Client dialogue - following up on medication with Josephine

Introduction

What follows is the continuation of my conversation with Josephine, the client with whom I wrote the post, Client dialogue: Adhd and Trauma and Bears... oh my. In the original post, we explored how women’s adhd is often misunderstood or missed by the medical system, leaving many feeling broken and unseen. Getting diagnosed gave Josephine a sense of clarity and a foundation to understand herself better. Medication helped calm her mind, making her feel more connected to her body and capable of making choices without constant anxiety or intrusive thoughts about danger or trauma.

We also discussed how trauma and adhd are linked—how past fears can haunt present decisions—and how discovering the absence of that constant chase allows for more deliberate, authentic living. This process is about moving from survival—being chased by the “bear”—to self-acceptance and growth.

And so, the reader might think, that's the end of the story: Josephine was on her way, and things were both hunky and dory. Though things were certainly better, Josephine struggled—as many do—with medication. I have a little saying that I use with clients about medication: the necessity of finding the right medication at the right dose. But as I think about that phrase, it is missing something: time. The updated version is as follows:

the right medication at the right dose that provides the right duration of support.

What follows is Josephine's story about her pursuit of those three aspects of rightness. I'll give away the ending here: she did, through hard work and perseverance and self-advocacy, arrive at a reliable and sustainable dose of a medication, which she has continued to take over a number of months.

Note to Readers: In Josephine’s story, she shares that she took an amount of medication outside of her doctor’s prescribed dose. It’s important to emphasize that self-medicating without medical supervision is not recommended. Proper diagnosis and treatment plans should always be guided by qualified healthcare professionals to ensure safety and effectiveness. This story does not condone or endorse self-medicating; instead, it aims to illustrate personal experiences and insights within a therapeutic context.

Nov 22, 2025 (me)

It's been a few months since I published our email dialogue on my blog. I have heard from a number of people that reading your story has meant a great deal to them. This is particularly true for women. But I had a session with a client the other day who has been struggling to find the right dose of the right medication (though in their case, the challenge has been getting their doctor to be attentive and take their condition seriously). Nevertheless, this client—who has been struggling to find the right medication at the right dose—was envious of how quickly you found a medication that worked for you, because that is how we portrayed it in our dialogue. It is clichéd to say, but... things are always more complex than they appear.

One of my lifelong struggles with writing is this underlying, gnawing concern that... what happens if I got something wrong, or was misguided, or was ignorant, or just plain dumb? By that logic, it is always better to have not written something for others to read, because if I don't publish it, I can't be wrong or misguided or ignorant or dumb. So... not making my writing—my ideas, my imagination, my creativity—available to others is always the safe thing to do. And by that token, I have led a very safe life.

That is all to say... it was good and appropriate to have published our dialogue when we did, rather than to have sat back and waited for all the details to have been collected. This is not a correction to our original piece of writing, but rather an addendum. That is, there is some complexity to the story about which we were unaware when the story was published. Actually... there is an enormous amount of complexity that has revealed itself since the story went live on September 2, but the thing we're going to focus on is the complexity around medication.

Can you introduce your own story of finding the right medication at the right dose? This is a phrase I like to use because, over the years of doing this work, I have known many clients who were on the right medication but an inappropriate dose—both too much and too little. I have known clients who were on the right medication but were given a formulation of that medication that didn't work for them. And, of course, I have known many clients who were simply on the wrong medication. As a result, it feels important to make sure that clients are on the right medication at the right dose.

I thought I would also offer my own story. When I got my diagnosis, at 52, I started on a long-acting stimulant formulation called Foquest. Foquest is the newest of the long-acting methylphenidate (Ritalin) formulations. The other options available in Canada are Biphentin, Concerta, and Methylphenidate SR. Foquest is, by far, the superior of these four.

The first day I took Foquest at the right dose (for me, 45 mg), I felt transformed. It was one of those experiences folks with adhd diagnosed as adults often describe. On that first day at 45 mg, I became aware that I had been living life as if I had been playing a video game in hard mode and, for the first time, was able to toggle to... a less hard mode. I thought I was set. But after a few days at 45 mg, I started to experience problems—namely stomach and oesophageal problems. As you can imagine, I was crushed. A solution was available to my lifelong problem, but I could not take advantage of it.

