Adderall (dextroamphetamine-amphetamine) is a stimulant medication that’s a mixture of different amphetamine salts. It can help reduce or improve the symptoms of attention deficit/hyperactivity disorder (ADHD), including having a short attention span and/or being hyperactive and impulsive. This drug is also prescribed for narcolepsy because it may help those with the sleep disorder stay awake and alert during the day.

The therapeutic action of Adderall remains unclear, but it’s believed to increase brain chemicals that play key roles in attention and thinking, such as dopamine and norepinephrine.

Adderall is also available as a generic and comes in a tablet that’s generally given twice a day. Adderall XR is a long-acting form of this stimulant that comes in time-release capsule and can be given just once a day.

Uses

Adderall is approved for the treatment of ADHD and is prescribed to improve focus and attention, as well as help manage behavioral problems. Though prescribed for narcolepsy as well, it should not be used to treat daytime sleepiness in those without the sleep disorder.

Adderall is approved for adults and children age 3 and older. Adderall XR is approved for adults and children over age 6.

Off-Label Uses

Adderall may sometimes be prescribed off-label as an adjunct treatment for treatment-resistant depression.  

Before Taking

Diagnosis of ADHD requires a comprehensive evaluation by a pediatrician, psychologist, or psychiatrist with expertise in ADHD. The disorder can begin as early as ages 3 to 6 and can continue into adolescence and adulthood.

The first-line treatment for ADHD in those under age 6 is behavioral therapy, including parent training in behavior management and classroom behavioral interventions. This is tried before medication is considered. For those ages 6 to 18, medication is a first-line treatment along with behavioral therapies.

Stimulants are typically the first medications used to treat ADHD and the two most common types are Ritalin (methylphenate) and various forms of amphetamines, which includes Adderall and Vyvanse (lisdexamfetamine). There are also extended-release versions such as Concerta (methylphenate) and Adderall XR that are longer lasting and can be taken once daily.

Each of the stimulants prescribed for ADHD can have similar effects, but a person’s response to either methylphenate or amphetamine is individualized. If the first type taken is ineffective, they may be switched to the other.

As an alternative to stimulants, there are also non-stimulant medications for ADHD that have been shown to help reduce symptoms of ADHD in children and adolescents, but in a less robust way compared to stimulants. These include Strattera (atomoxetine), Intuniv (guanfacine), and Kapvay (clonidine).

Research shows that approximately 40% of people respond to both methylphenate and amphetamine, and about 40% respond to only one type.

Nonstimulants may be prescribed for those who can’t tolerate side effects of stimulants or those with health issues, such as heart conditions or a history of drug abuse, that prevent them from taking them. The non-stimulants are also sometimes used as an adjunct therapy to stimulants like Adderall.

For narcolepsy, the medications that are typically used as first-line treatments are the wakefulness-promoting agents Provigil (modafinil) or Nuvigil (armodafinil), or the central nervous system (CNS) depressant Xyrem (sodium oxybate), which can (among other things) improve daytime symptoms through promoting better nighttime sleep.

If Provigil, Nuvigil, or Xyrem are not fully effective at improving the excessive daytime sleepiness and sleep attacks, or a person is unable to take these medications, then a stimulants like Adderall is typically prescribed as a secondary option to improve alertness during the day.

Precautions and Contraindications

Given risks associated with taking Adderall in certain cases, you will be asked for a detailed physical and mental health history. In addition to providing details about yourself, be sure to tell your healthcare provider about your family medical history, including any instances of sudden death, ventricular arrhythmia, suicide, bipolar disorder, depression, or addiction.

You will also get a physical exam and possibly undergo tests, such as an electrocardiogram (ECG) and echocardiogram, to check for heart abnormalities. Stimulant medications carry serious cardiac risks, including the risk of sudden death for children and adults with preexisting heart problems.

Adderall should not be used if any of the following apply to you:

  • Advanced arteriosclerosis (hardening of the arteries)
  • Symptomatic cardiovascular disease
  • Moderate to severe hypertension (high blood pressure)
  • Hyperthyroidism
  • Agitated states
  • Known allergy or sensitivity to stimulants
  • A history of drug abuse (Adderall is habit-forming.)
  • Glaucoma: There may be increased pressure in the eye that leads to vision loss.
  • Breastfeeding: Amphetamines can be passed to the infant in breast milk.

