I'm Back, Baby, I'm Back - Vyvanse and Adult ADHD

Well, hello everybody. Yup. It's me. Yup. I know. Nearly 3 months. Nope. I wasn't in prison. Nope - didn't get lost in the woods. Nope - not in Guantanamo Bay, either. Nope - didn't enter a fugue state, turn up at a McDonald's in Oregon speaking Dutch, claiming not to know my own name. Nope - not kidnapped either.

I've been here and there getting things done, and I think I was kind of waiting to get attuned to a new job (a contract position), new medication, and a new daughter (she's 3 weeks old and now our 2 1/2 year old boy is a big brother...) before writing more about my progress and journey.

I'm here and in good spirits. In fact, the best I think I've ever been in.

The last three months have been great - in large part to the new medication I'm on. I returned to the clinic I'd initially had my diagnosis at, and saw a psychiatrist who was recently the president of the Ontario Psychiatric Association for a second opinion. He was terrific. So I went off Strattera, and as soon as it cleared from my system, started taking a drug called Vyvanse to manage my ADHD symptoms. For me, it was nothing short of incredible. I started at 20 mg, and have now moved up to 60 mg. I initially called it my James Bond 007 medicine. More on that later. In fact, Vyvanse works so well for me that I almost feel that I wasted nearly a year on Staterra.

Vyvanse is essentially an extended release formulation of Adderall and was approved only in January of this year in Canada. It has been around in the U.S. for much longer, and of course is essentially Adderall - a well-proven psychostimulant which has been around for decades. What's different is that some clever chemists attach a lysine (amino acid) molecule onto the dexamphetamine, and ended up with the delicious-sounding lisdexamfetamine dimesylate. This pharmaceutical processing makes Vyvanse a prodrug - a pharmacologically inactive compound that require in vivo (in your body) conversion to release therapeutically active medications.

The prodrug aspect of Vyvanse achieves a couple of goals:

The first is to prevent the abuse of the drug, because the only way you can metabolize it into the stimulant dexamphetamine is by first orally ingesting the medication (gulp) and thereby allowing the drug to pass through your small intestine into your blood stream. It is on the surface of your red blood cells - after it has been absorbed through the microvillae on your small intestine's wall - that the lysine is cleaved away from the dexamphetamine, thus making it 'bioavailable'. So this precludes someone snorting the pill, or injecting it into their arm to get a quick rush. But from what I understand, even if you took a lot of the pills, their is still somewhat of what I call a metabolic turnstile, such that your body can only metabolize a certain amount of the prodrug at a certain maximum rate - so you wouldn't get an abuse-worthy amount of meds in your system if you tried.

The second goal is related to my last point, in a way. The medicine is metabolized at a given fixed rate - based on your system's 'throughput' rate and in this case, the psychostimulant is released in your bloodstream body over a period of up to 14 hours. This sustained, smooth release allows for full coverage throughout your waking day into the early evening - and doesn't give you a crash at the end.

And so I return to the James Bond 007 reference from earlier. The first week I was taking Vyvanse, I noticed clear and positive cognitive effects, and virtually no physical side-effects (other than some minor dryness of my mouth, which passed after a few days). I could focus appropriately and without effort. No longer did I unintentionally scoot from thought to thought, activity to activity, daydream to daydream and from topic to topic during a conversation. I stayed on track. I felt as though my situational awareness was heightened - yet controllably so. You can imagine a scene in a James Bond movie, or in a movie like the Bourne Ultimatum where the secret agent is in the middle of a mission requiring his full attention. This attention comes from a combination of extensive training, rehearsal, knowledge, physical fitness, mental acuity and a strong sense of confidence. Thus James Bond walks with sureness, certainty, does not get sidetracked, and goes about his dashing, albeit lethal business. Although in my case, the business does not involve blowing up embassies, shooting bad guys and rescuing wailing dames from the grips of deranged sociopathic baddies. Generally speaking.

Within a few weeks I stopped being so aware of my increased focus - which makes sense. I think I just got used to this improvement. But cognitive effects aside, the way I know that Vyvnase is really working for me is with my external environment, i.e. the world around me, the things on which I have agency and the world in which I take action.

My personal Action List, comprising all the large and all the minor things I need to complete in every arena of my life, which I have been diligent in gathering and maintaining over the past year, has decreased in length. Now it isn't often that a decrease in length is considered a significant selling point for a medicine (ba-dum-CHING!), but I have been able to tackle the really big projects on my list and been able to remove a lot of items from my list. I am acutely, almost painfully aware that I have a life-time of deficit to catch up on, and so I've been running at full steam to get things done - propelled both by excitement and happiness and indeed by a newly found focus. I can see the list diminishing, and with each item crossed off, I get a little bit stronger and gain a little bit more pride in myself. I suppose you could say my self-esteem is improving.