It turns out that stimulant medications can, for some, produce an excess of stomach acid. And if there is a preexisting injury or condition, that stomach acid can travel up into one's oesophagus and cause GERD: gastro-oesophageal reflux disease. This is what I experienced. And for me, that stomach acid (and other products of the stomach, such as digestive enzymes) travelled all the way up to my vocal cords, which can cause sore throat, loss of voice, and a host of other extremely unpleasant symptoms. It took some time for it all to sink in, but it pretty quickly became apparent that I could not take this medication.

But I kept at it. I had found a medication that was extremely helpful, and I needed that help. I was a new(ish) counsellor in a new(ish) practice, and I had a blended family with four children. I tried all the other long-acting stimulant medications. Vyvanse produced the same issues as Foquest. I tried the generic version of Adderall XR, and it worked great. On the first day I tried it, I had a very positive day, but... that evening I didn't go to sleep until 5:30 a.m. So... no dice on the Canadian version of Adderall XR. Lots of swings, and nothing but misses.

Long-acting medications are almost always tried first, and I tried them all. But for a variety of reasons, I couldn't take any of them. It should be noted that this process took months, and that is with a doctor who was and is extremely supportive. For every different thing we tried (and this is true for increasing doses too), I had to make an appointment. Part of the challenge of adhd is scheduling and planning. The whole thing was extremely challenging... but I did ultimately find a solution. I found that if I took the fast-acting version of Foquest—old-school Ritalin, first synthesized in the 1950s—I could get much of the positive effect without the entirety of the negative effect.

The point of my story is that the process can be long and trying and might ultimately produce less-than-perfect results. Reading this sentence made me laugh because... it's not the happiest of endings, and the endings that were available came at a cost. But, as they say: so it goes. In the end, I have a medication that works reliably and having to take it three or four times a day is not an issue for me (though it is definitely an issue for many clients who struggle with feeling situated in time). It is not uncommon that those of us with adhd, both for organic reasons—i.e., the uniqueness of our own bodies—and for medical/administrative reasons—doctors' variable care and willingness to work with patients to find solutions—the road to finding pharmaceutical supports and solutions can be a very long one.

That is to say: it is worth sticking with it, because partial solutions are preferable to no solutions at all.

Josephine's medication journey

Nov 22, 2025 (Josephine)

We did say initially that this writing project may be a work in progress, and with that, here we are...

As you know, I was diagnosed in early July 2025 by a nurse practitioner (NP) who specializes in adhd, and because I am impatient—and once I decided that I was ready for a diagnosis and medication—I did not want to wait for an appointment with the specialist that you recommended. I would have needed a referral from my GP, only to wait another 5–6 (or more) weeks to see a specialist to get a diagnosis... (YES, I waited decades and decades to know what was really going on, but there was no way—once I KNEW—I was NOT going to wait any longer than I had to). So, I paid for the appointments (the service is not covered by MSP). (My extended health insurance has a spending plan where NPs are covered 100%.)

I was diagnosed (no surprise there), and on the same day, the NP prescribed me Vyvanse. I started with the lowest dose, 10 mg, a couple of days later and moved up to 30 mg by week 3 (titrating). It's important that I point out here that, at this time, I did not know the generic version of Vyvanse that my pharmacy automatically prescribed me (without asking or telling me) is less effective than the actual brand name (I found this out after it was too late). (And there was no insurance reason for the substitution, as my provider would have covered it.) I will tell everyone who will listen: if your insurance provider will cover it, ask the pharmacist not to substitute it.

Okay, back to the story:

I was up to 30 mg and it was working well, and then it started to wear off early. I figured, okay—this is just my body getting used to it—so at my next appointment with the NP, I told her, and she gave me a 10 mg booster to take around noon (I wake up around 6 a.m. and take my meds when I wake up). I was experiencing some heartburn and acid reflux, so she also prescribed me pantoprazole (taken the night before) for that.

