By Valerie Seiling Jacobs
This feature story is from Brain, Child’s Special Issue for Parents of Teenagers, to order the full magazine, click here.
It’s 7:00 a.m. on a chilly Saturday in March—the SAT is due to start in less than an hour. Sam (not his real name), a junior at a New England boarding school, sits alone in his dorm room. Across campus, a few students are already filing into the test center. Sam is almost ready. He’s been studying for months.
There’s just one more thing he needs to do. He reaches into his backpack and retrieves the pill—a single capsule of Adderall. It only cost five bucks. A real bargain.
Mention the word “Adderall,” a drug often prescribed for Attention Deficit Hyperactivity Disorder (ADHD), and you are likely to elicit strong opinions. Add the words “cognitive enhancement” or “adolescent” and you are liable to start a brawl. As soon as I announced that I had taken on this project—that I was trying to figure what parents and teenagers think about these drugs—people began clamoring to stake out their positions.
Take the mother of the 16-year-old boy who was recently diagnosed with ADHD, a condition characterized by impulsivity, inattention, and hyperactivity. To her, Adderall is a godsend, a magic pill that enables her son to sit still for hours and stay focused. “His grades have improved and we’re not fighting about his homework anymore,” she said, before insisting on anonymity to protect her son’s privacy.
Or take Adam (also not his real name), the college student at an Ivy League university who uses it—without a prescription—to cram for exams. To him, Adderall is a great study aid that allows him to “power through” tests and assignments. “It’s like No-Doz,” he said, “only better.” (“Walk through the library during finals and everybody’s got it,” his girlfriend added.) He doesn’t under- stand why it isn’t sold over-the-counter. [Because these stimulants are Schedule II Controlled Substances—possession without a prescription is a felony in most states—no one wanted his or her name in print.]
One law school student estimated that half his peers are using it. A third-year medical student told me that he thinks he’s the only one in his class who’s not using it. One graduate student described how she and her friends use it to party. “We call it taking ‘wings,'” she said.
And then there were the professionals: high-powered Wall Street types (traders were mentioned a lot) who are buying it on the street or quietly asking (read demanding) that their internists write prescriptions. A fiftysomething female banker admitted that she had “borrowed” her son’s medication and used it as an appetite suppressant. I heard of one 70-year-old woman who is using it, with her physician’s encouragement, for the “lift” it gives her.
Most surprising, however, were the high school students—kids like “Sam” who told me how they had used it to take the SATs—again, without a prescription. (Sam estimated that 25% of his boarding school class had used it.) “It definitely helped on the math and reading,” he said. “Not so much on the writing.”
Another teenager described how her classmates would borrow, trade, and sell their ADHD medication (experts call this “diversion”) at her public high school, the going rate ranging from a dollar to twenty dollars a pill, depending on the number of milligrams, the type (regular or extended-release), and the demand. High stress events, like midterms and AP exams, apparently send the price skyrocketing.
To all of these people, Adderall and the other drugs in the ADHD arsenal, including Ritalin, Vyvanse, Concerta, and Focalin, are great drugs that increase focus and boost productivity and performance. Indeed, the axiom that the drugs would not work for those without ADHD has proven to be untrue—though some ADHD experts still cling to the idea that people who experience benefits must have a subclinical case of ADHD.
In fact, current research suggests that people who take the drugs not only feel better, but perform better, though improvement may not be as dramatic in non-ADHD individuals. As Dr. Stephen Donovan, an Assistant Professor of Clinical Psychiatry at Columbia University’s Center for Psychoanalytic Training and Research, explains: “The drugs certainly increase vigilance and focus and allow you to plow ahead where there is no immediate reward. So if you just have to get through something, they can help a ‘normal’ person.” Whether these drugs can actually make you more intelligent, however, is “very doubtful,” says Donovan.
But to some doctors and mental health experts, the widespread use of these drugs, with or without a prescription, is problematic—and especially so for teenagers and young adults. Indeed, recent data suggest that the number of people who are experiencing problems with these drugs is growing. According to a report released by the Substance Abuse and Mental Health Services Administration (SAMHSA) in January 2013, the number of emergency room visits involving ADHD stimulants more than doubled in the five years ending in 2010, with the largest rate of increase (282%) among 18- to 25-year-olds. Of those visits, half involved “nonmedical use” of the drugs, almost three times the comparable rate in 2005.
