Sunday, March 25, 2018

Take Your Meds




"It might be because I have severe ADHD.  It might be because it was jet fuel.  I don't try to draw the line".  - Stimulant user rationalizing use.


The above comment was made by a young man in the new Netflix documentary "Take Your Meds" about stimulant medications (but mostly Adderall).  Fortunately or unfortunately depending on your viewpoint - physicians are still charged with the task of drawing the line.  I don't typically like watching documentaries, but since this is my area of expertise I thought I would watch this one.

From the outset, it was apparent that the real downsides of using tremendously addictive drugs were not going to be emphasized.  This was a sanitized version of abusable drugs.  It was stated that prescription stimulant users were a class apart from methamphetamine users.  There seemed to be an implicit message that in an egalitarian society - if the methamphetamine users had access to stimulants they would be better off. If we all could get access to performance enhancing drugs like stimulants the world would be a better place.  A neuroscientist known for this kind of social commentary made some remarks basically stating that prescription stimulant use is another example of class factors in addiction.  In this case because over half of the story was performance enhancement - that class argument was also made.  Are those lower socioeconomic kids losing out because they don't have access to this performance enhancement?  Probably not because the film makers don't present any data that performance enhancement actually occurs.  It is the idea of performance enhancement. 

A modicum of of common sense and medical use was introduced.  They showed a very concerned pediatrician treating children of mothers who had some expertise in the field and nothing seemed to help their sons than stimulant medications.  In one scene the pediatrician spends a time convincing one of these teenagers that it is up to him to take the medications. I do not know how doctors can have those conversations in awkward examination rooms with the unexamined identified patient sitting on an exam table and the doctor just standing there talking.

We meet a number of individuals over the course of the documentary.  The first is a new college freshman.  She is the first to comment the competitiveness/ performance enhancing aspect of stimulants - namely "Everybody here is on them.  They are traded and sold.  In order to be competitive I have to be on them."

We meet a former professional football player who starts taking them.  We learn about how great he felt and how much of an advantage it seemed to make in all aspects of his play and in overcoming injuries.  We learn that in the NFL, if you are a player you can get an exception to play with stimulants and take them if a doctor says that you have ADHD and then only the prescription written by the doctor.  In this case the prescription was for Vyvanse 70 mg per day with 2-10 mg Adderall as needed on top of the Vyvanse.  The Adderall was occasionally increased to 20 mg twice a day in addition to the Vyvanse.  Either way he is taking more than the recommended total amount of stiumlant per day.  One day before the game, the player in this case ran out of his usual stimulants and took Concerta (methylphenidate) from another player.  Concerta had a different profile on toxicology screening and as a result he incurred a 4 game suspension.  The details of what happens next are not clear but we see him when he is not longer playing professional football and has moved on with his life.  In an interesting postscript, he talks about the conflict of being a different person on stimulants and what it means to take credit for what that person does.

We meet a Wall Street researcher and coder.  We get opinions on what coders think of using stimulants to write code and their aspirations to write perfect code.  He paints a picture of what it is like to work for a large investment concern.  A room full of people on computers, expected to work very long hours and get rapid results.  If additional time is needed, the plan is to take stimulants and get the work done.  One night he declines stimulants, leaves work and the guy next to him stays there and at some point has a seizure from stimulants.

The common threads are the idea that stimulants are used as performance enhancers to be more competitive in academic and business environments. The idea is that every student and worker is expendable and if they can't do the job, somebody else will step up and do it therefore stimulants are necessary.  Some seem annoyed by the charade of having to convince a doctor that they have ADHD in order to get a stimulant prescription.  They would prefer just to get it without any medical diagnosis.  Hallucinogens are brought up as additional performance enhancing agents - especially microdose hallucinogens.

There are the usual suggestions that this is a pharmaceutical marketing phenomenon.  There is a brief discussion of America's first amphetamine epidemic and how the Controlled Substances Act was used to shut it down.  The producers do mention that adult prescriptions for stimulant medications now exceed the prescriptions for children. They touch on problems with a totally subjective (first-person report) and a lack of clear objective markers for a diagnosis - but not the amount of fraud that goes on to get these prescriptions.  Nobody ever points out for example, that none of these otherwise high functioning adults would qualify for the diagnosis on level of disability alone.                 

The only small bit of scientific data in the film was the work done by Farah, et al (1) who looked at the performance enhancing properties of amphetamines in health college students.  Across a large number of neuropsychological variables it seems that the only one that was significantly improved was the persons perception of their performance.  In other words, there was no objective sign that their performance was enhanced on cognitive testing but the subjects all believed they were performing better. There is more data that the performance enhancing aspects of stimulants are overblown.

