Coming Soon to a Neighborhood Near You: Adderall Abuse

I've watched with worried vigilance for the past 15 years the growth in the use by adults of these potentially powerful and addictive drugs. Sadly, I believe only after stimulant abuse causes the deaths of enough young adults will we address this growing public health menace.
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The rise of both the ADHD/ADD diagnosis and the use of stimulant drugs like Adderall, Concerta and Ritalin is once again front page news. A Centers for Disease Control (CDC) telephone survey found that nearly one in five high school boys' parents have been told their child has ADHD/ADD. Express-Scripts, the largest prescription insurance processor, in a recent report confirmed the highest prescription rates in boys but also documented explosive growth in prescriptions for adults with ADHD/ADD.

Telephone surveys and prescription rates are interesting but indirect measures of the use of stimulant drugs in the United States. However, the Drug Enforcement Administration (DEA) maintains records of the annual quotas approved for production by drug companies in the United States for controlled substances like the stimulants. While the manufacturing quotas do not specifically indicate how much drug is actually taken by Americans, it is unlikely that drug companies would request a higher quota than they believed they could sell -- and if someone buys the drug, they are likely to take it.

Therefore, the quotas are probably the most accurate indicator of ADHD/ADD/stimulant trends in America. Here's what the data shows. Since 1996 (when I first collected these numbers for a book I was writing), the amount of methylphenidate, which is the ingredient in Concerta and Ritalin, has increased 600 percent to 80,750 kg. in 2013. Amphetamine, the active ingredient in Adderall, increased 28 times to 65,500 kg. Lisdexamphetamine or Vyvanse (an amphetamine linked with an amino acid to make abuse more difficult) didn't exist in 1996. Twenty-one thousand kilograms were approved for production in 2013.

The total for all the stimulants is 175,014 kg, or approximately 193 tons of legal speed produced in our country in 2013. That amounts to about 550 mg or about 27 20 mg. tablets of Adderall for every man, woman and child in the United States. We are 4 percent of the world's population but in 2012 produced 70 percent of the world's legal stimulants.

The Express-Scripts study for the first time provides numbers that break down how much of these drugs are going to children compared to those over 18 years old. In 2012, 42.5 percent of stimulant prescriptions were written for children and 57.5 percent for adults (Jennifer Luddy, Express-Script email, March 19, 2014). This data confirms that the adult market for stimulant drugs now constitutes the majority of users of legally produced stimulants in our country.

So what's the big deal? No matter how concerned one might be about the over-diagnosis and over-medication of children, the bottom line on pediatric stimulant use is that the meds are pretty safe. After nearly 80 years of use in children, stimulant drugs have not proven their long-term effectiveness. But there also have been no consistent reports of their deleterious effects on children (slight decreases in final adult height not withstanding).

However, the same child stimulant safety record is not historically shared in the adult population. Quite the contrary, there is an even longer history of adult misuse, abuse and addiction of amphetamines since their synthesis in the U.S. in 1927. Indeed, following an outbreak of street use during the 1960s, the DEA made Ritalin and other stimulants Schedule II in 1972, the tightest form of control for a prescription drug,. Amphetamine addiction is just like addiction to "crank" (methamphetamine). Addicts act quite erratically. They are often involved in crime. There are intense ups and downs and when down, there is great craving for the drug.

Furthermore, many polypharmacy abusers start with amphetamine for studying, staying awake, doing more, and getting high. They then need downers like Ativan, Xanax, Vicodin or Oxycontin (all also addictive) to balance themselves out. National data on drug rehabilitation admissions have caught the large increase in admissions for primary opiate addiction but have missed the introductory role the amphetamines played in starting the downhill process.National data on emergency room visits for amphetamine abuse and overdose have paralleled increases in the overall use of the drugs in adults. Now data from California admissions to rehab hospitals has amphetamine topping the opiates as the number one drug for admission. Respected long-term researchers James Swanson along with Nora Volkow of the National Institute of Drug Abuse (NIDA) have published data that suggests up to 30 percent of the legally-produced stimulants in the U.S. are being diverted for illegal use.

The last great doctor prescribed stimulant abuse epidemic took place in the late 1970s and early 1980s when women took them as diet pills. Doctors addicted many women. A public outcry arose. The great negative publicity, threats of malpractice suits and loss of licensure eventually caused doctors to end their prescription of stimulants for weight control.

The DEA has chosen to focus on opiate prescription abuse and has relatively ignored the stimulants. A couple of highly-publicized college campus busts, particularly of end users (it is illegal to purchase and use Adderall without a prescription) would have a great effect on the open market atmosphere that exists now around exam time when cramming becomes urgent.

There is clearly a limited place for these medications, especially for very hyperactive children and for the far fewer well-evaluated and managed adults with ADHD/ADD. I've watched with worried vigilance for the past 15 years the growth in the use by adults of these potentially powerful and addictive drugs. Sadly, I believe only after stimulant abuse causes the deaths of enough young adults will we address this growing public health menace.

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