Evan Flamenbaum, an ADHD specialist and private therapist who works with teens at an intensive outpatient clinic in New York City, has seen first- hand how adolescents can get into trouble with these drugs. These stimulants have been so “integrated into study styles” and so “normalized,” he says, that people don’t appreciate that they are psychoactive drugs.
And this is particularly true of teens, Flamenbaum says, who often have no fear: “They think it’s like taking aspirin, but wind up abusing it: they take too much, or grind it into a powder and take it intra-nasally to get a bigger hit, or mix it with other drugs to make a cocktail.” Thus, while Flamenbaum believes that these stimulants can be extremely beneficial for people with ADHD, he thinks that we need to be really concerned about the potential for abuse, especially when it comes to high school and college students.
Flamenbaum is hardly alone in his worry. One segment of the medical community has been sounding the alarm about these stimulants for years, repeatedly citing the health risks, including addiction. There’s a reason, those folks say, that these drugs are classified with cocaine. The website of the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, warns that these stimulants have a high potential for abuse, which can lead to a host of problems, including hostility, paranoia, and psychosis. Even without misuse, NIDA’s website cautions that high doses can lead to irregular heartbeats, dangerously high body temperatures, seizures, and heart failure.
In fact, it was the risk of addiction and cardiac complications that finally prompted the Food and Drug Administration to recommend “black box” warnings on these stimulants in 2006. The label on Vyvanse and Adderall, for example, now underscores the risk of abuse, dependence, and sudden death—and specifically states that the drug should be “prescribed or dispensed sparingly.” The warning on Ritalin is slightly less threatening, though still severe, warning of dependence and noting that people with a family history of drug or alcohol abuse should tell their doctors.
The warnings, however, have done little to dampen enthusiasm for the drugs. The sale of ADHD drugs is now a $7.9 billion a year business. An estimated 32 million prescriptions for ADHD drugs are written in the U.S. every year and the number appears to be increasing, especially among older teens. The number of prescriptions for ADHD medication for 10- to 19-year-olds has risen 26% since 2007. And a significant number of adolescents and young adults continue to use ADHD drugs without any medical supervision.
Reliable statistics are difficult to obtain, but the prevalence of non-prescription use among college students and young adults, a group that some have dubbed “Generation Rx,” appears to be significant—and growing. A 2005 study reported that of the 11,000 college students polled, 6.9% admitted to illicit use of the drugs. A 2007 survey conducted by Duke University found that approximately 9% of 3,407 students admitted that they had used ADHD drugs without a prescription while in college. A 2008 informal poll by Nature found that 25% of the 1,400 responders under the age of 25 admitted to using Ritalin for nonmedical reasons. And a 2008 study conducted by researchers at the University of Kentucky found that 34% of the almost 2,000 college students who had been surveyed admitted to having used ADHD meds without a prescription. Other factors, including the presence of sororities or fraternities on campus or the geographic location (e.g., being in the Northeast), can push the percentages even higher.
Moreover, the research shows that the practice has trickled down to high school students. In December 2012, the University of Michigan released the results of its annual “Monitoring the Future Study,” an anonymous survey of 45,000 to 50,000 teens sponsored by NIDA and the National Institutes for Health. The study found that while the use of tobacco, alcohol, and ecstasy was down in 2012, the illicit use of Adderall among twelfth graders was on the rise. According to the study, 7.6% of twelfth graders reported using Adderall without a prescription during the previous year, up from 6.5% in 2011 and 5.4% in 2009. NIDA has labeled this finding an “Area of Concern.”
In addition, while the number of even younger users appears to be holding steady or declining slightly, they are worth noting: 4.5% of tenth graders and 1.7% of eighth graders reported using Adderall without a prescription in the last twelve months. In any event, these statistics make ADHD medication the third most popular illegal substance among eighth, tenth, and twelfth graders—right behind marijuana and narcotics.
What is fueling this increase in prescriptions and illicit use? For those who obtain the drug legally, the increase may be the result of more publicity about ADHD, combined with better detection and diagnosis—though under the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), unless the symptoms appeared before the age of seven, the diagnosis may be considered suspect (there is a proposal to push that age limit to twelve in the new DSM-V, which is due out later this year).
But many believe the huge demand is simply the result of a growing desire among adolescents to enhance academic performance, a conclusion supported by the research and my unofficial survey. It’s no secret that the world has become a more competitive place, where getting good grades and doing well on standardized tests can provide a huge advantage in the cutthroat college admissions game. And for those already in college, boosting one’s GPA can help improve the odds of nabbing a much-coveted internship or getting into graduate school. It’s easy to see why students are drawn to these “good-grade” drugs.
