Health Letter, August 2013
The prescription of stimulant medications, usually used to treat attention deficit hyperactivity disorder (ADHD), has hit an all-time high in the U.S., increasing more than nine-fold between 1991 to 2009. Young adults represent the fastest-growing population of users of these drugs. According to The New York Times, nearly 14 million ADHD drug prescriptions were written for Americans ages 20 to 39 in 2011, more than double the rate of 2007.
Given the proliferation of such drugs, it is perhaps unsurprising that the U.S. has experienced rampant misuse and abuse of the stimulant medications, with the number of related emergency room visits more than doubling from 2005 to 2010. Young people are at the center of this dangerous trend of stimulant abuse: In one study of college students, 8 percent reported taking the drugs illicitly, mainly to improve academic performance.
Students, who feel pressure to perform at a high level academically; physicians, who respond to patients’ pleas; and the pharmaceutical industry, which conducts incessant drug-marketing campaigns, all drive a dramatic increase in the prescription and illicit use of these substances.
Risks of ADHD treatments
There are two main categories of medications used to treat ADHD: nonstimulants and stimulants. Nonstimulants, such as atomoxetine (brand name: Strattera) come with a number of serious side effects, but, according to the Food and Drug Administration (FDA), they may be less likely to be abused than stimulants and are effective in treating ADHD.
Some stimulants also are effective at treating ADHD, but they are addictive and far more commonly abused by young people due to their more potent and fast-acting effects. Most stimulants are amphetamines (such as the most widely abused drug among college students, amphetamine-dextroamphetamine, the active ingredients in Adderall), which are structurally and functionally similar (in one case, even identical) to street methamphetamine. Their addictive potential has led them to be classified as Schedule II drugs by the Drug Enforcement Administration (DEA). This means that under the federal Controlled Substances Act, the medications must be obtained from a DEA-licensed practitioner, prescriptions must be limited to a 90-day supply and the patient must return to the physician for further assessment to obtain refills.
Even when stimulants are used properly under a doctor’s supervision, they carry several potentially fatal risks. Cardiovascular effects include increased heart rate and blood pressure, and the medicines are thus contraindicated in patients with serious heart problems. A 2006 study concluded that approximately 1 in 400 patients exhibit psychotic behavior or suicidal thoughts while taking the medicines. The drugs also cause seizures and driving impairment, and they interact dangerously with numerous other medications.
Little is known about the long-term side effects of stimulants, because most controlled studies of the drugs have lasted no more than one to two years. What is known, however, is that the misuse and abuse of addictive stimulants result in thousands of visits to the emergency room per year. Abuse of the medications can lead to depression, mood swings, sleep deprivation, heart irregularities and severe withdrawal symptoms. Overdoses of methylphenidate or amphetamines have resulted in death and such life-threatening complications as prolonged seizures, tears in the aorta (the body’s largest artery) and heart arrhythmias. In addition, stimulants have been reported anecdotally to act as a “gateway” drug to the abuse of other prescription medications, such as painkillers or sleeping aids.
Overdiagnosis of ADHD
Some of the increase in stimulant use in young adults may be attributable to children and adolescents with ADHD who continue the medications into adulthood. Based on the Health Resources and Services Administration’s National Survey of Children’s Health, the percentage of children ages 4 to 17 diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007 and up to 11 percent by 2011. Another national survey showed that prescribed stimulants to individuals under the age of 19 increased from 2.4 percent in 1996 to 3.5 percent by 2008.
There are undoubtedly severe cases of attention disturbances, in which the new diagnoses represent an increased awareness among physicians and parents of significant mental illness. However, it is certain that the difficulty of diagnosing a vague condition such as ADHD has contributed to the jump in diagnoses over time. Many, if not most, of the new cases likely result from more dangerously liberal diagnostic standards within the medical community.
As the National Institute of Mental Health (NIMH) points out, anything from a middle-ear infection to a mild disruption in a child’s living situation can lead to symptoms similar to those of ADHD. The NIMH alludes to the situational and often transient nature of some of the symptoms that make up the criteria outlined in the official diagnostic guidelines. The agency notes that a child could qualify as an ADHD patient in one setting (e.g., school) while returning to “normal” childhood behavior once home and therefore advises that physicians pay “close attention to the child’s behavior during different situations,” which some physicians may not do, given time constraints.
The often deep-seated social or economic causes of ADHD-like symptoms lead to further overdiagnosis. According to a 2011 national survey conducted by the Centers for Disease Control and Prevention, children living in poverty or in a single-parent home were substantially more likely than other children to be diagnosed with ADHD or a learning disability.
Gender, race and geographical region are all potential factors in diagnosis and treatment for ADHD. According to a 2011 study, boys are three times more likely to be prescribed a stimulant compared with girls; whites are most often treated with a stimulant compared with other ethnicities; and in the Northeast, prescriptions increased from 2.7 percent in 2002 to 4.6 percent in 2008 compared with no increase in the Western states in that period.
