Generic Woes, Anxiety Shows and Sarcastic Doctor Blows

I am a 23 year old male, am currently on Adderal XR 30Mg bid, Xanax 1Mg bid, and Remeron at bedtime. I have been on Adderal XR for five years. (at 60mg) The last few months the pharmacy has given me (unbeknownst to me) generic adderal XR, and I noticed (without knowing it wasn’t the ‘name brand) a substantial change in my productivity and overall, an increase in ADHD symptoms. (honestly it feels like taking 30mg alone) And have finnally the last week, got out and old bottle of immediate release 30 Mg Adderal (not XR) and have taken 30mg(XR) AND 30mg (regular) in the morning and 30mg of the XR in the afternoon, and have done well. The doctor I am seeing has already lowered the xanx dramatically. (my other doctor had me on 4mg qid wich was a lot but I most days only took 2mg 2 or 3 times a day) And has sarcastically made comment about me being on “all the good stuff” and “great combination” I take he is very biased when it comes to sched. medications. Any way, I am very apprehensive to tell him about the Adderal problem as, I was doing great on 3mg of xanax and still he lowered it, I don’t want the same thing to happen with Adderal, If he did, I would be a more unfocused MESS. Also, I have been reading about Vyvanse. Is that possibly a good thing to switch to? (70mg bid?) (and what about 2mg xanax XR in the AM and 1 mg regular prn?) Does this seem like a logical request to ask a very closed minded doctor? (I can’t switch doctors for 6 months).

Your situation brings up many different issues that I think will be helpful to others.  Let’s start with the Adderall issue.  A number of months ago (can’t remember exactly when), Adderall went generic and everyone started getting “mixed amphetamine salts” instead of their brand name stuff.  Anytime this happens, there is a segment of the population that does not get the same benefits as they do from the brand name drug.  This switch to generic Adderall is no different.  I have received what I feel are credible complaints about it not lasting as long, “kicking in” too strongly, not getting the “boost” from the second half of the medicine, etc., etc. You identify the perfect scenario where you didn’t even realize that there was a change (they look very similar to each other).   The best solution for you would be to go back to the brand-only Adderall.  It worked for you for years and you had no difficulty with it.  You were not seeking more of it over time or playing with the dosages.  It will likely cost you more and your doctor may have to advocate for you (more about him later), but it would be the logical thing to do.  I would not switch to Vyvanse because Adderall was working for you in the first place.  Just go back to what worked.  I worry that Doctor Sarcasm would view a request to switch to Vyvanse as drug seeking, since Vyvanse is “the good stuff” now.

Now, the Xanax.  You don’t describe what role the Xanax has in your life.  Did you have severe anxiety in the past?  Has that been better lately?  Have you had the re-emergence of anxiety as the dose of the Xanax has been reduced?  These are all very important questions that need to be answered.  Most doctors (myself included) like to get people on the lowest possible dose of Xanax and, if clinically appropriate, off this class of medicine.  Xanax, in particular, has a nasty reputation of being addictive and abusable.  But the tapering of medicine should be clinically driven and not based on population based fear.  And it should never be accompanied by sarcasm.  You go to the doctor for help and advice.  If you want sarcasm, go talk to your family.  That is actually the most concerning issue raised by your letter.  Given how you seem to feel about the relationship you have with your doctor, I would say that 6 months can’t pass too quickly.  Try talking to him in a straight forward manner and address his sarcasm if he slips into that again.  You can try saying something along the lines of . . . “I hear by the tone in your voice that you don’t trust me with these medications.  I can assure you that I take only what is prescribed and only take these medicines to control my symptoms.”  Maybe the doc will listen, maybe he won’t.

Good Luck!

–Dan Hartman, MD

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