- Two basic types of ADHD medications, stimulants and nonstimulants, work very differently.
- Stimulants are divided into methylphenidate containing and amphetamine containing. Within this category, there are many forms.
- A provider can help with finding the right choice in terms of benefits and side effects.
On the face of it, ADHD medications look complicated – there are a lot of them. Not only patients, but many providers have a hard time making sense of them, especially as there are new ones on the market every few months. Below is a quick and easy guide to ADHD medications.
The first division is whether the medication is a stimulant or a nonstimulant. This division is not 50-50. Stimulants are used about 95% of the time. These are the medications most people associate with ADHD: Ritalin, Adderall, Vyvanse, or Focalin (although there are many other names, as you will see below). The nonstimulants are Intuniv, Strattera and Qelbree (currently only for kids).
On a biochemical level, stimulants activate the dopamine system more than nonstimulants, and do so rapidly. The biggest difference between the stimulants and the nonstimulants on a practical basis is that stimulants work right away, for the day you take them. They wear off sometime during that day. The next day it’s a new decision whether to take the medication or not. If you take it, then it works again. If not, it gets out of your system pretty quickly (though the chemical is not completely out of your system as quickly as the effects go away). The nonstimulants are more like antidepressants in that their effectiveness builds up over a few weeks to months, and once they are in effect, they work 24/7. Both stimulants and nonstimulants have side effects.
Stimulant side effects are directly related to their mechanism of action and so are the same for all of them: You may have worse sleep, worse appetite, and worse mood. The nonstimulants are far more diverse and have a wider range of side effects. In general, the non-stimulants tend to make you more sleepy rather than less, may cause some gastrointestinal upset, and can have negative effects on mood as well.
The stimulants are further divided. There are the methylphenidate-based ones (eg. Ritalin and Focalin) and the amphetamine-based ones (eg. Adderall and Vyvanse). Ritalin and Focalin are related to each other in that Ritalin (methylphenidate) has both left-hand-rotated and right-hand-rotated molecules in it. Focalin is dexmethylphenidate – just the right-hand-rotated ones. The same goes for Adderall and Vyvanse. Adderall has both left-and right-hand rotated amphetamine salt molecules in it. Vyvanse is just the right-handed ones (with another molecule attached that makes it slower to activate – to be precise, Vyvanse is a “prodrug" that must be metabolized in the body before it activates, causing slower onset and offset and longer duration of effectiveness).
Both the Ritalin/Focalin and the Adderall/Vyvanse categories have short- and long-acting forms (medium-acting too, if you want to be technical). The various forms of methylphenidate have different brand names. There are a lot of long-acting methylphenidates (Ritalins): Ritalin LA, Concerta, Quillivant, and Quillichew to name just a few. Focalin has an immediate-release version and a long-acting form, Focalin XR. Adderall also has immediate release and XR form (and also a really long-acting version called MyDayIs). Because it is a pro-drug, Vyvanse only comes in one long-acting version, but dexedrine is the equivalent short-acting dexamphetamine (without the part attached to Vyvanse that makes it a prodrug).
If you just know that much you already know a lot.
Where it gets a bit more technical is that each medication also has different release forms. What’s the difference, you might ask, between Ritalin LA and Concerta? Well, Ritalin LA is a soluble capsule filled little beads that have an inner and an outer core. The outer core releases 50% of the methylphenidate right away. The inner core releases another 50% in 4 hours. So the pill really releases methylphenidate in two pulses separated by a few hours.
In contrast, Concerta uses a different technology to achieve long-acting effects. Concerta has an insoluble capsule with a teeny little hole in it, and inside the capsule, there is a teeny little sponge. As your intestinal fluids seep through the hole, the sponge absorbs and expands, pushing methylphenidate out. The results is that about a third is released in the morning, the rest leaks out later in the morning and afternoon. Both Concerta and Ritalin LA have the same active ingredient – but because of this different release technology they can have different effects on different people.
The newer ADHD stimulant versions coming out over the past few years are all composed of the same two active ingredients – methylphenidate or amphetamine. Newer versions may be released more steadily. Steady-release means that instead of the 50/50 split in release times described for Ritalin LA (which is also how Adderall XR works), newer medications such as Quillivant and Quillichew are manufactured so the medication is released in a more steady stream throughout the day. As side effects may be related to when the medications peak in your bloodstream, these medications may have fewer side effects for some patients.
But this comes at a cost. Newer brands are always priced much higher than older versions, especially if the older ones are available as generics. Some people are not sensitive to stimulant side effects and may not need a medication with fewer of them. But for those who need the newer medications, many have manufacturer’s coupons available. Check online; the best ones are usually on the manufacturer’s website.
The take-home messages are: No single medication works best for everybody and doctors have a lot of alternatives to choose from. So work with your provider until you find the right one – in terms of effectiveness and side effects, but also in terms of price – for you!
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