Now I had just under a 2-month supply of 40 mg and closed my membership with the company that the NP worked for, because I was all set and done, and my GP could refill the prescription when I was ready.

This was where I was when we wrote our first part of this dialogue.

Fast forward two or so weeks and now the 40 mg wasn't lasting either. I was crashing out around 3:00 p.m., and I still had hours to go in my day with work and life. The crash on lisdexamfetamine (generic Vyvanse) is harsh: you are going about your day and all of a fucking sudden, it's like you stepped off a cliff—no warning. Just boom: eyes are heavy, sounds are louder, lights brighter, and everything that seemed fine mere minutes ago is now aggravating and overwhelming. It's not a great feeling.

I had to book an appointment with my GP and explain to her that I have adhd and the meds that have been prescribed have worked really well, but now they are not lasting long enough. To say the least, I was a little apprehensive (a lot), having to book the appointment (which, thankfully, was a phone call and not an office visit), because (of course) I was thinking of all the things that could possibly come up:

• What if she doesn't believe that adhd is real!??
• What if she thinks that I am a drug addict?
• What if I don't even have adhd?? (the feeling of “impostor syndrome”)

I had the whole dialogue in my head about what I was going to say and do if she denied my diagnosis and all the terrible things that could possibly go wrong... I had big plans... You and I talked about this at length.

She was fine. She seemed to understand the basics of adhd and asked me a few questions to see if I had any side effects like racing heartbeat, anxiety, loss of appetite, and any issues sleeping. I let her know that this was all negative, and she upped my dose to 50 mg—30 in the morning and the other 20 when needed.

Finally, I had the dose that was working for me!

—I’ll leave it here for now, as you wanted an introduction... I’m working up to the SHIT part. I can continue on, but then it isn't a dialogue now, is it? ;)

Nov 24, 2025 (me)

This is a great introduction to your experience with medication and fits with the experience of many of my clients over the years.

A couple comments, and then back to you for the remainder of your story. You bring up a couple important issues in your introduction:

• First, the experience of a post-stimulant crash,
• Second, the distinction between brand-name and generic medication.

The crash you experienced is a common experience during the titration period. Titration simply means the process where a person increases her dose of medication toward finding the optimal therapeutic dose. It is a critical part of the process, and it can take some time. It is important to say this, because both doctor and patient need to be prepared to try different medications at increasing doses with some regularity. This is a trial-and-error process, and it can be frustrating, but it is a worthwhile process to put resources toward.

For instance, it is not uncommon that clients get an adhd diagnosis late in life, and it is this kind of revelatory “holy shit” moment that explains so much about so many things over so much time. And then it turns out that there is this class of medication—stimulants—that are extremely effective. You go to your doctor and she prescribes you a month (sometimes two) of medication and tells you to come back at the end. Often, doctors do not make an appointment with their clients for the end of the prescription, so after 4 or 8 weeks the prescription runs out and then another appointment is made. What this amounts to is giving clients a prescription that will inevitably be insufficient, which then runs out. Not great.

Folks who are diagnosed with adhd are not experts in the medical system or experts in stimulant medications. Doctors are experts (or should be). Doctors should know that early on in the titration process, patients on too low a dose of stimulant medication will metabolize the medication before the day is done, and when that happens... they experience a crash.

This crash can take a number of forms: crushing fatigue and/or emotional dysregulation. This is how it often goes: you start on, say, 20 mg of Vyvanse. And the first couple of days you think, “Jesus Christ. Is this how neurotypical people walk around?” The world gets much quieter, you have the metabolic resources to run your body, and you can get things done. But after a few days of this, you start to notice that sometime in the afternoon, to use your description, “you step off a cliff.” After you step off the cliff... you crash hard into the ground. This is normal and is not a problem—except, of course, for how you feel that day.

A crash is simply a message that the dose you are on is insufficient. But what if you are in the situation, as a current client is, where the person who made the diagnosis and prescribed medication is uninterested in the fact that every single day at 3 p.m. it feels like gravity has increased in intensity by five times? When the titration process is not well handled by one's doctor, it can feel extremely dispiriting. I sometimes have to cajole clients into sticking with it, because it can feel like diagnosis and medication was a kind of existential joke played on us by the universe.

