Introduction

 

There’s a lot of confusion about what amphetamines are good for in the setting of ADHD and out of the setting of ADHD. This is just a summary of the big picture as good psychiatrists see it.

 

Disclaimers

 

Even if you’re sure you know what you feel you need when you go to a psychiatrist or physician, you should still trust them if they have a good reputation.

 

Discussion

 

From this discussion, you will be able to recognize which psychiatrists are putting you on drugs just to put their kids through college, and which are prescribing you medications in a safe manner that will really help you and make your medical and psychiatric problems go away in the safest possible way. Sadly, both types of prescribers exist. There are plenty of psychiatrists out there that just like to mask the problem, throw drugs at it, like that. They don’t practice in any kind of way that will generate any kind of self-help care plan. And, unfortunately, the care plan they are putting together for you, oddly, only keeps bringing you back to their office more and more often. Hmm.

 

So here are the people who really need amphetamines. And here are the people who only might benefit from them.

 

About 5% of the population has trouble focusing. About 95% of the population has no trouble focusing. Amphetamines are stimulants. So, stimulants will help both groups for thus very different reasons. Those that have trouble focusing will focus better because amphetamines stimulate neuropathways that favor focus. If you don’t have trouble focusing, the stimulant amphetamine will only help you by simply stimulating neurochemical pathways to help you function better and think better.

 

So, some people really need them, and some people really don’t need them, but could benefit from them.

 

Troubles begin when people without focusing problems feel they need to think and work and perform better than their neighbor for one reason or another to such a degree that the amphetamine dosing required for it exceeds the low dosing schedules acceptable for amphetamines as a stimulant. School, work, family. Whatever drives them, they feel will improve in those arenas if amphetamines are on board. These folks have no focus issues, no history consistent with focus problems. They’ve always driven well, not a lot of traffic accidents, focusing is not an issue for them. But they still want the amphetamines. They tend to escalate on them for the wrong reasons more than the folks with focus problems that actually need them.

 

More problems begin when, on top of this, you start seeing the side effects of the amphetamines which are going up and up because they’re working less and less. That process is called addiction by the way. Anyway, you start seeing some of the side effects at the higher doses. One of the classes of side effects is cardiac. That’s always bad. The other big side effect class is psychiatric, specifically anxiety.

 

A truly unfortunate situation which is extremely common is when a psychiatrist prescribes amphetamines either for focus or for hyper-function, and anxiety starts going up. Anxiety is an unacceptable side effect of amphetamines. When anxiety occurs with patient on amphetamines, the well wishing psychiatrist throws benzodiazepines at that anxiety. Oops, that’s wrong. The situation rapidly becomes a vicious cycle. Vicious cycles can be likened to a dog chasing its tail. Not a good clinical cartoon.

 

Throwing benzodiazepines at the amphetamine using patient now experiencing anxiety also allows the patient to seemingly tolerate higher and higher doses of the amphetamine, further increasing their chances for severe cardiac side effects (both medicines tend to be cardiotoxic).

 

So, whether you are using them for focus or for function, things can go wrong. There’s a couple of things you can do to make sure this never happens. One, you should most definitely use the lowest possible dose is that you can. Once that does has been determined, there’s really nothing that should cause it to increase. If it is going up, that means by definition it’s not working. In that it is not working means that you are probably becoming addicted to it. Your receptors have changed in such a way that it is not working for you anymore. Fix what changed and don’t just go up on the dose! Some new source of stress, gaining weight, a new habit like smoking. Like that. It’s no longer working for you and used to, so it is certainly not correct to just increase it.

 

Now if the higher dose is a required because it still being titrated, that’s another thing. But once you have reached the correct dose, other than growth and development if you were a child, the dose should really not change. Our brain size doesn’t change much after age 20. So you can’t blame it on that. After it has been effective, going up on the dose when it starts becoming less effective is nearly never the right thing to do. Pretty simple.

 

Another major principle of safe amphetamine use is honeymooning. Whether you are using them for focus or if you are using them for hyperfunction (note, the value of this incidentally is still under review), you absolutely have to honeymoon off that medication at least once a week. Honeymooning means don’t take it for a day. Preferably two days; every week. And, whether you are using it for focus or as a stimulant, you should not take this medicine while you are on vacation. There’s no need to focus on vacation. There’s no need to outperform your neighbor on vacation. I say these things as if they were obvious. They’re not so obvious to many people. Many on it don’t ever want to honeymoon from it.

 

The biggest downside of never honeymooning from your amphetamine is becoming addicted to it. That’s right. If it’s being used as a stimulant, if you don’t honeymoon from it at least weekly, you will become addicted to it. But escalation and refractoriness and addiction can even occur if you are using it for focus.

 

You may consider that honeymooning cannot be an option for you. You feel you need it every day and cannot be without it. Unfortunately, if you don’t honeymoon off it weekly, you will lose its efficacy in a period of years.

 

There are at least two advantages to honeymooning at least one day a week. One, you will be able to hold onto it for many more years than a few; and, two, every time that you honeymoon from it, it will work stronger the next day that you take it. Patients I can get to honeymoon from their amphetamine 1 to 2 days a week feel great benefit from it times many more years than those that don’t. They also report that they always feel great benefit from it the day after they honeymoon it. They also report that they like the way their brain feels on the days they skip it. It’s like exercise for the brain on those off days, as one lady put it. And patients having trouble keeping up with weight because amphetamines cause weight loss appreciate a couple of great meals a day on the days that they honeymoon off it.

 

Conclusion

 

The lesson here would be to avoid using amphetamines altogether unless you are one of the 5% that has a focus problem. And certainly whether you have a focus problem or not and insist on using them, use low doses always. And understand that increasing the dosage means that they are not working anymore, and this means that you have moved into the early throws m of addiction. And, under no circumstances ever throw benzodiazepines at the anxiety that is occurring while you are on amphetamines. Be aware of these things. Your psychiatrist may not be aware of the problem clinically, even if you alert them to it. Patient heal thyself.

 

Stay well,

David Allingham, MD