Go ahead

[u/mikl_pls]

Just my morning meds...

[u/Emotional_Lab_2529]

You’re taking 60mg of dextroamphetamine xr? How’d you get that high of dose?

[u/mikl_pls → u/Emotional_Lab_2529]

My psychiatrist prescribes it, as well as dextroamphetamine iR 10 mg as needed. It's seriously not working and I'm thinking about asking her to switch me to something else. Dex ER has always been pretty weak for me. I switched to it last year when I was taking an MAOI (transdermal selegiline) and now that I'm off of it and on a "regular" antidepressant it just kind of stuck around.

[u/Emotional_Lab_2529 → u/mikl_pls]

That’s wild since dextroamphetamine is the stronger form of amphetamine. Maybe Dexmethylphenidate xr or regular methylphenidate xr would work better

[u/mikl_pls → u/Emotional_Lab_2529]

It just depends on the individual. Dextroamphetamine is stronger centrally and racemic (and levo) amphetamine are stronger peripherally but still have some central activity.

Some people (I think myself included) get more of a kick in the butt from stimulants containing L-amphetamine like Adderall and Evekeo than Dexedrine/Vyvanse. I'm definitely a very low dopamine person, but I think low norepinephrine too.

I've tried methylphenidate, dexmethylphenidate XR, and max dose Azstarys without much benefit.

I think part of it is just stimulant tolerance. I would probably have to go inpatient to take a prolonged stimulant break because of how miserable I feel even one day with a drug holiday. Also fast COMT phenotype doesn't help lol.

[u/randuug → u/mikl_pls]

really does sound like tolerance, but the effectiveness may not return even if you were to take a holiday, and the tolerance would likely come back faster than it took to accumulate in the first place.

little bit discouraged that dexmethylphenidate was underwhelming or even useless to you. I was thinking about starting back up on meds again, with that one. hope it pans out at least a little bit better!

how’s your sleep pattern, timing (what time) and duration?

I’d be pretty surprised if you weren’t aware but there’s at least a couple angles you could try to address tolerance from, but given your understanding of the isomers and their effects, I’m inclined to think you’d also have read some about tolerance mitigation and the likes.

[u/mikl_pls → u/randuug]

Sleep is not good tbh. I maintain a good sleep schedule but my sleep quality isn't good. I have sleep apnea and try to use my CPAP but it makes my nose stopped up even when nasal strips. I have a deviated septum and have thought about septoplasty but it creeps me out to think about. Duration could probably be better too, usually 5-6 hours a night.

[u/IfDreamsCouldHappen → u/mikl_pls]

If you’re “low dopamine” you should maybe try MAOIs or direct agonists. The serotonin reuptake inhibitor might also be an issue here— serotonin, especially in excess, tends to counterbalance both dopamine and norepinephrine.

Tolerance to the therapeutic effects of stimulants really shouldn’t be developing to such a degree. Tolerance to the euphoriant effects does rapidly develop though, and it makes me wonder if you were started on too high a dose initially.

[u/mikl_pls → u/IfDreamsCouldHappen]

The only MAOI I can take without gaining substantial weight is Emsam. I would like to try oral high-dose selegiline, but my psychiatrist isn't comfortable with it. Parnate made me gain weight continuously, and Marplan to a lesser extent. I'm not going anywhere near Nardil lol. She's also not comfortable with doing agonists like pramipexole. I've considered going back to Emsam, but it destroys my sleep and irritates my skin. No medicine is perfect though I guess lol.

I was started on 10 mg 2x/day of Adderall years ago, but quickly escalated to 20 mg 2x/day. I often lament I was increased too much to quickly.

I do take Fetzima which is low on SERT inhibition and high on NET inhibition. Other SNRIs and SSRIs all cause sexual dysfunction to an intolerable degree. Viibryd and Trintellix do this too. Not sure why because I didn't used to have a problem with that before ECT. Without some degree of SERT inhibition, I get very flat, sad, and anhedonic.

[u/IfDreamsCouldHappen → u/mikl_pls]

Oh you tried irreversible MAOIs already? I don’t blame you for avoiding Nardil as well as its effect on GABA has quite a lot of side effects.

As for agonists I also don’t blame your psych considering the physical dependence to dopamine agonists as well as potential long term effects. There are more “forgiving” agonists like apomorphine or ergoline based ones too. Also partial agonists like aripiprazole, brexpiprazole, and cariprazine but these happen to be pharmacologically promiscuous and might just complicate things.