I'll give one more dramatic example of how this process can go terribly wrong when not handled properly by a medical professional: I had a client a few years back who, when I first met him, had his diagnosis for seven years. He was a person in his 40s. And when he and I first met—seven years after he had been given his diagnosis—he was still on the opening dosage of his medication, an older long-acting stimulant called Concerta. For seven years he had been on 18 mg of Concerta, and when I asked him about the medication's efficacy, he shrugged his shoulders. He had done the hard work of getting his diagnosis and getting medicated. But the dose that he was on was no more effective in treating his adhd than if he had been taking a sugar pill. Seven years prior, his doctor had never inquired about whether the medication was doing what it was meant to do. And because he was neither an expert in adhd nor stimulant medication, he thought that this was the most he could hope for. This is a dramatic example of the ways in which our medical system—and the people who practise within it—are disposed to working with those of us with this condition, but it is not an uncommon one.

The second issue you bring up is the distinction between brand-name medications and generics. I'll be honest... I was skeptical about this one. A couple of years ago, the patent on Vyvanse ran out, which meant that other manufacturers could start producing the drug. Vyvanse is an ingenious preparation: it is a kind of medication called a prodrug. What this means is that when you take Vyvanse, you aren't taking dextroamphetamine. You are taking dextroamphetamine bonded to an amino acid called lysine. Your body does the work of metabolizing the medication into the active drug.

Knowing this, it seemed to me impossible that the generic version would be less effective. But I have heard from both clients and pharmacists that there are clear differences for some. And the difference that I hear most commonly is around the duration of action, which gets us back to crashing. Thinking of one particular client: they found that 30 mg of the generic preparation was more intense during the day, and then they fell off a cliff at 3 p.m. After they started on the brand-name drug, they noticed the duration of action being extended to 6 p.m.

This is important for two reasons. First, crashing at 3 p.m. obviously stinks. But it also means that too much of the drug was being delivered to their system earlier in the day. After a point, more is definitely not better. We're trying to find medications that help quiet the various noisiness that is the hallmark of adhd: auditory, visual, food noise, emotional, memorial, existential, etc. Stimulant medication can be transformative in this respect. But also... when we take too much stimulant medication, we become (and you're gonna be surprised by this)... overstimulated.

Back to you.

Nov 24, 2025 (Josephine)

Okay—well fuck—I missed the mark... alright, I’ll recalibrate and come back to it. :)

Nov 24, 2025 (me)

Not at all. It's just that... you know me... when ideas are introduced, I like to expound on them. I like what you wrote, and it helped to get the ball rolling. I don't think there are any marks to miss. I want you to tell your story as you see fit. And then it's my job to offer some explanations and anecdotes to give a larger context.

Nov 24, 2025 (Josephine)

Okay, THAT makes sense! I thought that I fucked that all up and you wanted me to change it... adhd RSD strikes again! :p Cool.

Nov 24, 2025 (Josephine)

Having a dose that worked for me felt great. Sure... I was carrying around extra booster pills in a little keychain pill container if I was out for the day, but it was worth it. The fact that I was out and not overwhelmed—I didn't care that I had to pop another couple of pills to get me through the day. If this was my “new life”... I'm in!

Until they were no longer getting me through the day again. I thought that something was wrong with ME. Why doesn't the dose that my doctor said would work actually work?! So I built up the courage to make another doctor's appointment. At this point, I had done research (online) and read that the maximum adult dose for Vyvanse was 70 mg for adhd, so I figured, hey—what is there to lose? She's just going to up my dose, because... the internet said! Yeah, I was mistaken...

Instead, she said that I should try Foquest. I had heard of this. It was also a stimulant medication and was said to last up to 16 hours with one dose in the morning... SIGN ME UP! I was excited to try it. And then the bomb fucking dropped: she said that because it is a different stimulant, I would have to titrate again—which I couldn't wrap my head around. I already have been doing great on the other stimulant; what difference could it make?? She proceeded to tell me that she was going to start me at 25 mg and that “it will probably not do anything for your adhd symptoms until you're on a much higher dose,” and to take these for 2 weeks and make another appointment to discuss going up a dose.

