Question: Can sleep disturbances be caused by the “rebound effect” of stimulants?
Answer: Rebound means worse than if you hadn’t taken the medication. What’s worse? Symptoms that are helped by the medication may be worse right after it wears off. This is especially true of tablets, less with XR form of Adderall and Concerta. An example of rebound is number of math problems worked correctly in the classroom study on 5mg of Adderall tablets vs. placebo at 6 hours.
Clinically I have found that adjusting the last dose of medication - sometimes earlier and sometimes later - frequently helps with trouble falling asleep.
I have not found any formal studies relating to rebound insomnia. There is a reference in the current edition of Goodman & Gillman’s textbook, Pharmacology that after taking amphetamines for a long time, especially in higher doses it may take 2 months for sleep to get back to normal.
Support for the idea of rebound insomnia comes mainly from 2 sources - theoretical scientific principles and clinical experience. People with ADHD have problems falling asleep when they’re not on medication - especially those who have mental or physical hyperactivity. Studies show that physical hyperactivity continues while they are asleep and is generally helped by stimulants. There are occasionally patients who actually sleep better taking a stimulant at bedtime.
People don’t sleep best when they are not paying attention to anything - that invites random ideas and images to pop into their mind - frequently related to hassles of the day or anticipated problems of the next day. We fall asleep best when we lightly focus on something not too stimulating like soft music or reading something not too exciting.

FAQs: ADHD

Question: I have trouble falling asleep when I take Adderall or Concerta. What can I do about it?
Answer: In evaluating any presumed side effect of medication it is important to ask how the side effect (e.g. insomnia) relates to the last dose of medication. Adderall tablets reach peak blood level in 3 hours. Methylphenidate (Ritalin) tablets peak in 1 1/2 hours. Adderall XR and Concerta peak in 6 hours. After the blood level peaks, it starts down. If the last dose of Adderall XR or Concerta is at 4:00 pm and the sleep problem is at 10:00 pm, it’s probably due to peak blood (i.e. a direct side effect). But if the last dose of medication is at noon and the sleep problem is at 11:00 pm, it’s more likely rebound. In the first case the medication needs to be taken earlier. In the second case it could be taken earlier or later.
Some people need to be fairly high functioning well into the evening but also need to get to bed by 10:00 or 11:00 to get adequate sleep. Fortunately we have safe, effective sleep medications that provide normal sleep and wear off by morning (Ambien, Lunesta, Sonata).

FAQs: ADHD

Question: How is Desoxyn different from Adderall and Dexedrine?
Answer: There is a lot of literature to support the fact that abuse liability is related to reuptake blockade and/or increased release of dopamine in the nucleus accumbens. The best resource is ADD Treatment with Stimulants, by Solanto, et al, 2001.
Recent reports by 5 different agencies (including DEA and OIG) that monitor substance abuse have found that Methamphetamine (Desoxyn) is by far the most abused stimulant. All this data is available through the Freedom of Information Act at each agency.
I have been prescribing Desoxyn for over 30 years. It has been available since 1941. It is clearly the most likely to be abused. Clinically it is sometimes the best tolerated. The most likely explanation for this is a reduced relative effect on Norepinephrine.

I finally realized that I’m inspired to do a blog when I’m stirred up, aroused, upset. Yesterday morning while watching CNN news and the Today Show, I said to my wife, "Where in the hell is Bush?"

Then I saw his picture on page 2 of the Dallas Morning News playing a guitar. President Bush on August 30, 2005 He apparently was in San Diego at a prescheduled trip to a military base. He was showing every one he’s "one of the guys," but he was a prisoner of the moment – instead of being in the Gulf Coast area and in our homes on TV being a leader in a time of great crisis.

Senator Mary Landrieu on August 30, 2005

Of course we’re now hearing excuses about "these things take time." But last Friday morning, 6 DAYS AGO, we heard on the news that Hurricane Katrina had crossed Florida and was gaining strength in the Gulf. It was predicted at that time that it would hit New Orleans this Monday and that this would be a likely major disaster because of the fact that New Orleans is several feet below sea level and almost completely surrounded by water.

Today we learn that George W. cut his 30-day "working vacation" 2 days short and flew over the disaster dropping to within 1700 feet and said something like "what a mess!"

Later he gave a speech filled with platitudes, reassuring 100’s of thousands of victims – basically "we feel your pain" and "we’ll all end up stronger." Jeff Stahler understands how Bush "feels their pain" Of course the majority of the victims didn’t hear the speech because they’re without power!

I have believed for a long time that George W is ADD. Three years ago I was sitting across the desk from my physician discussing the results of my stress test and physical. He reassured me that physically I was 40 - the same as our president. But our president couldn’t sit still for his post evaluation meeting with the doctor. He ran on the treadmill while getting his report.

Then I saw an interview with an official who had just left his White House staff position. To paraphrase one of his comments - it’s hard to communicate with Bush, you can only hold his attention for a couple of minutes. Then you see him on TV when he’s not the center of attention and he’s acting up like a playful school kid - making faces, etc. It’s part of his charm, but unfortunately, also a symptom of his ADD. Next week, in a detailed article on the latest science of Attention Deficit Disorder, I will describe 2 subtypes of ADD - One is boredom/need for stimulation and associated with proneness to addiction (i.e. Clinton and Monica). The other subtype is deficit in executive functioning/maturity in thinking causing inability to separate important from the unimportant (George W sitting in classroom for several minutes on 9-11 and plunking a guitar on 8-30-05). Most ADD individuals have symptoms of both, and many people who are ADD have a lot of positive traits.

The best treatment option when ADD traits are causing problems for self or others is the use of medication. You can stimulate the brain of a bored ADD individual with Adderall XR or Concerta … or by starting a major project - like - a war. You can smile with amusement as the absent minded professor doesn’t get it, Wow! What devastation! or you can be more realistic - and panic. Our president is not with the program. In a recent book by a prominent psychiatrist, Justin Frank, MD (Bush on the Couch), he details evidence for George W.’s ADD and other emotional results of a traumatic childhood. Dr. Frank quotes Bush as saying, "I don’t spend a lot of time trying to figure me out … I’m just not into psychobabble." The author goes on to say, "For all his simplicity and affability, George W. Bush has remained, to paraphrase Sir Winston Churchill, ‘A mystery wrapped in an enigma.’"

Frank makes a convincing argument that our president lacks empathy. I didn’t vote for Clinton because I don’t believe the federal government can solve all our problems, but fair is fair - he kept us out of war, he balanced the budget, and if he were president now, he would be on the Gulf Coast and the victims of Katrina would know that he would lead us through this major crisis.

We don’t have a leader right now. We need to be proactive - if nothing else, go to the Red Cross and get involved.

Are we now at the mercy of big business?

Questions to think about:

1. How long would it have taken for Bush to take definitive action if the Gulf Coast had been attacked by a foreign army (answer in microseconds)?
2. What lobby group is representing the hurricane victims?
3. How can big business benefit from Katrina? Raise oil and gas prices? Tax subsidies to Insurance companies?

I also want to thank CNN for asking the hard questions while the NBC morning news group is being nice.