Ed Note: This post is by Johanna Ryan who covers most of our stimulant related topics.
Dr. Larry Diller is a pediatrician who specializes in children’s behavioral problems, especially Attention Deficit Hyperactivity Disorder (ADHD). He’s by no means anti-medication; he has prescribed stimulants to kids for decades. But twenty years ago he was already concerned about their overuse, and a tendency to over-diagnose ADHD in children. His 1998 book Running on Ritalin reported on a worrisome shift to diagnosing ADHD in older teens, and even in adults for the first time. It ended with this “ominous question”:
“As competition on every level intensifies, our preoccupations as a culture increasingly center on performance. Are we likely to see a time in the not-so-distant future when a large part of America will be running on Ritalin?”
That time has come, says Diller – and it’s worse than he could have imagined in 1998:
Today’s ADHD drug of choice is Adderall, not Ritalin. Now, it’s older teens and adults who are fueling an emerging epidemic of abuse and addiction. The not-so-distant future is here: We are living in the United States of Adderall.
The final chapter of “The United States of Adderall”, Diller’s four-part series for the Huffington Post, is available here. It contains links to the first three installments.
The over-prescription of Adderall and Ritalin to children is troubling, says Diller, but the rise of “Adult ADHD” diagnoses is even more dangerous. Clinical experience shows that adults are far more likely than children to like the effects of amphetamines, to crave more, and to become addicted. And by 2012, Diller notes:
“doctors were, for the first time, writing more stimulant prescriptions for adults than for kids.”
According to the Drug Enforcement Administration, U.S. manufacturers in 2013 turned out six times as much methylphenidate (the active ingredient in Ritalin) as in 1996 – but an astonishing 28 times as much amphetamine, the active ingredient in Adderall. And a list of the top 25 psychoactive drugs in 2013 shows combined Adderall and Vyvanse prescriptions rising 42% just in the past four years.
This explosive growth in prescribing is not backed by medical evidence. There are no reliable figures for rates of ADHD in any age group, and what estimates we do have, says Diller, “are founded in sand.” In addition:
There remains no objective test for the disorder, no blood test or brain scan that can pinpoint a clear difference between someone with attention problems and someone without them. The majority of patients who land a diagnosis straddle a line where problematic attention and performance merge into variations of normal.
That doesn’t mean that ADHD is merely “a figment of our cultural imagination,” says Diller. It does mean that diagnosing ADHD remains a subjective decision. And the bar is falling rapidly: Children are being diagnosed who would not have been twenty years ago, and far more are being diagnosed for the first time as teenagers.
As for Adult ADHD, the very nature of the disorder is subject to “a great deal of theorizing and speculation among experts,” says Diller. Thirty years ago the diagnosis did not even exist; what we now call ADHD was known as “hyperkinetic reaction of childhood”. The few studies following children into adulthood are fraught with methodological problems. And we can say even less about patients who were first diagnosed as adults.
Amber’s story: Getting by with a little Adderall from her friends
To illustrate the dangers, Diller tells the story of “Amber” (actually a composite of several patients), who began taking Adderall in college to keep up with the demands of her pre-med program:
By her second semester, Amber was struggling. She’d scored a B-minus on her first organic chemistry test, despite pulling several all-nighters to prepare. So when a friend offered her one of his Adderall pills during a late-night studying session, she didn’t hesitate. “Man, I remember feeling like I’ve never felt before,” says Amber. “Just feeling fucking amazing, flying high as a kite. So from then on, I would take it only on occasions where I really needed to study for exams.”
It didn’t take long for her to feel like she needed the drug — and not just to study.
“I found myself popping it more frequently for school. It became a crutch. Then I would pop some before work. Then, after work. Then, when I went to hang out with my friends. Next thing you know, I’m literally popping up to 120 mg in a day to chase that Adderall high … I now have to take high doses every day just to feel normal.”
Clearly, Amber is hooked. Is she part of a small minority whose bodies cannot handle the drug, or is her experience more typical? Diller cautions that we don’t know exactly. But even if the percentage were extremely low – say, one in twenty – it would amount to hundreds of thousands of addicts.
The “medical route” to Adderall dependency
Amber bought her pills from an informal black market of fellow students who sold their prescriptions. Today one in six college students admits to having “abused” prescription stimulants. But as Diller notes, many more have obtained doctors’ prescriptions for Adderall on the shakiest of evidence:
For prospective patients, getting a prescription can be as simple as filling out a form full of predictable questions about their tendency to procrastinate, ability to focus, or feelings about whether they are living up to their full potential.
That’s how Mike, an Atlanta area college student, became a regular user. A fairly strait-laced kid with a solid “B” average, he knew he didn’t have ADHD – but he learned to love the effects of Adderall borrowed from friends. It delivered energy, confidence, and the focused stamina that helped him earn straight A’s in college while working full-time. Mike found it all too easy to recite the symptoms a doctor needed to hear and walk out with his very own Adderall prescription.