I got off the phone with her and immediately emailed you saying, “What the fuck am I going to do with a much lower dose of the meds for weeks on end until the dose is right!?” and “I cannot go back to ‘before meds,’ and this is going to be a disaster.”

I was panicked and freaked out, but most of all I was pissed off at myself for not just “sucking it up” and dealing with the crash instead of asking her. And, of course, as you do, you talked me off the proverbial ledge, and we hoped that she would get me to an appropriate dose without having to go dose by dose (25 mg, 35 mg, 45 mg, 55 mg, 70 mg, 85 mg, 100 mg), as this could take over THREE months. You said that 25 mg is a pretty low dose, BUT IT IS NOT NOTHING, and that 50 mg of Vyvanse was roughly equivalent to 70 mg of Foquest. FUCK... I immediately started to count out how many doses of my Vyvanse I had left as a backup... I had just under a month's worth left.

So off I go to the pharmacy to pick up my new meds, feeling defeated, worried, and outright pissed off. I get to the counter and the pharmacist says to me, “She's only given you 25 mg??” I said yup, and she shook her head and said, “No, I am going to fax your doctor right now and tell her that this is too low!” Yes, you read that right: FAX! I wasn't going to linger on the fact that they still use insecure ancient technology to send personal information back and forth. I was just happy that this amazing human took the time out of her evening to advocate for ME. She asked me to check back with her, and if they hadn't heard back, to call my doctor and push for her to read and respond to the fax.

Four very long days later (me checking in every day), the receptionist at the doctor's office finally contacted the doctor and told her to fax the prescription to the pharmacy.

Five days after the initial appointment to change my meds, I got a call from the pharmacist that the doctor prescribed 45 mg. I was happy that it was 2 doses above the lowest. This was better than what I was expecting. I was feeling happy to give it a try, so the next day—which was a work day—at 6:30 a.m. I popped the 45 mg and waited.

Okay... that seems alright. It was quiet, and I had some energy in the morning to get stuff done. The first 2 hours were great and work wasn't super busy or stressful, but I could feel myself fading. I amped myself up on massive amounts of coffee and that pushed me through, but it was not lasting as I had hoped.

The next day was my day off. I was awake at my regular time, 6 a.m.—no sleeping in for this busy brain. Again, I take the meds, and in the morning I have the energy to get my laundry done. I drive the kiddo to university, and I have “big” plans: I have to drop a package off at Staples and then go and buy eggs. I have only had one cup of coffee and don't think about it, because on the Vyvanse I couldn't drink more than one coffee or I'd be overstimulated.

It's now around 11 a.m. and I'm standing in line at Staples, and it's brighter and louder than I remember it being. Why the fuck is this guy in front of me bouncing up and down like Tigger, and why is he irritating me so much that I feel like kicking him??

And... then BOOM... it fucking hits me... I AM NO LONGER MEDICATED! I need to get the fuck home—like 10 minutes ago. There is no way I can go to the grocery store. I will have to live without eggs. I get home safe and sound, but now it's only 11:30-ish and I am done. There is nothing more I can do but drink a shitload of coffee.

Interesting, though: on these new meds, the crash wasn't as drastic. It crept up on me slowly. I still didn't “see” it coming, but I felt a little less like shit on the crash than I did on Vyvanse.

By the time I had to go back to work, I said there was no way I could do this, and I took my Vyvanse instead (my doctor did not specifically say not to go back to my old meds, so in good adhd fashion, I just did whatever I needed to fucking do). I then booked another appointment—5 days after I picked up the first prescription—with the doctor.

I made sure that I took my prescribed dose of the Foquest on the day of the phone-call appointment and let her know that these are not doing the trick and that I need a much stronger dose, because I was anxious and overwhelmed and couldn't perform my day-to-day activities without it taking a tonne of energy and resources. And do you know what she said? “Well, anxiety is a different issue.” (Fuck you!! I did not say that, although I really, really wanted to.) I sat through her little “talk” and let her know that since starting on the stimulant medication—when it was working as it should—I had absolutely no anxiety whatsoever.

