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Adderall is a prescription stimulant meant to treat attention deficit hyperactivity disorder (ADHD). It contains a combination of amphetamine and dextroamphetamine, central nervous system stimulants that affect the chemicals in the brain that contribute to hyperactivity and inattention. Adderall and other medications in the stimulant class (Vyvanse, Ritalin, Concerta) can have a very positive impact on the professional and educational performance and experience of those with ADHD by increasing one’s ability to focus. It also supports elements of patients’ personal lives that may be impacted by attention disorders.

But has our country’s use of Adderall pushed past normal limits, and have pockets of our population not actually afflicted with ADHD gotten hooked? In a word: Yes.

In this article, we’ll explore the history of Adderall and amphetamines, spotlight some troubling trends that have emerged in recent years, and offer possible solutions to taking steps towards addressing the over-prescribing of and over-reliance on prescription stimulants.

 

The rise of amphetamines

In 1996, Shire Pharmaceuticals introduced Adderall, the patented blend of amphetamine salts, to compete in the market of ADD/ADHD medications like Ritalin, which had emerged onto the prescription drug scene in the 1980s and ‘90s. But the use of amphetamines far predates the late 20th century. Amphetamine was first synthesized in 1887 by Romanian chemist Lazar Edeleanu, who reported on it but never discovered its physiological effects. In 1929, Los Angeles chemist Gordon Alles discovered it as well. Alles was trying to develop a drug to improve upon ephedrine, which was used to treat asthma, colds, and allergies. Alles’ compound, called beta-phenyl-isopropylamine, was ultimately injected into his body to test its efficacy (self-testing was routine in the early days of scientific discovery), according to the Chemical Heritage Foundation. Several minutes later, his sinuses were clearer, but he noticed something more noteworthy: An unmistakable feeling of well-being.

Ultimately, as an asthma treatment, the compound failed; as a euphoria-producing stimulant, it soared. Alles approached pharmaceutical company Smith, Kline, and French (SKF) about a partnership—and in exchange for his scientific capabilities, SKF agreed to market amphetamine as a “wonder drug.” Benzedrine Sulfate, as Alles’ drug became known, was one of the first psychoactive prescription drugs, and was marketed as the first antidepressant.

By the late 1930s, college students used what they referred to as “pep pills” to increase productivity; American soldiers in World War II took amphetamine to counter fatigue and boost morale; amphetamine-based drugs even became popular among mothers and housewives in the 1950s to lift spirits and combat ennui. College students of the ‘90s and 2000s were certainly not the first group to get hooked on prescription stimulants—it just went by a different name, and was distributed for different reasons. The Chemical Heritage Foundation sums it up well: “Once Alles and SKF brought amphetamines into public consciousness, they never truly went away.

Despite Benzedrine Sulfate/amphetamines being marketed as a healer of mental malaise, studies at the time showed that it actually had little impact on severe depression or anxiety. Instead, scientists found that it could potentially exacerbate psychiatric symptoms, even causing psychosis in some cases.

Another major red flag attached to prescription amphetamines, even in its early days? the Chemical Heritage Foundation writes,“

“Almost from its beginning…amphetamine was ripe for nonmedicinal use.”

Indeed, this legacy is still very much alive today.

 

Stimulants in the 21st century: Trends & observations

Within the last decade alone, we have seen a huge increase in the prescribing of Adderall and similar prescription stimulants. This is a direct result of ADD/ADHD being diagnosed with much more frequency, which begs the question: Are we better able to diagnose ADHD today because of better screening practices and more access to care, or, are people, in this age of technological distraction, social networking, and school/career competition, seeking out Adderall just to keep up? It is certainly hard, in today’s climate, not to be seduced by all our available distractions. “It didn’t escape me that just as Adderall was surging onto the market in the 1990s, so, too, was the internet, that the two have ascended within American life in perfect lock-step,” observed writer Casey Schwartz in the New York Times Magazine last fall.

In many ways, I wear two hats when it comes to ADHD medications because I do have patients that are genuinely afflicted with this condition and need prescription medication to manage it. But I wonder if simple distraction is being conflated with ADHD, and if instead of examining and working on the underlying issues at-hand—be it boredom or distraction or depression—we are too often handing out Adderall as an easy cure-all.