That is certainly my experience interacting with amphetamine users for the last 30 plus years.  I caught the tail end of the first epidemic and starting seeing obese patients on high dose amphetamines.  Even though they had not lost a pound and were still very obese, they insisted on staying on high dose stimulants and were fearful they would gain weight if they stopped.  In those days it was not uncommon to get a call to the Emergency Department because there was a narcoleptic patient there form another state who was taking high dose stimulants (> 100 mg/ day of amphetamines) for narcolepsy.  My job was to figure out if the patient really had narcolepsy or they were lying to get stimulants.

Today my job is a little more subtle.  Adults are operating from many levels of misconception about both stimulants and ADHD.  Today I rarely meet an adult who does not think they have ADHD - even if they have a superior level of academic and vocational achievement. In some cases they have been swayed by the non-specific effects of stimulants - "I took my son's Adderall and for the first time I was able to focus and read well."  In many cases they are influenced by professionals who have heard about the high heritability of ADHD and interpret this to mean if they diagnose a child with ADHD it means the parents and in some cases the grandparents have it.  I have seen generations diagnosed this way.  I  work in the addiction field and everyone who is addicted to stimulants believes that they cannot live without them. They get quite angry if they are not supplied.  That same population is in withdrawal form using very high doses of prescription or non-prescription stimulants and they also present with a residual ADHD that cannot be distinguished from ADHD but it is due to acute and chronic changes from stimulant overuse.  Last but not last, the medical and potential medical complications of amphetamine use need to be carefully determined.  Hypertension, cardiac changes,  arrhythmias, and movement disorders are all fairly common in people who overuse stimulants.

 These are a few of the major points that the Netflix documentary leaves out.  It touches a few of the high points but like most media pieces it gets too focused on human interest stories.  Historical lessons like what happened during the First Amphetamine Epidemic seem to be lost.  When that ended in the 1970s even the rock bands of that era were sending the message that "Speed kills!"  Addiction is more likely to happen if it is taken because for performance enhancement.  Any time a person operates from the perspective that taking a medication will greatly enhance their performance, it is difficult to not think that "more is better."

If you are a bottom line person, I think you will be disappointed if you want to learn some science about ADHD and stimulant treatment in this documentary.  You will hear a few sound bites but not much more.  If your interest is more in the pharmaceutical industry selling stimulants and marketing them excessively, you will also get the superficial story.  They is much more detail on annual prescriptions and trends.  On a historical basis, I produced a timeline extracted from a history of America's first amphetamine epidemic that covers everything in the film and more without the film clips of Jack Kerouac.  If you are an addiction specialist like I am, I think there is a message there that most of the prescriptions for adults are not for ADHD but for some type of cognitive enhancement and the basis for that is thin.  That is a good take away message, but the real downside is not that apparent.

That downside is addiction.  Compulsively using stimulants to the point that your life, your relationships, and your health are destroyed is as possible with prescription stimulants as it is with methamphetamine.  Both are sold on the street by the same dealers.  Contrary to what you read in the press or pick up in this film all it takes is exposure to amphetamines and the right genetic make-up to create an addiction.  Having true ADHD, or the right socioeconomic standing, or willpower doesn't protect you against addiction.  Once an addiction to prescription or nonprescription stimulants occurs it is a very difficult problem to recover from.  Unlike opioids and alcohol - there are no known medications to assist in recovery. 

So like most treatments in medicine, stimulants need to be cautiously applied.  Indiscriminate use for performance enhancement does not seem like a good idea to me because it will cause proportionally more addiction and the cognitive gains across the population are minimal mostly restricted to the  perception that you are doing much better than you are. 

Not a good reason for taking stimulant medications unless you really need them.


George Dawson, MD, DFAPA
 





References:

1: Ilieva I, Boland J, Farah MJ. Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people. Neuropharmacology. 2013 Jan;64:496-505. doi: 10.1016/j.neuropharm.2012.07.021. Epub 2012 Aug 1. PubMed PMID: 22884611.

2: Smith ME, Farah MJ. Are prescription stimulants "smart pills"? The epidemiology and cognitive neuroscience of prescription stimulant use by normal healthy individuals. Psychol Bull. 2011 Sep;137(5):717-41. doi: 10.1037/a0023825. Review. PubMed PMID: 21859174

3: Bagot KS, Kaminer Y. Efficacy of stimulants for cognitive enhancement in non-attention deficit hyperactivity disorder youth: a systematic review. Addiction. 2014 Apr;109(4):547-57. Review. PubMed PMID: 24749160.

