribed, and often isn't even in the pharmacopoeia.
Why adderall is still in use in the US is an interesting question I don't have the answer to.
There is at least some evidence that levoamphetamine is more effective than dextroamphetamine for "hyperactivity and aggressiveness" associated with ADHD (https://jamanetwork.com/journals/jamapsychiatry/article-abst...), and other studies that have found that it has less of certain side effects than dextroamphetamine (though more of others).
A more cynical explanation is that where levoamphetamine and dextroamphetamine alone were not patentable, a new combination of the two (as Adderall is) was patentable, making it more profitable to research.
ADHD is a collection of symptoms that differ enough across individuals that it's almost certain some patients genuinely do respond better to different combinations of drugs.
Interesting research, thank you. Though worth pointing out this study is comparing pure l-amph with pure d-amph. I'm not aware of enantiomerically pure l-amph being used clinically, which is an interesting side note: why not?
Are you aware of studies comparing adderall specifically to d-amph? This has certainly piqued my curiosity.
> But as far as I know there's no clinically proven benefit
My impression of US pharma regulation and drug trials is that it would not have been approved if it did not show some benefit over the status quo. I don't know about adderall's clinical trials in particular, though.
Adderall was originally formulated and marketed as a diet drug. It had already been approved before it was rebranded and remarketed for ADHD, and the criteria for approving a new on-label use is significant but not as rigorous as approving a new drug.
Drugs that are still under a patent have a company with the incentive to go through the expensive approval process while generic drugs lack that. So a wacky mix of amphetamines designed as a diet drug that are still under patent have more corporate backing for that approval process than plain old generic dextroamphetamine, which has been around forever. There’s a similar story with the use of esketamine versus ketamine to treat depression.
I think I was still in the mindset of thinking adderall pre-existed dexedrine. So I guess I interpreted status quo as meaning amphetamine vs whatever else was available at the time.
Interesting little inversion of logic that can happen when two people have diametrically opposed ideas of the order of events.
It seems to me Adderall is not even marketed in Europe. Can't find anything suggesting otherwise, but it's hard to find a source on something never happening.
Though I can tell you definitely at least that here in Norway, Adderall is not an approved drug(neither is dexedrine). The only approved amphetamine here is Vyvanse and its generic form Aduvanz.
I did some digging and apparently no amphetamine based drugs had been approved for ADHD in Europe back in 2011.(1) Back then the only ADHD med was methylphenidate (ritalin, concerta). This must have changed somewhere between 2012-2014 when dextroamphetamine(attentin) and lisdexamfetamine(elvanse) got approved for ADHD treatment as well. So today in majority of EU countries (possibly in all) it is possible to get 100% dextroamphetamine based ADHD medication. As far as I can tell it seems like levoamphetamine is not approved for medical use at all so that's why adderall isn't prescribed here.
The adderall shortage is the result of a completely artificial quota set by the DEA. Those of us who use dexedrine have been mostly spared, but if the adderall users switch to dexedrine, we might start having issues.
I take this drug daily. The current supply crunch has meant I've had to take inferior versions of the product for nearly a year now. It fucking sucks. I need it to work but the side effects often mean little sleep, strange repetitive behaviour, absurd hypersexuality, etc.
Its a travesty, not in the best interest of the consumer. If you are on this medication you are treated like dog shit from the doctor to the insurance company to the pharmacy to the pill itself. All in the name of either preventi g addicts from getting it (who cares?) Or making more money for some massive company.