 

Prescription popularity

ADHD was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1987. According to the Centers for Disease Control and Prevention (CDC), in the 1990s, around 3-5% of American children were believed to have ADHD. By 2013, that figure rose to 11%. The CDC writes:

“The first national survey that asked parents about ADHD was completed in 1997. Since that time, there has been a clear upward trend in national estimates of parent-reported ADHD diagnoses. It is not possible to tell whether this increase represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed.”

The report adds that the number of FDA-approved ADHD medications also increased “noticeably” since the 1990s.

And somewhere along the line, ADHD diagnoses and stimulants made their way into the world of adolescents and adults. Schwartz, in her examination of what she calls “Generation Adderal”, notes that in 2012, roughly 16 million Adderall prescriptions were written for adults ages 20 to 39. She also points out that Adderall is all over college campuses, taken with and without prescriptions. Indeed, Schwartz notes that the off-label use of prescription stimulants was the second-most common form of illicit drug use by 2004 (after marijuana). In a college environment, which is very often filled with high-pressure situations, tough deadlines, and unrelenting stress, our young people have discovered that taking a pill can help them complete their tasks faster and with less distractions. The unmanageable suddenly seems very manageable.

 

From college to career

But what about when young adults transition their Adderall use from the classroom to the conference room? Over the last few years, there seems to have been a steady uptick of people in their 20s and 30s using Adderall to bolster their professional lives. Indeed, a recent study of 11 million U.S. workers found that workplace drug tests are coming back positive at the highest rates in a decade, and they’re continuing to increase. The study notably revealed that amphetamine positivity increased 44% between 2011 and 2015. Alan Schwarz, a foremost expert on the topic of ADHD and prescription stimulants, states,

“It stands to reason that if you feel as if you succeeded in college partly because of these drugs, you’re more likely to feel as if you need them to succeed in the workplace.”

It seems, however, there is a common “so what” attitude surrounding Adderall use since it’s a drug that is known for engendering positive behaviors. Indeed, a recent survey from Partnership for Drug-Free Kids revealed that one in five teens believe it’s ok to abuse prescription drugs as long as they weren’t doing it to get high. In some cases, young people don’t even see non-prescribed Adderall as an illicit substance so much as a study or work aid. But let us not forget: Adderall and similar prescription stimulants are classified by the Drug Enforcement Administration (DEA) as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.

The incredible pressure to succeed professionally, combined with an overprescribing and “quick-fix” culture, has caused something of an Age of Adderall. And despite Adderall lacking the same negative associations that drugs like opioids invariably have, there are major and worrisome impacts that we must pay attention to and address if we want to help our young people lead healthy lives.

 

Side-effects

Adderall’s most glaring side effects include weight loss (due to appetite suppression), anxiety, irritability, insomnia, and, of course, dependence. Adderall “crashes”—caused by stopping Adderall suddenly—can cause depression and sluggishness. Some regular Adderall users, when not taking it, experience anhedonia—the inability to experience a normal sense of pleasure or joy. It can be exceedingly difficult to transition from the constant “up” state of Adderall to no stimulant assistance, and the fatigue and lack of motivation can be crushing. In its most extreme states, prolonged Adderall use, especially when combined with a lack of sleep, can cause panic attacks, paranoia, and psychosis. Indeed, in Schwartz’s “Generation Adderall” she recounts her own harrowing experience with a panic attack after days of continuous Adderall use. A few years back, Alan Schwarz wrote an article detailing one man’s addiction to Adderall, ultimately leading to a psychotic episode and, weeks later, suicide. Of course, situations like this are more rare than commonplace, but it doesn’t diminish the underlying reality: This is a highly addictive class of drugs, and our young people, in growing more reliant on them, are at risk.

Something I’ve seen in my work at Mountainside Treatment Center is co-addictions, with Adderall being used in conjunction with other substances to balance its effects. It’s rare to find a patient who isn’t also abusing Central Nervous System depressants such as alcohol and benzodiazepines (like Xanax) to lessen the effects of Adderall, which has likely caused them sleep deprivation and anxiety. What this means for psychiatrists is that we’re treating a more complex patient when it comes to Adderall addiction.