6 comments:

  1. I recall a grand rounds from maybe 18-20 years ago in which the psychiatrist was saying that about 18% of all adults should be on high doses of speed, that the reason that many of the parents of kids diagnosed with ADHD were substance abusers was because, "If you had a kid with ADHD, you'd drink too," and that kids who had ADHD could concentrate intensely on video games in an arcade despite loud distractions all about because that is "not concentrating." (I always wondered what the heck it supposedly was). I kid you not.

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  2. I believe it.

    I have seen some concentrated pockets of providers with that extended family belief system. Luckily not all families buy it: "I have been successfully working and functioning for 20 years and now I need a medication?". Interestingly they seem to notice the lack of impairment, while the provider is caught up in the theoretical heritability observation. They missed the part that many people just adapt and many people do "grow out of it."

    Another very common story is the kid with real ADHD that always hated taking the medication and found a job where he had no problems and is doing fine.

    But the biggest problem remains the performance enhancement issue largely because people don't seem to know how human attention works and the idea that they will improve their performance with a pill.

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  3. At the core of it, I think we spend way too much time, effort and money addressing what is ultimately an organelle mitochondrial problem at the synaptic level with sympathomimetics/triomonoamines and similar drugs.

    I got about 10 minutes into the documentary and it quickly became too dystopian even for me, even though I see it all the time.

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  4. Having been off the past 10 days and away from all the drug seeking and frank manipulating by patients, I just offer this: maybe frame this as people think we will supply the masses with cocaine in a pill? It never ceases to amaze me when you talk to cocaine addicts in true recovery: their first high was so wonderful, and then they chase that experience the rest of their addicted life.

    So, maybe the way to frame some of these adults who are having their "epiphany" about being alleged ADD stricken folks and trying someone else's stimulant prescription is similar? Just a thought...

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  5. I did not see the film but have had concerns from my 25 plus years in provate practice.
    First, in real life a majority of children arrive at ADHD dx by way of teacher report that child is not focussing +/- " hyper'. Nothing much asked the child to understand what is distracting.info is given to pediatrician and bang ..stimulant. mamy do report ability to focus better but after the fact the behaviooral issues ex agression is worse. Antidepressant is thrown in as dx becomes " ADD depression",.By the time they sit in my chair in adulthood, many have done a stint in jail ( impulsivity)substance abuse. Sometimes it is in jail that they fist get tx for the Mood disorder..bipolar disorder that has been ignored. Some have figured the alcohol that calms them down and the maridhuana that takes care of the anxiety. Goals have been derailed. Part of the problem is the mental health profession has to emphasize diagnostic criteria even in the high powered APA session that often goes straight into tx.We ,psychiatrists are sometimes the culprits. How does one get a dx ADHD for the fist time in college when they make it clear they were ok before college? I did an 18 month stint in a midwest ED and honestly, i dont think one could get away with what I experienced if it were any other specialty.Methamphetamine was present 90 % .in a not insignificant portion ,stimulant in childhood was the intro drug.And now as adults, brought in by police ,giving history of agression. Whenever i had the oppotunity doing mt little research of asking an older family member..many had symptoms more consistent with mania..some psychiatrist still do not believe in pediatric bipolar d.
    Long after their contact, the patient and tbir families are picking up the pieces. There is a lot that can be improved in psychiatric evaluation and treatment of patients as well as giving training tools to the ist responders..pediatricians.
    In real life there are many whose injustices will never see the light of day...but we all may feel the results

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    1. Part of the problem is that research in just about all areas of medicine is undetermined. That is there are many more potential interpretations of the results - in addition to the conlcusion of the researchers. For example - just in your post there are papers written that claim there is a decreased risk for incarceration (or reincaceration) if ADHD is adequately treated.

      The majority of people I see are adults that were diagnosed and treated and adults that were diagnosed as kids. That latter group includes a significant (if not majority) who stopped stimulants during childhood because of side effects (weight loss, insomnia, and anxiety), lack of efficacy, or restricted affect. Contrary to the studies many of these people are highly successful. There is also a group who went on to become stimulant users and continue to insist that despite their addiction, they need to continue on the stimulant.

      When it comes to the overdiagnosis of adults - the parsimonius approach would be to ask about the person's success and ask them if they ae really interested in performance enhancement rather than treatment of ADHD. Lack of significant impairment should rule any adult out irrespective of how they score on typical rating scales or neuropsych testing.

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