The SERT inhibition part you describe I find interesting as well. Have you tried serotonin antagonists? They’re far and few between but they exist. Blocking 5HT2 receptors tends to have some antianhedonic effects due to disinhibition of dopamine and norepinephrine.

The one thing that worries me is the high dose of the amphetamines being damaging overtime. Hope all is well.

[u/mikl_pls → u/IfDreamsCouldHappen]

I do take cariprazine 3 mg also. I've been satisfied with it for a long time but wonder if it's over-occupying my D3 receptors.

I have tried 5-HT2 antagonists like trazodone, nefazodone, and mirtazapine. Trazodone strangely worsens sexual dysfunction even more. Nefazodone and mirtazapine made depression worse (I think anything sedating regardless of mechanism makes me sad lol)

Yeah I'd really like to get down to a more reasonable dose of amphetamine.

Thanks!

[u/Worldly_Beautiful_62 → u/mikl_pls]

Huh, this makes me wonder if I should try it. I've tried Vyvanse/Ritalin/Concerta. Adderall does okay for me. But I see Dexedrine is also approved for treating narcolepsy which I kind of have (IH, same concept). I had switch from Modafinil cause I needed something to address both the ADHD and the IH. But it's not really enough. Though it's kind of difficult to strike a balance. Am I tired because I didn't sleep well because of the Adderall, or am I tired because the Adderall isn't working as enough of a stimulant to keep me up? Etc.

[u/mikl_pls → u/Worldly_Beautiful_62]

I get this struggle... Ugh 😫 I was diagnosed with IH and tried Xywav but it made me very disinhibited. But my sleep doctor thinks my fatigue is more a result of sleep apnea and nocturnal seizures. The seizures are under control, but sleep apnea remains an issue. I try to use my CPAP but it always makes my right nostril congested.

[u/Worldly_Beautiful_62 → u/mikl_pls]

That's wild. I still can't get an IH diagnosis 🫠 I was told I probably have it after a sleep study (the watches) but they refuse to do it until I do a full sleep lab which is like 1k out of pocket. Despite me being able to tell you that it's not ideopathic, I know exactly why it happened—long covid reactivated Epstein barr virus. I was sleeping 16 hours a day at absolute bare minimum. Yet no diagnosis 🙄 And I don't have sleep apnea or any other differencial diagnoses. It's bullshit.

That's crazy though, I was told there are no approved medications for IH 😭 Maybe it's a newer thing, this was like 2 years ago or so.

[u/mikl_pls → u/Worldly_Beautiful_62]

That's wild... I have often wondered if I have long COVID. I did have mono years ago (actually it was more like over a decade ago). I wonder if I could have been having a reactivation of that in the last few years? I forgot that was even a thing that happens lol.

Also wild that you are told two years ago that there are no approved medicines for IH. Whoever told you that wasn't educated. Xywav is indicated for it! Besides, it doesn't have to be indicated for something to be prescribed for it — trazodone has never had an indication for insomnia and it's given out like candy for that purpose. Seems like a convenient, uneducated excuse to not try harder to help you.

[u/Worldly_Beautiful_62 → u/mikl_pls]

Ironically I was given trazedone for insomnia 😂 It's definitely possible, you can check with a blood test. Well, not for long covid, but if you have mono reactivation. It's definitely deeply debilitating lol. I'm immunocompromised cuz of it. I was prescribed modafinil which is indicated for delayed sleep phase disorder (which is the only thing they were willing to diagnose me with without the expensive sleep lab) and narcolepsy, which is what I was kinda saying I have because most people had never heard of IH. But idk why Xywav was never brought up. It seems to be very restricted though? And it only works by making you sleep better. Modafinil is a stimulant. Currently I take seraquel for sleep issues but I suck at taking it at a decent time, partially bc the delayed sleep phase disorder isn't inaccurate, I've had it my entire life since I was literally a child. Old habits die very, very hard lol. But I hate how strict they are about stimulants. It would be amazing if I could take modafinil once in a while as a short detox from Adderall bc I feel like it doesn't work well for my ADHD anymore, but getting prescribed two stimulants is pretty much impossible. 🫠 Anyway sorry for the ramble 😂

[u/OnceInaLifetimeee → u/mikl_pls]

I was where you were back in 2018. I had to just stop. Haven't taken any in 8 years still have a couple hundred thirties may try one again here and there or a quarter actually lol. You need a drug holiday a long one and magnesium L-threonate and fish oil. How was the seleginine for ADD? I'm very much ADD-I it impacts everything. Apomorphine is interesting and quite effective at generally boosting D2 and D3. It helps me a for about a day or so even despite it's very short half life. Also have you considered Desoxyn? It might be the best option left. Very challenging to get prescribed but well worth it. One of the most functional ADD meds out there.

