By Karen Weintraub
Like any other medication, drugs used to treat Attention Deficit Hyperactivity Disorder can be abused.
A story in last Sunday’s New York Times showed the potentially tragic consequences of such abuse, and revealed some of the systemic factors that enabled it.
There is no blood test to diagnose ADHD – no biological marker that says “yes” you have the condition or “no” you don’t. Accurate diagnosis relies on the sophistication and experience of the doctor and the honesty of the patient.
The New York Times piece suggested that one or both of these factors broke down in the case of Richard Fee, a college graduate who committed suicide at age 24, two weeks after his last prescription for the stimulant Adderall expired.
Drugs like Adderall are far more available now than they used to be, because awareness of ADHD and prescriptions have increased markedly over the last decade, particularly among adults.
Most people tend to see ADHD as a condition of childhood. Research suggests that 5-10 percent of children meet the criteria for ADHD and are impaired by it, while roughly 4 percent of adults do.
Although there has long been discussion about whether ADHD medications are overused in children, this story raised concerns about the drugs in early adulthood, when drug abuse is most common. “We’ve got a lot more drugs out there in that age population,” said Dr. Glen Elliott, chief psychiatrist and medical director at the Children’s Health Council in Palo Alto. “The need to be more alert to possible diversion and misuse and abuse in this population has certainly increased.”
In light of the story, I called Elliott and several other ADHD specialists this week, including two with whom I just finished writing a book about adult ADHD. These are their thoughts about The New York Times story and ADHD medications in general:
1. Abuse is not a problem among young children who take ADHD medications. Their parents or school nurse generally dole out the pills and keep track of them. (Overdiagnosis may be a bigger issue for this population, but that’s another story.) The biggest potential for abuse at this age is parents or older siblings taking the pills for themselves, which data suggests happens in about 10 percent of households, said Dr. Andrew Adesman, chief of Developmental & Behavioral Pediatrics at the Steven & Alexandra Children’s Medical Center of New York.
For children who are significantly helped by medication – better able to focus, to pay attention, to learn in school – the benefits of far outweigh the risks, Adesman and the other doctors said. “When this [medication] works, it should be dramatically effective and not cause problems that get in your way,” said Steven G. Dickstein, a pediatric psychopharmacologist with the Child Mind Institute in Manhattan. “If it does not cause a difference or causes dramatic side effects, that’s not the right treatment for your child.”
Over his decade of practice, mainly with school-age children, Dickstein said he’s seen many young people with ADHD improve markedly with medication. He said he’s never had a situation like the one described in the Times piece.
For teens with ADHD, the bigger risk may be avoiding medication. Research has shown that teens with untreated ADHD are more likely to develop substance abuse problems than teens who are medicated for their condition, Adesman said.
In high school and, especially college, the person with ADHD becomes responsible for their own prescriptions and has much less parental oversight, if any. That’s when abuse tends to kick in, the specialists said.
Having ADHD puts people at higher risk of all kinds of addictions, “because the disorder itself is characterized by impulsivity and poor recognition of consequences,” Ruth Hughes, CEO of the national advocacy group Children and Adults with ADHD (CHADD) wrote in a blog post this week. “We must help anyone with ADHD be forewarned that there is a higher risk of substance abuse and we must be vigilant for early warning signs.”
Those signs might include “doctor shopping,” as The Times described Fee doing, going from one doctor to another, looking for medications. Sudden requests to increase dosage is another sign, the specialists said.
In one survey of 91 college students taking ADHD medications, Adesman said, about 10 percent of the students said they misused their medications – often by drinking alcohol while taking the drug – and about the same percent admitted to “diverting” their prescription to others. “To my knowledge, this is not a kid who’s going out and becoming a pusher, it really is people asking” for a pill or two as a favor, Elliott said, and the kid with ADHD hands it over to be nice or make friends. It’s not clear how often this is happening, Elliott said.
Dr. Craig Surman, an assistant professor at Harvard Medical School and the scientific coordinator of the adult ADHD research program at Massachusetts General Hospital, tells his college-age patients not to let friends know about their prescriptions – so there’s no chance they’ll be pressured into giving pills away.