Moreover, the demand for these ADHD stimulants—what some call “academic steroids”—is facilitated by the drugs’ easy availability. For those willing to brave arrest (many teenagers seem to be unaware of the potential legal consequences— I spoke to one high school sophomore who was shocked when she was arrested and charged with a felony after being caught with Vyvanse), it does not appear to be difficult to find someone to pro- vide a few pills. And the internet has made things easier: a number of websites now advertise ADHD drugs pursuant to “cyber-prescriptions,” a matter of increasing concern to the Drug Enforcement Agency and federal prosecutors.
For those who decide to go the legal route and obtain a “real” prescription, the process can also be relatively easy. Some doctors rely on a simple checklist or a patient’s self-reported description of symptoms— even though the DSM-IV requires historical and other evidence from a constellation of sources and even though the better practice is to conduct rigorous testing to rule out other mental disorders such as depression, bipolar disease, and oppositional-defiant disorder, which have high co-morbidity rates. All of this, according to Flamenbaum, can take eight or more hours and cost thousands of dollars.
Moreover, the official DSM-IV diagnostic criteria, which include subjective symptoms such as “the patient is often easily distracted” and “the patient is often forgetful in daily activities,” are easy enough for a savvy teenager to fake. One study found that test givers could not distinguish between those who were faking and those who were “real” ADHD patients. As Flamenbaum observes, “It is really not hard to go to a one-hour meeting with a psychiatrist and say all the right things to get the medication—especially if mom and dad are pushing for it.”
Which raises another point. Although people are loath to talk on the record, there is anecdotal evidence that some parents may be pressuring therapists and/or coaching their children to get the diagnosis—and the drugs—as a way to gain a competitive advantage and gain entry into the country’s most elite colleges and universities. (The diagnosis alone may, if properly documented, entitle a student to extra time and other accommodations on the SAT, which are not flagged for admissions officers—a whole other debate.)
With or without parental help, the use of ADHD drugs solely to enhance cognitive functioning, what is sometimes called “brain doping,” is the source of huge controversy. To naysayers, the risks of these drugs outweigh their benefits, at least in people with- out ADHD. In other words, they say, while the side effects of these stimulants might be acceptable for people whose lives are truly impaired by ADHD, the ratio of risk to benefit cannot justify non-medical use in healthy individuals. And this is especially true, they argue, when it comes to adolescent brains, which are still developing. Moreover, opponents argue, the use of these drugs raise “fairness” and ethical questions.
Last year, a commentator in the Journal of Law and Education called for mandatory drug testing in schools to “eliminate the unfairness that currently exists” due to the “super-enhanced focus” and “academic advantage” that the drugs provide. A number of legal journals have noted that the illegitimate use of these drugs may violate basic principles of equality and justice. In 2011, Duke University officially declared that the unauthorized use of prescription medication—and in particular ADHD drugs—would hence- forth constitute “cheating” under its academic honesty policy (possession without a prescription was already a violation of its drug policy). Wesleyan University also considers the use of the drugs (without a prescription) a violation of its honor code and other schools are considering whether to follow suit.
Proponents of these stimulants, on the other hand, argue that the risks have been sensationalized. People have been safely using these amphetamines for decades, they say. And besides, they argue, there’s nothing wrong with wanting to increase one’s academic performance. After all, the argument goes, this isn’t like professional sports, where there are rules that prohibit steroids, blood doping, or other artificial means of enhancement. Unlike in the Olympics, society does not place a value on “natural” academic ability. Who cares if a student took a pill before her SATs? — It’s the end result that matters. And by the way, they ask, don’t we want to maximize everyone’s cognitive capabilities?
So who’s right?
According to most doctors and experts, the three most serious risks associated with ADHD medication are cardiovascular events, psychosis, and addiction. But how many patients actually experience those side effects?
When it comes to cardiac complications, the answer appears to be not many. According to two retrospective studies published in JAMA and The New England Journal of Medicine in 2011, researchers found no increase in the number of heart attacks, sudden cardiac death, or stroke among children or young adults who used ADHD drugs as compared with a matched control group of nonusers. (The researchers did note that due to certain statistical limitations, a doubling of the risk could not be ruled out among the youngest population, but nevertheless concluded that the “absolute magnitude of any increased risk would be low.”)
