Surprising? Stimulants Help People Be More FocusedOn Saturday, the New York Times’ Alan Schwarz told us about the rising tide of teens and young adults who turn to stimulants — specifically medications used to treat attention deficit hyperactivity disorder (ADHD) — to help their school performance. The next day, Matthew Herper over at Forbes asked where the news was in this story, given that there’s no significant rise in the use of these medications by teens and young adults over the past decade.

He also called out the myth perpetrated by Schwarz — that ADHD medications like Adderall and Ritalin work one way in people with ADHD, but in a different way in people without ADHD. This is not true, and you’d think a NY Times writer (or his editors) would catch that.

But I wonder — why do we find it surprising people make use of something that will improve their school (or work) performance? And is this a problem, or an enhancement we should all embrace?

7 Comments to
Surprising? Stimulants Help People Be More Focused

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  1. Umm, let me just say for the reading public that feigning a psychiatric illness to get controlled substance prescriptions is basically fraud. I don’t see it quite as malingering, but in writing this comment now, there are overlaps, and in the end all it does is alienate many people around these drug seekers, starting with physicians like me who are tired of the rush by teens and young adults to just get drugs for quick fixes and short term solutions for long standing problems.

    It is a shame that insurance companies do not take a more invested interest in patients who come in and claim to have psychiatric disorders who really do not. Just enforcing the patient see a psychologist or other licensed professional trained to do some simple but applicable psych testing to rule in or out ADD would be effective in deterring these false efforts.

    One reason why I am leaving a practice now is the sheer onslaught of ADD referrals I have had since working there. About 20% of my general practice of adult psychiatry has patients seeking stimulants for alleged first time ADD diagnoses, some of them older than 40 years old. That has never been a percentage of any practice I have had in the 19 years prior.

    Careful what you wish for in the end of your post, Dr Grohol, when more than 50% of those seeking controlled substance stimulants are allowed lax access to them and find out the consequences of using them in rampant fashion just to enhance performance.

    Ahh, didn’t we learn that lesson with anabolic steroids about 20 years ago!?!?

  2. As one of those people over 40 years old who just sought (and obtained) an ADHD referral, I can offer the view from the other side of that exchange. Many of us are not seeking pills, we’re seeking answers. Answers to patterns of patterns of behavior and deficits that have dogged us our whole lives, screwing up academic performance, our livelihood and our relationships.

    If all I wanted was uppers, any fool can order modafinil or similar analogues all over the internet, and for a fraction of the price of seeing a psychiatrist. For that matter, one can always find dodgy walk-in clinics that will write pretty much anything on demand. I went through the whole neuropsych testing, a full 9-5 day of endless assessments. They identified a math learning disability and inattentive type ADHD. Yeah, I got my ritalin script in the end, but that wasn’t the goal. I may decide to go back to atomoxine which I had tried prior to testing.

    I’m not looking for the buzz, I’m looking for ways to function like I should. I had self-medicated for years prior, and none of it was what you might assume. It was stuff like piracetam, ginko, hydergine, all non-euphoric but also largely ineffective for me.

    I’m sure there are plenty of drug-seekers around and I could see where MDs get tired of that, but patients also don’t much appreciated being put down for junkies simply for seeking help.

    • I have at least 2 issues here, the first I touched on at the end of my previous comment about a non physician advocating for a looser policy in prescribing controlled substances that have a high abuse potential, and the second being for every one person who may legitimately have a case to pursue an ADD assessment over the age of 30, easily the next 1 to 2 do not. And why are so many people arguing about getting testing done to confirm a subjective opinion by a provider who has spent an hour talking to you and being pushed to write for such a potentially damaging drug?

      And furthermore, why aren’t insurers more willing to allow for psych testing to minimize overprescribing of drugs that are in limited supply and costing more now to access? People who either aren’t on the front lines of this problem, or people who have a primary or secondary agenda to promote easier prescribing of said meds are so quick to speak out, and usually louder than the actual participants are allowed.

      Just today, I read in the APA newsletter of recent issue, page 22, a 4 paragraph summary noting CBT without Medication leads to Remission in Adult ADD. Here is the link from the article to read for yourselves this conclusion:
      http://www.biomedcentral.com/1471-244X/12/30/abstract , by Weiss, Murray, Wasdell et al.

      You know what burns me up the most? Listening to many of these older patients literally arguing or ignoring me when I promote them seeing a separate therapist to do limited CBT work to learn skills that meds won’t improve and the patients don’t have.

      Frankly, this call by Dr Grohol to loosen standards is irresponsible. What doesn’t surprise me is not reading other colleagues who know what are the true standards of care speaking out at least somewhat in agreement with me. And you know why? Because they would lose that monthly med check they bank on, literally, when prescribing a class 2 substance. Another black eye for psychiatry, eh?