Profiting from overuse
As with other psychiatric conditions, the pharmaceutical industry has exploited the diagnostic and therapeutic uncertainties of ADHD to maximal effect. Prior to the last decade, ADHD medications were approved only for children and adolescents, but this changed following Strattera’s 2002 approval for the treatment of adult ADHD. Four stimulants were then approved for use in adults within the next six years. This change opened the door for college students everywhere (as well as anyone 18 and older) to become potential new patients.
By 2008, the market research firm Datamonitor was highlighting the commercial potential of this new market of adult ADHD patients in a press release aimed at the drug industry: “Immature adult market continues to offer greatest commercial potential. … Estimated to be twice the size of the pediatric ADHD population, the highly prevalent, yet largely untapped, adult ADHD population continues to represent an attractive niche to target.” The firm then exhorted companies to undertake the tried-and-true strategies of disease creation and disease promotion to realize this potential: “Manufacturers would benefit from lobbying national medical agencies into developing much-needed diagnostic and treatment guidelines, in order to increase the awareness of proper diagnostic practices and increase the diagnosis rates of ADHD in adults.”
Over the last decade, companies have worked incessantly to expand the market for lucrative stimulant medicines from children to adults. Expensive direct-to-consumer ad campaigns (complete with billboards in Times Square) have proliferated. Industry-backed organizations that masquerade as patient-advocacy groups, social-media marketing and even mass public disease-screening opportunities have all worked to generate demand for ADHD drugs to adults, young and old.
By 2011, the investments were paying dividends, with prescriptions for ADHD in young adults almost tripling over the previous four years. Stimulant sales for all age groups more than doubled over the past five years, from $4 billion in 2007 to $9 billion by 2012.
Illicit drug use
In February 2013, The New York Times began a series of articles and student testimonials on the prevalence of stimulant misuse in high school and college students. In case after case, students reported using the pills as a way of getting ahead academically and fulfilling high expectations to succeed.
Stimulants are notoriously easy for young people to obtain without a prescription. One common method is to make arrangements with (or exert pressure on) classmates holding a prescription. Studies have found that 16 to 29 percent of children and college students with stimulant prescriptions who had been asked to give, sell or trade away their medications admitted to actually having done so at some point in the past. A recent survey of 334 college students showed that 76 had been prescribed stimulants for ADHD at some point. Of these, 29 percent had sold or given their medication to others. The going rate for illicit ADHD medicines on college campuses is anywhere from $5 to $10 per pill.
If they can’t borrow or buy the medicines from others, students may visit a campus doctor and fake symptoms to obtain their own prescriptions. In one of the articles on the topic in The New York Times, high school students discussed how easy it was to fool doctors by using a few canned complaints of trouble studying or restlessness. For their part, health care practitioners sometimes facilitate this practice by diagnosing ADHD on the basis of a single questionnaire.
Students reported that once they got the pills, they would use them to help fuel an all-night study session. Some even snort the medicine for quicker effects immediately before walking into an exam. Those who abuse stimulants often report improved academic performance, partly explaining the dramatic rise in the drugs’ popularity. As the number of students using the pills has increased, a “race to the bottom” can emerge, in which more and more students start popping pills just to keep pace with supposedly higher-performing colleagues, who may be doing the same.
Such a dynamic may be heightened in highly competitive programs, such as medical school. Two recent surveys of medical and other health professions students found that approximately 10 percent of students reported having used a prescription stimulant illegally, mostly to help them study. There are potential public health implications once these students graduate and begin seeing patients: Reports of prescription drug misuse are five times higher among physicians than in the general public.
In response to stimulant overuse and abuse, many college campuses have become reluctant to diagnose ADHD. Some have attached conditions and provisions to stimulant prescriptions being written. For instance, California State University, Fresno, requires students to sign a formal contract agreeing to submit to drug testing, to see a mental health professional every month and to not share their pills. In the contracts required by the University of Alabama and Marist College, students must pledge to not misuse the pills or share them with others. A handful of colleges and universities have even decided to “get out of the ADHD business” altogether, as one student health director told The New York Times. Some universities forbid their staff clinicians from making an ADHD diagnosis or prescribing stimulants, and instead refer students to off-campus providers.
Public health officials also have been promoting appropriate stimulant use, emphasizing the detrimental effects of misuse and advocating for more stringent policies around stimulant prescriptions. The Massachusetts Medical Society has been particularly vocal in calling for the prescriptions to be used only by patients who demonstrate medical need and highlighting the health consequences of misuse or abuse.
The overuse and abuse of prescription stimulants by young adults from high school through graduate school is now at epidemic proportions. Though laudable, the efforts thus far to address this vast problem appear insufficient to stem the nationwide tide of misuse.
The drug industry and the medical community are both to blame as suppliers of the drugs, which have addicted — and killed — untold numbers of the nation’s youth. Unless we address the undue pressure on students from high school onward and, more broadly, the socioeconomic roots of ADHD symptoms in so many children and adolescents, the epidemic will likely worsen.