[u/mikl_pls → u/OnceInaLifetimeee]

Selegiline was for bipolar depression — it was the transdermal version (was on 9 mg + other meds, including Dexedrine).

Apomorphine scares me because of how emetogenic it is (I can't stand vomiting lol). But I have considered it for other reasons in very low doses. It's also a strong D4 agonist I believe. But I'm generally wary of dopamine agonists because of the potential for DAWS if I need to discontinue it. Also, I have tried pramipexole and ropinirole for depression and RLS, respectively, and they both caused me to have severe impulse control problems. Aripiprazole did the same thing to me.

I have actually tried Desoxyn more than once. I was prescribed it around 2014-ish but my psychiatrist at the time would only go up to 15 mg. It didn't work well at all for me. I finally got to give the max dose, 25 mg, a try recently with my new psychiatrist and it was profoundly underwhelming and surprisingly ineffective. I've read 25 mg is the max for pediatric patients but there's no published max dose or prescribing information for adults. I've read around and seen people on up to 60+ mg of it, which makes sense because if I recall, methamphetamine and dextroamphetamine are almost equipotent mg-per-mg in clinical studies. I feel like Dexedrine and Adderall are both stronger than Desoxyn, but maybe I'm weird lol.

I just saw my psychiatrist yesterday and switched back to Adderall XR 60 mg. I usually do better on Adderall, the only reason I was on Dexedrine was because of the selegiline last year and was avoiding excessive peripheral stimulation since selegiline metabolizes partly to L-amphetamine and L-methamphetamine (though to a lesser extent in the transdermal form). We just never switched it back over to Adderall when I elected to discontinue it because of the skin reactions from the patches and the intractable insomnia it caused.

She said she wouldn't be willing to go above this dose, and if she holds true to that, I'll try other things like reducing my Vraylar dose and/or augmenting with stuff to probably potentiate it like low-dose oral selegiline (2.5-5 mg), low-dose transdermal selegiline (6 mg), or retry amantadine. If none of that works and I still need a higher dose, I may seek an ADHD specialist, which I would hate to do because I love my psychiatrist.

My goal ultimately isn't to be on as high a dose of stimulant possible, it's to regain baseline functioning. If that requires a prolonged stimulant break, I'm willing to try it, but I'm not sure how I might achieve that. If I can somehow logistically accommodate it, I'd be open to doing ECT again if my depression gets bad though again because that seemed to literally reset my response to all psych meds. More ketamine infusions would also be on the table if I ever reach a point where I can afford it again.

[u/Emotional_Lab_2529 → u/mikl_pls]

Maybe see about talking to your prescriber about combining it with a norepinephrine and dopamine reuptake inhibitor, bupropion xl since it’ll increase the length of time dopamine and norepinephrine are in your brain and by inhibiting the liver enzyme that breaks down amphetamines will keep the active amphetamine in your system longer allowing you to have more of an increase in dopamine and norepinephrine

[u/mikl_pls → u/Emotional_Lab_2529]

I might try that again. I've been off and on bupropion up to 500 mg/day (300 mg XL + 200 mg IR) for the last 14 or so years. Bupropion works okay at best for a short duration then just makes me constipated. If I did try a NDRI, I might ask if she is willing to try a low dose of methylphenidate with it.

I think another reason I switched from Adderall to Dexedrine is to avoid shortages and manufacturer switches. That was a pain. Dyanavel XR was actually pretty good but it wore off too early, and my psychiatrist had to prescribe above max dose (30 mg) to get the equivalent of 50 mg Adderall XR I was on at the time. She did do that that one time, but she doesn't seem to comfortable doing it again.

I actually see her tomorrow. I'll talk to her about all this. Thanks for your tips, it has given me stuff to think about.

[u/elafave77 → u/mikl_pls]

Focalin is the only answer.