So she prescribed me 55 mg. Here we go again: it was better but not yet what I needed. I tried it for two days. It lasted until around noon and then same shit, different week.

Then I did something that I will not condone (in other words, “don't do this at home”). I took 2 × 45 mg just because I needed to get shit done and said, fuck it—what is the worst thing that can happen? “Oooh, I might be overstimulated for a few hours.”

The result: DAMN. I was focused, I got a tonne of stuff done. It may have been a little too much at the time, but I felt the best I have felt since first starting the meds—clear, quiet—and I was breathing again.

Another appointment, 5 days later (even though she gave me two weeks' worth of meds every time and told me to book the appointment in two weeks—I was not waiting). She asked me if I have ever been on SSRIs for anxiety. I rattled off the LONG list of all the meds that I have been prescribed (we know the story from part 1), all the specialists, AND that I had waited a year to be seen at the Stress and Anxiety clinic—and nothing worked—because I DO NOT HAVE AN ANXIETY DISORDER. I have ADH-FUCKING-D! Seriously, why can she not understand this!?

So she wrote me my “last” and strongest dose of Foquest that she was going to write for me and gave me 30 days' worth, and basically said that “this is it,” and discussed that if this doesn't work we can add something like “dex” to it or move to dex. I kind of stopped listening when she said that she was cutting me off at 70 mg when the next one would have been 85 mg and then 100 mg—making me feel like I was begging for “drugs.”

Nov 27, 2025 (me)

Note to readers: I wrote back to Josephine a very long and excited response. She had hit on something that I had been thinking about for years: namely, the relationship between adhd and anxiety, and I took advantage of the opportunity.

Josephine and I spoke about it and decided, together, that the discussion around the relationship of adhd and anxiety was its own topic, and that we would, when time permits, spin this off into its own dedicated discussion.

Stay tuned: more to come on this topic!

Fun with insurance!

Nov 30, 2025 (Josephine)

So, I pushed through and took the 70 mg for a couple of days, when I realized that this dose STILL wasn't enough. You and I had a session at like 1 or 2 p.m. on day two, and I had taken my meds at 6:30 a.m., and they were all but worn off by the time we met—and it was pretty obvious. I felt disorganized with my thoughts, overwhelmed, and just outright unmedicated.

I was done waiting for my doctor to hear me. It was pretty clear from the last couple of conversations that I had with her that her understanding of adhd was not going to get better. She was not invested in learning any more than what she already “knew,” so I was at a loss. She even said at one point that having adhd is something that people live with every day and that it wasn't an emergency for me to get the right dose. Sure, it wasn't an “emergency” in the sense that I was going to be terribly ill or be in agony... but knowing that my life had improved dramatically since taking the meds—and seeing what they CAN do when they do work—was pretty hard to forget. I really just wanted to get back to that place.

Don't show me what I had been searching for my entire life and then just snatch it away. That is to say, it felt like an emergency to me.

The next morning I said, “fuck this,” and took 2 of my 45 mg doses of Foquest and signed back up for the paid subscription for the company that employs adhd specialists. Why we have to pay for health care like this isn't fair, but it is what it is, and at least I had another option.

I reached out to my NP, and she asked how the higher dose was working for me. I let her know that it works, that it lasts as long as I need it to, and that I have no side effects.

I noticed that Foquest is a much gentler stimulant than I found with Vyvanse. Of course, in the beginning, I didn't—or wouldn't—have known any better. We went through the background on the titration that my doctor had me on, and she wrote me a two-month prescription of 90 mg, which has been working incredibly well for me. It's probably a much higher dose than most people need, but it is just perfect for me: not too soft and not too hard—just right (I felt like a Goldilocks and the Three Bears reference was appropriate here).

Everything had been going great, and then a letter showed up in the mail from my insurance company telling me that they need a Special Authority Form (or something to that effect). They wanted the government to pay for a portion of the meds because they are costly, and I had to get this form signed by my doctor or nurse practitioner.