There are additional medical conditions and warnings that can make taking Adderall risky or possibly prohibit its use, including:

  • Hypertension and other cardiovascular conditions: Stimulants cause an increase in average blood pressure and heart rate that can carry risks for those with any underlying conditions, such as mild hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia. In general, those with structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease or other serious heart problems should not take stimulants.
  • Seizures: Stimulants may lower the convulsive threshold and increase seizures in patients with prior history of seizure or those with prior EEG (brain wave test) abnormalities.
  • Pre-existing psychosis: Stimulants may worsen symptoms of behavioral disturbance and thought disorder in patients with psychotic disorders.
  • Bipolar disorder: Stimulants may induce mixed/manic episode in patients with bipolar disorder.
  • Tics: The medication may exacerbate motor and phonic tics and Tourette’s syndrome. You don’t need to worry that Adderall is causing tics, as some medications can, but it can cause tics that you otherwise have to become more noticeable.
  • Liver or kidney problems: These organs may be affected by long-term use of Adderall.
  • Pregnancy: There are no adequate and well-controlled studies in pregnant women and there may be a risk of long-term behavioral, including learning and memory deficits, or neurochemical changes for children born to mothers who took amphetamines while pregnant.

Certain medications and ingredients can interact with Adderall and may alter potency or the risk of dangerous side effects. Your healthcare provider will evaluate your medication regimen and may adjust it if you need to take Adderall. You may also need to be monitored closely if you take Adderall along with other medications.

Medications that interact with Adderall include:

  • Monoamine oxidase inhibitors (MAOIs) or other antidepressants: Do not take Adderall if you’ve taken MAOIs within 14 days. MAOIs slow metabolism of amphetamines and increase their effects. This can lead to hypertensive crises and a variety of neurological toxic effects and malignant hyperpyrexia, which can be fatal.
  • Blood pressure medications: These medications can interact with Adderall in a variety of ways. Alpha blockers (also called adrenergic blockers) are inhibited by amphetamines, making them ineffective. Some thiazide diuretics decrease urinary excretion of amphetamines, raising blood levels of amphetamines. Guanethidine and reserpine are gastrointestinal acidifying agents that lower levels of amphetamines. Amphetamines also inhibit the effect of veratrum alkaloids that may be taken by those with high blood pressure.
  • Antacids (sodium bicarbonate): Do not take antacids with Adderall. These gastrointestinal alkalinizing agents increase absorption and blood levels of amphetamines.
  • Diamox (acetazolamide): Diomox decrease urinary excretion or amphetamines, raising blood levels of amphetamines.
  • Antidepressants: Amphetamines may enhance the activity of tricyclic or sympathomimetic agents in antidepressants. In addition, this combination can also increases concentrations of d-amphetamine in the brain and increase the potential for cardiovascular effects.
  • Blood thinners: There may be a harmful interaction when both drugs are used.
  • Antipsychotics: Haloperidol for schizophrenia blocks dopamine receptors, inhibiting the stimulant effects of amphetamines. Chlorpromazine blocks dopamine and norepinephrine receptors, inhibiting the stimulant effects of amphetamines (which is why chlorpromazine can be used to treat amphetamine poisoning).
  • Lithobid (lithium) for bipolar disorder: The stimulatory effects of amphetamines may be inhibited by lithium carbonate.
  • Opioid pain medications: Amphetamines may increase the analgesic effect of opioids, such as Demerol (meperidine).
  • Methenamine therapy for bladder or kidney infections: Acidifying agents used in Hiprex (methenamine) increase urinary excretion of amphetamines, making them less effective.
  • Norepinephrine: Amphetamines enhance the effect of norepinephrine.
  • Seizure medications: Amphetamines may delay intestinal absorption of seizure medicines, such phenobarbital, Dilantin (phenytoin), and Zarontin (ethosuximide).
  • Cold or allergy medicines that contain decongestants or antihistamines: Both Adderall and decongestants can increase blood pressure and heart rate and these effects can be amplified when taken together. Amphetamines may also counteract the sedative effect of antihistamines.

Dosage

Adderall comes in double-scored tablets (for easier splitting) that are available in 5 milligram (mg), 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 25 mg, and 30 mg versions.

Talk to your healthcare provider about all medications, supplements, and vitamins that you currently take. While some drugs pose minor interaction risks, others may outright contraindicate use or prompt careful consideration as to whether the pros of treatment outweigh the cons in your case.

Adderall XR capsules are available in 5 mg, 10 mg, 15 mg, 20 mg, 25 mg and 30 mg versions.

As with other stimulants, the usual philosophy is to start with a low dosage that is increased gradually and in weekly intervals as needed. Never increase your dose of Adderall without your healthcare provider’s OK.

Given that there are some concerns that the drug may restrict growth in children, those taking the medication may be periodically taken off of it under the guidance of a healthcare provider to see if it’s still needed over time.

In general, the dosage of Adderall is about half that of Ritalin (methylphenidate). I.e., 20 mg of Ritalin would be equivalent to about 10 mg of Adderall.