What these and other studies suggest is that the likelihood of cardiac complications from ADHD drugs has indeed been exaggerated. Dr. Carl Hart, an associate professor of psychology at Columbia University who specializes in the study of the impact of drugs on human behavior and the brain, agrees. In his opinion, the risk of cardiac complications from ADHD drugs is over-blown. “We overstress these risks,” he says, “when the fact is, in young people, it’s not an issue—the likelihood of cardiac risks is quite low.”
Dr. Wilson Compton, a physician and the Director of the Division of Epidemiology, Services and Prevention Research at NIDA, has a similar view. “These drugs are not going to result in major cardiac complications, except in persons with other risk factors,” he says. (And since children, teenagers, and young adults generally have healthy hearts, what researchers sometimes call “healthy-user bias,” those other risk factors are not a big problem when it comes to cardiac complications.)
But Compton’s caveat about other risk factors is worth remembering when it comes to psychosis, another potentially serious side effect. Certain patients, including those with a personal or family history of schizophrenia, depression, anxiety disorders, or bipolar disease, are known to be particularly vulnerable to drug-induced psychosis. For that reason, doctors are advised not to prescribe the drugs for those people or to proceed cautiously. Thus, although the official risk of psychosis may be relatively low (less than 10%), the numbers may not tell the whole story. The statistics may be artificially depressed as a result of the exclusion of susceptible individuals from the patient population. (In fact, in one 2009 study, more than 90% of the patients who experienced psychosis had no relevant history of disease.) The point is that for people who are not properly screened by a physician, the risk of psychosis may be higher than the official numbers indicate.
In addition, the risk of psychosis is known to increase with larger doses and long-term usage. Why this happens is not clear. It could be the pharmacology of the drugs, or it could be the insomnia that often results, one of the most predictable precipitators of psychosis. In Hart’s view, the sleep issue may be the most important public health message when it comes to ADHD drugs. Even for those who only use the drugs sporadically, large doses can disrupt sleep. “I can’t state it any stronger,” he says. “You need to attend to your sleep—and this is especially true for adolescents.”
In sum, the risk of psychosis appears to be low, though assessing one’s true chances of experiencing this side effect may depend on family or personal history, the size of the dose, and the length of the treatment.
And finally, the risk of abuse and addiction.
What makes these drugs so susceptible to abuse? Researchers believe that the answer lies in the drugs’ repeated stimulation of pleasure pathways and their effect on dopamine levels in the brain’s reward centers. Recent studies by Dr. Nora Volkow, the Director of NIDA, and other researchers suggest that the drugs may also impair one’s “inhibition reaction” and disrupt “executive functioning,” which can interfere with a person’s ability to recognize dependence and need for treatment.
But here again, personal and family history can make a difference and the likelihood of experiencing this side effect is difficult to predict. Researchers do not have reliable data on rates of addiction. What researchers do know, however, is that some subset of users will wind up abusing or becoming addicted to these drugs and that a family or personal history of abuse makes addiction more likely.
In addition, the method of delivery of the drug can make a difference. As Compton explains, “All other things being equal, getting it into your brain more quickly makes it more of a ‘rush’ and more addictive.” Thus, snorting or injecting Adderall is more likely to produce an intense high than swallowing a pill. Cocaine abusers report that injecting ADHD drugs can produce the same kind of high as cocaine.
So, assuming that patients are pre-screened and assuming that the drugs are used as prescribed, these drugs probably do not carry a terribly high addictive risk, though withdrawal is always a consideration. The problem, however, is that adolescents don’t always take the drugs as directed. As Compton says: “Sometimes they take more than prescribed, or what’s prescribed for somebody else, so the dosage might be quite high, or they crush them and take them intra-nasally, or even inject them sometimes.”
And for those teens who are using the drugs illicitly, no one is screening for risk factors—or monitoring the dose. According to Compton, this is one of the prime problems with non-medical use: “There’s no one looking over your shoulder.” As he says, “There’s a great propensity to minimize and ignore the symptoms because these drugs feel good—that’s part of the problem around becoming addicted—the surreptitious nature of the onset.”
In addition, the effects of the drugs can be exaggerated by the presence of other substances, including alcohol. There is little data on this subject, but the results of one 2011 study indicate that the combination of alcohol and certain amphetamines can elevate heart rates and boost the “good drug effects” of both drugs (compared to either drug alone). As Hart, who participated in the study, explains, “Mixing amphetamines with alcohol can decrease the disrupting effects of alcohol and allow people to drink longer, while at the same time enhance the euphoria.”
