The Daily Mail alleges, without providing documentation, that Done is being investigated for “misusing controlled substances.” The phrase “misusing controlled substances” is itself an example of the journalistic distortion that has been a cornerstone of the Daily Mail’s success in attracting readers. If taken literally, it implies that the company’s employees, clinicians, administrators (or all three!) are themselves “misusing” the substances! Presumably the author would claim she or he meant to write “mis-prescribing” and that it was an innocent “misuse” of language, a misuse not even deserving of an investigation, let alone a fine or jail sentence. However, if such claims of innocence were offered, I for one would be somewhat skeptical, as the tabloid she or he is writing for has what can only be described as an egregious record of distortion and sensationalism.
It is likely that the Daily Mail readership, employing their well-known incisive intelligence, are currently visualizing an entire telepsychiatry company staffed by “speed freaks” who are enthusiastic about generating fellow addicts, in the spirit of “the more the merrier,” so that patients and corporate staff can get together for the wild parties referred to later in the article where it is said that Adderall “is famously abused...as a party drug...”.
The article’s headline reads:
“THE GRAPH THAT EXPLAINS AMERICA'S ADDERALL SHORTAGE - AS IT'S REVEALED PRESCRIPTIONS DOUBLED DURING PANDEMIC”.
This headline states that the “explanation” for America's Adderall shortage is the pandemic. The fact is, the pandemic did not cause the Adderall shortage directly. If the author wanted to actually give readers insight into the causes of the Adderall shortage, she or he would delve more deeply. The result of such a “deep dive,” as elucidated below, would be that the Adderall shortage was a long time coming and the pandemic simply forced a lurking problem to reveal itself.
For the “Daily Mail”-type readers, I will here cut to the chase. Others can read on and follow the logic and assess the evidence, but the bottom line is there is an Adderall shortage because the disorder which Adderall treats, namely ADHD, has been undertreated since Hippocrates first described the over 2400 years ago. The pandemic, in one of its exceedingly rare positive effects, enabled access to treatment, through technology that people from as little as 100 years ago would regard as miraculous, for ADHD sufferers who otherwise would go untreated.
If medicine is to fulfill its goals of alleviating human suffering and treating disease, the improved access facilitated by telepsychiatry must not be regulated out of existence. The increased demand for stimulant medications such as Adderall for ADHD is not the result of abuse or misdiagnosis but is simply caused by a previously unmet need for treatment of ADHD, which telepsychiatry finally satisfied. The Adderall shortage will be successfully managed, because the pharmaceutical companies will increase supply (after the brief lag we are currently experiencing), and the highly deleterious effects of the serious scourge that is ADHD will be furtherthe ameliorated. ADHD will become a premier example of the numerous afflictions that have been managed or cured by the application of our steadily increasing understanding of the physical basis of disease.
To look “beyond or behind the headlines” of the Daily Mail article, the first sentence purports to “explain” the Adderall shortage by pointing to the increased prescriptions during the pandemic. Unfortunately, what the article offers is NOT an explanation but rather a restatement of the problem. This is because if we assume a constant supply, the only way for a “shortage” of a prescription-only medication to occur is an increase of the number of pills prescribed, which is exactly what the Daily Mail offers as an “explanation.” To truly explain the Adderall shortage, we need to find the CAUSE of the increase in its prescriptions.
To be fair to the Daily Mail, the article does go on to offer possible actual causes of the Adderall shortage. Increases in “diagnosis of behavioral issues” due to the stress of the pandemic, and improved access to health care as a result of “the move to telehealth appointments” are both among the causes of the increased demand for Adderall which led to the current shortage. Unfortunately, the Daily Mail writer then makes a completely illogical leap, connecting this increase in demand to an alleged “investigation” of Done and Cerebral by the US Drug Enforcement Administration. To literally add insult to injury, the article then veers into outlandish territory, when it says these investigations are for “misusing controlled substances”.
After correctly identifying two ACTUAL causes of the increase in Adderall prescriptions, the author ignores the fact that any enhanced scrutiny is not because of “misuse,” but simply because of that very increase. The connection of this phantom “misuse” with actions of the DEA is gratuitous, as though the writer has been compelled or directed to link the DEA’s actions with “misuse” or abuse.