Okay... no big deal... I send the form to my NP, and she tells me that she can't sign it until I try a different version of the meds that I am taking. I was instructed that I would have to take a medication called Concerta (which is the same drug—methylphenidate—but not as long-acting as Foquest) for a week.

I freaked out and asked her, “Why would I try a different med when I found the one at the dose that works for me?” She said that it is a requirement that I have a 7-day trial period on the less expensive one so that we can fill out the form to say that Foquest worked better.

I thought it was a fucking joke... you have got to be kidding me. And yeah, you heard about it. I was pissed off... and you put me at ease and let me know that this is really a thing and that I would need to comply with the request.

I picked up the new prescription, and at least it was close to the same dosage as the Foquest. I took it the next day and it was not right for me. It did not last as long as I needed.

And here we are today: the 7-day trial of Concerta is over, and the paperwork will be sent to the insurance company so they will pay for my prescription.

I have found the right meds at the right dose for me. It has been frustrating and disheartening, and now I know that I can't trust my doctor with my adhd care. But I got through it and am on the other side now!

I wanted to express my endless gratitude to you, Hart, for always being here and helping me push through this, because without your support I wouldn't be where I am today. As you once told me,

Viktor Frankl, the great existential therapist, wrote that if you know the why, you can bear any how.

Dec 4, 2025 (me)

There are so many threads to pull in hearing your story. There are two in particular I'd like to pull on: the hoops many of us must jump through to get to the point where we can say that we have found the right medication at the right dose (and then be done with the process), and your admission about taking more medication than was prescribed to you in the process of finding that right dose.

First... hoops: it is simply the case that we live in a society in which there are rules and procedures and prescribed sequences in which things happen. That is particularly so for all things medicalized. And for clarity, there are important reasons why these ways of doing things exist—most notably for safety reasons, i.e., when working with medications that can be potentially dangerous (as any medication can be). But it is also the case that the reason we engage in medicalized processes is for our own wellbeing, and that can sometimes get lost in these prescribed ways of doing things. This is the tension that we are always in with our doctors and medicines and procedures.

But then... there are also insurance companies. Insurance companies have their own principles and sequences. And since insurance companies are businesses, and businesses have a fiduciary responsibility first to their shareholders, insurance companies must find ways of maximizing profits. And the main way that insurance companies maximize profits is to spend the least amount of resources they can on those they insure. I certainly have lots of thoughts on the ethics and politics of this, but all I am doing here is stating the simple facts in a neutral way. Insurance companies are businesses first, and as such, their first principle is not the wellbeing of their clients but the wellbeing of their bottom line.

That insurance companies are businesses first is the reason you were instructed to first try Concerta before Foquest. Is Concerta a better medication? It is not. It is a less expensive medication. And so... you must try the cheap stuff before you are allowed the effective stuff. That is the sequence in terms of insurance.

In all my years of working with clients with adhd, I have known one single person who has preferred Concerta over Foquest. I have worked with many dozens of clients and their doctors to transition from Concerta to Foquest, because Concerta, in nearly every instance, does a poor job of delivering the active medication—the stimulant called methylphenidate—over the course of an entire day.

In the literature, Concerta's duration of action is rated at 12 hours. This is a very important bit of information, because if a person with adhd takes their medication at, say, 7 a.m., it should be in their system until 7 in the evening. That means the stimulant should be active in one's system throughout the work/school day, including getting home, preparing dinner, etc.

But what happens in nearly every single instance with every single client who takes Concerta is that the medication gets delivered and metabolized and is out of people's systems by 3 or 4 in the afternoon. For many with adhd, this is precisely the time when it is most necessary to have the medication active in our systems, because this is the time when it is most common to feel fatigued.