Another solution, Elliott said, could be to start patients like Fee – who was not diagnosed with ADHD until young adulthood – on non-stimulant ADHD medication. Doctors often prescribe stimulant medications first, because they have been shown to start working immediately and help 65-70 percent of people with ADHD. Non-stimulants, which don’t carry the addiction risk, are effective about 40 percent of the time, and can take days or weeks to make a difference. The antidepressant Wellbutrin has also been shown effective for some people with ADHD, without the addiction risk, he said. In this vulnerable young-adult population, fear of addiction should probably outweigh the need for a quicker fix, Elliott said.
Drug companies have also tried to make their products safer by shifting to longer-acting medications – avoiding the up and down cycles and making it harder for people with ADHD to skip a pill. The companies have also created compounds that are harder to snort, which abusers do to get a faster high, Elliott said.
2. There are other ways to treat ADHD besides medications, though there is far less research on these alternatives.
Stimulants are the fastest, most effective therapy, with the best results, particularly in children, research shows. All patients on ADHD medication should be under close supervision of a doctor, the specialists agreed.
But medications don’t “solve” ADHD, and other approaches are crucial, too. “Pills don’t teach skills,” said Dr. Timothy Bilkey, a Canadian adult psychiatrist in private practice. The medications can help someone focus, but don’t tell them what to focus on – so they might do a great job on something that’s totally irrelevant or unimportant.
Surman said it’s also crucial for adults with ADHD to exercise regularly, get enough sleep and eat well – habits that are often difficult for people with ADHD to keep. No one can function well if they’ve stayed up half the night playing video games.
Cognitive behavioral therapy – a type of talk therapy that redirects people and helps them get out of their own way – can be an extremely effective treatment for ADHD when paired with medication, Surman and his Mass. General colleagues have shown.
Surman is also researching neutraceuticals – versions of natural food – that might help with ADHD.
Adesman said there’s already research to suggest that fish oil supplements can have some modest benefit for people with ADHD.
3. The Times story highlighted problems with drug abuse, these ADHD experts said, not with ADHD treatment. (It wasn’t clear in the article whether Fee actually had ADHD, or merely said he did in order to get medication.)
Deciding when trouble with focusing becomes bad enough to require medication is subjective, Adesman said. That makes it possible for patients to lie to their doctors or twist the truth, if their real goal is to obtain medication. “It’s an imperfect process,” he said. “Even the most ardent defenders of ADHD have to acknowledge that it can be challenging when trying to address people in this gray zone where problems may be minimal and moderate rather than severe.”
Doctors aren’t always good at detecting people likely to abuse or misuse ADHD drugs – but that doesn’t mean there’s a problem with ADHD or the diagnosis, the specialists said.
ADHD often comes along with other problems, like learning disabilities, depression or substance abuse – and it can be tricky to discern whether the patient’s primary problem is ADHD or something else.
They all said that an accurate diagnosis of ADHD requires more than one visit and an interview with a parent, spouse or other long-time friend, to confirm that the person’s challenges are long-standing and affect more than just their temporary homework load or social life. “The diagnosis of Adult ADHD is based on a lifelong history of distractibility, forgetfulness, procrastination, poor time management, disorganization and underachievement in multiple realms,” Bilkey said.
4. Lots of young people take stimulant medications looking for an “edge” on tests and homework.
Stimulants will definitely keep people up longer – which might help on tomorrow’s test, or getting that paper in on time. But they don’t work substantially better than coffee at improving focus, Elliott said. “What the evidence suggests is that people have more confidence – that they think it’s working,” he said. “There’s very little evidence that it actually enhances performance in kids who don’t have ADHD.”
At high doses over extended periods, he said, stimulants can cause psychotic breakdowns, like the one Fee suffered. And, though teenagers and young adults may believe they can handle stimulant medications, “if you don’t need the drug [to treat ADHD], you’re taking it for the wrong reasons,” Surman said. Doing that, puts someone at risk for the kind of addiction that Fee apparently suffered. “You’re taking matters into your own hands. These drugs aren’t meant to be managed in your own hands.
(More information on stimulant abuse is available here.)
Karen Weintraub, a health and science journalist based in Cambridge, helped doctors Surman and Bilkey write a book, “Fast Minds: How to Thrive If You Have ADHD (Or Think You Might),” which was published this week.