August 14, 2007

How To Take Ritalin Correctly

This is a post about Ritalin, Adderall, Dexedrine, and others-- it is meant for those for whom it is written. You know who you are.

I've written three textbook chapters and a couple of articles on stimulants, and I may or may not have taken them at one time or another, so I'm an expert.

Because I work in a university hospital, and because I'm, well, different, I get approached by college or med students at least once a week for Ritalin or amphetamine prescriptions.  Every one claims to have "ADD." (NB: I don't give them out.)

They want the Ritalin to help them study.  I get it.  I'm not advocating it, but if you are going to use Ritalin you should probably do it intelligently, to maximize the gains.

First, a disclaimer:  you should only get Ritalin for indicated disorders by prescription from a physician.  Ok?  Because the doctor will rigorously apply artificial and unreliable diagnostic categories backed up by invalid and arbitrary screens and queries to make a diagnosis.  So after this completely subjective and near useless evaluation is completed, your doctor should be able to exercise prudent clinical judgment to decide if Ritalin could be of benefit.  In other words, he will ultimately decide based on little else but his own prejudices and/or consult the Magic 8 Ball.  That'll be $250, please.  Cash appreciated.

That said, the key to amphetamines and Ritalin is to stop thinking of them as stimulants, and to think of them as reinforcers.

Let's conceptualize how these drugs work.  Imagine getting a brain scan while you are performing a task.  The parts of your brain you are using for the task will light up, brighter than those you aren't using. 

Now you drink coffee (1).  The whole brain lights up brighter, proportionally.

Now you take amphetamines.  The parts of your brain that you are using light up brighter, but the parts you aren't using go darker.  Get it?  Caffeine is a global brain stimulant, while amphetamines focus your attention, reducing distraction.

This is entirely selective and controlled by you.  You have to decide what you want to focus your attention on.  If it's reading, the reading parts of your brain will be brighter.  But if you stop reading and decide to talk to your friend on the phone, you know, the hot one with the hotter roommate, then you'll be more focused on that (obviously).  Attention is always decreased when it is split among several tasks.  In other words, you can only concentrate on one thing at a time, even though it may feel like you are doing two things at once.

While amphetamines and Ritalin do stimulate you and keep you awake, using them to pull an all nighter completely subverts their awesome power.  If you want a stimulant, drink coffee or Red Bull.  Amphetamines should be saved for reinforcement.

You want to set up a study situation that as closely as possible resembles your testing context.  Do you take tests in the middle of the night?  Using multicolored highlighters?  With The Daily Show on in the background and eating Doritos?  Then you're a pig, and you deserve to fail.  You're dead to me.

You should study in the morning, at a desk, under the same "fed" conditions as on test day. (So you would have eaten before taking the test, not snacking at the test.)  Quiet room, no distractions.  Remember, attention is decreased with multiple stimuli in normal conditions, but on amphetamines, this will be be greatly magnified.  Studying while talking to your friend means your "talking to friend" parts of the brain are brighter while your ""studying" parts of the brain are darker.  Same thing with listening to music and studying.

Take the amphetamine (takes about 30 minutes to "kick in.")  Study, straight, with no distractions or interruptions, for about four hours.  Quit.  You're done.  Amphetamines give you about 4 hours tops of great concentration.  Go to lunch, the gym, watch a movie, etc. 

The power of amphetamines is this: you take them again, in the same dose, 30 minutes before your test. 

In a metaphoric sense, taking the amphetamines during the test, under the same circumstances as you had been previously studying, will "remind" the brain of that context. If you see a question that "resembles" something you studied, your mind will be primed to recall it better.

Remember I said you can only concentrate on one thing at a time, that attention decreases when it is split?  The trick here is to make everything about studying into one large "thing." 

Here's an example: if you listen to a symphony, you will hear music.  Musicians, however, hear both the music and every single instrument.  They can attend to each instrument individually and simultaneously hear how each instrument fits into the larger context.  A non-musician can't do that. If he's concentrating on the oboe, he doesn't "hear" the violas.

Studying has to become a large symphony, everything doing its part correctly, expectedly.   So on performance day (testing) you play the same symphony.  You're not trying to concentrate on each part, if you've practiced enough it should be second nature.  The amphetamine helps facilitate this.

Addicts can get physical feelings of withdrawal or "high" simply by being presented with the cues-- the environment-- of their drug use.  And they key into these cues much faster than non-drug related cues. That's what you're looking for here.  The amphetamine feeling "reminds" you of what you studied.

For example, what you don't want to do is NOT take amphetamines at testing if you had used them to study; or take them at testing if you didn't use them to study.  Or change the dosage, or change anything else you eat. (2)

Similarly, you should only be taking one pill a day.  Don't take amphetamines to study AND later to do other things (like go out at night.)  You are destroying the context specific reinforcement.  Additionally, tolerance to amphetamines happens pretty quickly-- if you take them every day, you're going to need higher doses as time goes on.  Ideally, you'd use them only for the last stretch of time before the test.  For example, maybe you'd take them only the last week or so before the test, when you are studying from back tests as opposed to a textbook.  (See the context?)  And you'd stop using them after the test, give yourself a break, etc.

As a public service announcement, don't worry too much about grades.  This is America, not Germany, where success is determined by the solidity of your goal and the amount you are willing to work.  I know you don't believe it now, but it's true.  Go have a drink.


and hey, what gives with the trilogy The Most Important Article on Psychiatry You Will Ever Read?  It's funny, dammit, so digg it! 


1. What is the best and healthiest coffee to drink?


2.  NB: diet and amphetamines are powerfully interactive.  Acidic foods/beverages will rapidly accelarate the clearance of amphetamines. In other words, dexedrine +  orange juice = a lot less dexedrine.  (BTW, does anyone have any idea how to make footnotes with Moveable Type?)