      • Full psych testing is great as a “gold standard” for confirming diagnoses, but it’s not without its problems and its unrealistic to insist that every single patient presenting with symptoms undergo it. As you note, not all insurance covers it. Without that coverage, it costs many thousands of dollars.

        It would be great if insurance companies covered it universally, but it may or may not be cost effective. In short order, we’d see it evolve into a routine childhood screening for every student who wasn’t pulling a 4.0 average. Full testing is not all that available either. The one place in my network took three months to get into, and if I hadn’t been able to make that one day, it would have been months longer to get another opening. And that was in a well-served market (Chicago area). The quest probably gets much more interesting if you live in Scratchback Idaho or someplace with no concentration of specialists.

        I’m glad I got it done, but if I had faced massive bills or had been working an inflexible job, I would just have been ineligible for treatment under your regime. I face the same potential dilemma with CBT. Nobody wants to cover this stuff, and I don’t have thousands laying around to pay for it. I’m going to do what I can to learn the “living strategy” side of treatment, even if I have to do so from books. Medication and other treatment build on each other, but neither is a substitute for the other.

        There is also a larger question within medicine these days of what role testing should play in general. It’s great we have so many tools, but they’re not substitutes for clinical reasoning or judgment. Many new MDs know testing and treatment flowcharts but seem totally lost when something doesn’t respond the way “evidence based medicine” says it should. Doctors who rely heavily on testing spend their days chasing down unimportant abnormalities with more invasive and dangerous treatment and testing while missing the obvious. I’ve known two people who almost died of appendix rupture because they had to wait 10 hours to get on the table. They had to wait for imaging to confirm the 99% suspicion that it was, in fact an acute appendix.

        Finally, if doctors have a financial incentive to push pills, that’s something the profession itself needs to grapple with. In recent years, doctors have been allowed to become hugely paid “consultants” and shills for many classes of expensive drugs, to the point that patients have no idea whose agenda drive treatment decisions at the end of the day.

  3. So the way I interpret your rebuttal, people who have cognitive struggles that overlap the ADD criteria, doctors should just reflexively prescribe controlled substances without any effort to validate the diagnosis fits responsibly because if people can’t access the standards, let’s just jump to conclusions without appropriate work ups.

    I have met my share of people who echo this kind of mentality, and it is what leads to the basis that creates mindframes behind managed care, diagnostic logarithms, and most loathsome, PPACA.

    Just curious, with the fact that stimulants like adderall and Ritalin are in limited supply these days, who decides who gets it and who is denied? People don’t think those endpoints through so easily, do they? As long as you get yours, everyone else is on their own, eh?

    That is why we have to have work ups. And equally curious, should we find out in the next few years that giving stimulants to adults over 40 for several years has somatic consequences like advancing heart disease or new neurological disorders, who gets blamed then? The very doctors you demand diagnose these disorders so easily now!?

    Phen-Fen seemed so good for weight loss in the early 90′s. Fascinating how history repeats itself so easily. And how the Internet speeds up these failures so spectacularly!

    • All I’m suggesting is use comprehensive testing as a tool, not the sole determinant in all cases. Some cases are flagrantly obvious, others less so. Some patients will have the means to get testing, others not.

      Some of those scamming for drugs will get away with it, whether with your or someone else. All you can do is your reasonable best to screen out the obvious ones. When a doctors gets so jaded about patients that he starts seeing all of them as hustlers, it’s probably time to retire or go into some non-patient contact role. Testing is one way to smoke out the fakes. But there are others.

      My initial psych guy gave me a trial of strattera. A speed seeker would have grumbled about that from the start. I was happy to give it a try, and it worked reasonably well. I simply cannot tolerate an adequately effective dose.
      The ritalin/adderall shortages are not the fault of patients or doctors. It’s not an industry problem. The chemistry is dirt simple. Shortages are completely artificial, engineered by the DEA. They use a Soviet-style system of inflexible production quotas. That’s what happens when you put cops in charge of health care.

      In the longer view, we ought be developing new technologies like ampakines or other alternatives developed in the light of modern brain metabolic studies. Our first line treatments for ADHD were developed when cars had running boards!

  4. As someone who has struggled with ADHD my entire life, I find it incredibly unfair that students without ADHD are using these stimulant drugs to get ahead in acedmics, and it’s offensive that you would compare it to drinking coffee. Also please don’t be fooled by the name “stimulant”. What you fail to consider is that most of us who have ADHD become CALMER, and therefore more focused when we drink coffee or eat sugary foods because our brains are sort of quieted down and less chaotic. The purpose of taking ADHD medication is to EQUAL OUT the playing field so to speak for those who have ADHD so that we can be on the SAME level of opportunity as those without ADHD. Abuse of this drug by those without ADHD is not only COMPLETELY unfair, but completely defeats the purpose of ANYONE taking meds for ADHD

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