What is the best approach to wean off Adderall (amphetamine and dextroamphetamine) 20mg after restarting it 3 months ago?

Weaning Off Adderall 20mg After Recent Restart

The safest approach to weaning off Adderall 20mg is a gradual taper of 10% of the original dose per week, which would take approximately 10 weeks for complete discontinuation.

Understanding Adderall Dependence

Adderall (amphetamine-dextroamphetamine) is a Schedule II controlled substance with high potential for dependence. After just 3 months of use following a previous history of use, physiological dependence is likely to have developed. Abrupt cessation can lead to:

• Extreme fatigue and mental depression
• Changes in sleep patterns
• Irritability and mood disturbances
• Withdrawal symptoms that can mimic or exacerbate underlying ADHD symptoms

Recommended Tapering Protocol

Initial Assessment

• Confirm current daily dose (20mg)
• Determine formulation (immediate-release or extended-release)
• Assess for any cardiovascular complications that might have developed 1

Tapering Schedule

1. Weeks 1-2: Reduce by 2mg (10%) to 18mg daily
2. Weeks 3-4: Reduce to 16mg daily
3. Weeks 5-6: Reduce to 14mg daily
4. Weeks 7-8: Reduce to 12mg daily
5. Weeks 9-10: Reduce to 10mg daily
6. Weeks 11-12: Reduce to 8mg daily
7. Weeks 13-14: Reduce to 6mg daily
8. Weeks 15-16: Reduce to 4mg daily
9. Weeks 17-18: Reduce to 2mg daily
10. Week 19: Discontinue

This schedule follows the Mayo Clinic Proceedings recommendation of a 10% reduction per week for patients who have been on opioids or stimulants 2, 3. For those who have been on Adderall for a shorter period, a slightly faster taper may be tolerated.

Monitoring During Taper

Monitor for withdrawal symptoms at each dose reduction:

• Fatigue and excessive sleepiness
• Increased appetite
• Depression or anxiety
• Irritability
• Difficulty concentrating
• Sleep disturbances

If withdrawal symptoms become severe, maintain the current dose for an additional week before proceeding with the taper.

Adjunctive Treatments

Consider the following supportive measures during the tapering process:

• For sleep disturbances: Short-term use of trazodone or mirtazapine 2, 3
• For anxiety/irritability: Brief use of benzodiazepines (with caution due to their own dependence potential) 3
• For autonomic symptoms: Clonidine may help with some withdrawal symptoms, starting with small doses and monitoring for hypotension 2, 3
• Non-pharmacological approaches:
  • Regular exercise
  • Stress reduction techniques
  • Adequate sleep hygiene
  • Cognitive behavioral therapy

Special Considerations

Protracted Withdrawal

Be aware that some patients may experience protracted withdrawal symptoms months after discontinuation, including:

• Dysphoria
• Irritability
• Insomnia
• Anhedonia
• Vague sense of being unwell 2, 3

These symptoms should be discussed with the patient in advance to set appropriate expectations.

Alternative Treatments for ADHD

If the patient still requires treatment for ADHD after Adderall discontinuation, consider non-stimulant options:

• Bupropion (norepinephrine and dopamine reuptake inhibitor)
• Viloxazine
• Atomoxetine 2

Common Pitfalls to Avoid

1. Tapering too quickly: This increases risk of withdrawal symptoms and relapse
2. Not providing adequate support: Psychological support is crucial during the tapering process
3. Ignoring cardiovascular monitoring: Adderall can cause cardiovascular effects that should be assessed during tapering 1
4. Failing to address underlying ADHD: Have a plan for managing ADHD symptoms that may re-emerge during tapering

When to Slow or Pause the Taper

• If withdrawal symptoms become intolerable
• During periods of high stress
• If significant mood disturbances develop

By following this structured approach, most patients can successfully discontinue Adderall while minimizing withdrawal symptoms and maintaining quality of life.