Attention deficit hyperactivity disorder (ADHD) is a neurological disorder characterized by inattention, hyperactivity and impulsivity. ADHD medications like stimulants help increase focus and attention in people with ADHD by increasing the levels of dopamine and norepinephrine in the brain. However, as the medications wear off, the improved focus and concentration goes away and ADHD symptoms can return.
The Crash
When ADHD medications wear off, some people experience something called the “crash”. The crash refers to when the medication stops working and ADHD symptoms come back, sometimes stronger than before taking the medication. This can leave people feeling restless, irritable, sleepy and mentally foggy. The crash tends to occur a few hours after the medication has worn off as the levels of stimulants in the body decrease. The timing of the crash varies based on factors like:
- Type of medication
- Dosage
- Individual metabolism
For medications like Ritalin or Adderall, which are short-acting stimulants, the crash can happen as quickly as 4-5 hours after taking a dose. For longer-acting stimulants like Vyvanse, the crash may not hit until 8-12 hours after the last dose. Some people may even experience a “rebound” effect where their baseline ADHD symptoms come back even stronger than before once the meds wear off completely. This rebounded increased ADHD symptom state can last for hours or even days after stopping the medication before leveling off again.
Why Does the Crash Happen?
There are a few reasons why ADHD medications may cause a crash when they wear off:
- The medication creates an artificial increase in dopamine and norepinephrine. Once the medication stops working, the levels of these chemicals drop rapidly. This quick change in brain chemistry leads to the crash.
- The body may have gotten used to functioning with the elevated levels of neurotransmitters. When those levels drop off, it causes fatigue and other crash symptoms.
- ADHD stimulant medications can temporarily mask symptoms. Once the medications wear off, all the ADHD symptoms that were being held at bay come flooding back even stronger.
Essentially, the medication provides a boost in concentration, focus and mental clarity. When it wears off, all those benefits disappear which can feel like a crash back to reality.
Managing the Crash
While the crash can be unpleasant, there are some things you can do to help manage it:
- Time doses correctly – Take medication at the optimal times to avoid intense crashes. For short-acting stimulants, this may mean taking a dose after breakfast and lunch. For longer-acting drugs, once a day dosing may be enough.
- Consider extended-release options – Longer acting stimulant formulations can provide a more gradual rise and fall in medication levels to reduce the intensity of a crash.
- Don’t overdo caffeine – Consuming caffeine throughout the day can worsen the crash when stimulants wear off. Limit caffeine intake, especially in the afternoon.
- Schedule activities wisely – Plan more focused work and tasks for when medication is most effective. Save less demanding activities for when the medication is fading.
- Get adequate rest – Make sure to get enough sleep, which can help minimize the effects of the crash.
- Eat a healthy diet – Eat regular, nutritious meals and snacks to help stabilize blood sugar and energy levels.
- Consider non-stimulant medications – Non-stimulant ADHD medications like atomoxetine (Strattera), guanfacine (Intuniv) and clonidine (Kapvay) do not cause a crash, but may not be as effective.
If crashes continue to be extremely bothersome, speak to your doctor. They may adjust the medication type, dosage or timing to provide more symptom coverage and minimize the intensity of the crash. Taking as prescribed and communicating with your doctor can help balance out the benefits and side effects of ADHD medications.
Other Side Effects as ADHD Meds Wear Off
In addition to the crash, there are some other side effects that can occur as ADHD stimulant medication wears off, including:
- Fatigue – Weariness and lack of energy.
- Mental fog – Feeling spaced out and mentally unclear.
- Mood changes – Irritability, anxiety, sadness or other mood swings.
- Headaches – Due to changes in blood pressure or clenching jaw muscles.
- Dizziness – Feeling lightheaded or vertigo.
- Sleepiness – Feeling drowsy and needing to take a nap.
- Increased appetite – Cravings for food and overeating, especially carbs.
- Depression – Worsening of depressive symptoms as dopamine drops.
These side effects tend to be most noticeable when the medication first wears off but can linger for hours or days depending on the individual. The same strategies used to manage the crash can help minimize these other medication-wearing-off side effects.
Rebound Effect
In some cases, ADHD symptoms can return even worse than before taking the medication. This paradoxical effect is known as rebound or a stimulant “hangover”. Reasons why rebound may occur include:
- Withdrawal – The brain has gotten used to functioning with the stimulating medication. When it wears off, the brain is thrown out of balance.