The cherry on top of this Concerta sundae is that not only do people experience the standard fatigue of an afternoon slump, but many people experience what is commonly referred to as a “crash.” We talked about this earlier in this dialogue, because this is the same thing you experienced on generic Vyvanse. A post-stimulant crash in the afternoon can be anywhere from unpleasant to disastrous, because this sets a person up for a poor evening. What I am about to say is important to hear both as a patient/client and for those who prescribe these medications:

Concerta simply does not live up to its purported 12 hours of duration. Foquest, on the other hand, is rated at 14 hours, and that rating is accurate. This means that if you take your medication at 7 a.m., it is active in your system until around 9 p.m. This allows clients to feel confident that they will not suffer an afternoon crash and will have metabolic resources to get home, get dinner prepared, deal with children, etc.

And for reasons that are not entirely clear to me, when long-acting stimulant medication works properly—that is, gets one all the way through the day and into the evening—there is no crash. The only caveat with long-acting stimulants such as Foquest is to make sure that it doesn't affect getting to sleep. This is rare but can happen.

Dec 4, 2025 (Josephine)

You make an excellent point about how the medication NEEDS to work for when we have LIFE to deal with, not just work or school. It sucks how the medical field doesn't give a shit about our actual wellbeing—only that we behave in “public” for as long as deemed necessary to appease the masses. No one cares if we are mean or impatient to our kids or partners or can't handle making dinner/going shopping/doing laundry (the list goes on and on), because we are too overwhelmed after the meds wear off.

The right medication at the right dose for the right duration

Jan 3, 2026 (me)

To recap: you have now been on 90 mg of Foquest for a while. We've written back and forth about your experience in getting here. You've been through just about every up and down on the way to getting to the end (a medication and a dose that works reliably for you). Here's the rundown:

1. You've had the original “holy shit” experience of realizing what medication can do.
2. You've had the experience of your medication not lasting an appropriate amount of time, i.e., afternoon crashes.
3. My recollection is that your doctor offered you lower-dose supplements that you were taking later in the day to help you get through the entirety of the day.
4. You then switched from an amphetamine-based long-acting medication to a methylphenidate-based medication.
5. You originally switched to Foquest, which eventually proved (at the right dose) to be an effective once-a-day medication.
6. After switching and finding the right dose of the right medication, your insurance provider directed you to trial another long-acting methylphenidate formulation, Concerta, because... it's less expensive.
7. You did that and found that it was not as effective as Foquest.
8. You have now settled on the right medication at the right dose.
9. In total, this process has taken you approximately 5 months.

Five months might seem like a lengthy amount of time to get to the finish line, but I will say that you have expedited the process substantially. I've had clients for whom this process has taken years, because if you don't advocate for yourself—as you have done—doctors will often start at the very lowest dose when starting a new medication. And most doctors will wait weeks (sometimes months) between increasing doses. Imagine if, with each change in medication, you had to start at the lowest dose and titrate upward by 10 mg every 2–4 weeks.

Jan 7, 2026 (Josephine)

I'm having a hard time figuring out how to wrap this up, so I'm just going to start typing and see where it goes: I've been on Foquest at 90 mg now for almost 2 months, and it's working well. I have a check-in appointment with my NP on Friday for my prescription refill, and this is the first time having a follow-up where I can actually say that everything is going really good and that I don't need a higher dose. My headspace is good. I have enough mental and physical energy to get through the day and EVENING, with only a very slight dip in the mid-afternoon when I have lunch and a coffee. I feel what I would think “normal” feels like... what people who don't have adhd feel like, and I really like it.

I'm loving that I'm sleeping well, have the drive to get daily exercise in, and I could drink alcohol if I wanted to but don't have any desire to.

I think that's where I'll end this chapter.

Jan 8, 2026 (me)

Honestly... I can't think of a better place to end, though... this event we are calling an “end” is a kind of beginning. You have gotten through the technical and medical and administrative process that we all have to go through—if we're lucky—to get to the sort of place that you describe: where you are no longer running from the bear, where you no longer feel that there is something irretrievably wrong with you, where you no longer have to use cruelty against yourself to get things done, and where—and this is the beginning part—you can grow emotionally.

I couldn't be more grateful for your participation in this and our former dialogue. Many clients and readers have let me know how valuable that first part has been to them, and I have no doubt that this dialogue, which has focused on the challenges of getting the right medication at the right dose, will be viewed similarly.