The year was 1971 and the use of marijuana and LSD of San Francisco's "Summer of Love" had metamorphosed into the graffiti messages on the walls of the Haight-Ashbury neighborhood that read "Speed Kills." That year, the federal Bureau of Narcotics and Dangerous Drugs (the Drug Enforcement Administration's predecessor agency) moved to place amphetamine (Dexedrine) and methylphenidate (Ritalin) as Schedule II controlled substances -- the tightest legal control the government can place on prescription drugs. The amphetamines (methylphenidate is very similar in structure and action to amphetamine) also happen to be the most effective and indicated treatment for attention-deficit/hyperactivity disorder or ADHD. Forty years later the benefits and risks of the amphetamines continue to confront our country.
Dr. David Smith is perhaps most famous for founding the Haight-Ashbury Free Clinic in 1967. Many consider him the father of addiction medicine. He was there in the late 1960s and recently confirmed for me what his chief pharmacist at the time, Daryl Inaba, told me about the effects of making the amphetamines Schedule II. "It basically cleaned up the street," Daryl said -- meaning prior to Schedule II both Dexedrine and Ritalin, along with methamphetamine, were readily available for misuse and abuse. Many of the hippies had become addicted. After Schedule II only illegal methamphetamine could be found, and the abuse/addiction that had become epidemic ended.
Dr. Smith is still associated with the Free Clinic but has assumed many other roles and positions as well. His perspective on the problem now is "that it is much broader these days." He said, "Prescription amphetamine abuse is no longer confined to 'the street.' It's actually a bigger problem in the elite prep schools and colleges of the Northeast. It's really a question of who has greater access to the medical system in terms of where the problem is today."
In this fifth and final installment on the United States of Adderall, I address the question of the diversion, misuse, abuse and potential addiction to prescription stimulants like Adderall, Ritalin and Concerta. In previous essays, I've detailed that in 2010 almost 84 tons of legal speed were approved for production in the U.S. In 2009 America, representing 4 percent of the world's population, produced 88 percent of the world's legal amphetamine. The drugs are used ostensibly in this country primarily for the treatment of ADHD in children and adults. While ADHD exists throughout the world, the U.S. by far and away leads in ADHD diagnosis rates and treatment of this condition with medication.
The second HuffPost essay I wrote highlighted the "Ritalin Wars," an ongoing polemical debate -- often featuring personal attacks -- on whether the ADHD diagnosis and its drug treatment is a good or bad thing for our country. I mention the wars at this point because I imagine defenders of Ritalin/Adderall to be presupposing that my raising concerns or questions about Adderall abuse is my attempt to denigrate or deny ADHD as a real condition and Adderall as a useful treatment. Anyone who has read any of the essays knows that I've been prescribing these drugs for more than 30 years.
I may challenge our overall use of these medications and their choice as a first and only treatment for ADHD. But in reality my concerns center on how their misuse and abuse in adults may lead to a societal backlash that will ultimately compromise their relatively safe and effective use in children. Ironically, these drugs are safer for use in children than in adults. Children don't have access to the medication themselves nor do they like higher doses. They complain, saying they feel "nervous or weird." Adults do have access to the drugs and many, on higher doses, say they feel "powerful and grand."
The history of the good and bad effects of prescription stimulants dates back as far as their synthesis in 1929. Nicholas Rasmussen's book "On Speed" finely details that as early as the 1930s, descriptions of the effects of the misuse, abuse and addiction of Benzedrine (an early commercial amphetamine product) were well-known. It seems like American society (and all the Westernized countries, including Japan) have gone through waves of doctor-prescribed stimulant abuse; the last in our country ended in the late 1970s. Then, doctors stopped prescribing amphetamines for weight loss in women, only because state medical boards threatened to take away their licenses for that discredited (ineffective) and potentially dangerous treatment.
The production and use of amphetamines in children took off in the early 1990s (see the third HuffPost essay). The publication of "Driven to Distraction" in 1996, which publicized ADHD in adults, greatly added to the demand. Current estimates have 40 percent of prescriptions now directed to adults, who also are the fastest growing segment of the population receiving Adderall prescriptions.