- Dopamine sensitivity – Stimulant medications increase dopamine signaling. After they wear off, the brain may be extra sensitive to dopamine drops.
- Altered circulation – Medications cause blood vessels to dilate. When it wears off, the constriction of blood vessels leads to rebound.
- Rebound insomnia – Trouble sleeping due to stimulant hangover which further worsens next-day focus and concentration.
The rebound effect resembles the crash but with worsening of ADHD symptoms like restlessness, impulsivity, distractibility and hyperactivity. Rebound can also trigger emotional dysregulation and flares of oppositional behaviors. The intensity of rebound depends on factors like the dosage taken, individual metabolism and how abruptly the medication wears off. Rebound symptoms may only last a day but can persist for up to a week in some cases.
Minimizing Rebound Effects
Strategies to minimize rebound effects include:
- Take the lowest effective dose
- Gradually taper off medication
- Use long-acting preparations
- Allow drug holidays on weekends or vacations
- Supplement with non-stimulants like alpha-agonists
- Avoid compensatory behaviors like caffeine use
- Practice good sleep hygiene
If rebound effects are severe, speak to your doctor about adjusting the medication regimen to help smooth out the peaks and valleys in symptom control.
Afternoon Slump and End-of-Dose Wear Off
In addition to the main crash that happens when ADHD medication completely wears off, some people may experience something called an afternoon slump or end-of-dose wearing off. This tends to occur about 4-6 hours after taking short-acting stimulant medication and resembles a mini-crash.
Signs of end-of-dose wear off may include:
- Mild mental fogginess
- Some loss of motivation and focus
- Fatigue or sleepiness
- Moodiness or irritability
- Sluggishness
The dip in medication effectiveness can make completing school or work tasks more challenging. Strategies like having an afternoon snack, getting light exercise, listening to upbeat music or doing a focused activity can help counteract the afternoon slump until the next dose kicks in.
For people taking longer acting stimulant medications, end-of-dose wear off is less likely because the medication stays in the body longer. But it can still occur towards the tail end of the medication’s effectiveness window.
Comedown
The comedown refers to the gradual wearing off of ADHD medication. Rather than the abrupt crash, the comedown is a more subtle, step-wise reduction in the medication’s effects. For example, Adderall XR has a comedown that begins about 6-8 hours after the dose rather than a quick crash a few hours after short-acting Adderall.
Signs of stimulant comedown include:
- Gradual decrease in motivation and concentration
- Mild mental fatigue or sluggishness
- Waning of medication’s peak benefits
- Inability to focus as intensely
The comedown is considered less intense than the crash because it happens incrementally over several hours rather than abruptly. Taking extended-release stimulant formulations can promote more of a comedown versus a harsh crash.
Tips to Manage ADHD Medication Wearing Off
Here are some tips to help manage ADHD when medication is wearing off:
- Time doses correctly – Take medication at ideal times to optimize coverage and prevent intense wear-off effects.
- Consider XR/LA formulations – Extended release versions provide longer symptom coverage with a gentler comedown.
- Communicate with your doctor – Work with your provider to adjust medication type, dose or timing if needed.
- Limit caffeine – Caffeine can exacerbate medication wearing off, so reduce intake especially in the late afternoon.
- Prepare for wear-off periods – Schedule tasks strategically and line up activities to match your medication cycle.
- Stay hydrated and eat well – Drink enough water and have nutritious snacks and meals to maintain energy.
- Use coping skills – Utilize cognitive behavioral techniques, exercise, mindfulness or other means to help counteract wear-off difficulties.
- Consider non-stimulant medications – Certain non-stimulant medications can smooth out effects and don’t have a crash.
- Get enough rest – Prioritize sleep, which can minimize the effects of medication wear-off.
While ADHD medication wearing off can be frustrating, being proactive and communicating with your doctor can help. Finding the right medication regimen takes some trial and error. But identifying strategies that work for your situation can allow you to manage symptoms throughout the day.
Conclusion
When ADHD medications like stimulants wear off, people may experience a “crash” where symptoms rebound. The crash often involves fatigue, mood changes, mental fog, and return of ADHD symptoms like inattention and hyperactivity. In some cases, there can be a rebound where ADHD symptoms get even worse after the medication stops working. Taking medications correctly, choosing longer-acting options, getting adequate rest, and communicating with your doctor can help smooth out the peaks and valleys of symptom control as medication wears on and off over the course of the day.