As though that is not enough, the article paints a falsely-alarming picture of the risks of Adderall treatment. It states, “Adderall is a drug that can be easily abused.” Another statement that is close to meaningless! Any medication that people use recreationally but which is intended only to treat medical conditions can and will be “abused.” If the medication clinically not intended for recreation and legally “prescription-only”, using it for the unintended purpose of recreation is “abuse.” “EASE OF ABUSE” is thus not an intrinsic property of the substance, but a function of EASE OF ACCESS. As a Schedule II controlled medication, Adderall is NOT easy to access. If it were easy to obtain Adderall, the spike in prescriptions, (which the article correctly attributes to improved access to ADHD care as a result of telepsychiatry appointments) would have been a slight hillock rather than a spike. This is because given easy access, ADHD sufferers would already have their medication. The advent of telepsychiatry for (almost) everyone would thus not cause a “spike” in Adderall prescribing rates.
After describing the “ease” with which Adderall can be abused, the article moves on to state that Adderall “is considered to be a schedule 2 drug by US officials, making it illegal to obtain without a prescription because of its addictive properties.” This single sentence contains so many inaccuracies and such confused writing that it is hard to know where to begin a critique. It is obviously illegal to obtain ANY prescription-only medication without a prescription, whether or not it is on a “schedule” of controlled substances. The reason many medications are deemed “prescription-only” is their unsupervised use may be harmful to the consumer, not because they might be “addictive.” For example, antihypertensives are prescription-only even though they pose no risk of dependence, because their unsupervised use could result in dangerously low blood pressure.
To deal with the problem of dependence, the regulatory agencies have superimposed another level of control on the straightforward mechanism of “prescription- only.” At least in theory, all of the medications on the FDA’s 5 “schedules” of controlled substances have a potential for causing dependence. In 1970, the schedules were created by the Comprehensive Drug Abuse Prevention and Control Act the purpose of which was to prevent “drug abuse”. As Wikipedia wryly notes, the term “abuse” is never defined by the Act.
Supposedly, the addiction potential of the substances INCREASE as the schedule number DECREASES. Thus, Schedule I contains substances considered so addictive that mere possession of them is a crime-no doctor can prescribe them and no pharmacy can dispense them.
Simple consideration of the fact that marijuana is a Schedule I drug, along with heroin, while cocaine is Schedule II, is enough to suggest that the numerical ordering of schedules by addiction potential must be include a significant subjective element . If you add to that consideration the fact that alcohol and tobacco, two of the most addictive products it is possible to consume without the prospect of immediate death (although in the case of alcohol, rapid death is also possible) are not only “unscheduled” drugs but are available without a prescription and without limit in virtually any store, it is proof that THE SCHEDULING OF SUBSTANCES BY ADDICTION POTENTIAL IS A MATTER OF POLITICS AND ECONOMICS, NOT SCIENCE.
Yes, Adderall has the potential to produce dependence. So does coffee, alcohol (severely, to a life-threatening or terminating extent), nicotine (ditto), and according to some states, gabapentin, also known by its brand name Neurontin.
If a substance is addictive, one would expect that it was addictive in all states of the Union. The way the current crazy-quilt of drug enforcement regulations has recently been arranged, however, one can be taking one’s prescription of gabapentin as directed for one’s chronic neuropathic pain in Illinois and get it prescribed and filled like any other medication. Unfortunately, if one moves a few miles to the neighboring state of Kentucky, suddenly your medication is “addictive” and any doctors or pharmacies one tries to obtain it from must labor under additional restrictions and bureaucratic regulations-with the result that it might suddenly be impossible to obtain the medication that was so helpful in Illinois! Clearly, such state to state variation in the way substances are legally managed cannot have a scientific basis, but must have a political basis.
Within the Daily Mail article, we find a box headed “What is Adderall?”
Before I focus on the substantive errors in the description of the medication, I will mention that this section contains spelling and stylistic mistakes that are surprising to find in a widely circulated periodical.
“The drug is prescribed for people who are diagnosed with ADHD. But addiction centers say many otherwise healthy people are taking the drug to help with their work or social life.” Ignoring the fact that no references or documentation are provided for this sweeping statement, it must be noted that its content borders on absurdity. By definition, ADHD is a disorder that affects one’s ability to work, and in most cases, one’s social life. The people who the article calls “otherwise healthy” have ADHD-without their treatment they are NOT healthy, and inserting the word “otherwise” to imply that they are not taking Adderall to treat an illness does not change that reality.