Jim Swanson is a professor of pediatrics at the University of California - Irvine's Child Development Center. Jim is a long time researcher in ADHD and its treatment. Our relationship goes back to the early 1990s when we both began sharing concerns about the societal factors involved in the ADHD diagnosis. Jim has worked closely with Nora Volkow, who heads the National Institute of Drug Abuse (NIDA). Recently, they published an article where they estimated that 30 percent of all the Schedule II stimulants are being diverted for non-medical (meaning not legitimate ADHD) use. Surveys of college students in particular show that up to 35 percent (and up to 80 percent of fraternity/sorority seniors) have used stimulant drugs obtained without a prescription (mostly from friends who got them legally from a doctor) for the purposes of studying or getting high.
But is this misuse leading to the serious problems of abuse and addiction? The only study to specifically look at the misuse of prescription stimulants analyzed data from a government sponsored survey in 2002. They found then that about 750,000 children and young adults (ages 12-25) had misused prescription stimulants. About 1 in 10 of those reported use consistent with abuse and addiction.
Seeking more evidence of a public health problem, I recently spoke to Dr. Westley Clark, Director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA). He was concerned that I might be trying "to magnify a problem relative to other problems." He wanted to place in perspective any fears of the abuse of these medications compared to the value they have in the treatment of ADHD. I asked him about the admission rates to hospital and rehabilitation centers for the treatment of stimulants abuse that had actually gone down 25 percent between 2006 and 2008. Dr. Clark told me that SAMHSA data collection does not distinguish between admissions for abuse of illegally produced methamphetamine (the street drug called meth, crank or crystal) vs. legal prescription stimulants like Adderall or Concerta. He felt the decrease in admissions represents a decline in the abuse of methamphetamine and couldn't comment specifically about Adderall abuse.
Drs. Smith and Swanson need no more proof with regard to their concerns. Dr. Smith told me he regularly sees patterns of misuse, especially in students, where Adderall alone will be used during the weekdays and then combined with other substance abuse (alcohol and other prescription drugs like Vicodin) on the weekends. He feels that the report of any illegal use of Adderall by age 15 is a red flag marker for subsequent polydrug prescription abuse.
Dr. Swanson also knows of many young adults who have required hospitalization for Adderall abuse. He thinks the questions of appropriate ADHD diagnosis are complicated by amphetamine's universal improvement on concentration. Dr. Smith feels many college students have gone online to learn the symptoms of ADHD and then repeat them to doctors in order to obtain the drug. There is no biological or psychometric test for ADHD. Someone can act perfectly normal in the doctor's office and still qualify for the diagnosis by history or report. Therefore, the opportunity to obtain the medication legally from a doctor is relatively easy. A local drug representative for the company that makes Adderall told me there were doctors offices close to the UC Berkeley campus that were well-known among the students for obtaining the shorter acting (and preferred) form of Adderall.
All of these reports are "anecdotal," and researchers and concerned clinicians continue to seek the "smoking gun" evidence needed to confirm this seeming-historic inevitability. Swanson says, "Our evidence is insufficient and not precise. Nobody has asked the question in a way that we can definitely determine there's a problem. But I think there's something definitely there."
Dr. Smith, while not denying the value of the medications, makes a plea (based upon decades of experience) for the victims of amphetamine abuse. He says (echoing the Haight-Ashbury experience of 40 years ago) it's a terrible problem once acquired. The numbers may be small now. But as the denominator of general misuse grows into the millions, that smaller numerator of abusers will become a significant social problem, he predicts. History certainly is on his side.
America's challenge then with Adderall is not unlike the much more public debate over the prescription opiates like Oxycontin and Vicodin. How do doctors and patients balance using these drugs effectively and safely legitimate medical reasons -- pain control in the case of the opiates and for ADHD, the stimulants -- while protecting the public from the scourge of abuse and addiction? I don't have an answer to that question, but I think it's important to begin asking it in a vigorous and persistent way with regard to the United States of Adderall.
CORRECTION: A previous version of this post stated that in 2010 almost 84,000 tons of legal speed [Adderall] were approved for production in the U.S. In 2010 almost 84 tons of legal speed [Adderall] were approved for production in the U.S.