February 7, 2013

Is An ADHD/Adderall Ice Age Ending?

(first appeared in the Huffington Post 2/5/13)

"Crrraackkkkk!" was the sound I heard of the arctic ice breaking in my head as I finished reading the Sunday New York Times front-page article "Drowned in a Stream Of Prescriptions." I'm speaking metaphorically of course. But the 5,000-word Times piece on the life and death by suicide of a young man, Richard Fee, addicted to Adderall (a form of prescription amphetamine), could represent a true thawing of what some feel has been a 20-year ADHD/Adderall Ice Age.

I am behavioral/developmental pediatrician who's been prescribing prescription stimulants like Ritalin, Adderall or Concerta to children, teens and adults for 35 years. I've never been against using medications in children. But I prescribe the meds only after giving effective non-drug interventions, like home/school behavioral modification and special education, a chance to work first. 


I've never felt entirely comfortable with the non-hyperactive form of ADHD, officially called ADHD-inattentive type, but to nearly everybody else called simply ADD. In kids, ADD generally represents learning or processing problems that first should be addressed educationally. For older teens and adults, I'm not sure who, at various times in their lives, doesn't qualify for the vague and broad criteria of adult ADD. The public has come to accept biological psychiatry and the use of drugs to treat their problems. Really anyone, who by temperament or talent profile, does not fit into a desired goal (like an adult with eighth-grade reading comprehension who wants to be an attorney) becomes a candidate for the universal performance-enhancing effects of the stimulant/amphetamine drugs.

While fairly safe when used properly, these drugs have an 80-year history of misuse, abuse and addiction throughout the developed world, including the United States, Europe and Japan. Children who don't have access to the drug and don't like higher doses ("I feel nervous... I feel weird") never become addicted to Adderall. History has shown though that adults who do have access to the drug and like higher doses ("I feel powerful... I feel grand") regularly misuse, abuse and can become addicted.

American society goes through cycles of use, abuse and ultimately renewed control of prescription stimulants (read Nick Rasmussen's fascinating history of prescription amphetamines, On Speed, The Many Lives of Amphetamine). American Psychiatry was the first to make adult ADHD legitimate, but the drug companies, by their promotion to doctors and direct-to-consumer advertising, took the proverbial football and ran with it. I and a small number of my colleagues have been concerned about the growing legal (and illegal) use of prescription stimulants since the publication of Driven to Distraction in 1994. However, our Cassandra-like worries have been drowned out by the medical/pharmaceutical industry.

That's what I've been describing as the ADHD/Adderall Ice Age -- about 20 years if you start from 1991, when rates of childhood ADHD diagnosis and stimulant use started to skyrocket. In 2010, America constituted 4 percent of the world's population and produced 88 percent of the world's legal stimulant drugs. But the Times piece suggests a thaw is coming to this medical/drug climate.

The article has all the attractions and pitfalls of anecdotal medical media. The story is dramatic -- ex-college class president and aspiring medical student starts Adderall prescriptions while studying for the AMCATs, and over the next three years, despite his increasing erratic behavior and the protestations by his parents, ultimately kills himself after obtaining multiple amphetamine prescriptions from different psychiatrists. Many of the abuses of the system are highlighted -- the ease to obtain the diagnosis of ADD and the medication, the minimal use of outside corroborators for the diagnosis, the young man's preference for the short-acting version of Adderall (college students choice as well -- better for cramming for exams or crushing and snorting it for a high), the multiple psychiatrists in their five- to 15-minute "med check" visits, and finally the doctors ignoring the frantic pleas of the parents to stop the drugs.

But the anecdotal report will lay the article open to a predictably huge counterattack by the supporters of the diagnosis and medication use. Most likely, they'll claim Fees had something else besides or in addition to ADHD, perhaps bipolar disorder or paranoid schizophrenia because of his delusional status toward the end of his life. However, misuse and abuse of amphetamines often result in paranoid ideation -- ask any methamphetamine or crack addict.

More importantly though, the Times front-page article on death by Adderall abuse represents the fifth or sixth article or op-ed the Times has run in the last 18 months that question or criticize the child/adult psychiatric diagnosis and/or medication use. Indeed, within my professional circles, doctors are asking "What's gotten into the Times? Why are they suddenly so against these diagnoses and treatments?" Indeed about a month ago, the Times ran a Sunday Dialogue in their Review section debating this very question.

What my questioning colleagues are missing is that the Times is likely reflecting a growing public awareness and concern about the use and risks of these drugs. Enough people are starting to get harmed that the media picks up on it first. Then, the medical research community starts to address it next. It is just beginning to publish studies of misuse and abuse of Adderall in college students. Larger studies showing growing admissions to rehabilitation/recovery centers for stimulant prescription abuse/addiction are likely on their way. Finally, lawyers and government step in to reregulate these drugs.

Forgive me for mixing metaphors, but altering the use and abuse of prescription amphetamines will be like trying to turn around the Titanic before it hit the iceberg. There are so many societal/economic/educational factors in the mix that has put America at the legal speed apex of the world community. I'm afraid it will take many more deaths of older teens and young adults before we take the necessary legal and social actions to put Adderall use back to its proper place in our country.

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