The potential interaction of these drugs with other substances makes their use as a “party drug” (or “wings”) worrisome. Indeed, of the 31,244 ADHD drug-related emergency room visits described in the recent SAMHSA report, 25% involved one other drug (19% involved alcohol), and 38% involved two or more other drugs, suggesting that this is a valid concern.
Another troublesome question when it comes to ADHD drugs and addiction is whether they are a “gateway” to the abuse of other drugs. The answer seems to depend on where you sit.
To those like John Schureman, a therapist who has been treating ADHD patients for three decades and who is active in CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder), a support group that bills itself as “the nation’s leading nonprofit organization serving individuals with ADHD and their families,” the answer is a resounding “no.” In Shureman’s view, the drugs actually help patients avoid drug abuse because they increase “competent agency.” In other words, they increase a child’s ability to control impulsivity and other symptoms of the disorder, which are linked to poor school performance and risky behaviors—including drug use.
Addiction specialists, however, are less sanguine.
Compton and his colleagues at NIDA, for example, believe that the jury is still out as to whether the medications are a risk factor for the onset of drug abuse later in life. While Compton acknowledges that “we’re not seeing an epidemic of drug abuse in the children who were treated with these agents,” he doesn’t think “the protective benefits are as clearcut either.”
Part of the problem may be the data itself. For instance, while the use of ADHD drugs has been correlated with the use of other illicit substances, no one has isolated or proven causation. In other words, did the ADHD medication or the disorder itself cause the addiction? Moreover, when the ADHD drugs are acquired illegally to begin with, there may be additional factors at work. As Hart notes, “Kids who do these things—who are willing to buy Adderall on the street—may be more likely to experiment or break the law anyway.”
So where does that leave us? What do we do when it comes to these drugs and teenagers? The prudent response is to exert caution—and avoid jumping on the ADHD medication bandwagon too quickly. Thus, in milder cases of ADHD, it might be wise to give behavioral therapies a chance first—a strategy that Hart and Compton endorse. But once the decision is made to medicate, the data suggest that even the more serious risks can be managed with proper diagnosis, screening, and monitoring. (Make no mistake: it’s not that these drugs are not dangerous—some subset of the population is likely to get into trouble with them no matter what—but for those whose lives are impaired by ADHD, the benefits appear to outweigh the risks.) Of course, this means that physicians will need to do a better job. But it also means that parents will need to educate themselves about these substances and get more involved. Simple steps like taking control of the medicine bottle and checking that your teenager actually swallows a pill could go a long way.
But what about for people without ADHD, those who want to use these drugs simply to enhance cognitive performance? Given the risks of unsupervised use, it’s almost impossible to argue that the drugs should be sold over-the-counter, though whether they should be classified with cocaine or whether possession should give rise to a felony is open to debate. But should people be permitted to use the drugs as long as they are screened and monitored by a doctor? After all, if the drugs are safe enough for people with ADHD, then why aren’t they safe enough for “normal” folks?
Bioethicists generally have two answers. First, if we allow non-medical use, we will wind up with a two-tiered system: those who can afford the drug and those who can’t. As a number of commentators have noted, however, this is not a terribly compelling argument. We already live in a world that’s pretty unfair—the cost of living in a capitalistic society. Is this really any different from hiring a tutor or paying for an SAT prep course—two things that our system already permits?
To many, the more persuasive argument is the bioethicists’ second claim: that allowing non-medical use will result in coercion. In other words, even people who don’t want to take the drugs will eventually feel that they must take them in order to compete. (One might legitimately ask whether we are already at that point.) The recent debacle in professional cycling is a case in point: How many of Lance Armstrong’s teammates have said that they felt that they had to use blood doping just to level the playing field? It’s not difficult to imagine a world where employers require workers to take the drugs or where students feel compelled to take the drugs in order to compete. And that is a brave new world that should frighten every parent.
Valerie Seiling Jacobs teaches writing at Columbia University where she is also working on an MFA. Her essays have appeared in The Atlantic, The New York Times, and other publications. Before turning to writing, she practiced law for over two decades. She lives with her husband in Westport, Connecticut. You can find her on the web at www.valerieseilingjacobs.com.
This feature story comes from Brain, Child’s Special Issue for Parents of Teens, now in its second printing.