Something else to consider is that because Adderall can create a false sense of interest and motivation, it can halt some users from identifying what truly gives them passion, especially for those kids who start taking it in high school or college, and then enter their careers still abusing stimulants. If and when the day comes that they stop, they may be left wondering what, professionally or personally, truly lends them joy or a sense of purpose.

 

Solutions

So, what can we, as medical professionals, do to help our patients from falling into patterns of addiction with prescription stimulants?

  • Be more vigilant about screening: Some patients really are struggling with ADHD, and those patients can be helped with prescription stimulants, but we must ensure that we’re not handing out prescriptions to kids who don’t really need it. It’s quite easy for someone to come in listing ADHD symptoms they read about online and inquire about an Adderall prescription. It is our professional obligation to be more attentive in our decision-making. One simple way to achieve this? Schedule multiple meetings with a patient before writing a prescription. Getting to know them better, and really understanding their needs, could help carve a clearer sense of what might help them.
  • Implement better prescribing practices: Research has indicated that the time-release Adderall, which releases smaller doses of the drug into your bloodstream over a period of time, are less prone to abuse than the fast-acting variety. If you do decide to prescribe Adderall to your patient, try the time release version first and see how it goes. Further, there are prescribing practices that we should all follow in terms of limiting the amount of prescriptions during certain amounts of time, not upping the milligram dosage at the patient’s request, and so forth. Some prescribers write-out four prescriptions at one visit and say, “Call me next semester when you’re back in town.” We have to be better than that.
  • Educate patients and families on potential dangers of stimulant use: Many young people want a quick-fix solution to their ailments, which can lead them to ask for an Adderall prescription without investigating the potential side effects. It’s important that psychiatrists inform patients (and parents when you’re dealing with teenagers) on the side effects mentioned earlier, as well as Adderall’s addictive nature. When meeting with your patients, investigate attitudes, situations, and behavior patterns that may indicate over-reliance, misuse, or “self-medication”, which may be ominous warning signs of their vulnerability to addiction. Additionally, before ever prescribing stimulants, consider non-pharmaceutical interventions, or non-stimulant medications, that might help improve their focus—especially if you’re not certain the patient has ADHD. Also, if or when you are meeting with your patients who are prescribed Adderall, it’s a good idea to do random urine toxicology screening to see if there are other substances in their system that shouldn’t be there. Your patients should test positive for amphetamines and negative for other illicit substances. This can be an opportunity to identify patients at risk for co-occurring addictions, or it will serve as an assurance that they are appropriately taking the medication you prescribed.
  • Uncover any co-morbidities or issues at play: As psychiatrists, it’s our responsibility to not just prescribe medications, but to get to the bottom of what is afflicting our patients. Perhaps a patient comes to you feeling distracted and listless at work. Instead of turning to the little white pad right away, it’s important to probe what else is happening in this patient’s life. Maybe a romantic relationship recently ended; perhaps, they are feeling insecure in their career path. Building a relationship and a mutual trust with our patients, and opening up conversations about what is really going on with them, could help us better diagnose conditions, and ultimately help our patients work on their issues in the long-term.
  • Changing attitudes: This is a much taller order and a very long-term pursuit. But I do believe that as caregivers and as a society, we must shift away from putting so much weight on quick-fix solutions. Our collective “there’s a medication for that” attitude needs to change. Our work in the psychiatric community must go beyond writing prescriptions: We should be guiding our young people to find their paths, helping them realize their strengths, passions, and yes, even weaknesses in this ever-complex world.
Randall Dwenger, MD
Dr. Dwenger is the Medical Director at Mountainside Treatment Center. Throughout his 30-year career, Dr. Dwenger has built extensive knowledge on psychiatric evaluation, substance abuse, and the intersection of addiction and mental illness. He is specifically passionate about and knowledgeable on millennials facing addiction and how to help them on their road to recovery. Dr. Dwenger is a graduate of Indiana University School of Medicine and completed residency training at the Institute of Living in Hartford. He is board-certified in both Psychiatry and in Addiction Medicine. His career path has included a variety of experiences, including developing and managing a detox center, directing an Adolescent Chemical Dependency program, and maintaining a private psychiatric practice. At Mountainside, where he has been caring for clients since 2008, he provides guidance and leadership over all facets of the clinical program, including helping clients as they begin their journey towards psychiatric wellness and addiction recovery.

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