And as a result of going on Vyvanse, I've had a few insights. One of them is that I've learned a large part of my difficulty with getting projects done was a combination of 1) my poor (neurobiologically influenced) pre-conscious attention modulation resulting in me rapidly turning away (without being aware of this) from thoughts of daunting, uninteresting complicated or mundane tasks, and 2) a life-long paucity of experience and learned competency with organization, planning, and coping skills. That is, 'was never good at it, so never learned it, and so now has to learn it'). And between my deficient and neurobiologically impaired attentional capacities, and my deficient executive-functioning skills lies a set of deeply engrained core schema beliefs about my ability to sustain and achieve real change and to attain a competent sense of agency & control over my environment, personal & work life, and relationships with others.

Another insight is that it would have been really (REALLY) nice if I'd been identified as having significant attentional problems when I was a child. Scanning through my grade 4 report card, I read the following note:

"He is is obviously a capable boy as his contributions at group time and comprehension reveal - oral, reading. He is also quite fluent. This ability is not reflected however in his written work which appears often hastily completed. At times he is disruptive to those around him and as well he's easily distracted. His projects cover a lot of material but lack organization. Record keeping was accurate but could have been presented in a neater fashion."

So I was a capable boy, engaged and interested in working in a group, and demonstrated good oral, verbal and reading abilities. I was seen as disruptive (i.e. impulsive). Easily distracted. Hastily finishing work due to poor organizational and time management skills. Demonstrated lower than normal executive functioning as seen in my poorly-organized written work (as compared to my otherwise notable conceptual abilities). Messy record keeping indicative of comorbid dysgraphia. I'm sorry - HOW did my parents, teachers, guidance counselors, and other involved professionals NOT see ADHD as a strong possibility, or at the very least, refer me for professional assessment? Forget most of the items - let's assume all of the adults were half-asleep, hungover, or preoccupied with much more important things. What about the 'disruptive and distractible' parts? C'mon, folks. This wasn't the 1950s. This was the late 1970s and 1980s where guidance counselors were lining up, salivating at the opportunity to deal with my confounding combination of high potential, high intelligence, ravishing good looks and very low performance. And NONE of them saw a pattern in the chaos.

I mentioned earlier that I feel that I'm catching up with a lifetime deficit of getting things done, resulting in a long list Action Items which I need to take care of. And in the same way, I'm catching up and dealing with a bunch of emotional baggage. As I get healthier, and stronger and begin to get more perspective on my life, I begin to feel quite sad for me: for that strained, hopeless, frustrated, 'lazy and helplessly stuck' kid, that teenager, that young adult who suffered so exquisitely with all of the symptoms and the consequences of severe ADHD, combined subtype. And with that comes anger, and some wondering of how I managed to slip through the cracks. And yet at the same time, I recognize these feelings are natural - and that probably every adult who is late-diagnosed with ADHD goes through the same motions and emotions. And I hope to cover off more of this in future posts.

Switching gears somewhat, I have to make clear that while Vyvanse is working for me, it is truly 'to each their own' when it comes to medication. Physicians can use a variety of medications to treat and address the neurobiological / cognitive symptoms of adult ADHD. Each individual reacts differently to the various medications, depending on their metabolism, the expression of their genes, existing psychiatric comorbidties (anxiety, mood disorders etc...), confounding non-psychiatric conditions, other medications they are on, the ADHD subtype ('maybe' - this is something I came across recently), and the medication treatment regime and circumstances (titration rate, dose - not too little, not too much) - and effective, appropriate medical follow-up. And I'm sure there are several more factors I'm missing. The long and short of it is that medication works for ADHD, but you and your physician have to figure out the right medication through an empirical, educated, and trial-and-error approach.

And while the psychostimulants can work quickly - and result in remarkable changes in a person's life - the other pieces of the treatment arsenal have be brought to bear. The most effective treatment is a combination of medication, psychoeducation (i.e. learning about the disorder and the various techniques, coping strategies and skills that can provide relief) and psychosocial interventions including individual, group, or family counseling and ADHD skills coaching.

Those other pieces of the treatment arsenal will have to wait for future posts, though. It is late, and I am tired.

Hope you're all doing well. I'm glad to be back.

Mungo

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