For those switching from the regular version of Adderall to the extended-release version, the total daily dosage is typically the same. For example, if a child was taking 10 mg of Adderall twice a day (20 mg altogether), they would now take one 20-mg Adderall XR capsule each morning.

How to Take and Store

For both ADHD and narcolepsy, the first dose is typically taken first thing in the morning with one or two subsequent doses taken at intervals of four to six hours apart. Late evening doses should be avoided to prevent insomnia.

If you miss a morning dose, take it as soon as you remember. But if it’s within a few hours of your next dose, skip it and just take the next one as scheduled. If you miss a mid-day dose, skip that one and instead take your next dose the following morning since taking one too late in the day can interfere with sleep.

Adderall XR is taken once daily in the morning. If you miss a dose of the extended-release capsule, do not take it later that day. Instead, take your next dose at the regular time the next morning.

Adderall can be taken with or without food and should be stored at room temperature (ideally 68 to 77 degrees F). As with all medications, keep it out of the reach of children.

Side Effects

Although generally well tolerated, Adderall comes with the risk of side effects, especially when first taking the medication. As side effects can be serious, it’s important to be aware of them when you begin taking the drug.

If you or your child take too much Adderall, call your healthcare provider or poison control center right away, or get emergency treatment.

Adderall has not been evaluated for long-term use.

Common

The main side effects of Adderall and Adderall XR include:

  • Loss of appetite
  • Minor weight loss: Let your pediatrician know your child doesn’t appear to be gaining weight or growing as you would expect, or if you experience unexplained weight loss.
  • Insomnia (difficulty sleeping), especially if the second dose is taken too late in the day
  • Moodiness and irritability
  • Nausea
  • Constipation
  • Diarrhea
  • Headaches
  • Dry mouth
  • Increased tics for those prone to them
  • Impotence or changes in sex drive

Severe

Severe and life-threatening adverse events, including heart attack or stroke or allergic reactions, can happen with the use of stimulants. Seek immediate medical care if you have any of the following symptoms:

Many children and adults have mild side effects that may improve with time. If side effects don’t improve, your healthcare provider may have to lower your dosage or consider changing to another ADHD medication, such as Vyvanse, Concerta, or Strattera.

  • Chest pain with exertion
  • Unexplained fainting
  • Heart palpitations
  • Rapid breathing or shortness of breath
  • Psychotic episode; hallucinations
  • Depression
  • Tremors
  • Convulsions; seizures
  • Rash or hives
  • Swelling of throat or face
  • Changes in vision
  • Restlessness
  • Confusion
  • Manic symptoms, such as euphoria or frenzied mood
  • Increase in aggression
  • Slow or difficult speech
  • Slowing of growth or height in children

Warnings and Interactions

Given the potential risks associated with taking Adderall, and particularly if you have certain health concerns, your healthcare provider may want to routinely monitor your blood pressure and heart rate, perform more involved tests of the heart, and regularly evaluate your mental health to look for any alarming changes.

Consistently medicated children may have a suppression of growth and should be carefully monitored. Those not growing or gaining weight as expected may need to stop the medication.

Difficulties with vision, including blurry vision, may occur while on stimulants and may need to be monitored or the medication may need to be stopped.

It’s important that you keep up with any recommended follow-up appointments.

Aside from being aware of the aforementioned medication interactions, know that Adderall also interacts with:

  • Alcohol: Taking Adderall along with alcohol may increase the risk of heart issues and may alter perception of drunkenness, increasing the risk of alcohol poisoning or alcohol-related accidents. This combination may also mask the effects of Adderall, making it seem less effective.
  • Caffeine: Like Adderall, caffeine is also a central nervous stimulant. As such, it can amplify the potential side effects of Adderall and should be limited or avoided while on the medication.
  • Citrus fruits: Ascorbic acid (vitamin C) in citrus fruits and juices are gastrointestinal acidifying agents that may lower the absorption of amphetamines, making them less effective. You may want to limit these foods and drinks while taking Adderall.

Risk of Abuse and Addiction

Central nervous system stimulants, including Adderall and Adderall XR, have a high potential for abuse and dependence.

Since Adderall is touted in some high school and college circles (and even some work settings) as a “cognitive enhancer,” those taking it may be pressured to share or sell their medication.

This medication should never be used by anyone other than the person it was prescribed to, and parents should speak with their kids about this concern (as well as monitor their use).

Of note, some adolescents with complex ADHD that co-occurs with developmental and/or mental health conditions may need to be closely monitored for stimulant abuse, as well as suicidal ideation.

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By Vincent Iannelli, MD

 Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Dr. Iannelli has cared for children for more than 20 years.