The Daily Mail’s attempt to verbally delegitimize ADHD as a medical disorder is a sad but loud echo of what many ADHD sufferers have heard their entire lives as a justification of denial of treatment-“you don’t have ADHD, you just need to try harder and concentrate.” If someone’s problems with work and/or social life are so severe they are motivated to seek out a doctor, when doctors who are willing and qualified to treat the disorder properly are few and far between, and then willing to take a severely stigmatized medication about which they see dire warnings everywhere they turn, the odds are very high that they DO have ADHD. The fact that “addiction centers” say that many people who take Adderall “don’t really need it” has very little credibility. The many “addiction centers” heavily invested in the “Twelve Step” approach also often deny the need for antidepressants or anxiolytics. Both treatment of depression with antidepressants and of ADHD with stimulants have been shown to significantly reduce suicide rates, so the “addiction centers” are entering dangerous waters when they tell people they don’t need those medications.
The article’s emphasis on the adverse outcome of addiction continues, with the attention paid to the potentially life-changing or life-saving benefits of stimulant treatment of ADHD not even mentioned. Another example is categorizing two neurotransmitters enhanced by Adderall, dopamine and “norephinephrine” (note the article misspelling of one of the best-known neurotransmitters) “feel good hormones” is a gross oversimplification and encourages the reader to subscribe to the “famous party drug” stereotype of Adderall mentioned above. The statement that Adderall helps ADHD sufferers “avoid behavioral issues” seems designed to make the reader think of “misbehaving” out-of-control children from the stereotype of the “hyperactive” subtype of ADHD, despite the fact that the vast majority of adult ADHD patients show no hyperactivity.
The article’s description of amphetamine withdrawal is simply incorrect and seems calculated to make that condition scarier than it is. In severe cases of amphetamine withdrawal, people are generally somnolent, as opposed to agitated. Perhaps “somnolent” did not sound dangerous enough, so they simply changed it to the opposite.
This Daily Mail article is a sad example of the currently prevalent indignant fear of anything with even the most remote possibility of being addictive. This primitive, emotional reaction, growing from seeds sown by media outlets such as The Daily Mail, disregards the huge range of severity of the addiction risk and omits the most crucial thought process in the evaluation of a medical treatment-the judicious weighing of risks versus benefits.
To direct “attention” again to a stage even larger and more fraught than ADHD, the weighing of risks and benefits is clearly awry when a useful medication with very mild if any addiction risk, such as gabapentin, is restricted and stigmatized, while alcohol claims more than 380 lives per DAY in the United States and elicits only symbolic action to control the problem. We are clearly dealing with hypocrisy, whether conscious or not.
In the case of ADHD, the evidence is compelling that treatment with Adderall, the medication which the article disparages and damns with faint praise, saves many lives and vastly enhances the quality of life of many more.
For those who have doubts about ADHD treatment actually saving lives, I submit the following simple calculation: using the fact that the suicide rate for ADHD is five times higher than for the general population, and that there are at least 9.2 million adults with ADHD, it is straightforward to calculate that if treatment of ADHD eliminated the “excess” risk of suicide that ADHD entails, the suicides per year among ADHD patients would decrease by almost 5000, from 6164 to 1235. Of course, treatment may not completely eliminate even the “excess” risk, but the figure of 5000 lives saved is far too large for ANYONE to ignore, and thus adds urgency to the task of presenting the truth about Adderall and similar ADHD treatments. They are treatments that are significantly underutilized, partly because of the fear-mongering exhibited in articles like this.
Despite the resistance to change that seems inevitable even when the change is clearly for the better, there are many signs of hope. The increased access to care that a huge number of patients experienced due to the explosion of telepsychiatry is important not just to the patients who directly benefited but also because there are more successfully treated patients to disseminate the knowledge that ADHD is a serious, but treatable, disorder.
I have pointed out that ADHD has been undertreated for at least the 2.4 millennia since it was first described, but with awareness of the obstacles described in this review, we can seize the opportunity and change ADHD from a sadly undertreated disease to one for which the full potential of our exploding medical knowledge is realized.