Is adult ADHD based on “patients” like Mike?
Mike’s experience highlights a notion that has become key to the selling of Adult ADHD: Amphetamines are presented as dangerous for the average person – but utterly safe and essential medicines for those with the disorder, whose brains are said to “need” them to perform normally. This view has been pushed by medical experts like Harvard’s Joseph Biederman, who educates doctors on “Managing ADHD through the Life Span,” and nonprofits like CHADD—Children and Adults with Attention Deficit Disorder. Both have enjoyed substantial funding from Shire, the maker of both Adderall and Vyvanse.
And if your initial experience of Adderall is not a wild, disorienting “high,” but a pleasant burst of energy and efficiency that helps you accomplish a lot and feel good about yourself? That may be all the proof a doctor needs that you do in fact “have Adult ADHD.” More than a few newly-diagnosed adults have “discovered” their disorder after taking a pill prescribed to their child for ADHD, and finding they liked the effects. In an article on EverydayHealth.com, psychologist Russell Ramsay urged patients to be open about these experiences, which could help their doctors arrive at a “proper prescription.”
To the human body, speed is speed
In reality this is nonsense. For eighty years we’ve known that the majority of people feel more alert and energetic on amphetamines, better able to focus on boring or complex tasks. Earlier epidemics of amphetamine abuse were based on their “medical” use for weight loss and depression rather than ADHD. And as Larry Diller explains, the human body doesn’t care if amphetamines come from a pharmacy or a street-corner dealer:
Meth, Adderall, Ritalin, Ecstasy: they all work essentially the same way. Inside the brain, within the spaces between nerve synapses, they increase levels of dopamine and adrenaline by preventing these neurotransmitters from getting broken down or re-absorbed by cells. That, in turn, boosts all the feel-good sensations of speed along with a rise in energy levels, heart rate, blood pressure, and wakefulness.
Along with this comes an uptick in “executive function”, the capacity for self-discipline, focus and all the other qualities harried modern adults wish they had more of.
Here are a few of the symptoms that, according to Dr. Ramsay, “might lead you to wonder if you have ADHD”:
You have trouble being patient with your kids.
You feel like you can’t stay on top of everything.
You lack the motivation to get things done.
You procrastinate on important tasks, such as only starting to gather your tax receipts a few days before (or on) April 15th.
You have a child with ADHD, and you see some of your own personality traits in the child.
You remember having trouble concentrating and studying in high school or college.
Have you spotted yourself yet, dear reader? If not, just add your inability to lose weight and keep to a strict exercise routine – and you’ll realize how many adults might believe their first dose of Adderall had shown them a way to overcome their “handicaps.”
“I now have to take high doses every day just to feel normal.”
The advantage, such as it is, seldom lasts. As Larry Diller points out,
Over time, as use continues, dopamine levels become depleted, causing fatigue, dissatisfaction with life and a craving for more of the drug. No one knows exactly how addiction develops, but in lab studies, rats repeatedly choose amphetamine over food, eventually starving themselves to death.
As Amber said, “I now have to take high doses every day just to feel normal.” Without the drug, she endured bouts of severe depression and numbing fatigue; while on it she became ever more irritable and “hyper.” After initially peaking, her grades began to plummet as her life became more chaotic. She regretted “everything this drug is sucking out of me,” but felt she couldn’t stop. Amphetamines also have the potential to produce hallucinations, paranoia and other symptoms of psychosis, as the tragic case of Lawrence Fee made clear.
Mike, the student who talked his way into an official ADHD diagnosis, quit Adderall before his life spun out of control. What bothered him was a change in personality – especially a tendency to be impatient or unconcerned with people and obsessed with work. He felt he had to give up the drug to “buy back his soul.”
He went on to found a website, QuittingAdderall.com, which struck an immediate chord with other addicts—most but not all in their twenties. Many blamed their “Adderall personalities” for romantic breakups, social isolation and compulsive shopping, web surfing or binge eating. Several told of being misdiagnosed as “bipolar” by doctors who could not make the connection between their “medical” amphetamines and their erratic behavior.
Yet many bitterly resented being seen as addicts. They hadn’t turned to Adderall for thrills or escape, they said – they’d used it to excel at school, work and other worthy goals! Some (especially those working in IT) insisted their jobs could not be done without Adderall. In an article in the New York Times last year, workers in law, finance and yes, healthcare reported pressure to use the drug to boost their productivity.
This is Larry Diller’s final point, and one worth a book all its own. It’s bad enough that money, power and convenience have led our “medical-pharmaceutical complex” to dish out amphetamines. But are we also using them to “adjust” ourselves to an increasingly inhuman and unsustainable economic rat race?
One thing at least is clear: We need to keep talking about the United States of Adderall.