Wednesday, June 13, 2012

Adderall Is For "A"

This New York Times article has already generated enormous controversy and not a little resentment from psychiatrists who seem to believe the Times is out to get them. The article would have us believe that the number of students using psychostimulant drugs like amphetamine and methylphenidate (Ritalin) has increased dramatically and that younger students than ever use the drugs to improve their performance on tests. I immediately connected the story to a recent listserv conversation among child psychiatrists touting the advantages of prescribing ever higher doses for presumed ADHD. How many of their patients actually take the higher doses rather than diverting to their friends, which of course could land them in jail? But perhaps more significantly, and more surprisingly to me, the article has generated numerous comments from physicians suggesting that anyone and everyone should have access to drugs that improve performance regardless of whether they suffer from a diagnosable condition.

Where will this take us? Some possible consequences:

  • Patients and their parents will lose credibility with some physicians.
  • Patients will drop reluctant physicians and seek out those more willing to write a prescription.
  • Payers will demand more proof that subscribers really have the claimed condition.
  • Schools and testing organizations will require pre-examination drug testing.
  • Test takers will require proof of need from students who test positive for drugs.
  • Increase in ADA complaints of discrimination if those who test positive for drugs are excluded from examinations.
  • Independent psychiatric examinations costing thousands to prove appropriateness of prescriptions. (Never mind that no objective test for ADHD exists.)
  • More will abuse or become dependent on the drugs.
  • More will suffer adverse effects and overdoses.

How far should we go in allowing access to these drugs for performance enhancement? Why even involve physicians in deciding who gets them if a diagnosis is not required? How can we assure fairness in high stakes testing of students?


  1. Even the hippies, who were IN FAVOR of getting high on drugs, used to say, "Speed Kills." There's a reason it's Schedule II.

    The Onion did a funny piece that said Harvard was giving an honorary degree to Adderall because it had helped with so many theses, degrees and other academic achievements.

    Here's a song I wrote that might be relevant:

  2. The addiction risk of these drugs is significant and always downplayed by the "cognitive enhancement" crowd. Further, many physicians do not seem to realize that an addiction to stimulants may be a contraindication to stimulants even in the case of rigorously diagnosed ADHD.

    To me this is another good example of the politics of prescribing rather than prescribing for an actual medical indication. The only way it should ever be considered is if there has been enough safety and efficacy studies done and an FDA approval for cognitive enhancement. The complication threshold for treating otherwise healthy people should be low.

  3. Unknown to me (for six months), my son was prescribed Adderall (20mg to start)while in college, and shortly after he started taking this drug, his grades dropped, his interest in school dropped, and unknown to me, he started compulsive shopping at the mall (instead of attending college), gambling, and Internet spending. Yes, I knew something was wrong, but his psychiatrist told me to “back out.” I regret backing out; he attempted suicide, gouged his gums and wound up in the psychiatric hospital for five weeks. His diagnosis is and always has been ICD and OCD, not ADD or ADHD.

    He has been off Adderall since January 2012, but he will do anything to get the high he felt from that drug, right down to self-injury.

    1. I am so sorry to hear that this happened to your son. I hope he has a complete recovery.

  4. So sorry Anonymous. Psychiatrists should insist on family involvement. Thanks for sharing.

    Nice song David.

    George, I agree addiction always trumps ADHD. Almost anything trumps ADHD. And there are ways to compensate for it without stimulants, even without drugs.

  5. ...this topic is so hard. But I also look at it through a certain lens. Having grown up LD (learning disabled), I was definitely pressured to take stimulant medication by my school system. The school wouldn't even diagnose LD (despite the fact that I tested that way) because they wanted an ADHD diagnosis so bad. This led to many visits to psychiatrists and lots of drugs. First it was Ritalin. Then the doc decided it wasn't ADHD and that I must be depressed. So I went on antidepressants, then atypical antipsychotic medication, and it just snowballed out of control until I got a bipolar diagnosis and was put on SSI the day I turned 18.

    Later on, when I was at community college, I was tested there and discovered that I am LD. Years later, my GP was pissed off when I finally showed her my IQ scores. The high school said there were no intellectual deficits and that I was too "emotionally disturbed" to learn.

    I really think the reason my school was ballsy enough to do that though was because stimulant meds have become such a norm. And it DOES help with LD. We can't deny that. I can't deny that. It's not just helpful in ADHD. I am gifted in certain areas of my IQ, but in other areas I am borderline mentally retarded. I have tried Ritalin in my adult years, and it is a big help. I can tell you that Ritalin really does help people with intellectual deficits. But, for some weird reason, I have to be careful with it because when "that time of the month" comes around, I turn into a weirdo on it. It's like PMSx100. And I have no clue why that is. Every other time of the month, I am fine. Maybe I have some weird female hormone disorder.

    Ugh, stimulants are such a tough one. Especially because I don't even know if I take it for ADHD or as a "performance enhancer." My GP thinks ADHD can cause certain learning disabilities. But I've met people who are geniuses and have ADHD. And not everyone who studies the subject agrees with her. A school psychologist I met absolutely believed that they are separate conditions. They can go together, but LD is not ADHD and ADHD is not LD.

    Do I have ADHD? Am I just slow and taking a performance enhancer? Do I have a weird female hormone disorder that causes my intellectual problems? Who knows.

    Though to be honest with you, I would think the problem of students taking meds (and having an unfair advantage)while test taking would be resolved with the extended time/separate room accommodation usually given to LD and ADHD students. I'm pretty handicapped, and I still got a BA from a university without using meds. I wouldn't think you would need the meds...unless maybe you were on a high dose and couldn't stop.

    I'm so torn. I don't think stimulant use should be the norm, especially because there are plenty of students who wouldn't want to take them and I'm sure a school system could easily say that they don't need to give extended time or make accommodations for students refusing to take a stimulant. But stimulants are also so helpful for LD, that I don't want to deny someone medication that would help clear up a handicap.

  6. Actually....maybe I'm missing something. I read some of the NYT article. Maybe I need to ask for Adderall. It gives you "tunnel vision focus" and "does the work for you." I feel like Ritalin didn't do that. It helped me to understand conversations happening in a group setting and process other basic things a bit easier...but it wasn't like a guaranteed A pill. Hmmm...on the to do list is to ask the Pdoc about trying some Adderall.

  7. It’s true that AD/HD meds should only be used to level the playing field for AD/HD’ers. It’s callous and destructive to say, "Almost anything trumps AD/HD.” I'm a successful psychotherapist today, because I was diagnosed and prescribed for in time to save my career. Adults with AD/HD don’t have parents, teachers and therapeutic support staff members to enforce rigorous behavioral programs. For all of the attention focused on such interventions, none have proved sufficient to replace medication.

    AD/HD can be disabling in one’s personal, academic, and professional life. It causes family members no end of frustration and despair. Psychiatrists shouldn’t look for excuses to deny appropriate medication for psychiatric disorders, even those that look like character flaws.