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I have learned all of this because six years ago I was in a similar situation to what you're in now. I had a doctor that was willing to work with me, but had no history with ADHD or knowledge of the medications involved. I was forced to learn a lot of this as I was largely directing my own treatment under the supervision of my doctor. Things changed a lot for me when I managed to find a psychiatrist who specializes in ADHD, and knows these drugs and what to expect from them, but is open minded enough to discuss novel options when I suggest them.

Unfortunately, it's hard to immediately quantify much of what I say here, because it's a synthesis of six years of trying to figure out my own ADHD situation, plus my own special brand of oversimplification. I read about these things, then try to break them down to the point that they're easy to communicate--not that I'm any smarter than anyone else out here, but it saves time to simplify, rather than trying to explain my process. However, I'll try to give you some jumping off points (the caveat is that this is my own understanding of what follows, and may or may not be perfectly accurate--I am not a chemist):

First, the precise reasons that stimulant-based medications improve ADHD are unknown. It is theorized that ADHD involves a lack of activity in the pre-frontal cortex of the brain, and that stimulants wake-up that portion of your brain, so to speak. While again, it is not known precisely how, it is known that stimulants cause an increase in the available amounts of two neurotransmitters, dopamine (which is implicated in, among other things, feeling satisfied) and norepinephrine (also called noradrenaline or adrenaline). It is believed that stimulants increase these neurotransmitters' availability by both blocking the reuptake of these chemicals (meaning that they're absorbed and broken down by one end of your synapses), as well as causing them to be secreted by the other end. The increased availability of these neurotransmitters seems to have positive effects on ADHD.

Adderall is formulated by mixing four different amphetamine salts. These are; amphetamine aspartate monohydrate, amphetamine sulfate, dextroamphetamine saccharide, and dextroamphetamine sulfate. The first two of these are racemic mixtures, which means they contain both dextroamphetamine and levoamphetamine. The difference between dextro- and levo- amphetamine is a slight difference in the three dimensional shape of the molecule, such that they rotate light differently, one presents a left twist (levo-), while the other presents a right twist (dextro-). While chemically these are the same substance, the difference in shape can change the way they behave, and what sites they will bind to in the body and the brain. Furthermore, a racemate (meaning a chemical made up of both d- and l- molecules) may have different physical properties and potencies than either enantiomer by itself.

The reason all of this matters is that it's suspected that dextroamphetamine tends to be responsible for more of the positive effects that ADHD sufferers derive from amphetamines, and less of the side effects. This is why most of the amphetamine medications available are dextroamphetamine only (including Dexedrine and Vyvanse). Because it contains so many different versions of the amphetamine molecule, Adderall tends to be effective in a wider range of cases than the less broad versions, but also tends to result in both the extreme highs and lows that you have described, as well as a higher rate of reported side effects.

For the above reasons, I consider Adderall more of a last resort than a first one. If I were directing someone's treatment, I would try a dextroamphetamine-only version (ideally Vyvanse) and a methylphenidate version (Concerta) before considering Adderall. Adderall will work for some people who don't respond to these other meds, but I would take the time to find out before jumping into Adderall. I have found Vyvanse to have a very smooth uptake and decline; I do find that late in the evening I hit a wall where all I want to do is sleep, but I do not get the depressive symptoms that come with Adderall.

Methylphenidate is a chemical cousin to amphetamine and works in similar ways. It is best known as Ritalin, and has been used for treatment of ADHD since at least the 1950s. As such has been studied rather extensively, and effects of long term use are very well established (that said, amphetamine has been around since the 1800s, and has been used extensively for other purposes for a very long time--both are safe if not abused). Methylphenidate works better than amphetamine for some, and less well for others. Unfortunately, the only way to determine which group you fall into is to try. Treatment of ADHD is very trial and error.

Wellbutrin is technically an antidepressant. It is considered an atypical anti-depressant because instead of working to prevent the reuptake (or absorbing and breaking down) of seratonin like Prozac and the other meds of that ilk, Wellbutrin works to prevent the reuptake of dopamine and norepinephrine, the same neurotransmitters that are implicated in ADHD. It is because it has the reuptake inhibition effect on the ADHD neurotransmitters that it is sometimes prescribed off-label for ADHD. The nature of this medication (because it only blocks reuptake, it does not induce secretion), it take several weeks to reach full effect, so evaluating it's effect takes longer.

This brings me to the potential bad news. Although you may find that you are part of the group that can find a medication and manage your symptoms with it long term, there is always the possibility that like me, you're part of the group that develops tolerance to medications very quickly. Anytime your environment changes, your body works to adjust to those changes and maintain its equilibrium. In cases like mine, it means that I have been unable to find a medication that treats my symptoms effectively over the long term.

I have always found that I experience what I refer to as a "honeymoon phase" on any new medication. This is the time when the medication is new and works very well for me. I have good management of my symptoms, but over a matter of weeks, or at most a few months, the positive effect begins to fade. I tend to experience a decline in function to the point that I end up back where I was without the medication.

In my own experience, the best effects were gained from Vyvanse and Wellbutrin. I tried a number of meds and combinations thereof, but it was when I stumbled upon Wellbutrin that my life really began to improve. I lost a good bit of weight, and was able to complete my university degree (somethign that I had been starting and washing out of off and on for fifteen years). I found that Wellbutrin gave me the best effect for roughly ten months before the decline began, and I don't feel I returned to baseline for over two years. Ultimately, however, I found myself in the same boat as always.

The reason I told you about tolerance is not to discourage you, but to let you know that this is possible, and something you may have to eventually face. Many, many people manage their symptoms for decades with no loss in efficacy, so it's certainly worth giving it a serious try. If you do find that you're in the same boat that I am, however, I encourage you to learn everything you can while you're getting the effects from your meds. You can re-train your brain to work well without the meds, and can come up with strategies to function, even if the meds don't work.

Take the time to look into Cognitive Behavioural Therapy (CBT). Buy a book, find a therapist, find a group, whatever it takes--learn this stuff. Addprogrammer tried to convince me to do this back in the day and I didn't follow through, but I should have. I'm working on learning CBT now, and the benefits are obvious. CBT is proven to work for a very wide range of mental health issues, and is big for ADHD. CBT is the future.

In hindsight, this post is a little more rambling than I usually do, but I've run myself short on time and can't fix it. I hope you can follow it, and I hope some of it helps. No matter what, don't get discouraged from anything I've told you. There is a bright future out there for you, it just might take a little more work to achieve it than it does for some of your classmates.

Best of luck.

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