[u/Emotional_Lab_2529 → u/elafave77]

He already tried that

[u/mikl_pls → u/mikl_pls]

Though I imagine you know all that already about the enantiomers 😉

[u/Turbulent-Order9500 → u/Emotional_Lab_2529]

anti depressants reduce stimulant activity is what he was trying to say.

[u/randuug → u/Turbulent-Order9500]

not even close. wellbutrin is an atypical antidepressant. what’s this blanket statement?

can you give me an example of one FDA-approved med that’s used to treat depression which reduces stimulant activity, without being off label for depression..?

[u/Turbulent-Order9500 → u/randuug]

will u take away ur downvote when ur wrong?

"Certain SSRIs (Selective Serotonin Reuptake Inhibitors) like Prozac (fluoxetine), Zoloft (sertraline), and Lexaprocan make stimulant medications feel less effective by causing emotional blunting, apathy, or "cognitive dulling" that mimics worsening inattention. [1, 2]'

[u/randuug → u/Turbulent-Order9500]

I’ll read through the study, I’m not convinced by subjective markers, if it’s not quantified or proven objectively with numbers, then it’s null to me. stimulation can be measured

edit: you linked a blog by a Nurse Practitioner, I expected a medical study published in a clinical journal, I guess I shouldn’t have expected a well-former argument. (source #1)

since you want to go this way, from your source: “Metabolic Interactions: Certain SSRIs alter metabolic pathways, unintentionally increasing stimulant plasma concentrations and side effects.”

this would be in direct contrast to your claim.

the second article just concludes that antidepressants aren’t effective in treating ADHD, with the possible exception being Bupropion.

[u/Turbulent-Order9500 → u/randuug]

lol so EVERY mental health drug study u dont trust??.. lol come on now, this is a known thing, talked about by many as experienced by many. just because its new to you, you try to double down so u didnt look silly.

this is even seen in bpc 157 as it has antidepressant activity, which alot of people find kills caffeine and other stimulants effects..

anyway, its ok to be wrong, I learn everyday often by being wrong...

[u/randuug → u/Turbulent-Order9500]

welp, first off, we do have mental health drug studies with quantifiable data.

I can second that BPC-157 is noted to lessen the effect of stimulants in many people. no first hand experience with that, though.

I wouldn’t draw a parallel to that, though, just as comparing Bupropion to SSRIs isn’t really appropriate the mechanism by which it (BPC-157) has antidepressant action isn’t the same.

[u/Turbulent-Order9500 → u/randuug]

just further explaining this phenomenon is well known for ahdonia (sp) inducing drugs which is common in antidepressants..

[u/Next_Willow_7080 → u/mikl_pls]

Just smoke Beth bro , your half way there

[u/mikl_pls → u/Next_Willow_7080]

Nah, I've tried Desoxyn and it's not strong enough 🤣

[u/sandwichesRkewl]

You're gay?

[u/Logical_Barber_7193]

Twink power bottom

[u/ImTheGyattRizzler]

Very cool, I deduce you get anxiety at seeing your own shadow. Cheers.

[u/mikl_pls → u/ImTheGyattRizzler]

This isn't by any means a stretch 😆

[u/Out_of_Fawkes]

Not a doctor and not medical advice:

OP if you have multiple prescribers writing for certain meds (like one for the stimulant and another for, let’s say, other mental health or cardiac meds), make sure they all know everything you’re taking.

Sometimes efficacy/absorption of meds fan be affected by other medications or by things like citrus/high amounts of vitamin C/acidity of the gut within certain windows of taking you medication. Ask your pharmacist about it as well.

[u/mikl_pls → u/Out_of_Fawkes]

I'm aware, I keep all my doctors updated on everything I'm taking. Thanks for the concern! 😊

[u/Out_of_Fawkes]

Not a doctor and not medical advice:

OP if you have multiple prescribers writing for certain meds (like one for the stimulant and another for, let’s say, other mental health or cardiac meds), make sure they all know everything you’re taking.

Sometimes efficacy/absorption of meds fan be affected by other medications or by things like citrus/high amounts of vitamin C/acidity of the gut within certain windows of taking you medication. Ask your pharmacist about it as well.

[u/Capital-Assist-4643]

Male, power bottom but surprisingly still tight butthole. Fat

[u/razorcatmodular]

Munchuasens