April 18, 2013

Rx for S.S.D. (Sick Society Disorder)

(This article first appeared in the Huffington Post on 4/16/13)

Shock and incredulity greeted a front-page New York Times article last week that nearly 1 in 5 American high school boys had attention deficit/hyperactivity disorder (ADHD). The Times analysis of the most recent Center for Disease Control (CDC) survey of 76,000 households had the overall rate of ADHD for children ages 5 to 17 at 11 percent. Approximately 6.4 million children have received the diagnosis. Two-thirds of those with a current diagnosis were receiving prescription stimulant drugs like Adderall, Ritalin or Concerta. Annual sales last year of these drugs reached $9 billion. 


In 2010, the Drug Enforcement Administration's (DEA) total annual quota for legal stimulant drugs (controlled substances because of abuse and addiction potential) was 84 tons. The U.N.'s International Narcotics Control Board (INCB) monitors legal stimulant production worldwide. According to an analysis of 2009 data, the U.S., which accounts for 4 percent of the world's population, produced 88 percent of the legal speed on this planet.

Some doctors have viewed last week's Times report (along with nearly a dozen articles or op-eds in the past 18 months) as some sort of anti-ADHD/medication crusade. It's hard to say whether the Times is leading or reflecting growing unease with our country's reliance on psychiatric drugs, especially for children (see the editorial in this week's Times). But as a doctor who's been prescribing Ritalin drugs to children for 35 years and wrote 15 years ago we could become a country "running on Ritalin," I can assure you these disturbing numbers and trends are only going to become more extreme in the next several years.

Our use of psychiatric drugs with children is tied to deep social, cultural and economic prerogatives. We fear our children's relative failure and differences that might temporarily lead to a diminished self-image or esteem. We've come to believe that behavior is brain-based and genetically determined. There is less stigmatization in use of psychiatric drugs to address children's behavior or learning problems. Older teens and college students are attracted to the "quick fix" nature of the prescription amphetamine drugs for cramming (and getting high). Finally, the medical/pharmaceutical industrial complex has had the largest impact on our view of children's health and behavior by co-opting medical education and research, and advertising to doctors and directly to parents (and their kids). 

There are children with serious problems associated with hyperactivity and impulsivity. A recent Kaiser analysis of 850,000 children ages 5-12 in 2010 had only 3.1 percent meeting ADHD criteria when a medical specialist made the diagnosis. However, the discrepancy between what parents have been told (in the CDC study) versus a specialist's diagnosis becomes meaningless when these drugs work as performance enhancers for everyone.

Yet what rankles more is the moral problem of using drugs for behavior problems and school performance. Drugs are cost-efficient and fast when compared to non-drug interventions like parenting strategies, behavior mod and special education. Parents prefer the non-drug strategies be tried first. Schools, insurance and drug companies prioritize efficiency. Reports from colleges and high schools raise the specter as well of a growing doctor-prescribed Adderall misuse and abuse epidemic.

These ADHD numbers are disturbing, but my 20 years' experience in what's been called "the Ritalin Wars" tells me that nothing leads to substantive change except the deaths of children. My cynical prediction is based on participating in the FDA Prozac and children's suicide hearings of 2004-5. When people learned that the FDA knew of seven negative Prozac studies that hadn't been shared with the public, a woman at the hearings, whose son committed suicide on the drug, pointed to an FDA official and alleged, "You killed my son!"

The hearings, with the additional political support of Senator Charles Grassley, led to tectonic type shifts in the relationship between the drug companies and doctors, new "sunshine" laws on the publication of medical studies and a decline in the use of Prozac in children.

 Changes in the prescription of the stimulants for ADHD will come only with very high negative publicity, and the threat of malpractice suits and loss of licensure to doctors. I've been proposing a major "summit meeting" on ADHD and Adderall much like a DEA-sponsored meeting held 17 years ago. The DEA this time seems preoccupied with opiates like Vicodin and Oxycontin. Perhaps they haven't checked -- amphetamine just passed the opiates in the most recent survey of high school students' use of illegal drugs.

Meanwhile, the highly-awaited, highly-controversial, next edition of the Diagnostic and Statistical Manual of Psychiatry (DSM 5) comes out next month. I suspect the disorder most ailing our country will not be included -- SSD -- or Sick Society Disorder. We even have the drugs to treat it. Your children are already taking them.

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