Posted by fachad on July 4, 2002, at 4:20:32
In reply to Dexedrine and anxiety (HELP please!), posted by Leor on July 3, 2002, at 21:49:44
Leor,
First, thanks for explaining about the refills. I was just concerned because sometimes trolls make up stories to malign psych meds, and pstims are a favorite target of these misguided crusaders.
Anyway, here are a few ideas on your post.
Leor: ...32 of the following 56 days saw me take more Dexedrine than I had been proscribed...I was taking 90mg per day...
fachad: Whew, that's a lot of dex. Can you retrace the thought process(es) that led you to decide to take more than 30mg the first time? The next time? How did you justify to yourself tripling your dose?
I guess what I am thinking is that you made a poor decision at some point, and kept making more incrementally worse decisions.
By becoming aware of how you came to take that action, you could prevent a future occurrence or at least be aware of what is happening before it gets so out of hand.
Leor: Since re-starting the Dexedrine (@ 15 mg) I have benefited again from its relief of my ADD. There is still a too-high level of anxiety...
fachad: Well, the drug holiday was a good idea. How did that go?
As to the anxiety, and other side effects, I think that once you become aware of a side effect from a med, you are much more inclined to experience it. It's like you always had that side effect, but it was below your threshold of conscious perception. After you notice it, you cannot not notice it. And anxiety feeds on itself anyway.
Leor: ...Is there a risk that I may start to build up tolerance to Dexedrine again owing to my previous abuse? If this is a possibility, what can I do to break out of that process without having to permanently stop taking Dexedrine?
fachad: I have a pretty strong opinion on this. I think this is totally related to why you increased your does and what you like or want to get from the medication.
If you are craving the speed feeling, or the euphoria, yes, you will develop tolerance and repeatedly need to increase the dose to get the same level of those effects. That is obviously a dead end, and is not a sustainable long term treatment strategy.
On the other hand, if you are able to derive and appreciate the benefits of dex in terms of relief of symptoms, but not try to create or maintain an artificial emotional high or an unnaturally high level of functioning, you should be able to benefit from the same dose for a long time.
So I guess I am saying that if you want to avoid tolerance and abuse, set realistic expectations for what this med is going to do for you, and realize that if you try for more, you will end up getting less in the long run because your "real" dose will not benefit you anymore.
Take a look at this post I did on this idea a few months ago:
http://www.dr-bob.org/babble/20020215/msgs/94906.html
Leor: ... What makes OCD appear in a person with an OCD tendency who is taking Dexedrine? Is it due to prolonged use or due to the dosage being too high?
fachad: Dex can create problems like anxiety or OCD, and it can magnify them if they are already present in a mild form. Lab animals that are given dex show "stereotyped behavior" like repetitive grooming or licking. It's just a normal biological response to amphetamines.
And dex stimulates the sympathetic nervous system, which means you always have a little "fight or flight" going on at a physical level when you are taking it.
Both anxiety and OCD symptoms are very dose related and increase dramatically as the dose goes up.
Leor: ...Was five days a long enough drug holiday?
fachad: What was the purpose of the drug holiday? If it was to reduce tolerance, then if 30mg worked again, it was long enough.
Leor: ...As previously noted, my anxiety level remains quite high. Perhaps this just indicates what my p-doc and I already know – that we must find a good anti-anxiety medication ASAP. On the other hand, I know that taking the Dexedrine increases the anxiety level somewhat and wonder whether this indicates that my use of the medication should be discontinued all together.
fachad: Well, there are several alternatives. You could try a lower dose of dex. Or, better yet, you could wait for tolerance to develop and see if the anxiety decreased as the tolerance developed.
Hopefully, you would still get benefit from it for your ADD, just less stimulation and anxiety. That way, you could actually be glad to have developed tolerance!
Another alternative to consider is Ritalin, especially the Concerta type. It is less prone to abuse for several reasons. First, it is released gradually, so there is no "rush". Second, you only get 1 tablet per day, so there is less temptation to "chip" small doses and increase your dose, "just for this (whatever) special need". Also, for me ritalin is much less anxiety provoking than dex.
Another alternative is to try a stimulating AD instead of a conventional pstim. Wellbutrin is often used to treat ADD in people with substance abuse history, and it is also less likely that other ADs to trigger hypomania in BP pateints.
I think that trying to lower the dose, or develop tolerance to the dose, or trying Ritalin or Wellbutrin are much better alternatives than adding another med to combat the anxiety created by the dex.
Treating anxiety in people with innate anxiety disorders is one thing, but treating anxiety that is caused by a medication is different. You can quickly end up on lots of meds, and it just feels a little too "Elvis" to me.
Speed to get going and tranks to cut the anxiety from the speed. Next thing you know, you'll be wearing white sequined jumpsuits and eating fried PB & banana sandwiches!
Leor: ...In order to treat the anxiety I am now taking 250 mg of Lamotragine. We are considering introducing Lithium to serve as a prophylactic for mania and a tricyclic to treat the cyclothymia. In past treatments with SSRI’s and anti-depressants I have experienced problems with fatigue and torpor, hence the shift of focus to these other classes of meds. Does this approach seem to make sense?
fachad: Yes, lamotragine, lithium, etc. seem like a good direction to go. Those meds reduce anxiety and prevent mania.
Tricyclics have been known to shift BP patients into manic episodes.
SSRI's can cause horrid torpor and fatigue. If you are prone to this, stay away from them unless you are really suffering from an acute depression. Again, Wellbutrin may be worth trying.
Leor: ...I suffer from Cyclothymia in addition to ADD. Do some p-docs vary the dosages of Dexedrine that they prescribe on a seasonal basis so as to accommodate their patient's decreased concentration level (resulting from cyclothymia)?
fachad: I don't know what pdocs do, but I've never heard of this approach.
My thinking is that since you have had a problem with dose escalation and abuse, you should not think of dex as a PRN med. In other words, you should not consider that it is taken as needed, or that the does can be adjusted according to need.
Rather, you should mechanically and rigidly stick to the same dose so increasing it for this or that "need" does not even enter your mind as an option.
If you do it that way, you'll never have to worry about abuse again, or try to second guess yourself if you are wanting to increase the dose for a legitimate seasonal variation or is it the start of another bender.
Leor: ...My observation of the affect that Dexedrine has on me is being complicated by my lack of a stable treatment for my Bipolar II. (I have tried various SSRIs and Anti-depressants over the past four years, so far without success). Where does one draw the line between ADD’s detrimental affect on concentration and the detrimental affect on concentration caused by anxiety disorder?
fachad: Well, BPII and anxiety have some overlapping symptoms, but they are not the same thing.
If you have BPII, you should focus on getting that under control, so you have a stable foundation to work from as you try to resolve the residual anxiety and ADD.
If you have predominantly ADD, the benefit of dex for concentration will outweigh the distraction of the dex caused anxiety. In that scenario, I would expect an anxiety med to worsen your concentration, even though the anxiety is alleviated. (That’s how it works for me.)
On the other hand if you have predominantly an anxiety disorder, I would expect your concentration to be worsened by the anxiety of dex, and helped by a BZD.
Sometimes response to meds really is the most valuable diagnostic tool.
Well, I hope these ideas are useful to you. Good luck on your quest and keep us posted as to how things are going.
-fachad
poster:fachad
thread:111294
URL: http://www.dr-bob.org/babble/20020628/msgs/111374.html